CLINICIANS' CORNER

Differential diagnostic analysis system

L. Levern Merrifield, Herbert A. Klontz, and James L. Vaden
Oklahoma City, Okla., and Cookeville, Tenn.

This article links clinical research to fundamental orthodontic concepts to give the clinician a
workable differential diagnosis system. The clinical research, conducted by the Charles Tweed
Foundation, attempted to establish a "profile" for the Class II malocclusion correction, Which,
because of certain characteristics, was destined to failure. The Cranial Facial Dental Analysis
integrates this clinical research with the total space analysis to give the clinical orthodontist a useful
tool for differential diagnosis. (AM J ORTHOD DENTOFAC ORTHOP 1994;106:641-8.)

Success in any endeavor depends on strat- 1978. All the data therefore represented similar
egy, discipline, and work. Strategy depends on the technology and treatment strategy.
intelligent use of information; thus information Each member who participated in Dr. Gram-
technology is the key to each orthodontist's diag- ling's studies furnished pretreatment and posttreat-
nostic and clinical analysis. ment cephalometric x-ray films with tracings of
Diagnosis, treatment planning, treatment tim- specified cephalometric landmarks. The points
ing, and treatment management are closely related were then checked by Dr. Gramling for consistency
parts of an orthodontist's concern for the patient, of technique. The pretreatment and posttreatment
and each plays a major role in the service rendered. Frankfort horizontal planes were standardized by
These interrelated criteria must reflect the funda- means of superimposition on the sella nasion
mental knowledge, skill, and philosophy of the plane. Contributors were not handpicked; anyone
orthodontist. who used the Sequential Directional Force tech-
Our objective in preparing this differential di- nology was encouraged to participate.
agnosis and clinical analysis article is to incorporate At the time he collected the "successful"
the results of clinical research conducted by the sample, Dr. Gramling also collected a sample of 55
Charles H. Tweed International Foundation for patients whose Class II malocclusions were deemed
Orthodontic Research with time-tested concepts unsuccessfully corrected by the contributors. The
and values that significantly influence orthodontic determination of an unsuccessful treatment result
diagnosis and the subsequent delivery of a quality was left entirely to the contributor, although some
orthodontic service to the public. general guidelines were given to standardize the
For a period of approximately 15 years, until his sample. Each contributor sent a pretreatment and
untimely death in 1993, Jim Gramling, Jonesboro, a posttreatment cephalogram of the unsuccessfully
Ark., was the Research Director for the Founda- treated patient. Frankfort horizontal plane of the
tion. During the years he was the Research Direc- pretreatment and posttreatment tracings was stan-
tor, Dr. Gramling compiled a rather large sample of dardized by repeating the original porion position
successfully and unsuccessfully treated Class II with superimposition on the sella nasion plane. The
malocclusions.Y all of which were treated by mem- same statistical analyses were performed on the
bers of the Charles H. Tweed Foundation. successful and unsuccessful samples. Many values
Dr. Gramling began collecting the sample in the were considered, but the values scrutinized most
early 1980s. The stipulation was that the patients closely are illustrated in Fig. l.
had to have been started in active treatment during The results of the studies of unsuccessful and
1979 or during the 1980s. The reason for the time successful treatment were compared and can be
stipulation was to insure that the clinical material seen in Table 1. Note that in the successful sample,
used reflected treatment with the Sequential Direc- the Frankfort mandibular plane angle (FMA) was
tional Force technology that was introduced in reduced, the Frankfort mandibular incisor angle
(FMIA) was increased, and the incisor mandibular
plane angle (IMPA) was reduced. In the unsuccess-
ful sample, FMA increased, FMIA increased but
Copyright © 1994 by the American Association of Orthodontists.
not as much as it did in the successful sample, and
0889-5406/94/$3.00 + 0 8/1/53129 IMPA remained the same. There was not as much
641
 Amencan Journal of Orthodontics and Dentofacial Orthopedics
642 Merrifield, Klontz, and Vaden
December 1994

