An Atlas andManualof

Cddmetric
Radiogr
ThomasRakosi,M.f)., D.D.S.
Professorof Orthodontics,
Chairmanof the OrthodonticDepartment,
Universityof Freiburg.

by R. E. K. Meuss
Translated

Wolfe Medical PublicationsLtd

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 Munich
Ori ginallypublishedby Carlllanser-Ve-rlag'
asAtlas Und RnteitungZur Pral(tscnen
Fernrontgenanalyseff homasRakosl'

@ 1979Carl HanserVerlag
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Foreword

The use of cephalometricradiographyin orthodontics servesto confirm diagnosis,

and also makesit possibleto include the morphology of the visceralcranium when
consideringpossibletreatmentprocedures.In the courseof treatment,roentgeno-
graphic analysiscan give valuableindications,by providing additionaldata when
treatment is first initiated, a monitoring function as treatment progresses,and
suggestingpossiblemodifications.On conclusionof treatmentit will often be the
most important method for determiningstabilityaswell asthe period of retention.
Cephalometricteleradiographywill not, of course,replaceany of the established
methodsof investigation.Radiographicdiagnosisratherthan analysis-i.e.making
important.therapeuticdecisionswhbly on the basisof radiographs-wouldindeed
be poor diagnosis.To emphasizethis point, the techniquewill alwaysbe referredto
as'cephalometricradiography'and not as'diagnosticradiography'.
The method presentedin this book is a practicalone, i.e. designedfor usein daily
practice.A greatnumber of analyticaland investigatoryproceduresarespecifically
designedto assistscientiflcresearch.The presentmethod also involvesscientific
researchesbut, if at all, theseare mentionedonly in passing.
A method designedfor practicalusemust be basedon meaningfulmeasurements.
All kinds of measurementsmay be made on a radiograph,but we are concerned
only with parametersthat provide the dataneededfor decision-making.Analysisis
basedon elementschosenwith greatcare,basedon the experienceof manyyears.
Its information value has been tested repeatedly, including the retrospective
analysisof completed cases.For a period of two years,the work of our under-
graduate, graduateand postgraduatestudentshasbeenassessed and checkedfor
accuracyby J. Jonas.Her conclusionshaveassistedus in the choiceof landmarks.
As exact definition of the different landmarks is of supremeimportance, the
chapter on o'X-rayAnatomy" includedin the presentvolumehasbeentaken from
her work.
In the planningof this book, didacticaspectswereconsideredaswell asthe medical
and scientific content. Its precursor entitled Leitfaden filr die Femrontgenkurse
(manual for the coursesin cephalometricradiography)waspublishedin 1973.On
the insistence of those who have attended our courses, the material from
innumerable coursesis now presentedin conciseform.
The introductory chapters discussthe general principles, X-ray anatomy, land-
marks, lines and angles.This is followed by chapterson the significanceof various
skeletal, dental and soft tissueassessments. Two further chaptersdeal with the
interpretation of results and of growth. Finally, practical examplesare used to
demonstrate treatment planning on the basis of radiological criteria. Countless
examplescould have been given to illustratethis chapter;the commonestform of
malocclusion, the classIIt anomaly, has been used to demonstratethe issues
involved.

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 show that the usefulnessof cephalometnc
The conclusionsdrawn in that chapter planning' Every stageof treatment
*ut*""t
radiography is not^llmiffi a; on"ruil pLnn OJ.t ttt. basisof radiographic
and innumerable t".t rri.uf details "t;;;; p'tottOutes' suchas determiningthe
findings. Even *;;;-;;;;tsiOereO"simi[ the
of traction f;;;;"dg"ar, plannirrgttb construciionbite or trimming
angle ed without radiological
acrylic of an activ-ator,cinnot'u"".^ii&tin"ry-p"tr"t
analysis. t-,-^^ possible
cephalometric radiography as far as
The aim of the book is to integrate to facititate
n"ro of o--rttrodontics,
ph;;i;in-.tt.
with investigatio;lnJtr*t*.it to be
in daily practice, ."JJ""uG the best form of treatment
decision-making
determinedfor?ach individual case'

reisgau,GermanY
Freiburg-im-B Th. Rakosi
August1978

Contents
Analysis Page
Cephalometryand Radiographic to
1 The Introduction of Cephalometry n

Orthodontics 8
2 Classificationof AnalYses. 8
i.t rrlieittoOorogicalClassification 13
;.t NormativeClassification Areaof
;.i Ciurrin.utionettotoing to the 15
AnalYsis t6
Radiograph
3 Producingthe Cephalometric 16
of the Radiograph
4 Diagnosticl;;;fi""t T6
4.1 Landmarks l7
4.2 LinesandPlanes t'l
4.4 The Rangeof AnalYsis 18
4.4 InterpretationofMeasurements
Cranium
X-ray Anatomy of the Visceral 20
L Normalateralis 20
; ii;;t outlines in the RadiograPh 22
3 Paranasal Sinuses 24
1 The Roof of the orbit 26
5 The SPhenoid Bone 28
6 The Maxillary Sinus- 30
i fn" PterygoPalatine Fossa a^

8 The Middle Cranialtsase

Landmarks 34
1 ReferencePoints 34
i.f Ftop"tti"t of RefeqencePoints J)
1'.i bednition of ReferencePoints 4T
2 ReferenceLines 42
i Angular and Linear Measurements 42
3.1 Angles M
3.2 LinearMeasurements

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 Significance
of AngularandLinearMeasurements
for
D ento-Skeletal
Analysis
1 Analysisof the FacialSkeleton 46
1.1 SaddleAngle 46
I.2 ArticularAngle 47
1.3 GonialAngle 47
1.4 Sumof thePosterior Aneles 53
1.5 LinearMeasurements (CianialBaseand
FacialHeight) 54
2 Analysisof MaxillaryandMandibularBases 54
2.1 SNAAngle 55
2.2 SNBAngle 55
2.3 ANB Angle )/
2.4 Comparison of SNA,SNBandANB 58
2.5 SN-Pog 60
2.6 SN-PrandSN-Id 60
2.7 HorizontalLines 60
2.8 BasalPlaneAnglePal-MP 61
2.9 Angleof Inclination 62
2.IO SN-MP 62
2.t1, N-S-Gn(Y Axis) 65
2.I2 AnteriorandPosterior FacialHeight 65
D ento-Alveolar
Analysis
3.1 Angulationof UpperIncisors 66
3.2 Angulationof LowerIncisors 67
3.3 Assessment of IncisorPosition 68
3.4 Inter-incisalAnsle 68
4 LinearMeasureirents on Skeletal
Structures 71,
4.I Extentof AnteriorCranial Base,Sella
Entrance - Nasion 7T
4.2 Extentof Posterior CranialBase.Sella-
Articulare 11
II

4.3 Dimensions ofMandibular andMaxillaryBase 71

4.4 Positionof Maxillain thePosterior
Section 76
SoftTissueAnalysis
1 ProfileAnalysis 78
1.1 Reference PointsUsedin ProfileAnalysis 79
1,.2 Assessment of TotalProfile 80
2 Lip Analysis 90
2.1, IvletricLip Measurements 90
2.2 Reference Planes for Lip ProfileAssessment 92
3 Analysis ofTonguePosifion byCephalometric
Radiography 96
3.1 TongueParameters 98
3.2 AverageFindings 98
4 FunctionalAnalysisbasedon Cephalometric
Radiography r01
Interpretationof Measurements
I FacialProfilesandSkeletalAnalyses 104
1.1 OrthognathicSkeletalRelationship 105
I.2 RetrognathicSkeletalRelationship 109
1.3 PrognathicSkeletalRelationship 113
1.4 Age andTreatment-Related Changes in Cases
of PrognathicRelationship 123
1.5 Corelative Comparisonof Sagittal
Malocclusions r27
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2 Assessmentof Vertical Relationshipsin the
FacialSkeleton 130
2.1 Growth-RelatedRotationof the Mandible 130
2.2 Determinationof the Centreof Rotation 133
2.3 The Significanceof MandibularRotation 133
2.4 Rotationof the Maxilla 135
2.5 Rotationas a Factorin TreatmentPlanning r37
2.6 HorizontalRotationof the Mandibleand
DeepBite 137
2.7 Vertical Rotation of the Mandibleand Open
Bite 140
3 Classificationof FacialTypes t47

Cephalometric andGrowth
Radiography
1 HowMuchFurtherGrowthMaybeExpected? 149
2 Time Table for Growth I49
3 Localisationof Growth Rates 149
4 Direction of Growth 1s1
5 Predictionof Growth 151
5.1 Methodsof PredictingGrowth 151
5.2 Sourcesof Error in GrowthPrediction 153
6 PostTreatmentGrowth Changes 157
6.1 Fine Adjustmentof OcclusionAfter
Treatment 158
7 HoldawayGrowth Prediction 161
7.I The TwelveStagesof the HoldawayAnalysis 161

CephalometricRadiographyin TreatmentPlanning
i The Role of Cephalometric Radiographyin
Treatmentfor ClassII' Patients 164
1 .1 Localisationof the Malocclusion 165
r.2 FunctionalAssessmentof ClassII Occlusion 165
1 . 3 Growth Direction 169
r.4 Growth Potential 169
1 . 5 AetiologicalAssessment 169
2 DetailedTreatmentPlan 1,69
2 .1 Eliminationof Dysfunction 170
2.2 The Usefulnessof Cephalometric
Radiographywith FunctionalOrthodontic
Treatment 185
2.3 Distal Movementin the Maxilla r93
2.4 CombinedTherapy 201
2.5 DiscrepancyCalculation 208
3 Late Treatment 209
3.1 Planningthe Anchorage 214
4 Correctionof ClassII, Malocclusions
with
VerticalGrowth Direction zt5
The RankingOrderof Cephalometric
Radiographyin Orthodontic
Diagnosis 272

Appendix 223

Bibliography 223

Index 't1 A

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C.phalometryand
Teleradiography
1 The Introductionof Cephalometry
to
Orthodontics
The assessment of craniofacialdimensionsis not a new skill in orthodontics.The
earliestmethod usedwasto assess facialproportionsfrom an artisticpoint of view,
with beauty and harmony as the guiding principles.Tasteschange,however,and
beautywasjudged by different standardsin antiquitythan, for example,duringthe
Renaissance.Dtirer analysedthe human face, determinedthe ideil proportions
and divided the faceinto quadrants,andhiswork still hasa bearingon orihodontics.
Mqly centuries later, his method was applied to the analysisbf cephalometric
radiographsby de Costerand Moorees.Cephalometry(scientificmeaiurementof
the dimensionsof the head)was the first method to proveof valuein orthodontics.
It wasusedto assess craniofacialgrowth and determinetreatmentresponses. More
accuratemethodswere basedon orientedimpressionsof the faceand dentures,an
examplebeing that of van Loon (cubuscraniophorus).The methodis demanding
but very useful and was introduced under the name of 'gnathostatics'in t922. A
further method for the analysisof craniofacialdimensionsthat developedon the
basisof cephalometryis cephalometricradiography.
The first X-ray pictures of the skull in the standardlateral view were taken by
Pacini and Carreru (L922). In subsequentyears, the following authors also
produced this type of radiographfor the evaluationof craniofacialmeasurements:
MacGo-wen(1923), Simpson(1923),comte (1927),Riesner (lgz9), and others.
Nolg of them gavean accuratedescriptionof the methodsusedto take the pictures
and for their evaluation,so that one canonly speakof individualstudies.It wasnot
until L93I that Hofrath and Broadbent simultaneouslyand independently
developedstandardisedmethodsfor the productionof cephalometricradiographs,
usingspecialholdersknown ascephalostats,to permit assessment of growth and of
treatmentresponse.
Cephalometricradiographywasintroducedinto orthodonticsduringthe 1930s,but
the method really only gainedwider acceptance for practicalapplicationduringthe
last twenty years.Over the years,a whole rangeof analyseshasbeendevelopedby
a number of authors.The aimsof assessment tendedto vary, rangingfrom studies
on facial growth, the locationof malformations,aetiologicalstudiesto the assess-
ment of treatment response,as a complementto statusanalysisin orthodontics,
etc. An analysiswill only supply the answersto a particularset of questions,and
theseanswerswill dependon correctapplicationof the methodand interpretation
of results. Over a hundred different analyseshave been developed.fhey may
be classffiedfrom a numberof viewpoints,in systemsdevisedby differentauthors.
For clinical application, the methodsdesignedto assistdiagnosisare of particular
interest. The many different diagnosticanalysesmay be differentiatedin a number
of ways, accordingto the method of deteimination, the standardsused, or the
particular basisof analysis.

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2 Classffication
of Analyses

2.I MethodologicalClassification
The basicunits ofanalysisare anglesand distancesin millimetres(lines).Measure-
ments (in degreesor millimetres) may be treated as absoluteor relative, or they
may be related to eachother to expressproportional correlations.

2.1,.1 AngularAnalyses
The basic units are angledegrees.

th.evariousanglesin isolation,comparing
2.1,J.! Dimensional analysisconsiders
them with averagefigures.Down's analysisis of this type (1948;Fig. la, b).

2.L.I.2 Proportional analysisis basedon comparisonof the various anglesto

establish significantrelations between the separateparts of the facial skeleton.
Koski's (1953) analysisbelongsto this group, and this was developedfurther by
Koski and Virolainon (1965). The results obtained with this analysisgive the
relations between the basic reference planes OP-N and OP-Pog in per cent
(Fig. 2).

2.L.1,.3 Analysesto determineposition Angular measurements may alsobe used

to determine the position of partsof the facialskeleton.The SNA and SNB angles,
for example, give the relationsbetweenthe maxillary and mandibularbasesand
the cranial base.
Angular measurementson their own are not normally sufficientfor cephalometry
and linear measurementswill be neededin addition.
Angular analyseshave certain deficiencies:
The lines are drawn in relation to a primary referenceplane, on the premisethat
this remainsconstant.If this plane showsdeviationsfrom the mean,the analysisis
not reliable. Measurementsare often related to particularnormsor meanvalues.
These norms are however subject to a number of factors, such as age, sex,
hereditary and ethnic predisposition,etc. They are basedon averages,and in the
individual caseit is the deviation from the mean that is characteristic.

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I
I 1a

I
I
I
-\--rrz--ti
I
I
I

I
\

T
t
I
1b
t \
I
I ,{r

I T
FH l_ _
I
}\

I
I \=_--

I
I
I
I Fig. 1. Downs' dimensionalangular analysis (1948)'skeletal
rl
I
analysis;(b) Downs'dento-alveolar
analysis.

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2

'-ft--t-
\p Ns V

Fig. 2. Proportionalanalysisof Koski and Virolainen(1956).This

comparesthe differentangles,to determinesignificantrelationships
betweendifferent parts of the facial skeleton.

2.L.2 LinearAnalyses
For linear analysis,the facial skeletonis analysedby determiningcertain linear
dimensions.

2.I.2.t Orthogonal analyses.A referenceplane is established,with the various

reference points projected onto it perpendicularly,after which the distance
betweenthe projectionsare measured.Orthogonalanalysismaybe partial or total.
Total orthogonal analysismay be geometricalor arithmetical. The de Coster
method is a total orthogonal geometricalanalysis(Fig. 3).
For the arithmeticalmethod, the referencepoints are projectedonto a horizonta
and a vertical referenceplaneand the distancesbetweenthe pointson theseplanes
determined(Fig. 4a, b).
Partial orthogonalanalysisinvolvesorthogonalassessment of only part of the facia
skull. Willy (1947)for instanceusedthe Frankfurt horizontalplaneasthe reference
plane. He projected a number of referencepoints perpendicularlyonto this, and
measuredthe distancesbetweenthe pointsthusobtainedin the plane.The method
differs from total orthogonalarithmeticalanalysisin that measurements are always
"made in one plane only.

10
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 ---// -( I
r-1---
! | A --f
I I
L_ \
\
t\

l
r --l- I i
I

/,,
I
ti II
_l___\
Fig. 3. de Coster's total orthogonalgeometrical Ma l-
occlusion is demonstratedby deformationof the quadrants.
Orthogonal analysesare illustrativeand suitablefor teachingbut not for diagnostic
purposes.A further developmentof orthogonalmethodsarearqhialanalyses,and
these are a useful diagnosticaid.
The most widely known method is the Sassounianalysis(1958),with the reference
points not projectedperpendicularly,but by drawingarcswith the aid of compasses
(Fie.s).
2.1,.2.2 Dimensional, linear analysesare basedon evaluationof certain linear
measurements, either direct or in projection.
The direcl method gives certain linear measurements(e.g. the length of the
mandibular base) as the distancebetweentwo referencepoints. The resultsare
given in absolute terms, so that age also has to be taken into accountfor their
mterpretatron.
Projected linear dimensionalanalysisdeterminesthe distancesbetweencertain
referencepoints that have been projectedonto a referenceline.

2.I.2.3 Proportional linear analysesare basedon relative rather than absolute

values.The different measurementsarecomparedto eachother, without reference
to norms.

Ll
 4a

\^

4b

\^

F!0. 4. , coben's total orthogonalarithmeticat

analysi.r""""i"
skeletal relationshipsparallel(a) and vertical (b) to the Frankfurt
horizontal.

L2
5

100 66

I Pnn
-_:r_ ___

Fig. 5. sassouniarchialanalysis.Landmarks are relatednot

vertically,but by arcsdrawnfroma centreC.
2.2 NormativeClassification
Analyses
mayalsobeclassified
according
to theconcepts
onwhichnormalvalues
havebeenbased.

2.2.L Mononormative
Analyse
Averagesserveas the normsfor these:they may be arithmeticalor geometrical.

2.2.1.1 The arithmeticalnormsare averagefiguresbasedon angular,linearor

proportionalmeasurements.

13
1g.9. . Averagetracingof geometrical
normsfor childrenaged10
(Bolton).
2.2.L.2 Geometricalnormsare averagetracingson a transparentsheet.Assess-
ment consistsin comparingthesewith the casi underanaiysis.Thesemethods
merelyproviderapid orientation(Fig. 6).

2.2.1'.3 Thedisadvantage of mononormative analysesis

thatindividualparameters
are consideredin isolation.Nor do they necessarily
representa 'normil'average,
as deviationsin the individualdimensionsof the jawJand facemay compensate
each other so that occlusionis normal, just as 'normal' measurements may
cumulativelyt91d to oneendof the rangeof normalvariation,the sumtotalbeing
malocclusion.Mononormativeanalysesare suitableonly for groupstudies,and
not for diagnosticpurposes.

2.2.2 Multinormative
Analyses
For these,a wholeseriesof normsareused,with ageandsextakenintoaccount
(Tables1 and2).

2.2.3 CorrelativeAnalyses
Theseare usedto assessindividual variationsof facialstructureto establishtheir
mutual relationships.Correlative analysesare the most suitablefor diagnostic
pu{poses,and are usedassuchby mosi authors.

14
 q)
q)
*c
0i-
t

'J,
ol
(u
cn
-u

m Q? Q
mtr m8/,,0
I X{ \
fF f q1 q
1 2 3 4 5 6 7 8 I t 0 1 1 1 7 1 3 1 4 1 51 6 1 71 8

Table1. Multinormative
meanvaluesfor SNAangle.Ageandsexanarysis.

o
0)
q.)
o/
t
o-

o1
c)
un
-U

mi4,9 mo m8 1 , 0
f76,6 fp f91,4
1 2 3 4 5 6 7 I I 1 0 1 1 1 ?1 3 1 { 1 5 1 6 1 7 1 8

Table2. Multinormative
meanvaluesfor sNB angle.Ageandsexanalysis..

2.3 Classification
Accordingto the Area of Analysis
The variousanalyses
mayinvolvelimitedareasor thewholeof the facialskeleton.

2.3.1" Dentoskeletal
Analyses
These analyzethe teeth and skeletalstructures.They may be madefrom norma
lateralis,normafrontalis,or three-dimensionally.
A morerecentdevelopment is
three-dimensionalstereometricanalysis,but this is not yet fully developedfor
clinicaluse.

2.3.2 SoftTissueAnalyses
Thesemay involvethe wholeprofilein normalateralis,or certainstructuresonly.
We usuallydo a partial lateralsoft tissueanalysis,for exampleto analysethe lipsin
a cephalometricradio$aph.

15
 AnalYses
2.3.3 Functional
may alsobe usedto assess functionalrelationssuchas
cephalometricradiographs and norma
;#;;l*."i" i",.".oiclusal ipu.r relationshipin norma lateralis
frontalis.

Radiograph
3 Producingthe Cephalometric
distancefrom tube
Cephalometricradjographsare producedat a considerable
skull is correctlyreproduced'
targetto Subject1i-Z ti"it";i, ; that the visceral isto
analysis
without enlargement oi distoriion.Theprincipalaimo,fthediagnostic
localisemalocclusion within the conteniof the facialbonestructures'Evaluation
cephalometric landmarks'
tfrr i.Jiograph is basedon standardised
"f planeswhichthen enableus to
The landmarksare usedto determinelinesand
make linear and angularassessment of the radiograph'

of theRadiograph
Assessment
4 Diagnostic

Standards,of generalvalidityfor diagnosticassessmentdo notexist'If ananalysis

this.neednot
doesnot revealthe natureof the anomalyunderinvestigation a
n.r.riutify be due-ioinuO.quu.ies in the radiogfuqh,but mayarisebecause
ttutbeenusedthatwasnotteiignedfor thatparticular area
methodof assessmrnt radiographs is
f" tfi"ituf practice,evaluation
of investigation. of cJphalometric
basedon ihe principles givenbelow'

4.1 Landmarks
Distinctionis madebetweendentoskeletal andsofttissuepoints,andthesemaybe
points may be
unilateral (meOianfo. Ufite'ul' pependilg-.on-,thtirorigin'
anatomical,anthropological, or radiological(Ftg' 1,1'
the regionof the cranial
(1) In the medianplane,unilateralpointsare locatedin
b^., for instancein the midfaceand in the profile'
plane.resultfrom super-
(2) Pointslocatedon eithersideand abovethe median of the
i,isill* lateralpoints.The mostimportantof theielie in the region
mandible."ftwo

We preferunilateral(situatedin.the.median or sagittalplane)to bilateralpoints'as

involvelossof accuracy'
,.pJfp"rition of t*o'pointr *ittt Uitut.ral locationmay
pointscapableof being
As far aspossible,the pointschosenare generallyknown
easilydefinedin a radiograPh.
the locationof landmarks'
we have investigatedthe degreeof personalerror in
are more reliablethan
and found (lonurj it ut anatomicatanOalsodental points
constructedPoints.

r
t
I
r
I
I
I
t
t
I
t
I
t lig.z. Median
Sassouni.
andbilateral
reference
pointsusedbyKrogman
and

t 4.2 Linesandplanes

I Having locatedthe points,.wedraw linesto mark the referenceplanes(Fig. g).

Linear measurements may be madeby connectingtwo points,angularmeasure-
ments betweenthreepoints.Numerouslinesare ised in the diffeientlinearand
I angular analyses,with
which the whole analysis
line representingthe referenceplane on
.one-partrcular
is based.Two suchplun.s are the Frankfurthorizontal
Plgn. and the sella-nasion.The Frankfurtiorizontal plane,
I being basedon
bilateral points (orbitale and porion), is more subject'to .rior. W? th.r.for.
prefer the sella-nasion plane which is constructedwith the aid of two median
landmarks.
I
4.3 The Rangeof Analysis
t Diagnosticanalysisdoesnot adhereto a rigid system.We do certainlinear
and
t angularmeasurements on a routinebasis,but go'beyondthesein individualcases,
dependingon the natureof the anomaly,on tf,epaiient'sug., unAlfre methodof
treatmentunder consideration.Distinctionis madebetweJnspecialand supple-
I mentarymeasurements.

l7
 I
I
Sello-nosionlone
I
N' Fronkfurt
;

a
H
ot
+
+
Ir I

+
Me
P nn

+
Fig.8. Themostwidelyusedreference
lines. +
4.3.1, ControlMeasurements
T
Theseare madewherethe resultsof routinedeterminations leaveroomfor doubt.
W-. 9o, for example,makea routineanalysisof the positionof the upperincisors
relativeto the nasalspineand the SN plane.If the resultsare not unequivocalin
either caseas,for example,in casesof ante-or retroinclination,*e .nakefurther
t
measurements in orderto get a clearpicture.As far aspossible,linearandangular *

il
measurements are usedin combination.

4.3.2 Special
Measurements
Specialmeasurements are taken in individualcaseswherepoints of particular
interestarise.An examplewould be the positionof the r;15-yearmolars,which
may be of considerable
importanceprior to andduringheadgear therapy(Fig.9a,
b and c).

4.3 Interpretation
of Measurements
Individual measurements are considerednot in isolation,but relativeto each
other. An unusuallylong mandibularbase,for instance,doesnot in itself mean
prognathism,but may be found with normal and evenpost-normalocclusion.
What mattersis the relationshipbetweenthe mandibleandthe wholefacialbone
structure.Only correlativeanalysiswill accuratelylocalisea malocclusion
within
the contextof the facialskeleton.
 9b

point R

9c

Fig.9. Specialmeasurements
to determine changes in
6th-year molarposition.
Reference points(a),
diagrammatic representation
of RandMverticalproiection
to givelinearmeasurements
(b),anddiagrammatic
representation of theangle
between theaxisof 6th-year
molarsandSN(c)to assess
movement of theteeth.

19
X-rayAnatomYof the
VisceralCranium"
1 Normalateralis of
is often difficult to a
establish clearrelationshipbetweenthe sizeand shape
It
skull on the one hand' and the contours
anatomicalstructuresin the macerated
teleradiograph on ;;.;;h.t. The differencesare due to the
seen in a lateral reprcsenting a three-
- i... it. tailsbt..ntiuipiol.:,i"1.il1tois mademoredifficult
used
technique Interpretation
structurein two dimensions'
dimensional structures'
il;iff;;les in density,or contrastof theprojected
usedin cephalometricradiologywill
Exactlocationof the anatomical landmarks
cranialbones andtheir
requireadequare k;;;i;dg. oi theX t.y;;.arance ofth.
relationship to adjacent structures'
suchaslines-theprojectionofbonystructures'
Numerous featuresarediscernible, - indicating
shadows- representing soft tissueslanJ iu,gt 'uiioiuttot areas
pneumatisation. . - --^,
andoutlinedrawinesalt^g\t:":::f:t:-!t?:fft:l
of radiographs
Below,a series
iliffi;il;;*o"i"t'r:d"9:1'^:':::":1ffi
ff'."J#"T:'it?J';liiff :1"::
inbrackets
given
rhengures
i*Lliii?i;tiili..iil, &rr+:;;,'i.i.ai"graphv.
thosein Figs'10to 16'
iotr.tponOto

2 BonYOutlinesin theRadiograPh
I nFi g.l 0a,b,thebony o u t lin e s c o n s is t e n t ly S e e n in X - r a y p ic t u r e sh a ve b e e n
tracei,Theirradiodensity mayof coursevary'
part,there,arethe following:The
Movingfrom aboveto belowin the anterior6on. of the
anteriorwallof tt.-t-niufsinus (1),,rr.""^J sinus(+), 1z;,thefrontalprocess
thefloorof thenose,the
maxilla(3), the uni.iio, wallof il; .;;il.y of themandible'
alveolarprocess theanterioraspect
"fi;;;;illi-(l),and structures maybe discerned: the
In the middlepart of thepicture,thefollowing intotheplanumsphenoidale
tonti"nuing
roof of theorbit(8),with theopaquefiot (to;, ino theupperandlowerlimits
(12),thecnbriformplateof theethmoi;;;;.
of ihe maxillarY sinus.
The hypophyseal fossain p,rofile (13)'itsdorsallimit
Posteriorly theX-ray shows:
pirt of theclivus- thebasion
continuing intotr,.?'Utii,tf +llii;'"'; ;li. mostcaudal
seen,andmesialto it a smaller'
(laa) - the shadow-"tit,l densaxis(15)maybe
ihe anteriorarchof theatlas(16)'
moreor lesstriangularoutlinerept.t.titittg
thecondylar process ofthemandible (17)isvisible;it
Ventrallyto thesestructures,
continues forwards'inio itrr mandibular inlisureandfinallythecoronoidprocess
(18).
is
Beingverysimilarto themacerated skull,thebodyandramusof themandible
easilydistinguished.
seenin lateralviewshavealsobeen
Some of the soft tissueoutlinescommonly
the uvula (19),and the shadowof the
it*.d. fne soft palateis outlined' with
(20)'
pottttl"t wall of ihe nasopharynx
desindividuellenFehlers
Erhebungiiberdie Griissenordnung
*From J. Jonas,Mathematisch-statische
Freiburg
ii iir nanryenkephalomefrie' 19'75'
'

20
!'
I
II 1 0b

I
rI
F
t "l

I
r
I
II

I
I
I
t
I
I
I
I
r Fig. 10. Bony contoursin the radiograph.
(a) ln the radiograph,

r (b)diagrammatic.

21
I
 Paranasal
Sinuses

Fig. 11a,b showsthe air-filledspacesin the skull.Theseare subjectto individual

vaiiationandtheirX-rayappearance alsodepends on thedegreeof pneumatisation:
Frontalsinus(21), sphenoidalsinus(22),ethmoidalair cells(23),maxillarysinus
(24) and nasopharyngeal space(25).
The lowestpoint of the frontal sinusis at the heightof the nasion,the anterior
upper end of the frontonasalsuture.Its supraorbitalrecess(28 in I2a,6) may
havepushedapartthe laminainternaandorbitalisof the innertableof the frontal
bone.
The ethmoidalair cells (23) lie betweenthe frontal cellsand the body of the
sphenoidbone.Their lowerlimit is the roof of the maxillarysinus,the craniallimit
the cribriform plate of the ethmoidbone.
The marginsof the ethmoid bone are not easilydefinedbecauseof its great
variability. The anterior air cellsmay be maskedby the frontal processof the
maxilla.The middlecellswith the ethmoidalbullalie behindthe zygomaticbone,.
and the posteriorwall of the sinusis maskedby the shadowof the greaterwing of
the sphenoid.
The sphenoidalsinus(22)liesimmediately belowthesellaturcicaandusuallyhasa
numberof components.Ventrallyandcaudallyit extendsbeyondthe floor of the
middle cranialfossa.Anteriorly, the planumsphenoidale formsits roof.
The nasopharyngeal space(25)liesbetweenthe shadowof the softpalateandthe
upperpait of ihe posteriorwall of the pharynx,It connects with the oralcavity.At
thd tof , the spaceis limitedby a line that is a radiologicalartefact,a projectionof
the posterior-edgeof the vomer.This is howevermaskedby the shadowof the
pterygoidprocesiwhichalsocoverstheposteriorpartof thesuperiormeatusof the
nose,so that the latter is only rarelyidentifiable

22
11b

Fig.11. Paranasal (a)Intheradiograph,

sinuses. (b)diagrammatic.

LJ
The X-ray appearance of the numerous
of structuresdifficultto identifybecause
linesseenin the radiographis discussed below.

4 TheRoof of theOrbit
In the upperpart of Fig. l}a,b, thefloor of the anteriorcranialfossais traced.This
is formedbiliterally Uyttreroof of the orbit (8) andin themedianby thecribriform
plate of the ethmoiO1tO;and the planumsphenoidale (I2).
The roof of the orbit (8) producesa denseoutline,usuallya doublestructure,due
to its beingbilateral.It rnergesdorsallyinto theplanumsphenoidal"\I2), almosta
straightline, and dividesinto two lessmarkedstructures ventrally.The upperone
goesin a cranipventraldirection, forming a dorsally concave line; the other one
t-endsin a more downwarddirection,runninginto the shadowof the cribriform
plate (10).
Somepointedelevationsaredistinguishable in the regionof theorbitalroof- these
representthe cerebralridges(26).
The externalsurfaceof the frontalboneterminateswith ananteriorlyconvexcurve
in the frontonasalsuture(30).Krogmanand Sassouni (1957)statethatbecause the
caudallyadjoiningnasalbone (2) differsin radiodensity,,itis not alwayseasyto
determinethe uppermostpoint of the frontonasalsuture.Thereis a risk of putting
this point too faf in the dorsalregion.Overlapwith the eyelidsin this areamay
produceanotherfine structurethat couldbe confusedwith the suture.
12b

Fig.12. Roofof orbit.(a)In the radiograph,

(b)diagrammatic.

IJ
5 The SphenoidBone

Fig. 13a,b: The outlineof the sellaturcica,convexto thevertex,standsout clearly

from its surroundings on everyradiograph.It terminatesin the tuberculumsellae
(34)anteriorlyand in the dorsumsella(35)posteriorly.As it is elliptical,a double
line is often seenin this area. Accordingto van der Linden (lgil), the most
radio-opaquelinesrepresentthe medianor sagittalplane.The mostcaudalline is
the floor of the sella,and the mostdorsalshadowthe medianof the dorsumsellae
(3s).
The image of the tuberculumsellae(3a) is frequentlymaskedby the anterior
clinoidprocesses sothat the anteriorlimit to the entranceof the sellais not always
clearly discernible.It doeshoweverstandout from the surroundingstructurbs
becauseit showscontinuoustransitioninto the line representing the floor of the
sella, with its shadow denser than those of the anterior clinoid processes
(van der Linden, l97I).
The lesserwing (33)showsasa line beneaththe tuberculumsellae(34)whichmay
showdownwardcrenationsindicatingtheopticcanal.The upperpart originatesin
the anteriorclinoidproces,sgl
(36)and continuesin a ventraldirectionparallelto
the planumsphenoidale (12),finallybecomingtangentialto the shadowof the
greaterwing.As alreadymentioned, theoutlinesof thelesser
wingof thesphenoid
are lessradio-opaquethan thoseof the adjacentplanu.msphenoidale and of the
greaterwing.
Dorsal to the cribriform plate of the ethmoid bone, the greaterwing of the
sphenoidappearsin relief, its faciescerebralisforminga densebroad line that
continuesin a ventrallyconcavearc acrossthe floor of the anteriorcranialfossa,
moving dorsocaudally.It producesa double contour in this area, the facies
cerebralisinterna(38)andthe faciesorbitalis(39).The faciestemporalis(40)may
sometimesbe visiblein the regionof the anteriorsphenoidalsinus(22).
The contourof thedorsumsellae(35),theposterior limitof thefossahypophysialis,
continuesdorsocaudallyinto the shadowof the clivus(14)whichconsiitsof the
bodyof thesphenoidandthebasilarpartof theoccipitalbone.The shadowextends
from its morecaudalpoint, the basion,cranioventrally
to theanteriorlowerpartof
the sphenoid.Acrossthe broadshapeof the clivus,the faintlysketchedline of the
sphenooccipitalsynchondrosis (42)runsfrom dorsocranial to ventrocaudal.
 --l

I
I
1
n
I
iI
_-L
22
I
l

L1
------/

,. i

Fig'13. sphenoidbone.(a)In theradiograph,

(b)diagrammatic.

z7
6 The MaxillarySinus

The sizeof the maxillarysinusdependson the degreeof pneumatisation.

