Color Atlas of Dental Medicine

Editors: Klaus H. Rateitschak and Herbert F. Wolf

Orthodontic
Dia osis
Thomas Rakosi
Irmtrud Jonas
Thomas M. Graber

Foreword by Robert E. Moyers

1001 illustrations, most in color

1993
Georg Thieme Verlag, Stuttzar' · - ,.,., .a.vrK
Thieme Medical Publishers mc., New York
VI

Table of Contents

V Foreword
VIII Preface

Fundamental Principles
3 Relevance of Diagnosis 35 Classification of Malpositlon - Nomenclature
4 Comprehensive Diagnosis 35 Malpos111on ol lndiv1dual Teelh
5 Diagnostic Process 37 Malpos111ons ot Groups of Teelh
45 Malocclusion
6 Growth of the Craniofacial Skeleton 47 Over1el
8 lntramembranous ossmcauon 51 Evaluabng lhe Occlusion
10 Enchondral Ossincauon
13 GrOWlh Mechanisms 57 Etiology of Malocclusion
14 Endosleal and Penosteal GrOW1h 59 Causes of Malocclusion
15 Corucal Dnll 60 Hered1lary Abnormahlles
17 Relocauon and Remodeling 60 Neuromuscular System
19 The "\!" Pnnc1ple 61 Dentition
20 Surface Pnnc1ple 70 Bones
21 Growth Fields 72 Skeletal Maloccius1on
22 Displacemenl 14 Soll Tissues
23 GrOW1h Processes 75 Acquired Anomalies
23 Max~lary Growth 75 Developmental Damage
24 Mandibular GrOWlh 77 Trauma
26 GrOWlh of the M1dface 80 Physical Factors
28 GrOWlh Equivalents 82 Premature Loss ol Deciduous Teelh
29 Growih-Conlrolhng Fact0<s 83 Breathing
30 Local Factors Concerning Craruotacial Morphogenesis 85 Bad Habits - Orolac1al Dysfuncllon
31 Factors Influencing Endochondral ossucauoo 88 Diseases
31 Faclors Influencing 1n1tamembranous Ossmcanon
32 Degree lo Which lhe GrOWlh Processes Can Be
Influenced
33 Mechanism of lhe Functional Matrices

Diagnostic Procedures

93 Case History 116 Tongue

95 tnterpretauon of the Case History 117 Lip and Cheek Frena
96 Questionnaire - Case History 118 G1ng1va
120 Palatal Mucosa and Palaia! Vault
97 Clinical Examination 121 Clinical Exarmnanon ol lhe Den11t1on
97 General Slate 122 Cnmcal Exarmnanon - Record Sheel
98 Denial Age
102 B1olog1cal Age and Hand Rad1ograph 123 Functional Analysis
123 Exam1na11on of the Refauonsh1p: Postural Resl Pos1hon -
108 Special Clinical Examination Habitual Occlusion
108 Cephalic and Facial Exammauon 123 De1erm1na11on of lhe Poslural Rest Position
11o Exammatton ol lhe Solt Tissues 126 Reg1slra11on of the Rest Posinon
110 Forehead 128 Evaluation of the Relalionsh1p between Rest Posruon
111 Nose and Habitual Oceluston
112 uos 128 Evaluallon m lhe Sag11tal Plane
114 Chm
 Table of Contents VJI

132 Evaluation ol lhe Relahonsh1p belween Rest Post- 194 Rota11on of the Maxillary ease
hon and Hab11ual Occlusion in lhe Vertical Plane 196 Combinations of Max1llaiy and Mandibular Rotalton
133 Evaluanon of the Relahonsh1p belween Rest Posi- 198 Analysis of Incisor Position
tion and Habuual Occlusion in lhe Transverse Plane 200 Rad1ograph1c ceonaiomemc Ctassiticanon of
135 Examina11on of the Temporomandibutar Jomt Malocclusions
135 Clln1cal Examinahon 204 Cephalometnc Radiography - Prognostic Assessment
138 Opening and Closing Movements of lhe Mandible 205 Record Sheet - Rad1ograph1c Cephalometnc Analysis
140 Temporornancnbutar Joml - Radiographic Examination (Lateral Rad1ograph)
141 Examination of Orofaaal Oysfunc1ions
141 Swallowing 207 51udy Cast Analysis
145 Tongue-Thrust 208 Metric Analysis ol Arch Form
155 L!p Dysfunctions 208 Denial Arch W1dlh
158 Cheek Dysfunclions 211 Anlenor Denial Arch Length
159 Hyperacov11yof Menlahs Muscle 213 lnlramaxillary Symmetry
165 Functional Analysis - Record Shee1 214 Analysis of Transverse Symmetry
216 Analysis of Anteropostenor Symme1ry
167 Radiologic Examination 218 Palatal Height
167 Dental Condition 219 Analysis of Supporting Zones
220 Pred1ct1onfrom Proport1onalily Tables
173 Photographic Analysis 221 Combined Rad1olog1c-Pred1c1JonTable Method
173 Profile View 222 Space Analysis in lhe Permanent Den1111on
176 Faetal D1Vergenoe 222 Space Analysis, According to NANCE
177 Frontal View 223 Space Analysis, Accordrng to LUNDSTROM
224 Discrepancy Calculation
179 Cephalometric Analysis of the Lateral Radiograph 2.27 Analysis rn lhe Vertical Plane
180 Cephalometnc Reference Points 228 SOLTON Analysts
182 Cephalometnc Reference L!nes 231 Analysis of the Apical Base, According 10 REES
184 Interpretation ol Cephalometnc Measurements 232 Exarmnanon ol Occlusion
186 linear Analysis of Jaw Bases 234 Record Sheet - Three-dunensronat Analysis 01 the
188 Analysis ol Jhe Skeletal Facial Prohle Denut1on
190 Vertical Analysis ol Jhe Facial Skeleton
192 Growth Direction - Rotauon of the Mandible 235 Treatment Plan

Treatment Planning- Case Examples

'
238 Trealment Planning Case Example 1
244 Treatment Planning Case Example 2
250 Treatment Planning Case Example 3

Appendix
258 Record Sheets
264 Acknowledgments
265 References
269 Index
 Diagnosis - Relevance 3

Relevance of Diagnosis

Diagnosis: The recognition and systematic designation of anomalies: the practical synthesis of the
findings, permitting therapy to be planned and indication to be determined, thereby enabling the
doctor to act.

Recognizing the problem

~
Formulating the problem

Carrying out the necessary

examinations

t
Interpretation of the results

~
Diagnosis

Numerous observations, individual findings and analyses, which allow a broad-based decision to be
made for the particular patient, are a prerequisite for a correct diagnosis in orthodontics.
The informations must be objective, relevant, and accurate. The diagnostic criteria should include
the entire orofacial system, yet should also be selective. Certain normseie required for diagnostics.
i.e. for the assessment of abnormalities of the stornatognathic system. Comparing to an ideal norm
(e.g. eugnathia) or statistically determined mean values (e.g. Pont index) is unrealistic. Personal, indi-
vidual norms do exist for each case which take into account the individual development oft he rnasti-
catory system (the "individual optimum" according to Andresen, 1931). Analyzing the individual
data systematically enables diagnosis to be carried out according to type. Grouping the cases
together results in larger groups, so-called typical anomalies, which can be divided into further
classifications. Atypical anomalies also exist, so-called borderline cases, which depend in their type
and number on the respective methods of considering the case and its classification.
4 Diagnosis - Relev..:. :a=n-=-=c=-=e=---------
Comprehensive Diagnosis
Nowadays. orthodontic diagnosis should be routinely
based on various methods of examination (Fig. I). TI1e
synthesis of these various individual findings deter-
mines the orthodontic diagnosis. TI1e individual results
must be checked prior to evaluation to ensure that
sufficient examinations have been carried out. and that
the most relevant examinations were included. and not
simply that an immense volume ofdata has been collect-
ed without having included the most relevant details.
The comprehensive diagnosis should be a summary
of'the rnost important factsand should not take insigni:fi-
cant secondary symptoms into accoum, as they are of no
relevance to the treatment, The more experienced the
orthodontist is. the quicker he or she will recognize the
problem, select the appropriate examinations for the
case. and make optimum use of ii.
Certain discussions as 10 whether the etiological.
clinical, functional, or radiographical aspects should
be considered most important for the diagnosis are
unwarranted. However, in some cases furtherexarnina-
tion methods may be required. For example, cinemato-
graphic or palatographic registrations should only be

1 Essential orthodontic
examinations
The seven d1tteren1 anal)'11cal lech·
mques are all of lhe same relev·
ance 10< ot1hodont1c d1a9nOS1S.
Pnor to carrying out lu~her
examrnallons, lhe nrne and ettoo
required sho<Jld be compared to
Ille possible therapeutic conse
queoces.
Even rn adult cases, where more
elabora!e diagnostic exammauons
are necessary. lhe ume and ettoo
reqw1ed must be retauve to the
p(lSSlble resuhs.

Srudycas1
anatysis
-

carried out in exceptional cases for a detailed investiga-
tion of specific problems.
Computer analysis has also been employed for
orthodontic diagnostics over the past few years. TI1e
computer enables quick and accurate evaluation of the
individual findings. It can correlate the various data and
indicate a particular problem. However, the computer
cannot make a diagnosis. The practitioner must still
interpret and synthesize the data determined by elec-
tronic means and plan the therapy. The so-called
computer diagnosis often includes a preprogrammed
decision which usually leads to standardization or the
treatment methods and results in stagnation in one's
speciality.
The causes of incorrect diagnoses are usually in-
sufficient informations or prejudiced decisions made in
order to adapt the case to a particular type oftrearment.
 Diagnostic Process 5

Diagnostic Process
Orthodontic diagnosis can be referred to as a diagnostic actions during the course of treatment, this initial
process (Fig. 2). diagnosis must be reviewed regularly. While doing so,
The diagnostic procedure commences with the initial the various data obtained during the initial diagnosis
examination. during which a large number of individual must be checked selectively 10 ensure that they are still
lindings and analyses of the etiology and particulars of relevant. The objective of regular examinations is to
the malocclusion are clarified by means of synthesis. reassess the initially defined therapeutic methods and Lo
The objective is to describe the morphological and func- establish whether further procedures are necessary or
tional characteristics of the case. using certain terms. whether the treatment plan should be changed. This is
and to provide a prognosis of the anomaly. i.e. a forecast called continuing diagnosis. The main objective of the
about the future development of the deformity. final check-up is to assess the stability of the treatment
Due to possible unexpected developments and re- results.
2 Diagnostic processfor
orthodont
ics - general course
of treatment
Once 1he on11ial diagnosis and
probable prognosis haV1l oeeo
established, the nooessuylor treat-
Orthodontic Diagnostic Process
meru and the plan of treaunentare
discussed at length with the pat-
Initial d.agnosis 1enl The degree of mo!rVation and
future compliance of the 0011ent
Ellology - De11nn1naaonol 91e ......,..iy -
~aflhe__,,aiy should be assessed and, when
children are being irealed. dts·

•
OlaQ001l11Pfogir-oell
cussed with !he parents.

Al !he begmrnng of the therapy

lhe ent11e course of treatment -
mltuonced by the gr0W1h pro-
' cesses - usually cannot be predict·
lnit.al therapy ed exaclly.
Aller each phase ol ueaimere,
the cnmcan muSI check 1tlat the
lherapy is correcl, thus, 11 neces·
sarv, enabling the course of 1rea1-
men1 to be ad1usted 1n good lime
ConlJnulng diagnosls The d1agnos11c process IS not

All••-•ntof: .............
UnPldciteble
°' __
dlu•IOllCM'Rll
complele until the trealmenl has
been hnahzed

I
lldlllm clegril01l1 'P1Q9Mlll1

Therapy

Ad;ust11ttml Temunation COnllnueaon

Final dlagnosi.S

AllllllT •ot .......

8' taw
atlNll ...
I
AMI clegMI 111
Growth of the Craniofacial Skeleton

• Bone formation
• Growth mechanisms
• Growth-controlling factors
• Possibilities of influencing growth mechanisms

Various aspects of the growth mechanisms are significant when assessing the etiology of
malocclusions and the possible methods of treatment. The development of the craniofacial
structures is not merely a symmetrical expansion of the outer bone contours (Fig. 3), but is based on
three different growth mechanisms: Increase in size, bone remodeling. and bone displacement,

3 Misconceptions about bone

growth
Bone grow1h JS nol based oo svm
melncal enlargement ol all SltUC·
tures and surfaces. i.e an adult's
mandible does not conespond 10
the photographic enlargementol a
child's mandible. as illustrated.
Bone is sub1ectect to a complex
remodeling process which simul-
ianeously takes place with In·
crease in 512e and attccts all sec·
tJOns ol 1he structure (according 10
Ten ca1e. 19801.
•

Unlike soil tissue, bone is a mineralized substance and
cannot grow by means of interstitial enlargement but
only by apposition of the outer. periosteal. and inner.
endosteal surfaces.
Deposition and resorption take place simultaneously
on the opposing bone surfaces. i.e. the outer and
concurrently the inner cortical plates respectively. The
deposition on the one side and the resorption of the
other side not only causes an increase in proportions but
also displaces the bone. New bone formation is closely
associated with the bone remodelingprocess during the
entire growth period. The two mechanisms must be
combined in order 10 ensure a well-balanced increase in
dimensions of the bone structures whiles maintaining
their shape and proportions. The third principle which
applies to facial growth is bone displacemem. and is
based on the process by which adjacent bones move
away from one another, where they are connected by
articular joints (sutures. synchondroses, condyles), due
to their increasing size.
The various growth mechanisms of the facial
skeleton are governed and influenced by endogenous
and exogenous factors. respectively. during the entire
development period.
 Theories 7
Mandibular growth

4 Various stages of
mandibulargrowth super·
Imposed on the condylar
region
Radiograms ol 1he mandibles al a
newborn baby, a5-year-<Jldandan
adult supenmposed on one an-
other. The anterior displacement of
1he mandible. whch takes place
durrng developmen~ 1s qul!e ap-
parent
The movement isdirectedS>muf.
1aneously forward and downward

5 Macerated mandibl..,. of a
neonate, a S...year-ofd and an
adult
Growth is consoderabty fas1er du•-
ing the early POStnalaJ penod than
dunng adolescence. The raoo-
grams of Ille bones shown m ins
1llustra1Jon are suf)ehmposed on
one anolher in Figs. d and 6.

6 Various stages of
mandibular growth super·
imposed on the gonial region
Due 10 the dive<g1ng growth d11ec-
11on of the 1wo rarm, most of 111e
uansverse developmem at lhe
mandible takes place ma posWior
d1rect1on The1ncrease1nw1dthan~
1er10<ly is m1n1mal. Supeflmposil1g
1he different mandibles shows the
regional remodehng processes
which take place parallel to lhe
increase 1n propof11ons.

•
8 Growth

lntramembran
ous Ossification
Intrarnernbranous ossification applies to two types of
bone:
- Bundle bone
- Lamellar bone
Bundle bone develops directly in uncalcified connec-
tive tissue. Osteoblasts. differentiating from the mesen-
chyme. excrete an intercellular substance containing
collagen fibrils. This osteoid matrix calcifies by depos-
iting apatite crystals. These centers of primary ossifica-
tion exhibit only minimal calcification density. The
apatite deposit is mostly irregular and exhibits a net-type
structure in both the cortical and medullar areas (Fig. 7).
Mineralization takes place very rapidly (several ten
thousandths of a millimeter per day) and can occur
simultaneously over a large area. Apatite deposition
increases with time(Fig. 8). The bone tissue is only then
considered "mature ., when the crystals are arranged in
the same direction as the collagen fibrils. The bone
tissue separates into outer cortices and a medullar area.
which is then dissolved by resorption; this process takes
place parallel to the advancing bone formation. The
surrounding connective tissue differentiates into perios-

lntramembranous ossification

7 1st phase
Depcs11JOOofapatrteontheconnec-
t1ve tJSSUe matnx. This results in a
1hree-d1menslonal netwolk ol
loose-packed bundle bone.
The m1netahzed tissue partrcles
lfuorescense yellOW under the
microscope creimcyct1ne su11nrng,
ttuoresceoce with blue hghl excita-
llonJ.

8 2nd phase
Deposits of lamellar bone (yellow)
on the spicules of bundle bone
(orange) The resuh1ng bOOo is
more comoact, Either a CO<t1cal
bone or trabecYlar bone rs formed
oependrng on the localization (v11a1
sta1mng, lluorescence W1th blue
tight exc11auon).

9 3rd phase
PerlOSleally denved cortex com-
posed of bundle bone.
The penosteal, radrating sp•
cules of bundle bone can be seen
on rhe extnnor Lt 1s quite aoparent
thal me bone deposited first is
th1cl<er (vital Slaming, fluorescence
wilh blue hght exc1tat100).

reum. Ifs inner layer is rich in cells. has an osreogenic
function and contributes to the formation of the thicker
sections of bone (Fig. 9) as wen as the endosteum.
BUI1dle bone which. in adults, is usually only formed
during rapid bone remodeling, is often only a prelimi-
nary type of ossification. II is reinforced by lamellar
bone.
Unlike bundle bone formation, Iamellar bone devel-
opment only takes place in a mineralized matrix (e.g.
calcified cartilage or bundle bone spicuJae). The mesh
in the bundle bone is filled to reinforce it. until compact
bone is formed. Osteoblast formations appear on the
mineralized matrix, which then form circles and
Ossification 9
surround the intercellular substance around a central
vessel in several layers (Haversian system or osteon)
(Figs. LO, 11). l..amellar bone is formed at a rate or
0.7-1.5 microns per day (Fig. 12). The tissue exhibits a
complicated arrangement of fibers. which is respon-
sible for its mechanical properties (Pauwels, 1965). The
arrangement of the apatite in the concentric layers of
fibrils meets the functional requirements.
Larnellar bones are subject 10 continual deposition
and resorption which can be influenced by environ-
mental factors, for example, orthodontic treatment.
lamellar bone formation
10 Formation of primary
osteons
The lrabeculae al bundle bone Iha!
ate deposiled penOSleally llim
1ogell>er to torm canals. which are
hned w1lh osteoblasts These are
then narrowed down to !he lumen
ol 1he blood vessels by ceoceomc
deoosnion al lamellar bone.
11 Migration of primary
osteons
The pnmary osteons dnh deeper
due to lurther surface deposmon ot
bone (calce1n sta1nm9; lluores-
cence w11h blue hghl e..c11a1oon1
12 Conversion to Haversian
syst&ms
Whtie bOne grOWlh 1s conhnumg.
the pnmary osteons. which have
drifted deeper, are being filled
even more.
Further layern ot lamenar bone
are deposued on lhe surface at !he
same lime (v1181 s1a1ning; nuores-
cence with blue bgtit excnanoo).
10 Growth

Enchondral Ossification
During enchondral ossification, tissue which is 10
become bone is first formed in cartilage and. apart from
around the join Ls and epiphyses, is surrounded by pcri-
chondriurn which later forms the periosteurn. Osteo-
genesis is based on cartilage ossifying 10 bone. Regard-
less of which material existed previously (connective
tissue or cartilage). the actual bone formation process
always takes place according to the same principle(refer
to section "Intramembranous Ossification").
Depending on the locality of the mineralization. ii
can be differentiated between:
- Perichondral ossification
- Endochondral ossification
Both types play a role in the ossification of long bones
whereas only endochondral ossification takes place in
the short and flat bones.
13 Endochondral ossification
Remnants of rrunerahzed cartilage
[serrated green structures) form
Ille centers of oeposuon for tarnet-
lar booe layers (red and yellow)
Perichondralossification commences at the perichon-
drium. The rnesenchymal cells of the tissue become
differentiated to osteoblasts. which surround the
diaphyses with a bone sleeve prior to endochondral
ossification, thus indirectly influencing its direction.
Endochondral ossification commences with charac-
teristic changes in the cartilage cells (hypertrophied
cartilage) and their surrounding intercellular matrix
{calcium deposits). i.e. the formation of the so-called
primary spongiosa. Blood vessels and mesenchyrnal
tissue then penetrate these areas from the perichon-
drium. The transported connective tissue cells become
differentiated to osteoblasts and resorption cells, e.g.
chondroclasts which erode the cartilage in a cavern-like
pattern.

R.ght The '"'"'II .s P.llher spicules

of primary spong1osa (as 1lluslrat-
edJ or, .... hen centered in the cort•·
cal layer, compacl bone. Rog hi
Section through uncalof1ed bone
(drtferen11al interference contrast,
1rnc1. according to Nomarslu).

The osteoid layer is deposited on the remaining calci-
fied spicules of the cartilage and then mineralized to
form bony spongiosa, with a fine. reticular netlike struc-
ture which has cartilage fragments between the osseous
spicules (Fig.13). The bony spongiosa can be converted
10 compact bone by filling its cavities (Fig. 13). Both
endochondral and perichondral bone growth take place
toward the epiphyses and joints. The increase in length
of the bones during endochondrnl ossification depends
on the growth of the epiphyseal cartilage. Once the
epiphyseal line has been closed, the bones no longer
increase in length. Unlike bones. cartilage growth is
based on both appositional and interstitial growth, In
those areas where cartilage is being convened to bone.
various characteristic zones. in accordance with the
individual stages, can be differentiated which conti-
nually blend with one another during the conver-
sion process (Fig. 14). The ossification of "primary"
cartilage (e.g. epiphyseal cartilage) differs from that of
"secondary .. cartilage (e.g. condyle cartilage).
Environmental influences (for instance. functional
orthopedic mechanisms) have a stronger effect on the
condylar cartilagedue to its more superficial localization.
 Ossrncanon 11

14 Growth of the epiphysial

__ ._ ....
rz .. _ .,. ~.~: :~4..:..:~
_. __ ....:...,_ Jal-I'~. _ ...
cartilage of long bones

~--·-··-·:, ~.
---·-.··' a Scllemat1cv1ew ot lhe ep1pllySeal
plate. The grOWlh is based on the
cell d1v1s1on rate ol !he columnar
cartilage zone
• • • • • b Dunng the grOWlh period ol the
camtage. lhe COiumnar cartilage
zone beeornes converted to hype<·
1roph1ed canilage zone wl'ltci\, 1n
• • tum. becomes the primal'( sooo-
• • • • • g1osa zone.
e With luriher ossit1ca11on the cam·
lage zone advances 10 tile upper
edge ol the diagram (Enlow. 1968)

a b

15 Eplphyseal cartilage
CharaClertSllC structure al 910W1ng
bone. Epiphyseal spong1osa. lhin
hyaltne cartilage zone, columnar
cartHage, hypertrophied cartllaga
The ground substance begins IO
calctfy and hypertrophied carblage
cells 10 dtSSOlve in lhe underly111g
mmereltzallon zone IDIC aoco<d·
1ng 10 Nomarsk1) The calc1f>ed
carttlage rs partly resortled and
forms the basis lor !l'le spong1osa
spicules

Right- Fluorogrephy (UV excaa-

1tonJ shows how me m1nerahzed
layers (marked with tetracychne
(yellow) and a1tza11ne fpmk) at
1-week 1n1ervals) retreat from !he
ep1physeal cartilage zone.

16 Condylar cartilage of the

temporomandibular joint
The condylar caritlage rs a second·
ary 1ype of camlage. which ....-as
transformed phyiogenei1cally lrom
!he penosteum. H1S1ologteally
Fb~ Ds.sue
com'll!ltbw condylar cartilage rs consdered lo
Probiera-~ have four d1tterem zones (long1ru-
dtnal seeuon):
Hyahnecartitaoe100e
t) Dense, horous connective us-
sue zone sparsely vascular;
2) Prolilera11on zone of unddfer·
ent1a1ed COMeCIJve !Jssue cells
(m1to11c zone). which become d1~
lerenuated lo chondrobfaslS;
3) Hyahne carblage zone wilh
randomly d1s1rtbuled chClndro-
blasls and hypertrophied cells.
The mamx ol lhese cells JS ma<e
calcd1ed toward the condyle.
4) EndochOndral osslf1CBl>On
zone. 10 wh1cl1 the cartilage is re-
sorbed and rlll)laced w11h tra-
beeular bone.
Right· The camlage and rmnerah-
za11on zones (llllal S1aintn9, ftuores-
cence microscope}.

Growth Mechanisms
• Endosteal and periosteal bone growth
• Cortical drift
• Relocation and remodel ing
• "V" principle
• Surface principle
• Growth fields
• Displacement
• Growth equivalents
Bone growth takes place according to several basic
principles, which can also be used to explain the growth
processes of the facial skeleton.
The theory that bones grow by simple symmetrical
enlargement is wrong, Such a simple growth mecha-
nism could not possibly create such a complex and diffe-
rentiated morphology as that of the mandible or maxilla.
Such morphology demands differential growth rnecha-
nisms and different types of development for the indivi-
dual bones.
Growth Mechanisms 13
The following two mechanisms are important for
bone growth in the facial and cranial regions:
- Direct bone growth by means of deposition and
resorption processes on the bone surfaces. which
cause the cortical plate to drift:
- Displacement of the entire bone due to growth of the
bone itself or expansion of adjacent structures.
20 Bone relocation and
remodeling
The hard palate of a newborn baby
is directly beneath lhe mfraorb<lal
nms. PlogrE!SSlveenlargement of
the nasal cavmes displaces Ille
palate downward during grOWlh of
the lacial skele1on.
Simultaneously with Ille down-
ward mowmeru, Ille bones are
remocteled by resorp11on and
apposat1onand increase 1n sae. In
adulls, lhe space wtllch formed lhe
hard palate and maxillary arch of
1he intarn 1s occupied by the
expanded nasal chambers (Ten
Cate. 1980).
14 l::lrowtn

Endosteal and Periosteal Growth

Approximately half of the cortical plate oft he facial and
cranial bones is formed by the outer surface, i.e. the
periosteum, and the other half by the inner surface, i.e.
the endosteum.
Appositional layers of cortical bone can originate en-
tirely from the periosteurn or the endosteum (Fig. 21).
In other cases, the same cortex is composed of
periosteal and endosteal bone layers which are separat-
ed by a so-called reversal line(Fig. 22). This type of bone
growth indicates that there has been a change in the
direction of growth at some time. As new cortical bone
is always deposited on the surface facing toward the
direction of growth, bone formation originating in the
endosteum can, at a later date and after reversal of the
direction of growth. even to a type of periosteal bone
formation, TI1e reversal line represents the interface
bet ween endosteally and periosteally produced bone
layers.

21 Periosteal and endosteat

bone formation .. . ••
+ = Bone appos111on ++ --·
- = Bone resorp1oon
+ -·
Left: tt the d11ec11on ol growth re-
mams constant, !he nghl conical
plate is locmed penostealty and the
left plate enclosteally. Bolh shift on
unison In the d11ect1on ol growth,
1. e. to 1he nghl.
+ +
R1ghr: The d1roo1on ol growth can
change during developmenl of lhe
bone. In Ille area matked w1lh an + +
asterisk, bone formation 1m11allv
occurs endosteally (above) and, at
a later dale alter reversal of Ille
+ +
direction ol growth, penosteally
(below) (En/Ow. 1982). + +
+ +

22 Reversal line

AK • Alveolar bone
P - Peoodontal space
z = Tooth rool
The interface be1ween pe11osteally
and endOSleally formed bone rs
termed the rewrsal hne I • = rever-
sal line).

Righr: Secuon 1hrough an alveolar

bone. The yellow stam1ng 1nd1cates
thal endosteal bone lormalJO<l
takes place in !he uppet section ol
Ille surface facong Ille 1001h and pe-
nosteal formation in Ille lower sec·
loon. ThlS leads 10 rotallon ol the
bone strucwre (lluornscenr ml·
CrQSCOPIC View after letracycfine
SlaJOlng)

Leh: lme-drawing ol lhe h1stolog1C

secllon.

c - =:=:=:=:=:=:-
--- ----------
------· --·- +
---
------- ----
__________
______- -·- -

Cortical Drift
All bone structures have one growth principle in
common, which was termed "drift" by Enlow (1963).
The cortical plate can be relocated by simultaneous
apposition and resorption processes on the opposing
periosteal and endosteal surfaces (cortical drift). The
bony cortical plate drifts by depositing and resorb-
ing bone substance on the outer and inner surfaces,
respectively. in the direction of growth (Fig. 23). lf
resorption and deposition take place at the same rate.
the thickness of the bone remains constant. Should
Growth Mechanisms 15
more bone be deposited than resorbed, the thickness of
the structure increases. During the developmental
period. deposition takes place at a slightly faster rate
than resorption. so that the individual bones slowly
enlarge.
The teeth follow the drift of their alveolae while
the jaw is growing and thus maintain their position
within the surrounding bony structures despite the bone
displacement (Fig. 25).

23 Cortical drift
(Diagrammatic view)

a Cortical plate of a bone.

b Increase 1n
th1cklleSS due to
apposmoo on ooe ol the SlJlfaces

e When lhe resorption process on

one Side ot the bOne exceeds the
apf)OSllJoo process on the oppos-
ing Side. the th1ctmessol ohe bone
will be reduced

d When resorption on one side of

1he bone corresponds in magn1-
1ude to aoposmcn on the opposing
Side. lhe bone will dnft witnout
Changing its size.

e The corttcal plate has dntted

complelely IO the nght when com·
r-----==::::::---=m pared 10 r1song1nal PDS<1tor11na) by
I 1he process of senece remodeling
I (Ten Cate, t980).
I

r--------r--mmmmm
I
I
I
I

I
I
I
I
d t.. - - -'--"UWWllW

r-------------- -
I
I
I
I
I
I

I
I
eL--------------
16 Growth
24 Cortical drift
Fonnallon of lamellar llOne on lhe
endostaaJ surface and restXpuori
on lhe penosteal surface cause lhe
eoure conex 10 dnlt Shoold bo4h
surfaces dnlt at the same rate. lhe
dimensions of lhe bone will be
maintained.

The asymmelnc coloranon around

Ille osteon shown rn 1he center of
Ille picture mdlcafes lhe cf11ecuon
of dn1l (marl<ed al 1-week intervals
USlllll seven d1ffe<er11 "1181 dyes;
ftUO<escence wrth UV excnabont.

25 Drift of alveolar sockets

during growth
ResorplJOn of !he alveolar bone on
the surface lacing toward the cfrrec-
uon of dnlt and appes111on on the
ooposne alveolar side. By lhJS
means, the looth re1arns its ana-
lomJC posmon 1ela1tve 101he alveo-
lar process as the whole bone dnfls
during growth (F•g.24). Theretore 11
is necessaJY that 1he focahzabOn of
lhe alveolar reSO<pllOn and aooos-
IJOn processes are 1den11cal ye1
lake place in the reve<se d1rec11on
10 the penosleal and endosteal
processes.

The heavy S1am1ng in the denim

(layer-by-layer marl<lng wilh VTl01
dyes) are caused by the con1mual
growth of the incisors rn 1h1s rodenl

Root of tooth

Periodontal
space
Bone deposition Bone resorption
Relocation and Remodeling
Due to new bone deposition on an existing surface. all
other parts of the structure undergo shifts in relative
position: a movement which is termed relocation.
As a result of this process. further adaptive bone
remodeling is necessary in order to adjust the shape
and size of the area 10 the new relationship. Selective
resorption and apposition processes functionally
remodel the area to conform to the new physiological
loading.
+
+ The POS!llon OI me gray zone
+ lhe marked area JS traosloca!Bd
+ bo<der of the ramus. without
Relocation and cyclic, structural remodeling are
growth mechanisms which are closely related 10 one
another: Remodeling is based 011 relocation and is a
secondary result of the displacement process. When one
level passes into the next due to growth, its position is
taken by the following level which undergoes the rele-
vant structural changes, TI1e information which initiates
the remodeling process is contained within the various
soft tissues surrounding the bone.
26 Relocation and
remodeling
(Otagrammallc View)
changes tn retanon to the ong1naJ
posmoo (A) duetoboneappos1t1on
(+)and resorpuon (-).Asaresultol
the level-by-level growth process,
lrom the postenor 10 tile anien0<
changing Its own position.
Left. suoeroosmon to show 1he
growth processes of the ramus.
Parts ol 1he condytar head are con-
vened into the ned< ol the concfyle
during the process al relocabon.
The sectJons through a) and bl
show the local remodeling
changes which are necessary lo
adapt the torrn and size of the
structures101helrnewrelawepos>-
uoos (Enlow, 1982)
J
27 Relocation and
remodeling of thl! mandibll!
during growth
The remodeling process ol the ra-
mus rakes place 1oward 1he poste•-
1or The body o( 1he mandible oe-
comes leoglhened by remodeling
parts ol the ramus, which s.mul-
lltneOUsly sh1f1s in baci<waid d11ec-
non (Enlow. 1968).
:
l
'
18 Growth
28 Primary displacement and
bone growth
These lwo basic growth mech
an1smsare closely mtrrrelared

Beginning at pos.tion (1) lhe en·

lire mandible rs displaced down·
W111cl and rorwaro (2). away from
its amcular 1omts. by the growth of
the surrounding soft ussues,

This tmnslatory movement snrnu

lales lhe entargemenl and remo-
oeltng (3J ot tne condyles and
ramr which Jake place parallel to
d1SPlacemenl

The booe growth processes are

duected upward and bacl<Wald by
an amount U1at eQuals rhe drspta-
cemeru ol the mancltbte. 1
The changes resulung from these
combined processes are shown tn
(4) (Ten Gate. 1980).

4
 Growth Mechanisms 19

The "V'' Principle

The "v" principle is an important facial skeleton growth The outcome of these growth processes is:
mechanism, since many facial and cranial bones have a
··v·· configuration or .. v··-shaped regions. J) Enlargement in overall size of the ''\/''-shaped area
Sucb areas grow by bone resorption on the outer 2) Movement of the entire "V" structure toward its own
surface of the •·v·· and deposition on the inner side due wide end
to the concept of surface growth depending on growth 3) Continuous relocation
direction. The +vr moves away from its tip and enlarges
simultaneously. Thus, increase in size and growth
movement are a unified process.

29 The •v• principle - Vertical

expansion
Lele. According to this growth con·
+ cept, bone is depos11edon the in·

+ ner surface of lhe V -shaped bone

and resorbed on the outer surface.
+ Thus. tne "V" moves away from l1S
narrow end (directJon 01 the arrowl
+
I
and enlarge<; in overall size.

Righi· long1tud1nal sec11on

lhrough the nght and left coroootd
processes of a mandible The pro-
cesses are enlarged durrng growtn
rn accoroance wllh the V pnn-
crple. Bone is deposited on the lin-
gual surfaces and resorbed trom
the opposing buccal surfaces The
structures rncrease rn hetghl. the
lips of the eo<onotd processes d,.
verge further. and lhelr bony bases
converge (Enlow. 19631

30 The ""V" principle -

Horizontal expansion
The mandible 111ewed lrom above.
rncludrng a horizontal sectlO<'I
through the base of 1he coronotcl
process.
Bone is dePOSttedon the hngual
side of the mandibular structures
up to the ramal sol.face. Th\lS. the
coroood processes move - de-
spite bone deposillon on lhe inner
surfaces - m backward direcbon.
and lhe oosteoor parts ol lhe man·
dible wrden (Enlow. 1982).

Leh: Mandrbular configurahon al a

5-year-old and an adull 111ewed
lrorn above.
Surface Principle

The surface principle states that bone sides which
face the direction of'growth are subject to deposition and
those opposed to it undergo resorption. These processes
always take place on conrralateral bone surfaces so that
th e conical plate follows the course of growth.
The direction ofgrowth is not the same for all areas of
the bone as each region of a structure has its own
specific growth pattern. Reversals in the direction of
growth can result in bone deposition and resorption
processes laking place directly adjacent to one another
on the same cortex.
As the individual parts of the bone grow in different
directions. only half of Lhe deposition process is
localized on I he outer cortical plate (periosteal bone
(or111a1io11). The other half of the growth process consists
of bone deposition on the inner cortical surface (endos-
teal bone formation), ·

31 Surface principle
(diagrammatic 111ew)

+ = Bone depos111on
- • Bone resorp11on

B B
The areas marked ·x·on tile outer
surfaces ol the bone and lhOSe A A
marked "B• on the inner surfaces
are m lhe c-1direction of growm
and are depos1tOI)'. Acrordingly.
areas ·A• and •y· resort> 1n the
opp()Slleduecbon (EnlOw, 1982).
+ +
+ +
.
-t- +

• T

+
•

+
+
y y
x + +
x
-1- +

32 Direc1ion of growth of
Individual areas of the
mandible

Red arrow = Bone deposmon

Blue anow = Bone resorpllon

RJgni. The arrows pointmg toward

the bone ind1cale penosteal bone
surfaces which do not iaee the di·
rectlon of growthand are, therefore.
resorpuve. Those arrows which
pom1 away from the bone lnd~e
periosteal surfaces whtch face
1oward the dorect1on ol growth and
aie depository
The main d1rect1on of growth of
the rarnus and the mandibular
corpus is aimed upward and
bad<ward (Enlow, 1982).

Leh· Macerated adufl mandible


Growth Fields
Bone growth is controlled by so-called growth fields.
These fields. which are distributed in a characteristic
mosaic-like pattern across the surface of a given bone.
have either depository or resorptive activity (Fig. 33).
If the periosteal growth field is resorptive, the oppos-
ing endosteal field is depository. On the other hand. if
the endosteal surface undergoes resorption, the perios-
teal surface is depository. Bone growth processes, i.e.
bone drift, are based on these periosteal/endosteal
relationships.
Growth Mechanisms 21
Growth fields have a pacemaking /1111c1io11, which is
controlled by the contiguous son tissue. Each increase in
length of the bone commences with the growth fields
migrating within the respective connective tissue
membranes (e.g. periosteum and cndostcum. sutures.
periodontal ligament). The enclosing son tissues deter-
mine the changes in the underlying bone parts which are
controlled by this specific growth field.
Not all growth fields of a bone exhibit the same
amount of activity or velocity of growth,
33 Arrangement of the
growth fields
Red helds = Bone depos1hon
Blue helds • Bone resorpl!On
Deposi1ory and reso<pt1ve helds
are d1smt>u1ed chara<:lenS11cally
across the enure inner aod outer
surfaces ol tlle neur0etamal and
faClal skeleton
The act1v11y of the growth field is
not located 1n the !>one r1sell. The
geneltc information resides within
the sofl ussues,
The soft ussue acts as a tune·
Ilona! ma111x lo conhol bone
grOWth. whereas the bone itself
only reports - Vlll a feedback
mecnamsm wh1cll rs connected 10
the conoecnve tissues - when the
shape. size, and b101T1echan1cal
aspects coincide wrth the tunc-
llonal requ1remen1S. Thts 1nlorma·
lion causes the h1stogene11cactJV1ty
ol !he os1eogen1c membranes to
respond (Ten care. 1980).
34 "'Growth centers•
This term rs ohen used 10 descnbe
very actlll!l growth fields which are
S1gnihcan1 10 the growth processes
such as the craruat and facial
sutures. the ma~ular eondyl~
lhe maxillary tuberOSl~es, the
alveolar processes. and the syn-
chondroses ol the cranial base.
However, !>one growth nol only
takes place in lheseareas.Allonner
and outer growth balds ot a gtven
!>one also play an active rote on lhe
process (Enlow, 1982).
Displacement

Apart from direct bone growth due 10 deposition and
resorption. the process of displacement, i.e. the trans-
latory movement of the whole bone caused by the
surrounding physical forces, is the second characteristic
mechanism of skull growth, The entire bone is carried
away from its articular interfaces (sutures. synchond-
roses, condylcs) with adjacent bones.
Displacement in conjunction with bone's O\Vl1
growth is termed "primarv displacement" by Enlow.
Displacement is initiated by the su111 of the expansive
forces or the son tissues in the growing face. Lt occurs
parallel to bone growth, thus creating a space around the
contact surfaces into which the bone can enlarge. The
degree of displacement exactly equals the amount of
new bone deposition. although the direction of displace-
rnem is always opposite LO that of the bone deposition.
Bone displacement due to the enlargement of bones
and son tissue which are nearby or not immediately
adjacent is termed "secondary displacement."

35 Primary dlsptacement of
the nasomaxillary complex
The bone structure 9rows upward
and backward (¢) due 10 depos1-
11on an<l resorcaon processes.
S.multaneously, the entire complex
IS drsptaced lorward (OJ. Thus.1he
necessaiy space lor bone deposr-
hon IS created around 1he articular
surlaces. Primary displacement
always takeS place m the opposue
duecoon to lhe vector of the bone
growth.

R•ghr Diagrammallc view ol 1he

events during pnmary displace-
ment The bone 1s remodeled and
sh1tted 1n 1he opposite drrec11on
51multaneously (EnloN, 1982).

36 Secondary displacement
of the nasomaxlllary complex
This process rs 001 associated w11h
growth of the bone llsell. This type
cl drsplacemen1 is 1n111a1ed by
enlargement of ad1acen1 or remote
bones and soll llSSues. Its ettact 1s
lransfe<red lrom bone 10 bone and
develops rn relallVely d1s1ani areas
Secondary d1solacemenl ol the •
nasomaxillary CQfllplex 1s caused
r
.... • •
•
by growth of the middle etanial
Iossa and the 1emporal lobe,and rs
••
-
I
•
•
•
•
•
directed forward and downward • •
10). •
• •
Right Oiagrammabc view ot I

secondary displacement The

bone 1s earned away wnhoof bemg
remodeled (En/OW, 1982). !~.< I

'- ,, '
)
Growth Processes
Maxillary Growth
Maxillary remodeling involves bone deposition on the
posterior wall of the maxillary tuberosity, resulting in a
posterior lengthening of the bony maxillary arch. Depo-
sition on the outer surfaces of the tuberosities and
resorption on the inner surfaces causes the cortical
plate 10 drill in a backward direction and the space for
the pneumatic cavities enlarges (Fig. 37).
This posterior elongation of the upper jaw is cou-
pled with pri111a1J' displacemont of the maxilla which is
directed anteriorly and exactly equals the amount of
posterior lengthening (Fig. 38). This increase in overall
J mruoffaryfissure is illustrated as an
/ inverted teardrop. as on a cecna-
• I
length of the maxilla creates tensile forces which initiate
tensile adaptive sutural growth.
Due to growth of the middle cranial Iossa, the
maxilla, the anterior cranial base. rhe forehead. and the
zygoma are shifted in a forward direction. This process
leads to secondary displacement of the maxilla, i.e, it is
displaced passively due to expansion of the middle
cranial fossa without the growth processes of the maxilla
itself being directly involved. The extent of secondary
displacement corresponds to the degree of anterior
extension of the middle cranial fossa (Fig. 38).
37 Remodeling of the upper
arch
The upper iaw IS eXIended pOSter-
iorly by means ot booe deposibon
on the outer cortical surface of the
maic•llary tuberoslly and resorplion
on 1he mner plate. This causes
1he pterygopala11neIossa and the
pterygomruoffary hssure (PTMJ 10
move pasteriorly (the pterygo-
t09ram).
Left· The pterygopalallne Iossa IS
posmoned berween the pterygotd
plates and the maxillary ruberosily
(Enlow. 19821.
i 38 Primary and secondary
displacement of the maxilla
Vertical plane ot re(erence •
PTM line
HonzomaJ plane ol reference=
Fund1onal occlusal plane
ton The maxilla increases rn
leogrh and is displaced anlenorly
simultaneously (pmnaiy displaoe-
' .• {
menn Both crianges lake place to
tho same amount
jI •
R1gh1 Secondary displacement ol
the maxilla resons from enlarge-
ment or the middle cranial Iossa
24 Facial Skeleton
Mandibular Growth
Contrary to previous assumptions, the condyles do not
govern the growth of the entire mandible. They are not a
type of "corurol center .. with direct control over the
growth fields.and function only locally. The significance
of the condylar cartilage layer is that. due to its articular
junction with the basicraniuru. compressive forces are
created. and cartilage is a type of tissue which adapts to
pressure (Fig. 39).
Downward and forward displacement of the mandi-
ble is an important aspect in the growth processes.
39 Mandibular displacement
II was previously bel•eved lhat
grow!h ol the condytar cantlage
was the cause of mandibular dis-
placement
Righi: According to olher growth
theooes. mandibular dtsplace-
ment 1s the prrmary process and
results from eruargement ol lhe soh
ussees,
Coodylar growth rs secondary
and adapl!Ve, and reesiabhshes
!he 1elahonsh1p of the displaced
mandible 1n the temperomand1bu-
1ar J<)lnt (Enlow. 1982).
When assessing mandibular growth. the horizontal
and ascending sections must be considered separately
as. according to the Hunter-Enlow law. the individual
structures should each be given a different growth
equivalent.
The maxillorv arch is the specific strutural counter-
part of the mandibular corpus, i.e. during remodeling
the horizontal section of the mandible is elongated
posteriorly by the same amount as the maxilla.
£/011ga1io11 of the mandible toward the ramus is
possible because the anterior surface of the ramus is
remodeled by resorption into the elongated mandibular
corpus (Fig. 40). Simultaneously, the entire mandible
is displaced anteriorly by an amount that equals the
maxillary displacement (primary displacement). The
posterior sections of the rarnus and the condyles grow
Previous theorists claimed that the pressure exerted on
the glenoid cavity by the growing condyle caused dis-
placement of the mandible out of articular contact
(Fig. 39). Experiments have shown that, even after both
condyles have been removed. the mandible can assume
a relatively normal position. These experiments indicate
that:
I) condylar growth is largely irrelevant to the growth
of the other mandibular structures; 2) mandibular
displacement, which depends on growth, sets in without
a "push" of the condylcs against the cranial base.
posteriorly. i.e. diagonally upward and backward, and
increase in height. keeping pace with the mandibular
displacement. By this means, the mandible is not only
displaced forward but also downward (Fig. 41).
Growth of the middle cranial base also leads to
secondary mandibular displacement, similar to that of
the maxilla (Fig. 42). As the expansion of the middle
cranial Iossa is largely directed forward. i.e. the enlarge-
rnent is localized anterior to the condyle and ramus.
secondary displacement does not carry the mandible as
far forward as the maxilla. This imbalance is made
up for by the horizontal growth of the ramus, which
leads to the correct anatomical relationship between the
maxillary and mandibular arch (Fig. -l3). Thus. the
ramus is considered the growth equivalent oft he middle
cranial Iossa,
 Growth Processes 25
40 Remodeling of the
mandjble
, The oody ot Ille mandible elon-
gates pos1enorly due to resofl)l;On
and remodeling of theamenor OOI·
de< ot lhe ramus.

Lelt: The mand1bulru COlpUS leng-

thens by an amount that equals the
enlargemen1 of lhe tnaJC1llary arch.
wh1cli 1s us Slroelural counleipart
(Enlow. 1982).

41 Primary displacement of
the mandible
Right 8ongauon ol Ille mand1bu-
1at corpus and an1e11or displace-
mern ol lhe mandible lake place
s1mullaneousty.