Table II. Comparison of successful and

unsuccessful samples by dividing the samples
according to FMA
Compansons

Successful Unsuccessful

Low Frankfort mandibular plane angle

FMA +1 +1
FMIA +7 -1
IMPA -6 0
ANB -3 -2
Z-angle + 10 +8
Medium Frankfort mandibular plane angle
FMA
IMPA FMA +1 0
FMIA
SNA FMIA +6 0
SNB
6 AND IMPA -6 0
7 OCC·FH
8 Z-Angle
ANB -3 -3
<;I PFH
10 AFH
Z-angle + 10 + 11
High Frankfort mandibular plane angle
Fig. 1. Cephalometric values used in study of successful and FMA +1 0
unsuccessful malocclusion correction. FMIA +4 -1
IMPA -3 -1
ANB -2 -1
Z-angle +8 +6
Table I. Comparison of successful and
unsuccessful samples
In the next comparison, the successful and
Successful Unsuccessful unsuccessful treatment results were divided into
PretreatmentlPosttreatment PretreatmentlPosttreatment
high, medium, and low Frankfort mandibular plane
angle categories (Table II). According to the data
FMA 28 27 29 30 from the low FMA category, the ANB angle
FMIA 58 63 56 61 changes were not much different between the
IMPA 95 90 95 95
groups. The big difference was in mandibular inci-
Z-angle 66 75 62 69
Y-Axis 62 62 65 65 sor position. In the successful orthodontic treat-
SNA 82 79 82 79 ment sample, the mandibular incisors were up-
SNB 76 76 75 75 righted more than in the unsuccessful sample. The
ANB 6 3 6 4 FMIA was increased 8° more in the successful
AOBO 4 -1 7 5
sample than in the unsuccessful sample. Thus,
facial change was more positive in the successful
sample. In the medium Frankfort mandibular plane
angle category, unsuccessful treatment was about
Z-angle increase in the unsuccessful sample as equal to successful treatment, except the mandibu-
there was in the successful sample. The SNA angle lar incisors were uprighted more in the successful
reduction was similar, but AOBO reduction for the sample of patients. An analysis of the high angle
unsuccessful sample was not as good as for the category showed similar results.
successful sample. The Y-axis values and the SNB The Class II malocclusion was successfully cor-
angle values remained the same for both samples. rected when the FMA was maintained, the FMIA
By studying the collected data from these two increased, the IMPA decreased, and the ANB
samples, it can be concluded that in unsuccessful angle reduced. The question, "What is the 'profile'
Class II treatment, the mandibular incisor position of a patient with a Class II malocclusion whose
is not corrected, or if it is corrected, the correction treatment is destined to failure?" was asked. The
is subsequently compromised by excessive, unrecip- general answers became (1) a very high or very low
rocated use of Class II elastics in an attempt to FMA, (2) a high ANB angle, (3) a high AO/BO, (4)
establish the proper anterior-posterior maxilloman- a low FMIA or a high IMPA, (5) a steep occlusal
dibular relationships. plane angle, and/or (6) a very low SNB angle.
Amencan Journal of Onhodontics and Deniofacial Orthopedics
Merrifield, Klontz, and Vaden 643
Volume 106, No. 6

Table iliA. Difficulty factors-weighted variables Table IIIB. The probability index
of the probability index Cephalometric Probability
Probability index variables value index

FMA: FMA 22°_28° 5

Variation - 5 points
ANB: Variation - 15 points ANB 6 or less 15
FMIA: Variation - 2 points FMIA 60 or more 2
DcPI: DCC PL 7 or less 3
Variation - 3 points
SNB: Variation - 5 points SNB 80 or more 5
Total _