Fig. 14a,b: The anteriorwall of the sinus(4) is usuallyclearlydistinguishablefrom
the surroundingstructures.It extendsupwardsandbackto form theupperlimit of
the maxillarysinus.This line is ratherdelicateandtendsto be iregular. It is partly
rnaskedby the ethmoidalair cells (23) and thereforenot completelyvisibleat
times.
The shadowof the anteriorwall of the sinuscontinuesdownwardsand backinto
the floor of the sinus.The caudalpart of a normallydeveloped sinusextendsbelow
the palatine processof the maxilla(6) which formsa long,dense linerunningmore
or lesshorizontallyacrossthe picture,terminatingventrallyin the antedornasal
spine(43). Accordingto Hunter (1968),superposition of anatomicalcontoursis
commonin thisareadueto the alaecartilagenes andit ispossibleto put the
nasales,
anteriornasalspine,the mostcaudaland anteriorpoint of the piriform aperture,
too far forward.
Beneaththe latter, the externalanteriorlimit of the maxillaformsan anteriorly
convexcurye running down to the alveolarborder of the centralincisors.This
contouris not alwaysvery radio-opaque, andwith poor contrastonerunsthe risk
of localisingthe deepestretractionof the curve too far"in the distal direction
(Krogmanand Sassouni, 1957).
The areais alsomaskedby the softtissuesof the cheek.Thisproducesan outward
curvingshadowin the regionof the anteriorlimit of the maxillarybase,and may
causemistakesin locatingpoint A.
The dorsallimit of the palatineprocess(6) is representedby the posteriornasal
spine. In children, this may frequentlybe masked by the imagesof unerupted
molars.
of themaxilla(3).Depending
Ventral to the maxillarysinusliesthe frontalprocess
on contrast,thismaybemoreor lessclearlydistinguishable from thecontourof the
nasalbone.
In the upper anterior sectionof the maxillarysinusappearsthe contourof the
orbitalfloor (9); dorsalto thisshadowaretwo approximately parallellinesrunning
in the cranialdirection- the anteriorand posteriorlimits of the zygomaticbone
(31).
Beneaththe orbitalfloor (9) an opaque,roughlytriangularstructuremaybe seen.
Different opinionsaregivenin the literatureasto whichspecificbonethisbelongs.
Bouchetet al. (1955)considersthesestructures to formpartof thezygomaticbone,
whilstEtter (1970)usedradiologicalstudieson isolatedbonesto demonstrate that
this arearepresentsmainlythe zygomaticprocessof the maxilla(44).
In the upper part of the posteriormaxillarysinus,the outlineof the middlenasal
concha(45)maybe noted.This appearsasa shadowclearlyroundedat theback.If
the inferior nasalconcha(46) is hypertrophied,it may be locatedbeneaththe
middle concha.
The coronoidprocessof the mandible(18)lieswithin the lowerpart of the sinus
outline, but its contoursare ratherindistinct.
 j,,,,,,.,
"|&;
..
F',
Wsr*
$"
li
i :.r r .i

(b) diagrammatic.
Fig.14. Maxillarysinus.(a) In the radiograph,
(Seetext,page28.)

29
 Fossa
7 The Pterygopalatine
The contour of the pterygopalatinefossais a roughlytriangularshapeendingin a
sharppoint caudally.
Fig. 15a,b: Its uppel limit is formedby the sphenomaxillary surfaceof the greater
wiig (ai). T.hem6OiAlpterygoidplate(48)is its.posterior wallwhilstventrallyit is
limited by the posteriorwitt of the maxillary sinus(l),.. clgarlyvisibleline that
continuei caudally into the maxillary tuberosity (51). The contours of the
zygomaticarch(31)and caudalto it the coronoidprocessof themandible(18)cut
aliort the uppei part of the pterygopalatinefossa.The shadowof the foramen
rotundum (47) appearsin the cranialpart.
with thecontourof
The caudalextensionof the anteriorpart of thefossaintersects
the floor of the noseand the soft palate.Comparedto the maceratedskull the
plane,at the sameheightasthe posteriornasal
fissureis situatedin the transverse
spine.

30
ljg,.1S,. Pterygopalatine
fossa.(a)In the radiograph,
(b) diagram-
matically.

31
 8 The Middle CranialBase
is made
In the middle regionof the baseof the skull, interpretationof contours
structures.The areais also subject to
Oim.utt by the riultiplicity of superposed
considerableindividual.andage-related variation'
the
Fig. 16a, b: In the upper anterior part of the diagramlies the contour of
to the
rpfi.noid bone,with the sellaturcicd1t:; continuingdownwardsand back
clivus(14).
Dorsal to the clivusis the upperinner marginof the petrouspart of the temporal
bone(52).
The region below this hasa broken up, cloudyappearance due to the air-filled
mastoidcells.
In the lower part of the diagram,the followingcontours-areshown,movingfrom
the anteriorto the posterioiparts:The zygomat]9_1rch(32), the articular.tubercle
(jtl,."o the condylu,pro.ri, of the manoibte(17)whichbordersonto the image
of the mandibularfossa.
the
Basion,the most caudalpoint of the clivus(14),is the mostanterioredgeof
(54).Their
foramenmagnum,the hferal borderof whichis the occipitalcondyles
mole
it*g. upp.u"ttcloseto the densof the axis(15),fglmjnga line thatbecomes
into the condylar fossa(55).
horizontalat its lower edgeand continues'dorsally
Acrossthe shadowof the occipitalcondylesliesthecontourof themastoidprocess
(s6).
From about the ageof L4onwards,the mastoidplocessextendscaudallybeyond
to the
the condyles. For-"differential diagnosis,its arc is more stronglyco-nv.ex
craniumthan thu condyles,and it iray alsobe locatedby the mastoidair cells.
Dorsal to the lower part of the clivus(14)liesthe openingof the externalacoustic
;;;6; (57), an approximatelycircularihape, and dorsocranial to it the smaller
contour of ihe openingto the internalacousticmeatus.
If earolivesareusedwith the cephalostat, the externalacousticmeatuspresentsas
a completelyradio-opaquestructure.

32
 I

-'... ii".lrlr

F ig.1 6 . M i d d l ecra n i a bl a se .(a )l nth e radiogr aph,

( b) diagr am.
m a t i c a l l y( s e et e xt,p a g e3 2 ).

aa
I
JJ
 Landmarks
I ReferencePoints

The effective evaJuationof radiographs depends on accurate definition and

localisationof landmarks,which provide the basisfor all further work.
Distinction is made between anatomicaland anthropologicalpoints which are
located on or within the skeletalstructures.
Radiological or constructedpoints are secondarylandmarks marking the int"er-
sectionsof X-ray shadowsor lines.

1.1 Propertiesof ReferencePoints

1.1.1 Easeof Location

According to Moyers (1973),this dependson the following factors:

1.1.1.1 Quatity of the radiograph.The quality of the picture is often marred by

magnificationor distortion
Magnification is due to divergence-of the X-rays. The smaller the focus-film
disianle and the greaterthe objEct-imagedistance,the greateristhe magnification.
Distortion arises from two-dimensionalrepresentationof a three-dimensional
object. All elementsnot in the ;rnag9pl$? are.subjectto distortion. Accurate
."ntti.tg and positioning of the treia win hrgely eliminate it. The median or
sagittaftlun. of the head'mustbe parallel and the centralray perpendicularto the
film.

1.1.t.2 Overlappinganatomicalcontours.Facialstructuresoverlap a great deal

(see X-ray Anaiomi, pug. 23), so that the location of certain landmarksmay
present pioblems. S;;d ridiological peculiaritiesneedto be taken into accountin
the selectionof landmarks

1.1;1.3 Observerexperience.Observerexperienceand pra-ctice play a major,role

in the interpretatibn of radiographs, with knowledge of anatomy and X-ray
anatomy as a key factor.

1,.I.2 Constancyof Contours

The structuresof the skull show dependenceon a number of factorssuchas age,
sex, growth, race, etc. The constaniy of contolrs is thereforenot entirely reliable
in co-ntradistinctionto points locatedcloseto the baseof the skull, wherevariation
due to growth is minimal (..g. nasionand sella).

34
 23 20
a

LU

Fig.17. Reference
pointsusedon a routinebasis.
L.2 Definition of ReferencePoints
The points we useon a routine basisare shownin Fig. 17. Our definitionof them is
as follows:

No. Code Definition

N Nasion. The most anterior point of the nasofrontal suture in the
median plane. The skin nasion (N') is located at the point of
maximum convexitybetweennoseand torehead(Fig. 18).
2 Setla.We use the midpoint of the sella (S) in our analysis,and
also the midpoint of the entrance to the sella (S"), after
A.M. Schwarz.The sellapoint (S)is definedasthe midpoint of the
hypophysial fossa. It is a constructed (radiological) point in the
median plane.

35
 It
I
T
I
I
t
t
I
I
t
pointA and prosthion'
I
Fig.20. Subnasale,
F i g .1 8 . Nasionand soft tissue naslon'
t
I
I
I
Fig. 19. Localisationof S and Se'
I
to A'M' Schwarzat
3 se Midpoint of theentranceto thesella,according
th e sa m et.o"tu' thejugumsphenoidale' ' indepe.nd ent'of'the I
depth ot tfre seffa-This pdint representsthe midp-oint:ii*:::
anterroropemng
connectingthe posterioiclinoid processand the
of the sellaturcica(Fig' 19)'
I
4 S n S u b n a sa l e .A skinpoint;thepointatwhichthenasalseptum
merges
-"riuuj
*iti ttre'integumentof the upper lip (Fig. 20). I
I
 A Point A, subspinare.The deepestmidlinepoint in the curved
outline from the baseto the alveorarprocess bony
of the maxilla,i.e. at
the deepestpoint betweenthe anterior
nasalspineand prosthion.
it is knowna, ,uurpirr"l.iFi;.'i,ii:- t
In anthropology,
APMax The anteriorlandmark for d,etermining
therength of themaxiila.rt
is constructedby dropping u p"rp.niicular
f?;;;;i;t e to tt.
palatalplane.
Pr ProsthionArveolarrim of the maxilla;the
lowest,mostanterior
point on the arveorarportion or trr.jr"*axilla,
plane,betweenthe uppercentralincisfrs in the median
in g.20).
Is (orIsl) Incisor,iy,:::t Tip of the crown
of the mostanteriormax'lary
centralrncisor.
Ap-l Apicale I. Root apex of the most anterior
incisor. maxilrarycentrar
10 Ii (or IsT) Incisorinkllts Tiv of thecrown
- of themostanteriormandibular
centralincisor.
11 ApT Apicare7. Root apexof the most anterior
incisor. mandibularcentral
L2 ld Infradentale.Arveolarrim of the mandibre;
anterior point on the alveorarprop.rr, ln the highest,most
tn. medianplane,
betweenthe mandibularcentral_.ii"^
tpi-g.Zt).
L3 B B,
lolnt supramentale.Mostanteriorpart of themandibularbase.
It is the.mos_tposteriorpoint i" th;';;;.on,ou,
dibularalveolarprocess, of the man_
in themedia;;i;;.. h
is known as supiamentale, betweeniniiul.ntule""irrrip'"i"gy,'i,
(Fig.21). and pogonion
I4 Pog Plsonio.y.y?rt anteriorpoinr of the bony
plane(Fig.21). chin,in the median

I
r
t
I 21

t
t Fig.21. Infradentale,
point B and pogonion.

37
r
15 Gn Gnathion. This point is defined in a number of ways, According
to Martin and Saller(1956),it is locatedin the medianplne of the
mandible, where thi anterior curve in the outline of the chin
mergesinio the body of the mandible.Many authorshavelocated
gnaihiottbetweenthe most anterior and the mostinferiorpointof
lhe chin. Graig defines it with the aid of the facial and the
mandibular pla-ne;accordingto Graig, gnathion is the point of
intersection of these two planes. Muzi and May give it as the
i;;;rt point of the chin (A.M. Schwarzusesthe samedefinition)
and therefore synonymouswith Menton (Fig' 22)'
Our own definition of gnathion is asthe most anterior and inferior
point of the bony ctrin. tt is constructedby intersectinga line
dr"*n perpendiculartyto the line connectingMe and Pogwith the
bony outline.
1,6 Go Gonion. A constructedpoint, the intersectionof the linestangent
to the posterior margin of ttt" ascendingramusand the manibular
base(Fig. 22).

Fig.22. Gonionand gnathion.

L7 Me Menton. According to Krogman and Sassouni,Menton is the

most caudalpoint ii the outline of the sy_mphysis;itis regardedas
the lowest point of the mandible (Fig. 23) and correspondsto the
anthropological gnathion.
18 APMan The anterior landmark for determiningthe lengthof the mandible.
It is defined as the perpendicular dropped from Pog to the
mandibular plane.

38
 T9 Articulare. This pointwas introducedbyBjork (1947).Itprovides
radiological orieritation, being the point of intersection of the
posterior margin of the ascendingramus and the outer margin of
the cranial base(Fig.2q.
20 Cd Condyli,on Most superior point on the head of the condyle
(Fig.2a).
2l Or Orbitale.lowermost point of the orbit in the radiograph(Fig. 25).
22 Pnl2 A constructedpoint It is obtained by bisecting the Pn vertical,
betweenits intersectionwith the palatalplane and point N'.
23 Int.FFI/ Intersection of the ideal Frankfurt horizontal and the posterior
R.asc. gnarginof the ascendingramus.

Fig.23. Localisation
of menton.

Fig. 2 4 . Articulareand condylion.

39
 24 ANS Anterior nasalspine.Point ANS is the tip of the bony anterior
nasalspine,in the medianplane(ng' 25)'
It conesponds acanthion'
to the anthropological
25 PNS Posteriornasalspine.This is a constructedradiologicalpoint, the
intersectionof Jcontinuation of the anterior wall of the pterygo-
palatinefossaand the floor of the nose.It marksthe dorsallimit of
the maxilla(Fig.25).
25

\ \-/

\or
\r/

Fig.25. Orbitale,anteriorandposteriornasalsPine.
26 S' Landmark for assessing the length of the maxillary base,in the
posterior section.It is lefined ai a perp'endiculardropped from
point S to a line extendingthe palatalplane'
27 APOcc Anterior point for the occlusalplane. A constructedpoint, the
midpoint in the incisor overbite in occlusion'
28 PPOcc Posteriorpoint for the occlusalplane. The most distal point of
contact betweenthe most posteriormolarsin occlusion.
We also use the following landmarks(seeFig' 7 and 8)'
29 Ba Basion. Lowest point on the anterior margin of the foramen
magnum in the median Plane'
30 Ptm Pterygomaxiltaryfissure. The contour of the fissure proje._cted
onto itre palataipiane.The anteriorw_allrepresentsthe maxillary
tuberosity outline, the posterior wall the anterior curve of the
pterygoid process.
This point correspondsto PNS.

40
 . o2\9
E n^lt
(1
c*'o
* \ tr
- vl

't''"(K

Fig.26. Referencelinesusedin our analysis. ;

!

2 ReferenceLines
The points describedaboveare usedto constructa considerablenumber of lines.
Below is a descriptionof the lineswe most frequentlyuse (Fig. 26).

No. Line Definition

1 S-N Sella-nasion.Anteroposterior extent of anterior cranial base
(Se-N)
2 S-Ar Lateral extent of cranial base
J
.A
ar-uo Length of ramus (1st measurement)
4 Me-Go Extent of mandibular base(Lst measurement)
5 N-A Nasion- point A

41
 6 N-B Nasion- PointB
7 N-Pr Nasion- Prosthion
B N-Id Nasion- infradentale
9 N-Pog Nasion- Pogonion
10 N-Go Nasion- gonionline, for analysisof the gonialangle
11 Pal Palatalplane(ANS-PNS)
L2 Occ OcclusalPlane(APOcc-PPOcc)
L3 S-Gn Y-axis
t4 S-Go Posteriorfacialheight
15 1-SN Long axisof upperincisorto SN
t6 1-Pal Long axisof upperincisorto Pal
t7 1-MP Long axisof lower incisorto mandibularplane
18 ManBaseExtentof mandibularbase(Go-Gn,2ndmeasurement)
L9 MaxBaseExtent of maxillarybase(APMax-PNS)
20 R.asc. Cd-Golengthof ramus(2ndmeasurement)
2I S-S' from pointS (startingfrom theSNline)to pointS'
Perpendicular
22 Pn line to SeN,drawnfrom the soft tissuenasion(N) as
Perpendicular
far as Pal
23 'H'line Modified Frankfurt horizontal; parallel to the SeN line which
bisectsthe Pn line from N to Pal (Pnlz- FH/R'asc')
24 EL Aesthetic line. Tip of nose- soft tissuepogonion

3 Angular andLinear Measurements

The reference lines enable us to make angular and linear measurementsand
determinedimensionsin the radiograph.The following anglesare determinedon a
routine basis.

3.1, Angles (Fig.27)

Pointsof Mean
No. the angle Definition value

N-S-Ar Saddleangle L23"X 5"

S-Ar-Go Articular angle 1"43"* 6"
Ar-Go-Me Gonial angle r28" t 7"
Sum Sum of sella, articular and gonial angles 394"
Ar-Go-N Gor, upper gonial angle 52"-55"

42
 I
t
\

l+ l+ J

Fig.27. The 21 most frequentlydeterminedangles.

6 N-Go-Me Goz, lower gonial angle 70":750

7 SNA Anteroposterior position of maxilla 81,'
8 SNB Anteroposteriorposition of mandible 79"
9 ANB Difference betweenSNA and SNB 2"
10 S-N-Pr Anteroposterior position of alveolarpart of
premaxilla 84'
LT S-N-Id Anteroposterior position of alveolarpart of
mandible 81_"
L2 Pal-MP Angle betweenpalatal and mandibularplane 25"
T3 Pal-Occ Upper occlusalplane angle L1_"
T4 MP-Occ Lower occlusalplane angle 14"
15 SN-MP Angle betweenSN and mandibular plane 32"

43
 16 Pn-Pal (L of incl.) Angle of inclincationafter
A.M. Schwarz 85'
l7 N-S-Gn (Y-axis)Angle betweenSN line and S-Gn line,
anteriorly 66"
18 1-sN Angle betweenupper incisor axisand SN line
posteriorly 102"
19 1-Pal Angle betweenupper incisor axisand palatal
plane, anteriorly 70" t )-
20 T-MP Angle betweenlower incisor axisand
ao
mandibularplane, posteriorly 90" + J

2I ii angle Interincisalanglebetweenupper and lower

centralincisoraxes,posteriorly 135'

3.2 Linear Measurernents(Fig.28)

28

U
U ,I

Fig.28. The principallinearmeasurements

usedin the analysis.

44
We also measurethe following linear distances.

Mean
No. Distance Definition value
1 S-N (SeN) Anteroposteriorextent of anterior cranial
base 71mm
2 S-Ar Extent of lateral cranial base 32-35mm
3 S-Go Posterior facial height
4 N-Me Anterior facial height
5 MaxBase Extent of maxillary base,correlatedwith Se-N
(seeTable 4, page62)
6 ManBase Extent of mandibularbase,correlatedwith SeN
7 R.asc. Extent of ascendingramus,correlatedwith SeN
8 S'-F.Ptp. Distancefrom S' to projection of the anterior wall
of the pterygopalatinalfossaonto the palatal
plane, expressionfor anteroposterior
displacementof the maxillary base
9 S-S' Expressionfor deflectionsof the maxillary base 42-57 mm
10 1-N-Pog Distancefrom incisaledgeof L to N-Pog line
11 T-N-rog Distance from incisaledgeof T to N-Pog line

It is not absolutely necessaryin practice to use hyphensbetweenthe.points used to define lines

and angles,e.g. N-Pog = NFog, S-N-MeGo= SN-MeGo.

45
 Significanceof Angular and
Linear Measurements for
D ento-SkeletalAnalYsis
Dento-skeletal analysisin norma lateralisis carried out in three stages:
(1) Analysis of facial skeleton
(2) Analysis of mandibular and maxillary base
(3) Dento-alveolaranalYsis

Analysisof the FacialSkeleton

the extent of
This consistsin determiningthe saddle,articular and gonial angles,
the cranial base,and facial height.

1,J SaddleAngle (Fig.2e)

The NS-ar.angleis the anglebetweenthe anteriorand.posterior cranialbase.
Witfrip the reg"ionLf ttt" p6steriorcranialbaselies a sagittal growth centre, the
,ptrettoo.cipitilsyncttonOiosis. The positionoJthe fossais determined by growth
.'nu"g.. in itris ui"u. e largesaddle^angle a
indicates posterior.position, a small
saddieangleun unt"rior po"sition of thJfossa.If this deviationin positionof the
by the length-o.ftL". ascending profile
fossais n6t compensated -tutut-'fl",fu-.:ul
becomeseitherretrognathicor prog-nathic. The meanvalueis 1"23" t 5"'
29

(go)' and
Fig.29. Sella angle (S),articularangle (ar),gonialangle
uplperand lower gbnial angles (Go, and Go.)'

46
 I.2 Articular Angle (Fig.2e,3o)

Ih." S."l-9o angleis one of thoserare anglesthat may be alteredby orthodontics.

If the bite is openedby extrusionof the poiterior teethor by distalisation,the angle
increases,whilst mesial movement of the teeth will mike it smaller. A hrte
articular angle imposesretrognathicchangeson the profile, a small ungt" on tfie
other
B"d prognathic changes.We havJfound a reducedarticular aigte in atl
casesof prognathism.The mean value is L43. t 6..

I.3 Gonial Angle (Fig.28,31)

The ar-Go-Me angleis an expressionfor the form of the mandible,with reference
to the relation between body and ramus. The gonial angle also plays a role in
growth prognosis.Alarge angleindicatesmore of a tenden'cyto posteriorrotation
of the mandible, with condylar growth directedposteriorly.e smattgoniafangle
on the other hand indicatesvertical growth of the condyles,giving u ?"nO"n.y"to
anterior rotation with growth of the mandible. The mean value is 128. t 7".
Riolo et xl. noted an age-dependentvariation in mean value from L32oto L24"
(Fig. 32, seepage48).
For,accurateanalysis,the gonial angleneedsto be dividedinto two, and this may
be done in a number of wavs

lig. 30. A reductionin articularangtemaygiveriseto prognathism.

Thisanglecanbe changedwithorthoAontic treatmeni.

47
31

Fig.31. Gonialangle,determined gonionandmenton;

by articulare,
diagrammatic.

32
136,0
131,0
132,0
130,0
128,
0
126,0
\U ,,0
17?,0
120,0
118,
0
11 17 13 1t, 1f
l3 ID
oge

Fig.32. Age-relatedchangesin gonialangle(Rioloet al).

48
I.3.1 Upper andLower GonialAnglesof Jarabak
The gonial anglemay be divided by a line drawn from nasionto gonion.This gives
an upper and a lower angle (Fig. 29, 33). The upper angle is formed by the
ascendingramus and the line joining nasion and gonion. An angle of 50' t 2"
indicatesanterior direction of growth. Growth of the ramusleadsto prognathism
of the lower facein this case.If the upper angleis greater(58-65"),the directionof
mandibular growth may be expectedto be sagittal,providing the lower angle is
smaller (60-70:). If the upper gonial angle is small (43-48'), the direction of
growth is likely to be caudal. Generally speaking,a large upper angle suggests
horizontal growth changes,whilst a large lower angleindicatesverticalgrowth; a
small upper angle relatesto caudal,and a small lower angleto sagittalgrowth.

, Jarabak'supperand lowergonialangles.
L.3.2 Analysisof MandibularVariationsdueto Rotation
With the division of the gonial anglewe have introduceda further measurement
for the following reasons:
The gonial angle has a marked influenceon direction of growth, profile changes,
and the position of the lower incisors(Fig. 34, seepage50). The magnitudeof the
gonial angle is determinedby the relation betweenanterior face height and the
length of the ramus. Disharmony between these two dimensionswill produce
extremevariation in the angle.With a relativeincreasein anteriorfaceheight,this
angle will tend to be obtuse(aswith skeletalopen bite), whilst with anterior face
height relatively small it is more likely tb be acute.On the whble, greateranterior
face height is concomitantwith a large gonial and also a'basalplane angle.The
causalrelations mav vary in suchcases:

49
34
! devi qti on
'l : .
"' ",

Fig. 34. lntluence of gonial angle on the lower tace protile.

(1) The increasedgonial angleis due to adaptationto greateranterior faceheight.
Adaptation may also occur in the posterior part of the facial skeleton due to
posterior rotation in the temporomandibularjoint, with the gonialangleunchanged;
the basalplane anglewill be increased,however.
Q) The height of.the alveolarprocessesadapts to an a pnon large gonial angle,
resulting in increasedanterior face height.
To analysetheserelationsin more detail, the following constructionwas usedto
relate the gonial angle to the skull as seenin the radiograph(Fig. 35):
A line wasdrawn at right anglesfrom gonionto the Se-Nplane,to dividethe gonial
angle into a smaller posterior (Gor) and a greater anterior (Gor) part. It was
assumedthat the vertical line thus drawn wasthe axisfor rotation of the mandible.
To expressthis rotation in terms of angles,we examinedthe correlationsbetween
the two parts of the gonial angleand the basalplane angle.
35

F i g . 3 5 . Constructionfor analysisof gonialangle.

50
 1.3.2-1 Posteriorgonial angle(Go). We also determinedthe rangeof variation
for the posterior angle(Gor) and found that this wasconsiderable.6n the basisof
Gor, two typesof gonial anglecould be distinguished:
(1) A gonial angleopening out posteriorly,with Gor relativelylarge (Fig. 36);

Goz4

Fig. 36. Gonialangleopenedout posteriorly(shadedarea).

(2) A gonial angle opening out anteriorly, with Gor relativelysmall (Fig. 37).

Fig. 37. Anterior rotation of mandible(shadedareas).

51
 In the first type, the basalplane angle(i.e. PAL-MP angle,lngle B) wirsrelatively
PAL-
small, in the iecond, it wai relativelylirge. A positivecorrelationof Go' to
MP angle to facial type was not demonstrable'
PAL-
There are alsocaseswhere the gonial angleis the same'but Gor and angle
MP show variations.
with
A relatively small Go, and gonial anglewith PAL-MP anglerelativelylargeoccurs
gonial
forward rotation of the mandible-A large Gor anglewith relalvely small
have
and basal plane angles points to posteiior rotation,of the mandible. We
a1a
(Table.3-) found
;;"ly*d the Go, unfil.r seenwith different typgsof anomalies
III
the mean value to 6e 5', with a range of variation from -9o to +1'5". Class
malocclusionsand open 6ites had e*treme values,despitethe fact that.the mean
gonial angle was almost the same.The reasonfor this was that 9p.enbites very
Ft.q""nttiwent hand in hand with forward rotation of the mandible(negativeGo'
ungiet), and prognathismfrequently with a gonial angleopeningout posteriorly
(largeGo').

Table3. Gq anglewith differentforms of skeletalanomaly.

Anomaly Go1 angle Range Go angle

mean

ClassII1 4.50 -30-12" 124'

ClassII2 4.9" - 1"-L30 t22'
ClassIII /.)- - Lo-15' 130'
Openbite 3.9" -g'-140 L3L"

L.3.2.2 Anterior gonial angle (Gor). To eliminatevariation due to Gor, the

untetiot gonial ut gi. (Got) w"ascireckedfor correlationwith the basalplaneangle'
Consider"ingthe uit"iiot ingle on its own, the following may be excluded:
(1) Angle PAL-MP becoming smaller.in relation to the gonial angle due to
posterior rotation of the mandible.
(2) A relative increasein anglePAL-MP due to anterior rotation of the mandible.
(3) A discrepancybetweenanglePAL-MP and the gonial angle-dueto-the gonial
itigf" opening out to the back, or the ascendingramustipping forwards'
(a
If the Goz angle is used, the posterior side of the angle is standardised
perpendicular)]and Goz reflectsonly variationsin the anteriorramusof the angle'
it
Standardisationof the posterior tu..tt of the angle becamenecessarywhen
becameapparent, from preliminary studies,that a largegonial anglemay be seen
also with horizontal growth, it ttr6 mandible rotates posteriorly; a small gonial
angle may occur with"verticaigrowth typeswhen the mandiblerotatesanteriorly'
ny"Oiuiaiirgthe gonial angle*5ut" ableio assess not only the sizeof the angle,but
atio its porTtioni"lative t6 the cranium,and hencetheeffect of the gol9l angleon
the prohle. It wasfound that only the anteriorpart of the gonialangle(Gor) hasan
effect on the basalplane angle; lorrelation betweenthe two angleswas therefore
positive(r : 0.78).
A correlation of ideal values was establishedalso for angle PAL-]VIP and Goz
4). We were able to determinethe
t*itft ."rsiderable variation, however;Table
ielevant anglesfor the horizontal (first colt'mn) and vertical (secondcolumn) types
of the malocclusionsunder investigation-

52
 'l

A third, transitional type was found only with Class II malocclusionsin the
material at our disposal(Table 4).
The ideal valuesin the tablemake it easierfor usto estimatethe type of mandibular
growth and expressit in angles.At the presenttime, we do this specialanalysisof
the gonial angle only in problem cases,as a check.
Table4. RelationshipbetweenanglespAL-Mpand Go2.

Anomaly PAL-MP angle Go2 angle

ClassIIl 17'-240 l,18"-119'

25'-30" I20'-124"
310-400 r25'-r34"
ClassII2 B'*25' 100"-120'
26'-290 I2r"-r30"
ClassIII L5"-29" Ll3"-r25'
30'-360 126"-r3r'

Openbite 22"-29" ll7"-r25'

30'-39' 126'-r35e

L.4 Sum of the Posterior Angles (Fig.38)

The sum of the three above-mentionedangles(saddle,articularand gonial angle)
is 396" t 6' (Bjork). This sum is significantfor the interpretationoflhe analylis.
If it is greaterthan 396o,the directionof growth is likely to be vertical;if it is smaller
than 396', growth may be expectedto be horizontal.

' lQ Ro+ Ao

Fig. 38. Bjork's sum of posterior angles (saddle,articularand

gonial angle)is 396 r- 6" on average.

53
I
 1.5 BaseandFaceHeight)
Linear Measurements (Cranial

Theseare done later for technicalreasons,in the sequenceshownin our casesheet.

2 Analysisof Maxillary and MandibularBases

The relative positions of the maxillary and mandibular basesare determinedby

two groups of angularmeasurements.

Group1
betweengenerallyverticallines,to determinesagittalvariation.
Measurements

Group2
Measurements betweenlinesthat aremoreor lesshorizontal,to anaiysevertical
deviations.
Group L consistsof measurementsof anglesbetweenS-Nanda thirdskeletalpoint
in the facialskeleton(Fig.39).

39

and
Fig. 39. SNA angle,SNB angle,SN-Pogangle,SN-prosthion
angles.
SN-infradentale

54
 2.1 S|,IA Angle (Fig.3e,40)
The SNA angle defines the anteroposteriorpositibn of point A relative to the
anterior cranial base.Its meanvaluq 81", indiiates a norm^alrelationshipbetween
maxilla and anterior cranial base.If the angleis lessthan normal, the maxillalies
more posterior in relation to the cranial base,if the angleis too large,the maxilla
lies more anterior. The anglethereforedefinesthe degieeof progriattrismfor the
maxilla. A large SNA
?lgte (greaterthan 84') makesthe anteibp6steriorposition
of the riiaxilla prognathic,a small angle (lessthan 78') makesifretrognathic.
variations due to age and sexare minimal with this angle (80.5-92").

2.2 SNB Angle (Fig.3e,41)

The SNB angledeterminesthe anteroposteriorpositionof the mandiblein relation
to the anterior cranial base,analogoui to the SNe anglefor the maxilla. This angle
9:fngt prognathismfor the mandible,the meanvaluJbein g7g'.If it is greaterthan
82o, the mandible is prognathic relative to the anterior crarial base,if i; is lessthan
77", the mandibleisretrognathic.The mandibleis describedasortirognathicif the
angle is between77o and82".
The size of this angle increaseswith age (froq 76' at 6 yearsto 79'at 1.6yearsof
u9"). Retrognathismmay thus be compensatedin the iourse of growth, ind it is
often difficult to distinguish the effecis of therapy from thos. 6f gro*th when
ClassII anomaliesare treated.

LL

40. SNA anglewith rangeof variation;diagrammatic.

55
41

tl
Lr, I
I lt
I II

Fig.41. SNBanglewith rangeof variation;diagrammatic.

2.2.L Morphologyof the Mandible
The three.relative_positionsof the mandible (orthognathic, retrognathic and
prognathic) alsoreflect to somedegreethe morphologyof the mandible(Fig. a2).

