_— The Biocreative Strategy Part 2 The Tweemac Analysis SEONG-HUN KIM, DMD, MSD, PhD HYO-WON AHN, DDS, MSD, PhD KYU-RHIM CHUNG, DMD, MSD, PhD GERALD NELSON, DDS ince the 1950s, cephalometric analysis has been an essential tool for accurate diagnosis and treatment planning.’ Although many metrics have been proposed to define skeletal and dental patterns, orthodon' have yet to agree on a universal approach. Consequently, teaching programs and practitioners tend to modify or combine existing analyses to fit the pa- tient or the clinician's preference. Last month, we described the foundations of the Biocreative Strategy. The key principle of this system, “Simple Is Best,” applies to diagnosis and treatment planning as well as to biomechanics. Because any movement of the teeth in nonsurgical treatment occurs in the alveolar bone below the palatal plane, Biocreative Strategy focuses on the maxillomandibular complex and the impact of treatment on the lower face. Part 2 in this series describes the measure- ‘ments and clinical interpretation of the Biocreative diagnostic system—known as the Tweemac anal- ysis—which allows simple and effective evaluation of the dentofacial problem mal num ber of landmarks. The Tweemac facial analysis involves three clements. The first is the Tweed- Merrifield triangle as applied to the lateral ceph- alogram.! Second is a transverse evaluation as br. Kim Dr Kims Professor and Chal Dr Arn ian Assistant Professor, and ‘rung Hee University S20. Katee. Or Nelson Isa Clinical Professor, fornia, San Franelace Dr. Kim Isa VOLUME Lil NUMBER 6-7 Chung isa Clinica Professor Department of O Separiment of Orotactl Selenice, Dison of Ot Fe ceo of nes ouinal of Crical Onhedentes e-mail Sraverthogginal com Dr. Chung © 2018.100, ne bes $nBIOCREATIVE STRATEGY PART 2 relati have been questioned because of the limita of SN and OP! Any inaccuracy in locating a reference plane will lead to a false appraisal of the jaw relationship. PP has been suggested as a more reliable reference because it is a skeletal landmark that lies closer to the area being sur- veyed." Broadbent wrote in 1937 that PP ap- peared to maintain parallel orientation through- ut the growth period.’ Brodie also found, in his, Jongitudinal study, that PP maintained a constant angular relationship with the anterior cranial base."* Nevertheless, in some cases invotving, dentofacial deformity, the cranial base and struc- tures of the upper face should stiil be considered. Lower incisor positions and the supporting, chin prominence are directly related to the esthet- ics of the profile. IMPA is a popular measure- ment, but it represents the axis of the lower inci- sor to MP, not to the symphysis outline. Normal IMPA values encompass a broad range and can be influenced by mandibular divergence or sag- ittal skeletal discrepancy. In younger patients, extraction treatment with skeletal anchorage can achieve harmony between the lower incisors and 368 Fig. 9 A. After eight months of treat n-masse retraction com- pleted in six months). B. After 11 months of treatment. C. After 14 months of treatment. D. After 16 months of treatment. E. Patientjust before debon chin through bone remodeling. In other patients, however, such factors as cessation of growth ora thin alveolar housing in the mandible may inter- vene. The Tweemac analysis correlation of LEA with IMPA provides an excellent esthetic assess- ment of the soft-tissue lower facial profile and thus helps determine the appropriate treatment plan—whether extractions, genioplasty, or man- dibular surgery. The application of LEA to skel- etal Class III relationships is a potential area for further study. Traditional two-dimensional cephalometric landmarks are not useful in three-dimensional cone-beam computed tomography (CBCT). pat= ticularly if the clinician is unfamiliar