PROBABILITY INDEX or as Gramling concluded by using FMA and

From the background of evidence established occlusal plane, control of the vertical dimension.
by these studies, Gramling formulated a "Probabil- Posterior facial height (Fig. 1) is a millimetric
ity Index'? for three specific purposes (1) to aug- measurement of ramus height from articulare to
ment diagnostic procedures, (2) to guide treatment the mandibular plane which is measured tangent to
procedures, and (3) to predict possible treatment the posterior border of the ramus. Anterior facial
success or failure. height (Fig. 1) used by Merrifield and Gebeck is a
The purpose of the index was to be of value in perpendicular millimetric measurement from pala-
isolating those Class II malocclusions that might tal plane to menton.
need alternate treatment procedures or those that The relationship of posterior facial height to
might require surgical procedures to affect a com- anterior facial height determines both the FMA
plete correction. Gramling's probability index was and the lower face proportion. In the growing child
based on the premise that control of the FMA, the with a Class II malocclusion, ramal growth change
ANB angle, the FMIA, the occlusal plane, and the and its relationship to anterior facial height in both
SNB angle were keys to the success or failure of the proportion and in volume is critical. In Class II
orthodontic treatment of a Class II malocclusion. treatment, it is essential to limit the increase in
The Probability Index suggested that the following anterior facial height by controlling maxillary and
conditions might be necessary for treatment success mandibular molar extrusion and by using an ante-
of a Class II malocclusion. rior high-pull force on the maxilla.
Merrifield and Gebeck":" stated that ramal
1. The FMA should be 18° to 35°.
height increase was found to be essential to a
2. The ANB angle should be 6° or less.
favorable mandibular response during treatment.
3. The FMIA should be greater than 60°.
Mandibular response (Fig. 2) is the term that de-
4. The occlusal plane should be 7° or less.
scribes the relative change in the spatial relation-
5. The SNB angle should be 80° or more.
ship of the maxilla to the mandible. It encompasses
Gramling established a difficulty factor and as- growth, development, and treatment change in the
signed a specific number of points to each variable horizontal and vertical dimension. Merrifield and
(Table IlIA). Gebeck'" stated that the ratio of change of poste-
In 1989 Gramling studied 40 successful and 40 rior facial height to anterior facial height was a very
unsuccessful Class II malocclusion corrections. M- valuable evaluation tool both during and after orth-
ter studying these 80 patient records, he revised odontic treatment. They found that a ratio of two
only one of the five premises of the Probability times as much posterior facial height increase as
Index. He changed the successful the FMA range anterior facial height increase was ideal for Class
from 18°-35° to 22°-28° (Table I1IB). II, Division 1 malocclusion correction and for den-
In a later study of successful and unsuccessful toalveolar protrusion reduction. However, even
Class II treatment, Merrifield and Gebeck':' stud- more important than the ratio was the volume of
ied a successfully treated Class II sample, an un- change. For example, a lO-mm posterior facial
successfully treated Class II sample, and a con- height increase with a 5-mm anterior facial height
trol Class II sample. As a result of their studies, increase was found to be more beneficial to the
Merrifield and Gebeck concluded that equally im- correction than a 4-mm posterior facial height
portant to successful Class II correction was control increase and a 2-mm anterior facial height in-
of anterior facial height and posterior facial height, crease.
644 Merrifield, Klontz, and Vaden Amencan Journal of Orthodontics and Dentofacuil Orthopedics
December 1994

