Treatment Design 2018

CCO® System
Complete Clinical Orthodontics®

Orthodontic Treatment Design
Ryan K. Tamburrino, DMD
The Goal
The aim of this manual is to provide a systematic, objective, and efficient
method for any orthodontic practitioner to formulate a rational, predictable,
and comprehensive treatment plan for any patient that may walk through his
or her door. Ultimately, this can lead to improved confidence for the doctor,
realistic clinical outcomes for the patient, and higher standards of care for the
orthodontic profession. Enjoy!
Glossary of Abbreviations
The following list contains abbreviations of terms and concepts

that are used throughout this manual:
ACP = Adapted Centric Posture

ANHP = Adjusted Natural Head Position
CAC = Center of the Alveolar Crest
CBCT = Cone-Beam Computed Tomography
CCO = Complete Clinical Orthodontics
FA Point = Facial Axis Point
GVL = Glabella Vertical Line
HPI = Head Positioning Instrument
MIC = Maximum Intercuspation
MGJ = Muco-gingival Junction
MOP = Maxillary Occlusal Plane
SCP = Seated Condylar Position
SL = Self-Ligating
SNV = Subnasale Vertical
SWA = Straight-Wire Appliance
Table of Contents
1 - Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
2 - The CCO Diagnostic Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3 - Orienting the Headfilm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
4 - Target Line Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
5 - Faulty Diagnosis from Intracranial References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
6 - Determining Tooth Spacing Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Incisor Inclination. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
Crowding/Spacing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Maxillary Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Dental Expansion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Curve of Spee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Tooth Size Discrepancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Resolving Space Discrepancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
7 - Case Example . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
8. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
1
1. Introduction
Treatment Design is the core of the Complete Clinical Orthodontics (CCO) diagnostic process, and once
mastered, will provide the maximum information about a patient’s proposed orthodontic treatment with
very little effort on the part of the practitioner. This exercise is a three-dimensional simulation of a proposed
treatment plan on the lateral headfilm before performing any actual treatment on a patient. While much of
the treatment simulation is performed in the sagittal and vertical dimensions, the information from the third
dimension (transverse) is incorporated into the decision making process.
By going through the exercise of Treatment Design, the practitioner has the ability to try different orthodontic
strategies to determine the one that is the most effective and efficient at achieving the treatment goals. In
addition, it allows for improved communication between the doctor and the patient when helping the patient
understand the methodology and rationale behind the proposed treatment plan. Most important, however,
Treatment Design shows the doctor the necessary mechanics for treatment and gives the doctor confidence
that the goals set forth for the patient can realistically be achieved.
With the proposed method for Treatment Design, multiple treatment plans for the same patient can be
simulated and either accepted or rejected in a very short period of time. Thus, there will be a minimal burden
on clinic, doctor, and staff time, and the patient will certainly benefit from the added effort that was spent
in treatment planning. Also, the CCO method will guide the doctor to ideal positions of the teeth, jaws, and
soft tissue. Deviations from the ideal, when needed, can be judiciously determined to not negatively effect
esthetics, function, airway, or the periodontium.
2 CCO® System: Orthodontic Treatment Design / Ryan K. Tamburrino, DMD
2. The CCO Diagnostic Sheet

At the core of Treatment Design is the CCO Diagnostic Sheet. The sheet’s main purpose is to serve as a
central hub and easy reference for recording all data that may affect treatment decisions for the patient.
Additionally, it serves as reference for the clinician to use as treatment progresses to ensure the treatment
goals are being appropriately addressed.
3
The CCO Diagnostic Sheet is strategically divided into three parts to easily organize clinical data, records
data, and the interdisciplinary treatment plan. However, the scope of this manual will focus only on the data
that will impact the Treatment Design portion of the CCO material, mainly the transverse diagnosis and deter-
mining the space requirement.
Clinical Data
Records Data
Interdisciplinary Treatment Plan
Steps for Treatment Design of the Orthodontic Patient
Treatment Design is performed via a series of nine logical steps while simultaneously using and recording
information on the CCO Patient Diagnostic Sheet. These steps are followed in the same sequence for every
patient in a manner which is extremely efficient. The rest of the manual will be dedicated to elaborating on
each of these points in detail.
5
3. Orienting the Lateral Headfilm
9 Steps for CCO Treatment Design

1. Orient lateral headfilm to adjusted natural head position
2. Perform SCP/MIC conversion of headfilm
3. Construct Target Lines for the hard and soft tissue
4. Set the desired inclination of the incisors
5. Determine tooth spacing requirements
6. Move mandibular molars into desired position
7. Move maxillary molars into desired position
8. Superimpose jaws to determine anchorage requirements
9. Accept result or modify tooth positions to satisfy treatment
objectives
The critical step to accurately completing the Treatment Design exercise

is to ensure the lateral headfilm is properly oriented into adjusted natural
head position. Treatment Design depends on constructing true vertical
lines on the cephalometric radiograph, because the resulting infor-
mation will not be useful unless the patient’s head is correctly positioned.
Additionally, while the Treatment Design can easily be performed with a
traditional or digital lateral ceph, the most accurate information will be
obtained from reconstructed cone-beam CT data, which is free of image
magnification and distortion.
There are multiple methods that can be used to transfer and reproduce
adjusted natural head position from the patient to the x-ray, and a few
will be illustrated in the following section. Acceptable methods described
here are aligning the digitized ceph tracing to a property oriented lateral
photograph, placing horizontal radiographic markers on the patient, or
using the Head Positioning Instrument® (HPI). Once again, using a CBCT to
obtain the lateral headfilm will allow for the most accurate diagnosis, but
all methods can be successfully implemented with traditional imaging as
well. The first way to orient the lateral headfilm tracing is to use a digitized
lateral photograph. For this method, the software used for digitization
must have the capability to manipulate the tracing. Additionally, it is critical
to have the lateral photograph taken with the head oriented in Adjusted
Natural Head Position (ANHP). Otherwise, the alignment of the tracing will
be inaccurate. The following photos depict the sequence for orientation
with cephalometric software that has the capabilities to rotate the tracing.
First, the lateral headfilm must first be digitized and traced.
Then, by using the capabilities of the software, the headfilm can be

properly aligned by superimposing and rotating the tracing on the
photograph.
Placing Radiopaque Markers on the Face
A method for orienting the headfilm when a digital tracing package is not available (or the software does
not have the capacity to orient the tracing) is to place radiopaque markers, such as barium paste, onto the
patient’s face. These markers should be oriented to true horizontal with the patient in ANHP. With these in
place, the lateral ceph can be taken and easily reoriented to ANHP by aligning the markers. This method is
technique sensitive because it requires aligning the dots properly but is still acceptable to use and easily done
when other methods are not available.
Head Positioning Instrument (HPI) ®
The HPI® (Steel City Dental Concepts, Philadelphia, PA) allows for objective measurements between fixed
points for the most accurate reproducibility. The method will be described below.
Step 1: Using a paintbrush, place a dot (1-2 mm in diameter) of barium paste or any radiopaque material on
the forehead. Note: If using a CBCT image, some machines may not have the capability to scan the entire
volume of the head. If this is the case, placing a marker on nasion or other easily visualized structure on the
midsagittal plane of the face will suffice.
7
Step 2: Zero out the slider and place the patient into the HPI®. Orient the head into operator-determined
adjusted natural head position. Place the upper fixed reference point of choosing against the radiopaque
marker placed on the head in Step 1.
Step 3: Have the patient smile and touch the facial surface of the maxillary incisor with the sliding pointer.
Record the horizontal distance between the two points. Because there are two fixed reference points, the
actual location of the points is NOT important. The critical concept is that the two points be fixed and easily
identifiable on a radiograph.
Step 4: Using this distance information, the headfilm can be appropriately oriented to adjusted natural head
position by reproducing this distance between the two fixed points (front of central incisor and radiopaque
marker) on the lateral view. The ceph is now ready for tracing.
The SCP/MIC Conversion of the Headfilm
A treatment goal for all patients is to achieve Andrews’ Six Keys1 of occlusion on the arc of closure from a
Seated Condylar Position (SCP) or Adapted Centric Posture (ACP)2. In order to finish with this desired result,
the treatment plan should be formulated from SCP. Often patients will present reasonable intercuspation of
the teeth, but, unknown to the practitioner, the temporomandibular joint position is not stable or is distracted
from the fossa. For these patients, who also have their initial radiographs taken in maximum intercuspation
(MIC), it may be necessary to convert the lateral headfilm to one in SCP for proper treatment planning.
Note: The instructors of the CCO course advise taking the initial lateral headfilm in MIC in order to best view
any condylar distraction/disharmonies on TMJ imaging and for difficulty of maintaining a non-deprogrammed
patient in a seated condylar position. However, if a patient has been wearing an occlusal appliance or is
having progress or pre-orthognathic surgery records, then positioning the patient into SCP and holding it
at the first point of contact with a wax registration before taking the lateral headfilm is advised. Also, some
digital treatment planning software packages require orientation prior to conversion, and some others will
allow after. You will need to read the software manual to determine the capabilities of your software.
The graphics below illustrate a patient who presented with a large initial SCP/MIC discrepancy on mounting
the models and shows how converting the ceph to SCP allowed for better representation of the occlusal
disharmony for treatment planning purposes.
MIC Ceph SCP Converted Ceph
For cases which present with a SCP/MIC discrepancy, like the one below, the first step is to use a millimeter
ruler or perio probe to measure the overjet and overbite on the mounted casts at the first point of posterior
contact and compare that to the models in MIC. Additionally, the molar relationship should be denoted.
1
Andrews LF. The six keys to normal occlusion. Amer J Orthod. 1972; 62: 296-309.
2
Dawson PE. New definition for relating occlusion to varying conditions of the temporomandibular joint. J Prosth Dent. 1995; 74(6):619-627.
9
Secondly, trace the MIC ceph with the tracing program of your choosing. Be sure to note the OB/OJ.
Using the ceph conversion feature of your tracing software, move the mandible until the ceph mimics the SCP
mounted casts with respect to overjet, overbite, and molar relationship. You will need to refer to the software
manual for information specific to your program as to how this is accomplished. This adjusted ceph is now
ready to use for the treatment planning process since the models and tracing are both oriented to the same
reference position and the data correlates.
MIC Ceph SCP Converted Ceph

4. Target Line Construction

Placing Target Lines on the lateral headfilm is the critical aspect
and foundation of Treatment Design. These lines are meant to assist
the orthodontist in visualizing the ideal positions of the teeth, jaws,
and soft tissue. They do not signify absolute requirements for the
location of these components, and that is the crucial concept to
remember. Instead they are used to guide the orthodontist in making
appropriate treatment decisions that will work towards achieving
esthetic and functional goals, not moving away from them. Since
many patients do not have “ideal” naturally occurring skeletal and/
or dental harmony, the guidelines will also help the orthodontist
and the patient visualize the limits of treatment needed to protect
the roots and periodontium, as well as preserve soft tissue support.
Additionally, the graphical nature of the exercise will aid in deter-
mining an objective, sensible, and easily understood treatment plan
with the patient if compromise or camouflage treatment is desired.
Using a properly oriented lateral headfilm, which is critical for this

analysis, the following three Target Lines constructed: Glabella
Vertical Line (GVL), Subnasale Vertical Line (SNV), and the Maxillary Hard Tissue Target
Occlusal Plane (MOP). These will be targets for, respectively, the hard Glabella Vertical Line (GVL)
tissue, soft tissue, and the dentition.
Soft Tissue Target
Hard Tissue Target (Glabella Vertical Line) Subnasale Vertical Line (SNV)
The Glabella Vertical Line (GVL) is constructed as a vertical line