with di nosis and treatment planning with CBCT. In contrast, the reference landmarks of the Tweemac analysis ean easily be converted to CBCT ima es, making 3D analysis a simple diagno: (Fig. 12). CBCT also provides the opportunity for the clinician to evaluate the alveolar bone housing, sinus extension, airway, and periodontal condition. (TO BE CONTINUED) JCO/JUNE-SULY 2018a KIM, HN, CHUNG, NELSON —— is. ‘Tweemac analysi fins WA. Patient after 17 months of Sreaiment. B. Tr tracings, Supetimposition of pre- and post-treatment 369 “OLUME Lit HUMBER 6-7BIOGREATIVE STRATEGY PART 2 = a a Fig. 12 Same Tweemac analysis 2P- plied to lateral cephalogram and Cone-beam computed tomography. 370 “sCO/JUNE-sULY 2078— KIM, AHN, CHUNG, NELSON goWL EDGMENTS: The auth Su ie A ade Set ‘kyung lle University on Pubishing Ci, Seoul, Korea, 240, AMeaetR¢:The 20 Prin ples he leaner Quintessence Publishing Co-loe-Alanoes Pot Te ae owen 9. Ricketts, RLM. Schulhiof, RJ: and Basha. L Oricntation — selhi-nasion of Frankfort horizontal, Am. . Orthod. 7 6¢% ae 654, 1975, Panchers,{1.and Gokbuget, K : The reliability of the Frankfort horizontal in roentgenographie cephalometry. Eur. Orthod. 18:367-372, 1996, M. Thsels Wand Nanda RS: Anais facto alsin 1-423, 1984. 1 tweed. He The Frankfort mandibular p wate diagnons lass dea am. J-Onthod. Or Sung, 32:175-230, I e ANB, Am. J. Orthod, 85:411-423, a. Sener, CC: Cephalometies or you and me, Am. J. Orthod 12, Tarvien, S An $oT3) 155, 1953. statistical appr sb A The Wis aor of ow disharmony, Am. 13. Bjork, A. and Skielier, Vi Growth of the macilla in theee dic i oho ‘mensions as revealed radiographically bythe implant method. 4, MeNanat AS A method of exphalomete mle Br.J. Orthod. 4:83.64. 1971 1 Otho Bhet49-$69, 1988, 14. Riolo, M.Ls Moyers, RE: MeNamara,J.A.and Hunter, WS, Kook, Y.AG Kim, S.Hls and Chung, An Atlus of Craniofacial Groseth, Ru A modified pa nsiurage plate for simple and elficient distalization, J Clin, (Ohod. 4719-730, 2010, 6, Chung. KR Kim. Y.S.; Linton, JL. and Lee, raph No.2, Cranio- facial Growth Series, Univesity of Michigan, Ann Afbof. MI 07, J: The 15, Broaent, BL: The face of the normal child, Angle Orthod. ripe wi be for skletah anchorage, J Clin, Orthod 7183-208, 1937, byva07-412, 20 16. Brovie, rowth changes in the human face, Angle TLR Tela of Dcrative Faery, Kiyungren Onhod. 234466157. 1955, Accelerated Orthodontics Webinar! Join us on Thursday, Sept. 13, at 8 p.m. Eastern time for this in-depth, one-hour webinar with Dr. John Graham, one of just a few clinicians to hold both medical and dental degrees. * With alveocentesis, distraction osteogenesis, photobiomodulation, piezocision, and vibration, along with the multiple products that trumpet faster treatment times, accelerated orthodontics can be a confusing area of claims and counterclaims. Dr. Graham explores the science and the current state of the literature regarding the {different methods of acceleration and provides advice on how you can incorporate acceleration into your practice. * $50 for JCO subscribers to attend, $100 for non-subscribers. Space is limited. Register at www.jco-online.com/continuing-education/wel 3n VOLUME Li NUMBER 6-7 bhBIOGREATIVE STRATEGY PART 2 TT TABLE 1 TWEEMAC ANALYSIS NORMATIVE VALUES Male Female Mean sD. Mean SD. D Lateral Cephalometric Analysis, Position of Mexila and Mandible Nperp-A 1.94mm 3.87mm, 2.69mm, 364mm 0.557 Nperp-B -1.09mm 6.04mm_ 175mm 390mm — 0.701 PA-PB 3.03mm 3.71mm 444mm 249mm — 0.192 Divergence PP-MP 25.76" 6sr 30.28° 427 «0.05 PP-OP 8.03" 40 nar 248" <0.05" MP-OP 18.82" 534° 19.727 353° 0.858 Incisor Axes upp 118.00" 51° 115.31" 485° 0.133 IMPA on91 543° 93.67" 7.058 0417 Convexity of Lower Symphysis Lower esthetic angle ome aay 143i" 5.65" 0.05 Frontal Cephalometric Analysis Shape of Mandible Body canting (Ag-Ag/Lo-Lo) 1.09" 