Ricketts

September 9, 2016

Articles in Jones folder for this seminar:

● Articles 9
○ Perspectives in clinical application of cephalometrics- pg 1-35 (35)
[Ariana]
○ Planning treatment on basis of facial pattern and an estimate of its growth-
pg 37- 59 (23) [Jess]
● Articles 10
○ Evolution of diagnosis to computerized cephalometrics- pg 1-9 (9)
[Natalie]
○ An overview of computerized cephalometrics pg 9-36 (27) [Natalie]
● Articles 11
○ Foundation of cephalometrics communication- pg 1-26 (26) [Jess]
○ Cephalometric synthesis- pg 29-54 (26) [Anh]
○ Analysis- the interim- pg 56-64 (9) [Anh]

Notes

Perspectives in clinical application of cephalometrics [Ariana]

- Cephalometrics are still the standard of care for most orthodontists.
- Initially, non extraction practitioners didn’t like cephalometrics (apparently
this is super important, starred like 10 times). People also didnt like the
fact that 3d structures were being represented on a 2d xray.
- Different individuals started coming up with diff landmarks to trace.
(Tweed, Downs, etc) and soon the mandibular plane became a standard
reference point.The Northwest analysis was developed by Reidel and he
uses SNA, SNB etc.
- Because so many diff landmarks were identified - now they had to decide
which ones were meaningful and dependable for both patient description
and for treatment decisions/evaluation of growth and tx.
Ceph measurements allowed clinicians to talk to each other in a sophisticated and
meaningful manner
Studies were done to compare results of intraoral elastics versus extraoral cervical
appliances - then the cephs were superimposed and the changes/orthodontic
movements were clear to see.
Standard of minimum of 4 points for superimposition
Ceph can also help us predict treatment results. - term = “visualized treatment
objectives”
For descriptive purposes : Comprehensive Analysis
1) Locate, evaluate and assess areas of dysplasia
2) Identify areas treatable by conventional methods
3) Identify factors that would work against treatment.