Dentition Target
extending downward from soft tissue glabella and is used to evaluate
Maxillary Occlusal Plane (MOP
the anterior-posterior (A-P) position of the maxilla. In an optimal
scenario, the facial surface of the maxillary central incisor will lie on
or slightly ahead of this line when it is centered in the alveolus and
is also ideally inclined relative to the occlusal plane (to be discussed
later).
The rationale for this Target Line can be illustrated via a publi-
cation by Dr. Will Andrews. This paper evaluated the position of the
maxillary central incisor, in profile smile, on a sample of “attractive”
people3. The result found that 96% of the “attractive” population had
the facial surface of the maxillary central incisor ahead of the center
of the forehead and/or slightly anterior to glabella. Given the esthetic
preference of modern society for a “fuller” profile and clinical goal of
not impinging on the airway or tongue space via excessive anterior
retraction, the results of this study reflect this esthetic and functional
ideal.
Andrews WA. AP Relationship of the Maxillary Central Incisors to the Forehead in Adult White Females. Angle Orthod. 2008; 4:662-9.
3
11
When comparing a patient with an ideal A-P maxillary incisor positioning (3 left pictures) with one that is
either retrusive (4th picture) or protrusive (5th picture) with respect to the GVL, the esthetic effects are
apparent.
Andrews’ study suggests that when developing an orthodontic or surgical treatment plan, the goal should
be to position the maxillary central incisor in a way that enhances the esthetics of the smiling profile, not
detract from it. While the ideal target is the facial surface of the incisor lying directly on the GVL, positioning
the incisor slightly ahead or behind the line is also acceptable. For most cases, positioning the incisor exces-
sively behind or in front of the glabella vertical line may negatively alter the smiling profile and thereby affect
lip support. The main idea is that this reference allows the clinician to have a visual starting point and make
subsequent clinical decisions with the hard tissue and teeth that will either be positive or neutral with respect
to the patient’s pre-treatment condition, and also help the clinician rule out treatment options which would
possibly have a negative esthetic effect.
Soft Tissue Target (Subnasale Vertical Line)
While the GVL helps to evaluate the position of the maxillary incisor
and hard tissue, the Subnasale Vertical Line (SNV) is used to evaluate
the balance of the soft tissue profile of the lips and chin in repose.
The line parallels the GVL and is constructed through subnasale.
The purpose of the SNV is to evaluate the prominence of the upper

lip, lower lip, and chin. However, for the most accurate analysis, the
lips must be relaxed and fully in repose upon imaging. Excessive lip
strain will produce an incorrect relationship due to distortion of the
soft tissue through the underlying muscle activity, as shown on the
next page.
Soft Tissue Target

Subnasale Vertical Line (SNV)
Relaxed musculature Excessive mentalis strain
To evaluate the soft tissue profile, three lines are constructed perpendicular to the SNV and extend to the
most prominent portion of the upper lip, lower lip, and chin. The horizontal distance from the SNV is then
recorded. The values below represent ideal soft tissue positions4.
Subnasale Vertical (SNV) Line
Used to elevate the

quality of the soft tissue
profile in repose
SNV-Ulip 3 - 5 mm
SNV-Llip 0 - 2 mm
SNV-Chin -4 - 0 mm
As was conceptualized when using the GVL, these numbers are NOT absolutes, only guidelines. The
important concept is the relationship and hierarchy of position among the components; mainly that the upper
lip is the most prominent of the three and should fall ahead of the SNV. The lower lip is not as prominent but
still slightly ahead of the SNV. Finally, the chin point should be slightly behind the line.
Arnett GW, Jelic JS, Kim J, et al. Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial
4
Orthop 1999;116:239-53.
13
The photographs below illustrate several patients, all having different soft tissue relationships to the SNV. As
you can see in the first picture, slight deviations from ideal can be quite esthetic and acceptable. However,
correction of gross discrepancies can be beyond the capabilities of orthodontics alone and may require
adjunctive treatment modalities or surgical intervention.
When patients do not present with ideal soft tissue relationships, once again, it is not an absolute requirement
to achieve optimal proportions. However, if “ideal” treatment is attainable in conjunction with the patient’s
esthetic desires, the measurements and relationships discussed are the universally accepted soft tissue
positional goals to achieve. Additionally, by having these guidelines, an orthodontic treatment plan can be
designed to enhance or maintain the patient’s esthetics, even when “ideal” is not possible or desired.
At this point, we have discussed the construction and rationale of references for both hard and soft tissue
esthetics. In an ideal world, optimizing the position of the hard tissue would automatically harmonize the soft
tissue. While this does happen in many instances, sometimes there are
outliers where it does not. In these instances, the soft tissue position
ALWAYS trumps the hard tissue. Therefore, if the hard tissue is
idealized, but the soft tissue still does not meet the esthetic prefer-
ences of the clinician or the patient, then the treatment plan should
be modified to ensure the soft tissue goals are met, irrespective of
the hard tissue position to the GVL.
Dentition Target (Maxillary Occlusal Plane)
The third target line is the Maxillary Occlusal Plane (MOP) and is
constructed through the cusp tips of the maxillary first molar and
premolars.
The MOP provides a reference position to set the inclination of the

maxillary and mandibular incisors for Treatment Design purposes.
Additionally, the MOP inclination is important for optimizing
the function of the dentition with respect to the anatomy of the
temporomandibular joint complex and plays a significant role for
harmonizing esthetics in orthodontic/orthognathic surgery cases.
While these are important aspects in their own right and deserve
Dentition Target
through discussion, the scope of this manual will be limited only to
Maxillary Occlusal Plane (MOP)
the aspect of relating the dentition to the occlusal plane.
Due to potential vertical variations of the pre-treatment maxillary incisors, especially in anterior open bite
cases where there is an exaggerated Curve of Spee, the incisal edge is not used for construction of the MOP,
as this may misrepresent the patient’s condition being used for diagnosis and Treatment Design. Therefore,
the functional occlusal plane utilizing the cusp tips of the maxillary molar and premolar is more clinically
accurate, as shown below.
In cases where a patient presents with an anterior and posterior open bite, often due to contact on the
terminal molars, using the maxillary occlusal plane only to evaluate the position of the lower anterior teeth
(to be discussed later) is not appropriate. Therefore, two occlusal planes must be drawn to evaluate the teeth
independently; one for the maxillary dentition and one for the mandibular dentition. However, this text will
focus only on the quantifiable inclination of the maxillary occlusal plane. Because the ultimate treatment goal
will be for both planes to coincide with the maxillary plane with the incisors in the proper overbite/overjet
relationship at the end of treatment, as shown below, there is no need to record a pre-treatment value for the
mandibular plane.
Initial Treated
15
For CCO Treatment Design, the MOP inclination is measured as the acute angle between the MOP and the
GVL, SNV, or any other true vertical reference line. Based on previous research, as shown below, the “ideal”
MOP inclination should measure between 81-85˚ to the True Vertical Line (TVL)5,6, with an average of 83˚.
Several prominent clinicians have proposed normal values for an ideal MOP inclination. Due to using a true
vertical reference for CCO Treatment Design, as opposed to a true horizontal used by these clinicians, the
numbers shown below may vary from the actual values published in the quoted literature. The measurements
cited in this manual are adjusted to reflect this difference reference but are clinically equivalent to previously
published values of those authors
Maxillary Occlusal Plane
Arnett = 85° to TVL
Andrews = 81°-83° to TVL

Maxillary Occlusal Plane
Measurement Ideal = 81°-85° to TVL
Properly constructing the MOP is critical for Treatment Design, as this will affect many of the clinical decisions
that will be made going forward, specifically with respect to determining the inclination of the incisors.
5
Arnett GW, Jelic JS, Kim J, et al. Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity. Am J Orthod Dentofacial
Orthop 1999;116:239-53.
Andrews LF, Andrews WA. Andrews analysis. In: Syllabus of the Andrews Orthodontic Philosophy. 9th ed. Six Elements Course Manual; 2001..
6
5. Faulty Diagnoses from Using

Intracranial References
Before discussing how to use the MOP to determine our incisor position for Treatment Design, we need to
understand the rationale for using this reference over other commonly used references. While there are many
potential reference positions for measuring existing and treated incisor inclination, most traditional analyses
use intracranial references that are anatomically unique to each patient but yet have “normal” or “ideal”
values attached to them for diagnosis. So, how is that possible? The following images illustrate many refer-
ences which are used to denote incisor position, but which one is correct? More important than being “right”,
however, is which reference can provide measurements which have consistent and reliable diagnostic infor-
mation for every patient, irrespective of anatomical variations?
Consider, for example, the following

Maxillary Reference Lines patient. A popular cephalometric
measurement, SNA, is used to diagnose
the pre-treatment A-P position of the
S-N maxilla. In a “normal” patient, like the
one shown below, the SNA measurement
F-H is 82˚. Values greater than 82˚ suggest
the maxilla is protrusive, and values less
Ba-Na than 82˚ suggest a retrusive maxillary
position, irrespective of any other hard or
Na-A soft tissue criteria.
However, let’s consider the cephalometric