1.05" 189° 1.54 0.096 Body asymmetry (Ag-Me-Aq) 121.18" 8.89" 118,92" 7.68" 0.482 Right ramal inclination (MSR/Co-Ag) 7.76" 187° 7.69" 3.08" 0.936 Left ramal inclination (MSR/Co-8g) 8.06 257° 7.50° 295° 0.555, Right ramal length (Co-Ag) 75.A4mm, 5.07mm 68.75mm 3.98mm <0.01* Left ramal length (Co-Ag) 76.26mm 550mm 68.47mm, 3.54mm —<0,001* First Molar Axes Right U6 79.18" 692 769° 719 (0.537 Left us 80.56" ear 78.78° 691° 0.432 Right L6 106.68° 5.05" 105.75" 593° 0.623, Left L6 104.18° 5.74" 105.47" 513° 0.486 ‘independent Vest used to compare genders 360 JCO/JUNE-JULY 2018TT HIN, ANN, CHUNG, NELSON proposed by Chung, using the postero-anterior {PA) cephalogram to assess basal bone width, al- eolar bone width, occlusal plane canting, and asymmetry’ These are combined with a dental cast ‘analysis of molar and canine width, as described by Alexander’ The Tweemac analysis evaluates seven key components: vertical maxillofacial re. jationship, sagittal relationship of the maxilla and mandible, skeletal divergence, convexity of the lower symphysis, airway width, shape of the man- dible (asymmetry), and inclination of the incisors and molars. ‘The normative values for the Tweemae anal- ysis were established from a sample lation of 15 males (mean age 29.3, range 25. and 20 females (mean age 29.8, range 24.7-37.9) ‘who had skeletal Class I relationships with normal occlusions and facial profiles (Table 1), Lateral Cephalogram Reference planes such as Frankfort horizon- tal and SN, which rely on the cranial base to de- termine the sagittal relationship of the jaws,” are remote from the maxillomandibular complex. Moreover, tracing of porion can be inconsistent, and studies have shown that the position of nasion varies among individuals, especially in the antero- posterior dimension. A reliable cephalometric analysis should be built upon a reference plane in an accurate, consistent, and convenient location. With this concept in mind, the Tweemac analy uses the line ANS-PNS as its primary horizontal reference plane (Fig. 1). Other key references are the palatal plane, occlusal plane, mandibular plane, nasion perpendicular to palatal plane, and lower esthetic plane (infradentale-pogonion), The sagittal skeletal relationship is assessed by projecting points A and B perpendicularly to the palatal plane (PA-PB). The vertical skeletal relationship is evaluated using three angular mea- surements: PP-MP, PP-OP, and MP-OP. PP-OP is a good indicator for planning differential intrusion of the maxillary anterior and posterior teeth, as is MP-OP for the mandibular dentition, The lower esthetic angle (LEA), or chin an- gle, measured from the nasion perpendicular to the palatal plane to the lower esthetic plane, is unique to the Tweemac analysis (Fig. 2). LEA depicts the relationship of the lower incisor position to the symphysis outline and its important effect on the Jateral soft-tissue profile. In a patient with a large LEA (more than 20°), pogonion is more posterior relative to the lower central incisor (Fig. 3). Ex- traction of four premolars and en-masse retraction of anterior teeth will improve the soft-tissue profile A Fig. 1 Pl ‘Tweemac analysis. A. 15 cephalometric landmarks, with ANS-PNS a: primary horizontal B. Other horizontal and vertical references: palatal plane, occlusal plane, mandibular plane, n: Pendicular to palatal plane, and lower esthetic plane (infradentale-pogonion). ve OLUME LI NUMBER 6-7 361BIOGREATIVESTRATEGYPART2_- ina patient with a large LEA and large IMPA, but 4 nonsurgical approach rarely produces ideal es- thetics in a patient with an excessive LEA. If the lower central incisor axis is normal, a mandibular anterior segmental osteotomy and/or advancement genioplasty is generally required to improve the soft-tissue profile. In addition, the soft-tissue thick- ness of the