03 Cephalometric Interpretation With Diagnosis and Treatment Planning

Cephalometric Interpretation
with Diagnosis and Treatment

Planning
Straight Wire Concepts: Diagnosis & Technique
Patient Name
Date
Attitude Toward Treatment:
Skeletal
Normal Beg
End
No.
Age
Sex
Good
Indifferent
Dental
Race
Poor
Normal Beg
SNA
(angle)
82
OCC to SN
(angle)
SNB
(angle)
80
Upper Incisor to NA
(mm)
ANB
(angle)
Upper Incisor to NA
(angle)
22
SL
(mm)
51
Lower Incisor to NB
(mm)
WITS
(mm)
-1+3
Lower Incisor to NB
(angle)
25
LOWER FACIAL HEIGHT
(mm)
60+5
Upper Incisor to Lower Incisor (angle)
GoGn to SN
(angle)
32
Po to NB
(mm)
varies
Y-AXIS
(angle)
66
AP to Lower Incisor
(mm)
+3-2
Po to NB
(mm)
2-5
End
14
131
Deciduous _______ Mixed _____ Permanent _____
Dentition:
Initial Occlusion:
Schwarz Analysis
Class:
starting
ideal
difference
Overjet ____ mm
II
III
Division:
Overbite _____ mm
II
Midline _____ mm
4.4
_______ m m
______ m m
_______ m m
Crossbite _____________________________________________
6.6
_______ m m
______ m m
_______ m m
Molar Relation:
Left _________
Right ______
5.5
_______ m m
______ m m
_______ m m
Cuspid Relation:
Left _________
Right ______
6.6
_______ m m
______ m m
_______ m m
Apexification of cuspids ________________________________

ANB _____________________________________________ degrees
Skeletal Classification _____________________________________
Missing Teeth: ___________________________________________

Impacted Teeth: _________________________________________
Wisdom Teeth Present: ___________________________________
Tooth Size Discrepancy: ___________________________________
Soft Tissue Profile ________________________________________

Pogonion to NB Line ___________________________________ mm
How much will Pogonion grow? ________________________ mm
Lower incisor to NB now _______________________________ mm
Does lower incisor need to be moved? _______________________
Forward ____________ mm
Initial TMJ Evaluation: ___________

Pain
Left
Right
Popping
Left
Right
Range of Motion:
Backward ____________ mm
Right Deviation ________________________ mm
How much crowding cephalometrically? ____________________

AP Line ____________________________________________ mm
Is this an extraction case? __________________________________
Transcranial position of the condyle:

Anterior _________ Posterior ________ Superior __________
Which teeth need to be extracted? __________________________

GoGn to SN _________
Type of Growth:
Y-Axis ________
SL ________ mm
Neutral _________ Clockwise ___________
Counterclockwise _________________
Habits:
Thumb
Tongue
Lip Sucker
Other: _________________________________________
Airway Problems:
Tonsils
Adenoids
Other ________________________________________________
Appliances Needed:
Transpalatal
Reverse Face Mask
Lip Bumper:
Wide
Thin
MDA:
Upper
Lower
NiTi Expander
Rapid Palatal Expansion
ENT Evaluation Advised _________________________________

Prognosis _____________________________________________
____________________________________________________
Lip Seal Exercises ______________________________________
Patient's Treatment Objectives: ____________________________
Retention:
Hawley
Vertical ________________________ mm
Left Deviation _________________________ mm
Lower Lingual
____________________________________________________
____________________________________________________
Treatment Goals and Plan:
RGG Form 92/2

Robert G. Gerety DDS - Produced by Kay C. Gerety
63
Caucasian Cephalometric Norms

Patient Name _________________________________ Case # __________ Age ____ Sex ____ Race _______
Date ______________ Attitude toward dentistry:
Good
Poor
Indifferent
Patients Chief Complaint: ________________________________________________________________________
Skeletal
Dental
Normal Beg.
End
Normal
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
80
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
22
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +3
L-Inc. to NB
(angle)
25
LFH
(mm)
60
U-Inc. to L-Inc.
(angle)
131
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
66
AP to L-inc.
(mm)
ANB ________ Degrees WITS ____________ mm

Skeletal Classification __________________________
Soft Tissue Profile _____________________________
Lower Inc. to NB ________ NB to Pogonion ________
Does lower incisor need to be moved?
Forward ___________ mm Backward ___________ mm
Expected Growth of Pogonion _________ mm
AP Line to Lower Incisor _________ mm
GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
Type of Growth Pattern __________________ Neutral
__________ Clockwise __________ Counterclockwise
TREATMENT OPTION 1
Beg.
End
+3 to -2
DENTITION:
________ Deciduous ______ Mixed _____ Permanent
Initial Dental Occlusion: _________________________
Class I II III
Division I II
Overjet ____ mm Overbite ____ mm Midline ____ mm
Molar Relationship _________ Left __________ Right
Cuspid Relationship ________ Left __________ Right
Missing teeth __________________________________
Crossbite _____________________________________
Wisdom Teeth Present __________________________
Recommend Extraction of: _______________________
Tooth Size Discrepancy: _________________________
ENT Evaluation Advised _______ Yes ________ No
TMJ Evaluation ________________________________
PHASE I INTERCEPTIVE
DIAGNOSIS AND TREATMENT PLAN:

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
64
African American Cephalometric Norms

Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
85
Occ to SN
(angle)
15
SNB
(angle)
80
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
24
SL
(mm)
51
L-Inc. to NB
(mm)
11
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
38
LFH
(mm)
60
U-Inc. to L-Inc.
(angle)
114
GoGn (angle)
to SN
38
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)

GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
TREATMENT OPTION 1
Beg.
End
0
8.5
DENTITION:
Class I II III
Division I II
Missing teeth __________________________________
Crossbite _____________________________________
TMJ Evaluation ________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
65
Hispanic Cephalometric Norms

Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
81
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
23
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
25
LFH
(mm)
67
U-Inc. to L-Inc.
(angle)
124
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)

GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
TREATMENT OPTION 1
Beg.
End
2
3
DENTITION:
Class I II III
Division I II
Missing teeth __________________________________
Crossbite _____________________________________
TMJ Evaluation ________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
66
Chinese Cephalometric Norms

Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
78
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
23
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
25
LFH
(mm)
67
U-Inc. to L-Inc.
(angle)
124
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)

GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
TREATMENT OPTION 1
Beg.
End
+2
+3
DENTITION:
Class I II III
Division I II
Missing teeth __________________________________
Crossbite _____________________________________
TMJ Evaluation ________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
67
Japanese Cephalometric Norms

Good
Poor
Indifferent
Skeletal
Dental
Normal Beg.
Normal
End
SNA
(angle)
82
Occ to SN
(angle)
14
SNB
(angle)
80
U-Inc. to NA
(mm)
ANB
(angle)
U-Inc. to NA
(angle)
23
SL
(mm)
51
L-Inc. to NB
(mm)
WITS
(mm)
-1 to +1
L-Inc. to NB
(angle)
25
LFH
(mm)
72
U-Inc. to L-Inc.
(angle)
124
GoGn (angle)
to SN
32
NB to
Pogonion
(mm)
Y-axis (angle)
67
AP to L-inc.
(mm)

GoGn to SN ___________________________________
Y-Axis ____________ SL _______________
TREATMENT OPTION 1
Beg.
End
+2
+3
DENTITION:
Class I II III
Division I II
Missing teeth __________________________________
Crossbite _____________________________________
TMJ Evaluation ________________________________

_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
68
The Case Against Early Extraction of Mandibular Primary Canines