ANS-NS
landmarks used for this measurement,
namely Sella and Nasion, and examine
Occlusal Plane
how anatomical variations can affect the
diagnosis. First, if the position of Sella is
improperly identified or varied among an
ethnic population, how would this affect
the measurement of SNA, the diagnosis
Maxillary Reference Lines for the A-P position of the maxilla,
and, ultimately the treatment planning
decisions and mechanics that will be
based on this information?
A-Po The example below shows the previous

patient but with varied positions of Sella,
which subsequently changes the SNA
Na-B
measurement and maxillary A-P position
“diagnosis” for the patient. Additionally,
Go-Gn
let’s consider variations in Nasion’s
position to see how that also could affect
Occlusal Plane
the SNA measurement and “diagnosis”.
Even though there are different numerical

values for SNA, the physical position of
17
91 98
82 82
82 78 79
Variations of Sella on SNA Variations of Nasion on SNA
the maxilla has not changed, and neither has the face of this patient. So, for this theoretical patient, an identi-
cally positioned maxilla in space could be “diagnosed” as normal, protrusive, or retrusive depending on how
the landmarks used are anatomically positioned in the skull. More importantly, though, the SNA information
(in all the variations as well) does not relate any information about the patient’s face or esthetics, nor does it
qualify how treatment should or should not affect it.
Finally, and most importantly, can this information be relied upon for definitive, universal diagnosis of subse-
quent patients? Consider the following example of three patients, all with SNA measurements of 82˚. The
maxillary A-P position for all three patients, while considered “normal” solely by the SNA number, estheti-
cally does not coincide to the clinical presentation of maxillary retrusion/normal mandible of the left patient,
normal maxilla/mandible of the center patient, and the combination of maxillary protrusion/mandibular
retrusion of the right patient. Also, the SNA measurement does not help quantify the discrepancy or facilitate
treatment decisions for esthetic and functional normalization.
82 82 82
The previous example illustrated one way how intracranial landmarks cannot be relied upon for skeletal
positional diagnosis with relation to the patient’s face. However, in addition to skeletal criteria, these
landmarks are also traditionally used to determine a universal dental “normal”, formulate a dental diagnosis,
and quantify the amount of dental change needed. Because it was demonstrated previously that these
landmarks can affect the skeletal measurement/diagnosis, is it valid to assume variations will affect the dental
measurements/diagnosis as well?
Using the same landmarks of Sella

and Nasion, two popular measure-
ments for measuring the inclination
of the maxillary central incisor are
U1-NA line and U1-SN line. The 19 120
normal values for these measure- 30 115
ments are 22˚ and 102˚, respec- 24 108
tively. Let’s consider measuring the
U1-NA line inclinations with varia-
tions of Nasion, and the U1-SN line
with variations of Sella.
Similar to the skeletal measure-

ments, there is significant
“variation” of the inclination of
the central incisor depending on
how the reference line is anatomi-
cally positioned for both of these U1 Inclination using the U1 Inclination using the
examples. In reality, though, the U1-NA line U1-SN line
position of the incisor is the
same, yet the diagnosis and potential plan for “correction” is different for each variation. Therefore, similar to
being unreliable for a skeletal diagnosis, intracranial landmarks are not the best reference choice for dental
diagnosis either.
The MOP as an Ideal Dental Reference Line
The previous information has already

shown that the GVL and SNV lines are Common Reference Lines
acceptable to use as global skeletal
and soft tissue references that are
non-patient specific and delineate
quantifiable treatment goals. Additionally,
the previous information showed how
intracranial reference lines can lead to
faulty information regarding skeletal
and dental positions for diagnosis and What does a
treatment. So, for the dentition, what tooth “see”?
does a tooth “understand” and what
does a tooth “see”?
The most basic premise of orthodontic

treatment is that the wire’s deflection
and its return to a previous shape is what
provides the power to move a tooth. The
19
bracket, which is cemented to the tooth, is the vehicle to attach the wire to the tooth. However, this bracket
has a rectangular slot cut at a 3D predetermined position (bracket prescription), which interacts with the
shape of the archwire passing through it. Given that Andrews’ research showed little variation in the surface
contour of the incisors, we can conclude that the 3D position of these teeth is essentially governed by the
interaction of the archwire and the bracket slot. To take this concept a step further, if one uses a true Straight-
Wire Appliance (SWA), then all of the bracket slots, when the brackets are ideally positioned on the Facial
Axis (FA) point of the tooth, will align and the teeth will be at the optimal inclinations and 3D positions.
0.019”x0.025” braided wires

4 weeks prior to debond
Day of debond
Since the treatment goal is to have both archwires parallel to the maxillary occlusal plane prior to debond,
then we can infer that the inclination of an incisor will then be dependent only on the interaction of the
bracket slot with the archwire. Additionally, because anatomic tooth variations are minimal, then we can
further postulate that specific interactions of wire size and slot size will also be universal, predictable, and
transferrable. This understanding how the inclination of a maxillary/mandibular incisor in a straight wire
appliance relates to the maxillary occlusal plane is a cornerstone of the CCO Treatment Design process.
MOP Inclination and “Torque” Expression
The fundamental concept of Treatment Design is virtually, and more importantly, realistically simulating
the orthodontic outcome prior to ever placing a bracket. Unless one knows what will happen consistently
with good bracket placement and treatment mechanics, this can be a difficult exercise that may or may not
coincide with the actual outcome of the case.
As was demonstrated previously, incisor inclination is related to the maxillary occlusal plane inclination.
Therefore, varying the occlusal plane inclination with the same bracket prescription/wire size would not have
any effect on the actual inclination, or “torque”, of the tooth - only the perceived inclination.
With the above rationale, given the identical wire size and bracket prescription for each of the scenarios
below, altering only the occlusal plane can give the appearance of incisors being “retroclined” or “proclined”.
Therefore, it is appropriate to conclude that “torque” in the bracket prescription is expressed relative to the
occlusal plane and not another internal or external reference.
Steep MOP Ideal MOP Flat MOP

Expression of Dental Inclination / “Torque”
Understanding how dental inclinations are expressed with respect to the appliance used has little impor-
tance unless it can have predictive value. Therefore, for Treatment Design, the practitioner has to know what
inclination the appliance is capable
of delivering CONSISTENTLY and “Torque” Expression
PREDICTABLY in order to have a starting
point for analysis. Without this ability
or knowledge, treatment planning is no Bracket Rx
better than a guess and can prove to
be a frustrating exercise, or one that is
simply done “on the fly”, neither of which
is in the best interest of the patient.
Wire Size Slot Size
Assuming the bracket is placed correctly,
the inclination of a tooth is dependent on
four factors – the “torque” prescription
of the bracket, the wire size used,
the slot size used, and the amount of Engagement
engagement.
21
The “torque” portion of the bracket prescription is self-explanatory. The higher the torque value, the more
torque the bracket has the potential to express. For this manual, the CCO prescription is used with the
following standard “torque” values.
Maxillary Central Incisor: 12˚ torque

Mandibular Central Incisor: -6˚ torque
The wire size and slot size go hand in hand, no matter if the practitioner uses 0.018” or 0.022” slot brackets.
The larger the wire size placed in a given slot, the more it fills the slot, and the more the torque value of the
bracket will be expressed.
The key variable in torque expression,

however, is the engagement of the wire Interactive SL Clip (In-Ovation)
with the bracket slot. A loosely engaged
wire will have less interaction with the
bracket slot, especially if it is less than
the full dimensions of the slot. This is
commonly referred to as “slop”. In order
to minimize “slop,” the wire must either
be engaged tightly or a larger wire size
must be used. Engaging the wire tightly
with ligature ties at every patient visit
is time consuming and the ligature wire
can fatigue in between appointments.
The alternative of using larger size wires
is often not appealing because they
are harder to engage and can be more
uncomfortable for the patient.
The solution is an interactive clip

mechanism as is present on the Torque Expression of Mandibular 2nd
In-Ovation self-ligating (SL) bracket.
With this bracket design, the gingival Premolar (22° Interactive SL Brackets)
wall of the bracket is a smaller
dimension than the incisal wall. Since
the clip flexes and “pushes” the wire Effective
In-Ovation
into the slot, full engagement is Torque
possible with a less than full slot size
wire and without ligature ties.
17” x 25” 17°
Studies have shown that with inter-
active SL brackets full “torque”
18” x 25” 19°
expression of 0.022” slot brackets can
be achieved with any wire that is 0.019”
x 0.025”” or larger. This is an important 19” x 25” 22°
concept and feature that is the key
to CONSISTENT bracket prescription
expression for Treatment Design 21” x 25” 22°
purposes.
Gick MR, Nóbrega C, Benetti JJ, Jakob SR, Zucchi TU and Arsati F.
Orthodontic Science and Practice. 2012: 5(17):37-46.
Setting the Incisor Inclination
One of the goals of the Treatment Design is to first evaluate the patient from an optimal treatment
perspective. Therefore, before decisions on treatment or potential treatment compromises can be made, the
orthodontist must first evaluate the patient as if full bracket prescription values have been expressed. This
provides a frame of reference to what “ideal” treatment is, and then the plan may be modified as needed to
accomplish the individual goals for the patient.
For the In-Ovation bracket with the CCO prescription fully expressed in a 0.019”x0.025” wire, the maxillary
incisors will be at 57˚ to the MOP, and the mandibular incisors will be at 65-70˚ to the MOP.
Maxillary Central Incisor: 57˚

Mandibular Central Incisor: 65-70˚
The following example is a pre-surgical decompensation case. No mechanics other than changing wires were
used up to U/L 0.019”x0.025” steel wires. Note the inclinations of the incisors to the MOP with full bracket
expression.
23
With the CCO prescription and 0.019”x0.025” finishing wire, the post-treatment maxillary incisor inclination
value has been shown to be exactly 57˚ for many cases. However, the mandibular incisor inclination has
shown more of a normal “range” instead of an single value. The rationale for this is due to the anatomical
limitations and dimensions of the symphysis (versus the maxillary alveolus being larger) of some patients as
well as additional factors acting on the mandibular teeth, such as the tongue, that can prevent full uprighting
to 70˚ over basal bone in every case.
The following example shows a case where there is very little width to the alveolus. If the lower incisor was
fully inclined to 70˚ to the MOP, the root would be fenestrated, off of basal bone, and unable to couple
with the maxillary incisor. Additionally, this could not happen anatomically due to the restrictions to tooth
movement. Instead, having the incisor at 65˚ to the MOP facilitated it remaining in the alveolus, positioned
over basal bone, and coupled with the maxillary incisor.
Initial Incisor Inclination Unrealistic Incisor Inclination Realistic Incisor Inclination

The importance of understanding what inclination of the incisors can CONSISTENTLY be achieved and how
this ideal inclination relates to the hard tissue esthetics and soft tissue esthetics of each patient is the starting
point of the entire Treatment Design process.
There may be cases where the practitioner chooses to not have an “ideal” inclination to the incisors in order
to camouflage a skeletal discrepancy or because of anatomical limitations to tooth positioning. However, this
decision for where to place and incline the incisors still needs to be framed within the realm of good esthetics,
periodontal viability, and realistic movements for stability.
Additionally, by knowing where “ideal” should be, these compromises can be quantified and visualized to see
how far from “ideal” the case may finish, as well as realize the potential side effects of doing so. Ultimately,
whatever position the practitioner chooses to be appropriate for the incisors needs to be consistent with the
rest of the Treatment Design process in order for the treatment plan to have meaning and validity.
The rest of this manual will focus on how to use this information to formulate a realistic, predictable, and
physiologic ideal treatment plan for a patient and also determine how to make rational compromises should
they be indicated or needed.
Andrews LF, Andrews WA. Andrews analysis. In: Syllabus of the Andrews Orthodontic Philosophy. 9th ed. Six Elements Course Manual; 2001.
7
6. Determining Tooth Space Requirements

Once the Target Lines are placed on the lateral headfilm and the maxillary and mandibular incisors are ideally
inclined and centered in the bone, the posterior teeth can be moved in order to determine the anchorage
requirements. The objective is to have no spacing or crowding remaining at the conclusion of treatment.
Therefore, the amount of needed movement of the posterior teeth, which will allow the incisors to remain at
their ideal position, is easily calculated.
The space requirement for the dentition and associated changes of space with tooth movement can be
derived from research performed by Andrews7. This analysis has proven to be comprehensive and accurate,
and modification of Andrews’ original concepts is not warranted. The space requirement is then calculated as
a sum of six individual components, all of which either contribute to net spacing or crowding of the dentition
of transversely coordinated arches, followed by methods for creating or closing space, for a final space
requirement of zero.
These components are measured to determine the overall crowding/spacing for an arch:
1. Change in inclination of incisors