chin—a key component of the Biocre- ative Strategy—and the chin prominence will af- fect treatment results. Thinner soft tissue means a less esthetic profile. In a patient with a small LEA, pogonion is more anterior relative to the lower cen- tral incisor. If the lower central incisor axis is nor- mal, setback genioplasty or reformation of labial cortical bone should be considered to produce the soft-tissue changes associated with these minimal- ly invasive procedures. If the LEA is normal or small and combined with a retrognathic mandible, then mandibular advancement surgery would be advisable. The superior airway width is the distance between PNS and the posterior wall of the airway, parallel to PP: the inferior width is the distance from the intersection of the anterior pharyngeal \wall and the mandibular body to the posterior pha- ryngeal wall (Fig. 4). These convenient and prac- ical Tweemac measurements, made in the sagittal plane at the nasopharynx for superior width and the hypopharynx for inferior width, simplify the evaluation of airway dimensions, 362 Fig. 2 A. Angular dental measure- ments: U1-PP, IMPA, and interincisal angle. B. Tweemac analysis super- imposed on lateral cephalogram. Frontal Cephalogram The PA Tweemae analysis offers a quick evaluation of mandibular asymmetry and trans- verse discrepancy (Fig. 5). References are the mid- sagittal reference plane (MSR), latero-orbitale (Lo-Lo) horizontal reference plane, midsagittal plane of the maxillomandibular complex (ANS- Mo), occlusal plane, basal bone width, and maxi lary alveolar bone width. In this analysis, a cant of the basal bone or occlusal plane relative to the horizontal reference plane can easily be distin- guished. Skeletal measurements include ramal length, from Co to the antegonial notch (Ag); ramal incli- nation (MSR/Co-Ag); mandibular border symme- tty, based on the Ag-Me-Ag triangle; and mandib- ular body canting (Ag-Ag/Lo-Lo). The basal bone width and maxillary alveolar bone width are eval- uated to determine the origin of the transverse deficiency, which is vital in planning treatment for Patients who require expansion. The axes of the first molars relative to OP indicate the amount of dental compensation required. Intraoral scanning data can be merged with the lateral and PA cephalogram measurements Us- ing Orapix* software for simultaneous model anal- ysis and cephalometric analysis, *Cenos Co. Lid nyangsi, Korea; wwacorapi JCO/JUNE-JULY 2018capi ar nmi KIM, AHN, CHUNG, NELSON ae Te angle (LEA) and IMPA. A. In patient with large LEA and large ame ett aetion of four premolars improves facial harmony, B. In patient ‘with large LEA and normal IMPA, lower manigh Segmental osteotomy improves facial harmony. ‘C. In patient with normal LEA and IMPA and retrognathic s Mandibular advancement surgery improves facial harmony. Fi Mpg Thtee cases evaluated using lower esthe Vo LUME Lil NUMBER 6-7 363BIOCREATIVESTRATEGY PART2__- Case Report A 14-year-old female patient presented with the chief complaints of facial asymmetry and crowding (Fig. 6). Clinical examination showed a skeletal Class | relationship and mandibular asym- metry. Lateral Tweemac analysis (Table 2) indicat- ed good sagittal and vertical relationships of the maxitlomandibular complex, a small LEA (prom- inent chin), flared upper anterior tecth, and a nor- mal IMPA (92.5°). The frontal cephalogram re~ 364 Fig. 4 Evaluation of superior and inferior airway widths. Fig. 5 Tweemac analysis of postero- anterior (PA) cephalogram. A. Refer- used for evaluation of first mo- es and mandibular asymmety: midsagittal reference plane, latero- orbitale horizontal reference plane, midsagittal plane of maxillomandibu- lar complex (ANS- Me), occlusal plane, basal bone width, and maxillary alve- olar bone width. B. Tweemac analysis ‘superimposed on PA