Planning treatment on basis of facial pattern and an estimate of its growth [Jess]
● 50 treated class II cases were analyzed, and it was shown that similar
malocclusions treated identically responded in entirely different facial behaviors.
Three main factors explained these differences in behavior
○ 1) Changes in the cranial base (NSBa)
○ 2) Condyle movement (mostly forward but moved posteriorly in some
cases)
○ 3) Growth at the condyle (in amount and direction)-- most important factor
■ Upward and forward growth of the condyle = increased depth of
face (brachycephalic)
■ Upward and backward growth of the condyle = increased length of
face (dolichocephalic)
● Condylar axis = bisection of condylar neck connected to a point at the greatest
curvature of the antegonial depression
○ Growth of the condyle in the majority of cases followed this plane,
although great variation was observed
● Procedure for growth estimate
○ For growth estimation to work, the cranial plane (basion-nasion) is
employed for reference
○ 1) Projection of probable changes in basi-cranium (points N, S, Ba)
■ SN- expected to increase 1mm per year during pubertal growth
spurt
■ SBa length- expected to increase 3/4th as much as SN
○ 2) Pre-determining behavior of the TMJ
■ Construction of coronoid process
● Tip of coronoid is usually always 3mm forward of pterygo-
maxillary fissure (pre and post treatment)
● Pterygo-maxillary fissure drops down about 1mm during
treatment
○ 3) Determination of the mandibular growth
■ Length of body increases about 1.5mm/year during active growth
■ Condylar growth estimate
 ● Superimposing BaN and registering Ba will reveal the
prospective condylar position relative to basion after all
condylar factors have been considered
● 2mm growth in lengthening of condylar axis during age 7-9
yo
● 3-4mm growth during puberty
● This is the most difficult aspect to predict accurately
● Forward direction of condylar growth is consistent with lower
mandibular plane angles
● Backwards condylar inclinations usually result in higher
mandibular plane angles
○ 4) Interpretation of muscle characteristics
■ High mand plane angles, small gonial prominences, thin rami, and
short condyle heads → often display excessive opening of bite
during treatment (due to rotation of mandible)
■ Acute gonial angle, well-developed body, thick rami, well-formed
condyle heads → often resist bite opening
○ 5) Changes in position of maxilla
■ Basion-nasion plane superimposed on N rather than SN or FH
■ Vertical changes: 60% of total face height increase is credited to
denture area; 40% is allotted to upper face (which locates level of
ANS)
● In cases employing intermaxillary elastics and cervical
anchorage for a long period of time, a slight tipping down of
palatal plane is expected
■ Horizontal: SNA tends to remain constant to BaN-- therefore, point
A is dropped parallel with the beginning line NA
○ 6) Planning arrangement of teeth
■ During normal growth the cant of the occlusal plane will decrease
(drops faster in posterior than anterior); class II elastics works in
reverse of this
■ Place lower incisors 1mm forward of projected point A-Pog line and
at 22 degree angle
■ Upper incisors arranged ideally at 130 degrees to lower incisors
○ 7) Speculation of soft tissue
■ 2mm of growth of nose can be expected during orthodontic
treatment
■ Upper lip: 2-4mm increase in thickness can be expected in severely
protruding cases. 1-2mm increase in cases where upper incisors
are not going to be moved excessively
 ■ Lower lip: almost same thickness before & after treatment
● Esthetic considerations and treatment planning
○ Classification of facial patterns done using Downs’ ceph analysis; should
also consider soft tissue of nose, lips, and chin
○ Esthetic plane = line drawn between end of the nose and chin
■ Analysis of models on magazine covers showed lower lip is about
2mm posterior to this plane, and upper lip is about 4mm posterior to
this plane
○ Relationship of anterior teeth
■ Ideal lower incisor is inclined 22-23 degrees forward of the APo
plane and located 0-1mm anterior to it
■ Axial inclination < 16 degrees and > 28 degrees with positions of 3-
4mm+ posterior or 4mm+ anterior to the APo plane are undesirable
■ Interincisor relationship of 130 degrees is advisable to promote
stability and allow for uprighting with lateral vertical development
● Comments:
○ This procedure has been used for 4 years with accuracy in 90% of cases
○ This method of planning suggests that lingual root torque of upper central
incisors should require the utmost attention
○ Extractions were necessary in 35-40% of cases
○ Extremely important to have a definitive objective

Evolution of diagnosis to computerized cephalometrics [Natalie] Article 10 pg 1-9

**The gist:** This article talks about 5 different eras of orthodontic history and how the
goals and considerations in orthodontic treatment have evolved in each era.

1st Era: Pragmatism (up to 1875)

● 1st goal: Alignment
○ Alignment was the first ever goal of orthodontics.
○ It was done by expanding the arch with various appliances ex. Fauchard’s
“bandalette”, labial arch, screw/springs to push the teeth outwards
● 2nd goal: Arch relation
○ Arch relation: the need for approximation of arches to each other
○ Kinglsey came up with the idea of arch correction by bite-jumping
procedure

2nd Era: Empiricism (1875-1925)

● By the mid 1800s, plaster models and Angle’s classification of malocclusion
were developed.
 ● In this era, treatment planning centered on molar occlusion
○ Diagnosis was made from the upper molar because it was hypothesized
that this tooth was the least variable and the most stable and reliable.
● The role of hereditary and environmental factors started to be considered more
by orthodontists
● 3rd goal: Functional equilibrium
○ Muscle action and functional realm became an added dimension in
orthodontics and orthodontics became a specialty.
● 4th goal: Esthetic equilibrium
○ Esthetics was considered in addition to function
○ Edward H. Angle - advocated for preserving a full complete set of teeth
○ Calvin Case – concluded that bimax protrusions exist and that interests of
esthetics were best served by judicious extraction of teeth in patients with
delicate structure, large teeth, or tight, limited musculature

3rd Era: Experimentation (1925-1950)