2. Crowding/spacing physically present
3. Change in maxillary jaw width
4. Change in dental arch width
5. Leveling the Curve of Spee
6. Tooth/size discrepancy
These components contribute to relieving the overall crowding/spacing
1. Tooth extraction
2. Molar distalization/mesialization
3. Interproximal reduction (IPR)
25
Case Example
For illustration purposes and for consistency, the tooth spacing requirements and movements will follow the
diagnosis of one patient. The case is a non-growing female with a non-contributory medical history, no TMJ
symptoms or pathology, and minimal SCP/MIC discrepancy on the mounted models. The intraoral images
represent the SCP occlusion well, and the lateral headfilm did not require conversion.
SCP Ceph = MIC Ceph (no conversion needed)

Diagnostic Sheet
For each patient, the space requirement portion of the diagnostic sheet will be used. As this text progresses
with the Treatment Design for the patient above, the CCO Diagnostic Sheet will be populated with data based
on the positions of the incisors and the molars. This will allow for decisions to be made for the treatment plan
as well as the mechanics needed to successfully complete the case.
Space Requirement
Maxilla Mandible
Incisor Inclination (X2)
Crowding/Spacing
Maxillary Expansion
Dental Expansion
Curve of Spee
Tooth/Size Discrepancy
Unresolved Space Requirement
Extraction
Distalization/Mesialization (X2)
IPR
Final Space Requirement 0 0
Incisor Inclination
As previously discussed, one objective of tracing the lateral headfilm is to ideally position the incisors within
the alveolus and at the proper inclination to the occlusal plane. As the inclination of the incisor changes,
however, the amount of available space for the dentition will either increase or decrease. Proclining the
incisors will create additional space, while retroclining the incisors will require space.
The rationale for this can be illustrated by the following photographs. Increasing the archform along the cusp
tips and incisal edges (by proclining the teeth) makes the effective “line” connecting the teeth longer, thereby
increasing the space available to accommodate the dentition.
27
Through Andrews’ research, the approximate change is 1 mm of space gain/loss per 1 mm of FA point change
of the incisor from its initial to desired position. Because this only accounts for one quadrant, the measured
change must be doubled in order to realize the whole-arch effect.
Looking at the case example above, the maxillary incisors were initially inclined at 64˚ to the MOP. By placing
them with optimal inclination of 57˚ to the MOP the FA point is slightly ahead of the GVL with the tooth
centered in the alveolus. For this to happen, the FA point moved facially 2 mm.
For the mandibular teeth, the initial inclination was 64˚ to the MOP. Idealizing their inclination to 70˚ to the
MOP allows them to couple with the maxillary incisors at the ideal OB/OJ and still be centered within the
alveolus. For this movement, the FA point moved lingually 0.5 mm.
Looking at this incisor position with respect to the Target Lines, the esthetic requirements for this case
are satisfied. Also, the incisors are centered in the alveolus over basal bone, so the periodontal goals are
achieved. Finally, the incisor inclination is achieved with full expression of the bracket prescription, so
the movements are achievable and realistic. This also shows that the skeletal diagnosis is Class I and no
compromise to the incisor position is needed.
The values entered into the diagnostic sheet are as follows:
Maxillary arch: 2 mm FA point change X 2 = 4 mm of space gained

Mandibular arch: -0.5 mm FA point change X 2 = -1 mm of space needed
Space Requirement
Maxilla Mandible
Incisor Inclination (X2) 4 -1
Crowding/Spacing
Maxillary Expansion
Dental Expansion
Curve of Spee
Extraction
IPR
If changes to the ideal inclination were desired, then the compromise position would be used for the space
calculation. On the diagnostic sheet, the box for incisor inclination values is divided into 2 for this purpose.
The first box represents the “ideal” space”, while the second box would be used for a “compromise” should it
be desired.
Limits of Sagittal Camouflage
The rationale for setting the maxillary and mandibular incisors at 57˚ and 70˚ to the MOP, respectively, and
centering them within the alveolar bone was previously discussed. This is the base understanding of what will
be achieved via orthodontic treatment with only using brackets and wires, specifically 0.019”x0.025” wire on
an In-Ovation active self-ligating central incisor bracket with the CCO prescription.
If the teeth couple at the proper OJ after this exercise, this tells the practitioner that there are ideal sagittal
skeletal relationships present. Additionally, this shows that minimal adjunctive work will be needed to achieve
the simulated result. The wires and bracket clip just need to work to allowing the full bracket prescription to
express itself.
Many times, however, the teeth set at 57˚/70˚ to the MOP will NOT couple ideally on the simulation. The
practitioner will instead see residual OJ (signifying a Cl. II skeletal pattern) or overlapping incisor tips/negative
OJ (Cl. III skeletal pattern) remaining. Understanding this phenomenon is critical from a treatment planning
perspective, as well as setting realistic pre-treatment orthodontic expectations for patient and/or the patient’s
parent with what can be accomplished with braces alone.
When the teeth don’t couple at the optimal inclinations, measuring the residual OJ along the MOP quickly
quantifies the underlying skeletal discrepancy for the practitioner. Once the amount of the sagittal
discrepancy is known, then the Target Lines are used to objectively qualify which jaw(s) is (are) contributing
to the discrepancy, and also quantify by how much they deviate from the ideal.
From here, the practitioner may now make rational treatment decisions, based on his own comfort level and
experience, for how to resolve the discrepancy.
In non-growing patients, the Target Lines for the hard and soft tissue, as well as the anatomy of the alveolus
and pre-existing periodontal biotype, will all need to be considered when deciding on sagittal limits of
29
camouflage. In growing patients, the growth potential along with the growth modification potential (realized
from the Jarabak cephalometric numbers on tracing) will be used to realistically decide what may or may not
be possible with orthodontic/orthopedic treatment alone.
Case Example #1:
The initial ceph tracing reveals a Cl. II skeletal deep bite with retroclined incisors. Currently, there is “6
mm” of overbite, “3 mm” of overjet, and a Cl. II molar relationship. However, this information is meaningless
because we do not have a reference to understand what is going to happen with treatment. Therefore, the
first step toward realizing the abilities of braces-only treatment for this patient is to set the incisors ideally at
57˚/70˚ and center them within the alveolus.
Space Analysis
Maxilla Mandible
Incisor Inclination (X2) 5 2
Crowding/Spacing
Maxillary Expansion
Dental Expansion
Curve of Spee
Extraction
IPR
This virtual “decompensation” of the incisors helps to better visualize the case. First, there is actually 4
mm of overbite and 7 mm of overjet present (not 6 mm of OB and 3 mm of OJ). Secondly, the facial of the
ideally inclined “treated” maxillary incisor falls directly on the GVL. This indicates that the maxilla is optimally
positioned at baseline, and 100% of the overjet/Cl. II pattern is due to a retrusive mandible. Thirdly, evaluation
of the soft tissue esthetics with the SNV line confirms the Cl. II skeletal pattern with optimal upper lip support
and a retrusive lower lip and chin. This case can now be qualified in the sagittal dimension as a “Cl. II skeletal/
dental pattern due to a retrusive mandible and normally positioned maxilla”. Most importantly, the sagittal
discrepancy can now be quantified as 7 mm.
Think of how powerful this realistic, qualified, and quantified information is when deciding on treatment
decisions and instilling confidence into the practitioner. Subsequently, when presenting objective options to
parents/patients, no speculation or guessing is needed.
Going forward, the aim for this hypothetical case would be to maintain the position of the maxilla and allow
the upper incisor to be optimally inclined. If the patient has mandibular growth remaining, and it is favorable,
then the practitioner’s preference for strategies to take advantage of this differential jaw growth could be
employed. If the patient is a non-growing individual, then gingival biotype, periodontal limits of the alveolus,
and quality of the soft tissue will determine the ability to confidently propose camouflage vs. orthognathic
options.
Case Example #2:
Space Analysis
Maxilla Mandible
Incisor Inclination (X2) -1 -3
Crowding/Spacing
Maxillary Expansion
Dental Expansion
Curve of Spee
Extraction
IPR

31
Idealizing the inclination of the incisors to 57˚/70˚ to the MOP reveals a Cl. II skeletal pattern with a combi-
nation of a protrusive maxilla/retrusive maxilla according to the GVL Target Line. However, the soft tissue
reveals a nearly optimal upper and lower lip structure with a mildly retrusive chin. Therefore, maintaining this
soft tissue relationship will be a goal of treatment, regardless of the underlying skeletal relationship to the
GVL.
When optimizing the incisor position for this case, the FA point of the maxillary incisor retruded 0.5 mm
(for a total space loss of -1 mm), and the mandibular incisor uprighted 1.5 mm (for a total space loss of -3
mm). Residual OJ is present, thus indicating an underlying skeletal disharmony. While an “ideal” treatment
plan might involve orthognathics to optimize the dental inclinations as well as the skeletal bases, this is not
possible for many patients, nor is it warranted for every case. Therefore, understanding how to simulate
camouflage via changing incisor inclinations within the periodontal and esthetic limits is extremely important.
A possible camouflage situation for this case is below:
Space Analysis
Maxilla Mandible
Incisor Inclination (X2) -1 -4 -3 0
Crowding/Spacing
Maxillary Expansion
Dental Expansion
Curve of Spee
Extraction
IPR

In this camouflage plan, the maxillary incisor uprighted/retracted for a change of -2 mm at the FA point (-4
mm total space change), the mandibular incisor inclination remained unchanged, the teeth are well positioned
in their respective alveoli, and the esthetic change is negligible – all which are acceptable to the overall
treatment.
It is critical in these camouflage cases to have the numbers used for the space analysis actually reflect the
proposed treatment. Therefore, while the optimal space change of the maxillary/mandibular incisors would
be -1 mm/-3 mm, these numbers are inappropriate to use. The proposed camouflage treatment calls for -4
mm/0 mm. These numbers (in red) are placed in the second column of the space analysis table and are the
ones to be used for the calculations going forward.
Crowding/Spacing
The crowding or spacing is determined by the amount of space needed to accommodate the dentition with
no rotations or residual crowding/spacing present. An optimal (treated) arch is shown below along with
illustration of the archform.
When determining the amount of crowding/spacing, the objective is to measure or estimate only the space
necessary to accommodate the dentition of the patient’s optimal archform. No allowances need to be made
for expansion, leeway space, etc. at this time. The following example illustrates both the untreated and
treated arches of the same patient and treatment archform is superimposed on the pre-treatment picture.
The larger picture identifies the 13 mm of space needed to align the teeth to the desired archform.
33
-5 mm -5 mm
-2 mm -1 mm
Using our patient example, the measured amount of crowding for the maxillary arch is 17 mm, and the
mandible presented with 4 mm of crowding. These values are entered as negative numbers in the space
requirement portion of the Diagnostic Sheet because they are values that “take up” space.
Diagnosis of the Transverse Dimension
The goal for transverse normalization is having teeth that are upright in the alveolus, centered in the alveolus,
and well-intercuspated at the conclusion of orthodontic treatment. For this to occur, ideally the patient
should have a maxillary skeletal base that is 5 mm wider than the mandibular skeletal base.
Several methods have been previously suggested to determine if these skeletal proportions exist naturally
or if the patient would benefit from maxillary expansion. However, due to variations of human anatomy,
it is difficult to force patients to conform to accepted “normals” of “standard” skeletal base measurement
Space Requirement
Maxilla Mandible
Crowding/Spacing -17 4
Maxillary Expansion
Dental Expansion
Curve of Spee
Extraction
IPR
averages8. Additionally, using pre-treatment interdental measurements to determine a skeletal expansion

need can lead to false negatives of an actual underlying skeletal issue9.
The contemporary transverse paradigm needs to consider each patient as their own “normal” and instead
optimize the individual’s relationship between the jaws. In other words, given that mandibular skeletal
base proportions are genetically determined and not easily modifiable through conventional orthodontic
treatment, this dimension serves as the reference position. The orthodontist’s role involves determining
when the patient would benefit from modifying the maxillary transverse dimension to achieve corresponding,
individualized harmony.
In the image below, three unique patients are presented with pre-treatment posterior dental relationships
where the teeth are upright in the alveolus, centered in the alveolus, and well-intercuspated. Note the
numerical mandibular skeletal base at the muco-gingival junction (MGJ-MGJ) measurements, and maxillary
skeletal base at the level of Mx point (Mx-Mx) dimensions are variable. However, in all cases the differential
Mx-Mx = 60 mm Mx-Mx = 62 mm Mx-Mx = 59 mm