(cont.)
The ironic aspect of this situation is that patients who generally appear to require early extraction of the
mandibular primary canines because of initial crowding of the mandibular incisor teeth are too often the very patients
who should not have these teeth extracted. Many of these patients, particularly those with low mandibular plane
angles (20o to 25o) have a hyperactive mentalis muscle, which creates some flattening of the profile through
retroclination of the mandibular incisors. The extraction of the primary canines then permits even further distolingual
repositioning of the mandibular incisors. This may cause the orthodontist to treat an already over-retracted
mandibular incisor position that was established before active treatment is undertaken. Thus, the first and decisive
step toward flattening of the profile is often taken before the orthodontist becomes a part of the decision-making
process.
Also, if the root of the primary canine acts as a functional matrix for the formation and maintenance of alveolar
bone, then it is evident that in a lateral dimension there would be less alveolar bone and therefore less available space
for eruption of the permanent canines after removal of their primary analogs. The overly crowded case, therefore,
would hardly benefit from early removal of the roots of the primary canines. Other remedial procedures, such as
disking of the primary canine, primary first molar or primary second molar should definitely be attempted first in
these cases.
The clear admonition to the orthodontist who treats casesaccording to the axiom of positioning the mandibular
incisors labiolingually where they are foundis obvious. The history and development of the malocclusion of the
individual patient must first be reevaluated. The requirements of cases that have iatrogenic over-lingualization of
the mandibular anterior teeth might change from an extraction to a non-extraction treatment plan, provided an
adequate dental history is obtained and thorough scrutiny of the orthodontics records (including a thorough
cephalometric analysis) is completed.
It can be determined from the cephalometric analysis if a child has a strongly clockwise or strongly
counterclockwise growth pattern according to the method advanced by Bjork6. It has been proposed that patients
having strongly counterclockwise growth patterns generally benefit from a non-extraction treatment approach7. If
the patient has a strongly counterclockwise growth pattern, premature extraction of primary canines could be
disastrous for the patient, resulting in a permanently increased vertical overbite or a concave facial profile. Early
limited mechanotherapy involving interrupted or segmental lower arches, headgear or lower bumpers may be
indicated in certain of these cases, to prevent or recover from over-distilization of the mandibular anterior teeth.
Although the angular and linear positions of the mandibular incisors can be useful guides as to what positions
will be stable for them, they are far from absolute. If the mandibular incisors have been permitted to shift to a far
more lingual position because of premature extraction of the mandibular canines, positioning the denture
anteroposteriorly according to the position of the lower incisors at the time of taking original orthodontic records
will certainly result in a flattening of the profile and disharmonious facial asthetics. The concept that mandibular
continued on next page
83
The Case Against Early Extraction Of Mandibular Primary Canines

(cont.)
incisors cannot be moved labially because that will be an unstable position for them has to be subject to question
in cases in which mandibular primary canines have been extracted prematurely. It is my opinion that labial
advancement is not only stable, but highly preferable in many of these cases. Also, the concept that space
maintenance is indicated in the mandibular arch only in the event of loss of the primary first molars or secondary
molars is open to question and does not take into consideration the possible lingual movement of the lower incisors
following early loss of the mandibular primary canines.
The value of an early orthodontic case analysis, treatment plan and consultation can not be overesti-mated. It
may result in the complete modification of a treatment plan which, otherwise, the operator may have become
committed to too early and which would be doomed to eventual failure anyway; elimination of the need for loss of
four or more teeth, shortening of time required to accomplish full-banded treatment or the elimination of the need
for full-banded treatment altogether.
In dealing with these cases over the past six years, I have observed that four things consistently happen when
the mandibular canines are extracted early; the mandibular incisors move distally and lingually, the vertical overbite
deepens, the horizontal overjet increases and the facial convexity is increased. Lip incompetence may be created
or exacerbated as a result of this procedure. Another possibility is that the mandibular permanent canines may
become impacted, necessitating the extraction of permanent first pre-molars. At best, early extraction of the
mandibular primary canines generally only accomplishes two purposes; a temporary realignment of the permanent
mandibular incisors and creation of the illusion in the minds of the parents that no serious crowding problem exists.
It is open to question how many adult Class II, Division I malocclusions may have been exacerbated by extraction
of their primary mandibular canines at age 7 or 8. I have never seen a case in which 1 mm of arch length was gained
from early extraction of the mandibular primary canines; nor was any case made easier to treat in the permanent
dentition. In virtually every case, extraction of the canines made a bad situation worse and increased the severity
of the arch length discrepancy.
There are cases in which extraction of the mandibular primary canines is indicated. Severe gingival stripping of
the erupted mandibular incisors, or the existence of an arch length discrepancy so great that it results in the complete
blockage of one or both permanent lateral incisors would constitute such indications.
Conclusions
Early crowding of the mandibular incisor teeth, gingival stripping or the development of a deep anterior overbite
are all primary indications for an early orthodontic evaluation and consultation. Cephalometric analysis including an
evaluation of the growth pattern (clockwise vs. counterclockwise) and linear and angular measurements of the
position of the mandibular incisors should be done for all children who show early signs of mandibular anterior
crowding before extractions. Extractions of mandibular primary canines should not be undertaken merely at the
request of concerned parents.
continued on next page
84
The Case Against Early Extraction Of Mandibular Primary Canines

(cont.)
Dr. Atkinson is Associate Clinical Professor, Department of Orthodontics, Medical College of Georgia
School of Dentistry. Send requests for reprints to Dr. Atkinson, 215 West Poinsett St., Greer, SC 29651.
1
T. M. Graber, Orthodontics: Principles and Practice, 3d ed. (Philadelphia, W. B. Saunders Co.,

1972) p. 363.
H. P. Hitchcock, Orthodontics for Undergraduates, (Philadelphia, Lea & Febiger, 1974) p. 255.
B. H. Mueller et al., The Effect of Primary Canine Extraction on the IMPA, J Dent Child, 45 (1978),
461-464.
C. J. Hill, H. W. Sorenson, J.R. Mink, Space Maintenance in a Child Dental Care Program,
JADA, 90 (1975), 811.
C. F. Moorrees and J. M. Chadha, Available Space for the Incisors During Dental Development:
A Growth Study Based on Physiologic Age, Angle Orthodontist, 35 (1965) 12-22.
J. R. Jarabak and J. A. Fizzell, Technique and Treatment with Light-Wire Edgewise Appliances,
2d ed., (St. Louis; C. V. Mosby Co., 1972), pp. 139-158.
J. R. Isaacson et al., Extreme Variation in Vertical Facial Growth and Associated Variation in
Skeletal and Dental Relations, Angle Orthodontist, 41 (1971) 219-229.
85
When to Begin Treatment

Patient Selection Criteria for the Beginning Doctor
1. Dont treat adults.
2. Dont do one arch treatment except in the mixed dentition (Phase I)
3. Dont treat TMJ patients.
4. Treat patients with an ANB difference of 0-8 degrees.
5. Treat patients with mandibular plane angle (GoGn to SN) of 37o or less (neutral or
horizontal growth).
6. Treat all cases non-extraction for at least nine months. This will enable you to work
through an archwire sequence.
Crossbites
1. Correct crossbites anterior or posterior as soon as they are diagnosed.
2. Crossbites are more easily corrected on the younger patient (3 years or older).
3. It is very difficult to correct posterior crossbites on patients 17 years or older.
4. You can use a removable appliance (Schwarz, 3-way etc.) or a fixed appliance
(quadhelix, transpalatal, nickel titanium expander etc.) to correct crossbites in the
early or mixed dentition.
5. Correction of crossbites in permanent or late dentition usually requires rapid palatal
expansion.
Lower Cuspids Caucasion Only
Figure G
Before minimum
growth spurt
86
Maximum
growth spurt
After maximum
growth spurt
Cephalometric Interpretation
ANB Difference Defined
SNA Measurement
SNA (82o +or- 4o) is in the normal range. SNA is the anteroposterior
relationship of the maxilla to the anterior cranial base.
SNB Measurement
SNB (80o +or- 4o) is in the normal range. SNB is the anteroposterior
relationship of the mandible to the anterior cranial base.
ANB Difference
ANB (0o to 4o) is in the normal range. ANB is the relationship of the
maxilla to the mandible in an anteroposterior relationship.
87
Skeletal Classifications
0 to 4
Class I Skeletal Configuration

When the ANB difference is 0o to 4o, the maxilla and the mandible will usually
be related well enough so that it will not be necessary to change the skeletal
relationship.
5 or More
Class II Skeletal Configuration

When the ANB difference is 5o or more, the maxilla, the mandible or a little of
both can be at fault.
In a class II skeletal discrepancy, it will be necessary to place an
auxiliary appliance (MDA, headgear, orthopedic corrector, etc.) to
retard and/or retract the maxilla and allow the mandible to grow to its
full potential.
0 or Less
Class III Skeletal Configuration

When the ANB difference is 0o or less, a rapid palatal expansion appliance can
be used to bring the A point forward to help the Class III skeletal configuration.
This rapid palatal expander will most often be used in conjunction with a
Reverse Face Mask.
88
Soft Tissue Profile Analysis