2.2.L.L Morphology of the mandible, orthognathic type.Ramus and body are

fully devgloped,with the width of the ascendingramui bqual to the height of ttr.
Po9f ofthe mandible,includingthe alveolarpartwith the teeth(mentonto inferior
incision). The occlusalsurfaceruns almost parallel to the plane of the mandible.
The condylar and coronoidprocessesare almoston the sameplane,the symphysis
is well developed,the lower incisorsare almostat a right angieto the ptanebtihe
mandible. The SN-MP angleis L8-25".
42

Fig. 41. Variations in mandibular morphology. (a) Orthognathic

type, (b) retrognathictype, (c) prognathictypelJarabak).
 2.2.I.2 In the retrognathictype, the ascendingramusis narrow, asis the condyle
in the anteroposteriordirection.The coronoidprocessis shorterthanth9 condylar
process,the mandibular angleis large, the symphysisnarrow. The anglebetween
the axis of the lower central incisorsand the mandibularplane is greaterthan 90"
(protrusion), whilst the SN-MP angleis 30-40'.

2.2.I.3 In the prognathic type, the ascendingramusand the body are wide, the
mandibulat ungie small, the symphysisis well developed.The angle_between the
axis of the lower incisors and the mandibular plane is lessthan 90" (u.ry upright
incisors), the SN-MP angle is small.

2.3 ANB Angle (Fig.a3)

This representsthe differencebetweenthe SNA and SNB anglesand definesthe
mutuairelationship, in the sagittalplane, of the maxillaryand mandibularbases.
The ANB angle is positiveif point A lies anterior to NB. If NA and NB coincide,
the angle wif be iero.If, however,point_A.liesposteriorto NB, ANB will be
negatiie. Apart from establishingthe relationship between the maxillary and
mindibulo, bur.r, the anglealsolargelydeterminesthe positionof the incisors.On
average,the angle is 2". Riolo et al. found higher averagesin children (Fig. aa).
High positivesoccur in ClassII, negativesin skeletalClassIII.

Fig.43. ANB angle.

)/
 44 q tl

8 ,0
7 ,0
6 ,0
rn
J,U

/.,,0
3, 0
2, 0
1, 0
0
6 7 I I 10 '11 12 13 1t, 15 16 ose
changesin ANBangle(Rioloet al).
Fig.44. Age-related

, 2.4 Comparisonof SNA, SNB andANB

The three anglesreferred to above(SNA, SNB and ANB) definethe relationship
of the maxillary and mandibular basesto the anterior cranial base,and also the
.h. mutual relationship of the maxillary and mandibular bases. A number of
I combinationsare possible.

2.4.L Normal SNA andSNB

This indicatesa normal position of the maxillary and mandibularbasesrelativeto
the cranial baseand also to eachother.

2.4.2 NormalSNA
Normal SNA anglesindicatenormal relationsbetweenmaxilla and cranial base,
with
(a) small SNB angle : mandible retrognathic.
(b) large SNB angle : mandible prognathic.

2.4.3 NormalSNB
Normal SNB anslesindicatenormal relationsbetweenmandibleand cranialbase,
with
(a) small SNA angle : maxilla retrognathic.
(b) large SNA angle : maxilla prognathic.

58
 2.4.4 Both Angles(SNA andSNB) Largeor Small
Large angles constitute prognathismof maxillary and mandibular bases;small
anglesconstituteretrognathismof maxillary and mandibularbases.
(a) ANB angle normal: relation of maxillary to mandibularbasenormal.
(b) ANB angle greater/smallerthan normal: abnormal relation of maxilla to
mandible.

2.4.5 The 'Wit's'Method \_

Jacobson describedthe 'Wit's' (Univ. of Witwatersrand)appraisalof jaw dis-
harmony, which is a measureof the extent to which the jawi ire related to each
other anteroposteriorly.The method of assessing the exlent of jaw disharmony
entails^drawingperpendicularson a lateral cephalometrichead film tracingfrom
pgT! A and B on the maxilla and mandiblerespectively,onto the occlusal-plane
which is drawn through the region of maximumcuspalinterdigitation.The points
of contacton the occlusalplanefrom A andB are labelledAO ind BO respectively
(Fig. aaa). It was found that with normal occlusion,point BO wasapproximately
1-- anterior to point AO. In skeletalClassII jaw dysplasias, point bO would be
located well behind point AO, whereasin skeletalClassIII jaw disharmonies,
point BO will be forward of point AO.

I
r Fig.44a. Perpendicular linesdroppedfrom pointsA and B on to the
I occlusalplane,Wit's readingis measuredfrom AO to BO.

59
 2.5 SN-Pog(4e.3e)
The sella-nasion-pogonion angle determinesthe basalposition of the mandible.
If the chin projectsto a marked degree,the differencebetweenSNB and SN-Pogis
large and is 80" from ageL6,whilst it is only 76' atage6, so that one may expectan
increaseof 4' betweenase 6 and 16.

2.6 SN-Prand SN-Id1rig.:o;

The SN-Prosthionanglede{inesthe relationshipbetweenthe alveolarprocesses of
the maxilla and the cranial base,the SN-infradentaleangle, and the relationship
between the alveolar processesof the mandible and the cranial base.These two
anglesmay be used to assessthe maxilla and mandiblefor alveolarprognathism.
Thesesix anglesdeterminerelationshipsprimarily in the sagittalplane.They are of
major importance for interrelationshipsin that plane.

2.1 HorizontalLines
Interrelations within the horizontal plane are assessedto determinethe vertical
position of the maxillary and mandibular bases.The most important horizontal
lines are the SN plane (S-N and Se-N), the Frankfurt horizontal(FH), the palatal
plane (Pal) and occlusalplane (Occ), and the mandibularplane (MP) (Fig. a5).

45

Fig. 45. The most frequentlyused horizontallinbs(A.M.Schwarz).

60
 2.8 BasalPlaneAngle Pal-MP(Fig.a6)
This definesthe angleof inclinationof the mandibleto the maxillarybase,the latter
being representedby the palatal plane. The angle thereforealso servesto deter-
mine rotation of the mandible. If the basalangleis large, the mandibleis usually
rotated backwards(vertical growth type), if it is small, the mandible is rotated
forwards (horizontal growth type). Our investigationshaveshown,however,that
the sizeof the basalangleis dependenton the inclinationnot only of the mandible,
but very much alsoof the maxilla. With retro-inclinationof the maxillarybasethe
basalanglewill be relativelysmaller,with ante-inclination,relativelylarger.These
changesin the upper side of the anglewill changethe angleassuch,a changenot
connected with the angle of inclination of the mandible. For a more detailed
interpretation of the basal angle, we also measurethe inclination, as definedby
A.M. Schwarz.The mean basalangle is given as 25o,but there is a very definite
decreasein the anglewith age, from 30'at 6 yearsold to 23' at16.

Fig.46. Basalplaneangle;diagrammatic.

2 . 8 . I Pal-Occ and Occ-MP (Fig.a7)

The basal plane angle is divided in two by the occlusalplane (Occ). The upper
angle thus produced (betweenpalatal and occlusalplane) is 11o,the lower angle
(between occlusaland mandibularplane) L4oon average.Schudyconsideredthe
size of the lower angleimportant for assessing the prognosisfor openingthe bite.
If the angleis large(more than 20') the prognosisis good,but if it is small(7"or less)
the prognosisis poor for treatment of the deep overbite.

6L
47a

47b

Ftg.47. Upperand lower part of basalplaneangle,diagrammatic;

(a) small, (b) largeangle.
2.9 Angle of Inclination(Fig.a8)
The angle of inclination is the anglebetweenthe Pn line (perpendicularfrom N')
and the palatal plane. A large anglesignifiesante-inclination,a smallangleretro-
inclination of the lower face. Determination of the angle of inclination is an
absolute precondition for accurateinterpretation of the basalplane angle. The
angle is also used to assessmaxillary rotation (Fig. a9).

2.L0 SN-MP(Fig.so)
This angle givesthe inclination of the mandible to the anterior cranial base.Taking
the mean value to be 32o, Schudy has introduced the concept of posterior and
anterior inclination. If the angle is greater than32o, inclination is posterior, if less
than32o, anterior. This angle registersvertical dysplasias,changesbetween sella
and fossa and also below the fossa.An open bite, e.g. with an averageSN-MP
angle, indicates that the molars havecome through in disproportion to the incisors.
Condylar and molar growth havebeenbalancedin this case,but were too extensive
to.achieve a balanced relationship with growth in the region of the frontal teeth.

62
 {.

,\/

Fig. 4 8 . Angle of inclination(J angle),betweenpn line and patatal

plane.

+50
,.{
\\
t'
\\ Pol 1

:\ix
850

,r f
Pol,

\'y,
l/
ilt
\
\

---i

I Fig.ae. Anteinclinationof 10"(95')(A.M.Schwarz).

$
63
 50

Fig.50. sN-Me-Go anglewith rangeof variation;diagrammatic.

If both the SN-MPandthe basalplaneanglearelarge,the dysplasia mustlie below
the fossa(usuallythe ascendingiamus decrease
is too short).-An-ag9-dependent
from 36. to 31"hasbeennoted"bet'ween the agesof 6 and16.A verticaldysplasia
may be assessed by correlatingthe {"g-f4"s we havejust beenconsidering'
Witt et al. referredto correlaiionof ANB, SNA and SN-MP,as shownin the
followingtable(Table5).

Table5. Accordingto witt et al.,correlationbetweenthe sNA and ANBllgte o9ne1$son the

(SN-MeGo angle).Thetables
maqnitudeof the Siln angle,but atsoon tn" verticalrelationships
lioE tt'reidealANBanglesfor differentSNAangles'

SNA< ANB< SNA< ANB<

68' 1,50 77' 21" 86' 5,7"

69' 1,1' 78" 2,5" 87" 6,10
700 0,7" 79" 2,9" 88' 6,5'
71" 0,30 B0' 3,3" 89' 6,9'
72" 0,1' 81' 3,7" 90' 7,30
73" 0,5' 82" 4,1" 91" 7 ,7"
74" 0,9" g3' 4,5" 92" 8,10
75" 1,3" 84' 4,9' 93' 8,5"
76" 1,7" 95" 5,3" 940 8,9'

il &
I
 2.11 N-S-Gn (Y-Axis) 1nlg.
st;
This angle determinesthe position of the mandiblerelativeto the cranialbase,as
an additional check. It has a mean value of 66"; if it is greater than that, the
mandible is in a posteriorposition,with growth predominantlyvertical.If the angle
is lessthan 66", the mandibleis in an anterior positionrelativeto the cranialbase,
and growth is predominantlyanterior.

Fig.51. Y axis.Anteriorandposteriorface
heightlargelydetermine
the directionof growth.

2.L2 Anterior and PosteriorFaceHeight (Figs.

51,s2,53)
The next measurementon our record sheetis a linear one. We determineanterior
and posterior faceheight,and usethe resultsto arriveat a figurefor the directionof
growth. The formula is as follows:
Posterior face height (SGo) x 100:anterior face height (NMe).
The mean value for this is 62-65Vo (Jarabak). A higher percentagemeans a
relatively greaterposteriorfaceheight and horizontalgrowth. A smallpercentage
denotesa relatively shorterposterior face height and vertical growth.

65
Fig. 52. Anteriorface height. Fig. 53. Posteriorface height.

3 Dento-alveolarAnalYsis
This considersthe angulationof the incisors,and frequentlyalsoof the sixth-year
molars.

3.1, Angulation of Upper Incisors

Two determinationsare done of the angulationof the upper incisor, its long axis
consideredin relation firstly to the SN and secondlypalatalplanes.If the evidence
from both determinationi is clear, these measurementswill permit important
conclusions relating to treatment planning, e.g. regarding the need for root
to^determinewhich
torquing. If the evidince is contradictory,it will be necessary of
the iwo measurementsis the more reliable. The inclination of the palataland the
SN plane, the SN-MP and the basal plane anglesneed also to be taken into
consideration.

3.1.1, FirstMeasurement
For the first measurement,the long axis of the upper incisor (Is 1- Ap 1) is
extendedto intersectthe SN line and the posteriorangleis measured.It hasa mean
of.!02"t 2'. Up to the 7th year, it is only 94-100'on average,wilh 1.02'angulation
achieved only i or 2 years ift"r Larger anglesusually indicate maxillary
"*ption.
incisor protrusion, smaller anglesvery upright incisors (Fig. 54' 55).
 3.1,.2 SecondMeasurement
Next, the anterior anglebetweenthe long axisof the incisorand the palatalplaneis
measured. The mean value from the 8th year onward is 70' + 5' (the posterior
angleis frequentlymeasured,and in that casethe meanis 1L0').An enlargedangle
signifies very upright incisors, a smaller than averageone incisor protrusion
(Fig.sa).

3.2 Angulation of Lower Incisor (Fig.sa)

The posterior angle between the long axis of the incisor (Is 1-Ap 1) and the
mandibular plane (MP) is determined.It hasa mean value of 90" * 3". From the
6th to the 1-2thyear, the angle increasesfrom 88" to 94". A wide angle denotes
protrusion of mandibular incisors, a smaller than normal angle, very upright
incisors.Treatment planning, evenfor simpleforms of treatment,alwayscallsfor
diagnostic analysisof lower incisor angulation.Without this, it frequently is not
possiblefor.example to get the correct designof activatorfor the lower incisors.
54

SN-Me0o
34

Fig. 54. Measurementsto determineangulationof upper incisors

(relativeto SN and palatalplane)and lowerincisors(relativeto MP).

6'.7 I
J
55

Fig. 55. Angulationof upper incisors relativeto SN plane,with

rangeof variation;diagrammatic.

of IncisorPosition(Fig.
3.3 Assessment 56,57)
Apart from determining the angles,we also use linear measurementsto assess
incisor position. The distanceof the incisaledgesfrom the NPog line (vertical)is
determined. For the maxillary incisor, the averagedistanceis 4 * 2mm, for the
mandibular incisor, -Z to *2mm. This figure is of considerableimportancein
treatment planning.The aim of treatment'at leastwith the permanentdentition-
is to achievethosenormal relationsto the NPog line. This particularmeasurement
(Fig. 58) therefore, is frequently the key factor in deciding:
(a) whether extraction is indicated,
(b) whether the lower incisorscan be moved forward,
(c) whether anchorageis critical.

Until the 9th year, these metric relations in the mandible are not sufficiently
stabilised to serve as the basis for major diagnosticdecisions.In the mixed
dentition period, interpretation must considerthe phasesof activegrowth still to
come.
Riolo et al. have noted considerableage-dependentdeviations from normal
incisor angulation in the maxilla (Fig. 59). This should be kept in mind for the
interpretationof the measurements.

3.4 Inter-incisalAngle
The angle between the long axesof the maxillary and mandibularincisorsis also
determined. It has a mean value of l-35".A good incisalangle on conclusionof
treatment is a major factor in denture stability and preVentionof relapse.

68
F
F
F
I
I
I

F
F
F ris.so.Relationof upperincisorsto nasion-pogonionplane.
!'"
I

F
57

t
t
T
T
r
fr

I
t
F 57' Relationof rowerincisorsto nasion-pogonion
prane.

:
58

of positionof incisorsrelativeto nasion'

Fig. 58. Consideration
pogonionplanein treatmentplanning.

59
13,0
12.0
11,0
10,0
9,0
B ,O
7,0
6,0
5,0
(,0
10 11 12 1( IJ 16

Fig. 59. Age-relatedchangesin positionof upperincisorsrelative

to nasion-pogonion plane(Rioloet al).

70
 4 Linear Measurementson SkeletalStructures

We also make a number of linear measurementson the skeletalstructures.

4.1 Extent of Anterior CranialBase,SellaEntrance- Nasion

This distance is used to assessthe proportional lengths of the maxillary and
mandibular bases. According to Holdaway, it increasesby 3/+mm annually.
BroadbentandBolton havedeterminedthe meanannualgrowthratefrom age1 io
18 (Table 6).
Table 6. Changesin extent of anteriorcranialbase,betweenthe ages of
1 and 18 (Broadbentand Bolton).

SN line SN line

Age Boys Girls Age Boys Girls

1 56.3 54.4 10 69.5 66.8

2 59.9 57.9 11 69.8 67.6
3 62.4 s9.8 T2 70.9 68.4
4 63.6 61.8 13 7t.4 69.2
5 65.0 63.4 I4 72.3 69.5
6 66.0 63.4 15 73.8 69.7
,7
67.2 64.4 T6 74.0 69.s
8 68.3 65.2 T7 75.1, 69.5
9 68.6 65.9 18 75.4 70.1,

4.2 Extentof PosteriorCranialB ase,Sella- Articulare(Fig,

60)
The extent of the posterior cranial baserelatesto the positionof the mandibular
fossa and therefore has a major effect on the profile. A short posterior cranial
basedenotesa shorter distancebetweensellaand articulare;the mid-faceappears
more prognathic, with a secondaryreduction in anterior face height. The mean
value is 32-35mm, with a meanrate of increaseof 8 mm betweenase6 and 16.

4.3 Dimensionsof MandibularandMaxillaryBase

The dimensionsof the mandibularand maxillarybasesand of the ascendingramus
are assessed
in relationto the extentof SeN.We usethe measurements proposed
by A.M. Schwarzand havecompileda table(Table7) for the idealdimensions of
mandibularbase,maxillarybase,and ascendingramus(Fig. 61).

7l
60

Fig. 60. Extentof posteriorcranialbase(sella-articulare).

Se- N
61

\
\
 4.3.I Extent of MandibularBase(Fig.62)
This is determinedby measuringthe distancegonion- pogonion(projectedonto
the mandibular plane). The meanvalueis 68mm at age8, with an annualincrease
of 2mm for boysand 1.4mm for girls (up to age 16).

4.3.2 Extent of Maxillary Base(Fig.63)

This is basedon the distancefrom the posterior nasalspineto point A projected
onto the palatalplane.The meanvalueis 45.5mm at age8, with an annualincrease
of 1.2mm for boysand 0.8mm for girls.

Fig. 62. Extentof mandibular Fig. 63. Extent of maxillary

base. base.

4.3.3 Extent of AscendingRamus(Fig.6a)

This is representedby the distancegonionto condylion.Locationof condylionmay
present difficulties, and we thereforeconstructan ideal Frankfurt horizontaland
intersect this with the tangent to the ascendingramus.The point of intersection
then representsthe constructedcondylion.
The ideal Frankfurt horizontal plane is constructedas follows (Fig. 65): The
distancebetweensoft tissuenasionand palatalplane,alongthe Pn line, is bisected.
From the point thus obtaineda straightline (H line) is drawnparallelto SeN.This
representsthe ideal Frankfurt horizontal
The mean for the extent of the ascendingramusat ageB is 46mm, with an annual
increaseof 2mm for boysand 1.2mm for girls,up to age16.

IJ
-a
64

Fig. 64. Extent of ascending

ramus.
65

e x teni of

Fig. 65. Constructionof idealFrankfurlhorizontal.

'74
Table 7. Comparativelinear measurementsof maxillary and mandibularbases and
ascendingramus.

Mandible Maxilla R.asc. Ramus Mandible Maxilla R.asc. Ramus

56 37 40 22 ]T 47 50.5 28
57 38 40.5 22.5 t2 48 51 29
5B 39 4L LJ 73 48.5 52 29
59 39 A)
23.5 14 49 53 29.5
-L
60 40 43 24 15 50 53.5 30
6I 40.5 43.5 24 76 s0.5 54 30
62 4l 44 24.5 77 51 55 31
63 42 45 25 78 52 s5.5 3I
64 42.5 45.5 25.5 79 52.5 56 3 1.5
65 43 46 26 80 53 57 3Z
66 44 47 26 81 54 58 at\

67 44.5 47.5 27 82 54.5 58.s 32.5

6B 45 48 27 83 55 59 33
69 46 49 27.5 84 56 60 33.5
70 46.5 s0 28 85, 57 60.5 34

Table 8. Multinormativetable (accordingto age) of the principal linear

measurements.

Age N*ANS ANS-ME S_N S-Gn Ar-Gn

6 yrs 42.5 5t.2 64.7 102.6 36.4

8 yrs 45.2 54.2 66.8 108.8 38.8
10yrs 47.5 56.0 68.2 1T2.8 39.8
L2yrs 50.0 58.8 69.6 TT7,5 42.4
13yrs s0.8 59.8 70.3 r20.r 43.8
14yrs 51.6 61.5 70.9 123.1 45.7
16yrs 53.2 63.8 7t.8 126.8 47.8

Table9. Multinormativetable (accordingto age)of the principalangularmeasurements.

Age SN-Pog SN-GoGn SN-Ar Ar-GoGn B< SNA SNB

6 yrs 78.3 32.4 tr9.3 129.6 25.6 82.3 78.3

B yrs 79.2 31,.6 r20 121.8 24.5 82.1 78.6
10yrs 80.1 31 r20.4 r21.2 23.8 82.5 79.2
12yrs 80.2 3r.2 r22 r27.6 23.3 82.3 79.2
13yrs 81.3 30.2 I2T.8 126.4 22.7 83.5 80.2
14yrs 81.9 29.4 121.8 125.6 22.2 83.9 80.8
16yrs 82.2 29.4 r22.2 125.2 21.6 83.7 80.9

IJ
 4.3.4 Width of AscendingRamus (Fig.66)
This is determinedat the height of the occlusalplane. The meanwidth is 27mmat
age8, and at ageL6 is 32.5mm for boys,30.5mm for girls'

66

Fig.66. Widthof ascendingramus.

4.4 Assessmentof the Position of Maxilla in the Posterior
Section
Certain measurementsare made to determinethe position of the maxilla in the
posterior section.A line is drawn a!.righ!anglestoSN from-pointS; its intersection
*ltn tft. palatal plane is calledS'. The distancefrom S' to the posteriornasalspine
enablesus to asiessthe position of the maxillain the horizontalplane.S-S' on the
other hand provides information on vertical relationsfor the pbsteriormaxillary
base(Fig.67).
'Fig. usedin analysis.(Seealso
d8 g'iues'asummaryof the principal measurements
Tables8 and 9.)
Fig. 67. Verticaland horizontalmeasurements
with the aid of the
S-S' referenceline.

N-Me0o340 SNA= 91o

S Nt o , / l= / 0 2 0 SNB= 790
S-NAr123o AN8= 20
Y oxiss $$o

S-Ar-[611'30

Pol-Occl'lo

=8/*o
SN-Pr
interincisolF
1350

sN-ld=910

SN-Pog=800
ll to Me0o
Fig. 68. Diagramshowing the principal parametersused in the
analysis.

"t'7
 Soft TissueAnalysis
The changeseccurring in soft tissueprofile in the courseof orthodontic therapy
representa major problem.Relativelyfew techniquesor routinemethodsof soft
tissueanalysishave beenestablished.One of the reasonswhy soft tissueanalysis
has been neglectedis that orthodontictherapywasprimarilyconcernedwith the
correction of hard structures.The resultsof functionaltreatmentmethodsand
relapseson the one hand,despitesatisfactory correctionof dentoskeletal
morpho-
logical relations on the other, have repeatedlyand clearly demonstratedthe
importance of soft tissue morphology. The assumptionthat soft tissueswill
automaticallyadapt to correcteddentoskeletalrelationshasnot beenconfirmedin
practice,asshownin makingthe aestheticprognosis.Aestheticaspects needto be
seriouslyconsidered,being a tactor of prime importancein the motivation of
patientscomingfor treatment.
A good mechanicalrelationshipbetweenmandibularand maxillarydentureswas
formerly regardedas the soleaim of orthodontic treatment.In the courseof time,
however, orthodontistshavebecomeincreasinglyawarethat facialaestheticsmust
also be consideredin planning.
Angle used terms like balance,harmony, beautyand uglinessin relation to the
profile. In 1907he wrote: "the studyof orthodonticsis indissolublyboundup with
the study of art where the humanfaceis concerned.The mouth is a very decisive
factor in determiningthe beautyand balanceof the face." Angle'sidealfacewas
basedon the Greek statueknown as the Apollo Belvedere.In his opinion,facial
aestheticsdependedon the position of the upper incisors,a view recentlycon-
firmed in the Holdaway analysis.According to Wuerpel, a face is beautiful and
showsharmoniousfeaturesif the proportionsof its individualcomponentsare right,
i.e. no individual structureis over emphasisedin relation to the others.This is
what he refersto as 'balance'.
For soft tissueanalysis,distinctionis madebetween:
(1) Profileanalysis.
(2) Lip analysis.
(3) Tongueanalysis.

1 Profile Analysis

Casewasone of the first to concernhimselfseriouslywith profile analysis.He took

plaster castsof facesto demonstratethe effectsof malocclusionsand the resultsof
treatment. In his opinion a balancedprofile should be one of the key factors in
deciding on the method of treatment for any form of malocclusion.
His assessment of the face is basedon the relationsbetweenthe chin, cheeks,
forehead and the dorsum of the nose.In addition he considersthe relationshipof
lips to chin, upper to lolver iip, and also the position of the lips at rest, during
speechand when laughing.

78
 analysesby cephalomerricradiography,usingcontrastmedia, have
::ll,i:.re
,D.e^"^1.dong by carrera (lg2z), Mccoven (1923), comteltgzT), A.M. Schwarz
(I229)and others-Simpion 1tsza\producedtwo radiographs,
one hard and one
tojl: Bjgtk (1950)placedan aluminiumfilter in front of the cassette.
we alsouse
a filter for soft tissueprofiles, and contrastmedia to outline the tongue.
The standardson which aestheticassessment is basedare:
(a) Classicalworks of art.
(b) Subjectswith perfect occlusion.
(c) Beauty queens,idealsof beauty.
According to Subtelny, everyorthodontisthashis own conceptof an
ideal profile
that existsin his mind only.
Downs considersthat there is a particularaveragefaceand profile; faces
deviating
from the averagein particularaieasmust compensatefor this in other
structuresto
present a balanced, harmonious appearan-e. Extreme deviations
cannot be
compensated,so that disharmonyand imbalanceresult.

11 ReferencePointsused in profileAnalysis(Fis.69)

frofile. analysisis based on a number of soft tissuepoints (indicatedby small

letters).

Code Definition
tr trichion (hairline)
n skin nasion
no tip of nose
SN subnasale
SS subspinale(concavityof upper lip)
ls labrale superius(border of upper lip)
sto stomion (centralpoint of the interlabialgap)
li labrale inferius (border of lower lip)
SM submentale(labiomentalfold)
pog skin pogonion
gn skin gnathion
Two.skeletal points are also neededfor constructingthe referencelines usedin
profile analysis.
Or orbitale, a point the width of the palpebralfissirrebelow the pupil
P porion, highestpoint on the auditory meatus

'19
69

/t--\
t

sto
ti

Fig. 69. Soft tissue points for profileanalysis.

I.2 Assessment
of Total Profile

1.2.L ProportionalAnalysis
The searchfor the profile with ideal proportions is one of the oldest aims of art.
These ideal proportions provide the basicstandardfor assessment of the average
profile (mean value, biometricmean,or average).The profile may be dividedinto
three approximatelyequal parts (Fig. 70):
frontal third tr-n ls
nasal third n-sn ls
gnathic third sn-gn r/t

The gnathic third may be up to a tenth greaterrather than smaller.

80
F
F
F,
F
tr
F
F
t
T (
\

tI
I

t
I
t
I
I
I
rio.zo.The divisionof the profileinto thirds
I Similar proportionsmay be seenwith respectto anteriorfaceheight,tr-go,with the
g.O-flq: (n-sn) occupying45Vo,the lower face (sn-gn)55% oJ tft. iotul h"igttt
I (Fig. 71).

I
81
I
71

Fig. 71. Proportionsof anteriorfaceheight(midfaceto lowerface).

1.2.2 Angular ProfileAnalysis,Convexityof Profile(Fig.72)

Subtelny makes the distinction betweenconvexityof:
(a) The skeletalprofile.
(b) The soft tissueprofile.
(c), The full soft tissueprofile (includingthe nose).

1.2.2.I Skeletalconvexityis represented

by N-A-Pog,with a meanvalueof.L75'.
We have found the mean value at age 12 to be 171.5'.This skeletalconvexity
decreaseswith age.

1.2.2.2 Soft tissueconvexityis detenninedasn-sn-pog.The meanvalueis L61';

and this does not change.

L.2.2.3 Full soft tissueconvexityis basedon n-no-pog.The meanis 137"for men

and 133'for women. We havefoundl37.5" in boysof 12 and L32.9"in girls.This
convexity increaseswith age. The age-dependentchangesin convexity demon-
strate that soft tissue changesare not analogousto skeletal profile changes.
Increased convexity of the full soft tissue profile may be explainedas due to
anterior growth of the nose.
Table 10 shows the mean valueswe have determinedfor the different forms of
malocclusion.
I
t
I
I
I
t
t
t
||n.rr. S-uoterny anarysrsrorconvexrty.
(a)skeretar
protite,(b)soft
rTssue profile,(c)totalprofile.

t Profile ClassI ClassII ClassIII

I Skeletalprofile
Soft tissueprofile
174'
159"
178"
163'
181"
169'
Total profile r33' t33'
I Table10. Meanvaluesfor convexity.
139'

t
I I.2.3 Thicknessof SoftTissueProfile
SubJgfqVfurthermore determined the thicknessof the soft tissue profile and

I establishedthe following:
(a) The thicknessof soft tissuenasionwas practicallyconstant.

t (b) The thicknessat the sulcuslab.sup.increasedby approx. 5mm.

(c) The thicknessof the soft tissuechin increasedby approx.2mm.

I In his view, the greater increasein maxillary as distinct'from mandibular soft

tissueexplainswhy the soft tissueprofile growsmore convexwith age,despitethe
tendency of the skeletalprofile to straightenout.
I
I
I
83
 .Burstonegave the following mean values(Table 11-,seealso Fig. 73).
Bowker and Meredith measuredthe thicknessof soft tissuepartsin relation to the
N-Pog line in both girls and boys. Their resultsare shown in Table L2 (seealso
Fig.7a).
This showsthe growth-relatedchangesin soft tissueprofile to be expectedin the
course of treatment.

73
Boys Girls

Glabella 7 6.6
Subnasale L8.7 L6.9
Sulcuslab. sup. 16.2 t4.7
Sulcuslab. inf. 12.9 LL.6
Soft tissuechin 12.8 12.2

Table 11. Thicknessof soft tissue profile

(Burstone).

Age 5 Age 1.4 Gain

mm mm

Nasion B 6.3 6.6 0.3

G 6.3 7.1 0.8

Tip of nose B 23.8 30.9 7.7

G 24.8 32.0 7.5

Convexityof B 1,4.5 16.3 1.8

upperlip G 14.7 17.5 2.8 Fig.73. Burstoneanalysis.
Skeletalpoints:(1)subspinale,
0.2 (2)incisiosup.,(3)Prosection
Labiomental B 9.7 9.9
of pointB, (4)incisioinf.,
fold G 9.5 9.5 0.0 (5)supramentale, (6)pogonion.
Softtissuepoints:
Soft tissue B 11.3 12.3 1.0 (A)subnasale, (B)sulcus
pogonion G rt.4 12.4 1.0 (C)
labialissup., labralesup.,
(D)labraleinf.,(E)sulcus
Table 12. Thickness of soft tissue profile (Bowker and labialisinf.,(F)menton,
Meredith). (G)glabella.

84
 pogonion

74. Bowkerand Meredithmethodof determination.

L.2.4 Profile Analysisafter A,M. Schwarz(Fig.7s)

Three referencelines are constructedfor profile analysis:
(1) The H line, correspondingto the Frankfurt horizontal.
(2) The Pn line, constructionof which hasalreadybeen described.
(3) The Po line (orbital perpendicular),a perpendicularfrom orbitaleto the H line.
The gnathic profile
!e-ld (GPF or A.M. Schwarz'sKPF, for Kieferprofilfeld)
permits assessment of the profile. .!n the averagestraightface, the subnasale(sn)
touchesthe nasionperpendicular(Pn). The upper lip ilso touchesthis line, *tritri
the.loler lip regresses,being approx.'l/s the*lAtn oi the gnathicprofile posterior
to it. The indentation of the lower lip comescloseto thi posteiior third of the
gnathic profile field.
The lowest chin point (gnathion) is on the perpendicularfrom the orbital point,
€Ol the most anteriorfoint (pogonion)at d miO-pointberweenthe two verticals.
The mouth tangentT (sn-pog)is Constructedto assess the gnathicprofile. lt bisects
the red of the upper lip and touchesthe border of the lower lip. Wiitr pn it formsthe
profile angle(T angle).In the averageand all straightfacestirisis 1"0'.rn" *iJin oi
tne gnathicprofilefield is 13-14mmin children,and 15-17mmin adults(Fig.76).
Depending on the position of subnasalerelative to the nasion perpendicular,
distinction may be made betweenthe following types (Fig. 77): I r
(a) Averageface; subnasalelying on the nasionperpendicular.
(b) Retroface;subnasalebehind the nasionperpendicular.
(c) Anteface; subnasalein front of the nasionperpendicular.

85
75 Fig. 75. A.M.Schwarz'sprofileanalysis.

--

76 Po

ll
Po Pn

GPF

Fig.76. Gnathicprofilefield
(GPF)of A.M.Schwarz.

Fig.77. (a) Straight-jawedprofile (solid line).The gnathicprofile

runs parallel and anterior to the average profile (broken line).
(b) Straight-jawedretroposition(solidline).Thegnathicprofileruns
parallel and posterior to the mean profile (broken line). (c) The
gnathicprofilesof straight-jawedantepositionand retropositionrun
parallelto that of the averageface(brokenand dottedline),the angle
betweenforeheadand nose is moremarkedwith an antepositionand
straightenedout with a retroposition(afterA.M.Schwarz).

86
If pogonion is displacedproportionately to the subnasalein casesof retro or
anteposition,this is known asa straightretroface.This type of straight-jawedface
is judged to be as balanced as a straight averageface. If pogonion lies more
dorsal than normal relative to subnasale,the profile is slantingbackwards,if the
opposite is the case,it is slantingforward.
The following variationsmay thus be seen:

I.2.4.L Three straightprofiles:

(a) Averageface.
(b) Straightantefac.e;
the gnathicprofile runs parallel and anterior to the average
profile.
(c) Stiaight retroface; the gnathic profile runs parallel and posterior to the average
profile.