● In this era, all three major diagnostic criteria (orthopedics, growth and surgical
application) became significant through the tool of cephalometrics
● 5th goal: Orthopedic jaw relation
○ Orthopedic jaw relations were recognized and orthodontists began to
consider basal bone relationships
○ Orthodontists used a technique called gnathostatic orientation to orient
casts as observed in nature. This technique revealed the cant of the teeth
in relation to the Frankfort plane and disclosed abnormal skeletal
relationships
○ X-ray was used to describe orthopedic relation of the jaws and facial
typing became a consideration in diagnosis
● 6th goal: Growth utilization
○ Although proposed primarily for the study of growth, the cephalometric x-
ray became useful for morphologic and functional diagnosis.
○ However, orthodontists continued to correct the malocclusion to the
existing morphology of the patient because of various beliefs:
● Brodie’s original findings suggested an orderliness to growth and stability of the
growth pattern.
● Treatment was thought to be limited to alveolar bone
● Tweed brought in patients who were treated earlier and were disappointed with
the relapses.
● Tweed focused the diagnosis on the lower incisor and concluded that it should be
placed directly over the bone of the symphysis. He believed that diagnosis must
include the lower incisor as a starting point
 ● 7th goal: Surgical application
○ Effect of surgery related to orthodontics or problems of occlusion were
considered
○ The growth of the maxilla was suggested to be altered following cleft
palate surgery so the kind and extent of surgery became a factor in
diagnosis.

4th Era: Scientific theory (1950-1965)

● 8th goal: Occlusion and temporomandibular joint
○ Orthodontists were pressured to finish cases in much finer details than
before due to breakthroughs in dentistry – new impression materials, bite
registrations, investigation of the posture of the condyle in the fossa, etc.
○ Brodie recognized the contributions of the teeth to the entire kinetic chain
of the posture of the head and teeth were studied in all three planes of
space
○ Diagnosis was expanded to analysis of the muscle and neuromuscular
systems
○ Lip function was recognized to be related to problems in bite function
● 9th goal: Environmental control
○ Although heredity was regarded as the most important factor in etiology,
environment was also seen as an etiologic factor
○ Things such as respiratory tract, oral hygiene, diet, habits, tongue and lip
function became an important diagnostic consideration
○ Mandibular posture and chewing patterns also became significant
● 10th goal: Critical prognosis
○ This era emphasized elements of critical prognosis, which meant having
an extensive and complete diagnosis as a basis
○ Details were added to ceph analysis: cranial base, cervical vertebrae,
glenoid fossa, functional dynamics of the mandible, and soft tissues in
speech, breathing and deglutition.
○ Cephalometric films of patients treated with extraoral traction began to
suggest skeletal changes in the midface which were beyond the usual

5th Era: Cybercultural communication (1965-present)

● 11th goal: Diagnostic feedback
○ Advances in cybercultural communication are changing dentistry
○ Information is gained through cooperation of orthodontists and general
dentists all over the world
● 12th goal: Biologic perspective
○ Man live now in a period of total involvement and instant communication
An overview of computerized cephalometrics pg 9-36 (27) [Natalie] Article 10 pg 9-36

Uses of cephalometrics and why it’s important:

● Gross inspection: cephs can be used to inspect the 3 “Ps”: physical morphology,
pathologic phenomenon, and physiologic conditions
● Description: cephs can be used for measurement and description of 4 “Cs” of
cephalometric analysis
○ Characterization or description comes
○ Comparison of one individual to another
○ Classification of factors
○ Communication of anatomical problems
● Growth and treatment: cephs can be used to record and measure change
● Planning ahead: cephs can be used for treatment planning

Setting objectives in planning with cephalometrics:

● Occlusion is the primary objective of orthodontics but functional and esthetic
equilibrium must be realized
● Orthodontists should consider the orthopedic factors such as:
○ Natural growth of the mandible
○ The extent to which alteration of basal upper jaw structure is possible
● Need to differentiate whether a problem can be corrected by growth or whether
it’ll require moving teeth mechanically.
● Contemporary treatment planning should include:
○ Visualized estimate of natural growth
○ Proposed orthopedic change
○ Tooth movement and soft-tissue behavior