The horizontal soft tissue profile is an aid in diagnosis. A line is drawn from the soft tissue of the chin
through the middle of the nose. The lips should fall on or slightly in front of this line to achieve a
pleasing profile.
If the lips fall in front of this line, the face has a convex appearance. In these patients, expansion
should be avoided as it would push the lips further forward and worsen the convexity. If the lips fall
behind this line, the face has a concave appearance. In these patients, extractions are generally
avoided because any distalization of the anterior segments will worsen the concavity.
Clinical studies have documented that the convexity of the profile will lessen with age. This is true of
all individuals, male and female, regardless of treatment. Finishing cases somewhat full is not a
concern because the patient's profile will continue to flatten.
Normal
Convex
Concave
Figure I
89
N-B Line
The lower incisor to pogonion in at least a 1 to 1 ratio
will usually result in a stable dentition and pleasant facial
appearance.
The lower incisor is measured from the NB line to the
most labial portion of the incisor in millimeters.
Pogonion is measured from the NB line in millimeters.
The lower incisor is +4mm to the NB line and pogonion
is +4mm resulting in a 1 to 1 ratio.
The lower incisor should be positioned at least at a 1 to
1 ratio with pogonion or the lower incisor should be
positioned 1 to 3 mm anterior of pogonion.
The lower incisor is behind the NB line -2mm probably

causing a concave appearance with pogonion at +4mm.
Extractions generally are avoided because it is undesirable to worsen the concavity of the lower face.
The lower incisor could be moved anteriorly improving
the facial appearance and gaining lower arch length. This
anterior movement is usually done by crown tipping to
avoid any stripping.
The lower incisor is forward to the NB line by +8mm and

pogonion only +4mm.
With the lower incisor at +8mm and if the lower dentition
is already crowded then to get back to a 1 to 1 ratio, you
must distalize using either a lower Wilson or lip bumper.
Either of these will aid in lateral expansion as well.
To move the lower incisor back to +4mm to the NB line,
the same as +4mm as pogonion, there is 8mm of crowding.
90
Pogonion
The Importance of Determining Pogonion
It is important to determine how much the pogonion will grow. Once we determine
how far the pogonion is from the NB line, we can then decide where to place the lower
incisor.
Dentition that has a 1 to 1 ratio between the lower incisor and the pogonion will
usually have the best facial aesthetics and will be stable.
The other important aspect of knowing where the pogonion will grow is in determining how much crowding cephalometrically you will have with the lower incisors.
Differences in Boys and Girls

Boys mature about 2 years later
than girls and grow longer. With boys
you start treatment about 12 to 12
years of age. Girls are usually mature
by 13-14 years of age. With girls you
start treatment about 10 to 10 years
of age. (See Figure 3-A below)
Possible Pogonion Growth

AGE
BOYS
GIRLS
10
--
0 to 3-4mm
11
--
0 to 2-3mm
12
0 to 3-5mm
0 to 1-2mm
13
0 to 2-4mm
0 to -1mm
14
0 to 1-2mm
0 to 0mm
15
0 to -1mm
--
16
0 to 0mm
--
Figure H
Boys - Expected Growth

Age 12
Pogonion Growth: 3mm to 5mm
Pogonion Growth: 4mm to 6-7mm
Pogonion Growth: 5mm to 7-8mm
age 12
age 16
Boys age 12 with a 0 pogonion will generally get

a 3 to 5mm increase by age 16.
age 12
age 16
Boys age 12 with a pogonion of 3 to 5mm will

at least double to 6 to 8mm by age 16.
91
Girls - Expected Growth

Age 10
Pogonion Growth: 1mm to 4 or 5mm
In a girl with a 0 pogonion at age 10, the best you

generally will get is a 3 to 4mm increase in the
growth of the pogonion (closer to 3mm).
Age 11
Pg = 0mm
AGE 13
Pg = 0mm
92
Age 14
Pg = 2-3mm
AGE 14
Pg = -1mm
The pogonion increases less after age 10. A

patient that has a pogonion of 4mm age 14 will
have that the rest of her life.
Girls with a pogonion of 3 to 4mm at age 10 will

usually double to 6 to 8mm by age 14.
AGE 12
Pg = 0mm
Age 14
Pg = 1-2mm
A patient that has a 0 pogonion at age 14 will not

get an increase in the pogonion. The pogonion will
remain 0.
Establishing Incisor to NB Relationship

1. Look at the age of the patient first.
2. Then look at expected pogonion growth chart
to determine how much pogonion will grow.
Age - 10.6
3. Then you can decide where to place the lower

incisor.
4. If this patient had 8mm of dental crowding,
then you could eliminate this by moving the
lower incisor forward to 7mm.
3mm
3mm
1. Pogonion has grown to 6mm.

2. The crowding has been eliminated by moving
the lower incisors forward.
Age - 14
3. This has produced a nice soft tissue profile.
7mm
6mm
93
Determining Crowding Cephalometrically
For every mm you decrease the lower incisor to the

NB line, you decrease the arch length by 1mm. This
total must be doubled because the lower arch will be
retracted.
There is no crowding cephalometrically in this example
because the lower incisor to the NB line is within
normal limits to the NB line.
There is no crowding cephalometricaly in this example

with the lower incisor to the NB line of -2mm.
The lower incisor is +8mm to the NB line present

ing a total of +8mm of crowding cephalometrically.
The lower incisor retracted to +4mm to the NB line
will decrease the arch length by 4mm on each side
of the arch. This totals -8mm cephalometrically.
94
Skeletal Classifications (Growth Pattern)
Skeletal Average Bite

GoGn to SN is 32o +or- 5o
32o 5o
Skeletal Closed Bite

GoGn to SN is 27o or less
27o or Less
Skeletal Open Bite

GoGn to SN is 37o or more
37 or More
95
Growth Indicator Measurements

Y-Axis Growth Indications
SL Growth Indications
S
Y - Axis
Y-Axis 65o +or- 5o

Neutral Growth
SL 51mm +or- 5mm

Neutral Growth
L
S
Y - Axis
Y-Axis 60o or Less

Counter Clockwise Growth
SL 57mm or Greater
Counter Clockwise Growth
Y - Axis
Y-Axis 71o or Greater

Clockwise Growth
Skeletal Open Bite
96
SL 44mm or Less
Clockwise Growth
Skeletal Open Bite
A-P Line Analysis

The position of the incisal edge of the lower incisor in
relation to the A-P line or diagnostic line is important to facial aesthetics and the stability of the dentition. The lower incisor should be on or slightly in
front of the A-P line. Use of the AP line for
diagnosis is accurate only when the patient has
a class I skeletal relationship.
AP to = +3mm
The normal range of the lower incisor to the A-P

Line is +2, +3, +4mm. This range usually results
in a nice, stable lower dentition and pleasing
facial aesthetics.
The lower incisor to the A-P line in this example

would lean toward non-extractions. The lower
dentition could gain between 10 to 12mm in arch
length. The lower incisor could be brought from
a -4mm to a +3mm, gaining a total of 7mm on
each side of the arch for a total of +14mm.
The lower incisor to the A-P line in this example

would lean toward distalization. The lips should
not be any fuller so you would want to treat any
crowding with lateral expansion and distalization
rather than any anterior movement.
AP to = -4mm
AP to = +8mm
97
Wits Analysis
Apical Base Class I
-1mm to +3mm Wits = Skeletal Class I

00 to 40 ANB = Skeletal Class I
Apical Base Class II
+3mm Wits or Greater = Skeletal Class II

50 and Over ANB = Skeletal Class II
Apical Base Class III
98
Less than -1mm Wits = Skeletal Class III

-10 and Below ANB = Skeletal Class III
Cephalometric Diagnosis
1. The age tells me if the patient is in a growth spurt and how much pogonion
may still grow.
2. Check SNA & SNB to see if both are within normal range.
ANB difference to see how the maxilla and mandible are related.
3. Check soft tissue profile.