the areas were weighted taking into consideration

the necessary diagnostic decisions and the complex-
ity and importance of treatment management.
When the cranial facial analysis is used in
conjunction with the total dentition space analysis,
(Table V) the clinician can determine the complex-
ity of the major clinical aspects of a malocclusion.
Use of both analyses will significantly improve the
clinician's ability to diagnose, plan, and execute
treatment. The sum of the cranial facial difficulty
and the total dentition space analysis difficulty is
.. Mandibular Response
the cranial facial dental total difficulty. This figure
I
~ gives the clinician a quantitative method of evalu-
ating the difficulty of correction of each malocclu-
sion. The analysis (Table VI) identifies the specific
areas of major disharmony-cranial, facial, or den-
tal, and gives guidance for treatment strategy.
Other clinical relationships and values, such as
habit evaluation, joint health, muscle balance, den-
tal malrelationships, and the other cephalometric
Fig. 2. Mandibular response measured along the original values, must be duly noted and evaluated by the
occlusal plane. orthodontist. The orthodontist must also evaluate
the patient's motivation and desire for orthodontic
correction. The range of values for the total diffi-
In 1989, Andre Horn studied and researched culty index that have been found to be most appro-
the relationship of anterior and posterior facial priate are as follows:
height. Horn suggested a Facial Height Index or 1. Mild-O to 60.
FHI. 6 The normal posterior facial height to ante- 2. Moderate - 60 to 120.
rior facial height ratio was found by Horn to be 3. Severe-120 plus.
0.65 to 0.75. If the FHI value was below or above
this range, the malocclusion was a great deal more The cranial facial dental total difficulty index
complex and the difficulty encountered in correc- can be a very valuable tool in patient and parent
tion was increased. For example, an index of 0.80 consultation because it will help the clinician ex-
was severe and indicated a patient with a low FMA plain diagnosis, treatment, treatment timing, and
with either too much ramal growth or too little treatment management. The use of the cranial
vertical anterior face height. As the index ap- facial analysis, the dentition space analysis, and
proached 0.60, the cranial facial pattern was one of ultimately, the cranial facial dental difficulty index
a severe vertical discrepancy that demonstrated will be illustrated with the analysis of pretreat-
too little ramal height or too much anterior facial ment records of a Class II, Division 1 mal-
height. occlusion.
The pretreatment facial photographs (Fig. 3)
CRANIAL FACIAL ANALYSIS (TABLE IV)
exhibit a very convex facial profile with maxillary
The Cranial Facial Analysis has been developed protrusion, mandibular retrusion, lip eversion, and
from Gramling's work, from Merrifield and Ge- strain of the mentalis musculature. The pretreat-
beck's work, and from Andre Horn's ratio studies. ment casts (Fig. 4) illustrate the Class II dental
The Z angle has been substituted for the FMIA occlusion, the deep overbite, crowding, and exces-
because it is a better indicator of facial form. sive curve of Spee. The pretreatment panoramic
Horn's Facial Height Index was added to further x-ray film (Fig. 5) exhibits a blocked out mandibu-
define horizontal and vertical relationships of the lar right second premolar, a retained maxillary left
craniofacial complex. second deciduous molar, and unerupted maxillary
Each cephalometric value used has been deter- and mandibular second molars. The third molar
mined to have significant merit. The interrelation- buds are present. The pretreatment cephalometric
ship of these key values has been weighted in tracing (Fig. 6) confirms a skeletal imbalance with
relationship to their significance and mathematical flaring of the mandibular incisors, and a relatively
value. In determining the difficulty of correction, steep occlusal plane angle of 13°.
Amcn( an Iournal of Orthodontic \ and Dentofut tal Onhopedu . .
Volume l Un, No n
Merrifield, Klontz, and Vaden 645

Table IV. Cephalometric values and cranial facial analysis

Normal Pre Rx Progless Progxess Fina.l

FMIA 67°
FMA 25°
IMPA 88°
SNA 82°
SNB 80·
ANB 2·
AO-BO 2mm
ace Plane 10·
ZAngle 75·
Uppedip =
Total Chin =
Post Face Ht 45rnm
Ant Face Ht 65mm
Index Po~ .70
Am

CRANIAL FACIAL ANALYSIS Ceph Difficulty

Normal Range Value Factor Difficulty
FMA 22° - 28° 5.
ANB 1° - 5° _----1.5-_
Z Angle 70° - 80° 2
OCC Plane 8° - 12° 3.
SNB 78° - 82°
EHI (pEH-AEHl 65 - .75 3.
C. F. Difficulty Total

Table V. Total space analysis

TOTAL SPACE ANALYSIS

Anterior Value Difficully

Tooth Arch Disc.
Headlllm Disc.
Soft Tissue Mod.
TOTAL
Mldarch
Tooth Arch Disc.
Curve of Spee
TOTAL
,.
OcckJsaJ Dishannony ",I

(ClassII 0( Class III)

Posterior
Tooth Arch Disc,
Expected Increase (-)
TOTAL ---L-
Space Analysis
__
II
.-
',
· ,
-
.. '- ~..