Left: This process 1s S11mulaled by

lhe postenor growth ol the con-
dy1es and lhe oosteoor borders ol
the ramus. The ramus rega1ns 11S
ong1nal width by means ol bOne
deposition as lhe posienor depos>-
IO<yand lhe anterior resolJ)llve ae-
11111iy are precisely equal !FIQ. 401

42 Secondary displacement
of the mandible
Left: The mand1bkl 1sd1splaced fa<·
ward and downward by lhe enlar-
gement of lhe middle cranial base.
As the middle cranial Iossa gro-Nth
rs mostly localaed an1e11or ID tne
condyles, seoondary d1splace-
men1 of lhe mand1bkl ls not as
pronounced as lhat ol tne maxilla
[Fig. 38) Thus, JhlS phase ends -
despite both structures having
been elongated by the same
amount- w11ha mruullomand1bular
Class II relallonsh1p

43 Horizontal growth of the

ram us
The rames, which 1s the specific
Slructural growth equ111alen1 of the
middle crarual Iossa. rs dlSPlaced
poSlenorty unnl its honzontal
d1mens100 COiresponds to those of
lhe m1dalecranialfossa The Simul-
taneous condylar growth. wh1cli
lakes plaoed1agonally upward and
baci<wara. causes anterior dis-
placement of the mandible at lhe
samehme.
R1gh1· This corneensates for Ille
sag11tal discrepancy belWeen lhe
upper and lowe1 iaws and dis·
places theocclusal plane mlen0<ly
Growth of the Midface
The horizontal growth of the rnidface is determined
by the expansion of the anterior cranial fossa. which
enlarges anteriorly to an extent that matches the sagittal
development of its growth equivalent, i.e. the maxilla
(Fig. 44). The resorption and deposition processes on
the endocranial and ectocranial surfaces lead to
displacement and remodeling of the underlying
structures (nasal bone. ethmoid bone). Thus, the
horizontal development of the midface is balanced
inferiorly with the anteroposterior elongation of the
maxilla and superiorly with the horizontal extension of
44 Sagittat development of
the mldlace
Expansion of (he frontal lobes
causes elongation al me anrenor
cranial base and displaces 1he
mldlace IOIWafd.
The morease 1n leoglh ot the
anterior cranial Iossa corresponds
10 1he sagmal developmenl of lhe
maxrllary arch. which rs its structur-
al coonterpart
Apart from these remodeling processes. the vertical
development of the maxilla is also associated with its
primary displacement (Fig. 46). the latter triggering an
equivalent amount of secondary sutural bone deposi-
tion (Fig. 46). The downward movement of the maxilla
is usually not parallel, but differs anteroposteriorly. This
applies 10 both the remodeling process and the displace-
ment. The result is a rotational 111ore1ne1110/1/te111a1:illa.
which can be compensated or increased by the sum of
variations in both growth mechanisms (Fig. 46).
Due to active apposition and resorption processes in
the bony alveolar sockets (Fig. 47). vertical drift of the
upper 1ee1/tsets in simultaneously 10 maxillary remodel-
ing. Further lowering of the upper dentition results from
displacement of the maxilla (Fig. 4 7). This type of down-
ward movement of the dental arch can. above all.
be influenced by thcrapetuirmeans. The structural coun-
terpart for the downward growth of the nasomaxil-
lary complex is the vertical enlargement of the ramus
the anterior cranial fossa.
During vertical displacement of the midface, the
maxillary arch is displaced in a downward direction due
to resorption on its nasal surface and simultaneous.
deposition on its palatal surface (Fig. 45). Thus. space is
created for the sinuses to expand. Their inner surfaces
are largely resorptive. Unlike other primates, the ante-
rior part of the human maxilla is resorptive. and the
premaxilla grO\VS straight downward and does not move
forward (Fig. 45).
and middle cranial base, as these growth processes
displace the mandible inferiorly (Fig. 42). Once the
upper teeth have moved into place, an upward drift of
the lower teeth and their alveolar processes corn-
mences, thus establishing the final occlusion (Fig. 48).
As the vertical movement of the teeth is physiologi-
cally greater in the maxilla than in the mandible. the
orthodontic therapeutic possibilities are also greater in
the maxillary arch.
Simultaneous to the drift of the lower teeth. remodeling
takes place around the chin. the mandibular corpus. the
lower incisors. and their alveolar processes. The incisors
rotate lingually and move posteriorly to establish the
proper overbite.
Resorption on the outer surface of the anterior
alveolar region and bone deposition on the anterior and
inferior external contours of the syrnphysis cause the
chin to become more prominent (Fig. 48).
 45 Bone enlargement
The bones ol the mtdlace are
enlarged and displaeed SJmulta-
neously. Deposl11on on !he atal
------------- cortical plate and resoronon on
lhe nasal corucat surface cause Ille
+++++++++++= palate and premaxJ!la to grow
- downward

------ -- Right: Reversal lme (O) on the

concave labial surface ol ine pre-
maxrtla The surface benea1h the
vertex is resocpuve (-).Thus, the
antenor part of tile maxilla fllO'JeS
ontene<ly with the palatal vault.

46 Primary displacement of
the midface
Aeco<d1ng 10 Enlow, the naso-
max1llary complex ls displaced In
an onlenor d11ect1on due to enlarge-
ment cl the conttguoussoil tissue.

Center: The changed tension effect

on lhe facial sutures leads secon-
darily to sutural bone depos111on.

Right:Thus, lheconlmuoussutural
contact Is rnamtamed {Entow.
1982).

47 Tooth drift
D1splacemen1 ol lhe nasoma)Clllary
I complex causes the upper teeth 10
dnll passively trom posmon 1) to ZJ.

Rlghc S1mullaneously, the teeth

dnft actively from poseon 2) to 3)
due 10 bony remodeling ol lhe;r
alveolar sockets
This process lakes place parallel
10 lhe remodehng process ol lhe

-.- - - hard palate and premax1lla.

48 Occlusal adjustment
The lower teeth onn, togelher wnn
their alveolar bone, m an upward
d11ect1on, thus es1ablrShlng the
oceiusoo.
The lower incisors and lheu
alveolar process move lingually
due 10 remodeltng growth. Al !he
same nrne, new bone Is deposited
around the chm •

•
28 Facial Skeleton

Growth Equivalents
The Hunter-Enlow growth equivalents concept is an and thus determine the adaptive changes in relation to
important principle covering the development of the the individual parts of the skull. For example, elongation
facial skeleton. As the individual components of the of the anterior cranial base is related with enlargement
skull develop in different directions, they must inter- of the nasomaxillary complex.
react directly. in order to compensate for the various
growth activities. This is achieved by growth equivalents Disturbances during realization of this growth pattern
which act in opposing directions. cause craniofacial anomalies. The disturbance can be
related 10 disproportions of the equivalents in the verti-
These growth equivalents coordinate the different cal or horizontal plane.
movements of the cranial base. the nasornaxillary com-
plex, and the mandible. which are due to development,
49 Growth equivalents
according to Hunter and Enlow
1 The an1enor cranial base (a). the
spheno-ocCJpdalcomplex (b). lhe
nasomaJUlla!y complex (cJ and the
mandible (d) are among the 1nd1v1
dual components ol lhe skull.
•
2 ElongBbon ol the anterior crama1
base (X) rs assoaeted with corres-
ponding enlargement ot the naso
maxillary complex. Thelauergrows
m pasten0< d11e<;lt()O (Q) and IS
d1Splacedantenorly \l) a1 the same
time. 1
3 Tho grOWlh of tho spheno ooc1p1-
ta1 synct>ondrosls tm, kl constttutes
1he growth equivalen1 ta< tho naso-
pharynx {p) and lhe ramus ol lhe
mandible (di The ramus grows
1n a posll;rlO< duectron (g) and !he
en111e mandible shifts forward fl).
ThJS process compensates f0< the
sagltlal relafionShlp ol the mand•-
oular areh 10 the protruding naso-
maJUliary complex.

4 The vertical lengthening of Ille

ciMJS and the ramus (b and d)
fa<ms Ille growth equrvalenl for 1he
verncal devetapmenl of the naso- d
maxlllary complex (cJ.
The lasl·menlloned process IS
baSed on nasal (na) and max1Uo- 2 3
alveolar (av) growth. The ramus
grows poslena<lyand upward (g)
end moves downward w<lh com-
pensa10<y condylar growth IYI
(Gtabet, 1972).

c(nat

e(av)
b •d 9

d
I
4
y
I

Growth-Controlling
Factors
Postnatal bone growth, comprising enlargement and
remodeling, is based on the iniramernbranous and
cndochondral ossification processes which take place in
the flat bones, the epiphyses. and sutures. (The long and
short bones of the diaphyses of newborn babies are
already ossified!) Postnatal growth processes take place
within a time period of approxitnatoly 20 years. They
occur within the individual structures to varying
amounts at different intervals and are oriented in
various directions. The control of such complex
morphogenesis requires a precise biologic regulator
mechanism. The most important questions from the
orthodontic point of view are: To what degree are these
Genetic Cranial synchondroses
influence
Facial cartilage tissue
Sutures
Local
influence
Periosteum
localize the control function for craniofacial osteogene-
sis in the surrounding son tissues rather than the hard
tissues. More recent hypotheses assume that postnatal
facial skeletal development is controlled by a rnultifac-
torial system which is influenced by intrinsic. genetic,
and local factors (van Lirnborgh, 1970 and Petrovic.
1970).
If one assumes that bone formation is determined by
endogenic preprogramrning only (Sicher. 1952), ortho-
dontic treatment of hereditary malocclusions would
have a poor prognosis throughout the entire growth
period.
Growth - Factors 29
developmental processes determined by pure intrinsic
genetics, and which factors influence the osreogeneous
control system? The various points of view on these key
questions are expressed in the divergent concepts of
dilTerent "orthodontic schools",
The three most common growth hypotheses dilTer. in
that the main control function of the morphogenesis is
associated with a different tissue type. According to
Sichcr (1952), osteogenesis of the chondrocranium and
desmocranium is controlled purely generically. and the
sutures are the dominant tissue structures. Scon (1967)
applies this control mechanism to the cartilage and
periosteal tissues, whereas Moss and Salentijn (1969)
50 Control mec:l1anlsms
governing the growth of the
facial skeleton
Complleuon ol lhe most 1mp0<1am
parameters
lf osteogenesis can be influenced by local factors.
then there are several questions concerning the thera-
peutic aspects:
I) Which local factors are important for craniofacial
growth?
2) Which tissues can they influence?
3) To which degree and
4) at which point in rime can local factors affect the
morphogenesis?
30 Facial Skeleton
Local Factors Concerning Craniofacial Morphogenesis
According to van Limborgh (1970. 1972) craniofacial
morphogenesis is controlledbyfire different factors:
Intrinsic genetic factors. local and general epigenetic
factors. and local and general environmental factors.
According to this growth theory, local factors as well
as genetic and general factors can cause anomalies.
The intrinsic genetic factors exert their influence within
the cells in which they are contained and determine the
characteristics or cells and tissues.
51 Mechanisms controlling
craniolllcial morphogenesis
(aecordlng to van LJmborgh, 1972)
Cranial
-
differenttahon
... Chondrocranoal
growth
... Desmocranoal
growth
Both, local and general environmental factors regu-
late or modify the morphogenesis controlled by the
genome. The tocat environmental factors (e.g, muscular
force during functional appliance therapy) are or much
greater relevance to the postnatal craniofacial growth
control than the general factors (e.g. food. oxygen
Epigenetic factors are those which are determined
genetically, and are effective outside of the cells and
tissues in which they are produced. Epigenetic factors
only occur indirectly. due to reactions or the structures
which they influence. According to van Lirnborgh.these
factors can have an effect on the adjacent structures such
as local epigenetic factors (e.g. embryonic induction
influences. brain. eyes, inner ear) or are produced at
distance and exert a general epigenetic influence (e.g,
sex and growth hormones).
[ Intrinsicgenetic fllctors _I
:CI
[ Local epigeneticfactors
I
I General epigenetic factors
l
supply). Jn order to be able to assess the importance
of local factors to the etiology of malocclusions and
to possible types of treatment. their effect on the two
different forms of craniofacial bone growth. i.c, endo-
chondral ossification and intramembranous ossifica-
tion. must be taken into account (Fig. 51).
 Growth - Factors 31
Factors Influencing Endochondral Ossification

Growth of the cranial synchondroses (e.g. sphenoeth-
moidal and spheno-occipital synchondrosis) and that of
the subsequent endochondral ossification are determin-
ed by chondrogenesis, Chondrogenesis is primarily
influenced by geneticfactors. similar to growth of the
facial mesenchyme during early embryogenesis and
to the differentiation phase in cranial cartilage and bone
tissue.
The process is minimally affected by local epigenetic
and environmental factors. This explains the fact that
the cranial base is more resistant to deformation than the
desmocranium.
Local epigenetic and environmental factors can neither
promote nor impede the amount of cartilage formation.
They merely have a slight effect on the shape and direc-
tion of endochondral ossification. This effect has been
primarily analyzed during growth of the mandibular
condyles (Fig. 52).

52 Endochondral ossification
Local epigene11c and enwonmen-
lal factorsonty 1nlluence the snaoe
( and direction ol cartilagelormanon
dunng endoehondral ossd>cal•on
Amount of (aCCO<d1ng to van LrmbO<gh). Tak·
Local 1ng 1nro accounr the 18CI thal
ep1gene!Jc
and
environmental
-
cartilage Iormatton

I
Endoc:hondral
oeelflc8tlon
condy1ar cartilage rs a secondary
type ol cartilage, rt ts claimed Iha!
local tactors exert a greater inftu-
factors Shape and direction of ence on mandibular concty!ar
cartilage formation gtOWth.

Factors Influencing lntramembranous Ossification

lntramembranous ossification of the desmocranium morphogenetic effect on iruramcmbranous ossification

(sutures and periosteum) is mediated by skeletogenetic
mesenchymal structures and achieved by bone deposi-
tion and bone resorption.
This process is controlled almost entirely by means
of local epigenetic and local e111·ira11111e11tal factors (i.e.
by muscle force. local external pressure, brain. eyes.
tongue. nerves. and indirectly. by endochondral ossifi-
cation). The genetic factors only have a nonspecific
and only determine the external boundaries and the
amount of growth as well as the growth periods.
Whereas genetically generated anomalies primarily
affect endochondrnl ossification, local epigenetic and
local environmerunl factors, including orthodontic
therapeutic measures. affect imramernbranous ossifica-
tion directly (Fig. 53).

53 lntramembranous
ossification
local epigenetic and envuommm-
( tal faciors are considered 10 be
parameters influencing 1ntramem-
Sutural branoos oss1hca11on.
Local growth
epigenetic
and lntramembranous
I ossification
environmental
factors Periosteal
growth