1".2.4.2 Six obliquetypes(Fig.78,79):

(a1) The basic type of oblique retrofacearisesfrom posterior rotation of the
average face; the maxilla is positioned posterior to the averageprofile, the
mandible even more posterior to it (retro-inclination).
(b1) The basic type of oblique antefacearisesthrough forward rotation of the
averageface; the maxilla lies anterior to the averageprofile, the mandibleeven
more anterior to it (ante-inclination).
(a2) Averageface, gnathicprofile slantingbackward.Backward rotation of the
profile and posterior displacementof the subnasaleare partly compensatedby
forward displacementof the mid-face, with the result that subnasaleis in the
averageposition.
(b2) Averageface, gnathicprofile slantingforward. Forwardrotation of the profile
is compensatedby retrogressionin the mid-facearea,with the resultthat subnasale
is in the averageposition.
(a3) Anteface, gnathic profile slanting backward, arisesthrough the combined
effect of backward rotation and marked forward displacementof the mid-face,
bringing subnasaleforward of the nasionperpendicular.
(b3) Retroface, gnathic profile slanting forward. Combined effect of forward
rotation of the profile and backwarddisplacementof subnasale.

1.2.4.3 With a ClassII molar relationship(Angle) wherethe mandibleis under-

developed, the maxilla being normal, the following relations may be found
(Fig. 80):
(a) Average face.
(b) Retroface; one might be deceivedinto thinking that the maxilla was also
underdeveloped.
(c) Anteface; one might be deceivedinto thi,nkingthat the mandible,beingin the
right position, was normally developed,the maxilla on the other hand over-
developed.

87
 78b

Fig. 78. Threeobliquetypes slopingbackwards.(a)Retroposition,

gnatnic profile sloping backward,(b) averagetype, gnathicprofile
Sloping backward, (c) anteposition, gnathic profile sloping
backward.

Fig. 79. Oblique types sloping forward. (a) Antepositionwith

forward slope,(b) averagetypewith forwardslope,(c) retroposition
with forward slope.
L2.4.4 With a ClassIII malocclusion(Angle) combinedwith an overdeveloped
mandible, the maxilla in all casesshowing normal development,the following
variationsmay be seen(Fig. 81):
(a) Average face.
(b) Retroface;onemight be deceivedinto thinkingthat themandible,beingin the
normal position,was normallydeveloped,and the maxillaunderdeveloped.
(c) With an anteface,it may be wrongly concludedthat the maxilla, too, is
involved in prognathic overdevelopment.
A.M. Schwarz'sprofile analysisis of major importancewhen making an aesthetic
prognosis.The aim of treatmentis a straightface,for only this will givea baianced
profile.

88
I
h"
l
80c

-l
+\
G I $
I
F, )t
!m. AngleClassll with mandibleunderdeveloped, but maxilla
nal in all cases.(a)Withaveragetypeface,(b)with retroposition,
fith anteposition.
I

l-t-t\ -1j
l l
81b 81c
ltt"

I
<f
G G G 1I
i fr th
Jgt. Classlll malocclusionwith mandibleoverdeveloped, but
hlla normal in all cases. (a) With averagetype face, (b) with
oposition,(c) with anteposition(afterA.M.Schwarz).
I Certain skeletalfactorswill influencethe profile,chief amongthem being:
t
(a) The relativepositionsof maxillaryand mandibularbase,i.e. the ANB angle.

It tUl Skeletalconvexityof the facialskull, i.e. the N-A-Pog angle.

(c) Incisor angulation,i.e. positionof the long axesof upper and lower incisors
I relativeto the facialplane (N-Pog).
T
' On the other hand, the soft tissueprofileshowschangesindependentof the bony
. profile in the following areas:
t
I (a) Nasale.

, (b) lnfranasale.
I
I (.) Soft tissuesof the chin.

89
 2 Lip Analysis
Analysis of the lips playsa significantrole in treatmentplanning.

2.1 Metric Determinations

2.I1 Length of Upper Lip (sn-sto;

Fig.s2)
The meanvaluegivenby Burstoneis 24mm for boysand20mm for girls.We have
found an averageof.22.5mmfor boysand 20mm for girlsat ageL2.
In ClassII (22mm) and alsoClassIII cases(20.9mm),the lip is slightlyshorterat
age12.A positivecorrelationexistshoweverbetweenlengthof upperlip and facial
height (N-Gn L04mmon averagewith ClassII, L01.5mmwith ClassIII malocclu-
sion).
The upper lip growsonly slightlyin lengthwith age (between6 and 12 years),by
1.9mm on averagein ClassII cases,and 0.9mm in ClassIII cases,slightlymore in
casesof ClassII than with ClassIII malocclusion.
The upper lip grows longer in the course of treatment, partly due to growth
changes,but partly alsobecauseof the openingof the bite achievedwith treatment
(averageincreasein sn-gnduring treatmentapprox.3mm).

2.1.2 Length of Lower Lip (sto-gn;

Fig.83)
According to Burstone,this is 50mm on averagein boysand46.5mm in girls;our
investigationshave shownit to be 45.5mm in boysand 40mm in girls.
The lip graduallyincreasesin length with age,slightlymore so in casesof ClassIII
malocclusion(with ClassII by 1.5mm on average,with ClassIII by l".9mm on
average).
During treatment, the lower lip showsa slightly greaterincreasein length with
mesiocclusionthan with distocclusion.The changesare principallyconnectedwith
growth and increasedbite height.
During treatment for Class II malocclusion,following retraction of the upper
teeth, the lower lip curls up and movesforward.
During treatment of ClassIII malocclusion,the lower incisorsundergo lingual
tipping so that the lower lip movesbackwards.

90
 20m
m
i
!

t n
H

I
u
I
10
I
11
I
'll yeors
I

I t, 2L

ill JJJJIEII}T.I11
11A

I 71,7
22.7

21,5
I 20,8
20,3=:==ea---
/| L
?!S
20mm
before treatment ofter treotmenl
II. m
Class
ClassIII. El
82. Lengthof upperlip with Classlland Classlllmalocclusion,
and aftertreatment.Upperleft,meanvaluesfor Classl, ll and

I 11
-l- 1aq
r
^1 h';';
l q7
'17 1 'JA,t

36,5 tt 1

36

treotment b:f*" treotment

class II. mott"r
ClassIII. E
I gg. Lengthof lowerlip with ClassHand Classlll malocclusion,
and aftertreatment.Upperleft,meanvaluesfor Classl, lland

9L
2.I.3 Fig.8a)
Thicknessof the Red Part of the Upper Lip 1ts-ts;
This is measuredfrom the labial surfaceof the most labial incisor to the most
anterior point on the red part of the upper lip. The averagethicknessis LL.5mm.
With ClassII malocclusion,the red upperlip is relativelythin (10.8mmon average
at age 10), with ClassIII it is thicker (\2Amm on average).The thinnerupperlip
seenwith ClassII is due to the angulationof the upper incisors(63"on average).
With ClassIII the upper lip is also thicker becauseit restson a lower lip that has
undergoneforward displacement.
The upper incisorsare retruded during treatmentfor distocclusion,and protruded
during treatment for mesiocclusion.
The thicknessincreasesslightlywith age (betweenages6 and 12 by 1.4mm on
averagewith ClassII, and 1.1mm with ClassIII). During treatment,l!. upperlip
grows thicker in casesof ClassII and thinner in thoseof ClassIII, with the result
that the differencein upper lip thicknessceasesto be significantafter treatment.
These changesare largely due to changesin angulationof the upper incisors.
The reasonis that the upper lip growsthicker asthe incisorsretract. Followingthe
elimination of lip tensiondue to 3 mm retractionof the incisors,upperlip thickness
increasesby L mm. Lip tensionexistswheneverthe soft tissuedifferencebetween
A-sn and the red part of the upper lip is more than * Lmm. The lip profile will not
changeuntil this tensionis eliminated (seealsopage L06).
Lip tension needs to be consideredwhen assessing the aestheticprognosisand
restorationof lip closure.

2.I.4 Thicknessof the Red Part of the Lower Lip ltiti; Fig.8s)
This is measuredfrom the labial surfaceof the lower incisorsto the most anterior
point of the red part of the lower lip. The averagethicknessis 12.5mm.
With ClassII malocclusion,the lower lip is thicker (14mmon averageat ageL0),
with ClassIII it is thinner (11.9mmon average).The thicknessof the lip depends
on the position of the mandibleand on the overjet.
Lower lip thicknessincreasesonly minimally from age6 to 12 (by an averageof
l.2mm in casesof ClassII, and 0.8mm in thoseof ClassIII).
In the courseof treatment, the lower lip becomesthinner in casesof ClassII, and
thicker in those of Class III. These changesare due to changesin mandibular
position and to pro-inclinationof the lower incisorswith treatrnentfor ClassII, or
ietro-inclination with treatment for ClassIII. Retraction of the upper incisors
causesthe lower lip to curl back or forward. Sublabially,lip contoursbehavein the
sameway as the roots of the lower incisors.

2.2 ReferencePlanesfor Lip ProfileAssessment

We use the
Some authors give specialreferenceplanesfor lip profile assessment.
constructionsgiven by Ricketts, Steinerand Holdaway.
 Lh
\\

13,4
)-:---
1 12,6
1',)
11,7
11,5

10mm
before trectment otter treotmenr
C l o ss.l[!l.
C l o ss.111,fl
Fig.84. Thickness of redpartof upperripwithOassil andclasslll
malocclusion, beforeandaftertreatment. upperleft,meanvaluesfor
Classl, ll and lll dysgnathia.

10mm
q'
6 78 9 12 ).
t ttl I

l t ,l
tq, r
11?
l5'rrrrntlffi ltf Il 111
| | ll lll I l l I llll l',1,1
13 rrrn'rrrm,rnl*r rrnn'r1r'iTfT
12,
'1
12
5HJ##l#lllJli
? *
l dultHs.
i++FFl-Fi-l-ifItFIln'FEEw
ftf-ififFt-ti 't,)-+]-U.l-l.t-'l'l
1?qu,[IulluL lr
r L,\4| | | Iffi i /
aa45
l- l'
tL,'+
t/n
1?L
f/

rin - lt-

I I'u 11,6

10mm
before treqtmenr ofter treotmenf
C l o ss.l lm
Closs.lllB

Fig. 85. Thicknessof rcd partollower lip with Classlland Classlll

malocclusion,beforeand aftertreatment. Upperleft,meanvaluesfor
Classl, ll and llldysgnathia.

93
 2.2.1. Ricketts'Lip Analysis(Fig.s6)
The referenceline used by Ricketts is drawn from tip of noseto skin pogonion.
Normal relationsmean thit the upper lip is 2-3mm, the lower lip L-2mm behind
this line.
86

Fig. 86. Ricketts'liP analYsis.

2.2.2 Steiner'sLip Analysis(Fig.87)

The upper referencepoint for the Steineranalysisis at the centreof the S-shaped
-bbt*een
curve tip of noseand subnasale.Soft tissuepogonionrepresentsthe lower
point. Lips lying behind the line connectingthose two points are too flat, those
lying anterior to it, too prominent.

2.2.3 Holdaway'sLip Analysis(Fig.88)

lip configuration.Holdawaydeterminesthe
This is a quantitativeanalysisto assess
' angle betweena tangenttb the upper lipand the NB line. The anglebetweenthese
two lines is called the "H angle".
With an ANB angleof 1*3', the H angleshouldbe 7-8'. Changesin ANB will also
mean changesin the ideal H angle (seeTable 13)'
Holdaway definesthe perfect profile as follows:
(a) ANB angle 2", H angle7-8'.
(b) Lower lip touchingthe soft tissueline (the line connectingsoft tissuepogonion
and upper lip, continued as far as SN).
(c) The relative proportions of nose and upper lip are balanced(soft tissueline
bisectsthe S curve).

94
Fig.87. Steiner'slip analysis.

(d) The tip of the noseis 9mm anteriorto the soft tissueline (normalat ageL3).
(e) There is no lip tension.
The upper lip is tensedif the differencebetweensoft tissuethickness,(A-sn) and
the thicknessof the red part of the upperlip is greaterthan t Lmm (Holdaway).
Following eliminationof lip tension,each3 mm retractionof the incisorswill result
in a Lmm retraction of the upper lip.

Fig. 88. Holdaway'slip analysis.

95
 ANB Ideal ANB Ideal
angie H angle angle H angle

10' 20" 2" 80

BO r7" 00
.)o
50
60 14" _L 2"
AO
+
AO
110 -.+ -10

Table13. RelationshipbetweenANB and H angb)

3 Analysisof TonguePositionbY
CephalometricRadiograPhY
Only a limited number of methodsare availablefor analysisof tongueposition in
the iadiograph. Successfulanalysiswill depend on the right choiceof reference
line. The-prbconditions for a referenceline that will serve the purpose are as
follows:
(1) The greatestpossiblearea of the tongue should lie above the line, as.the
radiograph cannot show the whole tongue (anatomically).
(2) The line should be independentof variation in skeletalstructures.
(3) Its relation to the tongue should not changewith changesin position of the
mandible.
(4) It should remain constantin relation to changesin tongueposition.
(5) It should relate to the anatomicaland functional propertiesof the tongue.
(6) Determination should be as simple as possible.
These requirements can only be met by a line constructedwith the aid of a
referencepoint located in the mandible.
Our own determinationsare based on the following referencepoints and lines
(Fig.8e):
I : incisal edge of lower central incisors;M : cervical, distal third g-f the last
erupted molar; V : most caudal point on the shadowof the soft palate, or its
projection onto the referenceline. I and Ir4 are connectedand the connectingline
continued to V; this is the referenceline. It offers the following advantages:
(a) A relatively largepart of the tongueasseenin the radiographliescranialto it.
(b) The line is independentof skeletalrelationships.
(c) It is independentof changesin tongueposition.
The line connectingI and V is then bisected,the point of bisectionbeing point 0.
From this, a perpendicularline is drawn to the roof of the mouth.
A transparent template (Fig. 90) is used for the dpterminations.This has a
horizontal line which is placed to coincidewith the referenceline traced on the
radiograph, and a vertical line which should coincidewith the vertical reference
line. From point 0 on the template, where three lines now meet, we draw four
more lines,all at 30"angles.This givesa total of 7 lines,and thesearemarkedout in
millimetres. The template is placed on the radiograph and the measurements
required for the analysisof tongueposition can then be read.off
Frg" 89. Constructionfor assessmentof tongue position in the
rdiograph.

FiE. S). Templatefor assessmentof tongue position in the radio-

graph.

97
3.I TongueParameters
Using the templatetwo typesof determination may be executed:

of TonguePosition
3.1.7 Assessment
On the radiographtaken in occlusion,the spacebetweentongueand roof of mouth
is definedby distancesin millimetres(verticalshadingin Fig. 89). If the lineson the
template are numbered from I to 7, the measurementmade along 1 gives the
distancebetween the soft palate and the root of the tongue (posteriorborder of
oral cavity), thosealonglines2-6 give the relationshipof the dorsumof the tongue
to the roof of the mouth, and that alongNo. 7 the positionof the tip of the tongue
(or its projection onto the line) relative to the lower incisors.

of TongueMotility
3.I.2 Assessment
The second determination relates to the motility of the tongue. For this, the
position of the tongue in dental occlusionis comparedwith that in rest position.
The template is used fo determine the height of the dorsum of the tongue on all
seven lines, in both radiographs(horizontal shadingin Fig. 89). The difference
between occlusal and rest position is then calculated. This method permits
assessmentof the actual change in tongue position, independentof the inter-
occlusal space.The occlusalposition is taken as zero, with changesin position
given in positive and negative flgures, i.e. a positive figure indicates that the
tongue is higher in rest position than in occlusalposition, and vice versa.

3.2 AverageFindings

3.2.L Resultsof TonguePositionAssessment

The results are shown in Table 14.

3.2.1.1 The root of the tongue(measurement No. 1). With anomaliesin nasal
breathing, a small space is found between the root of the tongueand the softpalate
(0.9 to 2.Lmm on average).A spacein this segmentis not alwaysdue to mouth
breathing, but may also occur with a small tongue (in casesof deep overbite). A
small tongue may sometimesalsobe seenwith ClassIII malocclusion,but it is then
in an anterior position, so that the spacebetweenthe root of the tongue and the
soft palate is large. In casesof mouth breathing, the spaceis also large (5.1 to
5.2mm on average).

3.2.L.2 The dorsum of the tongue(measurements No. 2 to 6) is relativelyhigh

with ClassII malocclusions.In casesof deep overbite, the dorsum is high at the
back. low in front. In all other casesthe dorsumtendsto be low.
I
I Malocclusion Measurementsin mm

I
ClassII1 0.9 3.1 5.0 5.8 7.8 9.1 6.2
I ClassII1 with
mouth breathing 5.1 8.3 r0.2 11.7 12.3 t2.2 10.0
2 .r 3.7 3.7 7.5 9.4 8.6
t ClassII2
ClassIII
ClassIII with
1.1 5.9 r0.2 10.3 10.9
10.4
9.8 6.3

t mouth breathing
Open bite
5.2
1.9
9.2
5.7
11.6
8.5
12.3
8.8
11.6
11,.2
8.4
9.2
5.2
2.4

I Table 14. Assessmentof tongueposition.

I
I 3.2.1.3 The tip of thetongue(measurement No. 7) is retractedin casesof ClassIII
and in ClassII caseswith nasalbreathing(6.3mm), and evenmore so in casesof
I deepoverbite.With ClassII andmouth breathingthe tip of the tongueis consider-
ably retracted(10.0*-), whereasretractionis less(5.2mm) with ClassIII and
mouth breathing,In casesof open bite the tip of the tongueliesforward (2.4mm).
I The resultsare shownin graphform, with the meanyaluesdrawnascurvesand the
two mean deviationsin each caseas areas.Spacepermits only one graph to be

I shown.This comparesthe tonguepositionsfor ClassII andClassIII malocclusions.

With ClassIII, we frequentlyseea lower tongueprofile (Fig. 91).

I
0
]r 1 Lsi0,
1+ n/
,)
L

3
t,
5
6 h {t | /

7
I
I 10,2!2,0
10 Glvrv-rru-
\____
11
tl

tt II /1
1',l
iII .
1t,

Fig.91. Analysisof tonguepositionin casesof Classll andClasslll

dysgnathia.

99
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 3.2.2 Resultsof TongueMotility Assessment
The results of investigationsbased on comparisonbetween rest and occlusal
position of the tongue are summarisedin Table 15.

Malocclusion Measurements
in mm

ClassII1 0.4 t. 2 - 0.8 0.4 - 1.9 -2.2 - 3 .2

ClassIIl with
mouth breathing 0.3 0.7 0.1 0.0 - 0.1 - 0.8 - 0 .3
ClassII2 0.2 0.0 -t.4 0.0 -r.2 0.0 0 .9
ClassIII 0.6 1.3 0.8 - 0.4 0.1 0.5 J./

ClassIII with
mouth breathing -r.4 - 1.5 0.1 0.4 0.1 0.2 2.6
Open bite .0.5 0.5 -0.2 - 0.9 0.1 -0.2 0.8

Table 15. Assessmentof tonguemotility.

Changesin tongueposition arepredominantlyreflectedby the positionof the tip of

the tongue. The position of other partsof the tonguedoesalsochange,though not
relative to the mandible, but in conjunctionwith it. The changesin positionof the
tip relate closelyto the different typesof malocclusion.With ClassII, the tongueis
further back in rest position, with Class III it lies further forward. It may be
assumedthat the changesin position of the tip of the tonguerelateto the tendency
to mandibular malformation.
Comparisonof ClassII and ClassIII malocclusionswill show,for example,that in
rest position the tip is retractedin casesof ClassII, but showsforward displace-
ment in thoseof ClassIII (Fig. 92).

/
92 z*7
f

.l
fq

+3 -?3,2!2,0
+L
a -/L-------
.1
-.- +fl
+l
tongue in
n occlusolposition
1
-l

I
-9

I
-J

Fig.92. Analysisof tonguemotilityin casesof Classll andClasslll

dysgnathia.

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 4 FunctionalAnalysisof the Radiograph

Cephalometric radiogtupll will also demonstratethe relationship

betweenrest
and occlusal positions. Relative to its occlusalposition,
the mandible may be
further back or further forward than in rest position.
If a radiographis takenin restpositionand anotherin occlusion,
mutualrelations
betweenthesetwo may be estaLhshed. In everymoulm"nt of the mandiblewe can
differentiate between a rotatory and. a gliding component.
The principle of
comparative assessmentconsistl in the teterirination of
on" urrgt. for the
rotational componentand anotherfor the gliding.o.npon.nt
(Fig. 93").

i,t
1nl.o/
I -)"' qno

I J
/l
I - ---- MP
--\
tl
ll
ll
\l
I

\r

I I
)
I p0g
.-\

Tg:.gs. AngleB givesthe rotationar

gllding
component andangreMMthe
componenifor movement fromrestto occlusion.

Correlative assessmentof the angles at rest and in occlusion

will give us the
'differential' values.
The basalplane u1gj" (B angle)for instancecan be usedto
showrotatory move-
ment, and the maxillomandigular(Ytutl angle(the angleberween
AB and palaral
plane) for.gliding motion. The difierencebetweenth-eangles
in restingposition
and in occlusionis representedby the angleBu for th" ,o,u,ory
component,and
1L: ulqlt MMu for the gliding component of moyement from rest to occlusion
(Fig. ea).
We have subjectedtheserelations to_statisticalanalysisand compiled
a table of
ideal values for Class II and Class III malocclusionswith
balancedfunctional
relationships(Fig. 95, 96).

www.ajlobby.com 101
 - --80

.\-\\

Fiq.94. Measurement of angleB in the restposition(BR)qnqll

rt"lrtil poiition teO)serves'iodetermine thedifferentialangleBU'

l5
4M0U MMi
q Hhf I h

7,1t1,

5,9r1,t

/ qrlta

{-') 6+fl i.=-o

,/,-/:!4J/

1,3t0,9 r?\ztt,t
.42;-.'
0]!0,1i?/

llt n0
il- ,t
"0 DU
n H
-l
:l
il. Closs ,l
;--=t--- ':l
.i
Fiq. 95. Graphic representationof the relationshipbetweenBu and
Mili, in Ctasi ll and'Classlll cases.The middlelinesgive the mean
-t
..j

uilues. Shadedareasfor sigmavalues,with'corresponding'cases

aitne centre,those with badkwardgliding motion above,and those
=j
with fonarardgliding motion below.
=
I
lm
www.ajlobby.com -t
 (a) Corres. (b) Backward (c) Forward (d) t1values
to gliding giiding between
B"u average motion motion
(a) (b) (a) (c)
mi ci mi oi mi 6t pVo p%

Angle 10 1 .1 6 +0.36 0.25+t.07 <5

ClassII 2" 2 .6 2 +0 .48 4.33+0.46 0.30+0.88 <0.1 <0.1
ao
J 2 .8 3 +1 .10 0.70+1.18 <0.1
Ao
-
5 .0 0 +1 .02 6.40+0.49 1.22+ I.90 <2.5 <0.1
50 5 .1 1 +0.93 6.66+0.93 <2.5
6" 5 .3 0 +0 .75 1.85+ 0.83 <0.i
10
Angle I 1.66+0.47
ClassIII 2" 2 .7 1 +0 .84 z.zotr.ss r.ooto.o <0.1
ao
J 3 .6 0 +0 .48 8.33+1.55 <0.1
AO
+ 4.72+0.78 8.44+L.6t t.33+0.47 <0.1 <0.1
50 4.66+1..76 3.00+0.0
6" 6.00+1.00 2.66+0.47 <0.1

Fig.96. Thesamerelationships as shownin graphicrepresentation,

ln tabularform for Classll and Classllldysghathia.

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 Interpretationof Measurements
Determination of the various dimensionsin the radiographis a routine task that
may be delegatedor done semi-automatically (digitiser'computer').The actual
medical work consistsin interpreting the results.
In the introduction, referencewas made to the fact that there are a number of
methods of interpretation, the most widely known and used being correlative
analysis.The aims of interpretationmay be summarisedas follows:
(1) To determine the skeletalstructureand the facial type.
(2) To establish the relationship between maxillary and mandibular base and
determinethe type of growth.
(3) To assessdental relationships.
(a) To analysethe soft tissuesregardingretiologyand prognosis.
(5) To establishthe location of the malocclusionwithin the facial skull, on the
basisof the aboveanalyses,and determinethe extentto which it is skeletalon the
one hand and dento-alveolaron the other.
(6) Treatment planning - after synthesisof the analytical results - calls for
determination of the possible methods of treatment. The question has to be
answered,for instance,as to how far treatmentcan be causaland how far merely
compensatory(for skeletalabnormalities).
In the following pagesthe problemsof cephalometricradiographyare considered,
but it shouldbe emphasisedthat it is only one of the investigationson which overall
case managementis based.All investigationsneed to be consideredtogether
before a definite plan is decidedupon. Radiographicanalysiscannottake the place
of clinical diagnosis,and one should not expect a radiographto provide all the
information neededfor treatment planning.

L FacialProfilesand SkeletalAnalyses

Depending on the criteria, classificationand purposeof the investigation,distinc-

tion may be madebetweena number of facialtypes.In assessing the relationshipof
facial skeleton to cranial base, for example, an orthognathic, retrognathicand
prognathic facial type may be defined. Cephalometricradiographywill give an
accuratedefinition of facial type. No closecorrelationexistsbetweenfacial type
and anomalyasdefinedin the presentcontext.A particularfacialtypemay occurin
conjunction with different malocclusionsor with normal occlusion.On the other
hand the samedento-alveolardeviationsare frequentlyseenwith different facial
types. A statisticallysignificantincidencedoeshoweverexistfor certainforms of
malocclusions,suchasClassII in retrognathicfaces,and ClassIII with prognathic
types of facial skeleton,whilst an orthognathicfacial skeletonis no guaranteeof
normal occlusion.

7M
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Individual measurementsare of no practicalsignificancewhen seenin isolation.A
normal gonial angle, for instance,does not necessarilymean normal dentition,
whilst a large gonial angle need not alwaysgo hand in hand with malocclusion.
The facial skeleton has a number of morphological components.Individual
components may deviate from the norm, but in combination with the others
compensationnray well have resulted in normal occlusion.On the other hand
individual componentsmay be moreor lesswithin normalrange,yet an unfortunate
combinationof componentsmay haveproduceda malocclusion.
Determination of skeletalrelationshipto the facial type is important in treatment
planning, despitethe fact that no definite correlationhasbeenestablished.With
ClassII and a retrognathicfacialtype, for example,treatmentwill be more difficult
and the prognosislesscertainthan with ClassII malocclusionoccurringin a faceof
the orthognathictype. In the sameway the prognosisis very much more uncertain
when treating ClassIII occurringwith prognathicthan with orthognathicor retro-
gnathicfacialtypes.
The anchoragemechanisms,the planning of extractionsand many other thera-
peutic problems will be different with a retrognathic facial type than with a
prognathicone.
The facial type also has a considerableinfluenceon dental relationships.Thus a
Class II anomaly will usually be dento-alveolarin the orthognathictype with
distocclusion,and treatmentmust be limited to the dento-alveolar region.If the
i.e. the anomalyis duealso
facialtype is retrognathicwith a ClassII malocclusion,
to unfavourable skeletal relationships, treatment becomesmuch more of a
problem, the prognosisis less certain, and it may often be ne-cessary to effect
dento-alveolarcompensationfor the skeletalabnormalities.
Skeletal analysisand determination of the facial type is also important for the
retiologicalassessment of anomalies.With an open bite that canbe localisedin the
dento-alveolarregion, for example,the causeof the anomalyis an oro-facial
dysfunction. With skeletalopen bite occurringwith a largebasalplane angleand
growth related posterior rotation of the mandible (vertical growth type), the
dysfunction is usually secondary,and treatment much more difficult, requiring
different methods.

1.1 OrthognathicSkeletalRelationship
il
tl
In the orthognathic face, the maxillary and mandibular bases show normal
relationshipto the anteriorcranialbase(SN plane).The SNA andSNB anglesare
normal. This group usually presentswith anomaliesinvolving dento-alveolar
abnormalitiesand a ClassI relationship(Fig. 97a,b,98).

1.1.1 Crowding
With this type of face, crowding is due to discrepancies betweenthe sizeof the
teethand their apicalbaseor to dysfunction;crowding maybeprimary(transversal
deviation in the frontal plane) or secondary (mesiodistal). For differential
diagnosis,it is important to know that with primary crowdingthe incisorswill tend
to persistin the bud stage(Fig. 99). With secondarycrowding,the positionof the
incisorsis generallynormal.

105
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 il
97a t
t
t
f
I

moxillo
I
f
f
Fig. 97. Orthognathicrelationshipof facialbones.(a)Relationship
of maxillaryand mandibularbase,(b) dento-alveolarrelationship. f
f
f
f

Fig.9 8 . Midfaceconcavityand convexitywith orthognathicprofile.

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 Fig.99. Bud stagepersistingwith crowdingin the maxilla;palatinal
position of lateralincisorsand labialpositionof canines

1.1.2 Spaces
in the Dentition

r|
Spacesin the dentition(guprbetweenthe teeth)arealsofrequentlyfoundwith the
orthognathictype of face, and theseare agiin causedby a discrepancy
between
tooth sizeand dentalarch size.Spacingmay alsooccurwith incisorprotrusionin
the upper jaw, the resultof dysfunction.
D
I

-t I.I.3 ClassII Malocclusion

I Relatively frequent with this type of face are:

t (a) Distocclusion,i.e. dento-alveolarClassII occlusionwith balancedskeletal

structureof the face (Fig. 100a,b).
(b) Casesof translocated closurewherethe mandibularbaseis well developed,the
I sum of posterioranglesnormal,and a normalrelationshipexistsbetweenihe iaws
in rest position, but there is dentaldistaltranslocationin occlusion.

I (c) ClassIIz malocclusion,with maxillaryand mandibularbasewell developed,

and incisaldistaltranslocation.

I 1.I.4 ClassIII Malocclusion

t Class III casesmay also be seenin orthognathictypes.and theseare casesof

translocation.Differential diagnosisdependschieflyon assessing
the extentof the
mandibularbasein relationto the anteriorcranialbase.the saddle,articularand

t gonial angles,aswell as functionalanalysis(seepage126).

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100a

100b

Fig. 100. Mesialmovementof upper 6th-yearmolarsin an oftho-

gnathic face.This is a caseof distoclusion.(a)Orthopantomogram,
(b) teleradiograph.

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 L.2 RetrognathicSkeletalRelationship(Fig.101)
With the retrognathic facial profile, the maxillary and mandibular bases lie
posterior to the cranial base,and the molar relationshiptendsto be ClassII. Five
types may be distinguished.

moxillo

Fig. 101. Retrognathicrelationshipof facialbones.

L.2.L NormalInterrelationship
of ApicalBases,ClassII
Malocclusion
In addition to a retrognathicfacial structure,ClassII malocclusionis in this case
usuallycausedby mesialmigrationof molars(due to earlylossof primary teeth) or
by dysfunction. Retrognathia is not very marked, and dento-alveolarClass II
malocclusionpredominates(Fig. 102).

I.2.2 Anterior Positionof Nasomaxillary

Complex
The SNA angle is too large, the SNB anglewithin normal range(Fig. 103).
This type of anomalyis-frequentlyhereditary,with dysfunctionalsoplayinga role
in the retiology. This really is a ClassII relationship,with the 'fault in the maxilla'.
Anterior displacementmay be:

L.2.2.I Basal,not involvingincisorprotrusion,and treatmentwill haveto consist

in 'bodily' retraction of the upper incisors;

L.2.2.2 Dento-alveolar,with more or less marked incisor protrusion, so that

usually a combinedform of tooth movement(bodily and tipping) will be required;

109
www.ajlobby.com
 \
\
\

mcxillo
I
I

mondible mondible

Fig. 102. Dento-alveolarClassll; diagrammatic'

Fig. 103. Anteriorpositionof maxillawith retrognathicprofile.

extreme
L2.2.3 A purely dental proclination, with the upper incisorsshowing
required'
forward incliination.iippiirg the uppei incisorswif be ail the correction
of upp91
For the differential diagnosisof this type of malocclusion,assessment
Tipping-,if
i*iro, angulationand p"osition(relativeto the NPog line) is important.
whereas bodily
irOl*t.A,"may be achievedwiih simple removable appliances'
movement representsa more sophisticatedform of treatment.

TYPe
L.2.3 Neuromuscular
For
This consistsin posterior displacementof the mandible due to dysfunctions'
differential diagnosis, it is diffrcult to distinglish this type from theorthogl{ll'
SNB
typ" *ittt transiocateddistal closure.For di*erential diagnosisthe-SNAand
(Fig' 10a)'
uirigt",are important, and alsothe sizeand morphologyoithe mandible

11 0
Fig. 104. Posteriordisplacementol mandibleand protrusionof
upper incisors in consequenceof dysgnathia.

111
 I
105 S,M
13.10
77
L
07,I "/"
I
SNA 800
I
SNB 770
ANB 80
SN-Pog 7l,o
I
1490
.

I
N-P o g

/0 0
1 + 1 0 mm
| * t , 3 mm
I
1160
I
I
I
Fig. 105. Posterior position of mandible,with SNB angle 72"
(mandibularbasewell developed) and smallgonialangle(116'). I
;
L.2.4 PosteriorPositionof MaxillaryandMandibularBase
The basalstructuresare in a posteriorpositionrelativeto the anteriorcranialbase,
L
the mandible relativelymore so than the maxilla.The SNA angleis small,the SNB
angle even smaller.The mandibleis short and retrognathic,with largesaddleand
articular angles,a short mandibularand smallposteriorcranialbase(distancefrom
t
sella to articulare). This is a ClassII malocclusionwith the 'fault in the mandible.'

I.2.4.1 The gonial angle may be small, the ascendingramuswell developed.In

,l
the mixed dentition period, activator therapymay be indicated(Fig. 105).