MGJ-MGJ = 55 mm MGJ-MGJ = 57 mm MGJ-MGJ = 54 mm
Difference = 5 mm Difference = 5 mm Difference = 5 mm
Ricketts RM, Grummons D. Frontal Cephalometrics: Practical Applications, Part 1. World J Orthod 2003;4:297– 316.
8
9
McNamara JA. Maxillary transverse deficiency. Am J Orthod Dentofacial Orthop 2000;117:567-70
35
transverse relationship between the maxilla and mandible are exactly the same (maxilla = 5 mm wider than
mandible). Therefore, achieving this differential relationship becomes the critical goal, regardless of the
independent measurement numbers of the jaws.
Two easy methods for determining if a skeletal transverse discrepancy exists will be presented. Both have
an equivalent diagnostic meaning. One method (Penn CBCT Analysis) uses cone-beam CT derived measure-
ments. The second (Hayes CAC Analysis) uses measurements obtained via dental casts or with an intraoral
scan. If a practitioner has the ability to use both methods, a double-check confirmation of the skeletal trans-
verse deficiency (or lack of) can be realized. However, in the absence of having a CBCT machine or in a
model-less/scanner-less office, there will always be one technique easily applicable to whatever technology is
available at hand.
The University of Pennsylvania (Penn) CBCT Transverse Analysis10,11
The Penn CBCT Transverse Analysis uses capabilities of the multi-planar view (MPV) screen available with
nearly every DICOM viewing software.
Penn CBCT Transverse Analysis
Tamburrino RK, Boucher NS, Vanarsdall RL, Secchi AG. The Transverse Dimension: Diagnosis and Relevance to Functional Occlusion. RWISO Journal,
10
September 2010.
11
Simontacchi-Gbologah MS, Tamburrino RK, Boucher NS, Vanarsdall RL, Secchi, AG. Comparison of Three Methods to Analyze the Skeletal Transverse
Dimension in Orthodontic Diagnosis. Unpublished Thesis. University of Pennsylvania; 2010.
On this screen, the practitioner can independently measure the skeletal transverse dimensions of the maxilla
and mandible basal bone at the level of the first molar using the sequence below.
1. Take a coronal cut through the mandibular first molar at the level of the furcation. This represents the
approximate anatomic position of the muco-gingival junction (MGJ).
Take a coronal cut through the mandibular first molars

at the level of the furcation (MGJ-MGJ)
2. On the corresponding axial slice measure the MGJ-MGJ distance from the inner cortical plate of one side
to the inner cortical plate of the opposite side of the midpoint of the 1st molar. Record this measurement
on the CCO Diagnostic Sheet in the box marked “mandible”.
Measure on the axial

slice where the coronal
cut intersects the inner
cortical bone at MGJ-MGJ
Mandible = 55 mm
Transverse Diagnosis
Skeletal CBCT CAC Dental Measured Ideal

Maxilla MGJ-MGJ
Mandible 55 FA-FA
Difference C-C
Ideal 5 5 P-P
FA-FA
Required
37
3. Take a coronal cut through the maxillary first molar at the level of the deepest concavity of the maxillary
process (Mx point).
Measure on the axial slice where the coronal cut

intersects Mx-Mx
Anatomically, the ideal location would be at the level of the furcation, just like with the mandible.
However, there are occasionally exostoses present on the buccal surface of the maxillary teeth and this
will produce erroneous maxillary diagnostics if the measurement is taken at the level of the furcation.
Using the Mx point will not change the transverse measurement due to the anatomy of the maxillary
process but will be above the level where an exostosis could skew the actual basal bone measurement. If
the measurement is obtained at the width of the exotosis, the result could produce a false positive that
the maxilla is wide enough to accommodate the dentition without inducing root fenestrations, when in
reality the root apex could be moved out of the bone.
Exostoses may give

false perceptions of
maxillary width
4. On the corresponding axial slice measure the Mx-Mx distance from the inner cortical plate of one side
to the inner cortical plate of the opposite side of the mesiobuccal root. Record this measurement on the
CCO Diagnostic Sheet in the box marked “maxilla”.
Note: This assumes that the patient with finish orthodontic treatment in a “Class 1” molar relationship with
the mesiobuccal cusp of the maxillary first molar placed within the buccal groove of the mandibular 1st
molar. In cases where the proposed case finish is either “Class 2” or “Class 3” molar, the measurement
location needs to change in order to keep corresponding measurements accurate.
For a “Class 2” molar finish, the pre-treatment maxillary transverse dimension should be measured at the
midpoint of the disto-buccal root. For a “Class 3” molar finish, the maxillary transverse dimension should
be measured at the midpoint of the 2nd premolar.
Measure on the axial slice

at the inner cortical bone
where the coronal cut
intersects Mx-Mx
Maxilla = 60 mm

Maxilla 60 MGJ-MGJ
Mandible 55 FA-FA
Difference C-C
Ideal 5 5 P-P
FA-FA
Required
5. On the CCO Diagnostic Sheet, subtract the MGJ-MGJ measurement from the Mx-Mx measurement to get
the difference.

Maxilla 60 MGJ-MGJ
Mandible 55 FA-FA
Difference 5 C-C
Ideal 5 5 P-P
FA-FA
Required
6. Since the ideal difference between the maxilla and mandible is 5 mm, subtract 5 mm from the difference
to determine how much maxillary skeletal transverse deficiency is present. This now determines how
much skeletal base expansion would be ideally required for the patient.
39

Maxilla 60 MGJ-MGJ
Mandible 55 FA-FA
Difference 5 C-C
Ideal 5 5 P-P
FA-FA
Required 0
Maxilla = 60 mm
Mandible = 55 mm
Difference = 5 mm
For the patient example shown here, the amount of expansion needed is 0 mm. This makes sense given the
initial presentation of the posterior teeth is already being upright in the alveolus, centered in the alveolus, and
well-intercuspated.
In other words, this patient already has an ideal skeletal transverse relationship, and skeletal expansion is not
indicated. Doing so when not indicated now creates a reverse skeletal discrepancy where the maxilla is too
large for the corresponding mandibular size. By obtaining these measurements objectively, the question of
“Would this patient benefit from an expander?” is answered definitively and quickly.
University of Pennsylvania CBCT Analysis (Adolescent Modification)
The Penn CBCT Analysis is a powerful tool and can be used on any patient of any age. However, one modifi-
cation of the mandibular MGJ-MGJ measurement is indicated for young patients in the mixed dentition.
The mandibular body lengthens during growth via resorption of the anterior border of the ramus12. For
immature patients, the ramus and its processes are very close to the mandibular 1st molar. On an axial CBCT
slice, this appears as a “bulge”.
If the MGJ-MGJ measurement is taken via the same methods described above on an “adult” patient, this
would grossly overstate the true size of the mandibular basal bone in children and produce a corresponding
expansion need far greater than required.
To overcome this potential for error, one must imagine the “adult” archform that will result once the skeleton
matures and the anterior ramus resorbs posteriorly. The MGJ-MGJ measurement should now be obtained
along this line at the level of the 1st molar. This will remove the error and be an accurate representation of the
mandibular basal bone dimension.
For adolescents,
imagine the adult
archform
The alveolar “bulge”

will over-estimate the
transversal need.
Enlow DH, Hans MG. Essentials of Facial Growth. Saunders. 1996.

12
Hayes JL. In search of improved skeletal transverse diagnosis. Part 2: A new measurement technique used of 114 consecutive untreated patients.
13
Orthodontic Practice US 1(4); 34-39. 2010.

41
The Hayes CAC Transverse Analysis
The CAC (Center of the Alveolar Crest) Analysis13 uses dental casts or an intraoral scan to determine the
skeletal transverse dimensions of the maxilla to determine if skeletal expansion will benefit the patient. Similar
to the Penn CBCT Analysis, the ideal relationship is for the maxillary basal bone to be 5 mm wider than the
mandibular basal bone. However, instead of measuring from the inner cortical plate to the inner cortical plate,
the CAC analysis measures the distance between the centers of the alveolar bone at the level of the CEJ.
Penn CBCT
Hayes’ CAC
Both suggest the

goal to have the
maxillary width
5 mm greater than
the mandibular
Similar to the Penn CBCT analysis, the existing dental positions or inclinations are irrelevant. The goal is
strictly to match up the skeletal bases to achieve skeletal harmony and set the foundation for positioning the
teeth. The sequence for determining the amount of skeletal expansion, if any at all, is as follows:
1. At the level of the MGJ of the mandibular 1st molar on the dental casts/scan, visually determine the
midpoint of the buccal and lingual cortices and place a mark. This midpoint can, but will often NOT,
correlate to the central fossa or any cusp tip on the molar. This will represent the midpoint of the under-
lying mandibular basal bone.
The CAC does NOT

necessarily correlate
to the central fossa or
any cusp tip on casts
2. Measure the distance between the right and left mandibular markings and record this measurement on
the CCO Diagnostic Sheet.

Maxilla MGJ-MGJ
Mandible 47 FA-FA
Difference C-C
Ideal 5 5 P-P
FA-FA
Required
3 At the level of the MGJ at the mesiobuccal cusps of the maxillary 1st molar on the dental casts/scan,
visually determine the midpoint of the buccal and lingual cortices and place a mark. This midpoint can,
but will often NOT, correlate to the central fossa or any cusp tip on the molar. This will represent the
midpoint of the underlying maxillary basal bone.
43
Note: Similar to the Penn CBCT analysis, this measurement assumes the case will finish in a “Class 1” molar
relationship. If the planned finish is “Class 2” or “Class 3” molar, then the measurement position needs to
be adjusted accordingly using the rationale described previously.
4. Measure the distance between the right and left maxillary markings and record this measurement on the
CCO Diagnostic Sheet.

Maxilla 45 MGJ-MGJ
Mandible 47 FA-FA
Difference C-C
Ideal 5 5 P-P
FA-FA
Required
5. On the CCO Diagnostic Sheet, subtract the mandibular measurement from the maxillary measurement to
get the difference. Ideally this difference should be 5 mm.