4. Check Pogonion to see if it will grow, which may allow us to move the lower
incisors forward to eliminate crowding.
Check the lower incisor to NB to see if it needs to be moved forward,

backward or remain the same.
5. Check GoGn to determine if this patient is a clockwise, counter-clockwise or

neutral grower.
99
Schwarz Analysis
S.I. = ______ mm (Upper Centrals and Laterals)
(S.I. stands for Sum of the Incisors, mesial-distal width in mm)
S.I. + the Following = Ideal
Narrow Face
6mm 1st Premolar

12mm 1st Molar
Normal Face
7mm 1st Premolar

14mm 1st Molar
Wide Face
8mm 1st Premolar

16mm 1st Molar
Upper Arch
Measurement Points
Distal Pits
of 1st Premolars
Central Pits
of 1st molars
S.I. + 8mm = 1st Premolar

S.I. + 16mm = 1st Molar
100
Lower Arch
Measurement Points
Central Part
of Middle Buccal
Cusps of 1st Molars
Mesio-Labial
Marginal
Ridge Points
of 2nd Premolars
S.I. + 8mm = 1st Premolar

S.I. + 16mm = 1st Molar
Diagnostic Summary
Panorex
Cephalogram
Models
1. Cuspid apexification
1. Age - Sex
1. Dental classification
2. Dental age
2. Skeletal classification
2. Crossbites
3. Third molars
3. Soft Tissue Profile
3. Constrictions
4. Congenitally missing teeth
4. Lower incisor to NB and

NB to pogonion relationship
4. Crowding
5. Impacted teeth
(molars or cuspids)
5. Overjet and overbite
5. GoGn to SN
(mandibular plane angle)
Robert G. Gerety - Produced by Kay C. Gerety CDA
101
Mixed Dentition
1. Almost all cases started in the mixed dentition can be treated non-extraction for several
reasons:
a. Approximately 2 to 3mm per side can be gained if you do not allow the permanent
1st molars to come forward at all while the deciduous cuspids, 1st and 2nd molars are
being lost and replaced by the permanent teeth.
b. You can usually move the lower anteriors forward to gain arch length.
c. Expand laterally.
d. The MDA appliance allows you to distalize the 1st and 2nd molars.
2. During the mixed dentition, a lip bumper or fixed lingual arch can be placed on the lower
first permanent molars to maintain the space from the deciduous molars.
a. If lateral expansion is desired, the lip bumper or fixed lingual arch can be activated to
achieve this.
b. In severely crowded cases, it may be necessary to distalize the lower first molars
using class III elastics to the lip bumper.
c. If class III elastics are used, it will be necessary to place a transpalatal arch on the
upper for anchorage.
3. In mixed dentition cases with severe crowding, it is advantageous to bracket the primary
dentition to aid in arch development.
a. In constricted cases, much space and lateral development can be accomplished by
bracketing the primary cuspids, first and second molars and progressing through an
archwire sequence.
b. Place cuspid, first and second bicuspid brackets on these primary teeth.
c. Placement of these brackets is not critical (ideally place them as gingival as possible).
d. When crowding has been eliminated, debracket and place upper hawley and fixed
lower lingual to maintain until permanent dentition.
4. In mixed dentition with Skeletal discrepancies, functional appliance therapy can be
instituted in an effort to change the skeletal features while waiting on the permanent
teeth.
a. Reverse Face Mask can be used for class III malocclusion.
The Transpalatal Bar has been designed for:
1.
2.
3.
4.
5.
Rotation of 1st and 2nd molars.

Expansion.
Distalization.
Torque.
Crossbites.
Expansion and Contraction
102
Rotation
Buccal Root Torque

Phase I Interceptive Treatment

Phase I or interceptive orthodontic treatment should be considered when there is moderate crowding,
loss of space due to extraction or premature exfoliation, or severely rotated or malaligned teeth
erupting. Literature published by Bjorn Zachrisson, DDS,MSD,PHD1 emphasizes the importance of
treating crowded or rotated teeth at an early age to improve stability. Resolving the issues of crowding
and constrictions in the mixed dentition lessens the severity of the comprehensive orthodontic
treatment during the permanent dentition. Patients and parents are concerned with the malaligned
teeth. By addressing these concerns with fixed appliannces, you not only develop the arches and make
room for the permanent teeth, you individually correct the position of the teeth for esthetics. With
removable appliances, it is not always possible to tip, align and rotate the teeth to the esthetic level
that both you and the parent are hoping to obtain. Anterior-posterior or skeletal class II correction is
not recommended in the mixed dentition.
As documented by Hans Pancherz, DDS, Odont.2 maintaining an anterior posterior correction in the
mixed dentition is difficult, if not impossible, due to the flat plane occlusion of the primary teeth. In
order to maintain the correction, appliances will need to be worn as a retainer until the permanent teeth
erupt allowing the dental intercuspation to retain the correction. Flared anteriors or class II division
I cases can be improved by tipping the maxillary teeth lingually for esthetics and prevention of trauma
and waiting for the class II correction during the permanent dentition. This conservative approach will
allow you to resolve the primary concerns within a reasonable treatment time of 9-12 months. While
correction of the dental and skeletal class II malocclusion can be completed in the mixed dentition,
the treatment time can be excessive due to the retention phase necessary to maintain the correction.
1. Journal of Orthodontics Volume XXXI Number 9 September 1997
2. Seminars in Orthodontics Volume 3 Number 4 December 1997
103
Phase I Technique (cont.)

1. Band first permanent molars and place brackets on all primary teeth. Use cuspid brackets on
the primary cuspids and first and second premolar brackets on the first and second deciduous
molars. Bracket placement on primary teeth is not critical. Place brackets as gingival as
possible.
2. Progress through routine archwire sequence of .0175, .016, .018 round.
3. Once you are up to the .018 archwire, introduce open coil spring where needed to gain sufficient
space or regain lost space.
4. Once you have gained adequate space, bracket the blocked out teeth & engage a flexible
archwire such as .0175 or .016 thermal and progress back through the archwire sequence of
.016, .018 and .020.
5. Once the arches are developed and the crowding has been eliminated, place an upper hawley
retainer and a fixed lower lingual for retention. On the lower, place a fixed bonded lower lingual
on the four permanent incisors if there are no missing teeth. If there are missing teeth, or arch
space to be maintained, place a fixed lingual arch from permanent first molar to first molar,
retaining the arch length and any spaces.
6. The upper retainer is worn for 6 months full time and can then be discontinued. The lower
lingual arch should be worn until the exfoliation of the primary teeth.
Step 1. Bracket the entire

dentition and use archwire
sequence.
104
Step 2. During the .018

archwire, introduce open
coil spring where teeth are
crowded or blocked.
Step 3. When you have gained

adequate space, bracket
blocked out teeth and place a
flexible wire to engage.
Step 4. Remove all

brackets &bands. Seat
retainers awaiting eruption
of permanent teeth.
The Six Keys to Optimal Occlusion

Key I - Molar Relationship
1. The distal surface of the distal marginal ridge of the
upper first permanent molar contacts and occludes with
the mesial surface of the mesial marginal ridge of the
lower second molar.
2. The mesio-buccal cusp of the upper first permanent
molar falls within the groove between the mesial and
middle cusp of the lower first permanent molar.
3. The mesio-lingual cusp of the upper first molar seats in
the central fossa of the lower first molar.
Key II - Crown Angulation - The Mesio-Distal

Tip
1. In normally occluded teeth, the gingival portion of the
long axis of each crown is distal to the occlusal portion
of that axis. The degree of tip varies with each tooth
type.
Key III - Crown Inclination - The Labio-Lingual or

Bucco-Lingual Torque
Crown inclination is the angle between a line 90 degrees to
the occlusal plane, and a line tangent to the middle of the
labial or buccal clinical crown.
1. Anterior crowns (central and lateral incisors): In upper
incisors, the occlusal portion of the crown's labial
surface is labial to the gingival portion. In all other
crowns, the occlusal portion of the labial or buccal
surface is lingual to the gingival portion. In the nonorthodontic normal models, the average interincisal
crown angle was 174 degrees.
2. Upper posterior crowns (cuspids through molars).
Lingual crown inclination is slightly more pronounced
in the molars than in cuspids and bicuspids.
3. Lower posterior crowns (cuspids through molars):
Lingual inclination progressively increases.
105
Key IV - Rotations
1. Teeth should be free of undesirable rotations. If rotated, a
molar or bicuspid occupies more space than normally, a
condition unreceptive to normal occlusion. A rotated incisor
can occupy less space than normal.
Key V - Tight Contacts

1. In the absence of such abnormalities as genuine tooth-size
discrepancies, contact points should be tight.
Key VI - Curve of Spee

A flat occlusal plane should be a treatment goal.
Measured from the most prominent-cusp of the lower
second molar to the lower central incisor, no curve
was deeper than 1.5mm in the non-orthodontic
normals.
1. A deep curve of Spee results in a more
confined area for the upper teeth, creating
spillage of upper teeth mesially and distally.
2. A flat curve of Spee is most receptive to
normal occlusion.
3. A reverse curve of Spee results in
excessive room for the upper teeth.
106
The Six Keys to Optimal Occlusion