1.2.4.2 The gonial angle may be large, the ascendingramus short and narrow. f
Extraction is often the treatmentof choicein casesof this type, asthe prognosisfor
forward movement of the mandibleis poor (Fig. 106).
t
I.2.5 Combinationof Groups1.2.2and1.2.4
This is forward displacementof the maxillaand posteriorpositionof the mandible
(Fig. 107), so that SNA is large, SNB small. This generallycallsfor a-combined
I
form of treatment, e.g. headgearfollowed by an activator.
I
Cephalometric radiography provides the answersto many important questions
with ClassII therapy, e.g.whethermovementdistallyor extractionis indicated,
I
1r2
rl
 S NA 77O
S NB 71O
A N8 60
SN- Pog 71,5o

N- Po g
510 1+ 8, 5m m
1290 ; ,,
l+q, lmm

Fig.106. Posteriorpositionof mandible,with SNBangle71o,retro-

gnathicprofile,and gonialangle129".Thelowergonialangle(Go2)in
particularis greatlyenlarged(78').

what treatment principlesshouldbe used,etc. A factor to be takeninto considera-

tion is the available forms of treatment; these are not unlimited, and some of
them are in dispute. Planning must include considerationof sagittalas well as
vertical relationships,aswithout the former it may not evenbe possibleto produce
the right bite constructionfor activatortherapy.
later.
The basicprinciplesof treatmentplanningfor distocclusionwill be discussed

I.3 PrognathicSkeletalRelationship
With a prognathic skeletalrelationship,the maxillary and mandibularbasesare
anterior to the anterior cranial base. Intermaxillary relationshipsare usually
ClassIII, though ClassI or ClassII occlusionsmay alsobe found if the mandibleis
large (Fig. 108).

Six types of ClassIII relationshipsmay be distinguished.

1.3.1 Normal Extent of Maxillary and MandibularBases

The upper incisorsshowlingual, the lower incisorslabialinclination.The causeof
the anomalycanusuallybe localisedin the dento-alveolarregion ]his typeis.often
difficult to distinguish from translocated closure with marked mandibular
prognathism(Fig. 109).

113
107 MM.
5 1 26 4 61,,lr"
I
"
1t 2 7L
08mm
13?o SNA 820
740 1070 SNB 1t o

1340 +-
\Y ,/
ANB 80
SN-Pog 710

rr-rug
q 7q 0
+13mm
1290 + 3,5mm
71,50

66mm

FfS.102. Combinationof group 2and4 configuration, with forward

displacementof maxilla(sNA angle 82")and-posteriorpositionof
mandibfe (SNB angle 74"), honzontalgrowth trend (64.4%).The
gonialalrgleis 129",as in Fig.106,butthe lowergonialangleis small
(Goz : 71.5"1,and the growthtrend more horizontal.
108

I
mondi bl e
I
Fig. 108. Prognathicrelationshipof facialbones.

114
t
I
 Fig.109. Labialtilt of the
lowerincisorsmayresultin
frontalcrossbite.

x"i-' LargeMandibularBase and AscendingRamus

Tle gomialan-gleis.large,the articularangleis small.The upper incisorsshow
lebrrl. rhe ilolverincisorslingual inclination.Edge-to-edgeor open bite are usually
$lff: romrallr'- and crossbitelaterally (prognathismwith 'fau[t in the mandible;;
F 1t - ^' - t r

65,7"l"

.-- af d
UJ
nln
JJ SNA 7Q0
SNB Rnl0
ANB
SN-Pog Q10

t 620 N-P o g
t 1360
7Lo
1 + 4 mm
i"
I Umm

I Fig.110. Girlaged9 with

mandibularbasealreadytoo
large(+3mm);prognosis 69mm
poor.
I
1 15
I
 Maxilla
1.3.3 UnderdeveloPed
with the mandibularbase
This presentswith crowding in-the upper front:."gion,
ttt" type may be distinguished'
;;;t ii;ttt. Two variationsit
ramusandpos.terior cranialbase
1.3.3.1 Verticalgrowthtendency.Theascending
(Go') greaterthan62"
are short, tte goiiut;;gi.'large, the upper goiiut angle
(Fig. 111a,b, seePage128).
and posteriorcranial
L.3.3.2 Horizontal growth tendency.The ascendingramus
gonial angle (Go') 40-55'
base are large, the lonial angle is small, the uppel
(Fig. 112a,b, seePagel29).
thesetwo types, so that
The crowding in the maxilla complicatestreatmentwith in
fixed appliancer us"arry required (mandibularprognathismwith the 'fault
the maxilla'). "t.

1,.3.4 Maxilla underdeveloped,MandibleNormal

e'g' in subjectswith cleft
This type occurswith maldevelopmentof the maxilla,
is characteristic
palatesand certai" tvtotot"., *h.r. mid-faceunderdevelopment
'fault in the maxilla').
imandibular prognait it* with the

1.3.5 MaxillaNormal,Mandibleoverdeveloped
prognathism, with a poorprognosis for
This groupincludes'genuine'mandibular
with the^'faultin the mandible';Fig' 113)'
effectivetreatmenr(frrognathism

Closure
I.3.6 PseudoTranslocated
by lingual
A fully developed skeletal prognathismmay be p-artlycompensated clinical
incisors-on
inclination of the lower und^tuSiutinclination of ihe upper
closure'but
examination,the anomalygivesthe impressionof be.inga translocated will
;pild*etric raJiogrupitl and 'meniat rePositionlng of incisor angulation
reveal a genuinemandibularprognathism('btg' r++'1'
to distinguishfrom
Even in adults, translocatedclosuresare sometimesdifficult
genuineprognathism
tru. frognathism. patient M.G.,2g years of age,.hasa
edge-to-edge
(ng but is neverthelessable to compensaiethis and achieve
iliiJ, tnough there is no contact laterally (Fig' 116)'
"Sj,

116
 SP
1 4 .5 .6 7
29.11.75
68,50 970
s NA 770
S NB 79,50
A NB - 2 , 5 0
S N-Po g 7 8 o

N-P o g
1 + 3mm
i ."
I + 0 tm m

Fig.111. Prognathism,with faultin the maxilla.SNBanglenormal,

SNA angle77', upperand lowergonialangleslarge.(a)Radiograph,
(b) tracing.

t17
2a

EA
2b l's g l 6 5 ,7
" /"
1t. O '7\
L '. J. I J

S NA 760
S NB 790
A NB - 3 0
S N-P o g7 9 , 5 0

N- Pog
1- 3m m
I omm

Fig.112. Prognathism, with faultin the maxilla.SNAangle76',SNB

angle 79'. Upper and lower gonial anglessmall.(a) Radiograph, 1
(b) tracing. i
II
j
l

118 .:.d
.:3
':-.ll
'::f,
,El3|
 with fault in the mandible.
Fig.113. Prognathism
114

Fig. 114. Genuineprognathism,partly compensatedby incisor

arigulation.The result is a pseudo-translocation'

Fig.115. Genu i ne
prognathismin a male
patientaged 28. (a)
:i::ir:,1
Anteriorviewofmouth,
.1 (b) lateralview of
mouth, (c) radiograPh,
(d) tracing,with ANB
angle10o,Prognathism
with the fault mainlYin
the mandible,and
horizontalProfile.

110 :'.rj]:
.:i

-
r
L
I
t
t
t
t
r|
r|
I
I
15d

I
t
560 1160
I ---
SNA 790
SNB 880
ANB 1n0
1330
I 7, 5 0
SN-Pog 910

T
I
t N-Pog
1-11mm

t r - 0mm

T
I 121
l/
Fig.116. Thesa m e
patientwith maximum
retractionof mandible.
(a) Frontaloverbite
minimal,(b) open bite
laterally,(c)
radiograph,(d)tracing.
ANB angle decreased
by 6" (to 4'), SNBangle
reducedto 82".This
genuineprognathism
paftly presentsthe
appearanceof
translocation.
I
I i.t

:"
;

/.q

t 78 73,7
"l"
: 'i

I SNA 780
SNB 820
:
I ANB to
-q

SN-Pog 850
\
I
I
I Jq
N-Pog
'l -(mm
' 11Q
0

I | -Dmm

I
I in Casesof
Changes
I.4 Age andTreatment-Related
I PrognathicRelationship
The differencesbetweenthe different typesof mandibularprognathismare not as
highlysignificantat later agesthanduringthe mixeddentitionperiod.For example
I in a caseof prognathisntwith the fault in the mandible(the body of the mandible
beingtoo long and anteriorin position),a maxillaof normalsizewill be retardedin
its further development,whilst in prognathismwith the fault in the maxilla (the
T maxillarybasebeing too short and in a posteriorposition),the mandible,having
been normal in sizeinitially, will becometoo long with age.This assumptionhas

I been confirmedby follow-upexaminationof our ClassIII patients.

The extent of the maxillarybaseand its rate of growth were smallin thesecases
(Table 16). Someextensionwasachievedwith treatment;the youngerthe patient,
I the more significantwas the difference.The extentof the basecould be changed
rvith treatmentup to the 10thyear of age(i.e. with treatmentinitiatedduringthe
9th year).
t In the older age groups, the maxillary base did not chanse with treatment
tFis. 117).

I The mandibular base was smaller than the averagevalue in children with
prognathismwho werein their6th and7th yearsof age; afterthat,it waslargerthan
lhe average(Fig. 118).Treatmentproducedno significantchanges,but it is an

l ;or anrageto initiatetreatmentat a timewhenthe mandibularbaseis stillrelatively

small in order to control the dento-alveolargrowth potential.A largemandibular
base was seen from the 8th year onward in our patients. The mandibular base
showsa marked tendencyto grow in patientswith mandibularprognathism.
:
lir
t23
 c.l
FJE
=^e
$ cl
H€ r tr J-l N
4tr0)9
.= ?,1i H ,rl c'l
tl
t-{ +l
00 \\
+l
\
ea a
ccr?€H
i*
q) c.i
XJ: ++ + ++ -t

(| rl
\Jrt q/
+(
v|-
.j .j
q
Fi
n
rc !
n C.i
qq
3c.i
V?
q.)
E 5€ E
Y tr
+t +l +l +t +t -rl tttt rll l +l
.e.9 qq oq qq $. v?
X rr#
RE
c) ON c\ oca ON. r{
rTl l< +l tl I I
t I
I

d
* .9,
F* .c
=n P
o
H! r F c'l n\ n
co9
.= ?E H c.i c.i
++
c{
+ ++ I ?-r a e o)
o
rrrY c !:
CL
a9)
-*
FH
I o
lr o
\n \o rn q9 v? c)
oo
/HT t. qd) oq o
(E
co ca
!E Xg
Nr c.l o
+t +l +l .L t + l +l +t +l +l .E
k
U^n)€
a. , - .
J-
F
f- v1 $ v'l 9
o. ! l x d \os '; o
U?lJi! O c.i f
4Lr
\e
0)
I
II ++ +
E
G
g)
oqq .g
!, tr
t c'i tt
+t |'n
+l +l -j
+l c
L
cclq)
itf.
-!- tr O\
II
tt
II
tl
SA e o
o
=,(J6t
trll. a OJ A A o
(!
H
?
a-) ++ - l. + -+-
o
;* n c'l n Et
c
'=
.1
.l. c.i c.i N c-l N c"i c.; ca;
:E
=L -J.r
ts d +t +l +l +t +l +l l ttt Iltl +l -g
E
N-.YF
L Ad)-
L. : 1
,--
X d
q cl
N$
=q
+c.i
n nv? \n
A c(!
+ rlf r- O)
^l i
- Ll I +l + J+ .LI
o
o
o
ll
-1 q q9
C)
\ cl '1 v? C)
X Nc{ c.i Fi C{^l co b
+l +l +l IIt t IIt l +l !ttt rltl +l -g
q\ \ qv? v? o x(E
Ff |'a) + +F-
\O \O
\n
\o r-
00
t<

E
at
+t l-i o
tj
vrrF
t) U)
o
H H v lr Il
d A-H -6\5 N
rwVf^
dYD?
).r-vJ
-

t'- cO ca \n oo sFi .a sf
z i :.i i *
E-d !
C /)O
lht r
o= ,g
4- .r o
(g> c
G
o o tr c,) E
O:] o
.5trX ctr x c
.X c€ c! OC gd
o
- CX x
k l-r k
o q)O ut
t- C) c.)
C) (.)'-'-
(,) c) 6) G'
bo bo b0
occ
- :) J

ts ,gg.F OC) o
.= lJr lJi r:
I .5 F* tJ.'i ?
L
(l)
fr
L lt
Lr G
z F

724
7 maxillorybose
mm
50

,
h,

45 t, t,1 t.'. 2 l, q u 4 l ,b
-i
I
e?

I Tlr2 L2,6
--
43,5
I
40 I, L
J

35
10,2
7,2Z3S,18,28.39,19,29,310,1 11 12 13
10,3 19
Length of moxillory bosebefore treotment
Lengthof moxillorySoruofter treqfment
Fig. 117. Changesin lengthof maxillarybasewith age and in the
course of treatment. :
80
mondibulor
bose 76,L
mln
af
,h
IJ

/
IL
70 68,
T_ 70u0

:Y_ a- l
I
l 67,I

65 -64-
I 6l 67,1 D/,
A( 6l 5
64,
61,
I
60
10,2
6,26,37,17,27,38,18,28,39,19,29,310,1 11 12 tl
10,3 16 19 yeor

ideol length-of rnondible

_ octuol length of rnqndiblein Lrntreotedcoses
Fig. 118. Changes in length of mandibularbase in cases of
prognathism,relativeto age and idealvalues.

The length of the ascendingramuswas comparedto the ideal valuesbefore and

after tre-atment.Prior to treatment,it wasshorterthan the relevantaveragefrom
the 6th to the 8th year, after which its extent increasedproportionally with age
(Fig.11e).
Our investigationshave shownthat the bestpossibletime for initiating treatment
for prognatLism is the period of primary dentition, before the permanentincisors
At thut point it is still possibleto haveconsiderableinfluenceon the develop-
"rrrpt.
ment of the rnaxilla and achievecorrect incisor angulation.
In the caseof patient H.I., a four-year-oldboy, activatortherapywasinitiated for
prognathir-. Th" activatorhad a qpecialconstruction,with pads'inthe upperlabial
iulcirs and a tongue guard in the mandibular portion. Normal overbite was
achievedafter foui months of treatment (Fig. 120,121).

r25
1 19 00
R.osc. f1
7
mm
55 I 7

/.4 /
50 48,3 -50 n
J
17.7 4nr)
q
L r
457 ffi .t71
L tItt
t4l,.l
I
45
q

I l')
t1 JtL
-15,77 t.

tnf
l{ 3,1 ar { t{J, J
II
1,0
6,26,37,17,2Z3 8,18,28,3gJ 9,29,310,1 11 12 13 16 1 9 I
10,210,3
Ro . sc.-
S o tt-L i i n ge
R o. sc.-
S o tt-L o nvge orBehondtung
Ro . sc.-l st'L ci n gnoch
e Behondtung
Fig. 119. Changes in length of ascendingramus in cases of
prognathism,relativeto ageand duringtreatmentcomparedto ideal
values.

120

Fig. 120. Treatmentof prognathismin a 4-year-oldgirl. Above,

before treatment.below. after I months treatment.

126
Fig.121. Activatorfor prognathism,
with padsin the maxillaryand
tonguescreenin the mandibularregion.
If treatment is again required at the mixed dentition stage, the prognathic
svmptomsare no longer so markedas a rule.
Reversalof a frontal cross-bitehad alsobeen achievedin the caseof E.K., a
fir'e-year-oldgirl, durationof treatmentbeing8 months(Fig.I22). The familythen
n'entabroadandtreatmentwasdiscontinued. Thepatientreturnedatage12,when
the family had movedbackto thiscountry,with a minor degreeof crowdingin the
upper and lower jaws (Fig. 123).Cephalometricradiographyrevealedno signof
ClassIII malocclusion(Fig. nq. The positionof the mandiblewasprognathic,but
this was compensatedin the maxilla,the SNA anglebeing85.5'.Early treatment
had enabledthe maxillato developto this extent.
Our investigationshave however shown that certain relationshipscan still be
influenced at the stage of early mixed dentition. Treatment of mandibular
prognathismwill usuallystill be effectivefrom the 7th to the 9th yearwith no risk
trt creatingtraumatisingocclusion.Even at a later age, treatmentofferssome
prospectof success,but the later it is initiated,the greateris the risk of a relapse
end thereforealsothe incidenceof late damage.

1"5 CorrelativeComparisonof SagittalMalocclusions

The differentiation of variousforms of ClassIII malocclusionsasshownabovecan
he made only on the basisof correlativeassessment of the variousrelationships.
Seen in isolation, skeletal dimensionsare not pathognomicfor mandibular
prroenathism.A large mandible, for example,may occur in conjunctionwith
ClassII malocclusion,or a ClassIII facial type with normal occlusion.
Comparisonof serialanalysesof ClassII and III showsthat the differencesbetween
rhe nvo groupsariseonly throughcombinationof a numberof individualvariations
, F i u . 1 2 5a b
, ).

127
 122

i:
l

l
I
I

I
i

I
I
l
I
l,
M,
I
ii I

i
i
i
I
I Fig. 122. Treatmentof prognathismin a s-year-oldgirl. Above,
l beforetreatment,below,aftertreatment.
I
I
I
1
I

j,
l

Fig. 123. Patientfrom Fig.122in her 12thyear,whenpermanent

dentitionwas complete.

128
 t. K. 6 7 ,9' /.
1965
1t,.12.76 60,5mm
S NA
640 1050 q1q0
S NB
A N8 /, n0

SN-Pog 8?| l0
1/'1,50

\s.
\r3o

N-P o g
1 + 6 mm
I *3 mm

70mm

W124. Tracingmadefroma radiograph of thepatientin Fig.123.

Pmgnathicprofile.Prognathismof the lowerfacewascompensated
by subsequentdevelopmentof the midface.
N rzso 68,6mm
1290 A?7 0 81,50
17 7? o
65,6mm

5l- 1 3 9 ,30
45,4mm(+0,61
---_=
\
I 41mm{-21 t5 mm[-1,51
I mm
\so,o t.zrt
L,t_' I
rl \
b0

0
132 71,3
mm{*3)
I
I
Abb. 125b
M- l25a I
I I I
Clcss n / Closs II - I /
fioss III
--./
"v
UN
Closs III - - 0n
Frgr125. MeanvaluesforClassllandClasslllskeletalrelationships,
alongthe SN line.
sttoil.nin diagrammaticform and superimposed
p) Angular,(b) linearmeanvalues.

t29
 2 Assessment
of VerticalRelationships
in the
FacialSkeleton
Assessment of facialtypesis mainlybasedon sagittalrelationships
(to determine
orthognathic,retrognathicand prognathicconformations).To determinethe
facial type, assessment of sagittalrelationshipsmust be combinedwith that of
vertical relationships.We thereforeuse not only the established nomenclature
(orthognathicetc.),but alsomakethe distinctionregardingverticalandhorizontal
facialtype. The reasonis that the directionof mandibulargrowthrelativeto the
cranialor maxillarybasemay differ.

2.1 Growth-Related
Rotationof theMandible
The directionof growth dependson the relativerate of growthin the condylar,
sutural,andalveolarregions.If growthin theposteriorface(condylargrowth)is in
equilibrium with growth in the anterior face (growthin the facial suturesand
alveolargrowth),the resultis a parallelgrowthdisplacementinvolvingno rotation.
Increased growth in the anterior region (sutural alveolar)causesbackward
rotation (vertical growth direction), increasedgrowth in the posteriorregion
(condylar)causesforwardrotation(horizontalgrowthdirection)(Fig. 126).

126

Fig.126. Horizontal
(shaded)
andverticalrotation
of themandible;
diagram.

The facial skeleton showscompletelydifferent relationshipswith vertical and

liorizontal growth types.

130
 2.1.1 VerticalGrowthPattern
With the verticalgrowthtype, the sum of posteriorangles,the lowergonialand
basalplane angles,and the anglebetweenanteriorcranialbaseand rnandibular
p.laneare large.Interpolationbetweenposteriorandanteriorfaceheightshowsa
shift favouringanteriorfaceheight.The ascending ramusis narrowani short,the
mandibularbasenarrew,and the symphysis is thin (Frg.I27).

2.I.2 HorizontalGrowthPattern
With the horizontalgrowth type, the differencebetweenposteriorand anterior
faceheightis less,sothat the horizontalreferencelinesaremoreparallel.The sum
of posterioranglesandthe basalplaneanglearesmall,theascending ramusiswide
and long, the symphysisis wide (Fig. 128).

59,
5"/"

=74
SN-Pog

132,80

Ft1.127. Vertical
growthtype. 8' /.
68,

-Pog= 80,20

Fig.128. HorizontalgroMh
type.
171,20

t37
 2.1.3 Measurements Region
in theDento-Alveolar
Additional measurements regionpermit the further
taken in the dento-alveolar
analysisof vertical relationships,giving them in percentage
figures(Fig. 129,
Biggerstaffet al., 1977).

In the maxilla
Perpendicularfrom mesialcuspof upper 6th to palatalplane x 100*
Pttptndicular fro- inr.rup. to pulutulpL* '
"
The meanvaluesarc91,Vo for boys,and897ofor girls.

In the Mandible
Perpendicularfrom mesialcuspof lower 6th to mandibularplane x 100*
to
pl*
f.tp*Oi.ular from in..inf. to tnundiUul'o.
at age16.
The meanvaluesareT5Voat ageL2andTBVo

129

Fig. 129. Measurements relatingto incisorsand 6th-yearmolars,

for the assessmentof verticalrelationshipsin the dento-alveolar
region.

132
2.2 Determination
of the Centreof Rotation
Determination of the centre of rotation permits the finer differentiationof
mandibularrotation.The centremay be locatedby superimposing cephalometric
radiographstakenbeforeand after treatment(Isaacsonet al.).
(1) Tracingsare madeof the two radiographs,includingthe followingcontours:
Basal plane of mandible, symphysis,posterior margin of ascendingramus,
mandibularcanal,lower incisors,lower sixthmolar,sella,contoursof forehead.
(2) On the first tracing,a referencepoint is found in the regionof the symphysis
and one in the regionof the mandibularcanal(Fig. 130a).
(3) The mandibularstructuresof the two tracingsare superimposed,
and the
referencepointstransferredto the secondtracing(Fig. 130b).
(4) A referenceline is drawnin the regionof the anteriorcranialbase.
(5) Now the structuresof the cranialbasearesuperimposed;
the referencepoints
no longercoincide.
(6) Correspondingreferencepointsare joined by a line (Fig. 130c).
(7) A perpendicular on eachof the linesthusproduced,andthe two
is constructed
perpendiculars are intersected.The point of intersectionrepresents
the centreof
rotation(Fig. 130d).
With horizontalgrowth,the centreof rotationliesanterior,with verticalgrowthit
is posterior.Its locationdependsalsoon the vectorof condylargrowth.
If condylargrowthis upwardsand forwards,the centreof rotationis low, whilst
with growth directedupwardand backit lieshigh.
With a high degreeof rotation (largedifferencebetweenposteriorand anterior
growthrate),thecentreof rotationliescloseto thefacialstructures;
thesmallerthe
differencebetweenposteriorand anteriorgrowth rate, the farther awayis the
centrefrom thesestructures.In casesof translation(parallelgrowth),the centre
lies at infinity.

2.3 The Significance

of MandibularRotation
Mandibular rotation is a major factor in the developmentof malocclusion.
Posterior rotation is frequently seen with retrogenia,anterior rotation with
progenia.
Skeletalopen bite is concomitantwith posteriorrotation,skeletaldeepbite with
I
I
forward rotation.
The variationsin directionof growthgivingriseto the aboverotationsarenot only
a factor in the developmentof malocclusions, but alsoplay an importantrole in
treatmentplanning.With forwardrotation,treatmentof ClassIII anddeepbiteis
difficult, with backwardrotation that of ClassII and open bite. It is therefore
importantto determinethe growthtypebeforeorthodontictreatmentis initiated.

133
130a 130b
'^t (
/-\
'/r

l^-1.
f , ii n
\.\I ii
tt
l/
-:- !./\,|
i. /
n
---- I
---- I
____\9,
- - - il
,

rtoc -?J 130d

7 /

Fig. 130. Determinationof centreof rotationby superpositionof

tw-o radiographs,after lsaacsonet al. (a) Locationof reference
of
pointsin tf,e rbdiographtakenpriorto treatment,(b)superposition
iracings along minilibular structures and transfer of reference
points] (c) suferpositionof structuresin the regionof the cranial
'base,birineciing the referencepoints which no longercoincide,
(d) p6rpendiculaisconstructedon the linesioiningth.epoints.The
centre of
ir<iiitt6f intersectionof the two perpendicularsis the
rotation.

1y
 2.4 Rotationof theMaxilla
Growth-relatedrotationmay alsooccurin the mid-face.The natureof it may be
determinedalong the palatal plane and expressedby the angleof inclination
(fig. 13.1a,b). Mid-facerotation is only partly due ro growth,ls it may alsobe
affectedby mechanical forces.Occlusalforcesactin theiranial;gravityattsin the
caudaldirection;theseforcesmayhavean effecton the inclinationof ihe maxilla.
Dependingon the directionof the forceapplied,rotationmayalsodevelopin the
courseof headgeartherapy.It hasbeennoted,however,that therapeutic parallel
displacements of the maxillaenforcedby translationare verymuchlessliableto
relapsethan rotationsobtainedby tipping.
To assess
theeffectof mandibularrotationon skeletalrelationships
in theface,one
alsoneedsto takeinto accountmaxillarymovement.Singlerotationswill frequently
have a combinedor compensatoryeifect, and there"area numberof pfssiblb
combinations.
Rotation may alsobe controlled,usinga speciallydesigned
activator,andutilised
for therapeuticpurposes.
Both ju*: may rotate in the samedirection (horizontallyor vertically)or in
oppositedirections(maxillavertically,mandiblehorizontally,or viceversa).

2.4.I Rotationin Opposite

Directions
Horizontalrotationof themaxillawith verticalrotationof themandiblewill cause
the bite to open. Vertical rotationof the maxillawith horizontalrotationof the
mandiblewill causethe bite to close.

2.4.2 Rotationin theSameDirection

The followingcombinationsare possiblewith rotationin the samedirection.

2.4.2.L Horizontalrotationof maxillaand mandible

(-u)fn. mandibleshowsgreaterrotationthan the maxilla,resultingin closureof
the bite.
(b) The maxilla showsgreater rotation than the mandible,resultingin bite
operung.

2.4.2.2 Verticalrotationof maxillaand mandible

(a) The mandible showsgreater rotation than the maxilla, resultingin bite
opening.
(-b) fne maxillashowsgreaterrotationthan the mandible,resultingin closureof
fhe bite.

135
131a ij
50 ,4' l"
6 4.67
1 t , . 5 .7 5

SNA 780
SNB 700
ANB 80
SN
- Pog 70,50

520
1210

131b I.J.
6r . 6 7 59
o/o
1.2.76 63mm

SNA 750
\ r,0 , SNB 7n c0

S \
ANB
E N rug
Jrr- D ^-
/*,50
7i,50

N-Pog
1+ 8,5mm
67mm I + J,Jmm

Fig.131. Changein angleofinclination indicates

lnlertical growth types it is frequently necessaryto encourage
anteriorrotition of ifre maxitla.In the caseshown here (1.J.)'with
vertical growth trend and ANB angle 8o,treatmentachieveda 5'
retro-incTination (from81'to 76').In this way it is possibleto adapt
the maxillarybasdto someextentto the lowerdentalarch.(a)Before'
(b) after rotationof the maxilla.

136
2.5 Rotationasa Factorin TreatmentPlanning
The rotation of the maxillaryand mandibularbasesis a major factorin:
Aetiologicalassessment.
Determiningthe natureof the anomaly.
Prognosticevaluation.
Determiningthe possibleformsof treatmentand the indication.
Choosingthe principlesof treatment.
Assessingthe stabilityof treatmentresults
grindingof the dentition.
of selective
Consideringthe possibilityandeffectiveness

2.6 HorizontalRotationof theMandibleandDeepBite

Growth inducedhorizontalrotation of the mandiblepredestines deepbite. The
mandiblerotatesupwardsin front, increasing incisoroverbite. This needsto be
very muchtakeninio accountin treatmentplanningandpost-treatment retention.
Wiitr ttris facial type the developmentof tertiary crowding of the lower incisors
tendsto be mostfrequent.
Deep bite mayexistalsowithout thischaracteristic mandibularrotation,in which
.ur.ih. treatmentpossibilities andprognosisare totallydifferent.Theproblemsof
treatmentthen havetheir focusin the dento-alveolar area.

Deep bitewith horizontalrotationof themandibleis designated skeletaldeepbite.

When cephalometric the
radiographyis usedto differentiate formsof deep
various
bite, one hasto considerthe qubstionasto whichgrowthprocesses werechiefly
responsiblefor this development.
The developmentof deepbite is determinedby growthchangesin the following
areas(Fig. 132):
joint.
(1) Temporo-mandibular
(2) Maxillary base.
(3) Posterioralveolarprocessof maxilla.
(4) Posterioralveolarprocessof mandible'
(5) Vertical growthof upperanterioralveolarprocess'
(6) Vertical growthof lower incisors'

131
 I
132
I
I
II
I

I
.l
I
I
I
I
andextentof growthchangesinvolvedin the
Fig.132. Localization
development
133
of deep bite (Schudy).
I
i
I
I
I
I
I
T
gffiEtrryS;,.1i:,,; ",,: i,, r.i, . : :,ilr,.t,l-
I
trend,shortanterior
Fig.133. Deepbiiewithhorizontalgrowth
space.
heightand smallinterocclusal I
138
I
 Dependingon the synchronisation of growth in theseareas,growth-related
rotationof the mandiblemaybeforwardor back.With forwardrotationdeepbite
will becomemoreandmoreserious, andit will finallybeskeletal.
In theteleradio-
graphthe symptomsof deepbiteareasfollows(Fig.133):
(1) Shortanteriorfaceheight
(2) Shortlowerface.
(3) Palatal,occlusalandmandibularplaneshorizontal.
(4) Gonialanglesmall.
(5) Basalplaneanglesmall.
(6) Ascendingramuslongandwide.
(7) Mandibularbasewell developed.
Thereis alsoa dento-alveolarasdistinctfrom skeletaldeepbite,with infracclusion
of the molarsor supracclusion
of theincisors.Thisformmayalsooccurin conjunc-
tion with verticalgrowthdirection.
Correctionof skeletaldeepbiteis possibleonly by movementdistallyor perhaps
even extractionof the 2nd molars.Premolarextractionis contra-indicatedwith
this facialtype.

Fig. 134. Openbite due to suckinghabit.(a) Beforeand (b)after

4 monthstreatment.

139
 il
2.1 VerticalRotationof the MandibleandOpenBite t
Different forms of open bite are distinguished,
relationships
and, depending on the skeletal
andretiology,onemaybe dealingwith a verysimpleanomalyor one
that is extremelydifficult to treat, with the resultsof treatmentuncertain.
I
Functionalanalysis will not giveaccuratedifferentiation
Tonguethrustis alwaysa concomitant
malocclusion.
of thistypeof anomaly.
of openbite,irrespectiveof iheoriginof the
The locationof the openbitewithinthefacialskeletonis a decisive
t
factor.
I
Open bite due to habit is an anomalyarisingthroughdysfunction.The anomaly
may be locatedin the dento-alveolar region,with skeletalrelationships
normal.
Horizontalgrowthis alsofrequentlyseenwith anterioropenbite.With ihisgrowth f
type, tonguepressureproducesbialveolarprotrusionwith spacing.During the
stageof mixed dentition,causaltherapymay be effectedby inhibition,i.e.
eliminationof the dysfunction (e.g.with a tonguecrib). I
In a five-year-old
girl with openbiteanda persistent

growthbeingaverage, furtherdevelopment
suckinghabit,the openbite
wascorrectedwithin 4 monthsby eliminatingthe dysfunction.
isexpected
The directionof
to benormal(Fig.134a,b).
f
R.S., a seven-year-old girl, presented
and verticalgrowthtype(Fig. 135a,b).
with openbite,tongueandlip dysfunction,
t
I
135a
I
f
f
I
Fig.135. Openbite I
dueto suckinghabit
withverticalgrowth
trendin patientR.S.
(a)Radiograph,
t
(b)tracing.TheANB
anglewas 5o,the lower
gonialangle77.5",the
I
relationof posteriorto
anteriorfaceheight
55.5%.Thefirst stage
I
of treatmentwas
designedto eliminate
the adversepressures
I
by inhibition(vestibu
lar
appliance).
I
1J0
I
 J J ,J / O

S NA 750
77,50 1080
S NB 700
A NB 50
SN-Pog 700

irr-rug
l D ^^

I + l l ,) mm
;..
l + l mm

Despite the vertical growth pattern, treatmentwas initiatedwith a vestibular

screen,to eliminate the dysfunction.After one year of treatment,maxillary
relationshipswere normal,the openbite corrected,and the ANB anglereduced
trom 5o to 2o.A vestibularscreenwill haveno directeffecton vertiial growth.
Correctionor eliminationof the dysfunctionshouldhoweverleadto improvement
in the furtherdevelopment of the facialskeleton(Fig.136a,b).

2.7.I Skeletal
OpenBite
Treatment is much more difficult with skeletalopen bite where the causeis
developmentaland locatedin the skeletalregion.In this anomaly,the sum of
posteriorangles- particularlythe lowergonialangle- is large,alsothe basalplane
angle. A retrognathicrelationshiphas developed;anteriorfaceheightis long.
posterior short, the ascendingramusis short. A dysfunctioncan causea ven
upright positionof the lower incisors.
A girl of 18presentedwith skeletalopenbite andmaxillaryaswell asmandibular
crowding(Fig. 137a-d).At this age,dento-alveolar compensation of the skeletal
discrepancyor surgeryare the only possibilities.The directionof growth was
extremelyvertical,56.3%,andthelowergonialangle85".Theupperincisorswere
far ahead(+ 17mm) of theNPogline.The four firstpremolarswereextracted,the
upperand lower dentalarchesaligned,andthe openbitecorrectedwith the aidof
intermaxillaryelastics.This achievedpurelydento-alveolarcorrectionand com-
pensation.The skeletalrelationshipsdid not change(Fig.138a-c).