l
32 Facial Skeleton
~~~~~~~~~~

Degree to Which the Growth Processes Can Be Influenced

Osteogenesis is mostly influenced by local functional
demands, Moss (1962) described these interrelations
in his so-called .. functional cranial analysis." which is
fundamental to the etiological and therapeutical asses-
ment of malocclusions.
According to Moss. a specific cranial component
controls each function. The size. shape. and spatial
position of the individual components arc relatively
independent of one another. Each component of the
skull consists of two parts. the functional matrix and the
skeletal 1111i1. The functional matrix includes the func-
tioning spaces and the soft tissue components required
for a specific function (c.g, breathing. sight. smell, and
mastication), The functional matrix carries out a given
function. whereas the skeletal units such as bone. carti-
lage, and ligaments protect and support the functional
matrix and are adaptable.
F1111c1io11al matrices. There arc lWO types of'functional
matrices, the pcriosteal matrix and the capsular matrix.
The periosteal matrix is best exemplified by a muscle
attachment. Capsular matrices are divided into three
types, i.e. neurocranial. orbital, and orofacial (Fig. 54).
Skeletal1111i1. The skeletal unit is composed of micro-
skeletal and macroskeletal units. The sum or the
microskeletal units of a skull component makes up the
macroskeletal unit (Fig. 55).
F1111ctio11a/ cranial cv111po11e111s. The neural mass. the
contents of the orbit, and the functional sinuses of the
orofacial matrix are protected and supported by a
capsule (capsular matrix). The skeletal units are
embedded in the capsule together with their specific
functional periosteal matrices, i.e. the muscle attach-
rnents. They are combined to form the functional
cranial components.

54 Capsular matrix

1 - Neurocramal capsular mamx

2 = Otolacial capsular matrox

Otagrammal1cview of lhe neuro-

cranial and orofac1al capsular
marnces.The neurocranial capsu-
lar ma1r1x ts 1epresen1ed by 1he
neural mass which 1s formed by
!he brain. lep1omerunges. and the
carebrospmal llutd.
The 0<ofaCUIJ capsular rnatnx is
f0<med by 1ha oral, ~. and
pharyngeal func1tontng spaces
IMO.SS and Salen111n. 1969)

55 Skeletal units of the

mandible
The mandible is an example ol a
macroskeleuil unll and consists ot
the condylar, coronod. angular.
alveolar and basat mu;;roskele1a1
units.
The 1emporal1S muscle rs me
pe11osteal mamx of 1he coronord
un11 and lhe masseter and medial
pter)'ljOld muscles are those of lhe
angular processes. The leeth influ-
ence rhe alveolar unn and lhe
blood vessels and nerves ol lhe
mancl1bularcanalhave an effect on
the basal un11 (Moss. 1962)
 Functional Cranial Analysis 33
Mechanism of the Functional Matrices

The capsular and periosteal rnatrices have a completely
different effect on the growth processes.
The capsular matrix exerts a direct influence on the
macroskeletal units and the functional cranial compo-
nents, and is only responsible for changes in the three-
dimensional position of the skeletal unit
The capsular matrix exerts a direct influence on the
macroskeletal units and the functional cranial compo-
tion, or perichondral or endochondral growth pro-
cesses. Thus, the periosteal matrix changes the shape
and size of the corresponding microskeletal unit.
Moss (1973) termed this change in size and in shape
during growth "transformation" (Fig. 56) and the
change in spatial position "translation" (Fig. 57). Only
a small percentage of the bone growth in the facial
skeleton is due to pure transformation or pure transla-
uon. A combination or both typeS of growth is usually
involved (Fig. 58), although translation almost always
results in bone transformation (Fig. 62).

• 56 Transformallon
A B Left Sehema11c view Show1119 lhe
peroosleal rnatnx as an elevaiorcar
The elevalor passenger represerus
Ille skelerar unit The passenger
can be spa11ally mowd upwaro or
downward by simply rranslOlming
,; '"'·
:;. -.·~ Ille floor of Ille car (removing {Al
1<:: 0< ra1s1ng !he floor boards [BD
(according 10 Moss. 19731

Right llluslratJOn showing pure

1ransl0<ma11onol lhi! mandible, 111-
duced by d!lPOSlllOO and resorp-
llon (depos1tt0n= red. resorptt0n=
- ha1c!led).

- 0
57 Translation
Left Bolh dragrams show the Sl<e-
leraJ macro-uni! as an elevator car
and the neuromuscular capsule as
Ille elevator Shall Upward move-
·----~
I I I rneot IC) and d<mnward move·
menl (Dl reposi11onthecar ttranSla·
II 'I
11on1 (Moss. 19731
,' Ir
t_ J _J Right Schematic vrew S11oWin9
~;<-.
pure downward translabon of the
~~$
.:,;,-.;;:-:· ... mandible
·~;~:~

58 Tninsformatlon and
translation of the mandible

Red = Bone deposition

Hatched - Bone resorpbon
Downward and upward growth of
1he mandible is l)l1manly due to a
1ranslal1on prooess which corre-
sponds lo lhe expanSIOfl of lhe
orofaciar luna1on1ng spaces {blue
contours)
\ The 1ransforma1ion processes
cause !he Chanyesaround thecon-
\ dy!es and gontal angles of lhe
mandible and areol illlle relevance
10 the growth of Ille mandibular
body
34 Functional Cranial Analysis
59 Mechanism of the
neurocranlalmatrix
ExpanSlOO ot lhe neural mass (neu
rocramal lunc11onal matnx) causes
passive uansla11on of the "al cra-
nial bones toward Ille direcl1on ol
eJ<pansion.

Rl!}flr In order to compensate 101

separation of lhecalvanal booes (a.
b) transtonnahve growth is usually
onduc;ed along the sutural edges
IC). The skull bones are traos-
lormed (d) due lo the 6'11ect ol
b
thelr telaled functional penosteal
mamces {Enlow. 1982)

60 Expanslon of the orolaelal

capsular matrix
The case shown on these two lat·
eral cepnalog1ams 1nd1cates thal
use of a Jowet llp screen 1ncteases
lhe volume ol the oral cavity.
A secondary ettec1 Is 1ha1 lhe
luncbonal loading on themd1VJdual
perJOSteal mamces iscnanged and
the skeletal unus embedded 1n the
capsule are translated and trans·
formed accordingly.

Transformation and translation

of the mandible using an
activator

61 Class II malocclusion
RadlOQraphJC oephalogram ol a
9-year-otd pabenl al lhe begmnmg
ol onhodonnc treatment

Right: CephaJograrn ol lhe same

patJen1 afier 3 years ol activator
lherapy. The mandible was trans-
laled 1nler!o<lydunng tne course ol
treatmeot, and simultaneously the
length al the mandibular corpus
1naeased by 7 mm.
The cephalometric 1rac1ngs are
supenmPOSed m Rg. 62.

62 Assessment of the
changes in posillon and shape
of the mandible
Supenmposmon of the two trac-
1ngs rn lhe area of maximum con-
gruency ol lhe bodies of me man-
dibles 10 1llusua1e mandibular
remodeling.

Right Total mandJbule1 d1splace-

men1 Is lhe cllange In posibon ol
me mandible along the hne S-N
(black= pnor lo. •ed =alter lreal-
menl). The translauon Is the differ-
ence between 10181 displacement
and local 1ransf01mahon (accord-
ing to Baumrmd el al, 1983).
 Classification of Malocclusion 35

Classification of Malposition - Nomenclature

Malposition of individual teeth Sagittal plane

Malposition of groups of teeth Transverse plane

Malocclusion Vertical plane

Malposition of Individual Teeth

Malpositions of individual teeth may be classified as Lischer's nomenclature describes malpositions as:
follows: 1) Mesio- and distoversion
2) Linguo-/labioversion and buccoversion
• Rotation 3) lnfra- and supraversion
• Inclination 4) Axi- and torsiversion
• Centric or eccentric malposition 5) Transversion
• Total displacement
• Retention Localization of the axis of rotarion is an important crite-
• Transposition rion for treating abnormally inclined or rotated teeth.
Centric and eccentric rotation are differentiated accord-
ing to the position of the longitudinal axis of rotation.
63 Malposition of individual
teeth
Mesia! 1nci1naJ1on ol upper nghl
cemral incisor wnh inadequate
space lor lhe unerupled 1001n on
1he oopcsue side.

Left. 01S1olab1al rotanon of upper

nghl laleral incisor, combined W•tn
distal inctrna11on.
36 Classification of Malocclu------
sion
64 Centric tipping of uppe<
teeth
l..ab<aJ (lettl and 11ngua1 troghl) incl.
natioo ol an upper 1nC1S0r

The cenier of rotation 1s located be·

!ween Ille m11:ldle and apical lhHd
o! the root (Scnwan. 19611

\
'
'
65 Eccentric tipping of an \ I
\
upper incisor
LBh U.btal 1ncl1nauon with the
center ol r01.at1on located tn dose
I
p1ox1m1iy 10 the 1nosa1 edge I
\
Righi As above. v.1th lhe center ol \
rotation loca!eCI rn close prox1m11)' \ \
\ I
to lhe aoex of the root.

\
' I
Snould Ille center ol rotahon be l<>-
canzed at the apex, the malpos.1100 \
can be ahgoed by pure upping rn I
I
the opposite direcllon. The fur1her
toward the 1oosal edge the center ,I
of rC>Ulbon IS localized tne more I
\ I
complicated rs its coerecuon
I '
66 Tooth Upping - Total •
displacement '
Leh Eccentr1c hngual 1ncl1natJon,
with the center ot rola!Jon 1n close
proximrty to the neck ol lhe tooth.

R1gnr: Tolal d1splacemenL This

type ol malpositlOO can only be
cotreaed by a bod1ty tooth move-
ment

I
I
I
' I

67 Lower tooth inclination

I
Leh: Labial rocnnanon of a lower
1nciSOf, with apical base 1nvotve-
~
menL I \
I I
Center. l.Jngual mchnat1011, with ( I
apical base 1nl/Olvemenl.

Righr. Labial mchnanon, withoot /I

I

I I
/1
apical base mvolvemenL
•\
\
I
: t. •.1
I
I
I
I l I I
l \ I I
I \

-/
/
I
'' ~-
I
l

Malposition
s of Groups of Teeth
Sagittal: Labioversion. linguoversion,
Mesioversion, distoversion
Transverse: Crowding, linguoversion,
spacing, buccoversion
Vertical: Supraversion
infraversion
There are two types of lobioversion: Labial inclination of
anterior teeth with and without spacing.
Linguoversion of the anterior teeth is mostly encoun-
tered with a deep overbite and a Class LI, Division 2
malocclusion. The latter is subdivided in different types
depending on the malalignment of the upper anterior
teeth.
Considering the amount of space deficiency, crowd-
ing is divided into three categories:jirst-degreecrowding,
second-degree crowding, and third-degree crowding.
The following classifications for crowding take the
etiology of the anomaly into account: primary, second-
ary, and tertiary. Primary ( herditary) crowding is
Mal position 37
determined genetically and is caused by disproportion-
ately sized teeth and jaws. The malalignment of the
anterior teeth is characteristic of this type of crowding
("Persistence of tooth germ position"). Secondary
crowding is an acquired anomaly caused by mesial drift
of the posterior teeth after premature Joss of deciduous
teeth in the lateral segments. The etiopathogenesis of
tertiary crowding is still debated. This type of crowding
=primarily of the lower anterior teeth -occurs between
the ages of18 and 20 and was previously associated with
the eruption of the third molars. Others accredit the
anomaly to differential arueroposterior growth of the
upper and lower arches terminating at different times.
The terms ..coronal crowding" and "apical crowding"
take the inclination of the teeth to their apical bases into
account. Narrow maxillary arches are divided into three
categories: anterior constriaion. posterior canstriaion,
and constriction of the entire arch (constriaed arch with
iabioversion).
Compared to anomalies with crowding, malalign-
ments of groups of teeth due to interdental spacing and
wide arches are uncommon in our population.
Sagittal malallgnment of
groups of teeth
68 labioverslon of anterior
teeth with spacing
Class II malocclusion· The upper
mcrsors are llared lal>lally ana
spaced
50 Labioversion of anterior
teeth without spacing
Class II malocclusion w11h Jabrally
1ndmed upper mcrsors and hrm
1ruerprox1malcon1ac1s.Deso11e che
increase m upper arch length due
o:
to the labial 11pplng the amooor
teeth, the upper incisors are nOI
spaced
38 Classification of ~~~~~~~~~~~~~~~~~~~~~~~~~~~
Malocclusion
Relationships of upper anterior
teeth In Class II, Division 2
malocclus•ona

70 Isolated llnguoversion of
uppe< central Incisors
The upper centrals are hogually
1nchned and the la1eral incisors are
1n lab1oversooo.

n Characteristic
malallgnments of upper
anterior teeth in Class II,
Oivison 2 malocclusion
From lop IO bottom·

a The central moSOlS are lipped a

lj_J
hoguatty, the laterals are m lab10-
ve<SJOn or normally 1not1ned.

b Alt lour incisors are lipped

lmgually and lhe canines are 1n
mesiolabioverston.

e Unguovers1on of all soc antenor

teelh. b
d Mixed type ol lronlal mall)OSlt1on.
w11h lingually inclined metSO<S on
one side.

72 Unilateral linguoversion of
upper Incisors
o.stoctusion, w11h a 1yp1cal Class 11.
01111Slorl 2 malaJ1gmenl on one
s.de. The incisors on the opposite
s.de are Hared labially.
 ---- Crowding 39
Crowding

73 Second-degree crowding
Malpos1uon er the upper antenor
teeth ma muced denl!IJOO. The tack
of space around the mesors IS
dearly vi511)te.

7 4 Classification of amount of
crowding in a mixed dentition

a First-degree crowd1rn;i: Slight

malalrgnmenl ol the anterior teeth
No abnormalny of the supporung
zone (-area of decoduoos canine,
deciduous hrSI and second molarJ
Right: First-degree etowd1ng With
resincted supporting zones, as a
a result ol canes and prema1u1e loss
of deciduous leelh.

b Second-degree crOWding. Pro-

nounced malal1gnmen1 ol ante110t
teeth. No abnormality of lhe sup-
porting zone.
Right: Second-degree crowding
with restncted supponing zooes.

c Third-degree crowdmg: Severe

malal1gnmen1 of all four inc1SO!l>
b The adiacen1 perrnaneru teeth un-
dermine me deciduous teeth due
to unusual root resorpuon flack of
space greate< than the width of the
lateral lnclSOf).
Rightc Third ·degree crowomg With
reslueled supportmg zones due 10
canesaoo/or underm1111ng resorp-
1100 !Horr. t980J.

Crowding 111 conjunction with

reduced supporting zones is con-
e Sldered more d1fflcul1 to ireat,

75 Third-degree crowding
Malahgnmenl of the upper areh
with extreme lack ot space IOI tile
anterior and postsnor teeth.
40 Classmcauon 01 Ma1occ1us1on
Primary crowding - fypical
relationships of the upper
incisors

76 "Staggered" position of
upper anterior teeth
The •perSl$lenl looth germ posi
IJOn" is a cnaracrensuc ol hereat·
lary croworng l.lngwlly bloci<ed
out la!eral mcrsors are the mosl
common type ot malallgnmenl

Righi Diagram Showing ine mat-

pos!bOlt

77 MeslolabiaJ rotation of the

Incisors
The upper anterior teem are oos-
!Joned like root Ules and e~h1b11
mesiolabtal 1a1a1ton.

Right Diagram showmg the mal-

posuon

78 Mesiolablal rotation of the

upper centrals and distolablal
rotation of the upper laterals
'Ploogh-share· pos1tiomng ol lhc
opoer mcrsors

Right Olag1am showing !he mat-

pos111on.

79 Distolablal rotation of the

central incisors
Upper centrals pos111oned like
dooble doors - a characteriS11c
symoiom ol true 1ooth-size 1aw-
s.ze d1SCrepancy.

Right. Olagram showmg 1he mal-

pos1110tL
 Crowding 41
Primary crowding - ClinicaJ
symptoms

80 Deciduous dentition
The following symptoms are char-
actensuc 1n an early m1Ked denh·
hon The upper anteuor deciduous
teeth are w1th0utmterdentaJspac-
ing and lhe lower deoouoes laleral
1noSOts are exfohated premalurely
caused by the eruphon ol tne lower
permanent central mosors ("un-
dermining 0< atY1>1cal resorpboni.

81 Undermining resorption in
the anterior region
Primarycrowdmg 1namixeoden11·
1100. with atypical resorption of •Ile
upper deciduous canines due 10
eruptJonol 1headiacen1 permanent
lateral 1nc1S01S (undermmmg re-
sorption).
The same process was atso
responsible for lhe premature loss
of !he lower Clec1duouscanines

The atypical resorptllln ot

deci-
duous teeth resullS m resu1ctJon
ot Iha supporting zones fre<n Ille
antertor.

Undermining resorption ol
second deciduous molars

82 Clinical findings
Undermining res0<p11on ol the up.
per second decoduous molars by
the&year molars. Th1sresullslrom
a relsuve underdevelopmenlofthe
maxillary tuberOSJty and a mesoatly
directed eruption ol the first per.
manent molars This d1sru1bance
has partly impeded the erupbon ot
both nrst molars.
When the hrst permaneru mola1s
emerge and the deciduous molars
are IOSl prematurely. the postenor
area et the suppomng zones
becomes severely restrtcted

83 Radiographic findings
Apart l!om the underm1n1ng
1esorp11on ol the deciduous
second molars. caused by the
upper hrSI permanent molars. the
deciduous canmes ot all quadrants
undergo undermining resorptlOO,
caused by the permanem laleral
1nosors. There IS a nSk that tile
upper supporting zones will be-
come restncted from the arnenor
and posterior sides duhng the lirst
stage or exlol•aoon
Left: Deladed view ot underm1n1ng
resorption ol an uppe. deciduous
molar due 10 ec1opiceruphon ot me
&year molar.
84 Secondary crowding
The lower leh supparttng zone is
reduced due to mesial 1nct1nat1on
of the 6-year molar aher p1ema1ure
extracuon ol the second deciduous
molar.

85 Supporting tones of the I

mixed dentition c 0
This section ol the dental arch ts
defined metncally as being the A e·
sum of the mes1od1stal widths ol
Uie deciduous canine, the hrst
deoduous molar and me second

-
(lec<duous molar.
Ma1ntamrng the supp011tn9 zone
ensures that sufftCtent space is
avadable for the permanent teeth ol
this secttOn which have not yet
erupted.
v \J
On average. the upper support-
mg 200e tC'-0') rs 09 mm longer
than lhe sum ot the mestodlstal
widths o4 their succassional per-
manent teeth CA'-61, the lower
zooe(C-0)1517mmlongetlhanr1S
respec1rve permanent teeth (A-BJ.
The arrows 1nd1cate the d1tterence
on width between the supporting
zone and the permanent teeth
1Nance's leeway space).

Any rssmcnon of the supporting

zones from the distal or me mestal
results 1n an inadequate SPSce tor
the unerupted permanent succes-
SJOOal teeth (Graber. 1972).
A 8

c 0

86 Primary and secondary

crowding
Arue<1or restnctlon or the support·
1ng zones as a result ol unde<m1n-
ing resorpnon ot the decoduous
canines due 10 eruption ol the lat-
eral incisors. The suppomng zone
oC the lower left Quadrant 1s also
reduced from the oosienoe due to
mesial 1nd1nat10n ot the first per-
manent molar ahet p1emature loss
o4 the second deciduous molar
The increased space between
IOOlh 36 and 1ooch germ 37, when
compared to the opposite Side, Is
typical for a mesoally migrated
6-yea: molar.

I relationship
I Occlusion of a lemaJe patJem Wiina
I
I I
I I
I I
f""'J
I I
I An expansion ol 1he demaJarch
I
I \
I I
I
I dental arch and lhe postenor 1eelh
\ I
\ I
\ I
\ I
Crowding 43
Apical base - Dental arch
width
87 Configuration of a normal
balanced relationship belween the
w1d1h of lhe denllil arches and lhe
transverse development of rhe
apical bases.
Le/1. In 5'Jch cases. the tangents
running along lhe OUlersurfaces of
the posten0< teeth are parallel to
one another (schemaJJc view ol a
long1tud1nal secuon lhrough Ille
upper arch. Schwan, 19611.
88 Disharmony In width of
apical base and maxlllary
dental arch (apical crowding)
The upper postenor 1eelh are lilted
buocally 1n companson 10 the.r
apical base.
left: Cramally convergent tangents
ol 1he pos1er10< buccal 100111 sur-
laces imply lhal the basal bone is
smaller than Ille derllal arch.
is conira1nd1ca!edWllh lhis type of
crowding.
89 Constricted upper arch
The maxilla shown on F"IQ. 88.
viewed horn below
Apical crowding With anteno<ty
constneted upper arch and antero-
posterior lack of space for Ille se-
cond premolars.
90 Disharmony In width of
apical base and dental arch
due to a broad apical base
The aprcal base ls wider lhan lhe
are tipped lingually. The discrep-
ancy 1s indicated by lhe lnterden-
tal spacing.
left· When the apical base rs
broade1 than lhe denial arch, lhe
tarlgents of lhe poslenor buccal
surfaces oonverge occtusally.
In conS111Cled denial arches wnh
trns l\lpe ol coeooat cr0Wd1ng an
expansion therapy LS md1cated.
44 Class1nca11on 01 Ma1occ1us1on ~~~~~~~~~~~~

Vertical malpositioning of groups of teeth is judged occlusion" indicates that they have not yet reached it.
in relation to the occlusal plane. "Supraversion" or This malpositioning usually occurs in conjunction with
..supraocclusion" indicates that the teeth have exceeded irregularities in the vertical development of the alveolar
the level of the occlusal plane. "infraversion" or "infra- process.

91 Vertical malposltioning of
groups of teeth

Hon2on1a1 plane• Occiusal plane

verucat olane • Tube<OSlly plane

Top Correct vertical relation of

lhe arnenoe and posteno< teeth to
lhe ocdosal plane tthe 1meg1nary
plane passes lhrough the ups of the
premolar cusps and IS perpend•·
wlar lo the luberOSlly plane).

BOltDm /e/r Supravel'Slon ol the

uppe• anle••o< teeth with overex·
tensron ol the antet10< alveolar
process.

Bottom nghl · lnfr....,ersion of lhe

upper antenor teeth In conjunc11on
Miil an underdeveloped anteo0<
alveolar process (Korl<haus, 1939) _,.?"-

92 Supraoccluslon of the
anterior teeth
Supravers1on of lhe upper 1nco·
SO<S comb.necl wi1h a verucatly
overextended anienor alveolar
process. and an excessive over-
t.ta

93 lnlraocclusion of the
anterior teeth
Open b•te rnalooclUS1on. lhe upper
onoSOts do not reach the occlusal
plane. The alveolar process IS
not>ceably Underdeveloped In the
antettor region.

Note. Ao anrenor open b•te may

also be due to an overerup1ron or
supraocctUS1on of the postenor
teeth.

Malocclusion
Sagittal: Disto- and mesioclusion
Transverse: Cross-bite, buccal nonocclusion,
lingual nonocclusion
Vertical: Deep bite, open bite
The traditional system for classifying malocclusions in
anteroposterior direction dates back to Angle (1907).
Angle assumed, wrongly, that the posterior occlusion
and the sagirtal jaw relationship coincide with one
another. However, the intermaxillary relation of the
posterior teeth. regardless of the skeletal jaw relation.
may have been changed due to malpositioning of the
upper or lower teeth (mesial migration. distal rnigra-
tion). When assessing sagittal variations from normal
rnesiodistal occlusion. it is important to differentiate
precisely between the terms ..'malrelotionship of teeth"
and "malrelationship of bony bases." In order to deter-
mine the trueanteroposterior basal bone relationships it
is often necessary to visualize the positioning of the
teeth prior to drifting. Exact reconstructions, however.
are sometimes difficult.
lnterarcn retatronsrup 45
Malocclusions of cross-bite can be due to the following:
I) Narrow upper jaw
2) and/or broad lower jaw:
- bilaterally symmetric
- bilaterally asymmetric
- unilateral
When considering aU types of transverse anomalies,
including their prognoses and possible methods of treat-
ment, one must differentiate between the dental and the
skeletal components of the malocclusion. This differen-
tial diagnosis is especially important when assessing
midline shifts.
Deep overbite anomalies are categorized into dentally
supported deep overbites and gingivaUysupported deep
overbites. Open bite anomalies are divided into ante-
rior, lateral, and complex open bites. depending on
the localization of the malocclusion (p. 145).
Ocelusal relalion - Jaw relation
94 Neutroelusion of the first
molars, in a skeletal Class II
malocclusion
The neu1rodusaon IS a 1esulfoi tne
mes1al tilling o1 lhe lower hrst molal
doe 10 premature loss of
nghl deoduous molars.
Ille""'"'
Leh. Rad1ograph1cview showing
lhe mesial inc11na11on oi lhe lower
nghl hrSl molar In order 10 recan-
s1ruct !he 1aw relationship. ooe
must visoaltze the posrtl()fl1ng ol
1he teeth prror 101nemesral onftrak·
1ng place.
95 Bilateral mesial migration
In the lower arch
Radiographic hnd1ngs oJ lhe pa·
11en1 shown m Ag. 94. Premature
loss ol the lower ngh1 oooduous
molars has causeo both the lawe<
nghr lust molar and all teeth ol 1he
lower lefl arch IO dnH iowaro me
space. Dewllron o1 lhe lower m1d-
1tne !award lhe rrghl JS a symptom
ol 1h1s rnesial m1grabon.
 '+0 lAi::t~~lllCi::tUUll UI IVIC:llOCCIUSIOn

Angle classification of
maJoccJusion

96 Angle Class I
(neutroclus
ion, normal
anteroposterior relationsh
ip)
Left: OcclusaJ relatJOn on an Angle
Class I case The mesiobuccat
cusp ol tile upper hrsl molar mter-
lOCl<s wilh the mesmbuccal groove
of Ille lower f11s1 molar
Right The cusp ol the upper
canine occludes Mtt the width ot a
premola1 behtnd the lower canine,
DelWeen the IJp of tile canine and
the top of the l11st premolar cusp 1n
the loWer arch.

97 Angle Class 11/0i•islon 1

(distoclusion with labioversion
of the maxlllary Incisors)
The lower dental arch is retruded 1n
relahon to !he upper dental arch
t1hemandible as the relerence potnt
10< lll•S claSSJhcauon. assuming
111a1 tile mandible is mobile 1118 lhe
TMJ).

ten: Diagram showing an Angle

Class lllDMsoon 1 malocclusion
where the mandibular den11t1on 1s
tn a distal rela11onsh1p 10 the maxol·
lary dent111on by lhe width of a pre-
molar around the canines and nrst
motais.

98 Angle Class II/Division 2

(distoclusion with llnguo-
version of the upper Incisors)
Lei!: Diagram Shc)wjng an Angle
Class 11/DIVls.on 2 malocclusion
with a OlSlal relat1onsh1p ol mandi-
bular 10 maxillary denlal arch by
tile width ol a premolar.

Rrght"The mandibular arch IS In a

pos1enor position by half the Width
of a premolar around lhe canmes
rS1ngular anlll1)on1sm"l.

99 Angle Class Ill

(mesiociusion)
The lower denial arch ism an ante-
no< relallon 10 the maxillary arch.

Lefr. Dlagramma!lc view ol an

Angle Class Ill malOcclUSlon with
anterior cross-bee, The mandrbu-
lar denmoon amculates m a relative
arnenor oosnon by lhe w1d1h ol a
premolar.

R19ht. The lower teeth are 1n a

mesoal retanonsmp to the upper
teeth by ', of the width ot a premo-
lar 1n lhe canme regJOn
 lnterarch relationship 47

Overjet
The extent of overjet is determined primarily by the
positioning of the upper and lower anterior teeth. Only
in a minority of cases, the anteroposterior skeletal rela-
tionship is reflected directly by the amount of overjet,
The mean value ofthe overjet in the "normal occlusion"
is approximately 2 mm; being correlated to the labio-
lingual thickness of the upper incisal edge and the age
of the patient (Fig. 100).
Depending on the direction and degree of abnormal
labial/lingual inclination of the upper and lower inci-
sors, different types of anterior malrelationship can be
present with the same anteroposterior malocclusion.
Should the sagittal dentoalveolar malalignment of the
upper incisors coincide with that of the lower incisors,
the overjet remains unchanged. Should this not apply,
the overjet is either enlarged or reduced. Many clini-
cians connect irregularities of the overjet with an
abnormal tongue and lip function or with a discrepancy
in intermaxillary tooth-size between the upper and
lower anterior arch.

100 Overjet
nvn This term os deflrl<ld as being me
5,5 a1s1ance berween the 111C1Sal edge
of the upper central 111c1sor and me
5,0
laboat sur1ace ol the lower central
4.5 1ncasor.
4,0
Right. Graph showing the avera9e
3.5 changes, according 10 age. on !he
3.0 OV9f}el of deaduous and perma-
nent 1eeth. separately fol boys ana
2.0
g11ls (Moyers el al .• 1976).
2.5
1,5
1,0
2 4 6 8 10 12 14 16 18 y"ars

101 Variations in overjet in

Class 11 malocclus
ions
Left: Increased oveqet wnn tne
upper and lower incisors on cotfea
axial 1nchnatoon.

Comer Reduced over1el. with me

upper anterior 1ee1h 1n l1nguover-
SJon and lhe lower incisors 1n COf-
reCI axial tncl1nahon

R1ghr· Reduced overiet wllh tns

upper antenoe 1ee1h 1ncorrectaJ<1al
pos111on ana the lower incisors
lipped labially.

102 Variations, depending on

the position of lower Incisors
Let1 Increased ovenet, With 1he
upper antenor teeth Hared labrally
and the lower 1nc1so<S 1n correct
axial 1nchnaJ100.

Center Increased over1et. w11l1 lhe

upper amenor teelh 1nci1ned labial-
ly and the lowru inosors lingually.

Right· ShghUy reduceo Ollefle•

with bolhlheupperandlowerame-
nor teelh 1n labtove<Slon
4tS lAass111cauon 01 1V1a1ut;1.;1u~1u11

Vertical malocclusions - Deep

bite

103 Excessive overbite -

Deciduous dentition
The overbue is coosrcereo to be
excesscve when the 1nc1sorsover-
lap by more than hall
Genume deep bole in a dCCI·
duous denrn1on where lhe 10..er
arueriOt teeth am covereo com-
pletely as a result of an mcreass in
height ol lhe upper anterior alveo-
lar process.
Ari e.ceSS<ve overb11e may be
encoontemd dunng any develop·
mental period of the dentotoon.

104 Deep bite with Class Ill

malocclusion
Deep bite 10 contuOCllon with man·
d11)ular prognath•sm and inverted
overb1la
nus vet11cal deviat100 can be
related with anv other anteroposse-
nor or uansverse malocctusion

105 Length of clinical ct0wns

Deep bile m a patient with long
clm1caJ crowns ol the incisors bul
wolhout any increase 1n he1gh1 ol
the anleflor alveo4ar process.

106 Closed bite caused by

loss ol posterior teeth
G1ngovalty suppor1ed closed b<te
resut11ng tram premaJure E!)(!(ac-
llon ol 1eeth m lhe mixed dentr-
tJOn
Pa!hogenetrcally,lhe closed bite
rs caused by an increased IO<Ward
and ul)Ward rotauon of rhe man-
dible. resulung from lack ot posre-
nor dental support
 lnterarch relationship 49
Transverse malocclusions

107 Btlateral cross-bile

Class II malocclust0n w11h a narrow
upper arch
The b1la1eralcross-bte rsa -eson
of !he maxillary connacnon

ten Long1tud11'18l seceon through

the models of a case with bilateral
cross-bue an<! narrow up- arch

108 Diagrammatic view of

transverse ecetuse! deviations
of the postenor segments

Center Normal bUCC011ngua •ela·

tton The cusp tips of tne lowe•
posieoor teeth 1nterd1g1tate..v1tti the
central fossae of the upper pas-
•
tenor teeth

Above/eh ln!CfTilaJ(tllaryrelatJon
in
case of a bilateral edge-t\Hldge
bole and.
Eage-to-edge-bt1e 8uoea1 nonoeetusion
Above nght a bdaleraJ. buccal
nonocclusion

Below ten: Occlus.oo on case of a

b1laleral cross-bile and.
Below nght a b1talll!al, hngua'
nonocctusion.

Transverse occiusat dev1at1onscan

be eotherunilateral or btlatetat The
1nd1v1dual malocclus1onscan beof
Normal usnsverse occtus10n
aofterent genesis

Cross-bite Ungual nonoccJuak>n

109 Buccal nonoccluslon

W11h this type ol maJ1elanonslllo.
the upper posterior teeth ocdude
completely buccally of the !ower
teeth. The devra1t0n rs classified
according to the l)()Slllon ol the
upper teett>

Leh long1tud1naf section lh1ough

a case with bilateral. boccal
nonocctusion caused by over-
expansion of !he upper arch
50 Classmcauon ot Malocc1us1on
110 Transverse malocclusions
of the anterior region
Compdat1on oC the vanoes causal
factets leading 10 the d1ffe1en1 Deviations of the midline
forms ot m1dtme shdL

• Maxilla • Dentoalveolar
• Mandible • Skeletal
• Combined forms • Combined forms

Midtine deviation

111 Oentoalveolar midline

sMft in the upper arch
The upper oenllal 100SOts have
dntted roward the r1ghl,across the
uppei m1dllne,due to the congeru·
tally missing upper nght lateral
anetsor

Right In cases oC dentoalveolar

drill. the contact pomt of the upper
ceniral 1nc1SOts no longet coin-
cides with the center ol the phtl-
trum

112 Mldnne shift in the lower

arch
In lhe mand1ble.111sd1fficu1110 ddfe·
roouate cllnically between a dental
mldhnesh1tt (resuf11ng lrom loath
m1gra11on1 and a mandibular de-
111at100 resulhng lrom a lateral 1aw
rotaf1on ol the bony base wnh
asymmet.r1c 1aw development

Right' Tracmg of a PA cephalo-

gram. In case or a dentoalveolar
drift. the menial spine o1 lhe man·
d1bleco1nc1desw1thIlle m1dsag111al
plane oC the skull and only the COt\-
tact poir11 ol the tower mersors rs
deviated.

113 Skeletal deviation of the

mandibular mldllne
Left. Diagramshowing the normal
morpnotog1c 1e1a11onsh1ps of the
mandible on a PA oephalogram.
The mentalspme ol the mandible
and the contact pointof the 1nc1SOrs
comade wllh Ille laoal m1dsag111al
plane

RrgnL Reiauonsh•ps 1n case ol a

laleral d0111ahon ol lhe tower bony
base. The skeletal m1dl1ne ol the
mandible (menial spine) and the
contact point of the lower onosors
are d1SJ)laaed m uni.son.

Evaluating the Occlusion
During the 1970s, Andrews extended Angle's classi-
fication of .. normal" intercuspation. He reformulated
the static prerequisites for optimal equilibrated occlu-
sion and called them the "six keys of occlusion," based
on the analysis of the tooth material, in particular tooth
crown morphology.
Ualike the classic parameter of assessment, the long
tooth axis which takes the root inclination into account,
the basic criteria of this extended occlusal diagnostic
concept is the long crown a.\isofthe tooth and the ocdu-
sal plane.
Keys of Occlusion 51
Both parameters can be recorded directly during the
clinical examination or on the study cast and do not
require further, expensive, time-consuming or radio-
graphic diagnostic procedures (e.g. cephalometric
radiographs), A further advantage of this type ofanalysis
is that the long axes can be determined individually for
the various types of teeth.
The occlusion is evaluated according to the following
keys:

The six keys of normal occlusion

I) Molar interarch relationship

2) Mesiodistal crown angulation

3) Labiolingual crown inclination

4) Rotations

5) Tight contacts

6) Occlusal plane (curve of Spee)

114 The first key of normal

occlusion
: Molar lnterarch
~ relationship
• Above. Diagram showing exam-
ples of occlusions with poor Class t
'-- molar relabonsh1ps, aocord•ng to
Andrews, caused by 1nsuHioenl
crown angulS11onoC the upper firs!
molar

\ I
' 7 - Bottom 1efe Diagram snowing an
improved Class I mOlar relat1on-
,._ sh1p
r
Bouom rtghr: Dragram showing
J J the correct Class I molar retanon-
' .)
\.. sh1p according to Andrew's first
key of occlust0n.

According 10 Andrew's ocdusal

concept
- The mesiObuccal cusp of the
uppe< llrSImolar should occlude
in the groove between Iha me-
sraJ and medial buccal cusp of
the lower first molar.
) - The mesiohngual cusp of Iha
upper f11st molar should occlude
1n rhe central Iossa of lhe lower
6-year molar.
- The crown of ltle upper first
molar must be ongufaled so lhal
11s dlsral marginal ndge ocee-
desw1lh 1nemes.al margonalnd·
11e of the fowe< second molar
(Andrews, 1972).
52 Classification of Malocclusion
115 Long axis of the crown

VertJcal lone • Long BJOs ot 1 he

d1n1cal crown (= LACCl
lA spol •Centerot lhe loog 8'05 ot
the din cal crown

Unhl<e other concepts. 11 rs no11he

long BXIS of the IOOth WhtCll 5fJMlS
as the plaoe at reference. 001 rather
11>elongaxrsotlheci1n1calctown II
passes 1nrough tne central, vertical
•
ndge ol 1he loolh, 1 e. lhrough the
most prominent part 1n the center
of the laDial or t:>uccal surface This
aophes 10 all teeth, except molars

116 Mesiodistal angulation of

the crown

- - - Perpend1cutar lo the occtu-

sal plane
- Long a.rs of the crown

The angulallon ol 1he crown rs de-

ltned as the angle whlCll the 1001h
forms with a line arawn perpendi-
cular lo the occtusal plane.

R.ght Drawing showing 1he mest0-

drsral angulat1on ot lhe crown
ol 1ne upper lett central tnc1sor 90
!Andrews. 19721. m d

117 Second key of normal

occlusion: Meslodislal crown
angulation
For the occluslOfl to De considered
normal, the gtngMll pan oC the long
axis oC tne crown must De distal 10
100 occtusal pan of the 8J(lS
The degree of angu1a11on de-
pends on the 1ype ot tooth.
.. .
Right. 01agrammallc Vtew oC !he
mas1oatstal angulalion oC 1he
crowns when the occiusron rs nor-
mal (Andrews. 19721

118 Mesiodistal crown

angulation for various types of
upper teeth

Honzontal plane of reference •

uoe passing through all LA SPOIS
(Andrews plane)
Vertical plane of re!erence =Per-
pendicular 10 Iha horizontal plane
90
According to Andrews. in lheuppe<
jaw the crowns of the canines exh1-
brt 1he greatest degree of angula-
bon and !he premolars tne leasl

2 11
 Keys ot Occlusion 53
119 Third key of oeclusion:
Labiolingual crown inclination

Tangent on 1ne etown of lhe

1ootn
Perpendicular tolheocclusal
plane

The 1hird key defines 1he angle be-

iween a 1angen1 to 1he LACC at 11$
cerner and a hne perpendicular 10
the occlusal plane
11 me gongrval area ol tne crown •s
more loward lhe lingual, Ille resu I
1s expressed rn positive values;
should !he opposite apply. 1ne
resuli rs negatwe

120 Labiollngual crown

' -r7• inclination between upper and
lower incisors (crowntorque)
~\ Tooth crown 1angen1
\I Perpendiculartolheocclusa·
plane
Crown rorque
\ - Long axes of tne Incisors
I The upper 1noSO<S form a posottve

\ angle with lhe crown 1ar1gent and

the lone perpend ocular to the occlu-
sal plane(+ 1") and anangfeof18"
berween 1he crown 1angen1 and lhe
long axis ol the 1001h
The crown lorqoe of lhe lower in-
cisor IS -1• and th&angle between
Occlusal plane nscrown 1angen1and1heaxasol 11>e
' mesors rs 16" The 1n1enoosa1
angle between the crown tangents
90 I of the uppe.- and lower mosoes as
174° for normal OCCIUSIOOs {unhke
lhe m1enne1sal angle between lhe
ax"5 ol 1he 1nc1sa<s which is con-
sidered 10 be. on average 139")
(Andrews. 1972).

I
I
16 -1- -I

r---11
121 Incorrect crown torque
10 and ocduAl findings
Should the upper antN10< 1reth be
in a 100 upright oosmoo (lhe lablO-
llngual crown 1nchnaJJOns ol the
upper 10C1SOrs have negative va~
ues). lhe occlusion rs unstable
The canme guidance 1s msumoent
and mere asa nsklhal me posieoor
teeth will drott toward the mes>al
!Andrews. 19721
54 Ctassitlcatron of Ma1occ1us1on
122 Anterior and posterior
occlusion in case or incorrect
crown torque
tt 1he posterior oc:cluso0n rs eo<red.
bUl the upper 1nasorsaiein hngoo-
verslon, this can resun in 1nterden·
lal spacing ol the anterior teeth
wtuch then IS ol1en rncorrectJy
assooa1ed wt1h a discrepancy m
tne 1ntermaxillary IOOtn·SIZC (An·
drews, 19721

123 Occtusal changes alter

orthodontic treatment
Cf1n1cal plClure of !he si1ua11on
schemallClllly shown In Fig 122.
Occlusal relations'" the oosueten-
llOn Slage alter onhodon11c neat-
menL
The long·Illfrn result is a denlally
supported bite wrth lingually m-
ci1ned upper incisors and a space
poster10t to the uppei nghl canine.
The canines are no longer in Class I
relallonsh1p.

124 Labiolingual incllnatlon

of the posterior teeth in
optlmel occlusion
The 1angents on the laetal surfaces
ol the crowns IO<m negatM! values
with the fine drawn perpendicular
to the ocdusal plane, IA the 91ng1-
va1 portions ol the 1eeth are more
proooonced bueeally than theocc-
tusal pomons.

The upper canines and premo-

) I I
lars are 1nci1ned al V!rlually the '
same angle, whefeby the molars
are tilted slightly more.
In the lower arch. the mctmauon
Increases progressrve!y from lhe I I I II
canine to the second molar

_/
 Keys ot Occlusion 55
125 Fourth key of occlusion:
Rotations
tn order 10 achieve cofrecaocclu-
sioo. nooe of lhe teeth shOuld be
rotated Rotated molars and pre.
molars occupy more space tn the
dental arch man normal Rota!ed
mosors may occupy less space
than those correctly abgod. Ro-
tated canines adversely allecl
esihehcs and may lead lo cx;ciusal
lnte<ferences

I~
126 Fifth key of ocelusiono
Tight contacts, no spacing
II there are no anomalies 1n the
shape ol lhe teeth, onntermaxrllary
drscrepanc1es in lhe meslodlSlal
toolh Size, lhe comact points
shOuld abut in n01mal occlusion.
cumear picture of a poor ex·
ample, with spaces between the
upper leelh and a Class I re!at1on-
smp ol lhe canines. These f1nd1ngs
are 1nd1catJve or a Bollon d1screp.
ancy (reler top. 228).

127 Sixth key of ocelusion:

Curve of Spee
a An excessive curve ol Spee re.
smcis lhe amount ot space avau-
able lorlhe upper teeth,which mUSI
then move 1oward the mesial and
drslal. lhus prevenllng correcl 111-
tercuspauon.

b A normal occlusion has a ltat

occlusat plane (acC01dm9 lo Ar>-
drews, 1he mandibular curve of
Spee should not be deeper than
1.5 mm),

c A reverse curve ol Spee creates

excessive space 1n lhe upper 1aw,
whrch prevents developmem of a
OO(mal occlusion (Andrews. 19721.
1111111
b

c
Curve of Spee - Occlusion
- Case uamples -

128 Reverse curve of Spee

This panoramic rad>OgraPll snows
the oectesal relauonsll1p resulung
from a reversesaQo«alcompensal·
1ng curve When compared lo 1he
upper iaw. 1nsuffic1en1 space is
availaDle 1n ""' lower aen1a1 arch
and 1heanten0ftee1n are crowded
The bite IS open antenoriy

129 A1tt curve of Spee

Flat sag111al compensabng curve
w1lh good ontercuspal1on around
the premolars and molars.
This type of curve rs considered
10 be "normal" according 10 An·
drews.

130 Excessive curve of Spee

PtOnounced sagltlal compensal·
1ng curve Wtth excessive space 1n
1he upper denial arch aod inade-
quate space in the lower arch.
The lower incisors ate etowded
aod lhe overbite IS increased.
 Etiology 57

Etiology of Malocclusion

Etiological assessment of malocclusion is an important aspect in orthodontics, as the genesis of the

deformity provides keys to the planning of treatment. The developmental process of dentition and
craniofacial growth takes place over a period of approximately 20 years, whereby the environment
has a modeling impact on the genotype, being an integral part of the factors of heredity. Due to this
interaction, it is difficult to classify the etiology of malocclusion exactly, as the causes are often
multifactorial and prevent exact differentiation between endogeneously and exogeneously induced
changes.

According to the current level of etiologic research, the malocclusion in orthodonticsj'only has a slight effect
the inherited pattern of malocclusion is usually not on the specific manifestatiou in the phenotype.
monogenic, but rather polygenic, i.e, the single gene Only the accumulative effect of the various numbers
which plays a role in expressing the characteristics (i.e. of genes involved determines the inherited trails.
131 Etiology or malocclusion
Comparison of the two drffernnt
:r
(II determ1n1nglact0ts in the gene5'S
~
of demoalveoiaf and skeletal
a
..
c:
Hereditary factors
~
malocclusons,

0
0
:::> .g
3

g., 0

.
c:
E
"O
e
::> Envlron1nemal effects
..
0
::>

O"
:i

Therefore, polygenic characteristics or rnalocclu-
sions do not have such a definite clinical appearance as
monogenic ones (e.g. hereditary enamel dysplasia),
which can be distinguished by their relatively stan-
dardized phenotype.
The etiology of malocclusion is mostly based on a
multifaaorial system with "additivepolygenesis" and thres-
hold effea, i.e. in order to become a distinctive factor in
the phenotype. the inherited bundle of genes can be
"tipped over the edge" for instance by environmental
factors (Jorgensen, 1966). Depending on the genetic
constitution, the exogenous influences must be mild
to severe for expressing the character of the deformity
in a more pronounced form. On the other hand. they
can also camouflage a deformity if they oppose the
bereditary factors (Figs. 132-134).
The exogenous influences can be either systemic or
localized. Whereas systemic factors such as climatic or
ecological conditions, nutrition, and diseases can influ-
ence the overall development of the human organism,
local factors in the etiology of malocclusions have an
effect on the masticatory system only.
The exogenous influences can be of a static or func-
tional nature. Static factors have an effect on only one
specific site or are only active once (trauma).
58 Etiology
132 Aggravation of traits in
the phenotype
Clinical findings of an 8-year-old
paneru w11h hereditary mandibular
prognathlsm (Class Ill)

R•gl>t. The malocclus1on. 1.e. im-

peded developm8fll of Ille uooer
iaw. was 8Xacerbated due to pre·
mature loss o4 lhe deCtduous teeth
and ea~y extracuon of the upper
len oermanen1 molar.

133 Interaction between

hereditary factors and
exogenous Influences Aggravation
II, m the euology of malocclus1ons.
the exogenic onnuences take place
m the same d11ect1on as the hered- A
itary factOJS. the resulling accumu- I
lauve affect leads to aggravated
cnaractensucs in the phenotype.

Vice versa. the trans of the geno- __ ,.,....._.~--Accu--m-u_la_ti_'°"

I _.I• __
type can be masked by the effect of
env1ronmenlal !actors.
+++++ +++++ +++++ +++++

....

_____ , _
+++++ +++++

. . 1. . eo_mpen
__sa_tion
__ __.l·
I
'
Camouflage I
134 Camouflage of hereditary
factors
An open bite due101humb-sucklng
and tongue-thrust 1n a 4-year-old
femalepauenL

R1gm· t year aher elim1na11ng lhe

exogenous onlluences (1ermrnat1on
ol 11>e dysfu11C11oos), the genelic
pre<JJSpOSl!IOn to dental Crowding
becomes apparent
 List ot Factors 59

Causes of Malocclusion

As it is not possible to classify dentofaciaJ anomalies precisely, their most common original causes
have been summarized in seven groups (Dockrell, 1952):

acts for a specific period of on a particular producing

Cause ----------'l> time ...:...------? tissue ----- ;;;. results

I) Hereditary l) Continual, I) Neuromuscular I) Malfunction

2) Anomalies due to intermittent, ussue 2) Mal-
maldevelopment or only once 2) Teeth occlusion
3) Trauma 3) Bone 3) Bone
4) Physical agents 2) Various age levels 4) Cartilage dysplasia
5) Habits (pre- or postnatal) 5) Soft tissue, except
6) Disease muscles
7) Malnutrition

Each causal faaor primarily affects a particular tissue
for a certain period of rime, which causes the deformity
(see above). As far as the time factor is concerned,
the specific cause can act continual. intermittent. or
operate only once, in any or all developmental stages
(pre- or postnatal).
The results of these disruptive factors depend on the
localization and texture of the tissue most affected by the
deformity. The primary tissue site may be: the neuro-
muscular tissue, the teeth the bones. the cartilage tissue,
and the other sojitissues.except the muscles (see above).
The primary deformities caused by these factors are:
malfunction, should the neuromuscular tissues be
affected primarily; malocclusion, should the teeth be
affected primarily; and osseous dysplasia, should the
bone tissue be affected primarily (Fig. 135).

135 Causal pathogenesis of

anomalies
Tile etiology of a demofac1a1 detor
m11y rs determined by lhe type a
Primary tissue site Anomaly
ussoe which Is pnmanly affeciS<
by Ille causal fac:tor
In many cases. a combmation a
all three anomalies cccursas.aaar
/ Neuromuscular tissue Malfunction from !he primary ussue Site tn.
Olher nssees, are usually second
./ Malocclusion
anly also involved 1n 1hedelorm11)o
Causal factor Teeth
<,
~ Bone tissue Dysplasia
60 tt101ogy

Hereditary Abnormalities
For a long time, inheritance was considered the most
important causal factor in the genesis of dentofacial - Neuromuscular system
deformities. although there is nearly no scientific evi- - Teeth
dence to support this thesis. Exact details about the - Bone/cartilage tissue or
significance or hereditary factors in the etiology of - Soft tissues
malformations can only be gained by carrying out
extensive studies on twins and families. According to
current knowledge, the following tissues can be primar-
ily affected by genetically transferred dentofacial defor-
mities:

Neuromuscular System

Hereditary deformities of the neuromuscular system
consist primarily of anomalies in
size, position, tonicity. contraaility. and in the neuro-
muscular coordinationpauern offacial, oral. and tongue
111usc11la111re.
Thus severe deformities of the dentoalveolar region
occur with both macroglossia and hypoglossia.
The configuration or the lips as well as their compe-
tence and function are or great importance if the oro-
facial system is to develop optimally. Certain types of
Lip configuration which occur several times within one
family may be hereditary and thus predisposing its
members to dysfunction and malocclusion (Fig. 136). It
is often difficult to decide whether tongue and lip habits
are due to hereditary factors or due to imitation.
Rare pathological muscular conditions, such as hyper-
trophy and atrophy, can also cause malocclusions.

136 Genuine Class II

malocclusion in three brothers

Top raw· Profile Views

Bollom raw OvetJel

Top row Whereas lhe oldest bro-

thet ffettJ has normal, compelem
lips, lhe )'QUfl9er s1bhngs show a
disturbed lip seal (open mouth
posture, sho<t hypotonlC upper
lip).
The youngest child (righQ has
tn add1t1on a hyperfuncbomng
merualJS muscle.

Bollom row.·Chmcal ptetures of the

correspoodong over1ets
The clJHerent degrees ol 1he
malocclusion CO<relate 10 !he d1f-
feren1 amount of neuromuscutar
dlSlurbance.
The oldest brother (/eh), with nor-
mal hps, has lhe smallest oveqet
and the youngest brother, with in-
competent tops and hyperact1vo1y of
the mentalis muscle. has the
largest ovenet (ngl>I).

Dentition
As has been shown by twin studies, very many features
of the denrition are hereditary:
- Size of the teeth
- Shape of the teeth
- Number of teeth
- Mineralization of teeth
- Path of eruption and primary position of tooth
germ
- Sequence of eruption
Severe deviations in shape and size of the teeth are the
most common causes in the genesis of dentofacial
malocclusions. From the orthodontic point of view, ii is
usually not the actual size of the teeth which is relevant
(Figs. L37. 138). but rather the size of the teeth in
comparison to that of their bony bases (Figs. 139, 140).
The prevalence of hypodontia - without taking the
third molars into consideration - was quoted by Dolder
(1934) as being 3.4 %; the anomaly being less frequent in
the deciduous dentition than in the permanent denti-
tion. The third molars are the most often missing tooth,
followed in descending order by the lower second
premolars, the upper lateral incisors, the upper second
Genetic Factors 61
premolars, the lower central incisors. and the upper and
lower first premolars. Hypodontia often occurs in
combination with other syndromes (e.g. ectodennal
dysplasia, cleft of'lip.jaw and palate, Down's syndrome)
(Fig. 141).
The data on prevalence of hyperodontia show a wider
range. Cases of hyperodontia are less common than
cases with congenitally missing teeth. All types of tooth
can be supernumerary, particularly in the permanent
dentition. Hyperactivity of the dental lamina occurs
more often in the upper jaw, especially in the anterior
and molar regions. The next most affected teeth are the
lower premolars and incisors (Fig. 151). The super-
numerary tooth can be formed either normally or
atypically. It can also be formed in such a manner that,
due to gernination and fusion. the supernumerary struc-
ture does not develop separately but rather results in an
oversized tooth (Fig. 156).
Supernumerary teeth are common in patients with cleft
lip and palate around the cleft area (supernumerary
lateral incisors) and in cases of cleidocranial dysostosis
(Fig. 154).
137 Microdontla
Mlcr0don11a ol the maxillary latera
1nCt.SOr&.
Of all the types ot teelh, lhe uppe1
lateral incisors vary most m Shape
Anomalies on tooth S12e can bE
fest/lCted 10 1nd1V1dual teeth Ot
may occur generally.
138 Macrodontla ol tndivlduaJ
teeth
Tooth anomaly In lhe upper anter-
oor region due 10 over;ozed lalera
inc.sors..
62 Etiology
139 Macrodontia ol the upper
teeth In relation to the si2e of
basal bone
Due to lhe dlspropomon in size be-
tween tne two suooures, the aruer-
1or 1eelh are crowded and the pos-
ler'°' teeth are severely lipped
buccally.

140 Microdontla or the entire

dentition In relation to the sin
of the basal bones
The spaces between the teeth are
the result ol a size discrepancy be-
iween lhe denial arches and the
basal Dones.

Hypodontia

141 Hypodonlia of deciduous

teeth
Congenitally m1ssmg upper lateral
deciduous 111C1sors 1n a case wi1h
lamrhal predlSl)OSltKl<'I 10 hypO-
donoa

Right: Corresponding panoramic

radiograph.

Hypodonlla IS rare among pnrnary

1eelh.

142 Hypodontia of permanent

teeth
OccluslOO of the pat1enl shewn In
Fig.141at11 years olage. The upper
laleral permanent inctsors are
mossing.
The uppet canines have erupted
mesially.
In Gaucasian populations. lhe
rtlOS1 common teelh ol lhe perma-
nem dentuoon to be affected by
congenital absence are lhe lower
second premolars and Ille upper
laieral incisors.
Genetic i-actors sa
143 Po$ilion of the deciduous
tooth In case of con11enltally
mluing permanent tooth
Submerging of perSISlent lower.
second deciduoos molars - a
m1crosymptom of congenttal ab-
sence of Ille mandibular second
premolars.

Hypodontie and occlusal

relations

144 Shape of the upper

dental arch
The anterior archotthts12-year-old
female pahent has been flattened
nouceably due to congen11ally
mlsslng upper lateral tnetsors.

145 Occtusal findings

The discrepancy m anterio< tooth
size between the upper and tower
arch promoted Ille developmeruof
an anterior cross-one,

146 Oflgodontie
Hypodonua of a large number ol
teeih In a patient wrth a b1latwal
cleft of hp, 1aw, and palate.
The patient shows congenrtal
absence of the upper lateral 100-
sors, the upper first and second
premolars. the lower leh central
Incisor, and the lower second
premolars. The tooth germs of the
upper permanem canines are dys-
topic.

Left The ol1godont1a in lhe maxol-

lary arch further impedes •Is devel-
opment.
64 euoroqy
Inherited ollgodontia of varying
expression in tour siblings

147 Teeth present in the

oldes1 brother
Hypodontla ol the upper canines.
the lower second molars. and the
wisdom 1ee1h at 1he age of 13.5
years. The upper nghl deciduous
canme 1s pe151stenL

148 Teeth present in the

second oldest brother
Congenital absence of the upper
canines, the upper rig tu lateral inci-
sor. and the lower second premo-
lars at the age of 9.5 years. The
upper lett lateral mc1SO< is hypo-
plasac,

149 Teeth present In the

youngest brother
The lhltd son of !he family has
severe ologodont1a at the age of 10
years - congenUal absenoe of the
upper right lateral lnosor, the up-
per nght first premolar,bolh upper
canines and second premolars.
and lower second premolars.

150 Teeth present in the sister

The youngest Child of the family, a
6-year-old girl, has hypodonua al
the upper right ta1eral metsor, the
upper left second premolar and
both lower second premolars. The
germ al the uppertefi ta1era11nc:1sor
is hyl)O!llasltc. The germ al the
upper right permanent canine 1s m
ectOPIC pcsmon,
Genetic I-actors 65
151 Hyperodontia
Radoograph ol a 22-~-old le-
maJe panem wi1h four supernumer-
ary 1eelh
Supernumerary teeth are pre-
sent 1n t>olh premolar regions ol
!he lower arch. The germ of a d1sto-
molar rs apparent m !he upper
leh QuadranL It 1scons1dered 10 be
the resull ol excess.ve l0<ma11on of
Jhe denial lamina

152 Meslodens
Supernumerary. rudimentary
IOOlh, which has erupted be!V>'een
!he upper central mesors,
This type of abnofmahty is often
Inherited and is the most common
type ol hyperOdonlla II can severe-
ty impede !he eruenon of the anter-
ior teeth

153 Odontoma
Supernumerary mineralized struc-
ture localed near the crown ol lhe
upper nght canine which mterleres
wllh eruption ol !he canine and.
together wnh the peneotonaJ cyst,
1s reta1mng 1t.

154 HyperodonUaln
cleldocranlal dY$0slosis
Muh1pfe, ectopic. lul!y or panlally
1mpae1ed permanent teeth m a is-
year-old lemale patient
The supernumerary 1nc1SO<S, ca-
nines, and premolars as well as the
persistence ol lhe deciduous deo-
unon are 1yp1cal findings in rrus
type ot skeletal delec1.
66 Etiology
155 Diagrammatic view of
abnormalities of tooth
morphology
a Geminatlon = Incomplete d1vi
OD 00 00
sion of one single loolh bud

b Tlvinning =CompJe1ed1V1s1on ol
ooe tooih bud 10 creaie 2 1ee1h.

c Fusion = Union ol 1he denun of

IWO leelh. from IWO lOOlh bi.Ids.

d Concrescence s Union of lhe

cellular cementum of two 1eeth,
from two looth buds. (Tannenbaum
and Al/mg. 1963).

156 Gemlnation
Incomplete dMs1on of the tooth
buds of ihe upper central 1nctSOrs.
These Olle!Slled, cosmet1catly un-
pleasant 1eeih a.re typical ol this
iype of anomaly.

Rtght The notch 10 the 1ncisal eo-

ge, and lhe axial groove lhrough
lhe crown, ts a resoll of incomplete
seoaraton of the 1001h bud

157 Tlvlnning
Supernumerary looth In the lower
anlenor region.
Judging by ihe shape and ssze
ol the teeth, the hyperodonua
appears to be a result of the bud ol
the nght cen11al mcisor d1V1d1ng
and forming two complelely seca-
rate 1W1 n teeth.

158 Fusion
Fusion beiween an upper lefl cen-
1181 incisor and a supernumerary
IOOlh.

Rtght Thetoolhcrownsare partial-

ly fused. In this case. the union can
be separated and the supernumer-
a.ry tooth extracted.

Inherited defects or the tooth struaure differ from
exogenic-induced disturbances in mineralization as
follows (Fig. 159):
I) An inherited malformation is present in both the
deciduous and permanent dentition.
2) It is localized in either the enamel or the dentin.
3) Inherited defects of the tooth structure are arranged
either irregularly or as vertical ridges and grooves
(Fig. 162).
Genetic Factors 67
Dysplasias of the enamel can be either hypoplastic or
aplastic (Fig. 162). Dentinogenesis imperfecta often
occurs together with obliterated pulp chambers, tooth
root deformities, and osteogenesis imperfecta (Figs. 160,
161).
The fact that retained teeth and ectopic teeth tend to
occur frequently in the same families indicates that these
abnormalities are determined genetically (Figs. 166-
169). .

159 Disturbances in ealclfi·

cation due to hereditary and
Abnomalities of tooth structures environmental factors
Compaoson of lhe d1fleren1 patho-
logic symptoms or IOOth structure
Hereditary Environmental

Deciduous and Deciduous or

permanent dentition permanent dentition
Enamel or dentin Enamel and dentin
Irregular or vertical Horizontal

DentlnogenHis lmperfecta

160 Clinical findings

Heredtlary dysplasla ol !he denun
1n a 19-year-old panenL
Shon.amber-colored upper and
lower anterior leelh. wilh splJniered
enameland marked attnlion ot lhe
Incise! edges 01e iyp1cal clmiml
llndings m trus d1srurbancem IOO!ll
lorrnanon

161 Radiographic findings

In cases of denunogen6SIS Imper·
recta, lhe rad1ographs reveal lhe
following findings
Reduced rad1ograph1c con1ras1
OI the dentin. Obfllera11on of !he
pulp chambers and root canals,
Shon. d1laled 10015.
Anomalies 1n lhe shape cl 1he
roots are also present with con-
~ric11on 1n the cervical regions.
Rad1ograph Ol the pauent ShOWn
1n Fog. 160
68 Etiology._ _
162 Amelogenesis imperfecta
- Hypoplastic type
The uun, chalky-white and brown
enamel ts hard and 11s surface Is
rough, coveJed Wtlh pits and fis-
sures. Annuon occurs at a higher
rate than normal and pans ol lhe
enamel have chopped trom the
undedy1ng denim.

163 Amelogenesis imperfects

- Hypomineralized type
This 12-year-old girl has yellowish·
blown. very soft enamel. The sur-
faoes of the toolh are dull and
OOJered wrth ndges and grooves.
Noticeable amounts of enamel
have fractured away.
The enamel d~lasaa is com-
bined w11h an open b11e.

Amelogenesis imperfecta
- Hypermature type

164 Mixed dentition

The permanent teeth halle opaque
white, dull enamel, and !he enamel
of !he inasors shows the first signs
of spltmenng. The pauent 1s a
9-year-Old boy.
The a1sturbance on enamel for-
rnanonocccrsjoqether w1thacom-
plex open bite.

165 Early stage of permanent

dentition
Theename!onthecanlnes,premo-
tars, and molars has been dJS·
solved and the dentin has been
siaioed dark brown. The crowns
of the teeih exh1brt anomalies In
shape and size

Righi. The surlace of lhe toolh rs

smooll\.

Occtusal findings ol the patient

shawn1nFig 164,al13yearsafage.
Genetic Factors 69
Impaction of teeth

166 Impacted second

deciduou.s molar
lmpac1ion ot the lower nghl pmn-
ary second molar in a 9-year-old
male pabenL
The space lor lhe unerupled
deciduous 1001h is rest1cteddue 10
meS1albppiog ot 1he aojacem 1001h
on the distal Side, whlCh is IYJ)Jcal
for cases of ankylosls. The perma-
nent looth germ has been dis-
placed distally by lhe 1mpaded
deciduous tooth
In lh1s case the erupuon aonor-
mahly •S hereditary (reler lo Fig
167).

167 Hereditary Impaction of

deciduous teeth
Aad1ograph of the 7-year-old bro-
lher ol lhe pa11en1 shown on Fig 166.
This patient shows ankytoos ol
lhe lower left deciduous second
molar. The underlying germ ot lhe
permanent tooth has been dis-
placed meSlally.
The space lor the unerupted
toolh has been narrowed due 10
rnes1aJ upping ot me hrst oerma-
nenl molar.
The erupuon ol ine upper left
dectduous second molar ts also
being disrupted by lhe same phe-
nomenon

168 Transposition of teeth

Two ad1acen1 teeth have ex-
changed pcsmcns m lhe denial
arch lor genetic reasons
Umta1eral1ranSP<)Slt1onol the lel1
upper canine and hrst premola!
w11h congenllal absence ol !he
upper lateral Incisors.

Left· Occiusal relation ol the leh

antenor region with the malpos;-
lloned uppei 1ee1h.
Transpos1Uonof tho upper ca-
nine and lhe premolars ts lho mos1
common iype observed,

16° Bilateral transposition

E!oth uppei canines and hrSI pre-
molars are transposed
The malahgnmenl m this female
oanent LS due 10 he1ed11ary tactors
70 Etiology
Bones Whereas bone size anomalies account for some of the
causes of hereditary micrognathism or macrognathism
Certain genetic factors influence bone development of (Figs. 170, 171), variations in bone location represent
the mandible, the maxilla. and the other bones in the some of the causes of prognathism or retrognathism.
craniofacial complex, leading to hereditary osseous Hereditary variations in jaw shape often cause asyrn-
dysplasia. The following may be affected by these metries.
aberrations: Unlike agnathism, which is very uncommon, hypo-
plasia and partial aplasia of the jaw bones occur together
- Bone size with craniofacial dysostoses, such as hereditary mal-
formations of the area around the first branchial arch
- Shape of the bones and the jaw bases
(manclibulofacial dysostosis, maxillofaciaJ dysostosis),
- Bone location
- Number of bones present cleidocranial dysostosis, and Crouzon's disease
(Fig. 171).

170 Hypoplasia of the

mandible, combined with
embryopathy
Facial profile and anleropostenor
1aw relallonsh1ps tn a J-ye111-okl
pallenf wnh dysmeha and vanous
organic defects. The hyPQplas1a ol
!he mandible has resulfed in a
receding laClill profile. The mal·
fooned exlemal ear rs also apoar-
em on thefacial view Due to severe
retrogna1h1sm al the mandible,
the lower lip IS posmoned behind
the upper incisors.

Right This type ol son-nssue

mO<l)hology ea11ses progressive
increase In over1et.

171 Hypoplasia of the maxilla

in Crouzon~s disease
(craniolacial dysostosis)
The cnaracrensoc extraoral symp-
toms of Crouzon's disease rn this
6·Ye31·old pattent are lhe exo-
ph1halmos, tlypertelonsm, lhe
broad rOOI oj me nose, and tne
orotrlld1ng lower hp.

R•gh1 Due to premature ossi-

f1eahon or lhe cranial sutures. this
syndrome causes coogemla! oxy
cephaly, wilh prommeru d1g11al
cranial marklngs. malformat1onsot
1he bony oiti.is, and hypoplas1a ot
the maxilla.
The maxillary deficiency causes
a skeleial Class Ill rela1JOnsh1p.
Genetic I-actors 71
Deformities of the face and
jaws caused by embryonic
malformation o'f the second
branchlal arch

172 Frontaland profile views

This 13-year-old pauem has hypo-
plas1a of the nght mandibular
ramus. The angle of lhe mouth and
the bony chm are d1stoned IOWard
lhe site of maltormanon,

RrghL The nght eans also affected

by the deformity. The right auditory
canal Is blocked aod the maldevel-
opmen1 of the elC!ernal ear resulted
m the formahon of auncular 1ags.

173 Radiographic findings In

the panoramic view
The roghl ramus is almost com-
pletely m1SS1ng Whereas the nghf
condylo1d process ts vest>gl81. 1he
coronold process is well devel-
oped.
The nghl corpus of the mano1oie.
Jtsgomal angle and lhe nghlhalfof
!he maxilla are underdeveloped
AU tooth germs are present 1n botll
arches.

174 Radiographic findings In

the posteroanterior and lateral
cephalogram
The ver11ca1 development o! tne
11gh1 half ol the lace has been
impeded, 1he occiusal plane dis-
toned upwards lo the nghl. and
the mandible. due 10 its hypoplasJa.
1s shilled to the rig hi toward the sue
of malformallon.

Right The maldevelopment ol the

lower 1awts associated w11h mandi-
bular retrognalhtsm
72 t:!JOIOQY

Skeletal Malocclusion

Genetics play an important role in the etiology of
most skeletal malocclusions. Although previously,
mandibular prognathism and Class II. Division 2
malocclusions were attributed to dominant inheritance.
the data derived from family and twin studies have
revealed that hereditary malocclusions are nearly
always transmitted as polygenic traits (Schulze, 1982),
i.e, the individual deformities only develop due to
the accumulative effect of several hereditary facrors
("additive polygenesis"). The variability in the expres-
sion of a malocclusion in one family is due to the
different numbers of genes involved (intensity) and due
to the environmental factors. The exogenic influences
may compensate or enhance the appearance of the
malocclusion. The genetically determined traits often
only become apparent in the phenotype due to the effect
of environmental factors.
According to current understanding, the following
skeletal malocdusions sxe hereditary: Class II. Division1.
mandibular prognathism, bimaxlllary protrusion, skeletal
open biles, and skeletal mandibular retrognathism.

Hereditary mandibular
prognalhism (Clau Ill)

175 Olffer~t degrees of

skeletal maloa:tuslon In four
siblings
Cephalometric lateral rad1og1aphs
ol lhe oldest (lelti and neJ<t oldesi
(nghl) b<olhar

176 Lateral cephalograms of

the two younger siblings
Left: Facial skeleton ol the youn-
gesl brother

Right Cramoractal mo<phology ol

Ille youngesl sisler.

The degree ol tne arneropostenor

malrela1Jonsh1p increases pro-
gressively from lhe oldest to lhe
)'OUngest child.
lieneuc r-aciors t".J

Occlusion of all four sibUngs

prior to commencing ortho-
donUc treatment

177 Oldest brothers

occlusion
The ~en0< teelh have only a
sllghl buccohnguaJ overbue and
1he upper leli lalelBI 1RCISO(ancl lhe
loWer canine are In edge-l()«jge
retanoo (see. Ftg 175, left).

178 Next oldest brother's

occlusion
The boy shows an um lateral cross-
brte on lhe left side associated wrth
an anter10< cross-bite of the lel!
lateral incisors (see Fig. 175, ngh1).

179 Youngest brother's

occlusion
The pahent IS 7 years ofd and has
total eross-bne (see Fig. 176, left).

180 Youngest sister's

occlusion
The girl was born last and has a
righl laleral cross-bile in lhe early
stage of 1he mixed den1tlion The
upper left cemral 1nctSOr Is etuptlng
1n10 an anterior cross-bite relatiQn
(see Fig. 176, nght).
74 Et101ogy
Soft Tissues

As hereditary anomalies of the soft tissues (excluding

the neuromusculature) often only have a slight effect - Facial clefts
on the genesis of orthodontic problems, they arc of - Microstomia
minor importance. The following hereditary anomalies - Anomalies of the frena
of the soft tissues can be observed: - Ankyloglossia

181 Labial lrenum

Cl1rucal p1ciure of a high, wtde
trenum which rs extended into the
rl'ICrSNe pap1fla and occurs to-
gether wuh a cenlral drastema.
The antenor up of the paptlla rs
beiv....en the upper eentrat rnc1sors.
The heredl1arycomponents of the
lab181 trenum include the heigh! of
1he point ot anaehment and lhe tex-
rure ot the us.sue.

lymphatic tissue

182 Adenoids
Endoseop1c picture of medium-
stzed adeooods
As tile Size and development
or lympha11c ossue may be here-
d~ary, hyperplasia of the aden01ds
tends to run in lam1hes.

Righi Position of the ade001ds in

relallon to the surrounding struc-
tures Is marked on 1h1s cephalo-
metnc lateral rad1ograph

183 Hyperplasia of the tonsils

Increases m the size ot lhe tonsils,
as well as ol lhe acenoos, oflen run
to fam11Jes.
Hyper1roph1c lymphalic ussoe in
the upper respuatory tract may
act as an ep1gene11c tactor and
mcreasetheseventyol a malocclu-
sion.

Acquired Anomalies
Developmental Damage
Those malocclusions which, etiologically speaking,
were caused by developmental damage during the fetal
period, are considered congenital anomalies (Moss,
1962, Enlow. 1982).
In many of these cases, the exact causal pathogenesis
cannot be determined. The following are included
among the causes of these dysplasias proven to date:
(embryopathies caused by virus diseases in the mother
(e.g. measles toxoplasmosis), ionizing radiation. poi-
• The hypoplasia ot the m1ddte sec-
Exogenic Factors 75
sonous effects (e.g. medication) or other teratogenic
harmful substances. Fetal damage with this type of
genesis and the following craniofacial abnormalities
have been proven to be closely connected with one
another: Maldevelopment of thefirst and second bronchial
arches, micrognathlsm, oligodontia, and anodontia.
The majority of cases with lip-jaw-palate clefts are
included in this etiological group. Hereditary ernbry-
onal defects only account for approximately 20% of
these patients (Schilli et al., 1970).
Fetal alcohol embryopalhy
184 Profile and frontal view
Physiognomy ol a 13-yeat-old
pa11en1 with the eJttraoral symp-
toms characteristic of lhis syn-
drome: hypoptasia of the middle
secnon of lhe face. otoss ol lhe
eyellos and a broa0 nasal rOOI.
Apar1 from lhe maldevelopment of
O(herorgans, lhe patien1'sgrowth1S
also srun1ed. Both are typical of
trus syndrome.
185 Craniofaciaf morphology
in the cephalometricradio--
graph and occiusal relation
hon of lhe face and the resulting
retruded pos1t10n ol rhe maiolla
caused severe skeletal mandibular
prognathism.
Lei!: The pa!Jenl has a 101al cross-
b11e.
The sketeral dysplaSIS.S ol 1111s
syndrome are conslde<ed 10 be a
resull ol chondrogooesis berng im-
peded by the le1a1 alcohol embryo-
palhy.
76 !::tJology
Median mandlbular cl.-ft

186 Profile view and lateral

cephalometric radi09raph
This 6-year-old boy hashypoplas1a
and a seve<elyretrucled mandible
with no chin, resulting from con-
gennal mandibular dvsotasa,

187 Radl09raphic findings

in the panoramicview
RadJOgraphoc survey ol the coon-
nuous clefts around the mand1b-
ulal median line. Apart from the
skeletal deformity, this pabenl
suffers from agene51A or several
lower anterior teeth.

188 Clinical picture ot the

occlusion
Thesolt tissues pull both segments
or lhe mandible toward the Lingual.
R1gh1· Plaang the toogue between
the two segments uprights them
toward the vestibule.
 ~~~~~~~~~~~~~
Exoqeruc Factors 77
Trauma Birth injuries are rare nowadays. Previously, forceps
delivery very often harmed the areas around the TMJs,
which sometimes caused ankyloses of the mandibular
- Prenatal trauma joints. As a result of these ankyloses during early child-
- Trauma at birth hood, mandibular growth was impeded severely, caus-
- Postnatal traun1a ing the patient to develop a "Vogelgesicht".

trauma can cause hypoplasia of the

Pre11111a/intrauterine
mandible. Should the fetus be positioned unfavorably
during pregnancy, the facial skeleton very often devel-
ops asymmetrically, although this is mostly compensat-
ed for during the first few postnatal weeks.
Pos111a1a/ trauma can occur at any age and in any area of
the orofacial system. The consequences are more or less
dramatic, depending on the extent and localization of
the trauma and at what point in the development phase it
occurs.

Ankylose$ of the
temporomand ibular joints

189 Occlusion and profile

Tins 19-year-0ld panent has anky-
los1sol boln TMJs due 10 trauma 1n
early infancy.
Considerable 1nh1b1tion of the
develapmen1 ol the mandible
occurred as a rosull of lhe early
damage 10 lhe 1oints The pa11en1
has an exaremecase ol mandibular
m1crogna1h1sm and lhetyp1ca1 pro-
hle of a ·vogelg9SJCht'.

190 Ff'ontal and late"'! cepha·

lometrlc radiographs
Three-d1menS10nalview 01 the la-
oal skeleton lo cover the ve11Jcal
and sa9111a1 mandibular dysplasia
Despite the ankyloses of the
mandibular l()lots and the d1stur·
bances in mandibular growth. the
1ntercondylar width developed
properly.
78 Etiology
191 Traumatic
deformities of theeth
Lett: The wllltish discolored areas
and notches in the labl8l surlaces
of these lowe< Incisors are rmcro-
symptoms of trauma experienced
at 2 years ol a9e. The h0f1zon1a1
shape ol lhese decaJClfled zones IS
a typical symp«im of acquired
damage.

Righi The nng·shaped, yellowish/

brown enamel hypoplasJa on trus
upper lateral incisor tS a result ol
damage by local deciduous tOOlh
trauma while the permanent teeth
were developing.

192 Dllac:eratlon
The ciown of the tOOlh and the /
hypoplastic rOOI ol trus upper first
molar rue angled acutely This
tooth anomaly ts a result of a maxi I·
lruy fracture along the Le For! I
plane at 2 years of age.

R1gllrcAadK>graph ol the duacerat-

ed and displaced tooth ol a female
patient at 9 years of age.

193 Deformation and

dlsplllCell\"'11
The clinical picture shows anoma-
lies of shape ano position of the
four upper 1oosors. resulting from
trauma to the deaduous teeth dur-
ing eaily childhood.
Enamel formauon was impeded
severely on lhe upper central ind·
sors resuttmg in gangrene. Pen-
apical IE!Sdorts have caused the
formabon ol fistula.

194 Physical damage to IHlh

during developml!flt
The teeth present after rad101hera·
"7f of a nasopJiruyngeal tumor 81
3 years of age.
As a resuil ol the rad1olherapy,
when the patient was tO years Old.
the root tormanon of the perma-
nent teeth 1s impeded se\1!rly. This
applies panicularty to lhe upper
leelh. Further radiographic hnd·
1ngs are: Hypoplasia ol tooth
germs 27, 45, 47, and aplasta of
the 17. 15. and 25
----------------------------=t:.:c. .x-=->ogen1c
ractors /~
Aaidemsinvolving the dentitionare differentiated accor-
ding lo the various sequelae:
- Injuries prior to the eruption of the deciduous
teeth
- Injuries to the deciduous dentition
- Injuries to the permanent teeth after eruption
Taking the developmental periods of tooth structure
into account, the type and localization of tooth mal-
developrnent indicate the time at which the accident
occurred. lnjuries to eden111/011s infant jaws lead primar-
ily to retained teeth, displaced teeth, and malformation
of the roots of deciduous teeth. Such injuries do not
usually harm the germs of the permanent teeth. Not
until the patient is 4 years old do traumatic intrusionsoi
the deciduous anterior teeth usually harm the germs of
the permanent teeth. Depending on the stage of the
permanent tooth germ's development when the trauma
occurs and on the direction and severity of the intrusion,
the crown of the permanent tooth may be damaged to a
greater or lesser degree; root formation may be imped-
ed, tooth eruption may· be disturbed and the teeth
may be displaced. Injuries to the permanent maxillary
anterior teeth are much more common in patients with
an Angle Class II, Division l malocclusion.
195 Deciduous teeth trauma
and damage to the germs of
the permanentteet.h
Sag111al secnon through the maxil-
lary alveolar process.
Left· Topographic retauonsh1psol
a 3-year-old. The germ ol 1he pet·
manent 100lh ts only damaged 11
deciduous tooth intrusion and
palatal t1lhng ol the rool tal<e place
simultaoeoosly.
Rrgnr· Al 5 years ol age the posiuon
or the tooth geim has changed and
1s endangeied by any tnltUst0n ol
the deciduous tooth fEschler.
1974).
196 Incisor eciopy
Horizontal displacemenl of the
nght upper centrai 1noS01 due to
crauma or the deciduous 1ee1h.
It 1s uncertain wherher rhe rooth
will become co<rectlyahgned rn the
demat arch.
Right: Oue 10 the premature loss of
the upper nghl deciduous lnosor
and lhe germ ol the permanem
toolh being displaced, lhe adjacent
teeth have dnlted roward the gap
and have severely resmcrea the
soece for lhe successooat per-
manenl tooth
197 Deciduous tooth trauma
and tooth deformities
Leh·Rad1ographshow1ng1raumat·
1c mtrUSton of the upper oen11at
pnmsry mosors of a 4-year-Old
R1ghl Rad1ograph of the perma-
nent incisors 4 years later. The
trauma impeded the development
of the roots of bolh teeth
The pa]Jenl rs now a years old
and has permanenl incisors with
ceMCat root lracturesasaresoltot
another accident al that pomt tn
ume.
HU t:tto1ogy,_ _

Physical Factors

The following factors, which enhance the development
of'an anomaly, or directly cause it. belong to this group:
- Feeding method
- Consistency of the diet
- Premature loss of deciduous teeth
- Mouth breathing
The feeding method during infancy is considered
important with regard to the etiology of a retruded
mandibular position in the deciduous dentition. The
main advantage, from the orthodontic point of view. of
breastfeeding compared to bonle feeding is that the
baby must activate and protract the jaw muscularure
much more to press the milk out of the mother's breast
(Fig. 198). This higher functional loading during the first
few months ofti fe helps to move the mandible anteriorly
and compensates for the physiologic retruded antero-
posterior jaw relationship which exists at birth. Even
specially shaped nursing nipples cannot fully match the
advantages of breastfeeding.
The child can already chew once the first deciduous
molars have erupted. It is particularly important for the
development of normal dentition that the child is given
solid rood from this point on (Fig. I 99).
Should the child be given further nonsolid foods, it
will become a "temporalis chewer," i.e. it will only carry
out chopping movements (Fig. 202), instead of a
"masseter chewer" which carries out complete grinding
cycles during mastication (Fig. 200). The insufficient
functional loading associated with a "temporalis chew-
er" adversely affects the formation of the bone struc-
tures, thus the consistency of the foodstuff indirectly
influences jaw development.