Key I: Interarch Relationships
Key I is the first of the six significant characteristics that were consistently present in the sample of 120
dental casts with optimal occlusion. Key I pertains to the occlusion and the interach relationships of the
teeth. This key consists of seven parts.
1. The mesiobuccal cusp of the permanent maxillary first molar occludes in the groove between the
mesial and middle buccal cusps of the permanent mandibular first molar as explained by Angle.
2. The distal marginal ridge of the maxillary first molar occludes with the mesial marginal ridge of the
mandibular second molar.
3. The mesiolingual cusp of the maxillary first molar occludes in the central fossa of the mandibular
first molar.
4. The buccal cusps of the maxillary premolars have a cusp-embrasure relationship with the mandibular
premolars.
5. The lingual cusps of the maxillary premolars have a cusp-fossa relationship with the mandibular
premolars.
6. The maxillary canine has a cusp-embrasure relationship with the mandibular canine and first premolar. The tip of its cusp is slightly mesial to the embrasure.
7. The maxillary incisors overlap the mandibular incisors, and the midlines of the arches match.
Fig. 3.15. Key I: Optimal interarch relationships and occlusal interfacing. A, Interarch relationships of molars and premolars:
a, marginal-ridge occlusion; b, molar cusp-groove relationship; c, premolar cusp-embrasure relationship. B, Mesial perspective of occlusal interfacing of molar or premolar: d, cusp-fossa relationship. C, Lingual perspective of occlusal interfacing:
e, cusp-fossa occlusion of molars; f, cusp-fossa occlusion of premolars. D, Interarch relationships of canines and incisors.
107
Fig. 3.17. From the mesiobuccal perspective the inclination of the crowns permits indirect judging of occlusal interfacing.
A, Correct inclination and correct occlusal interfacing: a, mesiobuccal perspective; b, lingual perspective; c, inclination
correlated with occlusal interfacing. B, Incorrect inclination and incorrect occlusal interfacing: A, mesiobuccal perspective; b, lingual perspective; c, inclination correlated with occlusal interfacing. Vertical lines on crowns indicate the axes;
junctions of vertical and horizontal lines indicate FA points.
Key II: Crown Angulation - The Mesio-Distal Tip

Essentially all crowns in the sample have a positive angulation* (Fig. 3.18). All crowns of each tooth
type are similar in the amount of angulation. In normally occluded teeth, the gingival portion of the long
axis of each crown is distal to the occlusal portion of that axis. The degree of tip varies with each tooth
type.
Fig. 3.18. Positive FACC angulation for each tooth type in the optimal sample. Wires are glued at the FA points, parallel to
each crowns FACC.
108
Key III: Crown Inclination

As they do in angulation, consistent patterns also prevail in crown inclination, with the following characteristics for individual teeth.
1. Most maxillary incisors (81.5%) have a positive inclination (Fig. 3.19A,B); mandibular incisors have
a slightly negative inclination (Fig. 3.19A,C). In most of the optimal sample, the interincisal crown
angle is less than 180: The crowns of maxillary incisors are more positively inclined, relative to a line
90 to the occlusal plane, than the mandibular incisors are negatively inclined to the same line (Fig.
3.20).
2. The inclinations of the maxillary incisor crowns are generally positive-the centrals more positive than
the laterals. Canines and premolars are negative and quite similar. The inclinations of the maxillary first
and second molars are also similar and negative, but slightly more negative than those of the canines and
premolars (Fig.3.21). The molars are more negative because they are measured from the groove instead
of from the prominent facial ridge, from which the canines and premolars are measured.
3. The inclinations of the mandibular crowns are progressivley more negative from the incisors through
the second molars (Fig. 3.22)
Fig. 3.19. Incisor inclination. Maxillary incisor inclination is

consistently positive (A,B); mandibluar incisor inclination is
consistently negative (A,C).
Fig. 3.20. Interincisal crown angle for the majority of the

optimal sample was less than 180.
109
Fig. 3.21. Maxillary crown inclinations. Central incisors (A) are more positive than lateral incisors (B); posterior
teeth are negative (C). Wires are glued at the FA points, parallel to each crown FACC.
Fig. 3.22 Mandibular crown inclinations. Central and lateral incisors (A) have the same inclination (generally
slightly negative). The posterior teeth are increasingly negative from the canines through the molars (B). Wires
are glued at the FA points, parallel to each crowns FACC.
110
Key IV: Rotations

The fourth key to optimal occlusion is an absence of tooth rotations (Fig. 3.23).
Key V: Tight Contacts

Contact points should abut unless a discrepancy exists in mesiodistal crown diameter (Fig. 3.23).
Fig. 3.23. Maxillary arch (A) and mandibular arch (B) showing no rotations and no interdental spacing. Dots indicate contact
points.
Key VI: Curve of Spee

The depth of the curve of Spee ranges from a flat plane to a slightly concave surface (Fig. 3.24).
Fig. 3.24. Mandibular arch with a curve of Spee within the 0-2.5mm depth range.
Summary -- Six Keys to Optimal Occlusion

1. Molar Relationship
2. Crown Tip
3. Crown Torque
4. Absence of Rotations
5. Absence of Spaces
6. Flat plane of Occlusion
111
Class I Occlusion as defined by Andrews
(A) Frontal view of an ideal occlusion in the skeletal remains of an adult. (B) Lateral view of the same
skull. The vertical axial line passing through the mesiobuccal cusp tip of the maxillary first molar meets
the vertical axial line passing through the buccal groove of the mandibular first molar. The vertical axial
line passing through the cusp tip of the maxillary canine meets the vertical line bisecting the embrasure
between the mandibular canine and first premolar.
The mesialbuccal cusp of the upper

first molar occludes with the groove
between the mesiobuccal and middle
buccal cusp of the lower first molar.
The distobuccal cusp of the upper first
molar contacts the mesiobuccal cusp
of the lower second molar.
112
Malocclusion Classification
A-C
Class II Division
I
D-F
Class II Division
II
G-I
Class III
A-C, Class II, Division I. D-F, Class II Division II. G-I, Class III. The vertical axial lines passing
through the mesiobuccal cusp tips of the maxillary first molars have different relationships with the
vertical axial lines passing through the buccal grooves of the mandibular first molars in different
malocclusion classes. A similar variation among malocclusion classes is observed in the relationships between the vertical axial lines passing through the cusp tips of the maxillary canines and the
vertical lines bicsecting the embrasures between the mandibular canines and first premolars.
113
Evaluate Premolar Position

If the upper premolars are in the embrasures of the lowers on one side, but are
riding up the inclines of the lower
premolars on the other side, two things
will be apparent in the occlusion. You
will have a midline discrepancy and/or an
overjet problem. The average width of a
lower premolar is 8mm. If the premolars
have end on end occlusion, you will have
to move the upper premolars distally
approximately 4mm to establish the solid
Class I occlusion and nice overjet. If you
have full Class II occlusion, you will
have to move the upper premolars distally
approximately 8mm. You should take
into account whether or not there is a
tooth size discrepancy.
114
Correct Premolar Occlusion

To achieve the proper overbite, overjet and correct midline the premolars have to fit in the
embrasures of the lower premolars and molar. When the upper premolars start to ride up the
inclines of the lower premolars then you will not be able to get the proper overjet or correct
midline.
115
Full Class II Occlusion

If you have an ANB of 0 to 8 and the upper premolars are end on end or full Class II,
the
quickest way to achieve the solid Class I occlusion is to distalize the molars with the
MDA.
116
Management of Blocked out or

Labially Positioned Cuspids
In considering treatment options for leveling, aligning and rotating the arches, upper or
lower, you must consider the resultsof an archwire sequence. If the cuspids are blocked
out or in labial version, upper or lower, progressing through an archwire sequence will
always move the anterior teeth forward. There are situations where you would like to
move the anteriors forward (Class II, Division II or lingually inclined lower incisors) and it
would be appropriate to engage the cuspids and move the anteriors forward. More often
than not, it will not be desirable to move the anteriors forward and you will want to initiate
treatment mechanics to make room for the cuspids through distalization.
By engaging blocked out or labially positioned cuspids on the upper, you will create
unwanted overjet because the cuspids will come down at the expense of moving the incisors out. This treatment is considered round tripping. The anteriors are moved out and
then have to be retracted. This anterior movement is not of any advantage and should be
avoided.
On the lower arch, the most likely cause of the mesial or labial position of the cuspids is
due to premature loss of the deciduous teeth and the cuspids have drifted forward. Engagement of these cuspids on the lower will have the same effect on the anteriors by
moving them forward. This anterior movement is not desirable and will position the
incisors too far labially and this round tripping should be avoided.
NOTE: Do not engage labial or blocked out cuspids, upper or lower, into the archwire
sequence until you have gained sufficient space for their position in the arch.
117
Results of Engaging Blocked Out Cuspids

Do not engage blocked out or labially positioned cuspids into the archwire sequence.
The posterior teeth will not move distally. The cuspids will come down at the expense of
the anterior teeth. Engaging the cuspids will cause the anterior teeth to intrude and flare
forward.
INTRUSION AND FLARING