141
136a Fig.136. PatientR.S.
aftereliminationof
adversepressures.
(a)Radiograph,
(b)tracing.TheANB
anglehas become
normal,with2",the
relationof posteriorto
anteriorfaceheight
was57.5%,thegonial
angleenlarged.
Verticalgrowthtrends
persistedafter
elimination of the
dyskinesia. Further
development needsto
be monitored,so that
the secondstageof
treatmentmaybetimed
correctly.

136bRS
I ( 68 5Z5"/.
28 1 7 7
68mm
S NA 7 6 0
700 990 S NB 7 I , O
A NB ?O
S N-P o g7 t o

0
12,5

600
1390 N- Pog
1 + Z5m m
i.
l +l m m

65mm

I
i

1
l
.1
1{1
.1:l
::l
::;::l
137a
I l

137b

Fig.137. Withskeletalopen bitein permanent dentitiononlyactive

mechanicaltherapyis possible,with the possibility of achieving
dento-alveolar compensation of the skeletaldeviation.Openbite
(a) in anterior view, (b) in lateralview showing markedoverjet.
(c) Radiographand (d) tracing.The radiograph(c) and tracing(d)
showthe ANBdifferential to be 6.5",relationof posteriorto anterior
faceheight56.3%,extremelylargelowergonialangle(85").

1.43
 137c

137d

H.M.
1953
7.6.11 SNA 790
?1 (o
SNB
,i
il ANB 6qo
il
1r SN-Fog 730
!.

1i:
tr[,
l"l ,

f;[
511
nr[..l
t{ 510
N-P og
Itr 1360
I + t/ m m
lI
It.,tl
t
850
1 * 7mm
ni
1I
lt1
lli
lli
lil.l.ll,
1, 1: 1.
i l i.
1ii,
l ii
l,li
ilirj 144
! ; i t il'
I 138a

I
I
r
t

13 8 b

ff=''

Figure.138. PatientH.M.afterdento-alveolar compensation of the

skeletaldiscrepancy. (a)Anteriorview,(b) lateralview.Thetracing
(c)showsa changein theskeletalstructures;following extractionof
the four first premolars,the upperand lowerdentalarcheswere
re-shaped, with a fixedappliance,
anddento-alveolar compensation
of the openbitewasachieved.

i45
138c H.M
1953 56,3
"/.
L 1 17 1
SNA 780
SNB 730
ANB 50
SN-Pog1t
tq
o

1t,o

250

510 N- Pog
1380 1+ 7mm
j *5m m

70mm

2.7.2 OpenBite SYndrome

of a numberof factors'leadto
A verticalgrowthtendencymay,,dueto summation
Suckinghabitsand
severeskeletalopen bite showingprogressivetendencies' in thecondition'
abnormalnasalbrelthil; *;y..oS iottittt seriousdeterioration
maybe definedasfollows:
so that one may rp*ii oTunopenbite syndromewhich
(a) Vertical growthdirection;the expression of skeletalopenbite'

(b) convexity of palatalplane;the consequence of a strongsuckinghabitpersist-

ing for years.
(c) Antegonialnotching;the expression of abnormalnasalbreathing with lackof
ipu.. in the ePiPharynx (Fig. 139)'
open-bite' causal
Treatment possibilitiesale severelylimited with a skeletal
isdento-alveolar compensa-
therapyis not possible.The only poisibilitystill open effectby
have a positive
tion of the skeletaldeviation.-Premolar"extraciions
of the teethbehindthe
closingthe bite, pt*iOing we caneffectmesialmovement
."ti..Tio" ,pu... In extremecasessurgeryis indicated'

146
 1,3,2"
l"

jb*
S NA 7 7 0
S NB 6 [ o
A NB 7o
SN-Pog 630

430
14E0

N- Pog
1+ 20m m
;"
t+ umm

FiE.139. Skeletalopen bite with verticalgrowthtype.The upper

gonialangleis 146",the lowergonialangle103";combination of a
numberof factors may producean extremecaseof open bite, so
that one mayspeakof an OpenBiteSyndrome.

of FacialTypes
3 Classification
of facialpatternsdeviatingfrom the norm comprises
The classification four basic
types(modifiedafter Sassouni).
(1) Retrognathictype (ClassII).
(2) Prognathictype (ClassIII).
(3) Horizontaltype (deepbite).
(4) Vertical type (openbite).

Combinationof thesetypeswill givefour more (Fig. 1a0):

(1) Retrognathictype with horizontalgrowthtendency.
(2) Retrognathictype with verticalgrowthtendency.
(3) Prognathictype with horizontalgrowthtendency.
(4) Prognathictype with verticalgrowthtendency.

147
Clcss ll deepbite Closs III deepbite

Closs I1 Closslll

Closs II openbite Closs I oPenbite Closs lil openbite

of facialtypes'
classification
Fig.140. Sassouni

Determiningthe classification of an anomalyunderexaminationis an important

elementin both treatmentplanningand diagnosticassessment.
is good
(1) With a ClassII anomalywith horizontalgrowthpattern,the prognosis
ioi.otr.rting the ClassII ielationshipbut not for openingthe bite.
(2) With a ClassII anomalywith verticalgrowthtendency,the prognosisis good
ioi correctingdeepoverbitebut not the ClassII relationship.
(3) With a ClassIII anomalywith horizontalgrowthpattern,theprogngsis.is good
ioi correctingthe ClassIII ielationshipbut not the deepbite (if this shouldneed
correction).
(4) With a ClassIII anomalywith verticalgrowth tendency,the prospectsfor
effectivetreatmentare altogetherpoor.

1,18
Cephalometric
Radiography
andGrowth
In orthodonticsparticularimportanceattachesto the significanceandassessment
of growthandalsoof function,two conceptsthatfrequentlyneedto beconsidered
together.In the contextof cephalometricradiography,briefmentionshallat least
be madeof the problemsarisingthroughgrowth.The methodis frequentlyused
for the assessment of growth, though it cannot provide all the information
requiredin treatmentplanning.The mostimportantquestions in
to be considered
this contextare the followine:

How Much FurtherGrowthMay beExpected

Quantitativeassessment of growthis an importantelementin treatmentplanning.
With youngerchildrenmoregrowthis to beexpected. The estimated growthrate
will be evengreaterif the biologicalageof the child is lessthanits chronological
age. For example,a grea,terrate of growthwould be expectedin a ten-year-old
child with a biologicalageof nine than in a ten-year-oldwhosebiologicalageis
alsoten. The changesthat treatmentcaneffectin skeletalrelationships will largely
dependon this question.
The biologicalagemay be determinedby a numberof methods.The mostwidely
usedmethodis evaluationof the radiographof a hand.Ossification of the carpal
bones- asdistinctfrom the longbonesof the extremities - occursduringthe first
yearsof life. Up to aboutten yearsof age,the biologicalagecanbe determinedby
usingthe carpalindex.We usethe schemegivenby GreulichandPyleto evaluate
the radiographof the hand.After approximately the tenthyearof life, epiphyseal
linesare still discerniblein the metacarpal
bones,andmaybe seento be gradually
disappearinguntil growth is complete.Bjork distinguishes sevengrowthstages
from the tenth yearonwardin boys,and the ninth yearin girls(Table17).

2 Timetablefor Growth
The individualdevelopmental stagesnot only permit quantitativeassessment
of
growth, but alsoprovideinformationon anotherpoint that playsa major role in
treatrnentplanning:the timing of growth rates.It is possibleto estimatewhen
growth spurtswill occurprior to puberty.

Localisationof GrowthRates
Increasein sizeshowscertaincorrelationsto growth'ratein the differentregionsof
the facialskeleton.During veryactivegrowth,a noticeableincrease maybenoted
particularlyin the followinglineardimensions:N-Me, S-Gn,Ar-Gn.
The prospectiverate of growthin a particularregionof the facialskeletonmaybe
estimatedwith the aid of Table 18.tfris sivesthe meanannualsrowthrates.

149
Stage Object Growth Phase

1. PPz Prox.phalanxof Width of epiphysis Priorto max.long.

indexfinger : widthof growth,rateof
diaphysis growthslow

2. MP: Middlephalanxof Width of epiphysis Max. long.growth

middlefinser =width of imminent
diaphysis

3. S Ulnar sesamoid on Signsof ossification As stage2

metacarpophalangeal
joint of thumb

+. Middle phalanxof of
Encapsulation Max. long.growth
middlefinger diaphysis (betw.S andMP3carp)

5. DP:u Distalphplanxof Epiphysisunited Max. long.growthover

middlefinger

6. PP:, Proximalphalanxof As stage5 As stage5

middlefinger
.7
MP:, Middle phalanxof As stage5 Pastmax.growth
middlefinser

8. Rc Distalepiphysisof United Growth complete

radiusand ulna

of handX-ray(modification
Table17. Tablefor assessment of Bjork'smethod).

Maxillary Mandibular
Age S-N S-Gn S-Go Ar-Gn N_ME base base

M FM FMFM M. M M

8 75.2 12.3'1.15.8
rr2 10 66.4 103.4100.7 113.6109.597.8 46.8 70.5 69.8
9 0 .7 0.3 2.6 2.2 1.9 2 . 1 2 . 4 1 . 6 2 . 3 2 . 6 0 . 6 0 . 0 1 . 8 1 .1
1 0 0 .9 1.3 2.9 3.4 1..7 r . 7 2 . 3 2 . 8 2 . 8 3 . 0 0 . 8 r.6 2.0 2 . s
1 1 1 .4 0.4 2.9 1.9 1.9 0 . 9 2 . 6 2 . 0 2 . 8 1 . 1 1 . 5 1 . 0 2 . 2 1 .1
t2 0 .1 0.6 2;/ 2.6 2.6 2 . 6 2 . 3 2 . 6 1 . 8 2 . 1 . 0 . 8 0 . 3 1 . 3 0 .8
1 3 r .2 0.6 3.6 2.3 2.7 2 . r 2 . 8 1 . 7 3 . 3 2 . 4 0 . 8 1 . 0 2 . 0 1 .9
t4 1 .0 0.5 3.2 2.2 2.3 1 . 8 3 . 0 1 . 9 3 . 7 1 . 6 0 . 6 1 . 1 2 . 5 1 .9

Mean 0.BB0.61 2.98 2.43 2.15 1..7 2.56 2.1 2.78 2.1 0.8 0.8 1.9 1 .5

Table18. Annualgrowthgainin principallineardimensions.

150
 4 Directionof Growth
Another importantaspectis assessment of the growthdirection.Cephalometric
radiographymay be usedto distinguish horizontil andverticalgrowthpatterns.In
extremecases,the changein growthdirectionduringfurtherdevelopment is of no
significance.
If treatmentis initiatedat the stageof mixeddentitiona changein
growth directioncannotbe excluded,exceptof coursein extremecases.Foi the
purposeof prediction,we combinethe resultsof cephalometric analysiswith an
assessment of mandibularmorphology.A broadmandibularbaseand ascending
ramustogetherwith a very marked,thick symphysis suggesta changein direction
to.1a1dhorizontal_growth,asdistinctfrom a narrowmandibleand thin symphysis
which are typicalfor verticalgrowth.

5 Prediction
of Growth

|opg .investigatorshave specificallyconsideredthe questionof forecasting

individualgrowth patterns.It shouldbe possibleto give an accurateforecastof
growth changeson the basesof radiologicalevaluationof craniofacialstructures
(Broadbent,Brodie).The conclusions arrivedat wereof minorsisnificancefor the
individualcase.
Bjork has made a differentiatedanalysisof growth in variousskeletalregions,
includingthe extentof individualvariability.The appliedpredictionof groivthis
generallybasedon hiswork, thoughit is alsoclearthatindividualpredictionshave
to be regardedwith considerablecaution.

5.1 Methodsof Predicting

Growth
A numberof methodsareavailablefora moreor lessdetailedpredictionof growth
changes;thesecannotgo into detailsconcerningcertainaspects,
suchas:
(a) Age-relatedindividualpeculiarities.
(b) Growth changesin untreatedcases,comparedwith thosein treatedcases,
taking into accounttreatmentmechanismand the age of the patient at the
beginningof treatment.
(c) Growth changesoccurringafter conclusionof treatment.
Growth is not a questionof simpleincreasein size,but a highlycomplexprocess.
During orthodontictreatment,complicatedchangeswill occurevenin i region
where growth is relativelyquiescent,e.g. in the cranialbase,examplesbeing
appositionalgrowthat basion,remodelling in the sellaandat nasion,andsutural
growth in the spheno-occipitalsynchrondrosis.

151
 5.1.1 Johnston
Method
L.E. Johnstonhasproduceda diagram(Fig. 1a1)on the assumptionof regular
annual changesand an averagedirection of growth. He statesthat accurate
predictioncanbe madein65% of cases.
Johnstondevelopeda simplifiedmethodof generating a long-termforecastby use
of a printed'forecast
grid'. Eachpoint wasadvanced
one gridunit peryear,usinga
standardS-N orientationregisteredat S.
141 N
F
ftlllfflltlnftlltttlltlttlltttllllllllf
^

Age B-13yeors
Growth
I unit p.o.

t
an
lu mm

Fig.141. Johnstondiagram.

5.7.2 Growthin SNLine

A numberof methodsare basedon the averageincreasein the SN line, usingthis
for differentiatedpredictionof verticalandsagittalgrowthchanges.
The reliability
of thismethodis saidtobe70%. The Holdawaymethodbelongingto thisgroup
will be describedin a later chapter.

5.1.3 Ricketts'Short-Term
Prediction
Thismakesdistinction verticalandhorizontal
between srowth.Themethodissaid
to be 80%reliable

5.I.4 Ricketts'Computer
Analysis
(Fig.142):
Thisconsiders
(a) Individualgrowthcurvesfor theseparate
regionsof thefacialskeleton.
(b) Unusualgrowthpatterns(5Voof cases).
 The techniqueusedwith thiscommercialised methodhasbeenfully documented.
The basicmaterialsarecephalometric datarelatingto structuralsynthesis
storedin
the computer,with a structuralanalysisdonein the individualcase.Individual
assessmentis againbasedon statisticalmeanvalues.
This computerdiagnosis requiresthepatientto be a certainageandis alsolimited
to specifictreatmenttechniques. Otherwiseit is difficultto explaintheclaimmade
in relation to it that, with treatmentdurationof two years,70-80Voof changes
were due to treatmentand only 20-30Voto growth.
The computercanonlybe anaidin selecting andevaluating informationwithinthe
contextof treatmentplanning;itcannotbeusedto determinetheactualtreatment.
The final decisionwill lie with the orthodontistwho usesthe compurerasa source
of informationand asa control.
142

Fig.142. Tracing
for Ricketts'
analysis.

5.2 Sources
of Error in GrowthPrediction
Growth predictionis frequentlycomparedto theweatherforecast.The prediction
can be basedon certaindata,but so manyunknownfactorsareinvolvedthat we
can merely discerna certaintrend, and not make an accurateprediction.The
principalsourcesof error are the following:

5.2.1 VariableGrowthRatein RegionalGrowthCentres

Betweenthe8th and14thyear,for instance,themeanannualrateof increasein the
maxillarybaseis approx.0.8mm, comparedto 1.9mmfor the mandibularbase.
The growthratioof S-Ntomandibularbaseis 1:1.35to 1.65,thatofS-ArtoAr-Go,
1 :1 .3 .

153
 5.2.2 GrowthPatternNot FullyTakenintoAccount
Individualsare assessed only in relationto a populationmean.Many methodsdo
not even include considerationof the growthpattern.Our owninvestigationshave
shownthat growthrateswill varyquiteconsiderably for differentgrowthtypes.By
determining vertical increaseat gonion and horizontalincreaseat gnathion
(Fig. 1a3), we were able to establishthe following relationshipof vertical to
horizontal growth: With averagegrowth types,an increaseof 1mm vertically
correspondsto one of 0.8mm in the horizontalplane.With the verticalgrowth
type this ratio is 1mm:0.3mm,compared to Lmm:L.7mmin horizontal growth
types.Generallyspeaking,horizontal growth changesare more predictable
easily
than verticalchanges.

143

/I
tl
il
I
I
,

l\

Fig. 143. Measurements

l-].\
'!,
-*
Gn
to determinegrowthgain in the vertical
directionat gonionand horizontaldirectionat gnathion.

5.2.3 Relationship
of FormandFunction
The interrelationshipof form and function is not taken into consideration.A
markedincreasein the lengthof the mandible,for example,will not automatically
compensatefor ClassII malocclusionif developmentis subjectto interference
through dysfunction.
PatientL Ch. showeda markedincreasein mandibularbase.Due to persistent
dysfunction,however,the conditionof the malocclusionwas aggravated(Fig.
lMa, b).

t54
 I Ch.
196[
17.373

620 1170 S NA 900

S NB 7 7 t o
A NB 2o
SN-Pog 8 0 0

N- Pog
1+ 3,5mm
| -l,3mm

,14bt. Clr.
196/.
g776

30
11 S NA
63 0 ?q0
S NB
/(0
A NB a,J

100
SN- Pog IU

N-P o g
1 + 6 mm
t-l ,tmm

E$ l{4- Patient l.Ch. presentedwith Class ll dysgnathia

d grondfi type, and tongueand lip dysfunction.No ortho-
ffifeaEnent was given(a).Despitea considerable growthgain
h tF rnandibularbase area,intermaxillaryrelationshipsbecame
tonie, due to persistingdysfunction(b).

155
145a WM. S NA 7l \t'
/. l{. 0J 03,2
"/" S NB 7 1 q 0
1?,L 7L A l mm
A NB
---- 60
SN-Pog 730

-t
\
\
14g0 820

110
270
'100

/,Q0

1210

62mm

145b W.M
7.4.63 ?L Eo/
I J ,J I O SNA 880
1 .7 ,7 6 SNB Q 1q 0
ANB /, t0

SN-Pog850

620 1020

N- Pog
1 + 5mm
;^
I+lmm

Fig. 145. Ghangein directionof growth,patientW.M.An originally

average growth trend, with 63% (a), changed to one that was
extremelyhorizontal,with 75.5%(b).

156
T
t .l
Factors
5.2.4 Age-Related
Theseare not usuallygivensufficientattention,nor the factthat beforethe ninth
I year, when the directionof growth is not yet stabilised,a changein peristasis
(functionalenvironment)will frequentlycausea changein growthdirection.

I W.M., a girl aged 11, showedaveragedirectionof growthwith open bite and

ClassII malocclusion(Fig. 145a,b). No orthodontictreatmentwasgiven,but two
yearslater, whenthe patientreturnedto havethe needfor orthodontictreatment

I reassessed, the situationwastotally different.The mandiblehadmovedforward,

and the rateof growthwas10mm,with forwardrotation,sothatthe openbitohad
disappeared. The directionof growthhadbecomehorizontalin the extreme.The
t skeletal relationship,originally retrognathic,had becomeprognathic.Ante-
inclination(y-angle)had reducedby 16"(ante-inclination maybe misinterpreted
asprotrusion;it is merelya pseudo-protrusion). Shehada historyof suckinghabit,
I -!
bui this had stoppedduringtheperiodof observation. The changes
predominantlydue to the growthspurtsof puberty,andchanges
werehowever
in the functional

I environment.

i al
{
of Treatment
6 GrowthFollowingConclusion

I s
Growth predictionalsoservesto assess growthchangeswhichoccurafter treat-
ment hasbeencompleted.A radiographof thehandwill helpto givea quantitative
assessment of suchchanges. Cephalometric radiographyenables usto estimatethe
I consequences growth
or effectsof post-therapeutic phases,a factorfor
significant
stabilityof resultsandlengthof retentionperiod.The post-therapeutic changes to

I
are
be expected shown in Table19 (the mean valuesgivenare intended asa guide
only; theyare not standards).

anteriorgrowth
pointA 1.36m m
; pogonlon 3.62mm

It condylargrowth
vertical
horizontal
5.4mm
1.0mm

gonialangle
caudal 4.34mm
anterior 0 .4 1 mm
Anterior growthof mandible.
occlusal Decreasein:
6 1.25
mm SN-MP, ANB, B, Go angles
6 0.99mm 1-tltt
T-position dependingon vertical
mesialtilt growthchanges(unfavourable
7.2" angulation* directionof
6 growth= tertiarycrowding).

growthgains.
Table19. Meanpost-therapeutic

1.57
 6.1 Fine Adjustmentof OcclusionAfter Treatment
growthchanges
Post-therapeutic andplaya rolein fine
mayaffectintercuspidation
adjustmentof the occiusion.

6.7.1 AnteriorGrowthof theMandible

This occursduringthefinalgrowthphase.Its meanvaluein thepogonionregionis
3.6mm.The SN-Pogangleincreases by 1.5",the ANB anglegrowssmaller.

6.1.1.1 With horizontalgrowthtendencies, this phaseof growthhasan effectin

the sagittalplane.The lowerincisorsmay becomemoreupright,or a shortageof
spacemaydevelopin theregionof thelowerincisors,resultingin tertiarycrowding
(Fig.146).If incisaloverjetisminimalandtheoverbitedeep,extended retentionor
at leastfollow-up until growth is completeare indicatedwith this growth type.
Fine adjustmentof incisor occlusionby selectivegrindingis definitelycontra-
indicatedbeforegrowthis completein thesecases(Fig.147).Thisfinalopportunity
for correctionshouldbe taken only whenfurther growthchangeswill no longer
affect the result.
146

Fig.146. Tertiarycrowding.
6.LI.2 With verticalgrowthtendencies, the final growthphaseaffectsrelation-
shipsin the anteriocaudal directionanddoes not influenceincisorocclusion,which
may theretorebe adjustedon conclusionof treatment.It is not usuallynecessary
to stabilisethe lower front regionby extendedretention.

6.I.2 MesialInclinationof UpperSixth-Year

Molars
This is 7oon average,with mesialmigration.It arisesthroughadaptationof the
dentition to forwardre-locationof the mandible.Finalstabilitydependson good
interdigitationof the sixth-yearmolarsat the end of the growthperiod.A ClassI
molar relationshipis not in itself sufficientfor good occlusion,and contact
betweenthe distobuccalcuspsof the uppersixthandthe mesiobuccal cuspsof the
lower secondmolaris alsorequiredfor stability(Fig.148;Andrews). With a ClassI
occlusion,thiscontactis obtainedonly throughmesialinclinationof theupperfirst
molars.

158
I i47

I
t
I
I
I
T
I
I
I
for
Fig. 147. Selectivegrindingof incisorsis contra-indicated
I horizontalgrowthtypesbeforegrowthhasceased.

t 148

I
I
l
t
I
I
Fig. 148. Mesialtilt of 6th-yearmolarsin the upperdentalarch.
I Cl a s sl o c c l u si o n .

1) 9
 6.I.3 FinalAdjustmentof Occlusion
The exactrelationshipof the molarsis determinedby thefinalgrowthphase.This
final adjustmentis calledthe 'occlusalphenomenon'. The changes are due to
vertical growth, especiallyin the condylarregion.Occlusalmigrationof upper
(1.25mmon average)andlowermolars(1mmon average) is observed.

6.1.3.1 In horizontalgrowthtypesthesechanges maycausea slightopeningof

bite, withoutprejudiceto the stabilityof treatmentresults.

6.1.3.2 In verticalgrowthtypes,showing minimaloverbite, a slightopenbitemay

developduring this final growth phase,and retrognathism may be enhanced
(Fig. 1a9).Extendedretentionor at leastfollow-upobservation will berequiredin
thesecases. grindingispermissible
Selective onlyaftertheactivegrowthperiod,to
achievea goodmolarrelationship at a timewhengrowthchanges will no longer
affectit.

149

Fig. 149. Selectivegrindingto correctmalocclusion

in the molar
beforegrowth has ceasedin vertical
region is contra-indicated
growthtypes.

16{j
7 HoldawayGrowthPrediction

The Holdawaymethodholdsa specialpositionamongmethodsof prediction.It is

based on accurateconstructionrelated to referenie points, but also permits
individualpeculiaritiesto be takeninto accountfor ratb of growth,direition of
growth, and treatment principles.In planning, one can assessthe different
possibilities,dependingon growth rate and treatment principles,and thus
'visualise'certaintreatmentobjectives.Holdawayactuallyrefersto hismethodas
'visualisedtreatmentobjective;.
An attractivefeatureof the methodis its flexibilityand the fact that it doesnot
lay down treatmentprocedures.The orthodontistis still free to make his own
decisions.We have testedthe method and, in view of the aboveadvantages,
includedit in our treatmentprogramme.It enablesus to makea dynamicassess-
mentof facialmorphologyin manycases,andalsoservesasa guidein thechoiceof
treatmentprinciples.

7.1 The TwelveStages

of the HoldawayAnalysis
To demonstratea two-yearpredictionof growth, the separatestagesof vTO
(visualisedtreatmentobjectives)are describedbelow.Holdawaydistinguishes
L2
phasesin the analysis.
(1) First, the fronto-nasalarea and SN and NA linesare tracedon a sheetof
acetatefilm. Growth predictionis basedon changesin SN (Fig. 150).
The-SNAanglemaybe takento beconstantfor short-termprediction.According
to Holdawayit probablychangesby 1"in 5 years.A concomitant
changein NA will
thereforealsoserveto determinemaxillarygrowth.
(2) Superimposing on line SN, thevTo is moved1.5mm alongSN,relativeto the
original tracing.This corresponds to an annualgrowthof % mm. In thisposition,
the sellais drawnin, andtakinginto accountthetreatmentprinciples,theY axis.In
most casesHoldawayopensthe SN-Gnangle(Y axis)by 1,-2"(Fig. 151).
We introduceda modificationto the effectthat the Y axiswasopenedby 1-2'if
there was distalisation,left in its originalpositionwith activatbrtherapy,and
slightlyclosedwith extractiontherapy.
(3) Superimposingthe 'VTO'Y axison theoriginalY axisandusingtheY axisasa
growth parameter,the mandibleis relateddownwardsand forwardto SN.
This determinesanteriorfaceheightand the anteriorpositionof the mandible.
The two Y axesare superimposed and the VTO is movedupward.The amountof
movement should be equal to three times the amount of growth expressed
previouslyin the fronto-nasalarea (in the presentcaseby 4.5mm). Nbw the
anteriorportionof the mandibleincludingthesymphysis, borderandGo-Gn(Mp)
line are drawn,and alsothe soft tissuechin, eliminatingany hypertonicityin the
mentalis(Fig. 152).
() Horizontal growth of the mandibleis outlinedby movingforwardalongthe
Go-Gn line. The posteriorpositionof the mandibleand ascendingramui are
drawn when the two sellaelie in the sameverticalplane(Fig. 153).

1,61
Figs.150-155. Holdawaystages1-6. stages7-12.
Figs.156-161. Holdaway

162
 (5) On the assumptionthat facial growth may be dividedinto three.sections
betweennasionand menton,and that the seciionbetweennasionand maxilla
representsone-thirdof the totalfaceheight,one nowproceeds
to determinethe
verticalpositionof the maxilla.
The two NA linesaresuperimposed;
407ooftotalgrowthwill lie abovetheSNline,
60VobelowGo-Gn.
The maxillais drawn in, then point A is estimated,dependingon the treatment
mechanicsandthe nose,takinginto account1mmof growthpeiunnu* (Fig.15a).
(f) Superimpose,with the two NA linessuperimposed and the growthincrease
distributed so that 50Vois above the maxilla, and 50Vobeloi rhe mandible
(Fig. 155).Now drawthe occlusalplane,it shouldlie 3mm belowthe lip base.
(7) At this stage,one of the most importantaspectsof the VTO, the extentof
repositioninggf the upperincisorsis determined;it servesasa guideto drawthe
soft tissueprofile betweennoseand chin.
Soft tissuethicknessbetweenpoint A and lip profile remainsunchanged.Its
repositionis determinedonly by the newpositionof point A.
The structuresalongthe maxillarybasearesuperimposed; thesofttissuethickness
taken from the originalis drawnin anteriorto the newpoint A.
The upper point for constructingthe H line lies 3-7mm anteriorto the new lip
profile, in the regionof subnasale.
The H line is drawnfrom thispoint to themostanteriorsofttissuepointon thechin
(Fig.1s6).
(8) Relocatethe upperincisors- dependingon treatmentprinciples- to allowthe
upper lip to rest exactlyon to the H line, to createthe desiredaestheticeffect.
The upperlip will not follow theupperincisorsuntil lip strainhasbeeneliminated.
The lip is free from strainwhenthe lip thicknessanteriorto the incisorsis within
1mm of tissuethickness anteriorto the A point.
The upper incisorsare movedback by the distanceto which the upper lip lies
anterior to the H line plus the extent of lip tensiondeterminedUy^ttreubou.
method, and verticallyalignedto the occlusalplane.
The p,rofileof the mouthis drawnin, with theupperlip on theH line,andthelower
lip 0.5mm anteriorto theH line (Fig.157).
(9). Superimposingthe symphysisand Go-Gn line on both tracings,the lower
incisorsare drawnin relationto the upperincisors(Fig. 158).
(10) The lower molarsare drawn, taking into accountextractionand available
space,with the drawingssuperimposedasbefore(Fig. 159).
(11) The uppermolarsare drawn,in neutralrelationship(Fig. 160).
(12) At the final stagethe constructionis completedin the regionof pointA, the
palate,and the symphysis (Fig.161).
Our follow-up-studieshave shownthat, with vTo, growth is more easilypre-
dictablein thehorizontaldirection,whilstverticalrelationships
anddento-alveblar .
movementwerelesswell demonstrated. I
Furthermodificationsrelatingto annualgrowthrates,moredetailedconsideration
of the.dire.ction_ofgrowthand the methodsof treatmentemployed,mayimprove T
the reliabilityof prediction. I

1,63 I
l
I
 T
I
CephalometricRadiography
in TreatmentPlanning I
I
Effective treatment planning dependson accuratediagnosis.This requires
objective,relevantandaccurateinformation,dataandanalyses.The criteriaused I

I
shouldcoverthe wholeorofacialregion,yet theymustalsobe selective. The key
facts need Tin
to be considered conjunction.
secondaryimportancefor decisions
Accessorydetails that are only of
to be madeandthe actionto be taken,should
j

be ignored.
Individual dataneedto be selectively relativeto the
for their significance
assessed I
i,
I
time. This proceduremay be designated
reactionsmaybe registered
total courseof treatment,so that unexpected
a continuousdiagnosticprocess.
in good

Cephalometricradiographyis just one link in the complexof datacollection.Its

II
I
i' relative value in providing information for overallplanningwill vary from caseto
i case,dependingon the natureof the anomaly,the ageof the patient,and the
i,
.l possible forms of treatment. Cephalometricradiographyis not a once-only
l

I
investigation,but needsto be repeatedin the courseof treatmentaspart of the
il continuousdiagnosticprocess.
,li With regardto treatment,accurateplanningenables:
li (a) Applicationof the simplestandmosteffectiveform of treatmentin eachcase.
(b) Selectionnot of the patientfor the method,but of the methodfor the patient,
i.e. the indication and contra-indicationof different methodsis established.
II
(c) Differential diagnosisto establishindication for variousfixed or removable
appliances,or for combinedmethodsof treatment.
As an example,let us considerthe mostwidelyseenanomaly,a ClassIL occlusal
I
relationship.
I
1 The Roleof Cephalometric in
Radiography
Treatmentfor ClassIL Patients I
Before proceedingto treat this anomaly(whichis a collectiveterm, and not a
particularcondition),a numberof differentialdiagnosticstepshaveto be taken.
Notonlli maythe anomalytakemanydifferentforms,butthemethodsoftreatment I
availableto us - and theseneedto be consideredin treatmentplanning- have
times.
changedwiththe
The different theoriesmay be summedup asfollows:
I
changesare possible.
(1) Only tooth movementand dento-alveolar
(2) Orthodontic techniquesmay be effectivelyusedto stimulatebone growth.
t
(3) It is possibleonly to bring out the individualpotentialfor optimumgrowth,as
already laid down genetically.
T
(4) Direction of growth may be changed.
(5) Orthodontic techniquescanbe usedto changethe time patternof growth.
I
(6) It is possibleto inhibit growth in the mid-faceregion.

L&
The term ClassIL malocclusioncoversa wide rangeof dysgnathicconditions,and
the form of treatmentto be chosenwill dependon the natureof the anomalyand
the developmentalstageof the stomatognathic system.Tooth movementin the
dento-alveolarregion is alsopossibleafter cessationof growth.Stimulationof
bone growth, encouragement of growth potential,and changesin directionof
growth cannotbe contemplatedafter thispoint in time.
The time pattern of growth changesand the sequence of tooth eruptioncan be
influencedonly in mixed dentition.Guidanceor inhibition of suturalgrowthin the
mid-faceregion can be effectedonly during activegrowth.
The transitionaldentition stagenevertheless
offers the best opportunity for
ClassIL therapy.