198 Feeding inlants

Due to the advaniages 11 olfers
regard11>g. among Olher lh•ngs, the The advantages of breastfeeding
development ol the den11uon. compared to bottle feeding for the child
breastleedmg 1s preferable

RJgllt: If the infant sr>ould be l)Otlie·

lad, the NUK nipples are coos-
deiad supeooc to convennonal
nipples as their physoologK:al
shape is mal!:hed to the inlanfs
anatomy.
- Reduced morbidity
- Satisfied sucking reflex
(- fewer sucking habits)

- Muscle activrty 60 x as strong

199 Changing lrom liquid to

solid loods
Once the lust deciduous molars
have erupted, 1. e at the 11me the
bl1B IS first ratsed physoolog1calfy
fat approximately 14 months ol
age),the child shOold only t>eg1ven
solid IOOIS 1n order to ensure that
the deciduous denhhoo develops
normally
AllOllS: Deep overb<te prior 10 the
eruonoo of the deoduous molars.
The posterior alveolar processes
are m contact with each other.
Below; The erupting Fust decid-
uous molars raise the bite and
reduce the overbite. ,
 cxogen1c i-actors 81
200 Advantages of •massete<

\-
>
"Masseter chewing• and development or the
deciduous dentition
chewing• for the development
of the deciduousdentition
ten The masiicatOI'( movemenlS
are mainly camed 001 by the mas-
seter. w111Ch exens a protrusrve
,,t r:/ 1) High functional load, strong bony
Joice on the growing man<l1ble.
..t ) framework
thus helping to compensate 10< the
c.h1td's phys1olog1cally relruded
2) Food is ground up mandibular P061UOO
3) Deciduous teeth are abraded
Righi. Table showing the cnarac-
4) Lower dental arch is displaced forward tensncs of a "masseter chewer•
• • 5) First molars are positioned favorably
~
6) Decreased overbite
•

201 Normal, mature

deciduous dentition of a
"massette< d!ewer"
Occlus1on ol a 5-year-old gorl at the
begmmng of antenor exfohatron.
The typical charactenst1cs of tt11s
masucatory mode are'. Physiologic
tormauon of gaps between the
anterior dooduous teeth, anten0<
dosplacemenl ol the mandible and
ast1gt\t overbite due loabrasioo ol
the dectduous teeth.

"Temporalis chewing" and development ol the
deciduous dentition
1) Low functional toad. incomplete development
of bony framework
2) Food is chewed superficially
3) Minimal abrasion of the deciduous teeth
4) Lower dental arch is not displaced anteriorly
5) First molars are in unstable occlusal position
6) Excessive overbite
202 Drawbacks of
"temporalis chewing" for the
devel.opment ol the deciduous
dentition
Lelr The temporatrs carnes oot
mos1 of the work dunng masuca-
tory eJ<curs10ns II exerts 1ens100
cranialty, pnmanty crarnoposte-
n0<ly, and tends to pr0<00te the fO<
rnanon of a deep overbrte.
This muscle does not exert a
protrusrve IO<Ce
R1gh1. Table sn0W1ngthe charac-
tenstJcs of a "temporahs chewer."

203 Abnormal deciduous

dentitionof a '"1emporatis
chewer' prior to anterior
e.xfoliation
The typical symptoms ol thos mastJ-
catory mode are: Tho deep over-
bite impedes maS11CSIOry function-
ing, the deciduous teeth are rio1
abraded and the mandible rs
retrognalh1c.
82 Et1olog,_,_Y _
Premature Loss of Deciduous Teeth

Premature loss of the deciduous teeth also has a physical duous teeth which takes place more than 6 months prior
effect on the etiology of many abnormalities of the jaws to the expected date of eruption of the underlying
and the dentition. The primary effect is the reduction in permanent tooth germ.
rnasticatory potential after premature loss of one or A deciduous crown which has been destroyed can
several deciduous teeth. The reduced masticatory neither function as a tooth nor maintain the space for the
potential leads to insufficient functional loading and can permanent tooth germ. There is also a risk that peri-
impede jaw development along the sagittal, transverse, apical infections of carious deciduous teeth will endan-
and vertical planes. ger the crown formation of the succedaneous tooth
The term "premature" applies 10 any loss of deci- germ.

canogenic load and premature

IOU ol deciduous teeth

204 Upper deciduous dental

arch
Premature loss ol all upper deodu-
ous crowns due to the canogemc
effect ol sugar-saturated 1nlan1s·
tea

205 Occlusion
Ocdusal retmonsl11p ol the patierl1
snown 1n Fig. 204
Smee 1ne rnasnceiorv function
has been reduced, me 1aws cannot
be loaded suffic1en1fy.

206 Deep overbite in

conjunction with premature
loss or deciduous teeth
A 91ngivalfy.supponed.deep 011er-
b1te after l!)(ll!RSIYe premature loss
ol upper dooduous teeth over a
long pertOd 0111me
The lad< ol IOOth suppo<t has
caused the mandible 10 rotate for-
ward and upward. resu111ng In a
closed bite or excessive overoue,
 l::xogen1c f-actors 83
Breathing

lo case of an impeded nasal respiration. the paraoasal
sinuses are not ventilated correctly and the growth-
promoting effect of the capsular matrix as described by
Moss (p. 33) is reduced.
Chronic disturbance i11 nasal breathing, or habitual
mouth breathing are primarily associated with impeded
maxillary growth, This maldevelopment of the max-
illa results in a narrow jaw with a high palate and denial
crowding as well as retrognathism or prognathism of the
mandible. The lack of maxillary growth associated with
oronasal respiration is due to the change in tongue
position of mouth breathers. As it lies flat in the
floor of the mouth it cannot play its normal role in devel-
oping the maxilla. As the tongue is displaced downward,
the centrifugal and centripetal forces acting on the
maxilla are no longer balanced. The functional hyper-
activity of the musculature of facial expression. espe-
cially of the buccinator. impedes the development of the
maxilla.

207 Pressure relationships

during nasal breathing
(paramedian sectionthroogh
the head and upper part
of the body)
In order to be able 10 breathe no<-
mally, lhe nose must allow suthc-
1ent air lo pass through and lheora!
airway must be sealed antenO<ly
While inspiring, a low pressure
zone develops between the tongue
and the hard palate caused by Ille
sltgh!ly stronger lract1on forces DP·
posmg lheau pressure. Theelasl1c
traenon forces ol lhe tracoecoroe-
c:h1al system. which is connected 10
the tongue vta the larynx and hyo.d,
are ol great Stgn1hcance.
The draw1tlg shows !he down-
ward displacement ot lhe tarynx
and !he diaphragm during 1nsp1ra-
11on. as a result ol !he elastic,
traction torces exerted by the
tracheobronchl<ll system {alter
eld<er-Mobius, 1962)

,.,,,,. __...---. . ... ...........

;
;
.
208 Oronasal breathing In
conjunction with an anterior
cross-bite
Lel1. Occiusal relauon.
Right Hab11ua! mandibular rest·
pos1t<0n of a 5-year-old pabenL To
allow oral respeauon, lhe 1ongua JS
!«!pt low and lhe mandible IS
opened further downward lhal1
normal when al rest.Such changes
m the balance of the orofacial and
mastieotory musculature aover-
sely affect the normal development
ol the cennnon {lhe dorsum ol the
tongue has been marked wdh a
contraSI med1um1.
84 Etiology
Oronasal breathing in
conjunc!.ion with a Class II
malocclusion

209 Extraoral findings

f'lofile view ol a 7-year-old pauent,
showing the retruded posmon ol
tne lowe< iaw

Righi The patient has a stenosts m

the leh Side of the nose. wtucll
impedes normal nasal breathing.

210 Oeclusion
The panent has aruenor crowding
1n bOlh the upper and lower 1aws..

211 Craniofacial morl)hology

and anteroposteriorjaw reta-
lion
The la!e<al cephlllogtam snows me
aownward and retracted pos1t1on
of the tongue. which •S typical lor
cases wilh dlSturbed nasal breath·
mg and a Class II maJocctus1on

Right As the mandible 1s 1n a retru-

ded posrtJon. the over1e11s 1nctea-
sed chrncalty.
 Exoqeruc Factors 85
Bad Habits - Orofacial Dysfunction

Impeded function of the orofacial system is the most

- Pacifier sucking common cause of acquired anomalies. The most
- Thumb sucking common bad habits are listed above.
- Finger sucking
- Tongue-thrust Although the different sucking habits may produce vari-
- Lip sucking or biting ous abnormalities, there is not always a direct causal
- Cheek sucking relation.
- Nail biting or pencil chewing Apart from the genetic predisposition, the relation-
ship between orofacial dysfunction and malocclusion is
determined by three essential factors: The intensity.
duration, and type of sucking habit.
Suci<ing habit and
malocclusion

212 Effect of the suci<ing

habit on the dentofaclal
deveJopment
ten. t.ate1at cephatogram of a
S.year-old girl pn"' 10 acqumng a
sucking habit The girl has a skale-
lat Class II and rs in the early m•xed
cennnon,

RJghL Conl1guration ol lhe craruo-

lac1al morphology at 7 yearsolage.
The girl began her sucl<lng hab•I
when she started school. which
mlluenced 1he pesmon ol bolh
lhe upper and lower permanent
loosors dut1ng their eruption.

213 Roentgenocephalometric
6yeanold SNA 83 7 years old SNA 81 findings
SNS T.l SNB 74 Cephalome1nc 1rac1ngs of the
ANB 10· ANB 7 lateral headplates shown 1n Fig
SN-PO!) 73.5' SN·Pog 75' 212.

65mm teu. lnibaJ Sll~On.

Right $1tua11on 1 yea• atter
commencing the sucking hab1L

When comparec 10 the 1nibal con·

d111on, the suclcJng habu caused
a tablal upping ol lhe upper and
lower 1oe1sorsandan antenor open
55• bile. S1mullaneous1y, the habit pro-
131• moted upward rotanon ol lhe aore-
76' n0< maxilla dunng ns development
(increase in theangleoflnclinalJOn
60mm
according 10 A M Schwarz!.

I
I

•
86 Etiology
Mechanics of sucking

214 Apposition of the sucking

linger on Ille maxilla
Leh. Sucking the nghl lhumb. in-
volving the nosa

Right. Thumb posmondepteled on

a rad1ograph. The pa11en1 presses
Ille lhumb 0010 the palate, on both
lhe fronl seeuon of !he maxilla and
the upper antenor teeth The f1nge<
also rests on lhe lowe< 1nosors as
a fulcrum.

215 lntraoral symptoms

Left. Sucking or p1essmg the
thumb against the maxilla pro·
motes the devel(ll)menl of a
Class II malocch.!Slon (same pa-
neru as m Fig 214)

Right If lhe finger IS rested on the

mandible. the lower teem are often
moved forwards resullmg m an
edge-to-edge bite or a cross-bue
(same pahent as 1n Rg. 216)

216 Apposition of Ille sucking

linger on the mandible
Left ihls9-year-<lld femalepallenl
IS demonstrating a typical hnger-
suciung p0S11lon: The nng fmge1
and hnle finger are pressed onto
the lingual sode<ll ihe mandibular
alveolar process and the lower
an1ett0< 1eelh; lhe index and mid-
dle hngers rest on the cheek.

Rtght Aadi<Jgraph depicting this

hab1L
This 1ype of S>Jckmg ha bll hits the
upper and lower teeth toward the
labial.The change 1n pesmon ot the
upper teeth is mostly mechanical
and lhaJ ol the lower teeth a
secondary effect ol lhe lorwanl
downward 1ongue oostere,

Tongue-thrust can be a primary etiological cause of a
malocclusion or it can be a secondary, adaptive factor,
as in cases with a skeletal open bite.
In many cases. the tongue dysfunction persists once the
long-term sucking habit or incorrect bottle-feeding
during infancy has been discontinued (Fig. 217).
l:::xogen1c I-actor 87
Visceral swallowing (infantile swallowing) has a time-
linked etiology for tongue-thrust. It is physiologically
normal until the child is 4 years old. After this time. the
visceral swallowing act is considered an orofacial dys-
function. Should this type of deglutition, with tongue-
thrust and contraction of tho facial musculature, persist
in older children and adults. it may be among others a
result of a long-term sucking habit associated with an
open bite (Figs. 218, 219).
217 Adaptive tongu•lhrust
Antenor open bite with tongue
dysluncuon.caused by a long-term
socking habit
In many cases, Lhe tongue dysJu.
nes.a perSISIS even after the suck·
1ng hat>1t has been d1scont1nueo
so that the malocclusion or demal
malallgnment cannot be restored
10 normal by autonomous adjust-
ment
Visceral swallowing
218 Tongue posture
Tongue posture typical ol visceral
swallowing Torn1uatetheswatlow·
1ng act, the upoj the tongue rests on
the Jower hp.
219 Oeelusion
Charactenstrc occlusion m case of
persistent visceral swallowing. The
tongue rs placed conunUO<Jsty
between the teeth, resulting m a
complex open brte. which os only
supported by the molars.
l:Sl:S t:llOIOQY

Diseases The following local diseases very often lead 10 dys-

gnathias:
Variousgeneral and local diseases may cause malocclu-
srons,
The most common systemic diseases are endocrine
disturbances (impeded increase in jaw length. distur-
bances in tooth eruption, reduction in tooth size) and
chromosome aberrations which affect the orofacial
system (e.g. Franceschetti syndrome, deidocranial dys-
ouosts. trisomy21, eaodermal dysplasia,amelogenesis and
dentinogenesis imperfeaa. as well as certain types of lip-
jaw-palate clefls).
- Nasopharyngeal diseases and impeded nasal
breathing
- Infections of the middle car in babies and
infants with damaged ternporornandibular
joints
- Gingival and periodontal diseases which may
already occur irr the mixed dentition
- Rare pathologic conditions (rumors and cysts)
- Caries and premature tooth extractions

Cleidocranlal dysostosis

220 Craniofacial radiographic

findings
This mostly dommanUy mhented
skeletal dysplasia results lrom
disturbances m miramembranous
0$Sihcat1on. whereby enchoodraJ
CSSlfic:atton is usuallyalso involved.

Lett: Brachycephaly and underde-

velopmen1 of the middle face with
relatm hyperplasia of the body ol
the mandible tending toward a
Class Ill malocclusion, which is
!yplcal of 1h1sdasease. are appareru
on rh1s lateral radJograph

Right. Disturbed ossd1oa11on

around lhe calvanum, which is 1YJ)t-
cal of ttns dysostosis. causes lhe
fonlanelles and cranial sutures lo
remrun open lor a long nme.
The persisting deciduous teeth
are also visible w11h hype,Odon11a
ano rell!lned permanent reelh.

221 Clinical findings

Lelt: Hypoplas1a ol 1he collarbones
and lhe resulUng hypermob1h!y of
!he shoulder 1oonts are !yp1cal of
lh1S syndrome.

Right. The 16-year-old lemale

paJJent has reramed her enhre de-
Clduous denlT11on except 10< lhe
lower central 1ncrsors. The pnmary
1ncJSOrs have been sub1ecred 10
seve<e annuon; lhe deep overb11e
IS g1ng111a,lly supporteo.
txogen1c i-actor H~
Ectodermal dysplasla -
hypohidrotic type

222 Extraoral findings of

ectodermal disease
This diseasea maldevelcprneru
is
syndrome ol derivatives al Ille
ectoclerm.
Thts lronJal v1ewshows a 9-year·
old lemale patient with the typical
palhOlogte symptoms. IJghl very
thin hair, underdeveloped eye-
brows. sparse eyelashes, a broad
nose, ridge-like hp configurabon,
and pronounced mentolabtal sul-
cus.

Left: Very dry, scaly ssm with

chrome eczema rs 1yp1ca1 o1 lhis
disease.

223 Panoramic radiograph

Complete anodonna ol the man-
dible. The only permanent tooth
wtuch has developed os the upper
leh molar The only teeth ol the
primary den111>on, 1. e. the two upper
second deciduous mOlars. were
1001 prematurely due 10 canes.

224 Skeletal and soft-tissue

facial profile
Lateral oephalogram and profile
facial View ol the pauent shOw the
underdevelopment ol the middle
lace and lower lac1al he!ghl
The hypoplas1a ol lhe alveolar
processes results lrom the vutualty
complete arooeona

Leh: Disturbances in the develop-

ment of the 1ee1h and skeleton haVe
produced cnaraciensnc changes
1n lhe son-ussoe profile.
~u t:1101ogy
Cysts and tooth eruption
- Case example -

225 Initial situation

Panoramic raoiograph ol a 4-year-
old female panentwho was sem lor
trealment or an abscess wtuch
resulted lrom canoes amenor deet·
duoos teem In the lower arch.
Severe premature IOSS of dee~
duoos teeth is apparent m all four
Quadrants

226 Teeth prl!sent alter

formation of Iha cyst
One year later a large cyst has
develo!)ed rn !he marnJ1ble,which
extendscon1inuouslylrom the nghl
lo 1he left premolar region.
or
Due to expatlSl()ll the process,
1he germs of !he lower canines
and premolars were severely dis·
placed.
The lower rncisois erupted pre-
mruurely The pressure exerted by
me cyst on then roots forced them
into a fan-like posmon.

227 Teeth present after

treating the cyst
FNemonths after the cysl had been
removed; the lower tooth ge<ms
have almost anamed !/leir previous
posmon 1n 1he iaw
The crowns ol !he lower 11\CtSOrS
are stlll llared dlSlally, however.

228 Follow-up
Rfieen months aner Cliagnoslng
the cys1. me lower antenor teetn
tiave resumed !heir correct axial
mclmallon. The gaps which re-
mained between the premolar
germs afier treating lhe cyst have
closed
The bone detects in the ameoor
mandibular alveolar process
caused 1he lower canines of this
6-year-Oldpatient to erupt prema-
lurely.

Nore· Supernumerary looth germs

1n !/le maxilla interfere with erup-
uon al central mclSOIS.
 Case History 93

Case History

The first step in the assessment of orthodontic cases is the critical examination of the case history.
The purpose of this is to understand the development of the malocclusion, so that by early
elimination of the causative factors, correct therapy can be undertaken. Such an approach increases
the likelihood of a more favorable prognosis and greater stability as compare-Cl to a purely symp-
tomatic approach to orthodontic or dentofacial orthopedic treatment.

As a rule, the case history is usually assessed with the help of a special questionnaire. Questions
related to the case history are divided into two parts:

• Family history
• Patient history

He<editary malocclusions
229 Deep bite in the
deciduousdentition
Masi hereditary dysgnath1as are
already evident 1n lhe deciduous
oeouuon. Dom1nanliy mherne<l
anomahes u>clude mand1tlular
prognathism, Class II, DM&On 2.
some cases ol d1S1oclUS<on. ske-
letal open bile. and bunaxillary
prot1usaon.
An excess.ve verncar oevelop-
mem ol the an1e<10< maxlltary gum
pads m lhe newbo<n rSchachtel·
b1ss"; engl "boxb11e•) 1s assessed
as the early 101 m o1 the congen•·
lal deep bite.

From the family history. one learns about certain
malocclussions and other abnormalities (for instance,
impaired nasal breathing) present in members of the
same family.
A relatively large number of dysgnathias are in-
herited and transmitted through a dominant gene,
whereas in cases of cleft lip and palate, it is mostly
through a recessive gene.
The patient 's history is divided into three parts. First
is the prenatal period, during which the following are of
interest: Nutritional disorders, diseases and accidents
to the mother during pregnancy. The best-known
example of this is the relationship between viral infec-
tion and cleft formation in the newborn.
The questions which relate to the birth include time
of birth, the fetal position at birth. and complications.
The most detailed part of the patient's own history is the
postnatal development. The manner of feeding, as well
as nutritional disturbances are noted (mineralization
defects of the teeth). Questions regarding the eruption of
the first deciduous tooth, the child's general develop-
ment (initiation of talking, walking), and information
concerning sucking and other "bad habits" are useful
Accidents in childhood, the state of the deciduous
dentition, and the early loss of primary teeth should also
be noted.
Other more generalizeddiseases are of interest, in parti-
cular conditions which affect the development of the
jaws (for instance, rickets. dysostoses). This aspect
would also include all diseases which are important in
influencing the type of breathing (colds. pneumonias,
otitis, allergies). Further evidence of disturbed respira-
tion includes the type of breathing during sleep (open
mouth, snoring) as well as previous adenoidectomy
and/or tonsillectomy. After adenoidectomy, the possi-
bility of homeostatic adaptation must be considered.
Specific questions should include medical conditions
which may limit orthodontic treatment (for example.
diabetes rnellitus, epilepsy, blood dyscrasias, rheumatic
disease, allergies to nickel and acrylic).
Psychologic aspects of orthodontic treatment should be
also discussed while taking the history and talking with
the patient (motivation of the patient, also of parents in
young patients, expectation with regard to treatment
result). Such information is helpful to estimate future
cooperation during treatment.

230 Bimaxlllary protrusion

The neted1tary cornpooern of this
dentoaJveolar abn0<mal1ly is usu.
ally localrzed 1n the neerornuscutar
syslem.
Because of heredrtary hp 1ncom-
pe1enoe. lhe muscular equ1hbnum
between 1ongue and lips 1s d1s-
1Urbed
The labial mcllnahonol lheanter •
'°' leelh results
hyperaC1Jv11y
lrom a retauve
of 1he 1ongue muscu-
lalille.

Right Weak 1onus of lhe orblcula-

ns ons muscle.

231 Drug-induced enamel

dysplasia
Decalof1cat1onol SO< an1en0< 1eelh
and firs! permaoeot molars m a 14-
year-old panent Chmcal s11ua1oon
lollow1ng 1etra~hne ueatmem for
meningms at the age ol 2 years.
Teeth which had nol ye1 calethed
al the bme ol ueaunen1 10< 1he
mening111Sate1101atfected (premo-
lars and second molars}.

232 Head and neck surgery

Dental cond1b0n of a 10-yeai-old
pabent after su1g1cal closure of a
bilateral cleh hp and palate, 1n lhe
newborn and 1nlan1 period.
Scar essoe can furlhe1 r8$1riel
sagtttal aoc ven1caJ maxillary
growth, resulung 1n mandibular
P<OQnalhisrn
 Case History 95
Interpretation of the Case History

In many cases. the findings of the patient's history may
give some clues regarding the cause of the malocclusion
and help in planning the necessary therapy. Together
with the interpretation of the case history, one has
to bear in mind that a single etiologicfactor does not
exist.
A combination of different endogenous and exogenous
factors is responsible for the individual abnormality at a
particular time. An inherited tendency may be present
as well as the acquired malocclusion. The effect of a
sucking habit is significantly less favorable in a vertical
as compared with a horizontal growth tendency (see
page 192).
The course of orthodontic therapy, and the stability of
treatment results, may be affected if causative factors of
the malocclusion have not been recognized.

233 Interpretation of the

patient's history
Cause of malocclusions A firsl impression ol the cause ol a
matocctusion can be ehaled from
I I the pauent's h1ssoiy. which may in·
Jluenoe 1tle timing of 11eatmen1 as
Endogenous Exogenous welt as the therapeutic possib1hlles
.
I I
Therapy Therapy
• In the late mixed dentition • In the early mixed dentition
(possibly in the deciduous dentition)
• Symptomatic
• Causal

Acquired malocclusions and

predispositions

234 Lip dysfunction Jn

neutroclusion
Morphological relabonsh1p 1n a
Skeletal ClassI case Wllh hp dys..
JunC11on.

R1g/>L The dyslunesia on this case

results in only a sllght changeol the
oveqeL

235 Up dysfunction in
dlstocluslon
Morphological relallonshlp m a
Class LI case wilh concomnanl hp
dyskmes1a.

R1gl>L Compared wnh Fl{l. 234:

The lunct1onal son-ussue dcstur·
bance leads to a greaJe< overJet 1n
lhe case of d1SIOCIUS1on.
96 Case History

Questionnaire - Case History

1) Family history

Father Mother S1bhngs Relatives

Rickets (R), colds (CJ
Adenoids (A), mouth breathing (Ml
Adenordectomv (Al), tonsillectomy m
Cleft lip (L). jaw (J), or palate (P)
Supernumerary teeth (S), missing teeth (Ml)
Protrusion (P), Class II, Division 2 (D), Class Ill (Ml
Open-bite (0), deep bite (D)
Dental crowding
Orthodontic treatment
Miscellaneous:

2) Patient history

I Prenatal J (course of pregnancy)

Diseases: Nutntional disorders: yes/no
Psychological problems: yes/no Med1cat1on: yes/no
Accidenls: yes/no When: Type:

I Birth I
Premalure-normal- tate: Posllion:
Course ot labor: Normal Forceps Cesanan section Suction cup
Weight: Length: lncubalor. yes/no

J Postnatal J

Developmentalstate al birth: Normal I underdevelopedI bospualtzation

Infant feeding: Breastfed up lo month bottle-fed up lo year spoon-fed after the month
fed solid foods after the month given the lollowmg aodmonat foods after the month:
Vilam1n D: Fluoride preparations: up to:
First loath: monlh Learned to walk during the month Learned lo speak during the month
Prematuretoss ol deciduous teeth: yes/no Which teeth:
Sucking: Which hnger nght/lelt, pacifier, comer ol the blanket From 10 years
NUK nipple: yes/ no From to years
Parafunctions: Nail billng, clenching, bruxism
Steeping habits: Posrtlon: Mouth opened I closed Snoring: yes/ no
Diseases: Rickets-colds-pneumonia -otilis-asthma -allergies
Systemic diseases:
Allergies:
Adenoidectornv/tonsdlectomy: Al age ol:
Accidents: Age: Type:
Teeth involved: yes/no Treatment:
Operanonsin the head I neck region:
 Clinical Examination 97

Clinical Examination

The clinical findings are the basis of diagnostic procedures. The aim of the investigation is the
recognition of the orthodontic problem from the patient's point of view as well as the examiner's, and
to determine the need for treatment, Clinical findings are the prerequisite for the correct assessment
and interpretation of the quantitative analyses, i.e. the overall generaland the specific clinicalfindings.
which serve as the foundation of treatrnent decisions.

General State
Examination of the constitution and physique of the An evaluation of the somatogram provides an indica-
patient. height and weight in relationship to the chrono- tion of the general growth tendency. Further factors
logic age and development of the facial skeleton. include the nutritional situation. assessment of mental
development, and the dental and skeletal age.
236 Somatogram
, __ Boys
: ~
-.. 1-
Girl$

••: ...
Girls
±
I ...
Girls
Left. Aeg1stra11on of cllronol091c
CM
176
2o ••
67.2

..
••
,. 165
... ..
••
560
... "'
2o
'-··· 115
2• ••
SIO
2"a L ...
185
2o ••
58.Q
2• age. he1gh1 (1n cm). we.gh1 (1n kgtru
1he time of exam1na11on.

...
115 15.0 16• 13 SAS +-190 16A +-t9..0 16A t-19.1
174 630 113 .. s -135 113 53.5 -13.S 163 .. .$ ~1s..~ Companson ol lhe dala 10 aver-
173 11.Q
.... 1•• •• 5 l'2 13 52 s 162 IS 525 age values The !ables are d1fleren1

. . .
17> 590 161 161 161 50.1 for bo)'s and g11ls.
...'"
171
110
......
57.J
56.7
SS.6 . •1•
160
159
158
13
, ..••O ..
49.2 •190
-135
1•
160
159
1••
13
"8
••O
+19.0
-135
1•
160 13 492 !-lt.C
•7.8 1-13 !
.. ,, Right Data are underfone<l in llletr

. •2•... ... . •••... ,. ... ,. "'

157 •S 1 157 •• 1 157 •S.1
117 158 442 •tt.O 158 442 +190 •• 2 fHIJ respective columns Ph}'Slcal ce-
118 52.S 155 •33 -130 1S5 ca.3 -•30 ~ •33 ~131 velopmeni 1s taken as normal when
,.
105
16A
51. 1+200
50.9 f-1 C.0 12
I ••
1'3 12 153 1!~ •2.• Imes are approx1ma1ely honzon1al

.... . ..
163

...... ..
1• 502 152 40.9 152 C09 C0.9
111> <t•
••• 1S1 •03 151 '4J 151 •03

...
161
160
16
47.
487 +200
150 39•
38.5 _,l
••8-5
0
150

......
)t.c +16.S-
3'.5 _,, 0
......
150
1•9
• 39• ~uu
385
37.5 ~· 1.tl
Near 11ght. II pa1holog1c differ-
ences from !he norm of the orde' ol

.. 15'
~!!
•S.8 -tc.o
•SO
..2 " .........
.. r
375
•••
358
3C. -re
35.2
l1

.....
375
"'"'
358
352
•1

...
147 •••
35.8
"'2 staodaro deviations rellrnng 10
!he oanent's cllronolog1c age,
he1ghl, and weight exist, as occurs
...
155 43.5 13 •150 13 1« 34.6 ....-15 c
3C 6 •150 13
15'
103 ,. •2 7
•20 +17 0
1'3 3• I
336
e 1'3
1•2
3• 1 -100
338
IC3
IC2
3C.1 -1oc
338
1n dwarfrsm, g1gan11sm, obes11y, or
152 C1.3 -12.0 anore;oa, a medical exam1nauon is
12
......
151
150
408
399
389
10
1'1
140
139
330
32.S
31 7
10
1'1
140
139
330
32.S
31 7 ...
1'1
1" ~-~
31.7
requ11ed (Kunze and Murker>. Un1-
versi1y ol Munich, 1974),

."'.... ,...
'3
3'.0
374 +\5.5
-11.0
13'
137
136
13
31 0
...
302 +1 l.0
••• ,_
137
136
v
31 0
.
302 ..-t 1.0
- 8.0
•
13'
137
138
13
3U)
302 t-11 c

--
211• - IC

' 135 18.9 135 28.9 135

"
...... ....". - ... .. .... ...,.. .
310
1U 13• 28• 13• 28.C 13• 26.4
lU 133 219 133 27 9 133 279
27• .,.10.

...
132 27 • +100 12 27 • •100 13.2
12 +11 5 131 131
•
- 75
• !!! - 75
• ~!.! - 7.
1Cl 33.9 130 -3
..,,, ... ,,
~
»•
.... ....
10
139 3,_, 1211
12&
280
2&.8
•••
128 25.6
129
128 258

... - ,,
136 31 I
.,o 5
..
127 12 25 1 127 12 251 127 12 25 1 • 8.t
:so.s
131
136
12
30,0 - 7.5
lal
••• -75 121 2•• - "7.5 12$
,
24.I

• 135
13' 291
7
125
12•
123
24.l
:n.a
tt.2
7
125
1••
123
2' 1
....
tt2
". '
125

123
24,1
-·
232

...
133 28 5 122 122
132 •a• 228 228 122 22.!

. . ....
280 121 12 22• • 5 0 1•1 12 22.4 +so 121 12 22.4 I+ ...
131 l1.4 - 85
1>0 " a•
•••
120
119
220 - 35 120 220 ,.. 3.5 120
119
22_0 .. $;
21.6
8 129 118 211
• 118 21 I
• 118 21 I
98 General l::xam1nat1on

Dental Age

Evaluation ofthe dental status is of great importance for Dental age can be determined by two different methods:
the prognostic assessment of dental development.
Chronologic and denial age are synchronous in the - Stage of eruption
normal patient. A child is labeled as an early or late - Stage of tooth mineralization on radiograph
developer if there is a difference of+ 2 years from the
average value. If the chronologic age of the patient is Determination of dental age from observation of erup-
younger than the dental age. one can rely on increased 1io11 has been the only method available (Fig. 238) for a
growth to a greater degree than when dental age is long time. la most instances, it is fairly reliable. ln
retarded in relation to the chronologic age {and possibly certain cases, however, the accuracy of the method is
biologic age). limited (Figs. 239-243). During the quiescent periods in
eruption, this approach is inadequate.
237 Timmble of dental
develOl)ment of the primary Deciduous teeth in the maxilla• Permanent teeth in the maxilla•
and permanent dentition
Stalement of ave1age figures ac- Toolh Stan of End of Rool Tooth Start ot End ot Root
cording 10 Logan and Kronfeld hard tissue enamel Erup- formahon hard ussee enamel Erup· lorma11on
formation lormation tion complete formation lormatlon Hon comple1e
(modtiied by McCall and Sehoui').
St/61 4 mo. in ute:ro 11\ mo 7'1,mo. 1 ', y. 11/21 3- 4 mo. 4- 5 y. 7- 8 y. 10y
SeQuenceand llmiog ol eruonon ol
Ille permaoen1 den1111on are gene-
11cally ceterrmnec and elhnrcally
d1fferen~ bul are scarcely in·
52162 4"> mo In utero 2 s rno
53163 5 mo. In utero
54/64 5 mo. in utero
9mo
6mo
9 mo.
18 mo.
14 mo.
2y
31. y
2!> y
12/22
13123
14/24
10-12 mo.
4- 5mo.
1"'>-l'•Y
·- Sy
6- 7y
5- 6 y.
8- 9y.
I l-12y
10-11 y.
11 y
13-15y
12-13 y.
15125 2-2t• y. 6- 7 y. 10-12 y. 12-14 y
llueoced by endocrine distur- 16/26 al blnh 2'->- 3y 6- 7y. 9-10y
bance Girls are slightly more 17127 21\- 3 v 7- 8 y 12-13 y. 14-16 y
advanced. 18128 7- 9 y. 12-16 y 17-21 y 18-25 y
• Mandibular teeth usually develop before •Mandibular teeth develop a lew months
maxnlary teeth lo -,.-1 yvar before the maxillary teeth,

Estimation of dental age from

denlal eruption Average age of intraoral emergence of the teeth of single dental groups

238 CorTelation table of Boys Girls

dental age and number of 2 3 4 2 3 4
erupted teeth
Estima11on ol dental age for boys
and girts separate (Mallegl<a and
Inc. centr,
Inc. lat,
·i
6 11
')
7•03
6:08
7 · 11
7:04
8:06
Inc. centr
tnc. laL
')
6:07
.,
7:00
.)
7:05
7:01
8:00
Lul<awva>. Canine 10.00 10 07 11 :02 11: 10 Canine 9:02 9: 10 10:05 II ·02
Premolar I 9.01 9:01 10:04 11 :01 Premolar I 8: 11 9:04 9: 11 10:05
The denial age IS determined lrom
tables by cornpanson of the num-
bet of erupted 1ee1h w11h average
Premolar II
Molar I
Molar U
10·01
·1
10 09
10:07
.}
11.02
11 :02
')
11 :09
.,
11 · 10

12:05
Premolar II
Molar I .,
9:10

10:05
.,
10:02
.,
10:09

11·04
.,
11 :03

Molar II 10: 10 12:00

values.

Oates gM!n in years :monrhs

·> EruptK>n occurs earlier than could be determined lo this study.

239 Accelerated eruption

Acceleraled erupllon ot the lower
righl premolars after early extrac·
lion of deciduous molars.

Rignt· lnsuff1c1en1 roel develop-

mem IS charactenS11c ot premature
erupuon.
During the 1ntraoral eruption
ssage. Ille tooth usually has one-
third ol 11S Ima! roo1 lenglh.

Acceleration in
dental development and eruptlon Umlng
I True • Endocrine disturbance
• Diabetes mellitus
I True
I False • Earty loss of deciduousteeth
• lnftammatory processes of
I False
alveolar bOne
Retardation in
de.ntal development and eruption timing
• Severe organic disease
• Prolongedperiods of delicrency
• Endocrine disturbances
• Bone disease
• Envlronmentallnftuence
• Post-traumatic situation
• Alveolar bOne hyperplasia
!leontlasis ossee)
• FibrousglngivaJhyperplasia
(Elephantiasis gingivae)
Dental Age 99
240 True delay of eruption
Retarded change to permanent
ceonnon as a late sequoia of
rickets.
lntraora! dental status of a 10-
year·old Wllh minerahzalJOn ce-
feels of the upper centre! mosors
anc the lour tower front teeth as a
symptom of Vitamin D oel1c1ency a1
1he age ol 2 years
Rrglll. Panoramic rad1ograph. Dis·
aepancy between chronological
(10 years) and dental age a
years
and 11 months)
241 Retarded eruption
The cause of delayea eruption of
the upper 1noSO<S •S def1oen1
space m the upper arueuor region
1n 1h1s 8-year -old pahenl
Rt(/ht. The rad1ograph shows the
posmoe of the IOOlh germs m the
upper anterior region. Undermin-
ing resorption ot the deciduous
lateral 1nC1SO<S by the central per-
manen1 incisors as cbaracteosne
feature ol a pnmary dental crowd-
ing
242 False retarded eruption
Alyp•cal eruption; in comparison
with the opposne side, delayed
eruption of the upper lelt perma-
nent 1ncLsors and the leh canine 1n
a 13-year-old pauem,
Right Displacement ol tooth
germs tollowmg trauma 10 the
primary teeth. causing intrus.on ol
Che upper tell deciduous 1noSO<s,
al 5 years of age.
243 Factors determining
tooth eruption and dental age
Table stiowing the different IOCal
and systemtc factors inlluenc:mg
dental development.
Leh: Accefl!fahng factors.
Rt(/ht. Relarding lactO<S.
100 General Examination
When determining dental age radiographically accord-
ing to the stages of germination. the degree of develop-
ment of individual teeth is compared to a fixed scale
(see Fig. 244).
For age determination, one does not rely on the last
stage of tooth formation but on the entire process of
dental mineralization. This renders the estimation of age
more accurate. The procedure can be used for the entire
deciduous and mixed dentition period. and is not
influenced by early loss of deciduous teeth. The calcula-
tion is made using a point evaluation system (Demirjian
et al. 1973, Schopf 1970). Each tooth is given a point
value according to its state of development (Fig. 246).
The sum of individual points gives the developmental
value, which can be transferred into the dental age with
the aid of standard tables. The smaller the sum of points,
the younger the dental age; the higher the sum, the older
the dental age (Fig. 24 7).
Experience shO\VS that the method is sufficiently
accurate if the stage of mineralization of teeth 1-7 in the
left lower quadrant is examined. The procedure is not
valid for patients with several congenitally absent teeth.

Dental age determination

according to the stage of
mineralization

244 Nine relevant stages of

dental development
o T001hgermwi1hou1 Stgns ol cal·
ohcatl(ln.
A Galc1ficauon ol Slng1e occtusal
points withoui tuseon ol drtferent
calcoficahons.
B FuSlon of m1neraii2alJon potnts;
the contour ol 1he occiusal surtace
is tee0gn1zable.
C Calof1C811onol lhe crown rs com- A B C D E F H
plete: 1>e91M1ng ol dentin oeco-
Slls
D C<own folmation •s complete up
lo me cementoenamel 1une11on
E Root length shorter lhan crown
hetghl
F Root leng1n larger than crown
hetghl
G Rool lormaUon hnlShed Apical
f0<amen Sidi open.
H Apical IOlamen IS dosed
(Dem1q1an et al, 1973J

Ab<Ne: DeYelopmeniaJ Slages ol a

singlerOOCed IOOth.
~ Developmental stages of a
mu111roo1ed 1001h A 8 c D E F G H

245 Case example

In !hos gorl aged 7 years and 8
mon1hs.1he seven permanem tOOlh
germs on 1he lower 1e11 quadcanl
show lhe IOllowing oevelopmentat
siages:
M.= S1age0
M• S1ageG
P, = Stage C
P = Siage 0
Cs SiageE
I. - StageG
I. = Stage H

Thisgwesapoon1sumol71.Sanda
denial age ol 7.7 years (see Fig,
246).
 Dental Age 101
246 Scores of different dental
formation stages
Boys The point value ol soeouc stages
Stage ol mlnerahza11on depends on The
too1h type an<I caueors gender
Tooth 0 A B c D E F G H The table was made for the left
mand1btJlat quadrani (Demirjian et
M2 0.0 2.1 3.5 5.9 10.1 12.5 13.2 13.6 15.4
al, t973)
M1 0.0 8.0 9.6 12.3 17.0 19.3
PM2 0.0 1.7 3.1 5.4 9.7 12.0 12.8 13.2 14.4
PM1 0.0 3.5 7.0 11.0 12.3 12.7 13.5
c 0.0 3.5 7.9 10.0 11.0 11.9
12 3.2 5.2 7.8 11. 7 13.7
11 0.0 1.9 4.1 8.2 11.8

Girls
I Stage
Tooth 0 A B c D E F G H
M2 0.0 2.7 3.9 6.9 11 .1 13.5 14.2 14.5 15.6
M1 0.0 4.5 6.2 13.5 14.0 16.2
PM2 0.0 1.8 3.4 6.5 10.6 12.7 13.5 13.8 14.6
PM1 0.0 3.7 7.5 11.8 13.1 13.4 14.1
c 0.0 3.2 5.6 10.3 11.6 12.4
12 0.0 3.2 5.6 8.0 12.2 14.2
11 0.0 2.4 5.1 9.3 12.9

Note: Stasie o- no mineralization

247 Conversion chart for

dental age determination,
Age Points Age Points Age Points Age Points calc:ula!AKI according to the
score-system of dental
formation
v d' Q y d' Q y d' Q y d' Q
The overall figure for assessment of
3.0 12.4 13.7 6.3 36.9 41.3 9.6 87.2 90.2 12.9 95.4 97.2 denial age 1s obtained by adding
1 12.9 14.4 .4 36.9 41.3 .7 87.7 90.7 togelher Ille separate values tor
.2 13.5 15.1 .5 39.2 43.9 .8 88.2 91 1 13.0 95.6 97.3 7 teeth in lhe tower lett quadrant
3 14.0 15.8 .6 40.6 45.2 .9 88.6 91.4 I 95.7 97.4 CY= years.~= l:>oys. 9 =girls).
4 14.5 16.6 .7 42.0 46.7 .2 95.8 97.5
.5 15.0 17.3 .8 43.6 48.0 10.0 89.0 91 8 .3 95.9 97.6 II one al the leeth rs m1ss.ng. the
.6 15.6 18.0 9 45.1 49.5 •1 89.3 92.3 .4 96.0 97.7
corresponding 1001h on lhe oppo-
.7 16.2 18.8 .2 89.7 92.3 .5 96.1 97.8
17.0 19.5 7.0 46.7 51.0 .3 90.0 92.6 6 96.2 98.0 site side rs used for the assessment
.8
.9 17.6 20.3 1 48.3 52.9 .4 90.3 92.9 7 96.3 98.1 (Dem1T11an et al.. 1973).
.2 50.0 55.5 .5 90.6 93.2 .8 96.4 98.2
4.0 18.2 21.0 3 52.0 57.8 .6 91.0 93.5 .9 96.5 98.3
1 18.9 21.8 4 54.3 61.0 .7 91.3 93.7
2 19.7 22.5 5 56.8 65.0 .8 91.6 94.0 14.0 96.6 98.3
.3 20.4 23.2 .6 59.6 68.0 .9 91.8 94.2 .1 96.7 98.4
.4 21.0 24.0 .7 62.5 71.8 .2 96.8 98.5
.5 21.7 24 8 .8 66.0 75.0 11.0 92.0 94.5 .3 96.9 98.6
.6 22.4 25.6 .9 69.0 n.o .1 92.2 94.7 .4 97.0 99.5
.7 23.1 26.4 .2 92.5 94.9 .5 97.1 98.8
.8 23.8 27.2 8.0 71.6 78.8 .3 92.7 95.1 .6 97.2 98.9
9 24.6 28.0 .I 73.5 80.2 4 92.9 95.3 .7 97.3 99.0
.2 75.1 81.2 .5 93.1 95.4 .8 97.4 99.1
5.0 25.4 28.9 .3 76.4 82.2 .6 93.3 95.6 .9 97.5 99.1
1 26.2 29.7 .4 11.7 83 I .7 93.5 95.8
.2 27.0 20.5 .5 79.0 84.0 .8 93.7 96.0 15.0 97.6 99.2
.3 27.8 31.3 .3 80.2 84.8 .9 93.9 96.2 .1 97.7 99.3
.4 28.6 32.1 .7 81.2 85.3 .2 97.8 99.4
.5 29.5 33.0 8 82.0 86.1 12.0 94.0 96.3 .3 97.8 99.5
.6 30.3 34.0 .9 82.8 86.7 .1 94.2 96.4 .4 97.9 99.5
7 31.1 35.0 .2 94.4 96.5 .5 98.0 99.6
.8 31.8 36.0 9.0 83.6 87.2 .3 94.5 96.6 .6 98 1 99.6
9 32.6 37.0 1 84.3 87.8 .4 94.6 96.7 .7 98.2 99.7
.2 85.0 88.3 .5 94.8 96.8 .8 98.2 99.8
6.0 33.6 38.0 .3 85.6 88.8 .6 95.0 96.9 .9 98.3 99.9
1 34.7 39.1 .4 86.2 89.3 .7 95.1 97.0
2 35.8 40.2 .5 86.7 89.8 .8 95.2 97.1 16.0 98.4 100.0
102 General Examination
Biological Age and Hand Radiograph
Chronological age is often not sufficient for assessing
the developmental stage and somatic maturity of the
patient. so that the biologic age has to be determined.
The biologic age is determined from the skeletal, dental,
and morphologic age and the onset of puberty.
Assessment of the skeletal age is often made with the
help of a hand radiograph which can be considered
the "biological clock." For the analysis of skeletal
maturity up to the age of9 years. the stage of mineraliza-
tion of the carpal bones must be determined; thereafter,
the development of metacarpal bones and phalanges
should be evaluated (Fig. 248). For the evaluation oft he
hand radiograph, various indicators regarding devel-
opment and maturity are established which occur
regularly in a definite sequence during skeletal devel-
oprnent.
In addition to evaluation of the hand radiograph using
standard tables and the atlas of Greulich and Pyle
(1959), the analysis of Bjork (1972) has been useful

15

248 Topographic anatomy of

the skeleton of the hand
1 = Ep1phys1s of lhe lhumb
2 • Ep1phys1s of the proximal
phalanx of lhe thumb
3 = Sesamo1dof the adduc1or
brevis mlJScie al 1he meia-
carpophalangeal 1omt ol 1he
lhumb
4 = Epiphysis of lhe dtSlal
phalanx of lhe index longer
5 • Ep1physlsof 1he middle
phalanx of lhe index fmger
6 = Ep1phySisof lhe proi<1mal
phalanx of rhe index finger
7 = Ep1physisof lhe diSlal
phalanx ol the rruddle finger
8 = Ep1physis ol 1he middle
phalanx ol 1he middle hnger
9 = Ep1physis ol lhe proximal
phalanx of lhe 11ng finger
10 = Epiphys1s of the distal
phalanx of 1he ring finger
11 • Ep1physis ol the middle
phalanx of 1he nng finger
12 = Ep1physis of the proximal
phalanx of lhe nng finger
13 • Ep1phys.s of the distal
phalanx of lhe hnle finger
14 = Ep1physis of the middle
phalani of !he smaJI linger
15 = Ep1phys1sol 1he proximal 24 = Hamale bone
phalanx of the htlle hnget 25 = Hamular process of the
16 • Ep1phys1sol lhe flrSI namare bone
metacarpal bone 26 = Tnquelral bone
1 7 = Ep<physis of 1he second 27 = PlS1form bone
metacarpal booe 28 = Lunate bone
18 = Epiphys1s of me 1h1rd 29 - Scaphoid bone
metacaroat bone 30 = Distal cp1phys>sof lhe radius
19 = Ep1phys1sol lhe lourth 31 = Distal eplphysis of me ulna
metacarpal bone
20 • El)lphys.s ol 1he fifth
metacarpal bone
21 = Trapezium
22 = Trapez.o1dbone
23 e Gap<Ullebooe
in orthodontics and dentofacial orthopedics which Since ossification of the hand bones shows consider-
divides the maturation process of bones of the hand able inter-individual variations. skeletal age determina-
between the 9th 10 the 17th year into eight develop- tion from hand radiographs alone may not be accurate.
mental stages.