Engagement of labially positioned blocked out cuspids, upper or lower, will cause
the anterior teeth to intrude and move forward.
OVERJET
Bringing in high cuspids when there is insufficient space, causes the anterior teeth to
flare forward creating overjet.
118
INCORRECT TREATMENT OF BLOCKED

OUT/LABIALLY POSITIONED CUSPIDS
AFTER
NOTE THE AMOUNT OF OVERJET AND ANTERIOR FLARING. THE PREMOLARS REMAIN CLASS II AND THE ANTERIOR TEETH
MOVE OUT.
BEFORE
119
120
AFTER
TREATMENT: This case exhibits an error in treatment sequencing. An archwire sequence

incorporating the upper cuspids and laterals was used before making space for cuspids and
laterals in the arch. Engaging blocked out teeth into an archwire sequence prior to making
space for them always results in the anterior teeth being blown out or flared. This is called
round-tripping and increases treatment time significantly. To correct, the posterior teeth
need to be repositioned into a proper class I relationship allowing adequate space for the anterior teeth to be retracted to eliminate the overjet and flaring. This entire phase of treatment
could be avoided by establishing the posterior relationship, gaining adequate space for the
blocked out teeth, and then incorporate them into the arches.
BEFORE
Final results of treatment to correct the improper management of the blocked out anterior teeth.
121
122
In this case, the lower cuspids have erupted mesially and are rotated allowing the lower posterior teeth to
drift mesially. Because of this, the posterior teeth appear to be slightly class I. Once the lower posterior
teeth are distalized so that there is sufficient room to rotate the cuspids into the proper position, the true class
II dental relationship will be obvious. On the upper arch, the cuspids do not have sufficient space for eruption and the right cuspid has erupted to the labial.
CORRECT TREATMENT OF BLOCKED OUT/LABIALLY POSITIONED CUSPIDS
Note that once the lower arch was established, the posterior teeth exhibit full class II occlusion. Notice that the upper cuspids have never been
bracketed or incorporated into treatment because there was not sufficient space for them in the arch. Once the lower arch is established, the
upper posterior teeth will be repositioned to allow space for the cuspids. This type treatment sequencing will avoid round tripping and
reduce treatment time.
TREATMENT: The lower molars and premolars were distalized to provide the proper space for the cuspids. After gaining sufficient space,
the cuspids and incisors were incorporated into an archwire sequence and the lower arch was leveled, aligned and rotated. If the cuspids had
been initially incorporated into the archwire sequence, they would have rotated into position at the expense of the lower anterior teeth going
forward.
123
Final results of proper treatment sequencing to manage blocked out

and labially positioned teeth avoiding round tripping.
124
Archwire Sequence
Archwire sequence is going through the archwires listed below in proper sequence:
Wire Size
Approximate Time
.0175
.016
.018
.020
2 months
2 months
1 month
1 month
Approximately 6 Months to Round Out the Arches

.016 x .022
.018 x .025
2 months
1 month
Approximately 9 Months to Level the Arches

019 x .025 Braided
1 month
Archwire Used for Re-bracketing and Fine Tuning
ARCHWIRE IDENTIFICATION
Archwires are identified by (3) black midline dots on the upper and (1) black midline dot on the lower.
If in doubt, the maxillary archwire always has a larger circumference than the
mandibular.
Some items to look for when going through the archwire sequence:
1. Do not go to the next larger size wire until the last archwire lies passive in the
brackets.
2. Introduce the rotating wedges during the .0175 twisted, usually the second wire,
and try to have 90% of the rotations out before going to the .016 wire.
3. Start placing AC - Accentuated Curves, RC - Reverse Curves, and CB Cinchbacks in the .016 archwire when needed.
4.
Start open coil spring on the .018 wire.
5. The arches should be rounded out by the .020 wire.

6. The arches should be close to level by the second .016 x .022 wire.
7. Start Class II elastics in conjunction with the MDA on .018 x .025 wire - the
arches should be level.
125
Treatment Summation
1. Establish the lower arch (level, align and rotate) to accept an .018 x .025 stainless archwire.
Before
Deep curve of Spee
Arch constrictions and rotations
Anterior irregularities
After
Curve of Spee leveled
126
Arch aligned and rotated
Anterior teeth leveled
Treatment Summation
2. Use the Multi-Distalizing Arch (MDA) to move the maxillary four posterior teeth
(molars and premolars) to fit the lower four posterior teeth into Class I occlusion.
Before
Class II Occlusion
Class II Occlusion
After
MDA to establish Class I Occlusion
127
Treatment Summation
3. Retract the maxillary cuspids into a Class I relationship. Use .020 round archwire and chain elastics
for spacing of 3mm or less. Use .016 x .022 with pletcher springs to retract cuspids more than 3 mm.
Before
Class II cuspid relationship
After
Cuspid retraction to Class I
128
Treatment Summation
4. Retract the maxillary anterior teeth if necessary using an .018 x .025 stainless steel
archwire with accentuating curve, pletcher springs to the posts, and Class II elastics.
Before
Anterior overjet
After
Anterior retraction and final bite opening
129
Treatment Summation
5. Rebracket any teeth as necessary to correct bracket placement errors. Place a .019 x .025 braided
archwire. You should also do individual root torque as needed in this size wire.
Before
Paralleling/Axial bracket
placement error
Height placement error
After
Rebracketing to correct tip
130
Rebracketing to level
Treatment Summation
6. Use posterior finishing elastics to lock in occlusion. Wear (1) 5/16 elastic as illustrated to
finalize the bite and add additional labial root torque to the posterior teeth.
Before Elastic Wear
Elastic wear for two weeks
After
Elastic
Wear
Occlusion Finalized
131
Treatment Methods to Establish the Lower Arch

In treatment planning and sequencing, it is recommended that you establish the position of the
lower teeth and arch first. You must decide and determine the position of the lower incisors,
premolars and molars in order to fit the maxillary teeth to the lower arch. The lower arch is
always the diagnostic arch. Establishing the lower arch means leveling, aligning and rotating all
the teeth that are available...second molar to second molar if possible.
#1
Bracketing with Archwire Sequence
The easiest and most simple way to establish the lower arch is with bracketing and archwire
sequence. Provided there is minimal to no crowding, this would be the treatment indicated. If
there is crowding present, the archwire sequence will move the anterior teeth forward and expand
the premolar area. In order to use this type of treatment, the profile must tolerate forward movement of the anterior teeth. From the ceph, can the lower teeth come forward? Look at the profile
and also the ratio of the lower incisor position to the chin button (pogonion). 75% of the time the
anterior teeth need to move forward and the premolars need to expand.
#2
Thin Lip Bumper or 3-D Lingual Arch to Utilize Available E Space
(E space is the mesial-distal width in millimeter difference of the deciduous second molar and the permanent second premolar.)
The next treatment consideration for establishing the lower arch would be to use a thin lip bumper
or lower 3-D lingual arch to maintain lower first molar position and take advantage of all the E
space. In treatment planning, you encounter slight to moderate crowding on the lower arch, a thin
lip bumper or lingual arch should be placed on the first permanent molar to freeze these molars
and allow the permanent teeth to erupt and drift to the distal, therefore, utilizing the available
space. No other teeth are bracketed on the lower arch and no archwire is in place. The crowding
correction comes from the teeth being allowed to drift distally and resolve the crowding.
#3
Thick Lip Bumper with Class III Elastics to Distalize
With moderate to severe crowding and permanent teeth in place without the presence of E
space, it will be necessary to place a thick lip bumper on the lower first molars and use Class III
elastics to distalize the posterior teeth to eliminate the crowding. If lower second molars are
present, they should be banded/bracketed and stabilized with a segmental .019 X .025 direct braid
archwire. The upper arch will need to be supported with either a transpalatal arch and/or an .018
X .025 stainless steel archwire for anchorage to use the Class III, 1/4 elastics to the lower lip
bumper. It will be advantageous to remove third molars if they are present. Place occlusal composite on the first molars to free the bite to that you can distalize the molars. It may be necessary
to mechanically retract the bicuspids and canines with power chains. You can gain approximately
4mm per side using the thick lip bumper with Class III elastics with the thirds removed.
132
#4
Lower MDA or CD Distalizer
With severe crowding (more than 4mm per side, blocked out teeth and in the full permanent dentition) it
will be necessary to place a MDA distalizing arch or a CD Distalizer on the lower to eliminate the
crowding. Treatment sequencing for a lower MDA is identical to upper MDA with the arches and
forces reversed. Do not round-trip the lower incisors by bracketing, flaring them out to align them, and
then retracting. The upper arch must be up to an .018 X .025 or a transpalatal for anchorage of the
elastics. Lower seconds must be banded or bracketed and incorporated into an .019 X .025 direct braid
segmental. Lower third molars should be removed prior to distalization. If using the CD Distalizer, no
arch set up is required. You can begin to distalize the lower molars immediately while doing an
archwire sequence on the upper.
#1 Archwire Sequence..................... ...............................................Lower Arch .018 x .025 SS
#2 Lip BumperArchwire Sequence.................................................Lower Arch .018 x .025 SS
#3 Lip Bumper/Class III Elastics/Archwire Sequence......................Lower Arch .018 x .025 SS
#4 CD Distalizer or Lower MDA/Archwire Sequence .....................Lower Arch .018 x .025 SS
Once the lower arch is level and aligned and the archwire size is .018 X .025 stainless steel, then you
make the upper arch fit the lower with the MDA on the upper.
133
Rounding Out the Arches

.0175 Twisted Wire
1.
2.
3.
4.
5.
First archwire to be placed.