Space Analysis Total _ Difficulty Total_

Fig. 3. Pretreatment facial photographs
646 Memfield, Klontz, and Vaden Amencan Journal of Orthodontics and Dentofocial Orthopedic \
De, ember 1994

Fig. 4. Pretreatment casts.

Table VI. Cranial facial dental analysis The cranial facial analysis (Fig. 7)
CRANIAL FACIAL ANALYSIS Ceph Difficulty Each cephalometric value that is used in the
Nonnal Range Value Factor Difficulty
FMA 22". 28° -....5- cranial facial analysis is placed in the "ceph value"
ANB1°·5° ~ column. The difficulty factor is calculated for each
Z Angle 70° . 80° ---..2..-
Occ Plane 8°· 12° ~ cephalometric measurement that is outside the
SNB 78° - 82" -....5- normal range. The total cranial facial difficulty for
EHI lPEH-Aft< 65 - 75 __ ~
C. F. DIfficulty Total this patient was 82.
TOTAL SPACE ANALYSIS
Difficulty Total dentition space analysis (Fig. 7)
Anterior Value Factor Difficulty
ToothArch Disc. -1.L The total space analysis and space analysis
HeadlilmDIsc. -l.-
Soft Tissue Mod. ~
difficulty are calculated. The total space analysis is
TOTAL divided into anterior, midarch, and posterior. The
Mldarch
ToothArch Disc. anterior tooth arch discrepancy for the six man-
Curve 01 Spee dibular anterior teeth was 4 mm. This figure he-
TOTAL
comes 6.0 mm in the difficulty column since ante-
Occlusal Disharmony
(Class" or Class III) rior crowding, because it is overriding, has been
given a difficulty factor of 1.5. The head film
PosterIor
ToothArch Disc. discrepancy was 14.4 mm (0.8 x 18). There was no
Expected Increase (-) soft tissue modification because total chin thickness
TOTAL ----L.. __
Space Analysis
equaled upper lip thickness. The total anterior
Space Analysis Total ==- DIfficulty Total_ space analysis difficulty was 20.4 mm.
C F. DWficulty TOlaI The tooth arch discrepancy for the midarch was
SA Dillicutty TOOII 4 mm. The curve of Spee required 3 mm of space
Total DIfficulty
for leveling. The difficulty factor for the midarch is
Index Difficulty: Mild 0 - 60 Moderate 60 -120 Severe 120+
1. therefore the total space requirement for correc-
 American Journal oj Orthodonucs and Dentofactal Orthopedics
Volume 106, No 6
Merrifield, Klontz, and Vaden 647

t----' -.~
~~--
~

~C~C:~
... ~.;:---­
'--"~-""""" ~ __ "IIl!I(""r

"
- ".~s,
•
o>•
t:- .
'":""":~

.... . .1.·...···
....::JI
,'.:"""

Fig. 5. Pretreatment panoramic x-ray film

FMA ,0
IMPA 103
FMIA 47
SNA 80
SNB 7.
ANB 6
OCC 13
Z 74
PFH 4~mm
AFH 67mm
FHI 63

Fig. 6. Pretreatment cephalometric tracing.