The delineation or single developmental stages is facili-

tated by inclusion of six further ossification centers
(Grave and Brown 1976) whereby the skeletal age can
be determined more accurately (Fig. 249). The different
stages of maturation are shown in Figs. 250-258.

249 Maturation indicators

of the hand bones for
determining skeletalage from
the 8th to the 18th year
Presence of 9 developmenlal
stages according 10 B1ork (19721.
Gtal'eand Brown (1976). The OSS•·
6 hca11on events are locall?ed m
me area ol !he phalanges. carpal
bones. and radius (R).
GroNth Slages ol lhe hngers are
assessed accord mg to lhe relat1on-
sh1p between the ep1physes and
the dlaphyses.
a
There are three stages of 0SS1f1-
cauon of lhe phalanges·

F1rsl stage:
Eptphyslssllows lhe same w1dl/l as
ine d1aphysis ( ).

n Secood stage.
Caop1ngstage (=cap), the ep1phy.
SIS surrounds 1he (llaphysis lil<e a
cap.

Thud Siege:
U-Slage {= u); bony fusion of eo•·
phys1s and d1aphys1s.

For assessmenl ol marun1Y tn lhe

area of lhe phalanges, fingers 1-5.
1:>eg1nn1ng w1lh lhe 1numb, are
labeled

9
104 General Examination
250 Rrst stage of maturation;
analysis of hand radiographs
according to Bjork. Grave,
and 8-rown:
PP2 = - Sta9e
Doagram and rad1ographs ol oss1 ·
f1ca11on SUlge.
The ep1ohyS1s of the proximal
phalanx ol lhe index finger (PF'2)
-
has lhe same width as the dia-
phySls.
This srage occurs approxima1ely
3 years belore 1he peak al lhe
puberal grOWlh spurt

1.

251 Second stage:

MP3 a- Stage
Eprphysisol lhe middle phalanx of
lhe middle hnger (MP3) IS ol the
same w1dlh as the diaphysos.

2.

252 Third stage:

Pisi·, H1·, and R a - Stage
This stage al develapmen1 can be
ldentd1ed by lhree d1S11nct ossdi-
cation areas; 1hese show mdMdual
vanaJJOns but appear al lhe same
nme dunng lhe process al matora-
bon.

Plsi·Slage a VIS!ble ossmcanon al

the p1SJ!oane.

Hl·stage = Oss1hcaoon ol Iha

hamula1 process ol lhe hamatum

A • ·stage. same width of epi-

phySls and dlaphysts al lhe radius. 3.
 ::>Ke1eta1 Age 1u:>
253 Fourth stage:
S· and H2-stage
S-stage • Firlil mmeral12a1ionol1he
ulnar sesamoid bone ol lhe meta-
carpophalangeal 1oon1 ol the
lhumb.

H2-stage = Progressive ossd1ca-

non of the hamular process ol the
hamatum.

The fourth stage is reached shortly

before or at lhe begmni"iJ ol the
puberal growth spurt.

4.

254 Fifth stage:

MP3c.p-, PP1u,.·, and Rc.. ··stage
Dunng trns stage, the diaphySlS rs
covered by 1he cap-shaped epo-
phys15.

In the MP3,..·stage, the process

begins at the mrddte phalanx ol the
lhird finger;
m the PP1.,..,-stage, al the p<OXJ·
mal phalanx ol lhe 1humb;
and rn lhe Rc:an·StaQe, at the
radius.

This stage ol OSS1f1cahon marks

Ille peak of the puberal growth
5. spurt
 I VO Ue'fle'I i::tl l::Xi::tf 111/ iauor I
255 Sixth stage:
DPJ.-stage
Visible union of ep1physis ano 01a-
physis at !he drSlal phalanx of !he
mrddle finger (DP3).
This stage of development con-
sntutes the end of puberal growth.

6.

256 Seventh stage:

PP3.-stag&
ViS>ble union of ep•phys•s and d•a-
physis al Ille proximal phalanx of
the ltnle finger (PP3).

257 Eighth stage:

MP3.·stage
Union of ep1phys1s and d1aphysts
at the middle phalanx of the middle
f1nge< is clearly vtS1ble (MP3).

'
I ,If"

8.
n
258 Ninth stage:
R.·stage
Compte1e umon of ep1physis and
diaph)'Sls ot the radius
The OSS1fica11on ol all the hand
bones 1s compte1ed and skete1al
growth rs hmshed
 Skeletal Age 107
Growth Rhythm

The puberal growth spurts are dependent on gender
and vary in their relationship to the chronologic age.
These variations determine the speed as well as the
duration of the growth processes. In girls, puberal
growth spurts usually start between the ages of 10 and
12 years, in boys between 12 and 14 years with variations
of 3 to 6 years on either side.
A disturbance of 'growth rhythm is only considered if
a difference of +2 years between chronologic and
biologic age is noticed.
The essential criteria for skeletal development are: a)
Growth within a definite time period, and b) develop-
ment to maturity.
Growth can be measured in millimeters; time periods
can be determined in weeks, months. or years; the
maturity process. however. can only be ascertained by
ossification assessment. ·
Evaluation of hand radiograpbs rs indicated in the
following cases:

- Prior to rapid maxillary expansion

- When maxillomanchbular changes are indicated
in the treatment of Class ill cases, skeletal
Class II cases or skeletal open bites
- ln patients with marked discrepancy between
dental and cbronologic age
- Orthodontic patients requiring ortbognathic
surgery if undertaken between the ages of16 and
20 years

259 Skeletal age assessment

Growth period Correlation lable belween osshca-
non stage$ or hand bones and the
skeletal age lor lhe penOd between
1. 2. 3. 4. 5. 6. 7. 8. 9. 81018yearsol age. Average values
of the pauerus' ages (1n years) are
PP2= MP3= Pisi s MP3081 DP30 PP30 MP30 Ru given for boys and girls separaiely
(Schopt 1978)
H1 H2 Reap
R= PPlcap As a rule, girls reacn Ille vancus
developmenlal stages 2 years ear·
her than boys.

r! 10.6 12.0 12.6 13.0 14.0 15.0 15.9 15.9 18.5

Q 8.1 8.1 9.6 10.6 11.0 13.0 13.3 13.9 16.0

260 Growth rhythm curwe

(Bjllrlt}
Skeletal age assessment aceo<d·
mg to B10rk. Grave and Brown
helps in determining the appro-
onate period for underlaking den-
tolaoaJ orthopedic therapy dunn9
!he mruumal puberal growth Sl)Ur1
1n adolescents CB/Ori< 1972).

'I
I

Child Juvenile II Adolescent Adutt

I I I
108 Special cxarrunauon
Special Clinical Examination

• Cephalic and facial examination

• Soft tissues
• Clinical examination of the dentition

Cephalic and Facial Examination

The shape of the head and the facial structures are
assessed: measurements can be evaluated according to
the cephalic index of the head (Fig. 261) and the
morphologic facial index (Fig. 263 ).
The form of the facial morphology has a certain rela-
tionship to the shape of the dental arch (Figs. 264, 265);
however, a direct relationship has not been established.
As a general rule, in borderline crowding cases of a
broad facial type, an expansion treatment should be
carried out, Extraction therapy should be considered
with long face types.

261 Cephalic index

The index is based of theamhropo-
metnc delerm1nation of the maxi- Cephalic Index
mum Width ol !he head and the Maximum skull width
maximum length. l=-------
Maximum skull length
LefL Classification aoo
index
values according to Maron and
Saller (1957). Classification:

• Dolichocephalic (long skull) x - 75.9

• Mesocephalic 76.0 - 80.9
• Brachycephalic (short skull) 81.0 - 85.4
• Hyperbrachycephalic 85.5 - x

262 Quadrate caput

Chafactensuc deformity ol lhe
skull, a persistent symptom ol
ncl<els which occurred when the
paiJeru was about 1 year of age.
The square defOlffirty ol lhe skull
IS caused by the protuberances of
!he frontal and panelal bones.
 Skull and facial Examination 109
263 Morphologic facial Index

Morphologic facial Index N .-Nas1on

Morphologic facial height
zv =Zygoma
I=~~~~~~~~~~ gn = Gna!t11on
Bizygomatic width
Left The morphologK:al ISC1al
he1gth Is defined as the distance
Classification:
between r>a5'on and gnath1on. lhe
• Hypereuryprosop Low facial x - 78.9 t>1zygomauc WJdfh as tne distance
} between the zygoma PQir11s..
• Euryprosop skeleton 79.0 - 83.9
Average
zy • Mesoprosop } facial skeleton 84·0 - 87·9 Right· Classrt1cat1on and index val
ues accordrng to Martm and Saller
• Leptoprosop } High facial 88.0 - 92.9 (1957).
Hyperleptoprosop skeleton 93.0 - x The facral index has to be taken
into account when estimating the
Pont Index (p. 208).

264 Broad faee

Intra- and eJCttaoral frnd1ngs 1n a
hypereuryprosop1c facial type.

Left: In these patients. the apical

base ol ihe jaw 1s wide in !he trans-
verse dimension.
II there rs denial crowding in
sueh a case, the inchnallon of the
reetrus confined lo the coronalpart
ot the dental arch and is descnbed
as coronal crowding.

In these laciat lyPeS. 1Ja11Sverse

expansion is indicated.

265 Narrow face

Intra- and extraoral findings In a
leploprosopiCtype.

Left: Parallel with lhe reduced

development of the b1zygomauc
widlh, lhe aP<calbase IS ohen nar •
row rn transverse direction.
The<el0<e, 1n cases of maxillary
crowding, no; only 1s lllere narrow-
ing ol the coronal arch. but also In
Ille apical regions.
110 Special Examination

Examination of the Soft Tissues

Extraoral: Forehead
Nose
Lips
Chin

lntraoral: Lip and cheek frenal attachments

Gingiva
Palatal and oral mucosa

Forehead

The profile is influenced by lhe shape of the forehead
and the nose and these therefore determine the esthetic
prognosis of the orthodontic case.
For harmonious facial morphology, the height oflhe
forehead (distance of hairline to the glabella) should be
one-third of the entire face height and is therefore as long
as the mid-third (distance ofglabella to the subnasal line)
and the lower third (distance of subnasale 10 menton).
The configuration of the forehead is genetically and
ethnically determined and varies according to age and
gender. In the frontal view. the forehead is considered in
its relationship to the bizygomatic width to describe ii
as narrow or wide. The lateral forehead contour can be
flat, protruding, or oblique. In cases with a steep fore-
head the dental bases are more prognathic than in cases
with a flat forehead (Fig. 267).

266 Height of forehead

The hetghl of lhe forehead •S
meas\lfed from the ha1rhne10 the
glabeUa and 00<mally measures HaJrhne
one-third of the toial face he1gh1
(dlSlallC8 harrtme 10 menton). ' 3

Righi. In lhe adul1111s the1efo1eas

,,,~ Glab<!Jla
high as the middle face height \ ~\
(dlSlance glabella 10 subnasale) 7 ~ • J
and the het9h1 ol the tower lace
(subnasate to menion). Subnasale
~...::3"
...--..... ' 3

Menton

267 Slope of forehead

t.£h. Flat fo1ehead

Middle: Prouud1ng forehead

Right Sleep forehead

The esthet1c appearance ol 1he

nasal prohle Is Influenced by the
curvature of the lorehead In cases
cl a steep lo1ehead the <1en1al
bases are more prognath1c tnan m
cases With a llat forehead.

Nose
Size, shape. and position of the nose determine the
esthetic appearance of the face (Figs. 268. 269).
The assessment of the nose in the prognosis of an
orthodontic case is therefore of special importance.
Before treatment it should be stressed that the nasal
profile is not improved by orthodontic procedures and
that a rhinoplasty may be necessary later.
Soft Tissues 111
The shape of the nose is not only determined by here-
ditary or ethnic factors but may be the result oftrauma in
childhood (Fig. 269). Besides the contour of the bridge
and the tip of the nose (Fig. 268). the size and the shape
and width of the nostrils as well as the position of the
nasal septum should be assessed. These findings can
indicate impairment of nasal breathing (Fig. 270).
268 Size of nose
The venteal nasal length measures
one-third ol total lace he1gh1 (d>S·
lance hairlrne 10 gnalhron).
Lei!: In lhe normal case, 1he rela-
nonsrep between vertical and horr·
zonlal leng1h of !he nose rs 2·1 as
viewed from lhe side.
M1cklle: M1crorhtn1c type w11h a
high root of lhe nose, shon nasal
bndge, anc! an elevated np.
Right Pauenl w11h a large nasal
nrnhle deep 1001 al the nose. long
nasal bndge. and a prolrudm9 up,
269 Nasal contour
Leh: Straight nose.
Middle· Convex nasel bndge.
R1gnt· Crool<ed nose. from pre-
vroos lrauma
270 Nostrils
The Wldlh ol lhe nostnts (aJar base/
rs approxrmalefy 70% ol the lenglh
of the nose (alSlance nasion 10 uo
ol nose).
Left· The nosmls are usually oval
and b•laleratly symmemcal.
Middle Nasal brealhmg is seldom
impaired byas1tgh1 nasal anomaly
with wide nostnls.
Right: D1s1uroed nasal breathing
due 10 5!enosis ol lhe nghl nostnl,
combined wrlh 3 carttlagtnOus
sepia! devrahon.
112 Special Exarrunanon
Lips

Configuration of the lips can be assessed by the follow-
ing criteria: Lip length, width, and curvature.
ln a blanced situation. the length of the upper lip
measures one-third, the lower lip and the chin two-
thirds of the lower face height (Fig. 271). in addition. the
length of the upper lip should be assessed in relation to
the position of the upper incisal edges (Fig. 273).
The observation of the nasolabial angle and in partic-
ular the mentolabial fold is indicative of the degree of
lip tension (Fig. 276, 277).
Apart from ethnic characteristics, lip protrusion is
influenced by the thickness of the soft tissues, the tone of
the orbicularis oris muscle, position of the anterior teeth.
and the configuration of underlying bony structures
(Fig. 274).
In patients with lower lip dysfunction, the upper lip
is often everted, paler and dry; the lower lip. however,
has a better blood circulation and is moist. in some
cases, indentations of upper incisal edges are present
(Fig. 277).

271 Vertical lip relationship

In a balanced suuanco, the upper
lip length (distance of subnasale
10 slomJOO) is one-lhird and the
length ol the lower hp and of the
chin (dlslance stom1on to menton)
IS two-thirds of the lower lace
StomiOn
he1ghl

Menton

272 Up morphology
Lefl: Harmonious lip proh!e with a
narrow mucosa! element.

Middle:Shon upper hpwilh narrow

mucosa! element and d1slurbed lip
seal.

Right: Short cutaneous upper and

lower hp with undlSlurbed hp
dosure. The hp 1nsuthc1ency rs
compensated by ever5'on of the
mucosa! part

273 Relation of upper lip

length to front teeth
The upper JoosaJ edges in tile rest
position and when smihng should
show 2 mm in a normal case.

Rignt· D1sharmomous 1elauonsh1p

be""-een length of upper lip and in·
CtSal edges ol upper Incisors. The
gmg1va and tne alveolar mucosa
are visible m casesol a shoo upper
f1p, 1n conJuncllOn with vertical ov-
e<development of lhe alveolar
process (- gummy smile).
 Soft Tissues 113
Horizontal lip profile

274 Clinical profile

Left: ProuusJon ol lower hp in reia-
non 10 upper lip - a symplom of
1he Class Ill maloccluS1on lll05'!Jve
lip step according to Korkhaus)

Middle. Nounal lip puilole. The up-

per lip orouudes stoghlly in retanon
lo lhe lower lip.

Rrglll. Marked retrusion of lhe

tower lip as a syml)lom of a Class II
maloccius1on (neg81Jve lop s1ep
according 10 Kolkhaus)

275 I.Ip step according lo

Korkhaus
O.ag1am ol d1fle1en1 vananoes ol
lip profiles, 1llus1ra11ng the lip step.

Leh: Posmve hp step.

Middle: Shghlly nega11ve 11p step

(normal case)

~1 R1gh1 Marked negallve hp slep

(according 10 Korkhaus).

276 Nasolablal angle

Left: Tense upper hp 1n maxillary
prognalhism wuh anterior procu-
nanon Ol the front teelh.

Middle. These patients usually

show coaractenste changes in lhe
son-nssue prohle, w1lh reduction
of the nasotabsal angle (angle be·
tween !he tanqents suonasate -an-
tenor-most poem of lhe columella
and subnasale -labrale supenus1.

Righi Enlarged nasolablal angle

as a Sign ol !he rel!IJsive poso11on
ol lhe upper lip lo lhe nose.

277 Tense lower lip

Righi Cl1mcal appearance.

Leh: Profile rad1ograph of a tense

lower no.

The marked labial pos111on ol lhe

upper amerlor teeth m con1unc1Jon
wilh the 1esult1ng lower hpdyslunc-
11on (lowe1 lip sucking} is lhecause
of lh1s func11ona1 disturbance.
114 Special Examination
Chin

The configurationof the soft-tissue chin is not only deter-
mined by the bone structure, but also by the thickness
and the tone of the mentalis muscle (Fig. 278). Further
factors include the morphology and the craniofacial
relationship of the mandible.
As well as chin width. the development of chin heigh/
is important from the orthodontic point of view
(distance from mentolabial sulcus to menton). Over-
development of the chin height alters the position of the
lower lip and interferes with lip closure (Fig. 279).
As a rule, the chin contour is assessed in connection
with the lower lip position and the configuration of the
mentolabial fold, as the profile of these two structures
is dependent on the position of the soft-tissue chin
(Fig. 280).
The midline of the mandible must be examined in
the clinical case of an asymmetry of the d1i11 (Figs.
281-283).

278 Relation of the soft-tissue

chin to the bony chin
Frontal and prohle picture of a
10-year·old pallent w11h a Hat sott-
ussoe c:.h1n.

M.ddlec The laleral cephalogram

shows a d1s11nc1 positive bony chm
contour, compared with rhe soil·
nssue profile. In lh1scase. the sl<ele-
tal contour rs compensaled by the
lhrn O>Je~ymg sol111ssue.

279 Overdevelopment of the

chin height
Fron1al and prohle view ot a 12-
year-old panern wrlh a long lower
lace and overdeveloped chm
hetghl. (drstarx;e trom memolabral
sutcos mentoo) causmg hyper·
actMly of tne mentahs musele
l.Jp closure rs drff10Ull rn trus rype
of 1ae1a1 morphOlogy.
In oroer 10 improve muscular
1mtia1ance. a gen1oplasry 1s re-
quired or a sorg1ca1 change of 1ho
1nser11on ot lhe mentans muscle
shoulo be COr\Sldered.

280 Chin formation and

profile contour
The degree ot chin tormatJon has a
marked 1nllueoce on the enhre
profile.

Middle Protruding chm wuh a

•
marl<ed men10Jabral solcus. caes-
1ng a retruded hp profile.

R•ght. Negative chm formaoonwnh

absence of li'le menrolab1al sufcvs.
caus.ng a prorruded lip profile.
Soft Tissues 115
Asymmetricchin position

281 Frontal view of sott-tissue

and skeletal facial configura-
tion
Frontal View of a 26-year-Od
female paben1 who shows a dis
placemen! ol lhe chin 101he left side
on chn1calexarmnanon.

Right· The pos1e1oanten0< ceplla-

logram shows lhal me asymme1ry
seen on d1n1cal examJnalJon iS
caused by a rOlaloon of lhe en11re
mandible lo the left - a mandibular
lalerognalhy. (The lronlal cepnalo-
gram is reversed.sotbat the asyrn-
metry IS In lhe same direcuon on
both, lhe lae1alphotograph and lhe
rad1ograph).

282 lntraoral findings

In occlusion. the modline of 1he
lower dental arch is msplaeed 10
11\e leh by lhe 1a1era1 devia1o0nof lhe
mandible
The molars are 1n cross-bite on
irus side.

283 Tomograms ol the

temPorOmandibular joints
In connmcuon With lhe mandibular
devianon, a marked asymme1ry of
form and posiuon of lhe JOmls rs
shown
The nghl eondyle (left) is clearly
larger lhan lhe lefl (right)
Also tbe Wldlh of lhe JO<nl space
differs between 1he t1gh1 and leh
Slde
llt:i ~pec1a1 cxamrnanon
Tongue

Shape. color, and configuration are assessed at the first
clinical examination. The iongue can be small, long, or
broad. These Ii ndings do no! allow conclusions to be
drawn about the relative tongue size (Figs. 284, 285). A
long, broad tongue does not mean that ibis is a case of
..macroglossia." Changes in the tongue position and
mobility are often associated with an abnormal lingual
frenum (Fig. 286). A rough assessment of tongue size in
relation to the size of the oral cavity can be made by
studying a lateral cephalometric radiograph (Fig. 284).
The diagnosis of a macroglossia requires in each case
a more detailed diagnostic investigation (for instance
cineradiography). and can only be made after exact
analysis of tongue position and mobility, and study-
ing physiological functions (for instance, speaking,
swallowing) .
Assessment of the character of the mucosa of the
tongue is of secondary importance from the orthodontic
viewpoint. Functional investigation is the most essen-
tial aspect of the clinical examination (see. p. 141).

284 Tongue length

ThecJ1n;eaJ p;cture of a long tongue
wllfch can reach the tip of lhe nose.
This single hndmg does not
pe1m1t lhe diagnosis of ·macro-
glossia.

Right· Pos.11on of 1oogue In the

l<r.elai cephalogram The longue
is 1009 but its volume is nQI loo
large In relation 10 the oral cavity.

285 Tongue width

Class Ill case with a broad and low-
lymg tongue, which eXlends over
the denlal arches.

R1ghr lmptlnls ot 111e teeth on the

late1al margins of the tongue 1nd1-
cate a discrepancy between the
width of the dental arch and width
of the tongue.
In these cases, the size ol theoral
caviry should not be decreased
funner by orthodon11c ineraoeune
procedures ttor instance. lOOlh
extractions!

286 Lingual frenum

Lett: lnuaotal photograph ot an
at!ached hngual lrenum.

Righi Tongue mob1hry rs impaired

by this soil l!SSue anomaly.
In these cases. the tongue lies
low so that impairment of funcuon
predisposes 10 toogue·thrustmg.
 Soft Tissues 117
Lip and Cheek Frena

Among the different frena, the maxillary labialfrenum in
the mixed dentition is of special importance.
A heavy labial frenurn may be the cause of a central
diastema (Fig. 287). The indication for frenectomy
depends on the differential diagnosis. It is only indicated
when the attachment is inserted deeply with fiber exten-
sions into the interdental papilla (Fig. 288).
The X-ray film shows a bony fissure between the
roots of the upper central incisors as the sign of an inter-
osseous fiber course. Frenectomy, however, should
only be done after eruption of the upper lateral incisors.
The mandibular labialfrenum is less often associated
with a median diastema. However, it frequently has a
broad insertion which exerts a strong pull on the free and
attached gingiva; this can lead to gingival recessions in
the lower anterior region already in the mixed dentition
stage (Fig. 2 89).
The presence of buccal attachments must be
examined carefully, especially in adolescence and in
adults.

Labial 1rena

287 Deeply inserted labial

fre:num in the deciduous
dentition.
In 1h1s 5-year-old female pauent, a
physiojog1cal variant of lhe maxil-
lary labial frenum aHachment
eX1s1S. a rene ol Ille lectOlabial
trenum.
At 1h1s siege, 1hete 1s no 1na1ca-
11on lor freneciomy. smce m 1he
course ol permanent meiscr erup.
1100, a spcn1aneous correction ol
the diastema can be expected

288 Deeply Inserted labial

lrenum in the maxilla
Soll tissue morphology m an 6-
year-Old pauenr rn whom Irenecto-
my 1s md1ca1ed

Righe II the upper IJp rs held away

and a pull IS exerted on the ke-
num 1he m1erdenta1 ussue and the
area around lhe mo51ve papilla
becomes blanched or anemic; 1he
condmon o1 a true d1as1ema ex1sis,
caused by interdentally running
fibers.
The exos1on has 10 d1ssec1 ou1
no1 oofy the son tissues but also the
1nterosseous fibers.

289 Anomaly of the

mandibular labiaJ trenum
The high msertion o1 the frenum
exerts a strong pull on the anached
mucosa of lower antenorteethand
leads lo mucoging1val lesions. tn
ttus morphologic ccoomon, pro-
phylacuc. 1. e. early penodomal
surgery should be earned oul

Right: AlyJ)lcal formabon of 1he

mandibular labtal lrenum 1n a
young female pahent wtth marked
g1ngwal recess.ons on Ille IOINl!r
ceniral 1ncasors.
118 Special Examination
Gingiva

Examination of the gingiva should include the following
criteria:
- Gingival type (thick-fibrous. thin-fragile)
- Gingival inllarnmation
- Mucogingival lesions
In children the most common form of gingivitis is
caused by piaque accumulation, and can only be resolved
by improving ora 1 hygiene. In other cases ofgingivitis, in
particular in the adult patient. periodontal 1rea1111e111
must be carried out (scaling, curettage, mucogingival
surgery) prior to orthodontic treatment. Local gingival
lesions may be a symptom of mouth breathing. ab-
normal occlusal, and functional loadings or of medi-
cation (for instance, epilepsy).
Gingivitis and poor oral hygiene are contraindica-
tions for orthodontic treatment. Therapy should only
be commenced following improved dental and gingival
care.

290 Healthy ginglva

Cltn1caJ plClure al healthy gums,
free of mflammat1011 sn a 12·year-
olcl lema!e pauent at Ille beg1nmng
ot onhadonuc treatment

291 Thln•lr.iglle gingivat type

$1tuauon In an a.year-old lemale
pa1tent The alveolar process rs
narrow. !tie roots can be palpated
t/lrough tile mucosa G1ng1val re-
cessions develOParound the low"'
central 1nc1sors.

Righi The dearly visible vascular

pattern of the mucous membrane
1s cnaraoensac 10< the th1n-frag1te
g1ngrval IYP0
A marked tendency exists in this
nssee type fO< produong peno-
dOnlal damage by tab1011ngual 0<·
thoclon1rcloath movements,

292 Idiopathic ginglval

hyperplasia
YC>UOQ pabent wllh a generalized
dense-fibrous gmg1val hyperpla·
ssa wt11ch •s hered11ary.

The abnormal ussue struciure

h1nclers denial erupllOn.
Soft Tissues 119
293 Oral hygiene - Gingivitis
In young oaueots, lack of orat
hygiene IS the ll'lOSlcommoncause
of 1h1s cond•l•on

Oral hyg1eoecan be assessed and

expla1n00 to me pauem by llllJSlfat·
mg the plaque usmg d1sciosmg
agents 01 lhe UV-lamp and thus
motivating the patient
The plaque score Is reoo<ded 1n
the to1m or an index (Lange. 1981.
Rateitsella!C el al. 1989/.

294 Hyperplastic gingiva

Left. Severe g1ng1V111s 1n a chronic
mouth breather
Besides PO()r oral hygiene. lhe
cond111on rs worsened by lhe dry-
ness or the mouth, caused by lhe
open-tip posture.

R1ghr· Mild librous hydan1om hy-

perplasia 1n a 12·year-old eptleptic
girt

Mucogingival lesions

295 Occlusal trauma

Left· G1ng1val coodinon ma 7 -year-
old g1r1 during 1he erupnon stage
ol anterior leeth The voper nghl
central mCISOr erupts m Closs-bile
so Iha! the mandibular anlagon1S1
IS subJSCled to nonp~ologrc
occiusat forces.

Righi I year late•. the tower lnct·

sor shows mC1eased mobtltty and
a mucog1ng1val lesion

296 Lingual reettSions

Rrgllt G1ngival recessions on the
lingual surtaces ol lower antef1or
teelh rn a young pa11en1w11h tongue
dyskulesta
The early damage results from
Ille noophysiolog1c ussue loading
as a consecueoce ol the dysfunc-
uon

Left lateral cephalOgram shows

clearly the anomalous relabon be·
tween rhe tip ol the iongue and
lower lnCJSOrs.
(Concretions• del)OSllS caused
by BacteroHies me/anioogerocus).
120 Special Examination
Palatal Mucosa and Palatal Vault

The palatal 11111cosa is examined as follows: pathologic
swelling, ulceration, scar tissue formation.
Pathologic swellings are indicative of displaced tooth
germs and cysts (Fig. 297).
Mucosa/ ulcerations and indentations are character-
istic of a traumatic deep bite (Fig. 298). Scar tissue
following palatal surgery diminishes I he prognosis for
development of the maxillary arch (Fig. 299). Changes
in the palatal mucosa can also be observed in conjunc-
tion with other systemic problems (Fig. 299).
As part of this examination, the size and degree of
inflammation of the tonsils should be assessed, including
an inspection of the oropharyngeal space. As there may
be possible effects on tongue position and nasal breath-
ing, suspected pathologic findings should be examined
by an otolaryngologist (Fig. 370).

297 Mucosa) swelling

Abnormal swelling on the palalal
aspect ol the nght antenor maxilla,
continuous upper denial arch. with
a missing canine.
Righi The X-ray him shows a
d1splacedand impacted canine.as
the cause of the swelhng.

298 Mucosa) Indentations

Rig/II. Traumatic deep bne m a
Class It, Oiv1s1on I case.

Left A deafly vos1blegroove on the

palatal mucosa caused by the low-
er amenor teelh as the result ot the
long S1and1ng verucal malocclu-
sion
Bes.des this find mg, ihere rs also
g1ngival dehoscence on the lingual
a51"'C1 ol lhe cemral mcisoes,

299 Palatal mucosa

Left ScaJred palate after surgical
closure of an isolated palatal clefL

Right: 81hd uvula on a 10-year-old

girl; mold mdrca11on or a lam1hal
dlSl)OSlbon 10 eren hp and palate
formru1on.
 uental status 121

Clinical Examination of the Dentition

Clinical examination of the dentition is made in the
following sequence:
I) Assessment of the dental status
2) Detailed recording of dental and occlusal anomalies
3) Assessment of the apical bases
4) Determination of the midline of the face and
coincidence with dental structures
Orthodontic treatment is contraindicated when carious
teeth are present. Therapeutic possibilities are limited if
severely carious teeth as well as dental structural
anomalies are present on account of the reduced enamel
resistance (contraindication for fixed appliance treat-
ment).
It is also important to determine the number of
teeth. In a superficial examination, one often overlooks
absent or supernumerary teeth, which are only found
later during the course of treatment.
The clinical and radiographic examination should
reveal all findings that are not clearly diagnosed on
plaster models.

300 Structure of tooth

surface
Enamel hypoplas1a 1n a case of
severe fluorosts.
The patted and Hat-shaped
brown1Sh d1scolorat1ons In the
chalky hypommerahzed enamel
are cnaractensuc of Uuonde·
induced changes.
The enamel delect is symmelnc
on both Sides.

301 Dental deposits

MIJfed dentmon with hard black
deposns which encircle and lie
parallel to lhe neck of the 1eeth,
pamculaf1y on dooduoos teeth.
The black-brown deposits are
caused by 8acrero/des melanlno-
gemcvs. Denunons wrth such re·
current accumulataons show great
resistance 10 canes. There as a
physl01og1c recession of these
changes In puberty.

302 Wear face!$

B11a1eral buccal nonocclusion with
marked wear lecets on lhe lingual
cusps of upper premolars.

In our panents, ocdusal abrasions

are oflen 1he result ol annnon and
1nd1calllle ol paraluncbonal mandJ.
Dular movemenls.
122 LA1n1ca1 r-inomqs

Clinical Examination - Record Sheet

1) General Findings
State of age related I overdeveloped I underdeveloped
development mentally normal I early/ late developer
lively I quiet/ nervous/ phlegmatic
easy I d1fftcul110 educate
Body height: cm Weight: kg
Stature: strong /tall I average I short/ adipose Dental age: years
Nutritional state: good I bad Skeletal age: years

2) Extraoral Findings
Head form: narrow I broad /long I short
Facial form: small /broad I round I angular I oval/ tnangular
Facial asymmetry: Scars:
Shift ol maxillary m1dhne relative to the facial midhne: yes/no right/left mm

lip form:
Lips: normal I dry I fissured I scarred I indentations/ after surgery
lip posture: competent/ incompetent/ evened
Lip step: posrllve I negative I straight
Chin form:
Mandibular angle: normal/ increased I decreased
Nose form: Nasal bridge: Nostrils (atar width):
Forehead height: Curvature:

3) lntraorat Findings
A) Dental tmdmgs
General impression of oral hygiene: good I poor I moderate
Canes susceplibility: none I moderate/ severe

I
Right I Left

c =canes a = nonvnat tooth

z = tooth not to be marntarned F = large filhng Fractured tooth:
x = tooth extracted W = wear facet
m = tooth matformahon ( = narrowed space Dental treatment·
D = discolorauon

BJ Exammar1on of the oral cawty

Maxillary labial frenum: strong/weak/deep msernon/frenectormzed
Mandibular labtal frenum: strong/weak/deep insert1on/frenectom1zed
Buccal frenum: normal! pathologic
Vest1buloplasbc: yes/ no
Grngiva: normal /inflamed I hyperplastic Recessions: Indentations:
Penodontal disease: yes/ no Penodontal chart from:
Oral mucosa: normal/ pathologic changes
Palatal mucosa: normal/ pathologic/ surgery I swellings
Tongue size: Tongue lrenum:

Apical base 1n lhe sagrltal direction: Apical base in the transverse duecnon:
Maxrlla: normal/large/small Maxilla. normal/ large I small
Mandible: normal I large I small Mandible: normal I large/ small
Palate: high/average/Hat
 Functional Analysis 123

FunctionalAnalysis

Modem orthodontics is not only restricted to static evaluation of the teeth and their supporting
structures, but also includes all functional units of the masticatory system (according to Eschler,
1952), i.e. the stomarognathic system. Therefore, nowadays, functional analysis constitutes a
considerable part of the clinical examination. It is not only significant for the etiologic evaluation of
the malocclusion but also for determining the type of orthodontic treatment indicated. The three
most important aspects of orthodontic functional analysis are:

• Examination of the postural rest position and maximum intercuspation

• Examination of the temporomandibular joint
• Examination of orotacial dysfunctions

Examination of the Relationship:

Postural Rest Position- Habitual Occlusion

• Detennination of the postural rest position
• Registration of the postural rest position
• Evaluation of the relationship: posrural rest
position - habitual occlusion, in three planes
of space
When the mandible is in its rest position, the syncrgists
and antagonists of the orofacial system are in their basic
tonus and are balanced dynamically. This position of the
mandible results from the reaction 10 the force of
gravity. It can also be affected. in the short-term, by
other influences (e.g. fatigue, stress, anxiety). As the rest
position changes according to. among other things. the
head posture. the rest position must be examined
under standardized conditions.
Determination of the Postural Rest Position
In order to determine the postural rest, the patient's
orofacial musculature must be relaxed. Muscle exer-
cises (e.g. "tapping test") can be used to help relax the
musculature prior to carrying out the actual examina-
tion. When using the "tapping test .. the patient is told to
relax and the clinician opens and closes the mandible
passively and with constantly increasing frequency.
Should the patient be very tense, the musculature can be
relaxed with mild electric impulses (e.g, Myornonitor ).
When the mandible is in the postural resting position, it
is usually 2-3 m111 below and behind the centric occlu-
sion (recorded in the canine area).

The rest position should be determined with the patient
relaxed and sitting upright. The head is oriented by
having the patient look straight ahead (habitual posi-
tion). lf this seems too variable. then the head can be
positioned with the Frankfurt horizontal parallel to the
floor (seep. 173 for definition).
The space between the teeth, when the mandible is at
rest, is referred to as the freeway space or interocclusal
clearance. Several methods can be used to determine
the rest position during the clinical examination (p. 124).
124 Functional Analysis
Command method. The patient is "cornmanded" to
- Phonetic method perform selected functions (e.g. swallowing), after
- Command method which the mandible spontaneously returns to the rest
- Non-command method position, In the strictest sense. the phonetic exercise can
- Combined methods also be considered one of the command methods.

Non-command method. The patient is distracted (e.g.

Phonetic method. The patient is told to pronounce
certain consonants or words repetitively (e.g. "M",
"Mississippi"). The mandible returns to the postural
resting position 1-2 seconds after the exercise.
the clinician talks to the patient) so as not to perceive
which type of examination is being carried out. While
being distracted. the patient relaxes, causing the muscu-
lature to relax as well, and the mandible reverts to the
postural rest position.

303 Border movements of the

mandible - sagi11al plane
Ptotedmg tne movements ol the
mandible 1hrough the lacial rmd-
h ne. along tile vertical and sagmal
planes, resullS 1n a charactenshc
panern {Posselt diagram,scllemal·
1c 11fus1ralJon):
A = Relruded contact posmon
A-B = Hinge SJ<lS movement
B = Transmon lrom hinge aos
mavemenl 10 posteoor
opening movemen1
C = Axis ol rota11on ol me
condyle when operung the
mandible Imm lhe rest
posmon
E • Maximum iaw opening
F = Protruded conlad posmon
G = Habitual inlercuspa!Jon
R = Mandibular rest position

The location ol 1he resl position in

1h1s schemauc 1llustra11on of bolder
envelope ol mandibular mouon rs
vanable. Usually, lhe postural rest
posouon ol lhe mandible IS 2-3 mm
pos.1erocnrer101ly 10 cenlric occlu-
SIM (according 10 Raml/orct and
Ash, 1966).

304 lnHuences determining

lntraindividual and
lnterindividual variations In the
rest posltlon
Ove<vleW of lhe ctonically relevan1
raciors affecting lhe penpheral and
central con1rot mechanisms oC the
postural muscle tone, either long-
term or snon-terrn,
Components affecting the rest position
Long-term Influences:
Short-term influences:
• Inconsistency in muscle tonicity • Attrition of the dentition
• Respiration • Premature loss of teeth
• Body posture • Diseases of the neuromuscular
• Stress situations system
• Dysfunction of the
temporomandlbular joint

Combined methods. These methods of determining the
rest position are the most suitable for functional analysis
in children. The patient is first observed during swallow-
ing and speaking. In the case of older children, the
"tapping test" is carried out in order to relax the
musculature. The patient is then distracted, similarly
10 when using the non-command method.
Rest Position 125
Regardless of the clinical method in use, the mandible
must be checked extraorally to ensure that it actually has
assumed the rest position. ln order to do so, palpate the
submental region: relaxed muscles in this area indicate
that the rest position has been attained.
The lips are then carefully parted with the thumb and
forefinger - ensuring that the line of lip contact is not
opened completely- to observe the maxillomandibular
relationships in the rest position.
305 Head posture tor
determiningthe rest position
The physiologic rest pos11Jon of the
mandible rs dependem on the
head posture. Therefore. chn1caJ
reg1strallon must be earned ou1
under Sjandard12edcondrtions.
The rest postt1on should be de-
termined wnh the panem comple-
1ely relaxed, sining upright and
looking straight ahead.
306 Manual guidance of the
mandible while carrying out
the "tapping tut•
The chin •S placed between lhe
thumb and the forefinger. The d1n-
ioan uses irus gnp 10 carry 001
passive apening and closing
movemenlS of lhe mandible rn rap-
•d suceessson 1n order to relax lhe
masncatory muscles prior tooeter-
mrmng the rest postbon. Ve111y
whether the musculature has been
relaxed by palpaung the submen-
tal muscles.
307 Rest posltlon speculum
Determmallon ol the mandibular
rest posmon using the rest postllon
speculum, according to A M.
Schwarz. The instrument 1s placed
laterally between the hps m 0<derto
observe lhe lunchonal 1aw rela~on-
srup.
Clonocal experience has shown
!he determmanon ol lhe phystolog-
re rest posrhon to be difficult ustng
the speculum, as thos instrument
Interferes with lhe tip seal and lhe
entire rellex mecllamsm ol lhe
resn ng 10n us.
126 Functional Analysis
Registration of the Rest Position

Registration of the mandibular rest position is important

in those orthodontic cases where the functional analysis
is significant for treatment planning. There are vari-
ous techniques of registration. The two most commonly
used methods originate from the field of prosthodontics
and include the intraoral indirect method (registration
with impression material) and the extraoral direct
method (registration by means of skin reference points).
The extraoral indirea methods are the most reliable:
- Roentgenocephalometric registration
- Kinesiographic registration
Roe111ge11ocep'1alo111e1ricregis1ra1io11. Two cephalograrns
are required. either in lateral or frontal projection.
depending on how the question is formulated:
- one radiograph in centric (habitual) occlusion
- and one with the mandible in its rest position.

Roentgenoeephalometric
registration of the rest position

308 Functional physiologic

rest p0sltlon
Left Cephalogram 1n centnc oc
ciUSIOn.

R1g11t: In oosiurat resting pos1bon.

The rest pos>Uoois 3 mm below

and poslenor IO 1he canine ocdu-
SJOrl. l.e Ille mandible 1s moved
from Ille rest oosmon lo centnc oc-
clusion by a rotational action only.
The advantage of lh1s rype ol
roentgenograph1c 1echn1Que is
thal unlike Olher methods, the
ph)'Sjologlc re11ex mechanism and
the line of contact of the lips are no1
dtSturbed whlle taking the regisua-
1100.

309 Rest p0sltion in Class II

malocclusion with the
mandible forced posteriorly
Left. Cephalogram 1n habnual oc-
clusaon.

Right: Rad1ograph In rest position.

When compared 10 habitual occiu-

soon, lhe rest posmon of lhe rnands-
bl<uslurther anteriorly. This finding
implies that 1he mandible rs sliding
ioward the poslenor due 10 occiu-
sal 1merferenceduring lheartieular
phase ol the dosing movemenl
from poslUral rest 10 lull ocdusion.

Should Iha mandible be guided

into a functional maloccluSlon - as
wi1h 1hls female pa11en1 - a third ra-
doograph should be laken with the
1eelh tn lheJr lrnllal premalure con·
facl posmon,

The rest position and freeway space can be determined
by comparing the radiographs.
Kinesiographic registration. The mandibular kinesio-
graph. according to Jankelson (1984). allows the mandi-
buJar rest position to be registered three-dimensionally.
The position of the mandible is recorded electronically
by:
- a permanent magnet, which is fixed with rapid-setting
acrylic to the lower anterior teeth, and
- a sensor system of six magnetometers mounted on
spectacle frames.
• -·'
Rest Position 127
Every movement of the mandible and the attached
magnet out of centric occlusion. alters the strength of the
magnetic field. These changes are recorded by the
sensors. processed in the kinesiograph and displayed on
a storage oscilloscope.
The mandibular movements and rest position are
recorded two-dimensionally on two preselectable
levels. The electronic circuitry also allows the rest
position to be recorded as three-dimensional coor-
dinates.
Kinesiographic registration of
the rest position
310 The recording unit
The soeciecte frame ol the rnarxn-
bular 1<mes1ograph. according to
Janke/son. •S aligned on the pa-
tienl The hghtwetght aluminum
frame supports a sensoe system
wh1Ch registers the lhree-d1men-
s1onalspa1raJ changes ol the mag-
net dunng e.<curslons of the man·
d1ble.
Leh: The permanent magnel fixed
into plaoe (Model K-5-R. Myo-
Trorncs Research Inc. Sea.ttle.
Washington. USA).
311 Stable rest position
Top /me: Vertical plane.
Center uoe: Saglltal plane
Bonam /me: Hoflzonlal plane.
Downward deviations ol the line
md1cate mfenor, pos1er10< and lel1
lateral movemenis of me mand•ble.
dependrog on the dimension
Slable mandibular rest posmoo,
When movrng lrom lhe rest po$llron
to me occlusal pos111on. the man-
dible moves upward and forward
and deviates toward the left. The
freeway space rs small (1 9radua·
11on on me scale = 2 mm).
312 Unstable rest position
When compared 10 Fig 311. the
lines Huciuale considerably over
SfM!ral recordings (same pabenl
as 1n Fig 311).
This is an example o1 1ncorred
reg1strahon or the rest po$ll1on. In
this case. 1he rest po$1b0!1 ol the
mandible was determined. based
on the centnc occlusoon. The rest
post11on cannot be determined
correctly using lhlS teennlque The
relal1onsh1pbetween posllJral rest
and centnc (habrtuaf} occlusioo
must always be regrstered Slatbng
from lhe rest posnlon of the man-
dible.
Evaluation of the Relationship between Rest Position and Habitual Occlusion

The movement of the mandible from the rest position to
full articulation is analyzed three-dimensionally: In the
saginal, vertical. and frontal planes.
The closing movement of the mandible can be divid-
ed into two phases:
- Freephase: Mandibular path from the postural rest to
the initial or premature contact position.
- Articular phase: Mandibular path from the initial con-
tact position to centric or habitual occlusion. In case
of functional equilibrium. the articular phase does not
occur (movement without tooth contact).
movements of the mandible from the rest position to
habitual occlusion must be differentiated for ortho-
dontic diagnosis:
- Pure rotational movement (hinge movement)
- Rotational movement with an anterior sliding com-
ponent
- Rotational movement with a posterior sliding com-
ponent
Evaluation in the Sagittal Plane

When closing from the rest position, the mandible may
undergo both rotational and sliding movement, The
objective of this analysis is to determine the amount and
direction of movement as well as the proportions of the
rotational and sliding components. The following
When evaluating the relationship of the rest position to
the habitual occlusion in the sagittal plane, the excep-
tional features of the Class II and Class ill malocclu-
sions are analyzed.

Metric analysis of the relation·

ship between rest position and
habituaJ occlusion
- case example -

313 Cephalomelric
registration of the rest position
Left lateral cephalogram wilh the
mandible 1n Its rest posmon,

Rignt: Radiograph taken m habt-

!lJal occl USIOO.

The rotahonal and shd1ng move-

rnentcomponents from the rest po-
SlllOO 10 occtosron can be recorded
melncally by corretanve analysis o4
these IWO rad1ographS.In the case
al this skeletal Class II malocclu-
sion,the rotauonal componenl is 5°
al1d the amenor sliding component
2.4 mm.
The evaluabon 1echn1Que rs
shown 1n Ftg. 314.

314 Method ol evaluation

B • Basal plane angle tB ~ 1n
ocdusion.
B, = The same angle, when the
mandible is rn us rest position.
MM,, = Distance beiween 1wo
perpendiculars drawn 10 1he base
line of lhe maxtlla. which pass
lhrough the pogonion and "A"
po1n1 and are extended lnfenO<ly
MM = The same relat1onSh1p 1n
Ille resl posmon.
The difference between tne
--
angles 80 and S. reveals lhe rota-
llOOal component The difference
belween MM,, and MM. 1nd1ca1es
lhe shdrng component
-- :-:MMo
-,MM,.