Archwire to get full bracket engagement.
Starts to level, align and rotate.
Place your rotating wedges to help rotate.
Start to get arch form because usually the
four anteriors and premolars will round
out to the cuspids and molars.
6. Usually it will take at least 2 twisted
wires which is 2 months before you go to
.016. Sometimes it will take up to 6
months with twisted in adult cases.
.016
1. Continue to level align and rotate.
2. Place your AC - RC - CB in the archwires
if needed.
3. Continue to round out the arches.
.018
1. Continue with AC and RC to level.
.020
1. Continue with AC - RC - CB
2. The arches should have good arch form.
134
Arch Leveling
.0175 Twisted
1. Start to level - align and
rotate.
2. Get some extrusion of
premolars and intrusion
on anteriors - labial
movement of the four
incisors in crowded
cases.
3. Usually takes at least 2
twisted arch wires.
.016
1. Start to place AC & RC
to continue to level.
Extrusion of premolars
and intrusion of
anteriors and flaring.
.018
1. Continue to place AC RC - CB if needed.
2. All rotations should be
complete.
3. Can start open coil
spring to open spaces
for blocked out teeth if
necessary
4. Continue to round out
the arches.
135
Arch Leveling (cont.)

.020
1. Continue with AC &
RC to level.
2. May want to take a
study model to check
bracket alignment
and height if your
bite is not opening
up.
.016 x .022
RC if needed to
level.
.018 x .025
RC to get final
leveling.
136
Diagnosing the Correct Treatment Method to Establish

the Lower Arch: Four Treatment Options
#1 Bracketing with Archwire Sequence to .018 X .025 SS
Normal
#1 Evaluate soft tissue profile and lower incisor to
NB and pogonion relationship from the ceph. Can
the profile afford the teeth to move forward? Is
the amount of crowding significant enough to
Convex
Concave
cause the lower teeth to move forward? Are

permanent cuspids mesial to the four anterior
teeth? #2. Will moving the lower teeth forward
result in a stable position to pogonion?
Indications for Utilizing Treatment Option #1

Concave profile
Lower incisor to NB measurement less than Pogonion
Minimal to moderate crowding
Concave Profile
Archwire sequence
beginning with .0175
.018 X .025
Stainless Steel
137
Case # 1018: Option 1 Bracketing with Archwire Sequence.

138
AMANDA HENDRICKSON
AGE: 11.9
07-19-90
# 1018
36
24
75
35
68
AP= +1
75
71
4
143
68
+1
22
12
BEGINNING CEPH
139
Case # 1018: Option 1 Post Treatment Models

140
AMANDA HENDRICKSON
AGE: 13.11
09-01-92
# 1018
38
23
77
AP= +4
35
73
132
74
71
3
70
-1
22
25
TREATMENT COMPLETION
CEPH
141
Option # 2
Thin Lip Bumper or 3-D Lingual Arch to Utilize Available
E Space
Normal Profile
Lower incisor to NB measurement will not allow forward movement of incisors
Moderate crowding
Mixed dentition with second deciduous molars present
Thin Lip Bumper
Normal Profile
144
Thin Lip Bumper
Crowding Eliminated
Case # 973: Option 2 Thin Lip Bumper to Utilize Available E Space.
145
146
147
148
KRISSI INGRAM
AGE: 16
02-14-95
# 973
Retention Ceph
151
#3 Thick Lip Bumper with Class III Elastics to Distalize

Normal Profile
Moderate crowding
Permanent dentition
Normal Profile
Molar Distalization
Retract Cuspids
152
Class III Elastics
Thick Lip Bumper
Retract
2nd 2nd
Bicuspids
Retract
Bicuspids
Archwire Sequence
Retract 1st Bicuspids
Crowding Resolved
Case # 898: Option 3 Lip Bumper with Class III Elastics.

153
SHERI McCARTY
AGE: 11.1
05-11-87
# 898
Beginning Ceph
154
SHERI McCARTY
AGE: 11.9
01-11-88
# 898
Ceph after
Lip Bumper
and before
Archwire
Sequence
155

156
SHERI McCARTY
AGE: 17.7
11-09-93
# 898
Retention Ceph
157
#4 Lower MDA or CD Distalizer

Normal Profile
Severe crowding
Permanent dentition
Molars need to be distalized more than 4mm per side to eliminate crowding
Normal Profile
Molar Distalization
Retract Cuspids
160
Archwire Sequence Using Available Teeth

Progressing Up to .020
Retract 2nd Bicuspid
Archwire Sequence
Lower MDA
Retract 1st Bicuspid
Crowding Resolved
Case # 783: Option 4 Lower multi-distalizing arch.

161
CLARISSA ARMSTRONG
AGE: 10
03-13-84
# 783
Beginning Ceph
162
CLARISSA ARMSTRONG
AGE: 12.2
09-23-85
# 783
Ceph taken prior

to placement of
upper distalizing
arch
163

164
CLARISSA ARMSTRONG
AGE: 14.2
09-02-87
# 783
Treatment
completion
Ceph
165
Case # 1369: Option 4 Lower CD Distalizer

168
Tate Williams
AGE: 13
07-07-98
# 1369
169
Pre-Treatment
Post Retraction
Post CD Distalizer
Lower Arch Leveled to .018 x .025
Post Treatment
Lower arch sequencing using the CD Distalizer.

170
171
Tate Williams
AGE: 15.9
04-17-01
# 1369
Finished
Ceph
172
Phase I Interceptive Treatment

Phase I or interceptive orthodontic treatment should be
considered when there is moderate crowding, loss of
space due to extraction or premature exfoliation, or
severely rotated or malaligned teeth erupting. Literature published by Bjorn Zachrisson, DDS,MSD,PHD1
emphasizes the importance of treating crowded or
rotated teeth at an early age to improve stability.
Resolving the issues of crowding and constrictions in
the mixed dentition lessens the severity of the comprehensive orthodontic treatment during the permanent
dentition. Patients and parents are concerned with the
malaligned teeth. By addressing these concerns with
fixed appliances, you not only develop the arches and
make room for the permanent teeth, you individually
correct the position of the teeth for esthetics. With
removable appliances, it is not always possible to tip,
align and rotate the teeth to the esthetic level that both
you and the parent are hoping to obtain. Anteriorposterior or skeletal class II correction is not recommended in the mixed dentition.
As documented by Hans Pancherz, DDS, Odont.2 maintaining an anterior posterior correction in the mixed
dentition is difficult, if not impossible, due to the flat
plane occlusion of the primary teeth. In order to
maintain the correction, appliances will need to be
worn as a retainer until the permanent teeth erupt
allowing the dental intercuspation to retain the correction. Flared anteriors or class II division I cases can be
improved by tipping the maxillary teeth lingually for
esthetics and prevention of trauma while waiting for
the class II correction during the permanent dentition.
This conservative approach will allow you to resolve
the primary concerns within a reasonable treatment
time of 9-12 months. While correction of the dental
and skeletal class II malocclusion can be completed in
the mixed dentition, the treatment time can be excessive due to the retention phase necessary to maintain
the correction.
1. Journal of Orthodontics Volume XXXI Number 9 September 1997
2. Seminars in Orthodontics Volume 3 Number 4 December 1997
1.
2.
3.
4.
5.
6.
Band first permanent molars and place brackets on all primary teeth. Use cuspid brackets on the primary
cuspids and first and second premolar brackets on the first and second deciduous molars. Bracket
placement on primary teeth is not critical. Place brackets as gingival as possible.
Progress through routine archwire sequence of .0175, .016, .018 round.
Once you are up to the .018 archwire, introduce open coil spring where needed to gain sufficient space
or regain lost space.
Once you have gained adequate space, bracket the blocked out teeth & engage a flexible archwire such
as .0175 or .016 thermal and progress back through the archwire sequence of .016, .018 and .020.
Once the arches are developed and the crowding has been eliminated, place an upper hawley retainer and
a fixed lower lingual for retention. On the lower, place a fixed bonded lower lingual on the four permanent
incisors if there are no missing teeth. If there are missing teeth, or arch space to be maintained, place a
fixed lingual arch from permanent first molar to first molar, retaining the arch length and any spaces.
The upper retainer is worn for 6 months full time and can then be discontinued. The lower lingual arch
should be worn until the exfoliation of the primary teeth.
Step 1. Bracket the entire