cephalogram. vealed negligible asymmetry of the rami but asymmetry of the mandibular body to the Jeft. 2s confirmed by the chin deviation. The upper left molar was buccally inclined (68°) relative 10 th transverse compensation: the lower molar 2x¢s were symmetrical from side to side. Th: exhibited an occlusal discrepancy from centri lation (CR) to maximum intercuspal position (MIP. or centric occlusion). The treatment plan involved extraction of the upper first premolars and application of the JCO/JUNEJULY 20 ; ___———.. Sa KIM, AHN, CHUNG, NELSON VOLUME Lit NUMBER 67 facial asymmetry, crowding, and severe discrepancy between max- imum intercuspal position and centric relation (CR) before treat- ment. B, Tweemac analysis indi- cates flared upper anterior teeth, prominent chin, normal IMPA, and deviation of mandibular chin point to left, with compensated dentl- tion, 365,BIOGREATIVESTRATEGY PART2_-—— TABLE 2 TWEEMAC ANALYSIS Norm Pretreatment —Post-Treatment Difference PAPE 430mm 3.10mm 1.61mm “143mm PP-MP 29.90" 20.21° 22.18" 197° PP-OP 10.80" 4.89" 43° -0.58" MP-OP y9.70° 1532" 17.87" 255" UTP 115.40" naar 115.70" ~207° IMPA 93.40" 92.48" 90.97" “181 Lower esthetic angle 73,90" 2.93" 0.85" -2.08* Body canting (Ag-Ag/Lo-Lo) 1.89° 0.88" 1.65" om Body asymmetry (Ag-Me-Ag) 118.92 132.66 124.04 8.62 Right ramal inclination (MSR/Co-Ag) 116 vase 9.80" -433° Left ramal inclination (MSR/Co-Ag) 8.06 2.99° 51 2sr Right rameal length (Co-Ag) 75.44mm 60.20mm 58.88mm 132mm Left ramal length (Co-Ag) 76.26mm 56.23mm 56.95mm 072mm Right U6 168° 7a 79.51° o.10° Leftus 78.78" 68.09" 198° 987" Right Ls 105.75" 9a" 95.60° oz Left Ls 105.47" 94.28" 96.36° 2.08" Biocreative Strategy. The patient wore a CR splint for two months to iinprove hier MIP-CR di ancy (Fig. 7). Mini-implants were impractica because of a narrow interradicular space with sinus eneroachment mesial to the molars; the fore, two short, T-type C-tube™* microplate inserted under local anesthesia in the upper po terior region, using a digi ement jig, and fixed with three 1.5mm-dia 4mm-long miniserews on eacit side (Fig. 8). At this point, 022" ceramic self-ligating QuicK lear by ets were bonded to the upper an 016" x 022" pret (nickel titani- el posterior 366 En-masse retraction was performed over six ‘months, with no brackets bonded to the upper pos- terior teeth. Treatment concluded with four months of .016" x 022" and O18" x .025" Biotorque*** archwires, two months of 017" x 0. ness steel archwvires, and three months of O19" x.) stainless steel archwires for finishing ( Total treatment time was 17 months. The crowding in both arches was resolved, and Chass | canine and Class 1 molar relationships were ed. The MIP-CR discrepancy was reduced 18 Co. Bacheon, Koreas www ennai ered tralemtatk of Forestauent GmbH, Pforzheim JCO/JUNE-JULY 2018—____________ KIM, AHN, CHUNG, NELSON 7 CR splint worn for two months to improve midline dis- crepancy. Fig. 8 A. Two short, T-type C-tube** microplates placed in up- per posterior region and fixed with 1.5mm-diameter, 4mm-long Miniscrews. B. En-masse retraction of upper anterior segment, beginning with .016" x .022" nickel titanium/stainless steel pre- formed C-wire. SS mandibular symmetry improved (Fig. 10). The Discussion 7P6 nd lower anterior teeth were uprighted, with “PP decreasing from 117.8° to 115.7%; IMPA The Tweemac a simple, intuitive, system based on eel from 92.5° to 91°; the esthetic angle was and comprehensive diagnost 'uced; and the molar axes were corrected (Table three-dimensional skeletal and dental evaluation feat years after treatment, the occlusion and of the lateral cephalogram below the palatal ‘al harmony remained stable, with no signifi- plane. Although ANB and the Wits appraisal are “ant relapse (Fig. 11). - most commonly used to assess the sagittal jaw Me SLUME LI NUMBER 6-7 367