Class II Malocclusions
Due to the different types of movement of the mandible
from I.he rest position to occlusion. the Class Il mal-
occlusions can be divided into three functional types:
- Rotational movement without a sliding component
The neuromuscular and morphologic relationships
correspond to each other, There is no functional
disturbance (functional true Class IT malocclusion)
(Fig. 316).
- Rotational movement with posterior sliding move-
ment
Rest Position - Habitual Occlusion 129
The mandible slides backwards and is guided into
a posterior occlusal position. This finding reveals
a functional Class ll malocclusion and not a true
Class 11 malrelationship (Fig. 317).
- Rotational movement with anterior sliding movement
Starting from the relatively posterior rest position the
mandible slides forwards into habitual occlusion. The
Class 11 malocclusion is actually more pronounced
than can be seen in habitual occlusion.
315 Functionalclassification
of Class II malocclusions
aeeordlng to the relationship
between rest position and lull
occlusion in the sagittal plane
Red = Mandibular path from the
rest POS11ton 10 full occlUSJon
a Mru<lmum ruuculallon
b Pure rolattonal movement of the
mandtble from postural rest to ha·
biluat occtusoon
c CIOS1ng movement of the man-
dible. wi1h pos1enor sl<d1ng ae11on
d Closmg movemenl ol the man-
dible. with anterior sl1d1ng ac1ton.
316 Class II malocclusion,
without sliding action
ten: Habitual centnc posmoo.
Right.· Rest posrtion of the man·
dibte.
Functional 1rue Class II malocclu-
sion whereby lhe mandible moves
lrom the rest posi11on 10 hab>luat
occlesion by means ol cotaI1ona1
movement Wllhoot severe shd1ng
action The mandible Ck>ses as
shown tn Fig. 315b.
317 Class II malocclusion with
posterior sliding action
When movtng from lherest position
(nghl) 10 habltual occlusoon, 1he
mandible performs a rotauonaJ
movemen1 as well as a postenor
shd1ng action. The mandible doses
as shown 1n Ag. 315c.
The functional relationships cor-
respOnd to those ol a Class I reta-
uonslup. When m habllual occtu·
S1on, the mandible rs rorced poste-
riorly The progllOSls lor correellon
ol 1he mandibular dtSplacemenl IS
very favorable 1n such cases.
130 Functional Analysis
Class fff Malocclusions

The functional relationships of Class II I cases determine
the orthodontic treatment possibilities and the prog-
nosis of the malocclusion. The closing path of the
mandible from the rest position can be divided into
three types (Fig. 318):
- Rotational movement with anterior sliding action
During the articular phase, the mandible shifts for-
wards and into a prognathic, forced bite (functional,
non-skeletal malocclusion, so-called pseudo-Class III
- favorable prognosis) (Figs. 319, 320).

- Rotational movement without sliding action
The anatomic/morphologic relationships correspond
to the functional relationships (non-functional, true
Class Ill malocclusion - unfavorable prognosis).
- Rotational movement with posterior sliding action
In cases with pronounced mandibular prognathism.
the mandible may slide posteriorly into the position of
maximum intercuspation. This masks the true sagittal
dysplasia.

318 Functional cfassificatlon

of ctess Ill malocclusions
according to the relationship
between rest position and lull
occlusion In the sagittat plane

Red = Mand1btJlar path lrom the

resl pos.oon 10 lull ocdus•on.

a Maximum art•C1Jlahon
b ClOSlng movement of !he man-
dlllle. With posterior stod1og action.
c Pure rotabonal movement ot the
mano1ble from POSlural rest 10
occlusal PDStl•On.
d Closmg movemenl ol 1he man-
dible, with at'llenor sl1d1ng action b c d

Functional Class Ill

malocclusion
- case example -

319 Occlusion
Class Ill malocclus.on in !he early
siages of the mixed dem111on
The deciduous canines show a
cross-bne rela11onst11p, are elon-
gated, and thetr lips not ab1aded.

320 Relationship between

postural rest and habitual
occlusion
Left: Rest PQStbon.
Center. lnitral toolh cootact
Righi. Hab<UJaJ occlusion.

M<Mng from the resl pos1bon !he

mandible slides forwards rn !he
arucuiar clostog phase due 10 pre-
mature conraci ol the deciduous
carunes [reter 10 Fig. 31Bd), Al-
though lhe prognosis tor 1he treat-
rnem ol lunalonat Class Ill maloc-
cluSIOOS 1s lavofable,the combma-
uon wun an open bile. as on this
ease, IS unla\/Olable,

Mandibular Prognathism
True Forced Bite - Pseudo-Forced Bite
Ln cases ofmesioclusion, an anterior sliding action is not
always a symptom of a functional Class Ill malocclu-
sion. With this functional diagnosis, the "true forced
bite». with its favorable prognosis. and the "pseudo-
forced bite". with its unfavorable prognosis. must be
differentiated as far as cephalometrics is concerned.
The term "pseudo-forced bite" includes those true
skeletal Class 11 l malocclusions where, due to partial
dentoalveolar compensation of the skeletal dysplasia in
the anterior region (labial tipping of the upper and
Lateral view
oeei
----- ---Restp.
Anl Max.Op.
Path ol oPening--
Palh of closure - - -
Rest Position - Habitual Occlusion 131
lingual tipping of the lower incisors), the mandible
occludes at the end of the closing path by means of an
anterior sliding action. If one reconst rue ts the tipping of
the anterior teeth in a pseudo-forced bite, these cases
have a pronounced negative overjet. The dentoalveolar
compensation of the skeletal dysplasia, which already
exists when treatment is 'started. greatly restricts the
range of orthodontic treatment possibilities and unlike
a true forced bite, is indicative of a very unfavorable
prognosis.
321 Oentoaveolar-
compensatedClass UI
In cases wlih part1allydentoalveo-
tar -compensated skeleial Class Ill
relationship. where the upper inci-
sors are tipped lab1allyand the low-
er 11101sors upped lingually. the
mandible may be guided toward
tt>e anterior while closing Howe-
ver. placing the incisors in the cor-
rect axial posmon reveals a pro-
nounced negative overiet which
ehm1na1es the anlenor shd1ng
componenL
Leh.· Cephatogram of a pabent wrth
paruaJly den1oa1veo1at-compen-
sated mandibular progna1hism
Pseudo-forced bite
322 Occlusion
Habilual occiusal posinon o1 a
Class Ill dysplaS1awdh hnguover-
sion of lhe lower mosorsaod tabto-
vers>onorthe uppenncosorsaswett
as a pseudo-lorced bile (refer to
Fig. 321. lettt
Left. Graphic reg1s1tauon of the
sag1nal closing movemem in trus
female pauarn The mandible
slides toward the antenor dunng
the anicular phase
323 Relationship between
postural rest and habitual
oc:cfuslon
Leh: Rest fl06'1Jon
Center. ln111al loath contact.
R1ghr. Habduat occlUSJon.
Aher me mandible has leh us rest
posmoo, tbe onclsal 9u1daneeolthe
upper labially and lower l1ngually
Inclined 1nctsots forces 11 10 slide
lowards lhe antenor dunng thehnal
stages of the ctosmg acscn
The 1oint analys<sol the mosoe
posrt1ornngand 1he luncilonal de-
via11on leads to the diagnosis of a
pseudo-forced b11e.
132 Functional Ana!Y,_s_is _
Evaluation of the Relationship between Rest Position
and Habitual Occlusion in the Vertical Plane

The vertical dimension of the freeway space is assessed.
This analysis is of particular importance to cases with a
deep overbite. According to Hotz and Miihlemann
(1952) one should differentiate between two types:
true deep overbites and pseudo-deep overbites (Fig.
324).
The true deep overbite with a large freeway space,
is caused by infraclusion of the molars. The prognosis
for successful therapy with functional methods is favor-
able. As the interocclusal clearance is large, sufficient
freeway space 'viii remain after extrusion of the molars.
The pseudo-deep overbite has a small freeway space.
The molars have erupted fully. The deep overbite is
caused by overeruption of the incisors. The prognosis
for elevating the bite using functional appliances is
unfavorable. If the freeway space is small, extrusion of
the molars adversely affects the rest position and may
create TMJ problems or cause a relapse of the deep
overbite.

324 Functional classification

of deep overbite
8 Qcdusal J)OSllJOO
b Pseudo-deep ove•b1lewi1h small
freeway space.
e True deep overblle W11h large
f1eeway space.

Schema11c mustranon of lh<l rwo

lunC11onal 1)'PeS ot deep overb11e.
aceo<d1ng 10 Hotz and Muhlemann
i1952J
The physiologic freeway space,
reco<de<l 1n the canine region, Is
apprOXJ.malely • mm in cl11ld<en
and 2-3 mm in adults.
a
325 Pseudo-deep overbite
l.efL Hab11ual OCCIUSl-0<1.

Right: Rest POSdlOO of the mandi-

ble

Class II maloCCluslon with small

freeway space 1n Ille postural J)()Sl·
Don.
The deep overbne 1s combined
with overerupt1on ot 1he !owes inci-
sors.
Pseudo-deep overb•le cases are
a1fficult to trea1as1h1s type ol mal-
occlUS1on cannot be CXlrreded by
ex1n.1S1ot1 ol lM molars.

326 Truedeep overbite

IA/t Hab11U8I OCCIUS1on.
Right Resl pos•tlOO of 1he man·
a1ble.

Class ti, OiVISlon 2 malocclUS1on

with a large freeway space 1n the
postural •es11ng position ol the
mand1bte The prognosis fO< sue-
cesslul correcnon of the deep over-
bite IS good, as this 1ype ot vertical
maldevelopment can be lreated
w11h functional appnances and by
ex1rus1on of tne molars. La1erat
IOOQUIMhrUSI and 1ongue p()SIUle
ate often assooatec wrth true deep
overbite cases.
 Rest Position - Habitual Occlusion
~~~~~~~~~~~~~~~~~~~~~~~~~~~~..;..;..~
Evaluation of the Relationship between Rest Position
and Habitual Occlusion in the Transverse Plane
The position of the midline of the mandible is observed
while the jaw is moved from the postural rest to habitual
occlusion. This analysis is particularly relevant for the
differential diagnosis of cases with unilateral cross-
bite. Depending on the functional analysis two types of
skeletal mandibular deviation can be differentiated:
laterognathy and lateroclusion.
Laterognathy.The center of the mandible is not aligned
with the facial midline in rest and in occlusion. These
133
dysplasias constitute true neuromuscular or anatomical
asymmetry. A lateral cross-bite with laterognathy is
termed true cross-bite. The prognosis is unfavorable for
causal therapy (Fig. 327).
Lateroclusion. The skeletal midline shift of the mandible
can be observed only in 'occlusal position; in postural
rest both midlines are weU aligned The deviation is due
to tooth guidance (functional non-true malocclusion)
(Fig. 329).
Mandibular midline shift:
Laterognathy
327 Schematic illustration
Drawing showing the morpholog-
1cal relahoosh1ps on the posterc-
ante11orcephalogram in case of la-
1e1ogna1hy
R1gnt: The center of the mandible is
displaced m habitual occiUSlon.
The skeletal m1dhne ot the lower
iaw (mental spine)1s shJlte<J lateral-
ly m rela11on tolhe lac.alm1dsagmaJ
plane (vertical hne of refe<ence} .
.. - Left: The lateral deviation ol the
mandibular rmdlme m relation 10
lhe facial m1dlme persests In the
postural rest p0srtion.
328 Findings in the
posteroanterior cephalogram
Rrght· Rad1ograph of lhe paJient1n
habitual occlusron,
Leh: Rad1ograph in the postural
rest PoStl•on
The mldline of the mandible IS dis·
placed 1oward lhe leh 1n the occlu-
sal pos1hon and in postural res!
(laterogr>athy).
This laletal de111ation ong1na1es
In the skeleton and rs associated
With an asymme111c shape ot 1he
glenood Iossa and 1he condyles
Same lemale patienl as in Figs.
281-283.
134 i-uncnonai
Ana1ys:..;.1s~----------------
Mandibular midline shift:
Laterocdus
ion

329 Schematic Illustration

Morphologic retauonsrups on lhe
PA cephalogram of a ease w1in la1-
eroctu&00
Rig/Jr When on occfusal po5111on.
Ille m1dhne of lhe mandible IS dis-
placed la1erally from lhe factal mld-
sagmal plane (Vemcal reference
f1nes1

Left· In postural resi both mldhnes

are cotnoden1 and well ceruereo

Relationship of postural rest to

occfusat position

330 Postural resting position

In 1he rest PDS•hon lhe eeniet o11he
mano1ble is aligned with the upper
ml(tlme (The mesrat contact point
ot the lower cerurat mosors com-
cldew11h 11leskelelal rmdtme ol lhe
mand10le).

331 Initial tooth contact

positlon
The mandible ssm Iha mrhal room
contaCI posmon, lhus 1erm1na11ng
lhe It"-!! phase ot theclos.og move-
men~ whtch slar1ed trom lhe resl
DOSt1100. The patient's right laleral
1nCtWrS eon1ae1 J)<ema1urely.

332 Habitual occlusion

In 1he hnal pnase of Iha clOslng ac-
hon. afler 1n111al 100lh cemaet, lhe
mano1bleslides 10 the leh
Mandibular devtahon rn habtlual
oociuSlon IS caused oy room mter-
le.rences. 1 e. !he skeleial mtdhne
sh1h of lhe mandible whrcti rs only
present 1n maximum 1n1ercusoa-.
non S>gn1hes a fune11onaJ rnaioc-
CIUSlOn (latetocluS>onJ
 Temporomandibular Joint 135

Examination of the TemporomandibularJoint

333 Clinic.at examination of

the temporomandlbular joint
Functional Radiographic This exarrunanon should •ncfude.
Auscultation Palpation
analysis examination asa manei of routine,meauscena-
hon and palpation of the iemoo
romand1bular '°'"' and lhe mus-
culanne associated w11h mancJ•bu-
Object
Jar movemenrs. as well as rhfl lune-
11onal analysis ol lhe mandibular
•TMJ •TMJ • TMJ •TMJ movcmenlS.
• Musculature • Mandibular Speollc radiographic; examina-
uon of the 1emporomand1bu1ar
excursions
1omts. as a pan of lhe or1hodon1ic
•Occlusion diagnOSAS. is only 1ndica1ed on ex-
• Rest position cepnonat cases.

•Premature
contacts
• Dysfunctions
Symptoms

• Crepitus • Pafpatory pain • Dislocation • Dislocation

•Clicking • Hypermobillty •Changes in
•Limitation shape and
structure
• Deviation
• Orolacial
dysfunctions

Clinical Examination

The main objective of the clinical examination is to
assess the severity of the clicking. pain, and dysfunction
which are characteristic of pathologic TMJ symptoms.
When ouscuhation is carried out with a stethoscope,
clicking and crepitus in the joint may be diagnosed
during anteroposterior and eccentric movements of the
mandible. Join! clicking is differentiated as follows:
Initial, intermediate. terminal, and reciprocal clicking.
Initial dicking is a sign of retruded condyle in relation to
the disc. Intermediate dicking is a sign of unevenness of
the condylar surfaces and of the articular disc, which
slide over one another during the movements, Terminal
clicking occurs most commonly and is an effect of the
condyle being moved too far anteriorly. in relation to
the disc. on maximum jaw opening. Reciprocal dicking
occurs during opening and closing, and expresses an
incoordination between displacement of the condyle
and disc. Clicking of the joint is rare in children.
Palparion of the temporomandibular joint during opening
maneuvers will reveal possible pain on pressure of the
condylar areas. Besides the right and left condyles can
thus be checked for synchrony of action. In children.
pain due to pressure on the joints only occurs in approxi-
mately S % of cases.
Palpation of the musculature involved in mandibular
movements is a considerable part of the examination.
Some authors (Krogh-Poulsen. 1973) recommend
palpating not only the rnasticatory musculature of adult
patients but also the entire muscles of the head. face,and
neck. Our experience has shown that in cases with func-
tional disturbances during childhood only one muscle
regularly causes pain due to pressure: the lateral ptery-
goid muscle. Masseter muscle pain is also encoun-
tered in children with TMJ problems. Therefore. these
muscle attachments should be examined on every
orthodontic patient as a matter of course. In most
patients, the initial symptom of TMJ disturbances is
considerable palpatory tenderness in these areas of the
muscles. which usually occurs on both sides. If bilateral
pain to palpation of the lateral pterygoid area is present,
the joint dysfunction is more protracted. In these
patients, the palpation findings of other jaw muscles is
sometimes positive, i.e. it only makes sense to palpate
the attachments of the remaining associated muscles in
cases of bilateral or manifest pressure sensitivity of the
lateral pterygoid.
136 Functiona:.:..l.:...A:::n::::a21y-=s.:. is:.__ _
334 Local, clinical findings of
the temporomandibular joints
Complla11on of palholog1c hnd1ngs Auscultation and palpation of the TMJ
of the 1empo<omand1bular 101nr 10 - Clinical findings -
be noted by d1ntcal lunctional
analys~
• Pain on pressure
• Clicking of the joint
- initial
- intermediate
- terminal
- reciprocal
• Crepitus
• Uncoordinated condyle movements

335 Ausculta1lon of the

temporomandlbular Joints
Sounds made by the temooroman-
d1buta1 jomts can beevaluatedwith
a stethoseope. Even slight ab nor·
mal sounds can thus be registered

Also the urning Of cl1ck1ngduring

Ol)emng and closure should be
noted: lruual, 1ntermediale. terrm-
nat, or reciprocal

336 Lateral palpation of the

temporomandibul:ar joints
Exert sllghl pressure on 1he condy-
lotd process wtlh lhe index lingers.
Palpale bolh sides simultaneously.
Aeg!S!er any lendemess to pal·
pa11on of the 1oonts and any 1rregu-
lan11es m condylar movemenl dur·
1ng apernng and clOS1ng maneu
vers. The coorcmanon of aCllon
be!Ween lhe leH and nghl condylar
neaos should be assessed at the
same ume,

337 Posterior palpation of the

temporomandibularjoints
Post11on !he hnle fingers 1n the ex·
lernal audrlocy meatus and palpate
lhe posienor surfaceOf the condyle
during Ol)entng and clOSingmove-
ments ol the mandible.
Palpa!Jon should be earned 001
in such a way thal lhe condyle dis·
places lhe ltnle finger when dos·
tng on full occlusion.
T emporomandibular Joint 137
338 Palpation or the lateral
pterygoid muscle
The pain pr0joct1on area of !he
la1eral p1erygo1d muscle is palpat-
ed 1n close prox1m1ty 10 the neck of
lhe condyle and lhe J()lnl capsule.
cranially behind the maxillary tu-
beros11y The examinanon rs ear-
ned OU1 with me mouth ooen and
the mandible d1SPlaced laterally

In the on11ial slages of TMJ dys-

funchon, the muscJe ohen hurts
upon palpation on one Side only.
In the advanced stage the pain rs
usually bilateral.

339 Pafpatfon or the

temporafis muscle
The temporal is muscle 1s palpateo
bilaterally and extraoralfy The
anterior, medial, and possenor pot·
uons of the muscle are examined
separately
The palpation is carried out whlle
the muscle rs contracted 1some111-
calfy

Lett The 1empo1al tencllnous at·

tachmenl on the coroood process,
Jn lhe posterotateral region of the
upper vesnbulum.rs palpated The
panenrs mouth st>ould be hall
open 10< the exarnmauon,

340 Palpatfon of the masseter

muscle
The superficial masseter muscle
1s palpated benea1h lhe eye, 1nle·
nor to the zygomatlc arch
The deep pomon 1s pafpa1ed on
1he same level, approl<lmatefy2fin-
ge< widths m front ol 1he rragus

Left During maXJmum Isometric

muscle contracnons 1he Wldlh Of
the super11c1al masseter and 11S
direchOn ol pull can be reg1Slered
around the gon1al angle This
muscle attachmen1 should be ex-
amined 10< pain on to pressure
Occasional lngger spolS may
occur which can be quite painful.

341 Recording the maximum

interineisal distance
On maximum iaw opening. the dis·
ranee between the mcisal edges
of the upper and !owe< central 1n-
osors IS measured with a Boley
gauge.
In overbite cases thiS amount
is added to the obtained value
whereas in open bne 1t 1S subtract·
ed The extenl of maximum raw
opening between the 1ncasal edges
IS usually 40-45 mm. In cases with
TMJ dystunchon, hype<mobflny 1s
oflen reg1S1ered m 1he1mllal stages
and bmuat1on m !he lalflf ~ages.
138 f-unct1ona1 Analysis
Opening and Closing Movements of the Mandible

The opening and closing movements of the mandible as
well as its protrusive, retrusive and lateral excursions are
examined as part of the functional analysis. T71e size
and direction of these actions are recorded during the
clinical examination. Deviations in speed can only be
registered with electronic devices (e.g. kinesiograph).
The first signs of initial ternporomandibular joint
problems include deviations of the mandibular opening
and closing paths in the sagittal and frontal planes. In
patients with malocclusion and malaligned teeth, distur-
bances in mandibular movements are the result of an
asynchronic pattern of muscle contractions. The
characteristic movement deviations include incon-
gruency of the opening and closing curves and unco-
ordinated zigzag movements. The "C" and "S" types of
deviation are typical signs of functional disturbances.
Occlusal analysis on an articulator is mostly not
necessary in adolescents. It is only indicated in patients
with manifest symptoms of temporornandibular joint
disease.

lnterlerence-free registration
of mandibular opening and
closing movements

342 Head frame of the

electronic recording unit
Frontaland lateral view ol lhe head
ftame m POSthOn. A permanent
magnet rs secured 1ntra0<ally on
the mandible to produce a lhree-
d1mensronal magne11c field The
head frame consists ol a system
of antennas whlch 1ecotd lhe
Changes 1n position ol the mag-
neltC held dunng movements ol
the mandible (S1rognathograph.
Siemens, Benshe1m,Germany).

343 Coordinate system

The cllanges 1n posiuon of tne
magneuc held dunng mandibular
movemenls, and the antenna sig-
nals, are convetted 10 analog
electrtcal cha1ges which are led
into a prooesso< and displayed as
mree reference values: x. y and z,
These can be graphically pre-
sen1ed via a plotter in one of the
followmg three lBC1al planes:

XZ plane = Saglttal plane

XY plane • Honzontal plane
YZ plane = Frontal plane

I
Case example
Ags. 344-346

344 Occlusal relalion$hip$

FroniaJ and lateral 111ew ol lhe hab>-
tual occlusion of a 2t-year-old
female pauent,
Tne left lateral mciSO<s are in
edge-1o-edge relallonsh1p. There
IS severe annhon al the upper
camnes
 Mandibular movements 139
345 Pattern of mandibular
movements duringopening
and closing maneuvers
Left·Opening and closing paths m
Ille sagmal plane (XZ ptane)
j The opening and ctos1ng arcs
cross-over lllCOl'S1Slenlly
The opening m011emeots snow
greater devtahons.
The closure pa11ern is strargh1er
and more consrant

Center· Opening and closing arcs

on Ille horizontal plane (XY plane).
The opening path IS patholog1·
cally C-shaped
At lhe end of lhe cl0S1ng move-
meru, lhe mandible shdls shghlly
toWard lhe left

R1gn1: Opening and c10s1ng paths

in the lrontal plane (YZ plane).
The extent ol maximum 1aw
"' opening is normal During Ille r1na1
stages of closing, lhe mandible
slides to the left due to occlusal
onter1erences (1 mtlhme1er = 0.5
mm movemeno.

346 Three-dimensional
reconstruction of the
mandibularopening and
closing movements
Three-d1men51onaJ diagram o1 the
recordings shown 1n Fig. 345
(marking of the opening and Clos·
1ng arcs).

Lett The attrrbon on the upper Ian

canine o1 this female pa11enr rs a
ci1n1cal symptom or !heocclusal 1n-
ter1e<ence. The occlusal relat1on-
sh1ps are shown In Fig 344.
140 i-uncuonat Anaiys.s
Temporomandibular Joint - Radiographic Examination

Only in exceptional cases are radiographic exarnina-
Lions indicated for children with functional disturbances
of the temporomandibular joint. ln contrast to adults,
pathologic radiographic findings are rare at this early
age. Several radiographic techniques, which are taken in
habitual occlusion and/or in open-mouth position, are
suitable for examination of the temporomandibular
joints (posteroanterior projections according to
Clementschitsch, radiographs according to Schuller or
Parma, tornograms). When analyzing the radiographs,
the foUowing findings are registered: Position of the
Radiograpttic examination of
the temp0romandibular joints
- case example -
condyle in relation lo the fossa, width of the joint space,
changes in shape and structure of the condylar bead
and/or the mandibular fossa.
Adolescents with Class ll, Division I malocclusions
and lip dysfunction (lip-biting or sucking) are most
frequently affected by TMJ disorders. For this reason,
orofacial dysfunctions must also be assessed as a part of
the functional analysis as they may lead to unbalanced
loading of the joints and thus trigger off temporoman-
dibular joint disturbances in adolescents.

34 7 Clinical findings
22-year-old panem with a pro·
nounced hp dyslunci1on.

R1gn1; Class II malocclusion with

increased ovetjet and lablOVersion
of the upper incisors.

348 Tomograms of the

temooromandibular
joint in
habitual occlusion
Tomographic film of the right and
left 1emporomand1bular Jomts in
run rntercuspalion (projected along
lhe saglnal plane).
There are nooceable differences
between the leh and nght sides re-
gardmg the shape ol the coody1es.
rhe roof of the Iossa. and !he width
ol lhe 10001 space.

Flight. The condy1e and lhe roof

ol lhe Iossa are nauened seve<ety:
1he condyle is dislocated antenorly
m the glenood cavity.

349 Tomograms of the

temporoma_ndibular joint in
maximum open..mouth position
Lelt: The 11ghl condylers subluxat·
ed when the 1aw IS maximally
opened.

Right: The vertex of the lett condy1e

Is pos.troned beneath the articular
wbercie.

Examination of Orofacial Dysfunctions
• Swallowing
• Tongue
• Speech
• Lips
• Respiration
Swallowing
Normal mature swallowing takes place without
contracting the muscles of facial expression. The teet h
are momentarily in contact and the tongue remains
inside the mouth (Fig. 350).
Abnormal swallowing is caused by tongue-thrust,
either as a simple thrusting action or as "tongue-thrust
syndrome". The following symptoms distinguish this
syndrome: 1) Protrusion of the tip of the tongue, 2) no
tooth contact of the molars, 3) contraction of the peri-
oral muscles during the deglutitional cycle.
Orofacial Dysfunctions 141
During their first few years, infants swallow viscerally,
i.e. with the tongue between the teeth (Fig. 359). As the
deciduous dentition is completed, the visceral swallo-
wing is gradually replaced by somatic swallowing.
Should visceral swallowing persist after the fourth
year of age, it is then considered an orofacial dysfunc-
tion. Infantile swallowing is seldom found in older
children and, even ifit occurs, then only as a mixed type
of visceral/somatic swallowing.
350 Cinematography of
swallowing
Clneradlographic Images of Indi-
vidual stages ol the deglubllooal
cyde during saliva swallowing.
Le/I: From top to bonom; sequ-
ence ot 111011emen1S ol somatrc
swallowing. The 11p ol lhe 1ongue
rs enclosed in lhe oral cavilyduring
swallowing: the upper and low·
er pcstenoe 1eeth contact one an-
othe! during lhe deglu11t1on cycle.
Right SeQuence ol 8CllVllyduring
visceral swallowing.
The up ol lhe 1ongue protrudes
and attempts to reach lhe lower hp.
The upper and lower posterior
teetn do nol come lnlO conlSCIdur-
ong lhe enure sequence of move-
ments (lhe dorsum ol lhe tongue IS
marked with a contras! medium).
142 Functional Analysis
351 Tongue peristalsis during
somatic swallowing - Collect-
ing stage
Dunng lhe hrst stage of swallow-
mg, lhe lood 1scollecled inthelore-
mosl pan of 1he mouth, in front of
lhe reuacled longue. The pOS1er101
atched pan of lhe d0<sum 1s m con-
raci wilh the soft palate,
The hpsarenot In conraaand the
teeth are not occluding.

352 Physiologic variations

during the collecting stage
There ate oenam vanauoos m lhe
first stage of 1he swallowing cycle.
The toed may be laken on front of
lhe retracied 1ongue.

Right: In ocher cases. 1he food

bolus IS collected on lhe dorsum ol
lhe loogue (cmeradiography).

353 Transporting stage -

1st part of movement
Ounng lhe second phaSe of swal-
lowing, Le. the uanspomng stage,
Ille tip ol lhe tongue hrst moves up-
ward and 1he anleI1or secuon of the
dorsum tsdecressed (according 10
Graber. 1972).

354 Transporting stage -

2nd part o·f movement
The eniire an1enor secbon of lhe
1onguelhenmovesupwardandlhe
cenual seenoo of lhe doesom 1s de-
pressed.
Th<S penstalsls uansocos lhe
bolus reatward
 355 Transporting stage -
3rd part of movement
Al rhe end ol the transporung stage,
!he soft palalo is dlSl)laced upward
and rearward.
The lip musculature contracts
simultaneously, the hps are 1oge1h-
er, the mandible is raised and !he
teeth come Into contact

356 Third swallowing stage

The dorsum of lhe 1ongue IS de-
pressed even rurther during the
1hlrd stage so that the bolus can
pass lluough the oropharyngeal
1slhmus; slmuhaneously !he ante-
nor part ot the tongue rs pressed
against !he hard palate. lhus forc-
ing more food rearward.
Passavant's pad and soft palate
form the palatooharyngeal seal
and close the nasopharynx. The
1eeth are rn full oodusion and the
hps in contact.

357 Fourth swaUowlng stage

Ounng the fourth stage ol the
swallowing aa. lhe dorsum of the
lOngue IS moved Nrther upward
and rearward agarnst the soft ear-
ale and squeezes the remaining
food bolus out ol the orooharyn-
geal area,

----~
(/
358 Final stage of swallowing
cycle
Once !he swallowing act has been
completed, !he mandible returnsto
11s resi oosmon.
144 i-uncuonat Ana1ys1s
359 Visceral (Infantile)
swallow in the neonate
The iaws are apart durong swal-
lowing. The tongue rs P<Jshed for-
ward and placed bet'M3enlhe gum
pads. The tip of the tongue pro-
trudes.
The mandible 1s siab1l1zed by1he
coruraction cl the tongue and the
orofacial musculalure as well as by
the tongue coruact with the lips.
Swallowing is troggereel oft and.
to a largeexten~ cameel out by sen-
sory interchange between the lips
and the tongue PenslalsJs already
commences 1n the vestibule

Flight The transverse secuon

shows lhal the tongue IS posmoneo
low m the mouth and that the cen-
tral furrow IS depressed (according
to Grabet, 1972).

\\ \ I (

360 Somatic swallow

1
As swallowing is tnggered ott by
contracnon of the mandibular ete-
valors (rnasseter muscle). the teeth
occlude momentanly dunng the
l
swalloWing act and the t1p of the
tongue rs enclosed 1n the oral cav-
ity.

R1gh1: The transverse sectlOfl

shows that the dorsum of the
tongue 1s less concave and ap-
proaches the palale during swal-
lowing (according lo Groller. 1972).
 Orofacial Dysfunctions 145
Tongue-Thrust

Tongue-thrust has an important effect on the etiopatho- Cases with an anterior open bite during childhood
genesis of malocclusions (Fig. 361). The thrust may (Figs. 362, 363) are often self-compensating. Complex
take place in the anterior or lateral regions or can be or skeletal open bites do not regulate themselves sponta-
complex.ln the first case, the dysfunction is significant neously, but rather persist.
during the development of an anterior open bite (Figs.
362, 363) and in the second case during the develop-
ment of a lateral open bite (Figs. 364, 365) or a deep
overbite. In case of a complex tongue-thrust, the occlu-
sion is supported only in the molar region (Fig. 366).

361 Etiology of
tongue-thrusting
Tabteshowing lhed1tteremcauses
Tongue-thrust and d1'Jergenl locahzation ol the
dyslunct1on

• endogen-
•primary •anterior
ous
•secondary • lateral
• habitual
•complex
•adaptive

Anterior open bite

362 Occlusion
Open bite in a deciduous deot1uoo,
caused by a tongue dyslunct1on
as a residuum of a sucfdng habit

363 Habitual position

The tongue rs posftloned loiwaro
dunng funcbonlng, thus impeding
Iha wrt1cat devetopmenl ol lhe
demoelveotar structures around
the upper and lower anie110< teeth.
Same pa11en1 as in Fig. 362.
146 Functional Analysis
Lateflll open bite

364 Occlusion
In lhlS 1ype ol open bite the
occ!USIOO on both Sides IS support·
ed only antenotly and by the first
permanent mOlaJs.

365 Habitual posiUon

The longue thrusts between Ille
teelll laterally.
The tongue dysluncuon occurs
in con1uncbon with a disturbance In
the physiologic growlh processes
around the llrS! and secood decid-
uous molars.
Same panent as on Ag. 36''-

366 Complex open bite

Severe venJcal malocclusion. The
teelh occlude only on the second
molars. Tongue-thrusting occurs
dunn9 lunc11on.

367 Tongue dysfunction and

malocclusion
In mandibular prognalh1sm, the
downward lorward dosptacement
ol Ille tongueol\encausesanan1e-
nor tongue-thrust hab<L

Primary - Secondary Dysfunctions
From the etiologic point of view, tongue-thrust may be
considered primary or secondary. Principally speaking,
all dysfunctions can be divided into primary. i.e. causal
or secondary, i.e. adaptive malfunctions (Fig. 368).
The primary dysfunctions cause malocclusions (Figs.
369 and 370) and the treatment must concentrate on
eliminating the orofacial dysfunction.
Causes of dysfunctions
Primary
• Endogenous factors
•Heredity
• Imitation
Orofacial Dysfunctions 147
Secondary dysfunctions can be considered an adap-
tive phenomenon to an existing skeletal or dento-
alveolar deviation in the vertical development (Figs.
371-373). These secondary abnormalities usually
correct spontaneously while the morphological dis-
crepancies are being treated (homeostasis).
368 Etiology of primary
and secondaryorofacial
dysfunctions
Compolatt0n of the vanous causes.
Secondary
• Adaptation
369 Primary tongue
dysfunctionin conjunctionwith
hypefl)lastlc tonsils
A retracted tongue would tooch
Infected. swollen tonsils 1f these
were to protrude lar oul ol 1he sur-
rounding struclures. In order to
a1101d painful sensancos and to
keep the Ofal a11way open the man-
dible ts dropped and 1he 1ongue
postureo forward (acoord1ng to
/.foyetS).
370 Hyperplaslic tonsils
Moderalely swollen palatine tonsils
which protrude Slgntficantty from
1he tonS1llar sinus.
148 Funct_io~n~a_l_A_n_a~ly_s_is~~~~~~~~~~~~~~~~~~~~
Adaptive tongue dY$1Unetion

371 Adaptive tongue

dY$funetion wtth tooth
mafpositions
Altet loss ol teein, 1he 1ongue ss
used to hll the gaps, thus sealing
the o<al caV1ty, r.e. compensatory
dysfunction.
In cases wuh p<ematu1eextrac-
uonol deciduous teetb.irns pnmar·
1ly physl(JIOQICdisplacement of lhe
tongue may petsist as a lunct1onat
abnoimabty even alter the perma-
nent teeth have erupted.

372 Adaptive tongue

dysfunction with skeletal
malocclusion
lateral cephalogram ol an open
bile due 10 rickets.
The open bite rs a symptom ol a
severe skeletal dysplasia with dis·
harmornes In Ille ver11cal develop-
ment The tongue dysfunction IS
an adaptalion to the skeletal and
dentoalveolar mo1phology

373 Open bite due to rickets

nus enamel hypoplas1a ol the
upper and lower anterior teeth as
well as of the lrrsl molars resutts
from a vnarmn D dehc.ency Which
occured at the age ol about t year
The skeletal and dentoalveolar
open btle Is aggravaled by the
adaptive 1ongue dysluncllon.
_____________________ O_ro_fa_c_ia'--1
Dysfunctions 149
Configuration of the Craniofacial Skeleton and Dysfunctions

The morphology of the facial skeleton (Figs. 3 74, 3 75) From the differential diagnostic point of view, it is
and the effects of tongue-thrusting are correlated to a important to clarify both the skeletal relationships and
certain degree. the tongue dysfunction in order to localize the results of
Whereas a horizontal growth pattern in conjunction the abnormal tongue functioning.
with tongue-thrust usually results in a bimaxillary dental
protrusion (Figs. 376-378); in a vertical growth pattern
with tongue-thrust the lower incisors are often in lingual
inclination (Figs. 379-381).

374 Horizontal growth pattern

scoemane 1llUS!ral1on of 1he mot-
pholog1c relanonsrups on lhe
cephalogram 1n case ol a growth-
related upward and forward rota-
hon ol the mandible.
The dashed hne represenlS !he
Y-axis.

\
\

375 Vertleal growth pattern

Schemabc 1llus1ra11on of 1he mor-
phologic relat1onsh1ps on lhe
cephalogram tn case of mandibu-
lar downward and backward rota-
non during growth.
150 Functional Analysis
Horizontal growth pattern
associated with anterior
tongue dysfunction
-
376 Clinical picture
In rnosi cases w11h lhls 1ype
al growth panern, 1ongue-lhrust
causes b1maxillary dental protru
s1on.1.e. labial lipping ol uooer and
lower amenor teeth

377 Lateral cephalogram

CephalOmelnc rad1ograph of the
cranlolaccaJ relat1onsh1ps.
Same pauent as rn Fig 376.

378 Schematic v1-

Sehemauc ollusuahon of the u1e1sor
relauonshlps in a casew11h an ante-
r1or open bile, 1ongue-11lrust, and
honzontal grow1h pattern,
Vertical growth pattem
associated with anterior
tongue dysfunction

379 Clinical picture

In cases wolh irus type ol g<owtll
pattern, tongue-thrust tends to up
the uppet •nc:tsors to the labial and
the lower incisors 10 the lingual.

380 Lateral cephalogram

Cephalometroc radoograph of Ille
cramofacoal rela1oonsh1ps.
Same oanent as on Fog. 379.

381 Sch.,,,,alic view

Schematic 1flus1ra11on of lhe onasor
retanonsrups on a case W1lh an an-
tettor open blle. tongue-lhrust. and
vertical growth pattern (overerup-
1100 ot postenm 1ee1h and steeper
than normal mandobulai plane)
152 F_ynctional Analysis
Methods of Examination

Various methods can be used to examine tongue dys-
functions. The different types of clinical examination
are: electronic recordings. electromyographic examina-
tion. recordings of the pressure exerted by the tongue
intraorally, roentgenocephalometric analysis, cine-
radiographic, palatographic, and neurophysiologic ex-
aminations.
The position and size of the tongue in relation to the
available space can be assessed using roentgenographic
cephalometrics (Figs. 389-391).
However, in most orthodontic cases. registering the
position of the tongue is more important than deter-
mining its size.
Pa/atographyinvolvesrecording the contact surfaces of
the tongue with the palate and teeth while the patient
produces speech sounds or performs certain tongue
functions (Fig. 382). A palatogram is an illustration of
rhese contact areas (Figs. 383-388).

382 Palatographic
examination
A Lh1n. umrorm layer of contrastJng,
precise 1mpress1on material is ap-
plied to 1he paueru's 1ongue with a
SPillula
Once the consonant has been
pronounced or the tongue move-
ment earned out (e.g. swallowing).
the palalogram can be document-
ed photographically using a sur-
face mirror.

Palatogram during the

pronunciation of .. S.

383 Accurate pronunciation

of the'"$•
Ounng arucutauon, the mandible rs
lowered slightly and pushed lot-
wards. Tue tongue rests on the
teeth and the alveolar processes.
and a groove Is lotmed in the
center lhtoughwhich the air Sir earn
is directed onto thecenual incrsors,

384 lnterdental sigmalism ........-

(llsping)
Ounng this deleclive pronuncr-
allOl1 ol lhe ·s·
sound. Ille 1ongue
rs usually prOltuded and clearly
visible between lhe anterror teerh.
Orolac1al Dysfunctions 153
385 Palatal sigmatism
Th.s abnormal pronuooauon 1s
caused by an unphysoologic lnc-
t-on oose between 1ongue and
hard palate

386 Lateral sigmatism on the

left side
The tongue rests on lhe antenor
teeth. The column ol air escapes on
lhe left sida

387 Bilaten1I sfgmatism

Pa1a1ogramof irus type of delectJ\ie
amcularion 1n a pa11en1 wrth rmcro-
gloss.a

388 Sigmatism due to

laterollexlon to the left side
Dunng this inaccurate fOfmation ol
!he ·s· sound, the 11p of the tongue
rs raised 100 high and rests on the
upper 1nc1sors.
The 11p of lhe tongue dev1a1es IO
1he le~ ol lhe m1dhne and lhe air
stream 1s forced lalerally.
 1:>1J runcnonai Ana1ys1s
Metric evaluation of tongue
posture

389 Assessment of tongue

position on the lateral cei>hato-
gram
Is T = lnc1sal edge of lhe ta.ver
cenlral mcsor
M = CeMcal diSlal 1hird ol the last
erupted molar 14
\3.
v = The most mlenor pemt ol the \ I
uvula, respect1VE>IY its prOJOO•on on
lhe reference hne (connedlng line
~l"-een ls T and MJ.
0 = mldpo<nl on tile reference line .7
between Is T and V 1$ 1
A lme is drawn lhrough 0, per-
pendicular 10 Ille honzontal base-
line. and eX!eocled to the palate. A
lurthet lcor lines are drawn, at 30"
lo each ocher, resulting In a lolal ot
seven Imes.

390 Tracing of the analysis on

the lateral cephatogrem
Marking ot the contours al lhe bony
palate and d01sum ol the 1ongue
Hoo.rontal and vertical reference
lines for rnernc evaluahon are 111us-
1raied

Left The morphologic relation-

ships 1n case ol a retracied, eteval·
ed t0ngue.

Rignt: Aelauonsn1ps m case ol

a downward forward longue-pos-
ture.

391 Template for metric

analysis of tongueposition
Transoarem ptasuc template with
an Inscribed mllhmeter scale tos
analyzing thel)OSlhonot lhe tongue
3
• 5
on the 1a1eral cephalogram. The
iemplate 1s onerued on the POIOt 0
shown 1n Ftg. 389.

7

Lip Dysfunctions
The etiology of lip dysfunctions is similar to that of
tongue habits and is assessed in relation to the configura-
tion and functioning of the lips.
Configuration of the lips
The configuration of the lips differs a great deal. Of the
many classifications, the following is the simplest and
most suited grouping for daily practice:
Competent lips. Lips which are in slight contact when
the musculature is relaxed (Fig. 392).
Orotaciat Dysfunctions 155
Incompetent lips. Anatomically short lips which do not
touch when the musculature is relaxed. Lip seal is only
achieved by active contraction of the orbicularis oris
and the mentalis muscles (Figs. 393, 394).
Potentially incompetent lips. The protruding upper inci-
sors prevent the lip closure. Otherwise, the lips are
developed normally (Figs: 395, 396).
Evened lips. These are hypertrophied lips with redun-
dant tissue but weak muscular tonicity (Figs. 397, 398).
392 Competent lips
Frontal aJld profile vrews. The lips
are rn cootact Wl'le<l the musceta-
ture 1s relaJCed
Incompetent lips
393 Habitual lip posture
Ana1ormcally short hPS with a wtde
gap between lhe upper and lower
hp 1n relaxed posotton.
394 Consciously closed lips
lncornpetent hps can only be
closed by increased coo1rac1>on o1
tile orb1cula<>s ons and mentahs
muscles
156 r-uncnonai Anarysis
Potentially Incompetent lips

395 Habitual lip posture

The upper incisors are labially
upped and then 1nc1sat margins
interpose beiween the lips orevent-
mg tile normal hp seal.

Right. Fat sealing the oral cavity

1he hp of 1he tongue IS 1n conlaa
with Iha lower hp.

396 Consciously closed lips

up contact IS acll1eved without
increased conuact1on ol the pert-
oral muscetaune,

Everted lips

397 Habitual lip posture

Fronlal and profile vteWS with 1he
hpsctosed.

398 lateral cephalogram

Due 10 the weak 1on1c1ty ot the hp
mUSOJlature. these pat1enls Olten
exhibit b1max1llary denlal protru-
sion (labial tncitnatron 01 both up-
per and lower 1nclSOtS).

Lip Habits
The various habits of the lips can be divided into
lip-sucking(Fig.399), lip-thrust(Fig. 400), and lip insuffi-
ciency (Fig. 393).
Lip dysfunctions can be observed while the patient is
speaking and swaJJowing. The lower lip often shO\VS
variations of dysfunction with regard to the tip of the
tongue. The lower lip and the tip of the tongue are often
-
Orofacial Dysfunctions 157
in contact. In such cases, the lower lip is sucked in and
pressed against the tip of the tongue. Any lip activity
during swallowing - apart from closing the lips - is
unpbysiologic and a symptom of an orofacial dys-
function. Visual evidence of mentalis muscle activity is
also abnormal.
399 Lip-sucking
Extt aotal findings. The tower lip 1s
postUOned behind !he upper tnCI•
SO<S. In many panenls, malposinon-
ong of the hps occurs in con1unc1100
w11h hyperaCIJvily of !he memans
rnuscle.
Right. The lateral cephalograrn
indicates Iha! the dysfunction of the
lowef lip causes funher protrusion
of the upper lllCISors and 1rnpedes
lhe torward developrnenl of the
lower anterior alveolar precess,
400 Up-lhrus1
Charactenstic prome ol the lower
third of the face fn a case Wl!h hy·
perac11v11y ol !he rnentalis rnuscle.
Rtr;hi: In rnany oauents, this type of
hp hab11 is combined wilh bngual
1ncllna11on of lhe 1oosors.
158 +uncuonai Anaiysis
Cheek Dysfunctions

In case of cheek-sucking (Fig. 401) or cheek-biting Lncreased Lateral pressure by the cheek musculature
(Fig. 402) the soft tissues are interposed between the on, for example, the mandible impedes the transverse
occlusal surfaces of the teeth, which promotes the development of the jaw, This type of cheek dysfunction
formation of a lateral open bite or a deep overbite. is common in cases with buccal nonocclusion (Fig. 403).

401 Cheek dysfunction

Extraoral f1nd1n9s m a case wllh
hyperlunctJon ol buccnatOf
muscle and cheek-sucking.

402 Cheek·bitlng
This female pat1en1 shows a weal-
like honzontal swelling ol the buc-
cal mucosa caused by the dysfunc-
non,

403 Cheek dys!unction and

malocclusion
Buccal nonoccluSlon In the decid-
uous den1rt>0n combmed w11h a
cheek dysfunction.

Hyperactivity of Mentalis Muscle
The deep mentolabial sulcus (Fig. 404) is characteristic
of a hyperactive mentalis muscle. This habitual pattern
of muscle behavior impedes the forward development
of the anterior alveolar process in the mandible
(Fig. 405).
Orofacial Dysfunctions 159
The abnormal rnentalis function often occurs together
with tip-sucking or lip-thrust (Fig. 403). Cases of
hyperactivity of the mentalis muscle which occur in
the same family, are usually hereditary (Fig. 404).
However, this finding may be based on an imitation of
the dysfunction.
404 Deep mentotabial sutci
and hyperactivity of mentalis
muscle
Profile View of a female palfent wtlh
me din1cal appearance of the ab-
normal muscle functJon.
R1ght. The same dyslunctlOfl IS
diagnosed In lhe SISier. whO IS
2 years older.
405 Cephalometrlc findings
in case ol hypertunetlon of the
mentaJis muscleand the lower
lip
The demoalveolar locauon of the
Class II malocclusion 1s character-
isnc,
Right: The hypetaCIJve mentallS
muscle pulls the lowe< Up upward
and rearward and presses 11
agains1 lhe lingual surfaces of the
upper Incisors. The upper hp re-
rnams relaJJvely mo11on1ess. The
normal lip seal lsdtSturbedandlhe
1ongue d1Sl)laced downward.
This type of sott-nssue mO<PhO-
logy aggravates the denloalveofar
malocclusion.
160 Functional Analysis
Mouth-Breathing

The mode of respiration is examined to establish
whether the nasal breathing is impeded or not. Chroni-
cally disturbed nasal respiration represents a dysfunc-
tion of the orofacial musculature; it can restrict devel-
opmenl of the dentition and hinders the orthodontic
treatment. The following clinical findings are typical
of patients with oronasal respiration: a high palate,
persisting "tooth germ position" of the upper incisors.
narrowness of the upper arch, cross-bite, often accom-
panied by poor oral hygiene and hyperplasia of the
gingiva (Figs. 407, 408). The extraoral appearance of
these patients is often conspicuous, and is termed
"adenoid fades" (Fig. 406).

406 "Adenoid tacles"

Frontal and prohle views of a 6-
year-old female panem with coro-
rucally resmcted nasal respiratory
lundlon.

407 Ocelusal and dental

findings in case ol oronasal
respiration
The upper iaw lS markedly cons-
u1cted.lha "tooth germ position· of
lhe upper incisors has persssted,
1he mandibular arch rs well lO<med
Ooe 10 the incongruence m arch
width a bilateral e<OSS·b11e extSls

408 Conliguratlon ol lhe

maxilla in oronasat respiration
The high palate and narrow upper
arch are charactenSlic leatures.
 Respiration 161
Pattern of Facial Morphology

The configuration of the facial skeleton and oral respira- is more common and more pronounced in patients
tion are correlated to a certain degree. Impeded nasal with oronasal respiration. The incidence of hypertro-
breathing shows a higher frequency in facial types with phied tonsils is also increased in this group (Figs.
vertical growth tendency. Proliferation of the adenoids 409-4ll).

Classification of the adenoids

on the lateral cephalogram

409 Small·sized adenoids

(+)
The rad1ograph1c images of the
adenoids on 1he lateial cepnale>-
gram appear as a sllgh1 curvaiure
on !he upper rear wall of lhe naso-
pllarynit.

Lett: Sc:llemat1c 11lustralJon of the

morphological reta11onsl11PS.

AdenolCls + J
410 Medium-sized adenoids
(++)
Noticeable prollfetallon of lym·
pho1d 11nsuo on 1ho upper rear wall
of lhe nasopharyruc. wh1c:ll occu-
pies approX1malety haJ1 o1 the \11S·
1ble pneumatic ca\/lly in the ep1-
pharynx

Lett· Schematic 1lluS1Ja!lon of the

relabonshtl)S. \

Adenoids++

411 Large-si:ted adenoids

(+++)
The lymphabc ussoe occupies
m0S1 ol 1he nasopharyngeal pneu-
mauc ca\/lly.

Left: Schemabc iuustranon of the

retat1onsh1ps.

Adenoids++ +
Tongue Posture

Two different tongue postures are possible in case of

oronasal respiration:

Type I: The tongue is flat and its tip is behind the Type 11: The tongue is flat and retracted. This type of
lower incisors, This type is often encountered abnormal tongue posture is conunon in cases
in conjunction with an anterior cross-bite with oral respiration and distoclusion (Fig.
(Figs. 412. 414). 413).

412 ~I tongue positlon

Class Ill malocclusson with a flat.
pro4rudmg tongue l)OSIUre.
The downward forward J)OS411on
DI the tongue has been marked
with cootrasj medusmon the lateral
cephalogram.

413 type II tongue position

Class U malocclusoon with flat. re-
tracted tongue posture.
The downward ba.ckward p051-
bonof lhe tongue has been marked
with contrast medium.

414 Tongue position and oral

respiration
These lateral cephalograms show
the poslbon ol !he tongue m a
paoentw1lh restncted oral respua-
bon poor 10 (/elf) and after (nght)
removal of the adenoldS
Alter ENT surgery and change to
nasal brealhl ng lhe in ltlally fla1
posmoned tongue was raised to-
ward tl'le palate.

Examination of Breathing Mode
The case history (e.g. details regarding recurrent
diseases of the upper air passages. sleeping habits) and
evaluation of tongue and lip posture as well as lip func-
tion, provide certain keys concerningthe breathingmode.
The following are various clinical methods of exami-
nation which permit a crude check of the degree of
nasal obstruction: the cotton pledge! test, the mirror test
(Fig. 415), and observation of the nostrils (Fig. 416).
When interpreting the findings, it must be taken into
Respiration 163
account that the respiratory mode is controlled by the
nasal cyde\vhich changes approximately every 6 hours.
This is a physiologic protective mechanism which
prevents the nasal membranes from drying out (Eccles.
1978: Masing and Wolf 1969). Due to the nasal cycle.
one nasal airway is always more constricted than the
other. i.e. an apparent unilaterally obstructed nasal
passage during the crude clinical examination is not
necessarily a pathologic finding.
415 Mirror test
The mirrors are held in Iron! ol boUl
nostrils. In nasal-breathers the
mirror wtll cloud wuh condensed
m01sture dunng expuanon as
shown on the nght
Examination of alar
musculature
416 Nasal respiration
The size and shape ol 1he external
nares ot a pallent wnh nasal resp1-
rat1on during mspuatoon (left) and
explrallon (nghr).
The very no1tceable changes 1n
the cross-section of the nasal on-
hces are typical for nasat-bream-
ers,
417 Oronasal respiration
The eross-secnon ot the external
nares of a patient wuh preva1hng
oral respiration durmg 1nhalrng
(lelr) and exhaling (ngh{)
The afar muscles are maceve -
nares do 001 change their sae -.
which Is a clinical Ieature of in-
creased oral respiration.
164 Functional Analysis
Differential Diagnosis

Differential diagnosis must be used to determine
whether the problems in nasal respiration are due to an
obstruction of the upper nasal passages or to habitual
oral respiration (Fig. 418). In the first case. an operation
by an ENT-specialist is indicated; i.e. in the case of
allergic rhinopathy, medication should be applied.
Should the nose not be obstructed, pre-orthodontic
therapy should be carried out to treat the restricted
nasal breathing. This 111ay include breathing exercises
(Fig. 419) or incorporation of a perforated oral screen
(Fig. 420).

418 Differential diagnosis of

restricted nasal respiration
The orthodontic treatment plann- Impeded nasal respiration
1119 '"' patients with restricted na-
sal resp1ra11on muSl be related to
lhedragnos1solthe ENT-specialist Minimal Severe
O!C11nmolog1c determination ol nasal obstruction nasal obstruction
the nasal teS1stance appears10 be I I
an important parameter to assess Habitual Oral respiration -
nasal breathing capaClty oral respiration organic causes
I I
Dentofacia<-- Oentotacial --ENT treatment
orthopedics orthopedics I
Exercises Wait,later
Oral screen mechanotherapy

419 Myofunclional exercises

for patie.nl'S with habitual oral
respiration
uo exercl$e$ with a piece of card-
board to1mp1ove thelip seal are 1n·
d1cated.

R1ghr The cardboard should be

held loosely m a nonzonta! posinon
wdh the lips.

420 Changing habitual oral

respiration
The custom-made.per1orated oral
screen JS placed on the vestibule.
The air holes in the appliance are
sealed ott one alter the other 10 con·
vert patients who breathe through
their mouth to nasal respiration
 Record Sheet 165

Functional Analysis - Record Sheet

1) Relationship: Rest position - Habitual occlusion

a) sagJttal
Habitual occluslon: distal I mes1aJ I edge-to-edge relationship
Rest position: mandible posterior - anterior

bl Transverse
Mandibular rrudllne shift
m habitual occlusion: mm
m rest position: mm
maximum 1aw opening: mm

c) Vertical
Freewayspace: normal - large - small

2) Temporomandibutar joint
Crepttus: right - left - both sides
Chckmg: right - left - both sides
inillaJ - intermediate - terminal - reciprocal

Pressuresensitivity: nght/left/both sides

Pressuresensmvitv - Musculature: lateral pterygoid nghVleft

masseter righVleft
temporal ls righVleft
others:

Mandibular mobility:
Maximum interinc1sal distance: mm

-
Maximum protrusive movement: mm
Maximum lateral movement: right: mm .....
left: mm

Dev1Stions
Path of opening I closure
lateral: yes/no
frontal: yes/no

Tooth guided sliding:

Tooth Interference at:
Cant of occlusal plane: no I yes nghVleft left MO
Working slde: righVtett
Palt1 of openmg ------ Palt1 ol opening _
Path of closure----- _ Palh of ctosure --- --- ---
3) Dysfunctions
Swallowingpattern: somatic - viscerosomatic - visceral
Tongue dysfunctions: tongue-thrusting - tongue-biting
Lip dysfunctions: Op-thrusting - lip-bibng
Speech defects: yes/ no Referred to speech therapist on:
Findings of speech therapist from:
Paralunctions: yes/ no Type: Diornal
Nocturnal

Respirallon
Normal nasal respiration: yes/ no Oral respiration: habitual/ anatomical
Referred to ENT-spec1allst on:
Findings of ENT-specialist from:
 _____________________ H-'a'-"d'--10-=-1-=o_,.,g'"""'1c'--Exam1nation 167

Radiologic Examination

Radiologic examination is absolutely essential in orthodontic diagnosis. Most patients are young. in
clinical practice, the type and number of radiographs should, therefore, subject the patient to as little
radiation exposure as possible while providing maximal information at the same time. ln some
cases, depending on the nature of the problems, a routine examination may necessitate supplemen-
tal radiographs. Broadly, there are two kinds of radiograph required for an orthodontic diagnosis.
The first are those taken to provide information regarding the condition of the teeth, the periodon-
tiurn, and the bony structures. The objective of the others is an assessment of the malocclusion in
relation to the facial skeletal structure. Radiographs of the hands and temporomandibular joints are
not among the routine requirements of orthodontic diagnosis. It is only necessary to take radio-
graphs of the temporomandibular joints in those cases where TMJ symptoms of dysfunction are
either_present or where changes are reasonably suspected, that are not seen clearly on the panoramic

Dental Condition

• Panoramic view Periapical view (small intraoral Jilin). A full series of

• Enlarged panoramic view
• Periapical view: small intraoral film
• Occlusal view
• Mental spine (genial tubercle) view
Panoramic 1•iew. For orthodontic diagnosis this is supe-
rior to all other radiographic methods. Not only does it
provide in one single film a total survey of the dental
status and adjacent bony structures of bothjaws, but at
the same time it also includes the remporornandibular
joints. It involves the least exposure to radiation. A
disadvantage oft bis rotary laminographic technique is a
possible distortion in the anterior region. Some cases
will, therefore. require supplementary radiographs,
such as an enlarged panoramic view or periapical view.
Enlarged panoramic 1•iew. Its advantage is the accurate
imaging of the region of the anterior teeth; its disadvant-
age is distortion in the posterior region.
intraoral radiographs (JO to 16 films) is required for
assessment of the periodontal state in adults. Otherwise
periapical films are only indicated where the panoramic
view suggests possible pathologic conditions (e.g.
congenitally missing teeth or malposed tooth germs)
(Figs. 428, 429).
Ocdusal 1·iew. This radiograph is indicated as a
supplementary projection to determine the three-
dimensional location of malposed unerupted teeth. The
oblique occlusal film is an alternative view to determine
the width of as yet unerupted permanent teeth in the
mixed dentition.
Mental spine (genial tubercle) 1•iew. This is an occlusal
view of the anterior section of the mandible to determine
its midline (Figs. 431, 432).
168 Haa101og1c_-=tx::.:.a::.:.mc.:..::.;1n-'-'a:::..:1.:..:10::.:.n _

421 Panoramic view

Panoramic View of a 9-year-old
boy wnn an atypical sequence of
erup11on ol pe1manent teeth aner
premature e>Uraction ol pmnaiy
tee1n m the lateral segments.

The canorarmc rad10!Jraph gives a

survey of the entire dental cond1-
non and abnormalities of the mu<ed
dent111on 1n one smgle exposure.

422 Chart for radiologic

evaluation of dental conditions
Thepanoramiev1ewshouldbesys-
tema1Jcally analyzed according to
I Radiologic findings: I
a predetermined cha1t By thrs
means, the osk of senoes mrsdtag-
noses du11ng the chn1cal routine. Hypoplasia: . • . . . . . . • .. . .. • . • . • • . .. • • • . . • . . Path. lesions at crown/apex.: .
whieh m1ghl attea the orthodoohc
ueatment IS m1mm1zed Impacted teeth: • • • . . . . . .. .. • • • .. .. .. • • • • . Supernumerary teelh ..

Narrow tooth germ posit.ion: .. • • • .. . • Ectopic tooth germs: - ..

Teeth not worth saving: .. .. .. . .. .. .. • • • .. Third molars: .. • • .. .. .. .. .. .

Root canal lllllngs: .. .. .. .. .. .. .. .. .. .. .. . Edracted permanent teeth: ..

Large restorations: .. • .. .. .. . • .. • .. .. .. .. • Root fragments: - .

Root resorption: •• .. .. .. . .. .. .. .. .. .. .. . • • Overretaine<I primary teeth: .

Path. periodontal ligament space: • . • • . . • Path. root formations: •.•...•.............

Bone loss: . . .. .. . .. .. .. . .. .. .. . . .. .. . • . • Trabecutar pattern: .

Atypical sequence ol eruption: .. .. • • .. .. Bony pockets: .

Other: .......................•.........................••...............................•
.... . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .

423 Panoramic view and

avaluetion of temporo-
mandibuler joint
Condrhoo 2 years aher condy1ar
neck fracture of the lefl TMJ m an
8.year--Old gul
While only crude assessments
can be made from the panoramic
view as regards the TMJ, some m-
lorma11on relating 10 fractures can
nevertheless be obtamed from 1L
The cond~ar shape can also be
judged from J111s view. How!Mlr a
detailed exarmnat100 of the fOlnl
space or the posibon of thecondyle
wrthm the gleood Iossa 1s nol pos-
Slble with this screening film.
uemai t.-ona111on lt>l:f
424 Panoramic view and
condition of anterior teeth
Right Panorarrncviewol a 10-year-
old boy who susta1ned trauma to
the primary leelh on the upper
anterior region at the age of 5 years.

Left lntraoral peroap1cal t1lm ol lhe

upper incisors. clearly showongthe
abnormal root panerns,

In paoorarrsc views the 1mag1ng ol

upper and lower mcOSO<S IS ohen
d1SI0<1ed. H necessary, 11 muSI be
checked woth other rad1ographoc
techniques.

425 Enlarged panoramic view

Maxillary view ol an 8-year-old boy
with a cleh lip, jaw, and palate on
the leh side. The rad1ograph re-
vealsa supptemenlal lateral 1ncrso•
In the cleh region.
In comparison 10 the standard
panoramic view, this type of mirao-
ral source radiography grves a
more precise appearance o1 the
antero0< tooth region, bul a less
precise appearance of the poste-
rior region.

426 Oenlal condition

The ontraoral denial stalus of a 23-
year-otd lemale panent befO<e
commencemenl ol orthodonuc
treatment
For adults, thlS shouk:t be the
lechnoque ot choice. as 11 allows
a more accurate assessment of the
periodontal cond111on and of the
aptces of the roots at the onseL A
him holder shouk:t be used 10 en-
sure tooth-film parallelism.
170 Had101091c cxarrunanon
Radiographic examination for
locallzatlon of an Impacted
canine
- Case example -

427 Panoramic view

Ectopic and impacted upper lefl
canine in a 16-year-old male The
crown ts angled mes1ally and lhe
roof 01stally.
The posmon ol !he impacted
tOOlh cannot be accura1ely deter-
mined lromthestandard panoram-
ic vtew

428 Muloeecentric periapicaJ

view
To determine lhe cosmon of lhe
canine. an exposure IS made wllh
1he X-ray tube angled at 30" me-
saally to the perpendicular prOjec-
non,

Lett Schema1oc 1llustrat1on ol 1he

ra01ograph1c 1echn1que and ap-
pearance ol lhe tooth.

F!Jgnt: Mesioeccentric rad1ograph

ot the case m quest10<c

429 Distoeccentric periapical

view
A second exposure IS made wilh
!he tube angled at 30' distally from
the perpendicular prajectlon.
Lett: Schematic 1lluslfal1on ot the
exposure direction and appear-
ance ot the tooth,
Right; 01stoeccen111c raa1ograph
al the case m question.

By correlal1ng Fogs. 428 and 429.

the posmon can be determined
precisely. As the 1mpaC1ed looth
appears to have moved in the same
dlreclion as the lube, its tocauon rs
palalal.

430 Oeclusaf view

I.Bit Schemahc lllusua11on of the
method ot exposure.
Center. Rad1ograph1c appearance
of lhe palalatly impacted upper leh
canine 1n the occlusal view.

Rignt: Schemauc drawing of thll

pr0fecl1on of the IOOlh 1n the rad10-
graph
 Mental spine view 171
431 Mental spine (genial
tubercle) view
Lelt Postenor view of the mental
spine (genial tubercles) on the
maceraied manchble.

Center: Anatoouc retauons ol lhe

mental spme region:
s = menial spine. sopenor pan
(supertor gemaJ lubercie)
= mental spine, 1ntenor pan
(mfenor genial tubercle)
99 = gemoglOSS1Js muscle
2 (pararnedran location)
mh • mylohy<>1d muscle
Arrows 1. 2, 3 1nd1cate the 111·
dlVldual exposuredlrectJOns for the
gg vanoes mental spine PIOJecl•oos
dep1e1ed on the r1ght

Rigm: Exposure In the direction

of arrow 1 V1soallzes Ille dooble
sptne of the supenor pan ol Ille
mental spine (supenor genial w-
bercie). Exposure m the duecaon of
I arrow 2 shows the unpaired spine
ol lhe 1nfer1or part (infert0r genial
2 tubefcleJ as well as the bJ1ruera1
structura of the sepenor genial w-
3
I bercle m the center. Exposure 1n
the duecnon of airow 3 prOJeclS
3 bony spines: lhe bonycon1oursol
the •nlenor genial tubercle and
those of the supenor genial tu-
bercles (according to Schwarz.
1961).

432 Appea11111ce of the mental

spine (genial tubercle) In the
radiograph
Left: Super1or part ol Ille mental
spine (supenor genial lubefcleJ
and the mental symphysjs rooe
Exposure from the direcllOn ol
arrowl m Flg.431,w1ththeheadWI·
ed backWaJd

Right Appearance of the medran

mien<>< pan of the mental spine
(mlenor genial tubercle) with
oblique prOfectJon from the ctlrec-
lfon of arrow 2 (F1g. 431).
ln both techmques the Film is
plaoed tmerocclusally.

433 Appearance of the mental

spine (genial tubercle) In the
panoramic radiograph
8-year -old pa11en1 with skelelal
mandibular m1dhne sh1tt 10 the lett.

The menial spine (genial lubercfe)

is onen clearly v1s1b1e m tne pan-
oramic view and allows certain
oeduct1ons concerning the trans-
verse 1aw rela110nsll1ps.
_1..:...7..._2
__ R_a:::..:d---10"-1-=-og
real l::xam 1 nation
Radiologic examinations ot
denllll status during the course
of orthodonlic treatment

434 Initial examination

The den!81 cond•t•on of a 10-year·
old g11t belore the beg1nn1r19 ol
O<thodont•c treatment.

435 Intermediate findings

Panoramic rad1ograph taken at the
end ol llle acuve treatment phase.
Supernumerary tOOth germs can
be detected 1n both tower first
premolar regions.

436 Anal findings

PostoperallVB exammauon after
removal of the supemume<ary
tooth genns and lower thud molars.
There is an ex1enstvefes>on asso-
ciated with the mesial root of the
lower nght firSl premolar (The
upper th11d molars are yet to be
removed}

The radJOloQIC exammanons un-

dertaken 1n the course of lll1s treat·
men1 demonsuate that a srngte
radiologic exam1nallon duI1ng
orthodonhc tteatment rs 1nade-
Quale.
 Photographic Analysis 173

PhotographicAnalysis

For the analysis of the relationship between the craniofacial skeleton and the soft-tissue facial
contours, profile and frontal photographs are taken under standardized conditions (Fig. 437).
This is done with the patient sitting upright in habitual occlusion and with relaxed lips and menta-
lis muscles.
A precondition for obtaining comparable photographs, which can be evaluated by measurement,
is a reproducable position of the patient. Such profile and frontal photographic views can be
achieved in various ways: (1) the frontal and lateral views are taken with a single camera as described
by Simon, with the patient in two different positions; (2) the two photographs are taken with a single
camera, obtaining the different aspects by the use of mirrors (A. M. Schwarz); (3) the frontal and
lateral views are taken simultaneously, using two cameras (Dausch-Neumann, 1987).

437 Extraoral photographs

In orthodon11cs, lateral (lelr) and
lrontal \llOWS (center) are taken asa
rule
An obhque racial \llew 10 assess
the smile hne can be taken in add1·
non (right}.

Profile View

For the profile exposure the camera is placed parallel lo
the facial midsagittal plane. The patient's head is
oriented in accordance with the Frankfurt horizontal
plane. The patient's eyes should be looking straight
ahead. unstrained, and the ears should be uncovered.
A. M. Schwarz ( 1958) compiled a detailed classification
of the variations of the facial profile (Figs. 441-443).
The evaluation is based upon the construction of
three reference planes:
I) Eye-ear plane (Frankfurt horizontal plane);
2) Skin nasion perpendicular, according to Dreyfuss;
3) Orbital perpendicular, according to Simon.
The perpendiculars delimit the "jaw-profile field"
(JPF). In children this is 13-14 mm wide. in adults
15-17 mm (Fig. 438).
In an ideal average-valueface the subnasal point touches
rhe skin nasion perpendicular. The "soft-tissue chin
point'' (the most ventral point of the soft-tissue part of
the chin) lies in the center of the "jaw-profile field," the
"skin gnathion" (the most inferior chin point) lies on the
orbital perpendicular.
 174 Photograph_ic_A_n_a_ly
__s_is
Depending on the location of the subnasal point
relative to the skin nasion perpendicular. there are
typical profile variations: Averageface= subnasale lying
on the skin nasion perpendicular; anteface = subnasale
lying in front of the skin nasion perpendicular; retroface
= subnasale lying behind the skin nasion perpendicular.
In straight-jawed ante- and rerrofaces the chin is
displaced to the same extent as the subnasal point. For
each of the above profiles two further facial types can
be differentiated, depending on the changed location of
the "soft-tissue pogonion" relative to the subnasale.
There are forward-slanting or backward-slanting faces,
that means nine differenttypes of profile in all
Photographic analysis
according lo A. M. Schwarz
_
The mouth profileis of great importance for facial
expression. The contours of the lower face are, therefore
further analyzed by means of the mouth tangent,
This method of profile analysis has the disadvan-
tage of being affected by a high or low-positioned carti-
lage nous tragus, and its clinical significance is thereby
reduced. The analysis can also be performed on the
lateral cephalogram which is preferable as ii allows to
use the bony landmarks of the external auditory meatus.
The clinical value of the photographic picture is that it is
more realistic and gives a better record ofany changes in
the soft-tissue profile during the course of treatment,
which is of great advantage.

438 Straight average face

Left: Schemabc 1llustrabon
N = Skin nasion
Sn = Subnasale
Gn - Skin gnartuon
Pog = Skin pogomon
P = Ponon (uppermost point
of tragus)
Or • Orbltale (a poon~ localed
below the pupil. at a
d1SJance equ1valen1 Jo !he
gap beJween the eyehds,
With the eyes relaxed ancf
loolong straight aheadl
H = Franklurt hOnzontat plane
Po = Orb11at pe1pend1cuta1
Pn = S!<m nasion perpendocul&
JPF •Jaw profile t1eld

R1gh1· Slf8Jgh1 average lace. The Po Pn

subnasal poonl hes on Jhe Pn·
perpendicular; Jhe vertex of the
soh-11ssue chm hes at the 11ans11lon
10 the posteriO< thud of the JPF.
1KPFJ
439 Slanting profile
In a staru1ng profile there •S a dis·
crepancy belween the subnasal
PO!fll arid the son-nssoe pogomon
m relanon to !he anreropostenor
post!JOO. This disturbs the harmooi-
ous appearance ot 1he facial pro-
Ille.

Lett· Backward-stam1ng re11oface.

The subnasal point hes behind !he
Pn-perpend1cu1ar; the son-ussoe
chin is displaced more postenony
than !he subnasale.

R1grw Forward-slanbng arnetace.

The subnasal oomt hes in 1ron1
of 1he Pn-perpend1culas. the son-
bssue pogoo1on hesd1spropomon-
ally more antenorly.
 440 lip profile analysis
Center. Melhod ol evaluation
Po Pn
Ls = labrale supenus
;;!"' Li = l2'lrale mfenus
._ __ '-_Sn. Sta • St0<mon
T • Mouth tangen1 ~oms sun-
nasale and solHrssoe po-
gonionJ
Siol--~:...j In a str8lght average lace ine
LI mouth tangem b1seas ine 11e1-
m1hon pomon of the upper lip; 11
touches lho border of the tower hp.
and 11 forms a 100 angle wnn 1he
Pn-perpendJcular
Pog
Left: Protrusrve upper and lower
bps.
R1gflt. Reuusrve lip profile

The nine passlble profile

variants according to the
classflication by
A. M. Schwan:

-
4
441 Straight-Jawed profile
Lett. A'leISge face

Center· Anteface

Righr.- Re11olace

A stra1ghl-1awed prohle - whelher

an average lace. an anrelace 0< a
retrotace - always looks harmoni-
ous. The stra1gh1 average lace {or
Aver898lace Ante lace Retrolace b101T1t1tnc lace) rs coosidered 1dea1

442 Backward-slanting prome

Ba-ckward-aJan11ng ptOhle:
The solt-l1SSU8 pogonion IS dis-
placed 100 lar pos1eoorty retal1•-e
10 lhe subnasal point

Lett Backward-slanhng average

face

Cenrer Backwafd-s1ant1ng ame-

face

R1gh1.- Backward-stan11ng retro-

face

Average face Ante face Ratrolace

443 Forward-slanting profile

Fotward-slantlng profite
Ttie son ussee ol lhe Chm •s loo
Jar anlenor in relalJon to tne sub·
nasal pomt.

t.ett: Forward-slan11ng average

lace

Cenret Forward-slanting anlefaoe

I
Average face Antefaee Rettoface
176 Photographic Analysis

Facial Divergence
Another analysis of the lateral photograph is based
upon evaluation ofthe divergence cftheface.The inclina-
tion between the following two reference lines is here
analyzed: (I) The line joining the forehead and the
border of the upper lip; (2) the line joining the border of
the upper lip and the soft-tissue pogonion.
The following three profile types are differentiated
according to the relationship between these two lines:
Straight profile: The two lines fonn a nearly straight
line.
Convex profile: The two reference lines form an angle
indicating a relative backward dis·
placement of the chin (posterior diver-
gent).
Concave profile: The t\VO reference lines fonn an angle
indicating a relative forward displace-
ment of the chin (anterior divergent).

Convexity and concavity of the r

soft-tissue profile
- 'Jj
444 Evaluation method
Malk1ng of Iha relerence lines:
Uppe1 line = Jouis glabella and
border of upper hp.
- --
~
~

LDwer /me= Joins border of uppe< ~

lip and the vertex ol lt>e son-ussue
~
chin, ~
Angle formed by the two hnes =
Facoal divergence Continuous
straighl lrne formed= Harmonious
proltle.
l
IP.ft Schemauc represemauon of a
sua1gh1 profile.

Cenrer A conwx profile.

Right: A concave profile.

445 Clinical profiles

t.stt· S1ra1gh1 profile.
Cemer. Convex proltle.
Right Concave proflle.

A convex son-ussue pro!tle sug-

gests a Class II jaw retauoosnrp.
A concave profile suggesls a Class
IU relauon.

The son-ussee profile inlluences

the physiognomy, biJ1 ti does not
always project 1he anterooostenor
relalion ol the unde<IY!RQ skeleial
structures.

•
 Frontal View 177
Frontal View

An analysis of the frontal picture is important in asses-
sing major disproportions and asy111111e1rierofthe face in
the transverse and vertical planes. Even a slight rotation
of the head from the plane of the film can result in major
discrepancies between the relative patterns of the right
and left facial contours. It is, therefore, absolutely essen-
tial for the camera to be placed perpendicular to the
facial midline during the exposure.
For clinical analysis it has proven practical to mark
the two orbital points and to construct the skin nasion
perpendicular (Fig. 446). During the evaluation of the
measurements the diagnostician should bear in mind
that a mild degree of physiologic asymmetry between
the two sides of the face exists in nearly all normal
individuals.

446 Facial symmetry

R1ghL
Ventcal reference plane= Facial
mldsagrtlal plane ~Otns lhe slon
nasion poml lo the sullnasal poin11,
Upper honzontal plane - Bipup•I·

.,,..-----...,
, ..
~, ~·· -
lary plane;
Lower hoflzontal plane = Parallel
to lhe b1pup1Uary plane through
lhe storruon
Bilateral markmg of the Olb•tal
l)Olnt
• • Schemallc 1llustra11on of a sym-
metric.propo<11oned lace Jn lhe

(~ fronlaf plane.

Lett· True frontal plClure of the pa-

I 11en1

<f>'
I <

l
44 7 Facial asymmetry
Left· 20-year-old peueru wllll a
marked leh-nghl d11terence 1n the
develOpmenl of the mandibular
body and Ille mandibular angle.
The relabve enlargement of me
nghl side 1s 8SSOCl8ted With hyper-
plasia of the nghl masseterrnesde,

Rrgh1· senemanc 1llustrab00 of the

photographic evatuauoo.
178 Photographic Analysis
Photographic representation of
facial asymmetry

4411 True frontal picture

11-year-okl boy wnh a noticeable
dltte<ence between the nghl and
left sides ol the lace.

449 First composite frontal

picture
Altereo lacial form alter pllotomon-
rage of the two roght Sides of the
face.

450 Second composite fron-

tal picture
Frontal View after pholomontage ot
the two leh facial sidesof the patient
from Fog. 448.

The photographic method 1Jlus·

trates the d1ffereoce 1n the conhgu-
rauon ol the two sides of rne face
A certa•n asymmotry on the laoal
paMernis phystolog1c,however

--
 Cephalometric
~~~~~~~~~~~~~---'-~~~~ Analysis 179