dentition and use archwire
sequence.
Step 2. During the .018

archwire, introduce open
coil spring where teeth are
crowded or blocked.
Step 3. When you have gained

adequate space, bracket
blocked out teeth and place a
flexible wire to engage.
Step 4. Remove all

brackets &bands. Seat
retainers awaiting
eruption of permanent
teeth.
175
Option 5: #1058 Phase I Interceptive
176
Thomas Kelly
AGE: 8.9
07-05-91
# 1058
Beginning
Ceph
177
Option 5: #1058 Phase I Interceptive

Post Treatment
178
Option 5: #1058 Beginning of

Phase II Treatment
179
Thomas Kelly
AGE: 12.5
03-27-95
# 1058
Beginning of
Phase II Ceph
180
181
OPTION # 5:
PHASE I/INTERCEPTIVE MIXED DENTITION TREATMENT
If in the mixed dentition it is determined that there is insufficient space to accommodate the
eruption of permanent teeth, orthodontic intervention is appropriate. In the past, it was customary to deliver removable appliances such as a schwarz or cross-bite appliance for expansion. The recommended type of treatment is now with fixed appliances so that lost and
broken appliances are no longer a concern. With removable appliances, the outcome of your
treatment is dependent upon cooperation from the patient. If they dont wear the appliances,
nothing happens. With fixed therapy, you take control of the treatment and also you are able
to individually address tooth position rather than just expand the arches.
THOMAS KELLY CASE # 1058
TREATMENT SYNOPSIS
08-08-89
Bracketed all primary teeth and placed bands on all first molars. Archwire
sequence beginning with .0175 up to .018.
10-24-89
Placed open coil spring to make space for both upper laterals and lower left
lateral.
01-16-90
Placed brackets on blocked out teeth and passively engaged them into the
archwire. Progressed through the archwire sequence up to .020 to engage
blocked out teeth.
05-30-90
Removed bands and brackets and seated upper hawley and bonded lower
lingual.
ACTIVE TREATMENT TIME FOR PHASE I: 9 MONTHS
182
Treatment Summation
1. Establish the lower arch (level, align and rotate) to accept an .018 x .025 stainless archwire.
Before
Deep curve of Spee
Arch constrictions and rotations
Anterior irregularities
After
Curve of Spee leveled
Arch aligned and rotated
Anterior teeth leveled
183
Treatment Summation
2.
Use the Multi-Distalizing Arch (MDA) to move the maxillary four posterior teeth (molars and
premolars) to fit the lower four posterior teeth into Class I occlusion.
Before
Class II Occlusion
After
MDA to Establish Class I Occlusion
184
Treatment Summation
3. Retract the maxillary cuspids into a Class I relationship. Use .020 round archwire and
chain elastics for spacing of 3mm or less. Use .016 x .022 with pletcher springs to
retract cuspids more than 3 mm.
Before
Class II cuspid relationship
After
Cuspid retraction to Class I

185
Treatment Summation
4. Retract the maxillary anterior teeth if necessary using an .018 x .025 stainless
steel archwire with accentuating curve, pletcher springs to the posts, and Class
II elastics.
Before
Anterior overjet
After
Anterior retraction and final bite opening
186
Treatment Summation
5.
Rebracket any teeth as necessary to correct bracket placement errors. Place an .019 x .025
braided archwire. You should also do individual root torque as needed in this size wire.
Before
Paralleling/Axial bracket
placement error
Height placement error
After
Rebracketing to correct tip
Rebracketing to level
187
Treatment Summation
6.
Use posterior finishing elastics to lock in occlusion. Wear (1) 5/16 elastic as illustrated to
finalize the bite and add additional labial root torque to the posterior teeth.
Before Elastic Wear
After
Elastic
Wear
Occlusion Finalized
188
Comprehensive Orthodontic Treatment Sequencing

Diagnosis and Treatment Summation
(1)
Choose one of the treatment options to establish the lower arch to an .018 X .025 stain
less steel archwire.
(2)
Use the MDA appliance to fit the upper first and second premolars to the lower first and
second premolars and molars into ideal class I occlusion.
(3)
Retract the maxillary cuspids if necessary using .016 x .022 and pletcher springs to
cuspid hooks. For more than 3 mm of space closure, use pletcher springs. For less than 3
mm, use .020 round archwire and chain elastic to retract cuspids.
(4)
Retract anterior teeth if necessary using posted .018 x .025 with pletcher
springs,accentuated curve and class II elastics.
(5)
Rebracket any teeth as necessary and use .019 x .025 direct braid archwire.
(6)
While using the .019 x .025 direct braid archwire, place individual root torque as needed.
(7)
Use up and down posterior finishing elastics with segmental archwire in anteriors only to
lock in the posterior occlusion.
(8)
Seat upper hawley and bonded lower lingual, cuspid to cuspid.
189

03 Cephalometric Interpretation With Diagnosis and Treatment Planning

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03 Cephalometric Interpretation With Diagnosis and Treatment Planning

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Cephalometric Interpretation

with Diagnosis and Treatment

Straight Wire Concepts: Diagnosis & Technique

Attitude Toward Treatment:

LOWER FACIAL HEIGHT

Upper Incisor to Lower Incisor (angle)

Deciduous _______ Mixed _____ Permanent _____

Apexification of cuspids ________________________________

Missing Teeth: ___________________________________________

Soft Tissue Profile ________________________________________

Initial TMJ Evaluation: ___________

Right Deviation ________________________ mm

How much crowding cephalometrically? ____________________

Transcranial position of the condyle:

Which teeth need to be extracted? __________________________

Neutral _________ Clockwise ___________

Reverse Face Mask

Rapid Palatal Expansion

ENT Evaluation Advised _________________________________

Left Deviation _________________________ mm

Treatment Goals and Plan:

RGG Form 92/2

Straight Wire Concepts: Diagnosis & Technique

Caucasian Cephalometric Norms

Patients Chief Complaint: ________________________________________________________________________

ANB ________ Degrees WITS ____________ mm

DIAGNOSIS AND TREATMENT PLAN:

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

African American Cephalometric Norms

Patients Chief Complaint: ________________________________________________________________________

ANB ________ Degrees WITS ____________ mm

DIAGNOSIS AND TREATMENT PLAN:

Straight Wire Concepts: Diagnosis & Technique

Hispanic Cephalometric Norms

Patients Chief Complaint: ________________________________________________________________________

ANB ________ Degrees WITS ____________ mm

DIAGNOSIS AND TREATMENT PLAN:

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

Chinese Cephalometric Norms

Patients Chief Complaint: ________________________________________________________________________

ANB ________ Degrees WITS ____________ mm

DIAGNOSIS AND TREATMENT PLAN:

Straight Wire Concepts: Diagnosis & Technique

Japanese Cephalometric Norms

Patients Chief Complaint: ________________________________________________________________________

ANB ________ Degrees WITS ____________ mm

DIAGNOSIS AND TREATMENT PLAN:

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

The Case Against Early Extraction of Mandibular Primary Canines

continued on next page

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

The Case Against Early Extraction Of Mandibular Primary Canines

continued on next page

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

The Case Against Early Extraction Of Mandibular Primary Canines

T. M. Graber, Orthodontics: Principles and Practice, 3d ed. (Philadelphia, W. B. Saunders Co.,

Robert G. Gerety DDS - Produced by Kay C. Gerety

Straight Wire Concepts: Diagnosis & Technique

When to Begin Treatment

Deciduous _____ Mixed _ Permanent ___

Neutral _ Clockwise ___

ANB Degrees WITS ____ mm

ANB Degrees WITS ____ mm

ANB Degrees WITS ____ mm

ANB Degrees WITS ____ mm

ANB Degrees WITS ____ mm