tion of crowding and the leveling of the curve of fore the space deficit was 10 mm. Because the
Spee was 7.0 mm (4 + 3 x 1). The patient had a difficulty factor is 0.5 for the posterior area, the
full step Class II occlusion on both right and left total space analysis difficulty for the posterior den-
sides. The 5 mm of space per side was necessary for ture area was 5 mm. The difficulty factor is lower in
correction. Because occlusal disharmony has a dif- the posterior part of the mouth because posterior
ficulty factor of 2, the total difficulty for Class II space requirements can be resolved simply with
correction was 20 mm (5 + 5 x 2). The total mid- extraction of third molars.
arch difficulty was therefore 27.5 mm. The actual space required to correct crowding
The tooth arch discrepancy in the posterior part for the dentition was 35.8 mm. However, when the
of the arch, measured from the distal of the first total space analysis difficulty was calculated, the
molar to the ascending border of the ramus, was 16 total difficulty was 52.4 mm. This figure included
mm. Because the patient was 12, she could expect the space requirement for the occlusal disharmony
an increase in posterior space of 6 mm."" There- correction, as well as space requirements for the
648 Merrifield, Klontz, and Vaden Amenwn Journal of Orthodontics and Dentofacwl Orthopedics
December 1994

CRANIAL FACIAL ANALYSIS Ceph Difficulty difficulty of malocclusion correction, this patient's
Normal Range ValUe Factor
FMA 22" - 28" -3lL ~ problem fit into the "severe" category.
AN81° -SO --L ---1.5....- The information derived from the cranial facial
Z Nv;je 70" - 80° -.liL --2....-
Ooc Plane 8° - 12" -1L --....a....... dental analysis can be invaluable to the clinician
SNB78" - 82" -.lL ~ during the diagnosis process. It is a tool, but a tool
EH IPFtWHl 65 - 75 --L --....a.......
C. F. DIHlculty Total that has clinical importance. It gives the orthodon-
TOTAL SPACE ANALYSIS tic specialist information that is useful and can lead
AnterIor to proper diagnostic decisions that will most advan-
ToothArch Disc. tageously facilitate correction of the malocclusion.
Headlilm Disc.
Soft Tissue Mod.
TOTAL REFERENCES
Mldarch
ToothArch Di&c. ~ 1. Gramling JF. A cephalometric appraisal of the results of
Curve of Spee -.a.L. orthodontic treatment on one hundred fifty successfully cor-
TOTAL -1IL --L- --LD....-
rected difficult Class II malocclusions. J Charles Tweed
O<x:UsaI Disharmony
Found 1987;15:102-11.
(CIBsa Uor Class In) -1lL --.:L.-2Q.lL
2. Gramling JF. A cephalometric appraisal of the results of
Poaterlor orthodontic treatment on fifty-five unsuccessfully corrected
ToothArch Dlse. --1.U.. difficult Class II malocclusions. J Charles Tweed Found
Expected Increase(-) --6.lL 1987;15:112-24.
TOTAL ~ --L- --5L
Space Analyala
3. Gramling JF. The probability index. J Charles Tweed Found
1989;17:81-93.
Space Analyala Total ~Dlfflculty Total~
4. Gebeck TR, Merrifield LL. Analysis: concepts and values,
C.F. OificultyTolal -.ll2.lL
part I. J Charles Tweed Found 1989;17:19-48.
SA OiIficultyTolal -..52.L
5. Merrifield LL, Gebeck TR. Analysis: concepts and values,
Total DIHlcuny ~
Index DIHlcuny: Mild 0 • 60 Moderate 60 ·120 Severe 120+
part II. J Charles Tweed Found 1989;17:49-64.
6. Horn A. Facial height index. AM J ORTHOD DENTOFAC
Fig. 7. Cranial facial dental analysis with total difficulty for ORTHOP 1992;102:180-6.
patient whose records were illustrated. 7. Bjork A, Jensen E, Palling M. Mandibular growth and third
molar impaction. Em Orthod Soc Trans 1956:164.
8, Ledyard Be. A study of the mandibular third molar area. AM
J ORTHOD 1953;39:366-74.
correction of crowding and uprighting of the man- 9. Richardson ME. Development of the lower third molar from
dibular incisors. ten to fifteen years. Angle Orthod 1973;43:191-3.
The cranial facial difficulty is combined with the
Reprint requests to:
space analysis difficulty to yield the cranial facial Dr. James L. Vaden
dental total difficulty (Fig. 7). Total difficulty was 308 East First St.
134.4. By using the criteria already established for Cookeville, TN 38501