Maxilla 45 MGJ-MGJ
Mandible 47 FA-FA
Difference -2 C-C
Ideal 5 5 P-P
FA-FA
Required
6. Subtract 5 mm from the difference to determine how much maxillary skeletal transverse deficiency is
present and how much maxillary skeletal base expansion, ideally, would be required. In this example the
patient is 7 mm deficient in the maxillary width and would benefit from 7 mm of skeletal expansion to
achieve ideal transverse harmony.

Maxilla 45 MGJ-MGJ
Mandible 47 FA-FA
Difference -2 C-C
Ideal 5 5 P-P
FA-FA
Required -7
The following case example illustrates the benefit of using both the Penn CBCT and Hayes CAC transverse
analyses as a double check as well as the consistency between the methods. In this example, for ease of
visualization of the measurements, the patient’s CBCT was used instead of the casts/intraoral scan for the
Hayes CAC method. The locations of the measurements are the same, however.
Note: While both the locations and actual measurements differ, the relationship between the measurements,
and thus the ideal skeletal transverse need, is identical. This is typical. On cases where both analyses are
used to confirm the diagnosis, the results will be within 0-1 mm of each other with respect to ideal skeletal
transverse need.
Hayes’ CAC
Maxilla = 45 mm
Mandible = 47 mm
Difference = 2 mm
Expansion Needed = 7 mm
Penn CBCT
Maxilla = 54 mm
Mandible = 56 mm
Difference = 2 mm
Expansion Needed = 7 mm

Maxilla 54 45 MGJ-MGJ
Mandible 56 47 FA-FA
Difference -2 -2 C-C
Ideal 5 5 P-P
FA-FA
Required 7 7
Maxillary Expansion and the Diagnostic Sheet
Sutural changes of the maxilla via palatal expansion will also increase the amount of space available for
dental alignment. If a deficiency is measured and corrected, according to Andrews’, 1 mm of maxillary sutural
expansion will correlate to essentially 1 mm of space gain for the arch.
1 mm of expansion = ~1 mm of space gain

For our case example, the existing transverse difference between the maxilla and mandible according to both
the Penn and Hayes’ analyses is ideal at 5 mm. Therefore, no skeletal expansion is needed and this value of 0
can be recorded in the maxillary expansion portion of the diagnostic sheet.
45
Penn CBCT Analysis
Maxilla = 63 mm Mandible = 58 mm
Difference = 5 mm (Normal = 5 mm)
0 mm Expansion Needed
Hayes’ CAC Analysis
Maxilla = 48 mm Mandible = 43 mm
Difference = 5 mm (Normal = 5 mm)
0 mm Expansion Needed
As with incisor inclination, some cases may require a compromise of the transverse dimension, such as adults
who decline surgically-assisted expansion or children who have very severe discrepancies, such as 10+ mm.
In these instances, the ideal space gain from the transverse change cannot be included in the space analysis
because it does not represent what will actually be happening for the patient. Therefore, this box on the
space analysis portion of the diagnostic sheet also has a place for an “ideal” and a “compromise/realistic”
value.
Also, the goal for maxillary expansion is to minimize the discrepancy to <3 mm. So, in cases where, for
example, 7 mm of expansion is indicated, but potentially only 4 mm of skeletal change will be achieved, then
only 4 mm can be used for the space calculation.
Mandibular non-surgical skeletal expansion is not possible due to the mandible being one solid bone, and
surgical mandibular expansion is contraindicated in nearly all instances of routine care. Therefore, this value
will almost always be zero.
Space Requirement
Maxilla Mandible
Crowding/Spacing -17 -4
Maxillary Expansion 0
Dental Expansion
Curve of Spee
Extraction
IPR
Dental Expansion
When describing “expansion” there is a significant difference between skeletal and dental expansion. Skeletal
expansion involves a skeletal diagnosis to normalize the skeletal transverse dimension. Dental expansion
involves inclining the posterior teeth ideally and
centering them within the alveolus in order to
harmonize the occlusion. The two concepts are inter-
related, meaning that the posterior teeth cannot be
positioned and inclined ideally on skeletal bases that
do not transversely relate to each other. Ideal = 2.5 mm/side
Looking at an example of optimal posterior dental Maxilla must be 5 mm wider than

intercuspation, one can appreciate that the mesio- the mandible if teeth are optimally
positioned in the alveolus
palatal cusp of the maxillary first molar and the mesio-
buccal cusp of the mandibular first molar are centered
in the central fossae of the molars in the opposing
arch. In this ideal dental relationship, the distance
between the cusp tips will be approximately 2.5 mm.
Therefore, in order to have the teeth upright and centered
within the alveolus, the maxilla must be 2.5 mm/side wider
than the mandible (for a total amount of 5 mm).
If one aims to set the dentition properly in the arches, dental

compensations for skeletal mismatches must be accounted
for in the pre-orthodontic diagnosis, and the treatment plan
should address their correction. Therefore, in a case that
has a maxillary transverse deficiency, correction will usually
involve buccal uprighting of the mandibular posterior teeth
and lingualization of the maxillary posterior teeth, as shown
in the following example:
A theoretical patient presents with a skeletal transverse

47
discrepancy. No dental crossbite is present, but note the buccally inclined maxillary molars and lingually
inclined mandibular molars.
Dental “decompensation” to optimally incline the molars and center them in bone would unmask the under-
lying skeletal discrepancy and show that the teeth are now in crossbite or an edge-edge relationship.
Maxillary expansion to first normalize the skeletal discrepancy will allow for proper intercuspation of the
posterior teeth at the ideal inclination once the brackets are placed. In order for this scenario to happen, the
maxilla must, ideally, be ~5 mm wider than the mandible. However, the goal is to achieve a skeletal transverse
discrepancy of 3 mm or less from ideal.
Similar to changing the inclination of the incisors, decompensating the posterior teeth and/or dentally
expanding the archform will also have a net effect on the intra-arch spacing. However, limits and targets have
to be established for the ideal positioning of these teeth. For this, the focus will be on the mandibular muco-
gingival junction (MGJ) as the frame of reference. Based on the work of Andrews14 and reinforced by Katona15,
the MGJ represents the level of the center of resistance of the mandibular first molars and is highlighted
below.
The importance of this concept is that, during uprighting of the mandibular posterior teeth, rotation will occur
at approximately this level. Also, this point identifies the location where coronally, is alveolar bone, which is
known to change and adapt to tooth position. However, apical to the MGJ, the minimal width of the skeletal
base is relatively immutable with conventional orthodontic treatment. Thus, it is a stable location to use for a
width reference of the mandibular skeletal base as well the position of the dentition.
14
Andrews LF, Andrews WA. Andrews analysis. In: Syllabus of the Andrews Orthodontic Philosophy. 9th ed. Six Elements Course Manual; 2001
Katona TR. An engineering analysis of dental occlusion principles. Am J Orthod Dentofac Orthop. 2009; 135(6): 696.
15
According to Andrews16 and verified by Ronay16, et al, the ideal position of the mandibular first molar is one
where the FA point of the molar is approximately 2-3 mm lingual to the MGJ when viewed occlusally. This will
center the tooth in the alveolus and place it at the ideal inclination.
The FA point of the mandibular 1st molar is ideally ~2-3 mm lingual to the MGJ
2-3 mm
FA point
Center of
MGJ
Resistance
In situations where the mandibular FA point is greater than 2-3 mm from the MGJ and the teeth are not in
crossbite, the dentition is often camouflaging a significant deficiency in the width of the maxilla.
Therefore, the only way for the dentition to compensate for the discrepancy is for the mandibular molars
to incline lingually and, often, for the maxillary molars to incline buccally. Thus, the MGJ-FA distance will be
larger.
The reverse situation, although less likely, is possible in cases of maxillary transverse excess. In this scenario,
the mandibular molars are inclined buccally, and the maxillary dentition must compensate by inclining
lingually. Therefore, the MGJ-FA distance will be <2 mm.
The illustrations below show the dental relationships when the MGJ-FA distance is ideal, too large (suggesting
a maxillary deficiency with good intercuspation), and too small (suggesting a maxillary excess with good
intercuspation).
16
Ronay V, Miner RM, Will LA, Arai K. Mandibular Arch Form: The Relationship Between Dental and Basal Anatomy. Am J Orthod Dentofacial
Orthop 2008; 134:430-8.
49
Excessive MGJ-FA (>3 mm) Ideal MGJ-FA (2-3 mm) Reduced MGJ-FA (<2 mm)
The dental and periodontal consequences of non-ideal tooth incli-

nations are beyond the scope of this manual and will be covered in Dental Measured Ideal
detail separately. For the purposes of Treatment Design, the goal is MGJ-MGJ
to understand where ideal tooth positions are located, how inclina- FA-FA
tions of the posterior teeth can affect the space available, and how
C-C
the methods described in this manual are aimed at idealizing the
P-P
dentition for function and stability.
FA-FA
The data and calculations for this portion are can be recorded on
the “dental” component of the transverse diagnosis on the CCO
diagnostic sheet.
Mandibular Dental Expansion
By knowing that the goal for the mandibular dentition is for the FA point to be 2-3 mm lingual to the MGJ,
theoretical decompensation and ideal positioning of the molars is straightforward. For this portion, we will
use casts of our case example and follow a series of measurements to objectively determine the amount of
mandibular dental expansion/decompensation.
1. Measure the distance across MGJ-MGJ of the mandibular first molars. As this distance will not change
with treatment, this is the “ideal” measurement and a stable reference position.
Initial Ideal
MGJ-MGJ 58 58
Mandibular FA-FA
Mandibular C-C
2. Measure the distance from the FA point-FA point of the mandibular first molar. As was determined previ-
ously, the ideal FA-FA distance is 2 mm less/side than the MGJ-MGJ distance, for a total of 4 mm. Since
the initial FA-FA distance for this patient measures 50 mm, the ideal FA-FA distance is 54 mm (with the
MGJ-MGJ = 58 mm). The actual number is unique to each patient, but the goal for the mandibular FA-FA
being 4 mm less than the MGJ-MGJ is universal.
Initial Ideal
MGJ-MGJ 58 58
Mandibular FA-FA 50 54
Mandibular C-C
3. Measure the distance between the central fossae of the molars. This distance will change the same
amount with uprighting the dentition as the FA-FA distance. It represents the amount of space gain/loss
that will also occur with optimizing the position of the mandibular dentition.
This value can now be entered on the space analysis table for mandibular dental expansion.
Initial Ideal
MGJ-MGJ 58 58
Mandibular FA-FA 50 54
Mandibular C-C 40 44
4 mm of space gained
51
Space Requirement
Maxilla Mandible
Dental Expansion 4
Curve of Spee
Extraction
IPR
Maxillary Dental Expansion
Once the mandibular teeth are ideally positioned, the amount of maxillary dental expansion or constriction
can be determined. The purpose of this measurement is to theoretically decompensate the maxillary
dentition to upright the molars, center them in the alveolus, and have the mesio-palatal cusp positioned
optimally into the central fossa of the mandibular molar following any required skeletal expansion.
There are two methods to determine the amount of dental expansion, one is objective and uses a previously
determined amount of palatal expansion, and the other is subjective, which can be used in the absence of
having a CBCT machine. Both methods will result in a similar determination of dental expansion needs,17 and
the CCO Diagnostic Sheet has the capability for recording this data under the “dental” portion of the trans-
verse diagnosis.
The first technique described will assume the practitioner has already determined the needed amount of
skeletal maxillary expansion via the CBCT or CAC methods.
17
Simontacchi-Gbologah MS, Tamburrino RK, Boucher NS, Vanarsall RL, Secchi AG. Comparison of Three Methods to Analyze the Skeletal Transverse
Dimension in Orthodontic Diagnosis [thesis]. University of Pennsylvania; 2010.
Method 1
1. Record the measurements for the mandibular CF-CF distance (previously determined) and measure the
palatal cusp-cusp (P-P) distance between the maxillary first molars.
Initial Ideal
Maxillary P-P 40
Maxillary Expansion
2. The goal is to have the maxillary molar palatal cusps fit into the mandibular central fossae for an ideal
occlusion. Therefore, the “ideal” measurements for the CF-CF distance and P-P distance must be
identical.
Initial Ideal
Maxillary P-P 40 44
Maxillary Expansion
3. By knowing the ideal amount of skeletal maxillary expansion, the amount of maxillary dental decompen-
sation required is then calculated as the difference between the ideal measurement of the mandibular
central fossae, initial measurement of the maxillary palatal cusps, and the required skeletal expansion.
Initial Ideal
Maxillary P-P 40 44
Maxillary Expansion - 0
Dental Expansion = 44-40-0=4 mm
Record this value in the maxillary dental expansion box of the space analysis chart.
53
Space Requirement
Maxilla Mandible
Dental Expansion 4 4
Curve of Spee
Extraction
IPR
Method 2
Dental Measured Ideal
The second method involves looking at maxillary cast and the MGJ-MGJ
existing inclinations of the first molar from the posterior. The CCO
FA-FA
Diagnostic Sheet has the capability for recording values for this
technique already built in via the split boxes for the P-P and FA-FA C-C
measurements. P-P
FA-FA
Andrews’ research established a guideline of 1 mm space change per
5° of molar inclination change. For this method, one must estimate
the amount of dental decompensation needed for both the right
and left molars to level the cusp tips (level the Curve of Wilson). These two values are then added together
to determine the total space needed to do this (which will be a negative value).
An additional way to think about this methodology is to envision the