Cephalometric Analysis of the Lateral Radiograph

Although the cephalometric radiograph in standard lateral projection was introduced into ortho-
dontics during the 1930s, the method has only become routine in recent years. Today, cephalometric
analysis has firmly taken its place in dentofacial diagnostic procedures. In principle, the analysis is
only oneofvarious diagnostic records made when planning treatment. "Cephalornetric diagnosis,"
i.e. diagnosis and treatment planning exclusively from the radiograph, is wrong and inadequate. The
cephalometric radiograph registers the anteroposterior and vertical configuration of the facial
skeleton, but provides no information about other important criteria, for example, the transverse
dimension or functional relations.
An infinite number of reference points, lines, and measurements can be made on the lateral
headfilm, However, the only useful radiographic cepbalometric measurements are those which
are of relevance to the treatment planning. The following information can be ascertained from the
cephalometric analysis:

• Configuration of the facial skeleton

• Relationship of the jaw bases
• Relationship of the axial inclination of incisors
• Assessment of the soft-tissue morphology
• Growth pattern and direction
• localization of the malocclusion
• Treatment possibilities and limitations

In cephalometric radiography, the considerable dis-
tance from X-ray source to subject (1.5-4 meters)
allows exact reproduction of the facial skeleton with
minimum enlargement or distortion. For cephalomet-
ric analysis it is essential to locate reference points in rhe
region of the craniofacial skeleton from which reference
lines and planes can be constructed. These can then be
measured linearly or angularly.
purposes; the recording of individual values is insuffi-
cient. Individual measurements are not relevant for !\VO
reasons:
I) The so-called mean values, to which the individual
value is compared, are only standard values which
provide a crude orientation but do not necessarily
define a malocclusion or treatment goal.

The most difficult aspect of cephalornetrics is the inter- 2) By summation or compensation of the individual
pretation of the individual measurements. Lo order to measurements which dilTer from the mean value,
assess the individual variations of facial structures, it is borderline readings can be obtained and extreme
necessary to establish their mutual relationships. Corre- readings can be compensated even in case of severe
lative analyses are the most suitable for diagnostic skeletal discrepancies.
 180 Cephalometric Analysis

Cephalometric Reference Points

Reliable evaluation of a cephalometric radiograpb
depends on accurate definition and localization of land-
marks, since these provide the basis for subsequent
measurements and analyses.
Reference points are usually located in the skeletal,
dentoalveolar and soft tissue regions. In contrast to
anthropology. radiographic cephalometrics include
anatomic. radiographic (intersection of two X-ray
shadows). and constructed points (e.g. S =center of the
hypophyseal fossa i.e. sella turcica).
Anatomic reference points are located on or within
the skeletal structures: (e.g. Nasion, A-point, B-point,
ANS, Pogonion, Menton).
ln general, unilateral reference points in the midsagit-
tal plane exhibit greater accuracy than bilateral ones
(e.g, Gonion).
The precision of location of reference points depends on
the quality of the radiograph, the density oftbe structure,
in particular, the surrounding and overlapping struc-

451 RadiograpMc
cephalometric reference points
- Definitions
N ~ Nasoon, lhe moSI amcoor poont
of the frontonasal sutufe in the rnfd.-
saglltal plane
S =Mtdpotnl of sena, seUa poonl (S)
rs defined as the center of lhe setla
TU!CICa II IS a c;oostructed (radJO·
logic) poml in the median plane
Se= M1<!po1nt oC 1heen11anceto the
sella
Cond - Condyhon; the most PoS-
ten0t superior paint oC the c:oodyle
ar = Ar11cu1are; a constructed potnt
at the 1ntersec1Jon ol the images ol
the posteoor margin ol the ramus
and the oeter margin ol lhe cranial
base
Ba = BaSton; lowesi POtnl on the
antenor margin ol the I01amen
magnum In the median plane
T1 = Most postet10< point on the
ramus m the region ot the angle ol
the mandible
Go= Gonion; a constructed pOIOI
at lhe mterseeuon or 1he llnes tan·
gent 10 the postetior border ol the
ramus and lhe tower border ol lhe Ns
Ba
mandible
T2=Mostpostenoronfenor oomton
1he body of 1he mandible
Me • Menton, lho mos1 mlenor
point oC lhe oollone of the symphySls
on the mldsag111aJ plane
Gn = Gnathion: the most amen0<
1merior pomt on the bony cmn T,
Pog = Pogoruon; lhe most amener
poont of the bony chin m the mlCl-
sag1nal plane
B • Pooni B, sup1amenlate; lhe Go
deepest point on the outer contour
of the mandibular alveolar process
between onfradentale and pogo-
mon
Id = lnfradentale lhe most an1en0<
supen0< point on the alveolar pro-
cess between the mandibular cen-
tral 1oosors m lhe median plane
Pr = Prosth1on; the most anterior
inferior point on the alveolar por-
uon ol lhe premax•lla between the
oppe< central incisors on lhe medi-
an plane

rures and on the experience of the diagnostician. The
most difficult points to locate among others include
Basion, Orbitale, A-point. anterior nasal spine (ANS),
posterior nasal spine (PNS), and the apex point of the
lower incisor. As a rule, anatomic and radiographic
points are more accurate than constructed points as in
the latter the methodological error of individual point
localization accumulates.
The constancy or the reference points is variable
during craniofacial growth. A so-called "fixed land-
Reference Points 181
mark" does not exist, Points which are situated close to
the base of the skull (e.g. Sella. Nasion, Basion), howev-
er, show little variation with growth after infancy.
The reference points described in this chapter are
used in the following cephalometric analysis on account
of their balance in reliability and validity.
A• Poml A, subsp1nale, lhe deep-
est m1dltne p01nt on the aruenor
oute• contour ol lhe ma.><1llary
alveola< precess between lhe ante-
rior nasat spine and pr0Slh1on
ANS = Anleroor nasal spine. lhe
most an1enor po1n1 of lhe lip of the
ante110t nasal spine 1n the m1dsag-
11tal plane
PNS = Poslen0t nasal spine, a
consirUCIOO 1ad1olog1c point, the
intersection of the cont1nuauon of
me antenOI wall of the p(erygo-
maxlltary hssure and the nasal
11001
Or= Orbuate: tower-rnost potnt 01
the bony orbn
Is 1- IOOSIOn supetous; 1ncisal op
ol lhe crown of the mosl anteoa<
maxillary central 1ncisa<
Ap 1 e Apex poon1 or the most ante-
nor maxillary central 10C1SOt
Is 1=Incision rntenus; 1ncisal 11p of
lhecrown of lhe moss anterior man·
d1bula1 cenual 1oosor
Ap l •.Apex pooru of the mos1 ante-
rior mandtbular cenlraf 1netSOr
PPOcP = Postenor poinl ol Ille
occlusal plane; the most distal
point or coniacl between the most
posleroor molars in occlusion
N' = Skin naslon; localed al lhe
point of maximum coneav11y be-
1\Yeen 1he nose and forehead
Ns •Tip ol nose; lhe most amenor
polnl or lhe sott-nssue nose
Sn = Suboasale; a skin poun, lhe
point ar which the cofumella
merges wnh lhe integument ol lhe
upper lip
Ls = tabrate supenus: edge of
upper hp
Li - Labrale mfenus; edge ollower
hp
Sm = fnfetlOI tabl!ll sulcus t e
men1olab1al told; PQIO! al which the
labrate mlenus meets sol1-11ssue
pogoruon
Pog' • Soh-DSSUe pogornon; 1he
most anlenor pomt of lhe soft.
nssue chin
182 Cephafometric Analysis

Cephalometric Reference Lines

Reference lines or reference "planes" must be con-
srructed before angular, linear, and proponional mea-
surements can be made. The majority of reference lines
are defined as a straight line connecting t\VO landmarks
(e.g, N-A line= Line joining N to point A) (compare
Fig. 451).
The lines most frequently used include (Fig. 452):
A tuerior cranial base line= Line joining point S and N
or point Se and N
Lateral cranial basefine= Line joining point S and ar
Palatalpfane=Maxillary plane; line joining ANS to PNS
Occlusafplane= Line joining the midpoint of the ante-
rior overbite and point PPOcP
Mandibular plane= Line joining point Me and T2
Ra111us line= Line joining point ar and T1

452 Radiographic
cephalometric refe<ence lines
1 = AnteroposterlOrexlenloHhe
anterior cranial base
(aooxd1ng to AM Schwarz)

2 = Antenor cranoal baseline

3 = l..aleral e>aent of cranial

baseline

4 = Palatal plane, maxillary

baseline

5 = Occiusal plane ------------

1

2
6 = Mandibular plane, mandib-
ular baseline

7 = Ramus length

8 • Y-rous 11

9 = Facial deJ)th
-- ---
10 = Pn-hne 10
1accord1ng 10 AM.Scnwarz1 13 1
11 = Constructed "ideal Franklun 14
horizontal' I
(according 10 AM Scnwarz) 7
12 = Postenor tac.al height

13 • Antenor facial height

\
14 = une )ooning nasion and
point A

15 = Line 10.mngnasion and

point B

16 • Line )om1ng nas.on and

pogomon
 Reference Lines 183

Y-axis= Line joining point Sand Gn Ideal Frankfurt horizontal = A straight line drawn
parallel to SeN from the midpoint of nasal perpen-
Facialdepth = Line joining point N and Go dicular (according to A. M. Schwarz)

Pn-line = Perpendicular on the SeN-line at point N' Posteriorfacial height= Line joining point S and Go
(= Point located 8 mm anterior 10 point N) extended
downward to the palatal plane (according to A. M. Anteriorfacial height= Line joining point N and Me
Schwarz)

Reference lines on lhe laleral

cephatogram
184 Cephalometric Analysis
Interpretation of Cephalometric Measurements
The aims of interpretation may be summarized
follows:
- Analysis of skeletal structure and facial type
- Assessment of vertical and sagittal relationship be-
tween maxillary and mandibular bases
- Differentiation of skeletal and dentoalveolar mal-
occlusions
- Analysis or dental relationships
- Analysis of soft tissues regarding etiology and prog-
nosis
Cephalornetric radiography will give an accurate defini-
tion of Jada/type. No close correlation exists between
facial type and anomaly. Malocclusions as well as ideal
occlusions occur in all facial types.
Determination of skeletal relationships is important
in treatment planning despite the fact that no definite
correlation has been established. Dentoalveolar and
skeletal anomalies can be differentiated according to the
vertical and sagittal relationships oft he jaw bases, i.e. the
measurements help determine whether the abnormality
is purely the result of tooth malpositions, i.e. localized
453 Classification of the mosl
Important skeletal malocclu-
sions
Correct mterl)lelahon of the mosl
sigmhcant measuremenlS forms
lhe tJaS<S of a re1evan1 oephalo-
memc analysis. Anteroposterior Relationship
Every abnormal~y os cnaracte- Class I
nzed by de\/lalion ol 1he 1aw bases
Class II
in lhe sag1ttal and ver11cal plane as
well as rotation of lhe 1aw bases lo- Class 111
ward ooe another.
- dentoalveolar
- skeletal
as primarily to the area of the alveolar process or whether a
dysgnathia is present as a result of skeletal discrepan-
cies, e.g. in the region of the jaw bases. Successful treat-
ment of a skeletal malocclusion is only possible during
the growth period or by orthognathic surgery, whereas
correction of de111oalveolaranomalies can be carried out
at a later stage. Late treatment of skeletal abnormalities
is only possible by compensatory treatment measures
whereby the clinical appearance of a skeletal malocclu-
sion is corrected by moving groups of teeth in the dento-
alveolar region. This compensatorypossibility is limited
and in severe cases a combined orthodoruic-surgical
approach is indicated at the end of the growth period.
Analysisofincisor position and relation to the jaw bases is
important from the diagnostic as well as the therapeutic
standpoint. The clinical appearance of the dysgnath.ia
can be compensated or aggravated depending on the
axial inclination of the incisors. The deciding factor with
respect to treatment possibilities is whether the teeth
need to be tipped or moved bodily, i.e. whether the
change in incisor position requires simple or complex
treatment mechanics.
Vertical Relationship
Open bite
Deep bite
- dentoalveolar
- skeletal
Rotation of jaw bas.es
in the same direction
- cranial (upward)
- caudal (downward)
convergent
divergent
Interpretation 185
OiHerentiation between
skeletal and dentoalveolar
malocdusions (diagrammatic
illustration)

454 Class II malocclusion

Lett: SkeleJal Class II retallonslup
with re1Togna1h1sm or the entue
mandible

Right. Dentoalveolar Class II reta-

uonsrup wrth 1etrus1on of the man.
d1bular alveolar process. The body
ol lhe mandible with the bony chin
exh1b1ls a notmal relallOOShJI) lo
the anterior cranial base.

455 Class Ill malocclusion

Leh· Skel!llal Class Ill rela~onstup
with mandibular prognalhlSlll and
maiullary def1c1encyloantenorcta·
nral base.

Right: DentoaJveotar Class Ill, with

mandibular alveolar process
an1en0tly posmoned Body or
mandtblewtlh bony chin esccrrect-
ly related to antenor cranial base.

456 Open bite malocclusion

Left. Skeletal open bne as a res1,111
or increased downward and bael<·
ward incnnanon of Ille mandible
The mandibular angle IS increased

Right: Open bite of den1oalveolar

ongin as a resutt ol underdevelop-
rnent anlenorly of the maxillary and
maodibula1 alveolar processes.

457 Deep bite malocclusion

Left. Skelelaf deep brte as a result
ol 1ncseased upward and IO<Watd
1nchnatronof Ille mandible. Man·
d1bular angle rs decreased.

Righi Deep bite of den1oalveolar

ougrn as a resuli of increased
he1ghl ol the mandtbular alveola<
process anienorty.
186 Cephalornetnc Analysis
Linear Analysis of the Jaw Bases

value for the length of the mandibular base in rela-

Length of anterior cranial base tionship to the anterior cranial base is 3 m111 greater than
Length of mandibular base the N-Se distance. The relationship of upper to lower
Length of maxillary base jaw base length is in the ratio of2:3. and the average rela-
Length of rarnus tion of the ramus to mandibular base. 5:7. Jaw base
length should always be assessed in severe dysgnathias
The dimensions of the jaw bases are assessed in relation- since differences within this parameter can yield impor-
ship to the N-Se distance in the form of a proportional tant information with regard to etiology and treatment
analysis as described by A. M. Schwarz. The ideal possibilities.

458 linear analysis of the jaw

bases
Se • Sella entrance
N s Nasion
N' = SolHissue nasion
Pn = Nasal pe1pendJCUlar
FH = Ideal Franl<lurt hOnzonial
ap.max •Most ante nor pomt of the

c
maxillary base: perpend1cula1
oonstruCled from point A onto the
.H-tine•
palatal plane
PNS • Poste<10r nasal SPme \ -
a.o.man=Most antenor pomt of the
mandibular base. perpendicular length o Imt..tla
coostruaed trorn pogoruon to the
mandibular plane
Go =Gonion
ra, = lntersecti<ln o1 ramus hne
and Franl<lurt honzonlal IH-line)
Length ol maxJlla •
a.p.max - PNS
Lengll'I ot mandible =
a.p.man - gonion
Lf11191h al ramus • Gon;on - ra

459 Table of measurements

showing harmonious
Ramus Ramus Ramus Ramus
propartions between jaw Mandible Maxilla Mandible Maxilla
length width length width
bases. ramus length, and
ramus width (A. M. Schwan)
The iable snows the odeat value of
1ndMdual dimensions The hrs! 56 37 40 22 71 47 50.5 28
catculauon >slodete1mmethe ideat 57 38 40.5 22.5 72 48 51 29
mandibular tengtn which 1s 3 mm 58 39 41 23 73 48.5 52 29
greater than an1en0< oanial base
lenglh as measured on the cepha 59 39 42 23.5 74 49 53 29.5
logram time N - Se) 60 40 43 24 75 50 53.5 30
61 40.5 43.5 24 76 50.5 54 30
The degree to which iaw base de·
vel(>pment d1lters flom the 1Cleat 62 41 44 24.5 77 51 55 31
can tie assessed by companng the 63 42 45 25 78 52 55.5 31
actual values wilh lhe 1deat values. 64 42.5 45.5 25.5 79 52.5 56 31.5
65 43 46 26 80 53 57 32
66 44 47 26 81 54 58 32
67 44.5 47.5 27 82 54.5 58.5 32.5
68 45 48 27 83 55 59 33
69 46 49 27.5 84 56 60 33.5
70 46.5 50 28 85 57 60.5 34
_____________________ L_e-'ng,._t_h--'o_f
_;_:.;JawBases 187
Class II malocclusion

460 Profile contour and

development of Jaw base
length
Ulft SofH1S&Jeprolile contcenn a
10-yeai-Old female pallenl The
cephalometric analysis reveals a
reduced mandibular leng1h.