Sequential order of using cephalometrics for comprehensive description:

● Nature of malocclusion itself
● Relationship of the jaws in 3 dimensions
● Relation of denture to skeletal balance or the position of denture reciprocally in
the skeleton
● Esthetic problems
● Determination of the jaw most at fault
● Morphological causes of a facial disharmony

Some things to note about ceph measurements:

● Certain measured values in cephalometrics change with age. Other values that
are a function of form rather than size do not change with age.
 ● Different values may be needed for different sexes
● Measurements need to be individualized to the specific ethnicity

In the ancient days, orthodontists sent off their film cephs to a “service organization” to
get traced with a computer. After sending them off, they would receive back:
● The original films
● Tracings of the films (in black)
● A growth forecast (in red) and a growth and treatment projection (green)
● Printout sheets of the measurements
● Summary analysis sheet
● Analysis of the forecast showing the needed soft tissue change and change in
mandible, maxilla and the upper/lower incisors

Cephs can be used for

1. Treatment planning
2. Patient education
3. Monitoring treatment and results
4. Research

Foundation of cephalometrics communication [Jess]

● Purpose of article is to inform orthodontist of the value of cephalometrics
● Ceph tracing technique first described in 1931, but analysis of treated cases
started in 1938
● You can not know how to treat a case until you know what you are treating-- so
cephs must come first in order to establish references for communication of
problems
● Cephalic = pertains to the head; metric = measurement. So cephalometric =
head measurement with the x-ray
● Analysis is objective; it is determined by emphasis on the characteristics of an
object rather than the thoughts/feelings of the operator
● Ceph analysis can be used to describe, compare, classify, and communicate the
nature of orthodontic problems
● Treatment planning with cephs is described as synthesis (means to combine)--
because need to consider how isolated parts contribute to the whole (e.g. how
growth of mandible will affect the face)
● During treatment planning growth is of primary importance
● Growth and changes in soft tissues of the nose & chin are important for harmony
in beauty & function
● He uses 15 points of reference. From this 5 measurements were designed to
provide a sensible method of informing the orthodontist of facial form & denture
position
○ Data comes from 1,000 consecutive cases with a “usual” orthodontic
problem
○ 1) Indicator of facial depth = facial angle
■ Formed via intersection of Frankfort horizontal with facial plane
■ Frankfort horizontal is almost parallel to earth and serves as a
valuable yardstick for the horizontal posture of the head
■ Mean = 85.4 degrees
● < 81 = retrognathic
● > 89 = prognathic
■ Angle is indication of the depth of the chin to craniofacial references
(i.e. protrusive or retrusive chin)
■ Angle increases with growth
○ 2) Indicator of facial height = XY axis
■ Formed by crossing basion-nasion (cranial plane) with the Y axis
(SGN)
■ Helps describe forward or backward divergent faces; and when
combined with facial angle, the chin can be rather critically located
■ Mean = 3 degrees
● >6 indicates short face or prognathic chin (>8-9 = short face
with close-bite tendency)
● < 0 indicates long face (open-bite or retrognathic tendency)
○ 3) Indicator of facial contour = Point A to Facial plane
■ Point A = anterior limit of true basal bone of maxilla