1.1 Localisation
of theMalocclusion
The key questionin decidingon a courseof treatmentis the localisationof the
anomalywithin the facialskeleton.This is considered
at four levels.
{trJ Level one is the occlusalsituation.This may be changedat any time, by
nninororthodonticproceduresor selectivegrinding.
11) Level two is the relationshipof the teeth to the periodontium.Treatment
proceduresin this area are indicatedwith dento-alveolar anomalies,or if com-
pensationof a skeletalmalocclusion in the dento-alveolarregionis required.At
rhis level,effectivemeasuresmay be takenevenaftercessation of growth.
t3J The third levelis that of the facialsuturesandtemporo-mandibular joints.At
this level, effectivetreatmentis possibleonly duringactivephasesof growth.In
casesof skeletalmalocclusion, growthmaybeinhibitedor stimulatedby headgear
or activatortherapy.Oncegrowthhasceased, in skeletalrelationshipcan
changes
be effectedonly throughsurgicalmeasures.
l-f The fourth level, that of the synchondroses
and cranialsutures,cannotbe
frnfluenced
by orthodontictherapy.
Localisationof the malocclusion,takinginto accountthe periodsof activegrowth
still to come,permitsthe decisionto be madeasto whethertreatmentshouldbe
causalor compensatory.Dento-alveolarClassII relationshipsusuallypermit
causalrehabilitation.With skeletalClassII relationships,
on the otherhand,thisis
possibleonly duringactivegrowth,on theconditionthatthe directionof growthis
also favourable.
Cephalometricradiographyprovides the data for diagnosticdifferentiation
bet"rreen
skeletaland dento-alveolarClassII anomalies.If the anomalyis skeletal
the ANB angleis large, due to the SNB anglebeingtoo smalland/orthe SNA
angle too large. With a dento-alveolar Class II anomaly, the upper incisors lie
anteriorto the NPog line, with the lower incisorsfrequentlysituatedbehindthis
line; protrusionis frequentlyseenin the maxilla,andvery uprightincisorsin the
mandible.The skeletalrelationshipsare balanced.The historywill often reveal
dysfunctionor earlylossof primaryteeth.

of ClassII Occlusion
t.2 FunctionalAssessment
Cephalometricradiographywill provide valuable additional information in
functionalanalysis.

165
Lz.l Relationship Position
of Restto Occlusal
This can be accuratelyrecordedand analysedby radiography.The following
variationsmay be found.

I.2.I.1 The movementof the mandibleis hinge-likeasit changes from the rest
to the occlusalposition, i.e. functionaland morphologicalrelationshipsare in
accord,the anomaly'shows Intermaxillary
functionalbalancewith no translocation.
relationshipsand the rest positioncan only be changedduringactivegrowth,if
at all.

L2.1,.2 The mandiblemovesforwardasit changesfrom the restto the occlusal

position.The functionaldisorderis more seriousthan assessment of the occlusal
positionwould suggest.Translocationresults in forward sliding of the mandible,
ind the full exteni of the anomalycan only be assessed once this has been
eliminated.The prognosisis poor with anteriordisplacement of themandible,the
only possibleform oJcorrectionbeingdistalisation of the upperteeth.

L.2.I.3 The mandiblemovesbackwards fromtherestto theocclusal

asit changes
position. Its anterior position at rest showsa ClassI relationship,retrusion
bccurring through translocation.This may arise not .only through abnormal
contacts-inthe intercuspidation,but also through incisor guidancewith deep
overbite.Adequatecorrbctionmay be achievedby eliminatingthe translocation.

L2.2 Assessment in Relationto Incisor

of Lip Configuration
b)
andAngulation1rig.L62a,b;163a,
Relationship
The relationshipof upperand lowerincisorsto the lowerlip maybe shownin the
radiograph.De^pending on the directionof loading,the upper incisorsmay be
tipped hbially throughpalatinalpressureand/orthe lowerincisorslingually.Lip
dyifunction witt have much mor-eseriousconsequences with a ClassII skeletal
relationship- becauseof the unfavourablerelationshipof the maxillaryand
mandibulai bases- than would be the case with an orthognathicskeletal
relationship.

of
of TonguePositionandConsequences
1,.2.3 Assessment
TongueDysfunction
The position of the tonguemay be demonstrated radiographically.-.yitla flat,
retraited tonguethe prognosis ior forwardpositioningof the mandibleis poor.
Dependingoi cranialielitionships, tonguedysfunctionwill havedifferenteffects
in a ClassI"Irelationship.With a horizontalgrowthpattern,tonguethrustresultsin
bialveolar protrusion; with vertical growth-pattern, it causesvery upright
positioningbfttre lower incisors(Fig. 164'165).

of UpperAirwayPatency
I.2.4 Assessment
Enlarged adenoidsmay be distinguished in the radiograph.A- flht tongueand
verticil lip incompetenteare further symptomscharacteristicallyseenwith oral
breathing(Fig. 166a,b).
 162a 162b 163a 163b

Fig.163. Lip configuration for horizontalgrowthtype,in occlusal

(a)and restposition(b)of the mandible.
Fig.162. Lip configuration for verticalgrowthtype,in occlusal(a)
and rest position(b)of the mandible.

164
uu,u / 0

SNA 760
SNB 770

N-P o g
1 + 2 mm
1^
t-l mm

Fig.164. Tracingfrom radiograph of a patientwithtonguethrust,

horizontalgrowthtype. Tonguethrust has produceda bialveolar
protrusion.Relationof posteriorto anteriorface height 66.6%,
protrusionof upperand lowerincisors.

t67
16 5 WD.
13 .1611
qA ?o/
16.10.73 JU, L / O

S NA 7 L O
S NB E g O

N-P o g
1 + 1 mm
;.
| -t mm

Fig. 165. Tracingfrom radiographof patientwith verticalgrowth

trend and tonguethrust.Tonguethrust has givenrise to upright
positionof incisors,mainlyin the mandible.
Relation of posteriorto
anteriorface height56%, inclinationof long axis of lowerincisors
relativeto MP71".
166a 166b
1 66b

Fig. 166. Assessment n the radiograph.(a) Large

adenoids,patencyof upperrespiratorypassagesreduced.(b)The
samepatientafteradenoidectomy.

16b
I.3 GrowthDirection
For treatmentplanning,it is essentialto determinethe directionof growth.
If the growth type is horizontal, correctionof antero-posteriorjaw relationship
usually presentsno difficulties, whilst that of deep bite is difficult, and will no
longer be possiblefollowing extractionof the premolars.
If the growth type is vertical, openingthe bite usuallypresentsno problem, but
correction of the antero-posteriordental arch relationshipis frequently not
possible.Good resultsmay be obtainedfollowing extractionof the premolars.

I.4 GrowthPotential
Therapeuticcorrection of the occlusionis partly contingenton phasesof active
growth. One problem of diagnosisis determinationof prospectivegrowth.If the
mandibleis too smallin casesof ClassII malocclusionin mixeddentition,growth
may be expected to be quite considerable.A well developedmandible in a
posterior position must be consideredto offer poor prospectsfor successful
correction of Class II malocclusions,except in caseswith translocation.In
assessment, distinctionmustalwaysbemadebetweenpositionandsize,andit is for
this reasonthat not only anglesbut alsodimensions are determined.

1.5 AetiologicalAssessment
When the anomalyhas been localisedwithin the facial skeleton,and functional
relationshipshavebeendetermined,it is possibleto drawcertainconclusionsasto
With skeletalClassII anomalies
the causeof the malocclusion. the causalfactoris
hereditary. Dysfunction on the other hand will give rise to malocclusions
region.
localisableto the dento-alveolar

Plan
2 DetailedTreatment
Evaluationandassessmentbeingcomplete, to decideon the
it is nownecessary
planof treatment.
DuringthemixeddentitionperiodClassII occlusionsmaybetreatedasfollows:
(1) Eliminationof dysfunction therapy.
by inhibitional
(2) Anterior positioningof the mandiblewith functionalappliances.
(3) Movementdistallyin theupperjawwithheadgear therapy.
of (1) to (3).
(4) A combination
 2.I Elimination of Dysfunction
Adverse habitsmay be treatedby inhibition or the useof a screen(the Frdnkel
function correctoris an applianceof this type). If the causeof the anomalyis a
functionaldisorder(e.g.consequence of a suckinghabit),eliminationof thecausal
factor should enablefurther developmentto follow a norrnalcourse.Tongue
thrust or lip suckingneedsto be eliminatedand functionrestoredto normalif
optimum developmentof the dentition is to be ensured.A pre-conditionfor
successful treatmentin thesecasesis that endogenous development must follow
normal trends. Cephalometricradiographyplaysa key role in the differential
diagnosis.If the historyandclinicalandfunctionalanalysissuggest dysfunctionas
the causalfactor in the anomaly,radiographywill be neededto confirm the
tentativediagnosis.The influenceof abnormalmusclepressures maybe localised
in the dento-alveolarregion.If thereshouldalsobe a skeletalcomponent,thiswill
be developmentalin origin and can be influencedby inhibitorytreatmentonly
indirectly,at the beginningof the mixeddentitionperiodat the latest.Inhibition
therapywill only inhibit the functionalfactor,permittingunrestrictedgrowthto
the patient'sinherentpotential.
The effectsof dysfunctionare entirelylimited to the dento-alveolar region,asis
evidentfrom numerousclinicalandexperimental studies.Hypoglossia providesan
excellentillustrationof this.The conditionwill causeinhibitionof growih,but only
in the dento-alveolarregion.

A male patient aged35 presentedwith severemalocclusion due to hypoglossia.

Cephalometricradiographyrevealeda horizontalgrowth type, a small gonial
angle, and normally developedmaxillaryand mandibularbases.Severeabnor-
mality washoweverfoundin the dento-alveolar relationshipof the anteriorteeth.
The upperincisorswere8mm anteriorto the NPogline, with their longaxisat an
angleof 117"to theSN plane.The lowerincisorswereL6mmposteriorto theNPog
line, and very upright,at 74"to the MP (Fig.167a,b; 168a,b).
Inhibitionaltherapy,designedto restoreabnormalfunctionto normal,is a causal
form of treatment,and can be effectivelyusedonly during the phaseof active
growth. It will be most effectiveduring the eruptionof the permanentincisors,
when not only bonegrowthbut alsothe eruptionpotentialarefully utilisable,and
it is possibleto influencedevelopmentin the regionof the facialskeleton.
A 6-year-oldboy (8.N.) presented with markedClassII' malocclusion andadverse
lip pressuresafter eruptionof the lowerincisors(Fig. 169a,b). The anomalywas
verymarkedfor suchan earlyage,with a skeletalanda dento-alveolar component
aswell asseveredysfunction.Early treatment,duringthechangingof the incisors,
was indicated.It is still possibleat this stageof developmentto eliminatethe
dysfunctionand normalisefunction, and thus alsoachievea positivechangein
skeletaldevelopment. Whenall theincisorshaveerupted,thispossibilitygenerally
ceasesto exist.
The patient showedmarked horizontalgrowth tendencies,the relationshipof
posteriorto anteriorfaceheightbeing67Vo.Mid-facedevelopment wasconsider-
able, with an SNA angleof 81.5".The mandibularbasewasretrognathic,with
SNB 74.5",and too short(-8mm). The basaldiscrepancy of theANB angleswas
7". The upper deciduousincisorswere9mm anteriorto the NPogline, the lower
permanentincisors4.5mm posteriorto it.

170
Inhibitionaltherapywasinitiated.A screenwasmadeto fit the vestibule,andthis
was designednot-only to eliminatethe dysfunction,but alsoto permit forward
movementof the mandibleand inhibit growthin the uppel apicalregion.

of InhibitionTherapy
2.I.1 Principles
of inhibitionor
At this point, referencemay be madeto someof the principles.
screeningtherapy.This approachis governedby considerations'
functional

2.]1l1 Functionalsoimpliestheapplication forceexertingstrain.

of mechanical
is
If the mechanicalstresshasa fixeddirection,a change producedin the dynamic
balanceand hencein bonestructure'
The functional forces applied producechangesin alveolarbone, with tissue
adaptationoccurringsecondarily.The conceptson which inhibition therapyis
basedmay be summarised asfollows:
influenceon structure'
(a) Functionhasa considerable
(b) A naturalfunctionwill producea naturalstructure.
(c) An unnaturalfunctionwill producean unnaturalstructure.
(d) Changesin functionwill alsoleadto changesin structure.

2.1.1.2 On the otherhandit mustbe stressed functions,

that,like all biological
tissueshavea common property, i.e. a certainabilityto adhere to a developmental
predetermined'
trend that is phylo-genetically
Negativeexternalfactorsarethuscounteredby heredity.If thehereditarydisposi-
tioi is a normal one, the developmental trend of the stomatognathic systemwill
alsobe normal.
The effectsof externalfactorsare undercertainconditionscounterbalanced by
hereditaryfactors.The pre-condition for achieving such a balanceis elimination of
unfavourible externalfactorsduringthe earlystagesof development. The early
exclusionof harmful exogenic factors can enable normal development of the
dentition to take place.
The principleof this form of screening is that the situationnormalises itselfonce
externalfactorsliableto interferewith normal development havebeen eliminated.
The pre-conditionsfor this are:
developmenttrend.
(u) A normalendogenous
(b) Causalinterventionhasto be appliedat an earlystage,whenthe masticatory
systemstill hasgrowthpotential.
The therapy is called inhibitory becausereflexesof unphysiological origin are
inhibitedan-dno.maldevelopment Thisform of treatmentdoesnot
is encouraged.
enableone to move teeth or guidedevelopmentin the maxillaor mandible.It
merelyexcludesmalfunctionto permitnormaldevelopment, i.e. oneis simulating
spontaneous correction.The treatmentis physiological and causal, with no risk of
tissuedamageor relapse;we are thusbreakingthe unnaturalreflexsequence at
one point, and enablingthe rehabilitationof naturalreflexes.

177
 2.I.1.3 The requirementsfor theseapplicances, which do not involvethe
applicationof force,but merelythe eliminationof pressure,areasfollows:
(a) They are designedto eliminateunnaturalfunction.
(b) They must not preventthe tissuefrom returningto its normalconfiguration.
(c) They shouldreplacethe originalsignal,the stimulus.
2.7.7.4 The vestibularscreenindicatedin the caseof patientB.N. had to be
constructed,accordingto specificprinciples,to meet the requirementsoutlined
above(Fig. 170a,b, c).

67a

i7b

Fig.167. Malepatientaged35withhypoglossia. (a)Floorof mouth

clearlyvisible,(b) patientwith maximumprotrusionof tongue.

172
l'"
15Ea

138 b
M.H ,
2 5 ,8 .3 9
1 37 .7 t, 7 1 ',7 " 1 "
SNA 8.]0
SNB 720

'2130

N-P o g
1 + 8 mm
| -t"0. mm
|

Fig.1 6 8 . M a l epatientaged35 with hypoglossia.

(a) Radi raph,
(b)tracing.

LIJ
 t.
il
I

69a

69 b b!
2i 5 7 0 67"1"

S NA 8,],50
6250 980 S NB 7(,50
A NB 7o
SN-Pog 770
1130

N-P o g
1 + 9 mm
j-L , lrt

(b)tracing'
(a)Radiograph,
Fig.169. PatientB.N.,beforetreatment.

1-'
t
I ',-0,
I
t
I
I
I
riob
I

I
I
I
I
t '- 0 c
|

I
I
I
;

I Fig.170. Vestibularscreendesigned pressures.

to inhibitadverse
ta) Anteriorview,(b) innersurfaceof the appliance,
(c) appliance
withholes.
 I
171a I
I
l
t
I
I
t
t
I
171b B .N , I
\<.
7101"
u,.5.70
7 3s , 7 7
S NA
S NB
A NB
SN-Pog

\':;

N-P o g
1 + 1 , mm
5

Fi1.171. PatientB.N.,after12monthstreatment.
(a)Radiograph,
(b)tracing.

a -a
1rO
 The screenis madein revisedworking bite, doesnot comein contactwith the
teeth, and extendsthroughoutthe vestibule,from the upperto the lower muco-
labialfold andposteriorlyasfar asthe lastmolars.Directcontactwith the mucous
membraneexistsonly in the regionof the uppermucolabialfold. The teethon the
plaster model were coatedwiih wax befoii the screenwasconstructedon the
model,to preventdirectcontact.

Sft9. oneyear'streatmentwith thevestibularplate,extensivechanges

werenoted
in the skeletaland alveolar_regions(Fig. 17ia, b). The ANB aigle had been
|9dy^ce!to 1.5o,due to a reductionin SNA to 78",whilstSNB hadincreasedto
76.5'. Forwardmovementof the mandiblehad occurredin conjunctionwith
a
5mm increasein its length.The age-related incrementwouldhavebeenno more
than 2mm. No growth changes*ere noted in the area of the maxillarybase.
Vertical growth showeda considerableoverallincreaseamountingto 7mm in
posteriorface height (5mm abovethe averagerate) and 8mm in Interior face
height (also 5mm above the average).ThJ horizontalgrowth tenOencynaA
increased(to 7-7vo),the incisor relitionship becomenoimal, with the upp",
incisorsnow 1.5mmanteriorandthe lowerincisor1.8mmposteriorto the f.ieog
line.

I:. ?PPttunce was usedduring a phaseof activegrowth. It eliminatedfactors

inhibiting mandibulargrowth,lno intriultedgrowi"hin the maxitiatyiegion. rt
would not havebeenpossibleto achievethe5.5-"reductionin ANB ungi.*ittt ru.t
simplemeansat a later stageof development.

2.1.2 Indicationof InhibitionTherapy

Thisform of treatmentisfrequently
indicated
in bothprimaryandmixeddentition.

2.L.2.I With primarydentition,it maybe used:

(a) For all acquiredanomaliesarisingthroughmalfunction.
(b) For disordersof speech,swallowingand breathingthat are of peripheral
origin.
(c) As a preliminaryform of treatmentwhereactivatortherapyis to follow.
(d) For follow-uptreatmentof habitualmouthbreathingafteradenectomy.

2.1.2.2 Indicationin MixedDentition

With mixed dentition,inhibitiontherapywill not tisuatlybe adequateasthe sole
form of treatment,and it will be necesiaryto usethe methodin c^onjunction
with
others.

2.1.2.2.1 Inhibitiontherapyastheonlyform of treatmentisin principlesutflcient

only wherethereis no needto alter the restpositionof the mandible.In contra-
distinction1o the primary dentition,the rangeof indicationis limited with this
{oup. 9{y recently acquiredanomaliescin be considered,where no other
abnormalityis presentapartfrom the consequences of dysfunction.
very much as in the caseof the primary dentition,it is enoughto changethe
externalfactorsto allow spontaneous correctionto takeplace.

777
 In thesecases,inhibition therapyis causal,effectiveand physiological.
The resultsof treatmentwith screenappliances
arenot resultsof treatmentin the
activesense.We arehowevermakingit possiblefor the dentitionto developin the :;l
I

normal way for that particulardentition.

That is the essentialnatureof inhibitiontherapy,andthe methodis not difficultto
use.In makingthe diagnosis, it is howeverimportantto makean accurateclinical
assessment, and here functionalanalysisand cephalometric radiographyare of
prirne importancein determiningthe indication.If developmentis followinga
normalpatternandno changes arerequiredin therestposition,inhibitiontherapy
may be expectedto givegoodresults.If development is not alongnormallines,our
effortsto changeexogenicfactorsarein vain.We arethennot dealingwith normal
development,but one that is normal for that particulardentition only, and,
accordingto our concepts,abnormal.

2.I.2.2.2 In mixed dentition,inhibition therapyis very frequentlyindicatedin

conjunctionwith anotherform of treatm'ent:
(a) In caseswhere inhibition therapycorrectsthe part of the anomalythat has
been causedby dysfunction.Any anomalystill persistingafter suchpreliminary
treatmentmay be considereddue to heredity.
Treatmentis then continuedwith activdtherapy,and afterpreliminaryinhibition
therapythis can givegoodresults.
Inhibition therapyis frequentlycombinedwith functionalorthodontictherapy,
where eliminationof the dysfunctionand its sequelaeis followedby functional
appliancetreatment.This approachis indicatedparticularlywheredysfunction
needsto be eliminatedbeforefunctionalorthodontictherapyis initiated,or for
childrenwho becauseof lackof tonein the circumoralmusculaturehavedifficultv
in gettingusedto a functionalappliance.
In the courseof suchpreliminarytrea,tment,
onewill oftenobservea considerable
changein intermaxillaryrelationships.
(b) The usualform of functionalorthodontictherapymayalsobe combinedwith
concurrent inhibition therapy; if an activatoris worn at night, for example,
harmful externalfactorscanbe eliminatedduringthe dayby useof a lowerlip or
tonguescreen.
(c) Inhibition therapyis alsoindicatedas a preliminaryto activatortherapyin
casesof habitualmouth breathingwith lip incompetence,
We havefound that the restingpositionof the tonguetakestwo forms:
Type 1: The dorsumis flat, the tongueextendsoverthe floor of the mouthwithin
the lower dentalarch.This tonguepositionis seenwith prognathism and
wheremouth breathingis nasalin origin, occurringin conjunctionwith
massivelyenlargedadenoids.
Type 2: Tongueretracted,with dorsumcurvingto form an arch.The tip of the
tongueis on the line joining the premolarsor siith-yearmolars.
The vestibularscreenis effectivewith the type 2 tongueposition. Following
insertionof the screen,the tongueachievesa higherposilionand hencecontact
with the soft palate.
In establishingthe indicationof inhibition therapy,cephalometricradiography
may be usedto supportclinicalassessment and functionalanalysis.

178
 2.L.2.3 The o.fCephalometricRadiography
.Rol. in
theIndicationfor Inhibitiontfi.iipi -^
Esrablishing
cephalometricradiographymakesitpossibleto judge
whetherif afterelimination
of the dysfunction growth trend is likery;;G;;r-a_r.
.tfre
requiredto establish The principalsigns
the indicationmay be summarised asfollows:
{a) Differential diagnosisof primary ard secondary
tongr,re dysfunction.with
primaryrongue dystunction, tireanomaly islocateJ rnirre"oent;-.1;;;ilr.gion.
The SN-MeGoangle,the.angleof thebaseplane,
it.-*gt.
and mandibularpranes,is inall, with the'growrii'jvp. betweenthe occlusal
rnalocclusionhas-beencausedby tongue more horizontar.The
disfunctiori secondarytonguedys_
functionconsistsof adaptationin ihetongueiunction
toa skeletalopenbite. The
above-mentioned angleiare rarge,with g:rowtilil; verticar.
(b) Differentiald-1|g-no:itof overjetdle to lip dysfunction andoverjetarisingfrom
a discrepancybetweln the maxillarybases.'
lvith overjet due to lip dysfunction,skeletal
relationsare within normalrange
tA\B angle).The upp-erincisorsare tippedr.uaily, the lowerlingually.The
lowerincisorslie behindtheNPogtine.iftne ou.r;.t ""d
i, o* to skeletaldiscrepancy,
the ANB angleis large,the loweiincisorstt.qurntty
tie anterior
a3d.thg lip dysfunctionmay be secondary,aii. io'uoupiution to theNpog line,
skeletalrelationship. to the undeslrabte

Inhibition therapyis indicatedonly with

the firsrgroup.
2.1.3.1 LowerLip Screen
trfa ClassIIl1 malocclusion in the mixeddentitionwith markedoverjetandlip
dysfunction is to becorrected,a combinationof actrvator orperhapsalsoheadgear
ylerapyanda lowerlip screenwill frequentlybe themethodof choice.A lower
lip screenis in fact the lowerhalf of a vestibularscreen. It is positionJ in tt.
regionof theloweralveolarprocess andextends to thelevelof theincisalitriiOot
the lowerteeth.Contactwiththemucosa is limitedto theareaof themuco-labial
frdd-aodthereis no conractwith theteeth.Anchorage ,rt il;il#;; ,iring
w€rEd Arlnmsclasps fittedto thesixth-year molarslApaitfromthis,the;;;een
doesnottouchthete-eth, andevenin closed bitethereisnocontact withtheupper
teeth(Frg.172a,b).
Tte indicationfor a lowerlip screenis basedon the facialtypeand
the angulation
Q-'---
of the lower incisorsasdeterminedby cephalometric radiography.

*nverted teeth, (b) with

Adamsctaipsin miieil"niiiion.

779
 :*l:
lt,:
I

il
I
',,,I
i:

In patientswith mentalismuscledysfunction,lower lip screentherapyaimsto

achievea directeffecton thelowerlip. The useof the screendoeshowevercausea
shift in the balanceof the orofacialsystem.Our own palatographic studieshave
shownthat a lower lip screenwill havea directeffecton the tongue.A changein I
functionalbalancein the labialregionwill leadto a forwarddisplacement of the
tongue(Fig.173a-d).
therapywill produce
Labialtilt of thelowerincisors
similarside effects.
will alsobe noted.Headgear
I
73a
I
I
I
I
ttt*
r
I
I
73b
I
I
I
I
I
I
I
Fig. 173. Palatographic study of the tongue.(a) Distancefrom
thetip of thetongueto the upperincisors,(b)palatogramof a patient
I
without
mouth.
(c) and with lower lip screen, lower lip screenin the
(d)
,.,,
".,;i
I
180
; rl
173c

173d

(a) A verticalgrowthtype showspredisposition

for visceralswallowing.
Tonguethrustis frequentlyseenin thisgroup,andthe thrustis quitemarked,with
considerablecontractionof the circumoralmusculature.The tonguelies flat,
protrudinginterdentally.Marked contractionof the mentalismuscl-e causesthe
anterior segmentsof the lower arch to be retro-inclined,givinga very upright
position.
(b) With the horizontalgrowthtype,the tip of thetonguedoesnot protrudeto the
sameextentduringthrust,andpresses againstthe upperandlowerdentalarches.
As a result,one often seesbialveolarprotrusion.
It is only rarely that one notessuckingin of the lower lip with this growthtype.

181
174a

t-

F ,K 2?. 11.66 o
74b r 4. 8, ?5 sNA- 82o
SNB ?6O
Atts 6o
SN - Pog ??

\;

N - Pog

I nrnr

1.5 m m

Fi1.174. Nine-year-old and

girl (F.K.)withClasslll1 malocclusion
110'labialtippingof upperincisors.(a)Cephalometric radiograph,
(b)tracing.
The inner archof the headgearindirectlyhasthe effectof screeningoff theperioral
musculature.This will inevitablycauseforwarddisplacement of the tongue.
The undesirablesideeffectsof inhibitiontherapyshowup earlyin the radiograph'
The sideeffectsdue to screening wereclearlydemon-
of the perioralmusculature
strablein the caseof our patientF.K. (Fig.17aa.b).

r82
 F. K. 2?. 1l. 66 sNA 8Q
o
15, 9. ?6 SN B ??,5O
ANB 2a5
SN - Pog ?9-

\,,"

N - Poir
I - Bntnl

r - LJ llln)

fig. 175. PatientF..{.after a year'streatmentwith headgearand

lowerlip screen.La.pialtipping of upperincisors121".(aic"pnrio:
metricradiograph,(b)tracing.-
The patient, a9-year-9!dgirl, presented
with a ClassIL malocclusion, labialtilt of
the upperincisors,andlip dysfunction.As theSNA anglewasenlarged,treatment
wasinitiatedwith headgear.In the courseof this,ChsJI dentitionias achieved in
themolarregionandtheANB anglereduced.Screening of theperioralmuscglature
by the innerarchof the headgeaididhowevercausea verymarkedlabialtilt of the
upperincisors(Fig. 175a,b).

183
 *" 8.
t.
t:

.i-
i:
, t:
ti 76 a

F. K.
(ia
2?. 11, 66 6',1
,8 SN A 800
21.6. ?9 SNB
176b ANB 10
SN - Pog ?90
t2 4 .5 0
\ 32"

143,50

\n ,"
\ ro ,s o

<4 0

1230
N - Pog
1 + 4,5 m m

T +2,5nr n

Fig. 176. PatientF.K.on conclusionof activatortherapy.Angula-

(a)Cephalometric
tion of incisorscorrected. radiograph,(b)tracing.

lt requiredseveralyearsof activatortherapyto achievecorrectincisorangulation

t Frg .1 7 6 ab. ) .

18,+
2.2 TheUsetutnessof Cephalometric with
RadiographY
Functiona\OrthodonticT r eatment

Principlesof Activator Therapy

Orthodontic treatmentalwaysinvolvesthe applicationof force, in the form of
pressure,traction,and shearingforces.
This applicationof forcecauses in the tissues,with thetreatment-induced
stresses
changescontinuinguntil a new stateof balanceis established. Methodsof treat-
ment differ in the sourceof the forceapplied.
With the activator, the force componentsoriginate in the musculature.In
constructionbite, the mandibleis displaced from its balancedposition(i.e. therest
position) and the muscle tension thus producedprovidesthe force used in
treatment.
(a) The forcemaybe transferredto the temporomandibular jointsandthesutures
of the facialskeletonto encourage or inhibit growthin theseareas.
(b) The dento-alveolaror parodontalaction of the activatorarisesthrough
transferof the forceto the teethand alveolarprocesses.

TheIndicationsfor ActivatorTherapywiththeAid of
CephalometricRadiography
to determineif the
To establishthe indicationfor activatortherapyit is necessary
conditionsfor a forwardrepositioningof the mandiblehavebeenmet.

2.2.I FirstCondition
The first conditionis that the mandiblemust be in a posteriorpositionand the
SNB anglesmall.If the mandibularbaseis too short,theposteriorpositionmaybe
assumedto be due to growthdeficiency.If the mandibleis well developed,trans-
locatedclosuredue to backwardmovementof the mandiblemay be found.The
probable diagnosisbasedon the radiographmust be confirmedby functional
assessment. A growth-conditioned posteriorpositioncan be correctedby func-
tional orthodontic treatmentduring the growth phase,posteriortranslocated
closuremay alsobe correctedat a laterage,whengrowthhasceased, by changing
the occlusalplane.

Condition
2.2.2 Second
Correctionof malocclusion of conventional
consisting activatortherapyis possible
only wherethe growthpatternis horizontalor at leastindifferent.If the growth
directionis vertical,the mandiblecannotbe broughtforward,but only downand
forward,and thiswill not correctthe skeletalClassII relationship.The treatment
prognosisis unfavourable if theratioof posteriorto anteriorfaceheightis lessthan
60%, the sum of posterioranglesgreaterthan 400o,or the lower gonialangle
greaterthan 76". If the lower incisorsare very upright,correctionof a ClassII
ielationshipcanbe supportedby correctingthe angleof the lowerincisors.If the
showhbial tilt, dento-alveolar
lower incis"ors compensation is not a possibility.

185
 2.2.3 Third Condition
A further preconditionfor correctionof ClassII malocclusionby bringing
forwardthe mandibleis that themaxillamustbein normalposition.If themid-face
is convexandthe maxillaprognathic,themandiblecannotbebroughtforwardinto
anunnaturalprognathicpositionaswell.An excessivelylargeSNA anglefrequently
indicatesthe needfor distalmovementin themaxilla.Combinedtreatmentis often
indicated,bringingthe mandibleforward and effectingdistalmovementin the
maxilla (Fig. 177)'
177

bosol {

F \

foractivator
Fig.1T7.Indication Theprincipal
therapy. radiological
diagrammatic.
criteria,
2.2.4 TakingtheWorkingBite
to determinethe extentof
Before taking the constructionbite it will be necessary
forward and openingmovementrequired,and whethermid-line correctionis
indicated.The skeletalrelationship,inclinationof the incisors,and directionof
growth shouldbe assessed radiographically.
As the musculatureis activatedwhen taking the constructionbite, the skeletal
patternin the skullmustalsobe takeninto account.For a horizontalgrowthtype,
the constructionbite is takenasfollows:
(1) Maximumforwarddisplacement in thesagittalplaneuntil edgebiteisachieved,
parallelto the functionalocclusalplane.
(2) In the verticalplanewe stayin the rangeof the rest position.With the bite
takenin thisway,intermittentforcesof themasticatory musculature areactivated,
and myotaticreflexactivityis initiatedvia musclespindles.
Activator therapy was indicatedin the caseof a girl aged 8 presentingwith
averagedirectionof growth,retrognathicskeletalrelationship,andlabialinclina-
tion of the upperincisors(Fig. 178a,b). With anaveragedirectionof growthat this
age,a shift towardsthe horizontalmaybe expectedduringsubsequent years.

186
 I

17 8 b H. U.
2 2 .0 6 ,6 5
2 I,0 8 ,7 4 srtn zzo
SNB 7'IO
ANB 30
P oq /50

\,
\
I7 ,7,5 0

7o
t /,c
\

- Poq
'8,5 ml
. 1,5 ffirl

Fig. 178. Patient H.u. with retrognathicskeletalrelationship,

(a)
ru-.r.gr growth trend and labialtipping of incisors. Cephalo-
metricradiograPh, (b)tracing
therapy
This is anotherreasonwhy with thistypeof skeletalrelationshipactivator
is indicatedin the earlymixeddentitionperiod'
Treatmentwassuccessfully concludedwithin a periodof 4 years.The follow-up
that
examinationrt o*, ttr. stabltityachieved,confirmingthe originalassumption
growth would becomehorizontal(Fig. 179a'b)'

187
 I
179a
.
!i
I
I
::i

t
I
180

I
I
I
I
I
t], tJ,
179b 2 2,0 6 .6 5
t4 , 1 I. /9
-- -n
S N A /o,>-
S N B l 60
I
A N B 0,50
\lo
\
S N .P O9770
I
7a
\ 12,50

N .POg
1- l nr i l

I * U ,) In'n

"fig. 179. PatientH.u.on conclusionof activatortherapy.

Horizontal
relationshipof facial_skeleton,
incisorangulationcorrect,growth
incrementin mandibleB1/zmm. (a) cephalometric radiolrapn,p;
tracing.