amount of change of each FA point as the tooth is decompensated. For
this, 1 mm of horizontal FA point change is 1 mm of space needed. The
superimposition below illustrates how the FA point changes horizontally
as the tooth uprights around the center of resistance.
While this method may seem somewhat difficult to envision at first,

experience and looking at many casts will lead to the conclusion that
most cases will call for 0 mm, 0.5 mm, 1 mm, or 1.5 mm of change/side.
Do not try to be more precise than the nearest 0.5 mm, as it is very difficult to do and will not be clinically
significant enough to alter the diagnosis.
For our case example, these values on the diagnostic sheet below are previously determined from measuring
both the skeletal transverse need and the dental casts:

Maxilla 63 48 MGJ-MGJ 43
Mandible 58 43 FA-FA 50 54
Difference 5 5 C-C 40 44
Ideal 5 5 P-P 40
FA-FA 60
Required 0 0
Looking at the maxillary casts from the posterior, the first molars are buccally inclined by 1 mm/side.
Therefore, it will take 2 mm of space to upright these teeth. The “actual” P-P and FA-FA measurements are
then adjusted to represent the P-P and FA-FA measurements of decompensated teeth with a level Curve of
Wilson.

Ideal 5 5 P-P 40 38
FA-FA 60 58
Required 0 0
The palatal cusp of the maxillary first molar needs to fit in the central fossa of the mandibular first molar,
assuming a Class I molar relationship on debond. Therefore, the ideal maxillary P-P distance is the same as
the ideal mandibular CF-CF distance. Note: If the case is considered for a Cl. II or Cl. III molar finish, then
these measurements must be altered to reflect this change to ensure a transverse discrepancy is not inadver-
tently missed.

Ideal 5 5 P-P 40 38 44
FA-FA 60 58
Required 0 0
55
In an ideal jaw relationship, the ideal maxillary FA-FA measurement is 5 mm greater than the mandibular
FA-FA measurement, which is the same target ideal as the CBCT and CAC methods. This value is then calcu-
lated and recorded.

Ideal 5 5 P-P 40 38 44
FA-FA 60 58 59
Required 0 0
This method also provides a triple check for the skeletal expansion need via the difference between the
ideal maxillary FA-FA and the adjusted FA-FA. There may and often will be a 1-2 mm variation among the
three method,s and this is clinically acceptable. However, if a gross discrepancy is revealed, this would
necessitate reconfirming the skeletal measurements to ensure they are correct. Additionally, the goal for
including skeletal expansion as a part of the treatment plan is for skeletal discrepancies greater than 3 mm.
A discrepancy of 3 mm or less allows the practitioner to record “0 mm” as the maxillary expansion (since
skeletal expansion will not be performed) that will actually be performed, regardless of the measurement.

Ideal 5 5 P-P 40 38 44
FA-FA 60 58 59
Required 0 0 -1
The amount of dental expansion is the difference between the ideal P-P and the measured P-P, minus
the planned amount of skeletal expansion being performed. For this case example, the maxillary dental
expansion is 44-40-(-1)= 5 mm. However, since no maxillary skeletal expansion is being performed, the actual
calculation is 44-40-0 = 4 mm, which is identical to the previous method.

Ideal 5 5 P-P 40 38 44
FA-FA 60 58 59
Required 0 0 -1
Record this value in the maxillary dental expansion box of the space analysis chart.
Space Requirement
Maxilla Mandible
Curve of Spee
Extraction
IPR
Maxillary/Dental Expansion Review
The previous explanation of dental expansion involved theoretical transverse optimization of both the jaws
and the dentition. If the patient is planned for segmental surgical expansion of the maxilla, then decom-
pensation before expansion is appropriate to more precisely target jaw movements and improve long-term
stability. However, when performing expansion on adolescents and children, as well as surgically assisted
expansion of adults, it is prudent to make expansion the first procedure. The rationale for adolescents is to
employ expansion early to ensure easier separation of the palatal suture. However, the diagnosis is identical.
The following graphics are meant to aid visualization of the procedure from initial presentation to ideal result.
The initial presentation: Note lingual inclination of mandibular molars and buccal inclination of maxillary
molars without dental crossbite. This is a common dental compensation for an underlying skeletal maxillary
transverse deficiency.
The dentition immediately following maxillary expansion: The maxillary skeletal width is normalized, but the
dental compensation is still present.
57
Placement of bonded appliances on the mandibular

teeth while the expansion is stabilized will allow for the
mandibular dentition to upright in the alveolus to the proper
inclination.
After removal of the expander, the maxillary appliances are

placed. With arch coordination and the expression of proper
torque in the molar brackets, the maxillary posterior teeth
will upright to their ideal inclination.
The final ideal result: Note the upright position of the

molars, centralization of the teeth in the alveolus, and
optimal intercuspation. This dental relationship is possible
only when the skeletal transverse dimension is normal.
Curve of Spee
A functional goal of CCO treatment is to level the Curve of Spee. To do so requires space. When evaluating
the patient, the maxillary and mandibular casts should be viewed from the buccal, and a flat object should
be placed from the incisor to the second molar. The greatest vertical distance from the flat object to the
dentition should be recorded. Only the side with the greatest depth needs to be recorded.
Once again, research from Dr. Andrews18 has produced a relationship between the depth of the Curve of Spee
and the needed space to level the curve. This table applies for both the maxillary and mandibular dentition.
Curve Depth Space Needed

2 mm 1 mm
3 mm 2 mm
4 mm 3 mm
5 mm 5 mm
6 mm 7 mm
Andrews LF, Andrews WA. Andrews analysis. In: Syllabus of the Andrews Orthodontic Philosophy. 9th ed. Six Elements Course Manual; 2001
18
For the case example, the following space requirements to level the Curves of Spee are noted and recorded.
Depth of Curve = 0 mm Depth of Curve = 2 mm (Space Needed = 1 mm)
Space Requirement
Maxilla Mandible
Curve of Spee 0 -1
Extraction
IPR
For patients that are in the mixed dentition or present with under/oversized teeth, the space analysis needs
to be performed with respect to the permanent dentition. Therefore, if primary teeth remain, the leeway, or
E-space should be placed in this category as space available (usually 3-4 mm in the mandible and 2-3 mm in
the maxilla).
59
Additionally, many patients present with a Bolton discrepancy

of the anterior or posterior teeth. For the teeth to fit ideally at
their ideal inclination with no spacing and crowding, the mesial-
distal dimension of the six anterior teeth must coincide, as
shown in the treated case below.
Patients will commonly present with undersized or missing

maxillary lateral incisors. A decision that needs to be
accounted for in the treatment planning phase is whether or not to restore these teeth to their ideal propor-
tions. If they are to be restored, the orthodontist must allow for a proper amount of space to have an ideal
restoration. While there are many methods to determine tooth-size discrepancies, a quick method is through
the use of the Chu Gauge (Hu-Friedy).
Use of this gauge allows for planning proper dimensions of the maxillary central incisor, maxillary lateral
incisor, and maxillary canine based on an optimal width/height proportion of 78%19. Optimal proportions and
use of the gauge is illustrated below. Note the position of the stripes for optimal proportions.
Tooth Proportions
Tooth Width Length

Central Incisor 8.5 11
Lateral Incisor 6.5 8.5
Canine 7.5 9.5
Initial Required
Width Length Width Length
Central 8.5 10.5 Central 8.5 11
Lateral 4 6 Lateral 6.5 8.5
Chu SJ. A biometric approach to predictable treatment of clinical crown discrepancies. Pract Proced Aesthet Dent. 2007;19(7):401-409
19
As an example, this patient presents with a width of #7 of 4 mm. Using the gauge to place the tooth in
proportion with the central incisor requires 2.5 mm of space to be created to optimize the restoration.
Therefore, in the space analysis sheet, this would be placed as -2.5 mm since space is required.
For our case example, the teeth are in optimal proportion, and no E-space remains. Therefore, values of 0
mm are entered for both the maxillary and mandibular arches.
Space Requirement
Maxilla Mandible
Curve of Spee 0 -1
Tooth/Size Discrepancy 0 0
Extraction
IPR