■ Mean = 4.1mm
● ⋜ 2mm = straight
● 3-6mm = moderately convex or concave
● 10mm+ = severely convex or concave
■ Adults have straighter faces than children
■ Not all facial convexity should be condemned (some classically
beautiful faces are bimax protrusive)
○ 4) Indicator of denture position = Point A to Pogonion plane
■ Pogonion = anterior limit of basal bone in mandible
■ Incisal tips are measured to line connecting Point A to Pog
● Ricketts considers this the most revealing measurement to
the orthodontist in the entire analysis
● Line connecting Point A to Pog = denture plane
■ Lower incisors to APo plane
 ● Mean distance = lower incisal tip 0.5mm anterior to APo
plane
● Mean angulation (lower incisor long axis to APo plane) =
20.5 degrees
● Lower incisors maintained constant relationship with APo
plane with age-- so as convexity decreased with age, lower
incisors became more upright/retracted
■ Upper incisors to APo plane
● Mean = 5.7mm
○ 5) Indicator of facial esthetics & lip abnormality = Esthetic plane
■ Esthetic plane = line from tip of nose to end of chin
■ Lips relative to this line
● Lower lip = 0.3mm ahead of line
● Upper lip = 0.7mm behind line
● This value becomes more negative with age
■ Functional abnormalities of lips
● 1) Lip atrophy (shortness of lip)
○ Can be combined with tongue thrust and open bite; lip
not strong enough to oppose thrusting tongue and lips
break apart and fall above plane of occlusion
○ Patient will have a large amount of gingival display
● 2) Lip strain (result of stretching soft tissues over protrusive
teeth)
○ Causes furrowing of levator anguli oris and wrinkles in
the cheeks when the lips are closed
● 3) Mentalis habit
○ Usually a compensation for either protruding teeth or
severely long faces
○ Chin elevated in an attempt to gain lip closure
○ Get "balling up" of tissue in area just anterior to roots
of lower incisors
○ This is severe manifestation of lip strain
● 4) Lip sucking/biting
○ See lower lip completely under upper incisor
○ Can be either a habit or swallowing reflex
● 5) Sublabial contraction
○ Identified as a furrow below the lower lip resulting
from a gripping action of orbicularis oris and
buccinator --> retraction of lower incisors, crowding of
lower incisors, and "button" appearance of chin
 ○ Often associated with class II, div II (retrusion of U
incisors and severe deep bite)
○ Indicator of facial width-- he ended up eliminating this for routine use
■ Can be done via subjective viewing of frontal headfilm, or by
interpreting facial angle & XY axis
■ Short, prognathic faces (chin upward & forward) = broad,
brachycephalic face
■ Long, retrognathic face (chin downard & backward) = high
mandibular plane angle and narrow, pointed chin
● Craniofacial analysis (deep structural considerations)
○ Divided into three aspects:
■ 1) cranial base
● Angulation of cranial base measured by angle N-S-Ba
(mean = 129.6 degrees)
● SGnN angle used to represent proportionate length of the
anterior cranial base (mean = 35 degrees)
○ < 35 = short anterior cranial base
○ >35 = long anterior cranial base
■ 2) tempromandibular
● SBa plane was bisected to yield point called SOR (spheno-
occipital reference), which is indicator of condyle and/or
fossa position
● Working condyle axis created by a point in the center of the
condylar head and a point bisecting the condylar neck; this
usually crossed the border of the mandible near the
antegonial depression. This line tended to the be the growth
axis of the mandibular condyle
■ 3) nasopharyngeal
● Discussed in other publications

Cephalometric synthesis [Anh]