1g-Il"lryd,19 (ryS ) presented

withClass
IL malocclusion
andaverage
direction
or grorilth(fig. 180a-f).A smallGo' angledid howeverindicatethalhorizontal
glgwth tendencieswere likely to developlThe maxillawasorthognathic,with an
sNA angleof 81o,the mandibleretrognithic,the sNB anglebein! 7a?.rneANB
angle thus was 7'. The extent of thJmandible was sligh"tlybelownormal-The
upp.elincisorswere tilted forward and7.5mm anterio"rto the Npog line. The
position of the lower incisors,at *3mm, wascorrect.Their forward"angulation
wasextteme,however,at 108".Themid-facewasconvex,with theconvexiiydueto

188
IT
I

Ii
I
I
r
| 80r 180d

I
I
I
I
I
p;n rao. PatientN.G.,before-orthodontic treatment.(a),(b)' (c)
(d)orthopantomogram,
fvi6O"l, (e)radiograph, (f)tracing'
of 5" (90"insteadof 85")'
an ante-inclination
for the following
Headgeartherapywaschosenfor the first stageof treatment,
in the mid-facerJgionwasindicated,because of the
reasons:Inhibition
tt.iag.ur with appropriatetiactionwill not only,inhibitgrowth
ante-inclination.A "ig.*ttr
potential,but alsoreducJante-inclinition. Correctionof theClassII malocclusion
of themaxillawas
6y adaptingthe positionof the mandibleto the forwardrotation
malocclusionby
;6i pl,|tT.. A' f"rth.t' problem with correctionof ClassII
lower incisors'This
bringing the mandibleforward, was the angulationof the
the antero-posterior
neededcorrection,-lutU.lngingthe incisorJupright-made
relationshipworse.Dental Jompensation basedon the lower dentitionwasnot
the mandible
p"triUf.. Cjnthe contrary,afteriorrectinglowerincisorinclination,
would needto be broughtevenfurtherforward'
molarsand the ante-
After headgeartherapy,both the positionof the sixth-year
then usedto induce
inclination*.r. .oiii6teA (fig. tbla-e). An activatorwas
to an upright
forward movementof the mandible,and the lower incisorsmoved
angiehad been
p*itlon. After tt"utr.nt, the ANB angle was 1", the SNA
reduced,the SNB *i.tged. The ungirlutionof theincisors theirposition
and
""Jf. ;.i."norrnul. Th"einclinationof theniaxillawasnow83''
relativeto the Np"fi;
The horizontatgro?ih tendencyhasincreas ed to 657o.In the courseof the last
themandibularbase'
lfiil" y.u.r, un ii...use of 6.6mm wasnotedin the lengthof
therapy'the
and of 4.5mm in that of the maxilla.During the stageof headgear
in the posteriorregion,
increasein growthoccurrednot in the anteri6r,but ralher
so that the distanceS-S'wasreduced'
189
 -'r
181
180e

{r.iAii:

W 181

180f N 0
17 7 6 5
1 71 17 5 62,1',l"

S NA 910
000 1170 S N8 '11o
Iq

A NB 70
SN-Pog 750

160

1 ?5 0

N- Pog
1+/5m m
;"
| +Jmm

,]
l
l

19tr
 ffi

Fig.181. PatientN.G.after3 yearstreatment.(a),(b) photographs,

(c)orthopantomogram, ' '
(d) radiograph,
(e)tracing.

191
181d

.;l:,1
YA

181 e5 16
17765
7779 64,g' /"

x
625mm
SNA 7 7 , 5 0
66,50 100,50 SNB 75,50
ANB 2o
SN
- Pog 7 7 0
11f ,q0

5 hu

1 qq 0
\

q Q r ,0

1260 N-P og
6fi q0 1 + 3,5mnr
+0,5mm
71mm

^v -
2.3 DistalMovementin theMaxilla
Headeeartreatmentto effectdistalmovementin themaxillais indicatedif the aim
of treitment is to inhibit growth in the mid-faceregion.The methodwill often
achievea considerable reductionin theSNA angle.Cervicalheadgear therapywill
effect distal movementand elevationof the teeth.
This form of treatmentis, however,only possiblewhenthe directionof growthis
not vertical;otherwiseelevationof the molarswouldhavean undesirable effect.

A lGyear-old girl (R.U.) presentedwith ClassIL malocclusion, deepbite, and

horizontalgrowth tendency (7L.aVo). There was marked convexity of the naso-
maxillaryc6mplex(SNA angle82"; Fig. 182a-e).The mandiblewasaveragein
efient andweli deveioped,its positionposterior(SNBangle75.5")' The smallGo,
angle (65') and markedlyhorizontaldirectionof growthsuggested that_for-the
*iut*poiterior dentalr-elationship the chancesof correctionwere good,whilst
thosefor openingthe deepbite werepoor.
This secondand ditflcult problemwastackledfirst, the aim of treatmentbeing
alsoto inhibit growthin thb maxillaryregion.Headgeartherapywasinitiated,and
thiswasfollow"ed by activatortreatment(Fig.183a-e).After a treatmentperiodof
3Vzyearsincludingretention,the anomalyhadbeencorrected,andthe following
qhangeswere notJd: The deepbite had beencorrecteddespitethe fact that the
horiz-ontalgrowth trend had increased.The SNA and SNB angleswelg within
normal range(81"and 79"),with ANB 2'; the skeletalrelationships hadbecome
normal.ThEmaxillaryand mandibularbaseshadincreased by the normalannual
growth rates.Growth in the verticaldirectionon the otherhandhad beenabove
iuttag., amountingto 9mm in both posteriorand anterior face height, i'e'
3 and 2mm respectivelyabovethe average.
Upper incisorangulationand relationshipto the NPogline had becomenormal.
The lower incisorsshowedthe right relationshipto the NPogline, but still had a
labialinclinationof 104".This labialinclinationof the incisorshadexistedprior to
treatmentand wasnot correctedfor the followingreasons:
therapyhadbeencombinedwith a lower
In view of adverselip pressure,headgear
lip screen.
Accordingto Schudy,the relationshipof the lowerincisorsto the NPogline is a
more impbrtantfactorfor stabilitythanis their angulation.

193
182a

182b

182c

.'

.tiiii lit-r
- "++s 1l l

ii*$i,,,
:iit1
r:i$,,:
i,ii.:*
u\,S- :

fl$ lAZ. PatientR.U.,beforeorthodontictreatment.(a),(b)photo-

(e)
(d) radiograph,
griphs, (c) orthopantomogram, tracing'

191
1 &d

: , ,.

1 8 2 e ;i.i .
: 2 61
e . 17 t , T4
I1,4
IOI
to

68mm
S NA 8 2 0
1230 060 0
117 S NB 7qq0
A N8 fi q0
SN-Pog 770

1l,Lo

:s.
\r'

530
N-Pog
i180
+12mm
+'1mm

70mm

195
183a

183b

Fig. 183. PatientR.U.,after3% yearsorthodontictreatment.(a)'

1O;enotographs,(c)orthopantomogram, (e)tracing.
(d)radiograph,

19c
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I 183d

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SN8 7 9 0
ANB 2 0

! SN-Pog8 1 0

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 2.3.I HeadgearTherapywith Convexityof Nasomaxillary
Complex
Convexity of the nasomaxillarycomplexis frequentlythe causeof a skeletal
ClassII relationship.The SNA angleis largein thesecases,andANS andIs1 are
far anterior to the NPog line. Ante-inclinationof the maxilla(largeJ angle)will
increaseprotrusion,whichA.M. Schwarzreferredto aspseudo-protrusion. This
ante-inclination arisesthrough anterior swingingof the maxilla. The mid-face
height (N-Sn) is short.In extremecasesBimler speaksof microrhinaldysplasia.
This form of ClassII malocclusion canbecorrectedby cervicalheadgear therapyin
mixed dentition, a pre-conditionbeingthat the directionof growthis not vertical.
A boy of 8 (G.Ch.) showedgood development of the mandibularbase,with
prognathism.'Class'II malocclusionwas due to forward displacementof the
(pseudo-protrusion).
maxilla. Protrusionwasenhancedby a 94oante-inclination
After headgeartherapyof almost2 yearsduration,intermaxillaryrelationshad
becomenormal and the ANB anglewas reducedfrom 1.0"to 2" (Fig. 184a,b;
1 8 5 ab, ) .
A reductionin ANB by 8" is the maximumobtainablewith headgeartherapy.If
treatmenthad startedafter the tenth year of life, a correctionof this magnitude
could not havebeenexpected.Wieslanderhasshownin hisfollow-upstudiesthat
headgeartherapyinitiatedduringthe eighthyear givesvery muchbetterresults
than treatmentgiven18monthslater (Fig. 186andTable20).

Changes in
horizontal(?) Early Latg
'-
! n.
IJllrerence
or vertical(Jj) treatment treatment
direction

ANB -3.24" 1.84" 1.40"

6 3.13 t.43
--)
1.70
Pogonion 0'.12 0.37 0.49
ANS ls.40 3.69 r.7L
Menton Le.73 7.33 2.40

Table20. Resultsachievedwith headgeartreatmentgivenearly

(treatmentstartedat age8) and late(treatmentstartedat age1072)
(Wieslander).

198
,I

tsI , 184a
l-

rl

II

184bc ch.
I 8 . 2 .6 2
7 6 ,7 .7 0
7 1 ,1
l ""

I 660 1070
S NA 910
S NB 810
A NB 100

I SN-Pog 830

I 1[30

130
L 1[0

I 520
1200
N-P o g
1 + 1 2mm
;^

tl 690
l+ l mm

I 69mm

boy,G.Ch-,
Fig. 184. Eight-year-old
;
psludoprotrusion, treatment.(a) RadiograPh,
beforeorthodontic

Ii ,l
(b)tracing.
199

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35a

15b
0.ch
I 2,62 71,3
1" "
10,12, 06mm
71
SNA 830
1720 640 1080 SNB 810
ANB 2o
'l SN-Pog830
l
1120

\,,'

N -P nn

520 1 + 5 mm
;.
1710 l+ lmm

74mm

FiE.185. PatientG.Ch.after 2-yearheadgeartherapy.(a) Radio-

graph,(b) tracing.

2N
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106

cephalometric
Fg.186. Wieslander's to assesstheresults
analysis
d headgeartherapy.

2.4 CombinedTherapy
A combination of headgearand subsequentactivator therapy is frequently
indicatedwith mid-faceconvexityand alveolarretropositionof the lower dental
arch.
A 9-year-oldboy (T.Ch.) presentedwith ClassIL malocclusion includin_g_ deep
growth
bite, adverselip'piessure'andhorizontal direction ol70% (Fig. 187a-g)
The conditioniould be describedas'skeletalClassII malocclusionwith thefaultin
the maxilla and dento-alveolarClassII malocclu.sionwith the fault in the lower
dental arch'. The SNA anglewas83o,SN-Pr86', the upperincisors protruded to
8mm anterior to the NPoe line. The mandibularpositionwasnormal,with an
SNB angle of.79'.
The mandibularbasewasa little short (-3mm), the ascending ramuswaslong
(+3mm). The lower incisors were very upright (86")and 4mm posterior to the
NPogline. In the lowerdentalarch,therewaspracticallynospacef9r thecanines.
Analysisof the modelindicatedextractiontherapy.Calculationof the discrepancy
-however,
did, revealthat by movingthe lower incisorsforwardit would still be
possibleto makespacefor the lowercanines.

20r
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Fig. 187. Nine-year-old boy, T.Ch.,with Classll1 malocclusion,
ho-rizontalgrowth trend, and lip dysfunction,beforeorthodontic
treatment.(a),(b),(c)Model,(d)lackofspaceforcanines inthelower
dentalarch,(e)orthopantomogram, (g)tracing.
(f) radiograph,

2m
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 Il
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r
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1 8 7 9 1C h ,
tD S Dq 70"1"
2 73 7 3

r 620 1170
SNA
SNB
a'l0
iq q0

r
- ANB 1 q0

SN- Pog Q? t0

1300

N-Pog
1+ 8 m m
t -t-tt

203
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iji
ll

l,: 188a
l
ii
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i,

i
Ir{
1 8 8 bi . ' .L l't.
1 6 I6 4
Lt. J. tq

SN A R 7q 0
I
620 1060 SN B 79,50
AN B 3o
\,,
SN- Pog 50
R?

l
\,r.
i
43,5mm

N-Pog
1+ 3 m m

I
Fig.188. Intermediate
(a) (b)
T.Ch. Radiograph, tracing.
therapy,patient
result,after1-yearheadgear
I
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 Treatmentwasinitiatedwith headgearand a lower lip screen.After one yearof
treatment,the upperincisorshad becomeestablished to a goodrelationship;the
lower incisorshad been uprighted,but were still 4mm behindthe NPog line
( F i g .1 8 8 ab, ).
Treatment then continuedwith an activator.The lower incisorswere tipped
forward, the caninesshowedgoodrelationship.On conclusionof treatmentthe
lower incisorswere still 2mm behind the NPog line, indicatingthat there was
spacein reserve(Fig. 189a-f).

I Fig.189. PatientT.Ch.,afteractivatortherapy.(a),(b)Photographs,
(c) canineswell alignedin the lowerdentalarch,(d)orthopantomo-

I| gram,(e)radiograph, (0 tracing.

20s
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 189e

1 8 9 f TC h
1 6 .69{
1 19 7 7 71,1"
|"
76mm
SN A 830
'1230 600 1 007 SN B 020
AN B 10

r
SN-Pog850
1310

:
n7q0

I \,:

I 030
N-Pog
l * 2m m

rl
1310
1 -2 mm

t 80mm

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20'7
 Calculation
2.5 Discrepancy
The discrepancy givesthe relationshipof spaceavailableto spacerequired.It may
consistin tbo Hitlespacebeingavailablefor the teethin the lowerdentalarch,for
instance. To determine whether the dental arch can be correctedwithout
extractionor whether extractionwill be necessary, the discrepancy has to be
calculated.Model andradiographicrelationships areusedfor the calculation,and
distinctionis madebetween:
(1) Dental discrepancy(DD), calculatedon themodel.
On the model,the clinicallengthof thedentalarchis determined(frommesial6on
the onesideto mesial6 on the other),takinginto accountcrowdingin front andthe
lossof spacein the supportingzonefor the cuspidsandbicuspids. The difference
betweenlength of dentalarch and placerequiredfor the dentitionis the dental
discrepancy(DD).

(2) Sagittaldiscrepancy(SD), calculatedon theradiograph'

On the radiograph,the distancefrom the lowerincisors(Is-1)to the NPogline is
determined.This representsthe sagittaldiscrepancy(SD). If the curveof Speeis
exaggerated,1-2mm needsto be addedto the sagittaldiscrepancy to makeup for
this.

(3) Totat discrepancy(TD), a combinration

of thetwo.
halfthedentaldiscrepancy
(TD) is thesumof thesagittalplus
The total discrepancy
asfollows:
T D =SD+ t/zDD
Treatmentshouldbe plannedso that the lower incisorsare no more than 4mm
anteriorto the NPogline.If spaceis lackingin themodel,it maybepossibleto gain
spaceby protruding the lower incisors.Otherwiseextractiontherapywill be
indicated.A total discrepancy of 7mm for examplewould meanthat a spaceof
7mm wasneededin eachquadrantof the lower dentalarch,whichis practically
the width of a premolar.
in mixeddentitionis subject,it will beremembered,
Interpretationof discrepancy
to certain and
reservations, furtherperiodsof activegrowthshouldbeconsidered.
for
The principal resultsof model analysisand calculationof the discrepancy
patientT.Ch. areshownin Table21.

208
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 Maxilla Mandible

SIo:36mm SIu:25mm

Support- Ideal 23.7mm 73.4mm 36mm

Spaceavailable:
ing
zone r. r.
Spacerequired:39mmDD =
Found
26.5 22.0
For the curveof SpeeLmm is required.
+ 2 . 8 + 1 .8

[,ength ldeal 21mm 19m m Distanceof

of lower incisors
dental Found 25mm 14mm fromNPog:-4mm SD = *6mm
arch
Diff. *4 mm - 5m m -2(DD) + 6(SD): *4 mm(TD)
Discrepancy:

Table21. Principaldatain modelanalysisof patientT.Ch.

3 LateTreatment
I With horizontalgrowth trends,the possibilityof changingthe antero-posterior
the time factor.Once
I skeletalrelationshipalsodependson a fourth dimension,
activegrowthhascbased, correctionof is
malocclusions possibleonlywith regard
to translocatedclosures.Treatmentbecomeslimited to distalmovementof the
upper teeth. Again diagnosisand treatmentplanningare largelydependenton
T analysisof the radiograph.
In the caseof 8.A., a girl aged15,the ClassII malocclusion with deepbite and

I horizontalgrowthdirectioncould be corrected only

(Fig. 190a-f),skeletalcorrectionbeingno longerpossible
an SNA angle of 85o,
in the

and
dento-aiveolar region
at that age.The facial
SNB angleof 82'. The
skeletonwasprognathic,with
t mandiblewas-welldeveloped,andTmm aboveaverage
with ClassII malocclusion, the fault being in the
in length.Shepresented
maxilla.In viewalsoof her age,
distal movementof the upperteethwasthe only feasibletreatment.The upper
t incisorswere tipped labially,and 8mm anteriorto the NPog line. The lower
incisorsshowedc-orrectangulationandnormalpositionrelativeto the line.Distal
movementof the upper teethwith intermaxillaryanchorage wasindicated.The
I aim in a caseof this type mustbe to keep
position,merelylevellingthe compensatory
only
the mandibular incisors in their existing
curve,andto effectdistalmovement
means of correctingthe deepbiteaswell
bf ttreupperteeth.Thiswouldbe the
I|| as the diitocclusion.The horizontalgrowthtrend contra-indicated
the premolars,as that would make correctionof the deepbite impossible.To
extractionof

establishthe correctrelationshipof upperand lowerincisors,it wasnecessary to

I effectdistalmovementof the wholeupperdentalarch.If the germsof thewisdom
teeth are present,extractionof the upper l2th-yearmolarsis indicatedin these

I
CASES

r
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 &",

190d

(a),(b),
Fig. 190. Girl aged15,8.A.,beforeorthodontictreatment.
(c) Model,(d)photograph basein themaxilla,
showingsmallapical
(e)radiograph, (f) tracing.
:

I
190f
I B A.
.
9,2.59
60,7"/.
1g.L,7L
I 67mm SNA 8 6 0
SNB 8 2 0
61,0 i150 ANB Lo

I SN-Pog A/,q 0

I 1320

I \- ?o

I \5 0

I N-Po g
1 + 8m m

I I +lmm

I
I 211
 had
After a 3-yearperiod of treatmentand retention,the ClassII malocclusion
beencorrectedby dento-alveolarchanges. hadremained
The skeletalrelationships
unchanged.The lowerincisorsweremaintained in the
position, upperdentalarch
had beenmoveddistally,andthe deepbitefully corrected.No appreciablegrowth
changes werenoted (Fig. 191a-d).
theindication,cephalometric
Apart from establishing is alsorequired
radiography
in-caseswhere active growth has ceased,to plan the anchoragerequirement,
decideon the form incisormovementshouldtake,and to monitorthe results.

91 a

91 b

Fig. 191. Patient8.A.,afterorthodontictreatment.(a),(b) Photo-

(d)tracing.
graphs,(c) radiograph,

212
rr
I. 191c

t
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9.2.5S

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S N A 86 0
S N 8 81 ,05

I ANB / r,0
\--
X- SN-Poq 84 0

I 13350

I \=ss'
\r:,s'

I
I N -P og
1+ (mm
1
| + ^,
t,! mtn

I
I 213
 -=l

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-
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f,
I
I
3.I PlanningtheAnchorage :

When distocclusionis correctedat a late stage,distalmovementof the upper

dentitionrequiresratherheavyforces.We haveto considerveryseriously how to
applythesefbrcesin keepingwithour anchoringvalues.Depending on theform of
unittorug. used,distinctionismadebetweenthreedegrees of anchorage (Fig.192).
The forri of anchorage useddependslargelyon whether treatmentwill or will not
includeextraction.
192

t
.3
o
t
a
a
a
a
a

Fiq. 192. Availablespacefor mandibularanchorage. The dotted

lin-eindicatesthe limii for mesialmovementof anchorteethwith
minimal anchorage;the brokenline shows the anteriorlimit of
mesialmovementfor theanchorteethwithmoderate anchorage;the
solid line showsthe limit with maximumanchorage.

(I) Minimal anchorage; The forceappliedmay be reciprocal'

(a) Spacesleft after extractionare to 3/+closedfrom distal,and only to Vc from
mesial.
(b) The lowerincisorsareveryuprightandbehindtheNPogline,the lowerdental
arch is well aligned.
(2) Moderateanchorage; The forceappliedcal no.longerbe reciprocal,. the load
oti tt. anchorteethmustbe distributed,or theirresistanceneeds to be reinforced.

(a) Spacesgainedby extractioncanbe closedto betweenlz andl+ ttom distal,

and betweenl/zand3/+from mesial.
(b) Calculationof the total discrepancyshowsthat, after treatment;the lower
incisorswitl be a maximumof.Z-4mmanteriorto the NPogline.
Reciprocal intramaxillaryanchorageis contra-indicatedin this group. Inter-
*a*illu.y anchorage with vertical
will usuallybe suitable(thoughcontra-indicated
growth trends).
(3) Maximum anchorage;No spacemust be lost from the distal side in the
anchoragearea,and anchorage mustthereforebe stationary.
(a) The spacesprovidedby extractionmustbe closedfrom mesial.
showsthat the lowerincisorsare4mm anterior
(b) Calculationof the discrepancy
io'the NPog line (with antero-positiongreaterthan that, extractionis usually
indicated).Anchorageneedsto be reinforcedby extra-oraltraction(headgear in
maxillaor mandible).

214
 In the caseof our patientB.A., the dentaldiscrepancy was 1.5mm,sagittal
discrepancy 0mm, andtotaldiscrepancy, afteraligningthecurveof Spee,2mm.A
total discrepancyof 2mm allows very little room for anchormovement,and
maximumanchorage is required.In thiscase,it wasreinforced in
with headgear
the mandible(Fig. 193).

193

Fig.193. Headgear with maximumanchorage.

in the mandible,

4 Correctionof ClassIL Malocclusions

with
VerticalGrowthDirection

Certainaspects requirespecialconsiderationwhentreatinga ClassIL malocclusion

with verticalgrowthtrend.Correctionof deepbite usuallypresents no problemsin
this group, but with antero-posteriorocclusalrelationshipsthere are certain
reservations.Distal movementand extrusionof the buccalteeth will enhance
mandibularretrognathism.Extractionof the first premolarson the other handis
indicated,asmesialmovementof the buccalteethwill weakenthe verticalgrowth
trend. It is sometimesalsopossibleto extractthe premolarsin theupperarchonly,
with no risk of deepbite developing.

21.5
 I
Taking into accountthe skeletalfeaturesof thesecases,we havedevelopeda ;
specialactivatorfor correctionof ClassII malocciusionwithverticalgrowthtrends,
the 'V' (vertical)activator(Fig. 19a).This utilisesthe forcesof the musculature
morein theverticalandlessin thehorizontaldirection.We achieve thisby usinga
high working bite for the activator,without bringingthe mandiblemassively
t
forward(Fig. 195a,b). Thispositionincreases
the visco-elastic
myostatic reflexactivityandutilises
propertiesof the soft tissuesfor the applicationof force.The
muscleforce thusproducedis moreintensiveand of greaterdurationthanwith
t
activatorsdesignedto use swallowingas the chief sourceof power.The 'V'
activatoris rigid in constructionin orderto evokeisometricmusclecontractions
I
whichagainarelongerin durationthanthosedeveloped with an elasticactivator.
194 I
I
I

Fig.194. Diagramshowingverticalactivatorwith
highworkingbite.
| 95a

,':!i,,1
,.ri!;:l::
{ffi!:'
.f1t .

Fig.195. Construction
bite(a)with horizontalgrowth -
type,{b)with
verticalgrowthtype.

'l1A
F I

t
t I

il
*

+
+
+
+
F
#
+
+ Cephalometricradiographyis of vital importance,not only in establishing the
indicationfor this constructionof the activator,but alsowhenthe workinsbite is

F !ak9n,asnot only the directionof growthandfunctionalrelationships,butilso the

inclination of the mandibleand mandibularplane and the positionand axial
inclinationof the incisorsneedsto be takeninto account.

I. I A bite chamferanteriorlygroundinto the acrylicto hold or supportthe upper

incisorsis frequentlyaddedto a 'V' activator.This constructionenhancesthe

it|
growthinhibitingeffectin the maxillaryarea(Fig. 196).
Patientswith a vertical type of facialskeletondo not toleratemassiveforward
movementof the mandibleby the appliance.It wouldcertainlybe wrongto treat
with growth and not take the growth patterninto account.A verticaliyraised
activator will bring the mandibleslightlyforward and downward,with simul-
taneousadaptionof the maxillato the lower dentalarch.

t 2r7
196

Fig.196. Frontalsupportwith verticalactivator.

A 9-year-oldboy, G.F., presented with ClassIL malocclusion,tongueand lip

dysfunction,andlip incompetence. The directionof growthwasvertical,at55Vo,
and the sum of angles406"(Fig. l97a-e).The gonialanglewasnot large,with
125",but the lowerGozanglewasgreatlyenlarged,at 78".The ascending ramus
wasshort(-10mm), themaxillaryandmandibular basesshowednormaldevelop-
ment.The facialskeletonwasretrognathic, SNA being77', andSNB71".Incisor
angulationwasnormal,with the upperincisorsl}mm anteriorto the facialplane.

Treatmentthereforehad to achievethe following:

(1) Inhibit the sagittalgrowthtrendin the maxilla,rotateit downwardsandmove
both 6 year molarsin the distaldirection.
(2) Bring the mandibleslightlyforwardand down, with slightforwardrotation.
The activegrowthphasesthat lay aheadwereto be utilisedfor thispurpose.
The 'V' activatorpermitsdistalisation of the two 6 yearmolarswith fixationpins,
and the upper front to be supportedto enableanterior-inferiorrotation of the
maxillatowardsthe mandible.With a carefullyplannedworkingbiteandselective
grindingof the activator,it is possibleto encourage anteriorandsuperiorrotation
of the mandible.

Fig. 197. PatientG.F.,verticalfacetype,beforeorthodontictreat-

ment.(a),(b),(c) Models,(d) radiograph,
(e)tracing.

2r8
I
I 197d

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T.
197e0 F.
2 8 56 5 55,4
"/.
t,
1 71 . 7

I
SNA 770
SNB 710
1010
7 to ANB 60

F SN
-Pog 71,5o

I 1590

F l '10

I 1250
N- Pog
1 +12mm

I
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l +ir m m

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 the caseof patient-G'F''
With treatmentcontinuedfor a threeyear period^i1
of the teethwere utilised'The
active growth pt ur.t and the eruptioniotentiat
ioUo*iig changes werenoted(Fig' 198a-d)'
In the maxilla,inclination wasreducedby 3.5",andSNA by 1';the maxillarybase
asplanned'with growth
sained1.5mm throughgrowth.Rotationwasachieved
Inhibited.
changein direction.ofgrowth
Themandible rotatedupwardsand forward,with a
from51Voto 58Vo. but Gozwai reduced,againthrough
itr" g'oniulangleincreased,
grownby 7 mm, the SNBangle
rotation of the mandiblE.The mindibularbasehad
from 6" to 3o' Mutual
increasedby 2", whilst the ANB angle had decreased
to restorenormalocclusion'
rotation of the *u"iiiuiy andmandibulirbasesserved
198a

198b

Fio.198. PatientG.F.afterthreeyearsof treatmentwithvertical

(d)tracing'
(c)radiograph,
;;1";i;. (a),(b)Photographs,

220
'l
I', 8c

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I
 The Ranking Order of Cephalometric
Radiography in Orthodontic Diagnosis
Cephalometric radiography was introduced into orthodontics by Broadbent and
Brodie and by Hofrath in 1930.For manyyears,however,treatmentcontinuedto
be given without benefit of cephalometrics,and it was not until the 60s that it
gradualy'gained acceptancein dalty practice. Scepticswould be right to ask,
therefore, if it is not merely a passingfashion.
The real need for cephalometricsin orthodontic diagnosishas arisenwith the
developmentof orthodontic therapy.In the old days,'universal'applianceswere
g"n"ruily used.There were activafor 'schools'and plate 'schools',and diagnostic
methodswere not very demanding.
Today, not only are different methodsused,but variousmethodsare even usedin
for the same jlhis
patie.nt. calls
combination during different stagesof treatment
for accurate differEntial diagnosisand continuous diagnosticmonitoring. High
quality treatmentmeansthaisophisticatedmethodsof diagnosiswill alsohaveto
be used.
In an age of ergonomics,the time factor tendsto be a major problem..Makinga
tracing*and the required measurementsis time-consuming.Can this task be
delegited? Accuratb localisation of reference points is a pre-_c_ondition for a
relia-bleanalysis,and this demandsknowledge of anatomy and X;ra] anatomy.
This task, i.e. the localisationof referencepoints,shouldnot be delegated.Joining
up the points and measuringout distancesand angles,on the other hand, can be
left to assistantsgivenrequisltetraining.The interpretationof the resultsis one of
the most importint stagesin the analysis,and canorrlybe doneby the orthodontist
himself as major decisionsare basedon this interpretation.
How far can modern technologyassistus? Apparatus for the semi-automatic
determination of anglesand distancesis available.Thesemachinesare known as
cephalometric tracers or digitisers. Their interpretation, and the choice of
treatment are, however, the task of the orthodontist.
The systemknown as computer diagnosis,with completetreatmentpl?ls and all
decisibnsprovided by automatic mlchines, is too rigid a system,.u1d tJ is only
programmed for speCificmethodsof treatment.In medicine,too, it hasbeen the
bxpEriencethat the final decisionand logical analysisremainsthe function of the
physician.
A common problem in producingthe radiographis the linear distancefrom tube
target to subject. A distanceof four metreswill producepracticallyno-.enlarge-
*""nt. In daily practicethis is, however,not usuallyfeasible.Taking radiographs
from a great distance presentsproblems of both spaceand finance. Spaceis
required to install the unit, and a .high-powerfour-valve apparatushas to be
acquired.Smallerunits are thereforegenerallyused,with a distanceof.ll/z metres
befween fitm and object. The angulai valueswill be practicallyth9 9am9as with
4 metre radiographs.Linear dimensionsneddcorrectionby about67obeforethey
are interpreted. the llz metreunits certainlymakeit easierto introducecephalo-
metrics into daily practice.
Cephalometricradiographyenablesus to analysethe facialskeletonfor treatment
planning and servesas a reliableguide as treatmentprogresses.
The more demanding forms of treatment cannot today be envisagedwithout
cephalometricradiogiaphy, but even with'simple'anomalies, the method offers
securityagainstmisjudgement.

222
 Appendix
Case Sheet. CephalometricAnalysis
of patientT.Ch.(continuousdiagnosis)

Name: T.Ch. Freiburg Analysis Name: T.Ch. Freiburg Analysis

d.o.b. 16.09.64 rtl il IV d.o.b.16.09.64 I ii iii iv

Norm 27.3.7321.5.7421.1.76 11.8.77 Norm 27.3.73 21.5.7421.1.76 't1.8.77

NS-Ar (saddle angle) 123"+5. 1ZS 126 125 129 1SN 102"+2' 117 106 106 107
S-ArGo 1 Pal (Schwarz) 70'+5'
143'+6' 130 131 132 131 59.5 69.5 69 68
fariicJir anglel
T MeGo(posterior) 90"13. 86 go.s 94 q)
Gonial angle) NPogto l
*,Ulfil;?,iiiiln 396' 388 388 387 385
NPogto T - 2 - +2 m m -4 -4 -2 -2

Go1(upper)Ar-Go-N Inler-incisal angle 135" 130 136 134 136.5

52-55. 63 62 61 63
Go2(lower) NGo:-Me 70-Z5d 70 69 69 68
S-Ar 35mm 34.5 36 38 39
silA 81' 83 82.5 82 83 N S e( +3 m m = 74- 49-7 5 -50 -75-50-76-50.5
mandible) 53 53.5 s3.s -€(}
SNB 79" 79.5 79.5 81 82 Mand./maxiffalasc.r 7449-7449.57t4158e52_
length/ramuswidth 56 -56 -57 45
ANB 2" 3 .5 3 1 1
Symphysis thick thin normal thick thick thick thick
Sl{-prosthion 84" 86 84 84 85.5
S'-F.PtP 14-15mm ,17 17 14.5 16.5
Sll-infradentale 81" 80 79.5 81.5 83.5
SS' 42-57mm 41 '42 42.5 45
w 80' 82.5 82.5 84 85
urstance to aesthetic line
Pd-ffio(basal <)) 25' labralesuo. - l to -4mm +1 0 -2.5 -2
24 22 22 20
labrale inf. 0 t o +2 m m -1 -1 -3 -3
Pd{}cc 11' 8769
Otherdetaals:
Ho-Occ '14' 16 15 16 11

Sf$-IeGo 32" 27.5 27 27 25

S e f l - P a l ( < o t i n cl.) 85' 89 88 87 87.5

F-Gn (Y axis) 66' 62 62 51 60

S-Cro: Nile x 100 62-65yo 70Vo 69.1% 69.2% 7.1j%

7 3 5 1 0 5 7 4 ;107 76:109 79:111

Bibliography

l- Andrews, L. F.; The six keys to normal occlusion. Am. J. Orthod.62:

TEW.tn z
2- B,jirk, A.; Skieller, T.r Facial development and tooth eruption. Am. J.
Onhod. 62: 339 -383, 1972
3- Brcadbent, B. H.; Golden, W. f1... Bolron standards of dentofacial develop-
Enr growrh. Mosby,.St. Louis 1975
1- Grculich, W. W.; Pyle, S. J.: Radiographic atlas of skeletal development of
the hand and wrist. Stanford Universitv press. Stanford 1970
5. Holdaway, R. A.r The "V.T.O.". Thi University of Texas press, Houston
tvt6
6. larabak,J.R.;Fizzel,J.A-:Light-wireedgewiseAppliance.Mosby,St.Louis
Lgn
7 - Krcgm, W. M. ; Susom| Y: ; Syllabus in Roentgenographic Cephalometry.
Center of Research in Child growth. philadelphit 1957
8- Rakosi, Th.: Die Fernr6ntgenanalyse. Die Funktionsnalyse. Leitfaden fiir
Fortbildungskurse, Freiburg 1973
9- Ricketts, R. M.. The value of cephalometrics and computerized technology.
Angle Orthod. 42: 179-199, 1972
lO. Riolo, M. L. ; Moyers, R- W -; McNmara, !. A. ; H unter, lry' S. I An atlas of
craniofacial growth. Center of human growth and deyelopment. Ann Arbor
t974
11. Schwarz, A. M.: Die Riintgenostatik. Urban & Schwazenberg, Wien 1958

223

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