Space Requirement
Maxilla Mandible
Curve of Spee 0 -1
Unresolved Space Requirement -9 -2
Extraction
IPR
Once the components of the space analysis are analyzed, the unresolved space requirement to idealize the
dentition is determined by adding all of the values for the maxilla and the mandible. For the case example,
this calculation results in a net space requirement of 9 mm in the maxilla and 2 mm in the mandible.
The goal is to resolve the crowding and have the final space requirement be zero for both arches. Therefore,
two treatment plans are possible according to the space requirement. For the maxilla, the most efficient and
61
practical way to create 9 mm of space is to remove maxillary premolars. However, for the mandible,the 2 mm
of crowding could be resolved in two ways, either by extraction of the mandibular 2nd premolars (if a Cl. I
molar relationship upon finishing is desired) or by interproximal reduction (with anticipation of a Cl. II molar
finish).
Treatment Possibilities
Plan 1 Plan 2
Maxilla Extract 1st bicuspids Extract 1st bicuspids
Mandible Extract 2nd bicuspids Non-extraction
Space Requirement
Maxilla Mandible
Curve of Spee 0 -1
Treatment Option 1
Extraction 14 14
Distalization/Mesialization (X2) -5 -12
IPR 0 0
Space Requirement
Maxilla Mandible
Curve of Spee 0 -1
Treatment Option 2
Extraction 14 0
Distalization/Mesialization (X2) -5 0
IPR 0 2
In order to compare the feasibility of both plans and to determine the mechanics for achieving them, the
posterior teeth have to be moved into position. To calculate the movement needed with extraction of the
mandibular second premolars, the assumption used is that both premolars are 7 mm in width, thus giving
14 mm of space. Because the Treatment Design only shows one side of the dentition, the resultant space
is divided by 2 and the molar is mesialized this amount along the occlusal plane. The same is done for the
maxillary molars.
Mandibular Dentition Maxillary Dentition

14-2 = 12/2 = 6 mm/side 14-9 = 2/2 = 2.5 mm/side
Superimposition of the maxilla on the ANS-PNS line and the mandible on the Corpus Axis allows for evalu-
ation of the required movements and the anchorage requirements.
Arch Anchorage Feasibility

Maxilla Minimum Yes
Mandible Minimum Difficult
63
Simulate of the second option with extraction of only the maxillary premolars.
Mandibular Dentition Maxillary Dentition

14-2 = 12/2 = 6 mm/side 14-9 = 5/2 = 2.5 mm/side
Again, superimpose on the ANS-PNS line and the Corpus Axis to evaluate the tooth movement and
anchorage requirements.
Arch Anchorage Feasibility

Maxilla Minimum Yes
Mandible Minimum Yes
When evaluating the superimpositions and different treatment options, the goals of treatment as well
as treatment feasibility and efficiency need to be considered. For this case example, the breakdown is
as follows. The first two options will allow for normalization of the jaws at the correct OB/OJ, with a
compromise having a mildly retrusive chin. The third option will normalize the teeth, efficiency, as well as
esthetics, but of course, a genioplasty is elective and does not have a bearing on the orthodontic movements.
Additionally, for this example, extraction of the lower second premolars would result in a large amount of
posterior space to close and necessitate precise anchorage control. While possible, this would require careful
mechanics and take a significant amount of time. By extracting the upper premolars only and finishing in a
Class II molar relationship, the treatment efficiency is increased with no compromise to the treatment goals.
Goal Exo U4/L5 Exo U4 Exo U4 + Genio

Function  Yes 
Esthetics Compromise Compromise 
Stability   
Feasibility Possibly  
Efficiency No  
This is the power of Treatment Design. By simulating potential treatment options before ever placing a
bracket on the patient, the orthodontist has the capability to determine the most effective treatment plan
to achieve the treatment goals. Following is the completed Diagnostic Sheet for the patient example, which
consolidates all of this information.
65
Case Example Adult Self
Crooked Front Teeth
Improve Smile, Correct Bite
None
None Relevant
40
x 63 48 58
58 43 50 54
5 5 40 44
40 38 44
60 58 59
0 0 -1
x
4 -1
132 -17 -4
0
4 4
0 -1
0 0
x -9 -2
14 0
-5 0
0 2
Hawley bite plate with acrylic on labial bow Restore wear facets PRN
Hawley retainer with acrylic on labial bow
Bond U/L 7-7
Extract maxillary 1st premolars
IPR L 3-3 (2mm)
Gingevectomy/Osseous Reduction U anterior

67
The following pictures are the initial bonding, 6 months, and 11 months into treatment, immediately prior to
space closure on the maxilla. Note the ~2.5 mm of space remaining distal to each maxillary canines with the
maxillary anterior teeth at the optimal inclination, which illustrates the accuracy of the space analysis method-
ology presented earlier.
Initial Bonding 6 Months 11 Months

7. Case Example - Gianna D.

The following example is a 12 year old female, and illustrates the CCO treatment planning process from start
to finish. A CBCT was not available for this patient, so the data reflects the technology used – mounted casts,
lateral headfilm, panoramic film, and photographs.
69
Initial Models
Converted Lateral Ceph Tracing
MIC Ceph SCP Ceph

71
The Treatment Design for Gianna calls for the Cl. II correction to be resolved with growth, and the dental
positioning will be optimized with good bracket placement and predictable mechanics, as described on the
diagnostic sheet.
Goal RPE + HPHG + B/B U/L

Function 
Esthetics 
Stability 
Feasibility 
Efficiency 
73
Execution of the plan is as follows:
Initial
Post-RPE
U/L
.016”
Sentalloy
U/L
.020”x.020”
BioForce
U/L
.019”x.025”
SS/OCS
U/L
.019”x.025”
DKL/SS
U/L
.019”x.025”
SS/Elastics
Final
Gianna’s final photographs depict good dental intercuspation, good function in all excursions, good
periodontal health, and good facial/smile esthetics.
Functional
Protrusive
Occlusion
R Working
L Working
75
While this result would satisfy most practitioner’s desires to provide good orthodontic care, the true measure
of the Treatment Design process is proving that the movements and mechanics that were planned at the
beginning actually occurred. If they did, then the practitioner was successful and the assumptions and
diagnostic criteria that were used can be applied for future patients. If they did not, this provides a critical
learning experience. The practitioner can then learn truly what they “think” is happening vs. what “actually”
happens to be able to effectively use that information for the future.
Looking at Gianna’s case, the following superimpositions show what actually occurred:
Superimpositions
Her plan called for the incisors to be optimally inclined, the HPHG to restrict the forward movement of the
maxilla while the mandible grew to correct the Cl. II relationship, and for the vertical dimension to remain
unchanged.
The true power of the Treatment Design exercise is to provide a realistic simulation of what will happen with
orthodontic treatment, so expectations of both the practitioner and the patient can be set at the beginning.
The simulation should provide a virtual realization of the outcome, along with any potential compromises that
could be made while maintaining good esthetics, good periodontal health, and good dental function.
Gianna’s comparison of her Treatment Design to the actual outcome shows a nearly identical result to what
was planned pre-treatment, thus highlighting the viability of the plan and the realistic assumptions that were
objectively determined using the Diagnostic Sheet.
Comparisons
77
7. Conclusion
Treatment Design is an essential tool for any orthodontist who wishes to provide the highest quality of care
with confidence for themselves and for their patients. This manual focused on the importance of head
positioning, target lines, and space analysis along with the roles they play in successfully constructing a
treatment simulation. Additionally, the methodology presented was one where having a logical progression
for analysis, while keeping treatment goals in mind, will naturally lead to a proper diagnosis. Further usage
and practice with Treatment Design will afford the practitioner a diagnostic tool that is much quicker, easier,
and more comprehensive than other previously established techniques. Ultimately, this will lead to improved
treatment outcomes for the patient.
As long as the practitioner understands the core concepts presented in this manual, the foundation for
predictable, advanced treatment planning is in place. Additional sessions will build on this material, and upon
completion, the orthodontist will have a comprehensive and complete strategy for building a clinically sound
and efficient practice.
Ryan K. Tamburrino, DMD Dr. Tamburrino grew up in Pittsburgh and his tinkering and technical
interests during his early years led him to Duke University where he
received degrees in Biomedical Engineering/Materials Science. Wanting
to also be involved in healthcare, he enrolled at the University of
Pennsylvania where he received his Doctorate of Dental Medicine and
specialty Certificate in Orthodontics.
In addition to maintaining several locations of the Center for

Orthodontic Excellence with his practice partner, Dr. Shalin Shah, Dr.
Tamburrino is on the faculty at the University of Pennsylvania in the
Department of Orthodontics. Dr. Tamburrino also lectures locally
with various study groups as well as internationally/nationally with
the Complete Clinical Orthodontics Course. He strongly believes
that it is important to teach and to help raise the standard of dental
care for local communities as well as for the entire profession, and he
thoroughly enjoys any opportunity to do so, either written or through
speaking.
Outside of his professional practice he enjoys spending time with his

wife, two sons, and two crazy cats, Tomato and Basil. He is also an avid
golfer and model railroader.
+D807120057081/$$7201801F www.ccosystem.com
800.645.5530
www.dentsplysirona.com/orthodontics
© 2018 DENTSPLY GAC International, Inc.
All Rights Reserved.
120-057-08 Rev. 02
Academy

Treatment Design 2018

Uploaded by

Copyright:

Available Formats

Treatment Design 2018

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Treatment Design 2018

Uploaded by

Copyright:

Available Formats

CCO® System

Complete Clinical Orthodontics®

The following list contains abbreviations of terms and concepts

ACP = Adapted Centric Posture

2 - The CCO Diagnostic Sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

3 - Orienting the Headfilm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

4 - Target Line Construction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

5 - Faulty Diagnosis from Intracranial References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

6 - Determining Tooth Spacing Requirements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Tooth Size Discrepancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Resolving Space Discrepancies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

2. The CCO Diagnostic Sheet

Interdisciplinary Treatment Plan

Steps for Treatment Design of the Orthodontic Patient

3. Orienting the Lateral Headfilm

9 Steps for CCO Treatment Design

The critical step to accurately completing the Treatment Design exercise

First, the lateral headfilm must first be digitized and traced.

Then, by using the capabilities of the software, the headfilm can be

Placing Radiopaque Markers on the Face

Head Positioning Instrument (HPI) ®

The SCP/MIC Conversion of the Headfilm

MIC Ceph SCP Converted Ceph

MIC Ceph SCP Converted Ceph

4. Target Line Construction

Using a properly oriented lateral headfilm, which is critical for this

The Glabella Vertical Line (GVL) is constructed as a vertical line

Soft Tissue Target (Subnasale Vertical Line)

The purpose of the SNV is to evaluate the prominence of the upper

Soft Tissue Target

Relaxed musculature Excessive mentalis strain

Subnasale Vertical (SNV) Line

Used to elevate the

Dentition Target (Maxillary Occlusal Plane)

The MOP provides a reference position to set the inclination of the

Maxillary Occlusal Plane

Arnett = 85° to TVL

Andrews = 81°-83° to TVL

5. Faulty Diagnoses from Using

Consider, for example, the following

However, let’s consider the cephalometric

A-Po The example below shows the previous

Even though there are different numerical

Variations of Sella on SNA Variations of Nasion on SNA

Using the same landmarks of Sella

Similar to the skeletal measure-

The MOP as an Ideal Dental Reference Line

The previous information has already

The most basic premise of orthodontic

0.019”x0.025” braided wires

MOP Inclination and “Torque” Expression

Steep MOP Ideal MOP Flat MOP

Maxillary Central Incisor: 12˚ torque

The key variable in torque expression,

The solution is an interactive clip

Setting the Incisor Inclination

Maxillary Central Incisor: 57˚

Initial Incisor Inclination Unrealistic Incisor Inclination Realistic Incisor Inclination

6. Determining Tooth Space Requirements