❖ TL;DR: do not leave growth prediction to

chance in order to attain the best orthodontic
results possible - in treatment planning,
orthodontists should use cephalometric data to
help attain a more accurate estimate
➢ Static synthesis is used for cases
where growth is not expected
 ■ In these cases, a formula for tooth arrangement can be derived
based on local and environmental factors
■ The APog plane is the reference plane most useful for the
application of this formula
➢ Dynamic synthesis is used for cases where growth is expected
❖ Regarding relative positioning of teeth and changes during treatment:
➢ The lower incisor should be placed within +/- 1.0mm of the APog plane
■ The upper incisor is positioned relative to the lower incisor (around
140 degrees to, and 130 degrees in mixed dentition cases to allow
for later uprighting with growth)
➢ The lower arch tends to move forward 3-4mm during “ordinary” Class II
treatment, and the lip thickens slightly following retraction of upper incisors
❖ Research from the Dark and Stone Ages has indicated that the mandible is the
most important determinant of facial morphology. For this reason, in estimating
facial changes, the future of the mandible should be the primary concern.
➢ We should also consider, to a lesser extent, changes in the middle face
❖ Estimation procedures can be classified as short-estimation (<24 months) or
long-estimation (>24 months)
➢ The procedure for short-estimation cases are as follows:
■ 1) Establish cranial reference points
● SN growth is an example of an important reference line
◆ SN line increases in length by 1mm/year at the pre-
pubertal age
■ 2) Prognose behavior of the chin
● Measured by increase in length of Y-axis from S and its
change in direction from SN plane
● Average case shows a 1 degree change, but can be as
much as 5 degrees
● Technique for anticipating chin change:
◆ 1) Taking into consideration shape, size, form of the
mandible
◆ 2) Evaluating facial pattern
◆ 3) Planning treatment results
◆ 4) Changing direction of growth on Y-axis
◆ 5) Growing chin by lengthening Y-axis
■ 3) Estimate changes in maxilla
● A point changes significantly during treatment
● Earlier treatment results in greater change in profile
● Technique for estimating behavior of point A is as follows:
 ◆ 1) “Divide the increase in facial height roughly into
thirds. Lower palatal plane from SN line about one-
third of the total height increase… Tip palatal plane.”
◆ 2) Modify depth of point A following the listed factors
(torque, anchorage, elastics, etc)
■ 4) Set up the teeth cephalometrically
● Mentally align the incisors (please see beginning of
summary)
● Estimate the change needed in the lower molar
◆ Without arch length problem, will erupt normally
◆ In extraction cases requiring space closure, the lower
molar will move forward about 4mm without retention
● Estimate the change needed in the upper molar
◆ “Can thus be seen by simply arranging the upper
molar in Class I occlusion or as desired…” (???)
◆ In Class II cases, holding the upper molar in original
position will produce correction if growth is great
enough
■ 5) Change soft tissues of profile
● End of nose is advanced away from ANS in the setup about
1mm per year in the mixed dentition in both sexes
● You can anticipate almost no change in contour of upper lip
if the upper incisor does not move or if there is no growth
● Lower lip thickens very little, but will curl backwards or
forwards depending on positioning of lower incisors
● Increase in chin tissue will occur if mentalis strain is resolved
● Greatest noticeable alteration is in the sublabial area, as
denoted by the root position of the lower incisor

Analysis- the interim [Anh]

❖ TL;DR: there is much controversy

surrounding cephalometric points, and no
one can agree on anything. However, the
author believes that the Downs Analysis
“is the best solution for orthopedic
registration, despite its problems.”
❖ Downs divided his analysis into the
bony structure of the face, within its
 housing, and description of the dentition. He also gave classification to facial
types.
➢ The author expresses his opinion that Downs’ Analysis was mocked by
proponents of non-extraction treatments. People dismissed
cephalometrics because of their personal beliefs, and not their
professional qualifications.
➢ At the same time, the author believes that cephalometrics should be used
a guide rather than a manual
■ - “Treat the patient, not the numbers!”
■ The normal must be a guide but a successful case must be the
standard
❖ Two major problems in teaching cephalometrics:
➢ 1) Technique (e.g. equipment selection, exposure factors, patient
positioning, film processing)
➢ 2) Interpretation
❖ Five major ways in which cephalometrics can be used:
➢ 1) Gaining insight into physiologic and biologic structures
➢ 2) Evaluation of soft tissues
➢ 3) Pinpointing of specific anatomical locations and areas
➢ 4) Evaluating serial growth and treatment
➢ 5) Prediction
❖ Real significance of cephalometrics is to apply the information derived from
findings on a clinical basis, including three practical areas:
➢ 1) Morphologic descriptions of the cranium and face
■ Description of bony profile contour can be used to relate tooth
positions and locations
➢ 2) Natural growth impulses and developmental characteristics in absence
of treatment
➢ 3) Changes in structure and relationships made possible by the presence
of treatment
❖ Changes in Y-axis by change in growth direction of the mandible or by muscular
kinesiological changes produce significant changes at the occlusal level