Rrght: Configura11on1n a Class II

malocclu&on due 10 an overoevel-
opmenr ol lhe maxillary base
according to lhe cepllalometne
rneasuremerns,

461 Underdevelopment of the

z. M. SNA 78' mandible
9 years SNB 7fF
ANB 8' Class II malOCCIUSlon w1lh marked
SN-Pog 71 reirognathl!lm of lhe mand1t>le as a
resull of decreased mandibular
6Smm len91h
The aewal lenglh is 12 mm less
lhan lhe ideal value. In contrast, me
maxtllary length rs only slightly 100

--- short

43mm I

462 Accumulated
HM. SNA 8C1 discrepancy of maxillary and
10 years SNA 75' mandibular base lengths
ANB S" Class II maloedusion w1lh over-
SN·Pog 75" developmem of max11laiy lenglh
67mm and undcrdevelopmem of man-
dibular base.
The d1SC1'epancy oelween the
actual and ideal values amoums 10
1.5 mm 1n lhe maxilla and -d mm rn
the mandible.
AJ1hough lhe discrepancy m
each arch IS small, when added
48mm together lhey reveal a marl<eaan-
1eroPOSter1or malrela11onsh1p of me
,aw bases
188 Cephalomernc Anaiysrs
Analysis of the Skeletal Facial Profile

Clinical Standard
Angle Definition Value

SNA Anteroposterior position of A-point (most anterior point of the apical base
in the maxilla) to anterior cranial base 81 °
SNB Anteroposterior position of B-point (most anterior point of the apical base
in the mandible) to anterior cranial base 79°
ANB Anteroposterior relationship between A-point and B-point
with respect to nasion 2°
SN-Pog Anteroposterior relationship of pogonion (basal position of mandible)
to anterior cranial base 80°

463 Anteroposterior analysis

of jaw baH relationships
1 • SNAangle
2 - SNBangle
3 = ANB angle
4 = SNPog angle

The anteropostenor raianonsrups

of the taoal skeleton are assessed
by angular measurements made
from rl3SIOO to verbeal reference
lines.

464 OrUlognathic facial

skeleton H. M. 14 years SNA 81
The measurements Whocb relate 10 SNS 71f
ANS 3
the anteroposteroor configuration SN-Pog 79
ol tne 1aw basesconcroewnn clino-
cal standard values. In 1h1s type of
conf,gura1100 a skeleJal Class I re- /?.er=
la110nsh1p 1s often present
I
 Skeletal Facial Profile 189
465 Col'l'elatlon between
skelelal facial profile
and anteroposter ior jaw
SNA1=
relationship
SNB1= ANB 1'. Compansonof commonly encoun-
SN-Pog~ tered combinations of facial !ype
and amarcocstenor raw relalion-
shlp (ANB <!:).
Skeletal facial There rs no close correlallon be-
profile tween the anteroposteno< lacial
m0<phology and the skelelal maxil·
lomand1buta1 discrepancy. Dysg-
Orthognathic Class I na1h1asancl 1dealocclusal relabon-
Retrognathic Class II sh1ps occur m all lacial !ypes
Prognathic Class Ill

466 Retrogn.athlc facial

M. B. SNA 76" pattern
9 years SNB rr The iaw bases are posiet!Or m rela·
ANB ..i non to anterior c1an.al base. Th!S
SNPog 74 phy51olog1c vanable m anteropos·
tenor facial type IS often combined
with a skeletal Class u retauonshlp.
Treatment of doS!ociuston 10 a
re1rognath1c faoal type IS mored•!·
11cut~ and the p<ognosis less favor·
able, than the same rnaloccluson
in an 0<1hognath1C facial type

467 Prognathic facial pattem

K. s, SNA 83 With respeci to slandard values,
12 years SNB 82 the maxillary and mandibular
ANS 1
SN·Pog82 bases are an1er10< 101he facial skel·
etoo,
In this type ot faoal prol1le a
Class Ill malocclUSJon •Soften pre·
sent
190 Cepnalornetnc Analysis
Vertical Analysis of the Facial Skeleton
Clinical Standard
Measurement Definition Value
Sum of posterior Sum of sella (NSar), articular (SarGo) and genial angle (arGoMe)
angles according to Bjork
Go 1 Upper gonial angle (NGoar) according to Jarabak 52°-55°
Go.1 Lower gonial angle (NGoMe) according to Jarabak 70°-75°
SN-MeGo <}'.. Angle between anterior cranial base (SN) 34°
and the mandibular line (MeGo) according to Schudy
Pal-MeGo1 Angle between the maxillary line (Pal) and mandibular line
(basal plane angle). The measurement is influenced by changes in the
inclination angle.

468 Vertical analysis ol the

facial sk.eleton
Olagrammallc 1llustra1Jon of the
angular and linear measurements.

1 ~ Sella angle (NSar <t)

2 = Arucular angle (SarGo -l:l

3 = Gonial angle (arGoMe 4:)

4 = Upper gon1al angle

(NGoar -1:)

5 • Lower gomal angle

(NGoMe <l:I

6 = Angle between antenoe

ctamal base (SN) and
mandibular plane (MeGo)
(NS·MeGo 'I:)

7 • Basal plane angle

(Pal-MeGo <l:)

8 = lncl1na1Jon angle
according to AM. Schwarz
(I 'I:)

9 = Angle berween Y-axis

(SGn) and anlenOf crarual
base (SN)

1 Oa = Posteriof lacial height

(SGo)

10b = Anterior laoial heJQhl

(NMe)

11 • Angle between occlusaJ

plane (OcP) and maJUllary
plane (Pal)

12 • Angle belWeen occlusal

plane (OcP) and man-
dibular plane (MeGo).
 Vertical t-aciat ~keleton 191

Clinical Standard
Measurement Definition Value
I 1'. Inclination angle according to A. M. Schwarz; the angle between the 85°
Pu-perpendicular line and the maxillary line (Pal)
SN-Gn 1'. (Y-axis) The angle between the anterior cranial base (SN) and the most 66°
anteroposterior point of the bony chin (gnathion) in the center
of the setla
SGo: NMe% Percentage ratio between the posterior (SGo) and the anterior facial height 62-65 %
(NMe) according to Jarabak
Pal-OcP 1'. The angle between maxillary plane and the occlusal plane (OcP) 11 °
MeGo-OcP 1'. Angle between mandibular plane (MeGo) and the occlusal plane 14°

Tracing of measurements on the

lateral cephalogram.
 192 Cepharometnc Analysis
Growth Direction - Rotation of the Mandible The displacement of the mandible in relation to the
anterior cranial base, in particular, mandibular rotation
Typesof rotation in relation to anterior cranial base: is growth-related; its direction is stabilized by approxi-
mately the 9th year of age. It is dependent on the rela-
Parallel displacement Neutral growth type tionship between the growth rates in the posterior
(condylar growth) and the anterior (sutural-alveolar
Forward rotation Horizontal growth rype growth) regions of the facial skeleton. With a neutral i.e.
average growth direction, the growth increments be-
Backward rotation - Vertical growth type tween both areas are balanced. In the horizontal type,
condylar growth dominates, whereas in vertical growth
types, sutural-alveolar growth is increased compared to
the condylar region.

469 Horizontal and vertical

rotation of the mandible

Red - Honzomal rotation

Blue = Vertical rotauon
Tracsng of amener cramal base
hne. of the NPog-hne, and ol the
Y-axis.
With increased ho<tzonlal rota-
bon ol the mandible, tho difference
rn length between an1e110< and
posterlOf facial 11e1gh1 1s de-
creased The ramus rs long and
wide. Themand1bularsymphysis1s
ll11ckand the baseof rhe body ol 1he
mandible is high.
In case of vertical rolallOn ol lhe
mandible tn relation to the antenor
cran131 base. oeveicornem of the ' '1
antenor facsal heigh! rs d1spropor- I
1iooa1ely greater The morphology I
ol lhlS facial 1ype shows the lollow- I
1ng Character1S11CS: a Sho<1 and nar-
'"" rarnus, a small mandibular
\ ,,.... .... _- .,,, " \ I

base. and a 1h1n symphysis. I

In cases of nonzoruat rotation of I
,
I

the mandible there IS upward and I

I
fO<Ward rotation during the growth I
period (honzontal growth pattem). \
\
In rhe case of lhe ve111cal morpho- \
logy the downwaid and backward
rotanon ol 1he mandible increases
(118ftlca/ growth pattern).
A predlspos111on to deep b•lo
e><1stS m the case of a honzontal
growlh type, the tendency to an
open olle on the vertical growth
1YPe
For the assessment ol 1he lacsal
type, as well as the ctass1ficauon of
tne anteroposten0< 1aw ciscrep-
ancy, lhe analysis ol vertical re-
lalJonst11p should be mduded. AS
the direcllon ol g1ow1h ol the man-
dible wuh resoecr to the amenor
cramal base and 101he maxilla may
show marked differences and thus
exe11s a dtvefgent influence on
OCClusal relat1onsh1ps. The rolal1on
of the mandible can be influenced
by dentofacial orthopedic therapy.
 Hotanon ot the Jaw ~ases 193
470 Mandibular rotation and
facial profile
The reduced lower lace he1gh1 IS
charac1enst1c lor lhe prairie con-
tour m a pallenl with enhanced ho-
nzonlal mancllbular roia11on.

R1gh1· The lower lace h1gh1 IS long

1n e.xcess;ve verncal r0ta:tson

4 71 Cephalometric findings in
RA. horizontal mandibular rotation
11 yeats In lhlS skeletal facial conltguralion,
all measurements whlctl relale lo
the posmon ol 1he mandible rn reta-
oon 10 I/le an1e11or ctanlal base are
smaller lhan 1he standard values:
Sum ol PQS1en0< angles. genial
angle. NGoMe angle, basal plane
angle. SN-MeGo angle, angle of
!he Y-aJ(IS.
The percentage ralio berween
amenor allQ posterior facial height
is larger than lhe standard values.
The horizontal reference lines of
lheanafys.sseem nearlyparalfef to
each 04hcr.

R1ghr. Original rad1ograph ol the

uacmg.

472 Cephalometric findings

C'1 K. in vertical mandibular rotation
a years In an increased downward and
backward rotanon of the rnandrbte,
403 ihe angular measuremenis wh1Ch
575 oulllne 1he relalJOnship ol lhe ver-
neat position of the mandible tothe
124
anterior cranial base are increased
10 retanon 10 siaodard values. The
~ percentage ra110 ol lacsal he.ght 1s
decreased The can! ol Ille man-
145' dibular plane ts steeper than nor-
mal in re1a11on to the olher honzon·
3' lal reference planes.

R1gh1· Ongmal rad1ogral)h ol lhe

traCJng.
194 Cepnatometnc Analysis

Rotation of the Maxillary Base

Classification of rotation of the maxilla in relation to The inclination angle records the rotation of the maxil-
the anterior cranial base, according to A. M. Schwarz: lary base lo the anterior cranial base, i.e. to the N-Se-line
as described by A. M. Schwarz. The angle is not
measured directly but is defined as the angle between
Normalinclination: I<): - 85° the Pn-perpendicular and the palatal plane (Pal). With
anteindination there is a forward maxillary rotation;
Anteinclination: l <): = > 85 ° with retroindination there is a backward rotation of the
maxilla. The maxillary inclination influences the clinical
Retroinclination: l <): = < 85° appearance of the anterior tooth position. It can be
changed by dentofacial orthopedic treatment.

473 Anterior and posterior

rotation or the maxilla

Red = Anterior rOlalJon

Blue = Posterior re1auon

Tracing of ralerance lines to ceier-

mme the l)OSlllOO ol the maxilla ac-
cording 10A M. Schwan:·tha plane
of me amenor cranial base (N-Se).
the f'n.perpendteular. and 1he pa-

-- -
latal plane.
Marking of Iha 1nclm1111on angle
and ol the angle be1ween the N-Se
line and the palalal plane.

In cases or entenor ro1a11on ol the

maxilia. as compared with the cl1n1·
cal Slandard values (ante1ncllna-
noo), lhe angle between the palaial
plane and lhe Pn-perpend1CuiaJ IS
Increased. The an1e1nc1tnat1on ol
the maxilla 1scorretated with anten-
OI rotauon of the 1aw bases. and re-
--- 95°

sults tn a labial poslllonmg ol the

upper antencr teetn.

-
In cases of postenor rotauon of
the maxilla (relromclmallon) the 75°
1nchnalfonang1eascomparedwilh
the siandard value rs decreased. In
this type ol maxillary displacement
tile 1aw bases are translated poste-
norly and rhe axial 1001tna11on ol
1he upper 1nosors appears to be
hpped lingually.

The maxillary 1nchnaJ1on 10 the an.

tenor cranial base can be in-
nuenced bydeniofacial oohopecfic
trealmenL
 Rotation of the Jaw Bases 195
474 Maxillary inclina'tion and
occlusal findings
Maxillary rotanon influences !he
amoun1 ot overb11e and lhe d1nicat
appearance ol 1he 1ncllna11on of
the upper anter10< teeth

Left: Maxillary 1atro1nchna11on w11h

increased overbt1e and 1he chnical
picture of lingually tipped uppe•
anlenor teeth.

Righl Maxillary an1eind1nauon

w11h reducecJ ovorbtleand thechni-
cal ptclure of labially tncimed up-
per 1ncts10< 1eeth.

Mandibular growth patternand

maxillary Inclination
S.M.
8yaars
475 Cephalometric findings
in maxilJary relroinclin ation
The 1ncJ1na11on angle IS r101 ccrre-
61"' lated to the mar\dibulaJ growm pat-
tern.

Left Vertical rotauon ol the man·

d1bte, combined with maxillary
ratrolnchna11on. The ellect ot the
increased mandibular downward
and backward rotanon on the oc-
etusal relallOOShtp IS compeosar-
ed by the l)()Slenorly directed ma·
x1tlary rotalton. This compensauon
is roflecled by the size of the basal
plane angle. Maxillary tndrnation
has always IO be taken into account
when analyzmg the basal plane
angle

Right Original rad1ograph ol the

tracing

476 Cephalometrfc findings

in ma_xillary anteinelination
M.G.
8 years Leh: Horizontal mandibular rota-
1100 combined with mruullary an-
1e1ncl1natton.
The anterior rota(lon or the max-
68.6% illa compensa!Os me tendency to
deep b11e. caused by the mancflbu·
lar rotalton. The measurement of
the basal piano angle correlrues
closely with !he standard value on
account of the opposi1e rotallon of
!he rnaxllla and mandible.

Right: Ongmal radlograph ol the

1f8Clng.
196 Cephalometric Analysis
Combinations of Maxillary and Mandibular
Rotation

Types of maxillary and mandibular rotations:
- Convergent rotation of the jaw bases
- Divergent rotation of the jaw bases
- Upward rotation of both jaw bases
- Downward rotation of both jaw bases
Combination of the maxillary and mandibular rotation
determines the degree of the anterior overbite.
When jaw bases are rotated equivalently in the same
direaion (upward or downward), the vertical dimen-
sion during growth remains constant. ff one of the rota-
tions is greater, the result is either bite opening or bite
closing. The convergent rotation results in a deep bite.
the divergent rotation leads to an open bite. Dentofacial
orthopedic treatment of the vertical discrepancy is very
difficult in these rotations of the jaw bases in opposite
directions.

Rotation of the jaw bases

477 Convergent and

divergent rotation
The cort11ergent rotauco of the 1aw
bases duung the growth period
results In a ceep bite which rs very
dlff1CUll IQ correct.

Right. In a skekllal open bite. a

divergent rotahon of the 1aw bases
IS often presenL

I t
I

•
478 Rotation In the same
direction
In a crarnally directed rotaoon ot
bolh iaw bases, an increased uo
wara and lOfWSrd rotancn ol the
mandible can be compensated by
an antemcfmahon of the maxilla

Rrght In an 1nfet1orty directed rota-

bon ot both iaw bases. an in-
creased downward and backward
rotation of the mandible can be
compensated by a retromcl1nabon
oC the maJOlla.
 Rotation ot the Jaw Bases 197
479 Occtusal relationship and
rotation of jaw bases
Cc;mbonallon ol max1llaiy and
rnand1bulao rota11on IS ol omDOl·
lance 101 the oociusal 1ela1oonst11ps.

Lett The tendency 10 an open b<te

m a marked verncat rnandmuiar
ro1a11on 1s cornoensateo by maxil-
lary 1e1tomchna1Jon (see Fig 480).

Right The d1ve1gent rotahoo cl

both 1aw bases resuns in an open
b<te [see Ag. 481).

480 Cephalometrlc findings

in downward rotation of the
jaw bases
ten Tracing cl lhe tateral ceph
H.C. aJogram showing 1he relevan1
10years
measurements. The increased
downward and backwa1d 1ota11on
ot lhe mandible rscompensated by
~ rotanon ol 1he maxtlla on the same
direcnon.
\
Right The ongmal cephalometnc
radoograph.
The occJusaJ relauon of this
lemale pauent rs on 1he leh see ol
56" Fog. 479
13T
81

481 Cephalometric findings in

divergent rotation of the jaw
bases
Lett.- The measurememsOI the trac-
M.K. ing ol 1he cephalomelnc rad10-
10 yea"'
graph 519ndy a skelelal open bile
W11h vemcal mandibular rotallon,
aggravated by lhe maxillary ante-
(;F-z::72;_......;...;-;;...== 1nd1na11on.

Righi:The original latetal headhlm.

~
\ / Fig. 479 (r~hl) shows the occro-
\ /
sal relauonshop of 1hls lemale
patoenl.

~
58
140
82
198 Cephalometric A~,_s_is _
Analysis of Incisor Position
Clinical Standard
Measurement Definition Value

!. - SN 1: Angle berween long axis .!. and anterior cranial base 102 °+ 2
!. - Pal <1 Angle between long axis l and the palatal plane (Pal) 70 °± 5
according 10 A. M. Schwarz
1 - MeGo<}: Angle between long axis I and the mandibular plane (MeGo) 90 °+ 3
JJ <}: lnterincisal angle between the long axes of upper and lower 135 °
mcisors
1 - N-Pog Distance of incisal edge !. to the N-Pog-line +2-+4mm
l - N-Pog Distance of incisal edge 1 to the N-Pog-line -2-+2mm
'--~~~-'-~~~~~
482 Analysis of incisor
position
Leh. Tracing ol angular measure-
ments.
1 • Angle of long axis of upper
centtal 1ncS01s (Is !- Ap 1) 10 the
amener cranll!l base
2 = Angle al long a.is ol upper
central incisors 10 palalal plane
3 • Angle of long axis ot lower
central tnetsor (Is 1- Ap !) to the
mandibular basal plane
4 a lntenncasal angle (JJ '!'.}

Righi Tracing ol linear measure-

menlS Outer Traang of the per-
pendicular from the N-Pog-hne lo
me 1ncisal edge ol Ille most ante-
norly posiuooed upper ceo11a1 inci-
sor

Centet Tracing ol the perpen-

dicular from the N-Pog-lrne to me
mcisat edge ol the anterior - most
lower centtal 1r"ICJSOI'

483 Bimaxnlary dental protru-

sion WI
Leh· Tracmg ol lateral cephato- 11 years
gram.
Upper and lower mosors are
rncl1neo labially. The dlSlance ol 110
1nosal edges 10 the N-Pog-hne rs
marl<edly increased in bOlh 1aws.

Flight. Ongmat latef3J headhlm ol

the tracmg

N-Pog
1 13mm
10 mrn
 Incisor Positron 199
484 Analysis of incisor
position and therapeutic
Incisor inclination lncisal edge Therapeutic movement consequences
to N-Pog-line of anterior teeth Assessment ol 1nc1SO< a:.1al mcbna-
lJOO and distance ol 1nc1sa1 edges
10 N Pog-hne determines tile ne-
Labially inclined position
Lingually inclined position
+ Anteposition
+ Retroposition I ....Tipping movement
-.a
cessary looth movements.

Depending on the comb1na11on or

the m.11pos11100 ol lhe ante110<
labially inclined position + Norm position f -.... Root torque
reeth, cenecuon requires either
Lingually inclined position + Anteposilion 1tpp1ng - root torque - 0< bodlly
movement of the tee1h.

Normal position + Anteposition f -.... Bodily tooth

Normal position + RetroposiUon movement

Class II malocclusions
FU
21 years 485 Correct axial inclination
of upper central Incisor with
antepositlon to N-Pog-line
Left. The relevant measurements.
Bodily looth movement 1s re<iuired
10 correct 1he malposmon ol lhe
upper antenor leeth.
To correcl Ille posiuon ol 1he
lower 1nc1sor. slight lrppmg and a
labial r001 torque rs necessary.1 e
the root is moved lab<ally.with lhe
cemar of r01a11on at lhe 1ncssa1
edges.

Right 011g1nal lateral cephalo-

gram

The N·Pog llne may snu allet us

retanonstup during me g10Wlh
peuods W11h verncst fOlahon ol ltle
mandible, lhe distance of 1ncisa1
N·Pog edges to lhr? rclcrence hnc m-
14 tm>
1 • 5 mm
creases, but wnh honzomal growth
pauer«, 11 decreases.

486 Labioversion of the

FA. upper central Incisor and
14 years antePosltion to the N-Pog·line
Lett· According 10 lhe angular and
lmear measurements. lhe labial
mchnabon oC the upper ameNO<
teelh, can be reahgned bytOOlh11p-
p1ng as !heir lnosal edges are m
antepcsrttoa to lhe N-Pog-hne.
To improve lhe pos111on oC me
lower mesors, labial root 1orque ss
md1ca1ed m thrs case

R1gllt: O!tg1nat cephalog1am oe the

lfllCUlfl.

N Pog
t 15 mm
' Jmm
200 Cephalometnc Analysis
Cephalometric Classification
of Malocclusions

Class D Malocclusions

- Dentoalveolar Class ll
- Anterior position of nasomaxillary complex
- Retrognathism of the mandible
- Neuromuscular Class Tl
- Combination iype.s

487 Class II malocclusion

with mandibular retrognathism S.P SNA 75
8 years SNB 67'
In IOIS 8-year-old girl, lhe d1stoclu-
ANB 8
soon is caused by lhe oosrenoe SN-Pog 68
pos11JQn of !he gleoo1d Iossa (NSar
angle 133") and underdevelop-
ment of the mandibular base. 57,5'-
The skeletal Cltscrepancy IS pan-
lyden1&11ycompensated by the hn- -----mm 65
91
guoversooo ol lhe upper 1nctS01s.
The prog110S1s foracausal thera-
fY'I ol this skeletal malocclusooo IS L-
unfavorable because ol ihe vertical
growtll panern.
19

61'
'
136
75
61 mm

N-Pog
1 • 9mm
T +1 nvn

488 Class 11 malocclusion -

Combination type
The S!<elera/ causes ol lhe amero- M.A. SNA 82'
l)()Slerior iaw discrepancy are lhe 11 years SNB 75
amsnor posinon o1 1he maxillary ANB 7
base, as well as Its oveidevelop- SN-Pog78"
ment on length, and the poslenor 68.2%
posot1on of 1he glenotd Iossa (NSar
angle 130").
DentoalveOtty Ille malocclusion
isenhanced by lhe lab1overSJQn ol
!he upper antenor teeth 137
The forward displacement ol lhe
mano1ble is 1nh1b1led by the amen-
or neuromuscular imbalance. w1lh ~\\ t-1--:;\~~~•s~mm~
hype<actMty ol the meruaf1S
muscle.

N-Pog
l ~9.5 mm
I +1.Smm
 l.;lass 11 - Glass 111 Ma1occ1us1ons :.!Ul

Class Ill Matocdusions

- Dentoalveolar Class I II
- Overdevelopment of mandibular base
- Maxillary deficiency
- Combination types
- Pseudo-forced bite
(deruoalveolar compensation of skeletal
Class HI)

489 Class Ill with

overdevelopmentof the
LM SW. 78
9yea:rs SNB 81
mandible
ANB 3 Mandibular p1ognalh1sm W•tn an-
SN Pog 82' terior posiuon (N$ar angle 119"1 of
an elongated mandibular bOdy.
65% The lenglh or 1he maod1bular
63mm base IS excessve by 7 mm. even
before !he start of ma.imum growin
~119 spurt.
~

155'

~~4 r;--..l~~~

-~"'iN-Pog
1_ a 1 rrwn
1 •3 mm

490 Class Ill malocclusion

A. y SNA 76 with underdevelopment of the
10yurg SN8 77 maxjlla
ANS -1 Class Ill malocclUS1on with a shof1
SN·Pog Tl
ma~llla. Clinical appearance of1he
61.9'1. Class Ill is increased dentoalveo-
64mm larly because ol lhe relatively
upnght position of upper 111c1sor
leeth
The prognos1s of lh•s dysgna1hta
147 - rs n01 lavorable because ol lhever-
ucal growth 1endency ol 1he man-
dible (facial he1ghl ratio= 61.9%).

N-Pog
1 -1 rrm
r t-2 nvn
202 Gepllalometnc :....A;;..:n.:::a:t..lY-=.S:..::1s _

Open bite

- Dentoalveolar open bite

lnfraposition of anterior teeth
Supraposiiion of molars

Skeletal open bile

Vertical growth direction
Anteinclination of maxillary base

491 Open bite - combination

type H.S.
Class II maJOCCluStOn, wllh marked 10 years
procnnanon ol upper and lowet 1n-
osa< teelh, caused by long-s1and-
1ng suclong habll
The causes of lhe anlenor open 64,1 ...
bite are. sl<.elerally. an1eu1chnauon
of lhe maxilla and dentoalveolatly.
100 malpo5111on al the amener
leelh. In this anomaly, lhe prog-
nostic assessment for orthodonuc
ueatrnen1is tavorsbte,

11"
58
128 70

1 +• nvn

492 Skeletal open bite

()ysgnalhia with a vertical growth K.R
pattern. 9 years SNA 80'
SNB 7Z'
The downward and backwatd MIB 8'
relation of lhe mandible is 1he SN.f'og rr
cause of (he aotenor open bite. The
gonlal angle and •Is lower segrnenl
are markedly enlarged. 57,2'1.
The ci1n1cal p!cture of Ille open 62mm
1:11te is partly compensated by lhe ~121·
IJnguoverSIOn of Iha upper antenor
1ee1h.
As lhe age of ma;nmum growth
148'
increments - the puberal spun -
has no1 ye1 been reached, an in-
crease in lhe open b11e can be ~:;\:t::--1"~~~~~~M1.,,:::)
expecied.
SS'
130
81

60mm

-....:.-1 N-Pog
1 + tOmm
l + snvn
 Open Bite - Deep Bite 203

Deep bite

Oentoatveolar deep bite

Supraposition of anterior teeth
lnfraposition of lateral teeth

- Skeletal deep bite

Horizontal growth direction
Retroinclination of maxillary base

493 Dentoalveolar deep bite

F.M SNA Tr
Deep 011erb1te in a case ol verucal
10 ve8ls
SNB 74" growth 1ype, comb<ne<:l wilh an-
ANS 3" 1e1ncl1na1100 ol the maxilla
SN-Pcq 75" The ehology of the deep bt1e is
denroalveolar sopraposibon ol 1n-
60,6% osors w11h lingual 11ppmg ol 1he
lower incisors and rnlral)OSJ110fl ol

~··
69 rrrn hrst molars.

As downward and bacl<ward rota·

1100 ol lhe mandtble rs 10 be expect-
143' ed, the progflOSis for therapeutic
bite opening 1s favorable

~~ rt- .....
~.._,.,

1~ 'R')-...fJJ-\1
79

1 ~a rrm

494 Skeletal deep bite

c.c. SNA 7ff' The deep overbrte iscaused by lhe
15 ye.ar..s
SNB 75" marked honzonlal growth dorectlon
ANS 3" ol lhe mandible, which is nol com·
SN-Pog n pensaled by the an1emd1na11on ol
the maxilla
nmm
Oentoalveolarly, lhe skeletal dys-
ptassa 1s increased by the hnguo-
I
I vers1on ol lhe upper antenor leeth.
-T
I
I
I

46
100
60
79mm 100

-"'IN-Pog
-
1 +o nwn
I 3 nYl'I
204 Cephalometnc Analysis
Cephalometric Radiography - Prognostic Assessment

Cephalornerric radiography provides important infor- The opposite to this is the unreliable treatment prog-
mation for the prognostic assessment of the malocclu- nosis for anterior displacement of the mandible in a
sion. For example; Class II anomalies with a horizontal Class a malocclusion with vertical growth tendency.
growth pattern have a good prognosis for changing the The prognosis regarding correction of a deep bite is
anteroposterior jaw relationships; however, the favorable.
prognosis is bad for bite opening. The prognostic assessment of sagittal and vertical
dysgnathias is determined by the growth direction:

Malocclusion Favorable Prognosis Unfavorable Prognosis

Class with a Change of sagittal ---.....::;. Bite opening

horizontal growth pattern jaw relationships

Class Jl with ----;;:.. Bite opening Change of sagittal

vertical growth pattern jaw relationships

Class Ul with Change of sagittal ---.....::;. Bite opening

horizontal growth pattern jaw relationships (if necessary)

Class Ill with Nol favorable Bite closing

vertical growth pattern

Dentoafveolar Skeletal
Deep bite
Open bite } malocclusion malocclusion

Cephalomelric follow-up
HG
10 years
Gray ~ Prelreatmeni lfacing 14 years_
Red • Posttreaimeni 1rac1ng

495 Class II malocclusion

with a horizontal growth
pattern
Dunng 4 years of obseMlhon lhe
re1Nded po511ion of the mandible
has been self-carrecled by forward
growlh of 1he mandible.
Changes are lhe resull of
marked increase in length of the
mandibular base and lhe phys>o-
logic upward and lorw3Jd d1spla-
cemen1 of the mandible.

496 Class II malocclusion

with vettlcal growth pattern ~
9 years
The 1nillal findings show a Class If •3 years-
re!a11onsh1p with a dentally sup-
pe<ted ovet01te.
Theanle<Ol)()Slenor 1awd1scsep-
ancy persists at me end ol lhe
3-year observauon perlOCI, wtuc!J
means 111a1 spontaneous bataoc-
1ng due to growth did not occur.
It is charac1e<1Sllc lor 1he verti<:al
growth rype tllal there rs downward
and backward rotauon o! !he man-
dible
An anlertO< open b11c IS p1esen1
at lhe end as Jhe resul1 of m11nd1bu-
lar rOla!IOll.
 Record Sheet 205

Record Sheet
Radiographic Cephalometric Analysis (Lateral Radiograph)

Patient Dale of Birth: Sex:

Clinical Actual value Clinical Actual val.
Standard value (Date) Standard value (Date)
NSar (saddle angle) 123°±5° 1-SN 102°+ 2°
SarGo (articular angle) 143°+ 6° 1-SpP (acc. lo Schwarz) 70°±5°
GoMe (gon1al angle) 130°± 7° 1-MeGo 900±30
Sum of postenor angles N-Pog to 1 +2-+4 mm
Horizontal growth 394° N-Pog lo 1 -2-+2 mm
Vertical growth
lnlenncisal angle 135°
Go, (NGoar angle) 52°-55°
S-ar 35mm
Go, (NGoMe angle) 70°-75°
NSe (+3 mm= ideal mm
SNA a1• mandibular length)
SNB 79° Ramus Ramus
20 Mandible Maxilla
ANB length Width
SN-Pog aoo . Ideal value
Pal-GoMe (basal angle) 25° Actual value
Pal-OcP 11 °
Symphys1s: normal - thin - thick
MeGo-OcP 14°
Distance
SN-MeGo 34° to esthettc line
SeN-Pal (Incl. angle) 85° lab. sup. -1 --4 mm
NS-Gn (Y-axis) 660 lab. inl. 0-+2mm
SGo: NMe X 100 62-65% Other findings:

Findings

Facial Skeleton

a) Vertical
Rotation of the mandible: neutral - horizontal - vertical
Rotation of lhe maxilla: normal - antemcnnanon - retroincunatlon
Rotallon of Jaw bases: divergent - convergent - same direction upward/downward

b) Sagrttal
Maxilla: orthognalhic - retroqnattuc - prognathtc
Mandible: ortnoqnaituc - relrognathic - prognalhic
Jaw base relanonstup: Class I - Class II - Class Ill

Measurement of Jaw Bases

Maxilla: normal - decreased - increased
Mandible: normal - decreased - increased

Dental ana/ySJs
Maxillary mcisors:
Axial inclination: ccrrect - labial - lingual
Relation 10 N-Pog: normal - anterior - posterior

Mandibular mcisors:
Axial inclination: correct - labial - lingual
Relation to N-Pog: normal - anterior - posterior
 suov cast Analysis zu r

Study Cast Analysis

Study cast analysis is a three-dimensional assessment of the maxillary and mandibular dental ar-
ches and the occlusal relationships.
The importance of this method of evaluation for orthodontic diagnosis and treatment planning
has in the past been over-emphasized. The disadvantage of odontometrics lies in the fact that it
concerns correlation analyses, which in dependence on tooth size asses the width and length of the

497 Orientation of study cast

<;
Tubero5'1Y ptane L---_....: :---
Modpalatal raphe
models
For lhe necessary exam1M110n,Ille
plasler models are oeenred w1lh
respect to 1hree reference planes.
which lie al nghl angles 10 one an-
other,
M1dpalatal tap(le plane e m1d-
sag1rtal plane, which cs defined by
anarormcat points on tne pala"ne
raphe {see Fogs. 511, 512). 11 IS Ille
reference plane for assessment of
transverse d1setepanCfes.
TuberOSJty plane = paratrontal
plane which runs lhlough 1he
mruullary tuber0St11esrespectively
1hrough the drslaf-most luberosrly
l11s lhe reference plane for analysis
of anteropOSlenor denial maJpos1-
nons
Occlusat plane • honzorual
plane lhrough the tips ol the buccal
cusps ol lhe premolars or lhe lops of
the mes1obucca1cusps ol the flrSl
molars and first premolars. This
plane allows ver11caJ matposmons
to be assessed

dental arches arithmetically. Too often, model analysis is not correlated with other important
diagnostic criteria, i.e. cephalograms and panoramic radiographs. A certain correlation between
arch length, width, and mesiodistal tooth material does exist, however. These relationships are
defined as indices by various authors. The indices of Pont, Linder, Harth, and Korkhaus are the
most commonly used in German-speaking countries. ln these cast analyses, the actual value of
the individual case is compared with the standard values of the "normal arch". With present-day
knowledge, this method is often considered to have minimal diagnostic value. Nevertheless, this
procedure is still widely used in orthodontic practice.
Despite these limitations, a great advantage of study cast analysis is that the degree of malocclu-
sions can be diagnosed in three dimensions, The plaster models for study cast analysis are oriented
to the following planes: l) midpalatal raphe (midsagittal plane), 2) tuberosity plane. and 3) the
occlusal plane (Fig. 497).
208 ~tuoy cast_A_na_1_,y
s1_s
__ ~----
Metric Analysis of Arch Form

• Sum of upper incisors (Sl")

• Anterior arch width
• Posterior arch width
• Anterior arch length
• Palatal height

Dental Arch Width

The standard values (often referred to as "normal
values") of the transverse arch width in the premolar
and molar region depend on the mesiodistal size of the
four upper incisors (SI.) (Poat, Linder, Harth). Since the
dental reference points for maxillary and mandibular
anterior and posterior arch width lie exactly opposite
each other in the anatomically correct occlusion. the
ideal values are equal for both jaws.
Comparing the ideal value with the actual value. the
followingdeviations from the norm may occur: narrow-
ness and broadness of dental arches.
The correlation analysis is inaccurate if the SI,, is very
large or very small, and is influenced by morphologic
variabilities of the upper incisors. In these cases the SI.
has to be calculated with the help of the Tonn Formula,
using the sum of the lower incisor width.
In principle, the so-called Poat relation discrepancies
are on! y to be taken into account iflarger differences are
present and should not be interpreted in isolation but
only together with other findings. These measurements
are a guide, not a goal.

Sum of the Incisors

498 Sum of upper incisors

(SI.)
Start1ng·PQ1nl •0< incisor widln/
arch width 1nde•accord1ng loPonl
rs 10 determme the SI
The maximal rnesrodistal w1dlh
of each maxillary 1nc1sor rs mea-
sured and lhe single values are
added 1oge1her

R.ght The measurements can be

earned out on the model or - lor --{ \
grea1er precision - directly 1n the
moulh dunng elm.ail e.am1na11on

499 Sum o1 lower incisors

(SIJ
If upper cenual or lateral 1nc1rors
are missing, determ1nal•ons may
be made based on lhe sum of the
lowef mctsorw1dlh. using the Tonn
Formula ol all four upper lllCISOfS
r <
which calculates lhe appropnate ~t
widlh.

R.ght· In cases of hypo. or hype1

ptasla ol maxillary rocrsors.me SI,
\..,
must be calculated by lhe Tonn
..,#
Formula when using lhe Pont-ta-
dex. \._.-{..,_~~./_~~'1'::_;Tonn Fotmui.a
4
Siu - Sli.3• + O 5
 Dental Arch Width 209
Anterior and posterior arch
width

500 Measurements of dental

arch width after eruption of the
lirsl premola!$
The reference PQ1nls for measure-
ments 1n lhe max111a1y and mand,b·
ular a1ch are del1ned so Iha! 1n an

I
} ana1om1c.ally correct occtusion,1he
upper and lower pomls ared,recuy
opposed
--~ Delm1rion ol reference fX)lnlS ·
Mil)t}l/a anre,,or = lower-mos!

- l)O'"I of the transverse hssure ol lhe

nrst premOlar
Maxilla pos1enor = po<nl ol 1nier-
secaon ol Ille Jraosve•se f<SSU1e
with the buccal hssu•e et lhe f1t01
permanent molar.
Mand10/e amenor = lac1aJ con·
tact po1n1 be1ween f1tst and second
premotars
Mandible pos1e11or = 11p of me
med1obuccaJ cusp of the lowe• f1tt;1
- permanenJ molar.

The anterior arc.h Wldlh rs dehned

as Jhe d1S1ance between Jhe an-
tenor relerence pomts fpremolar
region). The possenor width IS ine
d1s1ance between tne flfst molars.
The "1deaf•va1uesofamenor ano
(JOSle11or a1ct1 width are Oeler~
mmed by using lhe Pont index

501 Measurement of dental

arch width In the early mired
dentition
The antenor arch w1dlh 1s mea-
sured 1n lhe region of 1he f1t01 deCl-
duous rnotars when pnmary teeth
are still preseru 1n 1ne supp0~1ng
zones.
~,. Delm1tJon of reference pom1s
MilXllla· posrencr grOOYe ot lhe

~
r rraosverse 11ssure of lhe h<sl deci-
duous molar.
r Mandible. d•slobuccal coso J1p
ol hrst deciduous molar.
I '- '-.
The posrenor arch width IS mea-
sured l!l<Clilslvely 1n lhe region of
!he 6-year.rriolars.

':.. ~ r,.
•
I '
~

"
I;:-
':=t r
•'
~
\
210 Study Cast Analysis
502 CorTelalion table
between the sum of upper
incisors and dental arch width Posterior arch width
Slu(mm) Anterior arch width
Table Of mean values forarchwldlh
assessmem according 10 ddteron1
lllVestJgato<s (Weise and Ben-
111a!«J, 1965). Since lhe maxJllary Pont Harth Schmuth Ritter Weise Pont Harth Schmuth Ritter Weise
and mandtbular reference points
correspond, lhe standard values
are valid cmm1 tor both ,aws. 35 34.8 42.5 41.5 43 47.1
27 33.5 32
The formula lor lhe PonHndex
according 10 under and Hanh. 27.5 32.5 35.2 42.3 47.5
28 35 33 36 36 35.5 44 ·43 44 48 47.8
Ideal value an1erior arch w1dlh 28.5 33.5 35.8 43.8 482
29 36 34 37 36.5 36.2 45.3 44.5 45 48.5 48.6
Sl,.x 100
= 29.5 34.7 36.5 45.3 48.9
85 30 37.5 35.5 38 37 36.8 46.9 46 46 49 49.3
lcleal value poslenor arch Width 30.5 36 37.2 46.8 49.7
31 39 36.5 39 37.5 37.5 48.2 47.5 47 49.5 50.1

- si, x 100
65
31.5
32 40
37
37.5 40 38
37.8
38.2 50
48.5
49 48 50
50.4
50.8
32.5 382 38.5 50 51.1
The deviauon tr11he traosverse de·
33 41 39 41 38.5 38.8 51.5 51 49 50.5 51.5
velopmem ot me arch w1dlh 1s re-
presented by the drfference be- 33.5 39.5 392 51.5 51.8
1Yo-een the aC!ual and lhe standard 34 43 40 42 39 39.5 53 52.5 50 51 52.2
1scxaUed normal) values.
34.5 40.5 39.8 53 52.6
35 44 412 43 39.5 40.2 54.5 54 51 51.5 53.0
35.5 42 40.5 54.5 53.3
36 45 42.5 44 40 40.8 56.3 55.5 52 52 53.7

503 Correlation between

dentalarch form and sum of
incisors
The l'onHndex 1s based on various
exammabons ol lhe geometry of
nomial denial arches.
According IO ll'lese graphic cia-
grams.1he S1Ze ol 1he near-iillrpllcal
shape of lhe maxlllary dental arch
IS rela1ed lo the w1dlh ol 1he upper
1flCJSOr 1ee1h.

Rrghf.· Depend mg on mesum value

of the upper mcsors. 1he elhpucal
forms are of dttterem SIZe bul ot so-
""lar shape CKorl<haus 19391

504 Correlation between

dental arch width and arch
lenglh
View ot a wide, snort maxillary arch.
The shape of the normal arch de-
pendson 1hedevelopmen1 ol width
and length, which is m the ra110 of
2J FD< example, 11lhe arch W1dlh rs
111c•eased by 2 mm, Jhe arch leng1h
IS reduced by t mm.
The ideal arch w1dtn value deter·
rruned aroo<dmg to Ponl can be in·
dMdual1zed 11 both parameters
lfanglh and wldlh) are considered

Anterior Dental Arch length
The anterior arch length according 10 Korkhaus (Lu in
the maxilla, LL in the mandible) is defined as the perpen-
dicular from the most anterior labial surface of the
central incisors to the connecting line of the reference
points of the anterior arch width (p. 209). The measure-
ment should reveal the anteroposteriormalpositioningof
the anterior teeth.
As with the Pont-Index, the standard values of the
anterior arch length are statistically correlated, depen-
dent on the sum ofmesiodistal tooth width of the upper
incisors (S[J. Theanteroposterior length of the anterior
Lu
- I
-::).
..., I
'
LL
Anterior Arch Length 211
mandible is normally 2 mm shorter than the maxillary
arch (labiolingual diameter of the incisal edges of the
upper incisors). Certain diagnostic and prognostic indi-
cations regarding an anteroposterior displacement of
the incisors can be gained by comparison of the standard
and actual values.
The anterior arch length is, however. not only altered
by malpositioning of the anterior teeth, but also by
migration of the first premolars. The correlation be-
tween arch length and arch width varies considerably
with different facial types.
SOS Measurements of anterior
arcll length
OveMewol the maiollary and man-
dibular arches, with marklng ol the
reference lines tor anter10< arch
length determ1naJJon.
The arch length is dellned as lhe
distance perpeno1cular 10 tne hne
connecting the reference PQ1nts or
an1er1or arcn width m 1hemldsa91t·
iaJ plane. II is measured from lhe
mte<section of the IWO lines IO me
labial surface of tile mosl anterior·
pos111oned central 1oosor.
506 Correlation between
maidllary and mandibular
a.nterior areh lengths
Schemauc 1Uustra11on ol 1he ante-
rior arch lenglh of lhe mruulla and
mandible tn the ameroPOS1enor
plane. In normal oc:dUSIOO. lhe
measuring points ol bOth iaws l•e
dnecttv across from one anolher.
Lt.(mm) -Lu(mm)-2 mm The anten0< arch length ol the
mandible l'-<l is sho<1er than the
maXlllary arch length 11.ul bylhe la·
blolmguat width of 1he 1ncisa1 eoge
ol the upper central 1oetsor. As a
rule 1he following relabonsh1p ap-
PhP.~. SIJ!ndllrd value L, =standard
value L - 2 mm
212 Study Cast Analysis
~--''-------~
507 Correlation table
between Ille sum of the
maxillary incisors and the
Siu 27 27.5 28 28.5 29 29 5 JO 30.5 31 31.5 32 32.5 33 JJ.5 34 34.5 35 35.5 35
maxillary anterior arch length
Standard values of lhe upper anle-
nor arch leng1haccord1ng 10d1tt11r-
em 111vest1ga1ors 11>gures 1n mmJ.
The formula tor calculaflng Ille
Korilh•u• 16 16.3 1~5 16.8 17 17.3 17.5 17.8 18 18.3 185 188 19 19.3 195 19.8 20 m 21
standan:I vaiue ol ltle upper aruen-
or arch lenglh, ar;c0<d1ng 10 K()(I<·
nsos (1938J. 1s as follows: Welu 164 16,6 16.8 17.0 172 17• 176 17.8 !80 J&.2 18-C 186 18.8 190 19.2 19.4 196 19.8 20.0
SI. x 100
L,= ---
160

The measuremen1 perrnns a crude Brune 16.Ji 16.8 16.9 17 1 17 2 17.3 17 5 17 6 17.8 17.9 18.0 18-2 18. 18-6 18.7 18.B 18 9 19.0 19 2
analyslS ol lhe anteroposteuor
pos1t100 1f 1nosors.

Shortened arch lenglh

508 Unguoversion of central

incisors
Snortened an1e1101 arch len111h m
lhe maiolla resulUog from lingual
1ncl1nauonol upper central 1nc1sors
1n a Class 11. 01V1S1ot1 2 malocctu-
son,

509 Mesia! position of

premolars
Markedly shollened anterior arcn
length 1n lhe maona as tne resull of
mesial ontt ol postenor reelh 101-
lowmg early loss ol deciduous
leelh on 1he suppo<1mg zones.
The axial 1ncJonation ol lhe upper
1nctSOrS 1s apprOX1malelyconect,
in sp~eof a reduced L,,

510 Interpretation of
measurements of anterior arch
length Finding Anterior arch length
A shor1ened or elongaJed an1enor
arch lenglh IS not always 1he resull
of an an1eropos1er10r malposi100-
1ng of lhe IOCISO<S. Lu IL,_ shortened
• Bilateral mesioversion of posterior teeth
• Unguoversion of anterior teeth Lu IL,_ shortened
• Labioversion of anterior teeth • Lu IL,_ increased
• Bimaxillary dental protrusion Lu+Lt. increased
• Oistoversion of premolars • Lu/4. increased
• Mandibular prognathism 4. increased

lntramaxillary Symmetry
- Transverse symmetry
- Anteroposterior symmetry
These symmetry analyses estimate the right-left diffe-
rences in transverse and anteroposterior tooth positions
(Korbirz 1909).
For performing these measurements, precisely
defined reference planes are necessary. The midpalatal
raphe (midline of the maxilla) which is defined by two
anatomical points on the palatine raphe is the reference
plane for the transverse symmetry analysis. Construe-
J 10 the raphe rn trus segmcnL
• tal raphe and luberosuy plana
,!
_::;~·ymmetry
Assessment 213
tion of the mandibular midline is more difficult. The
direct transference of the midpalatal raphe is of minor
accuracy. 11 is more precise to mark the anterior point
of the mandibular midline using the mental spine film
(p. 171) or by using the lingual frenum (Korkhaus 1939).
The posterior point for construction or the mandibular
midline is determined by a perpendicular. which runs
from the posterior edge of the midpalatal raphe from me
maxillary to the mandibular cast.
The tuberosity plane is the reference plane for
comparing anteroposterior symmetry. This plane is
perpendicular to the midpalatal raphe and runs through
the distal-most tuberosity.
Constructionof the reference
planes
511 Midpalatal raphe
The m1dpalata1raphe rs coesnuct-
ed w11h lhe help ol two anatomic
reference 001n1s on the palaune
rapne.
Antenor poml (X)· Cross-sec·
hon of the second pala11ne rugae
w11h the pataune raplle
PQSlenor point. (d) The bo<de<
of the hard and soft pata1eon the
raphe respectJvely lhe m1dpo.nl
between !he paired loYeolae, ne.<l
512 Marking of the reference
planes
Construction ol m1dpalalal raohe
tMPR) through anatomically de.
lined m1dpom1s on lhc pafahne
rapheollhemaXtlla TheMPRisthe
maxdlary m1dhne and reference
plane for assessing rrans.erse
symmetry
The arueroocstenor symmetry
assessment rs made using the rela-
l10nsh1p lo the IUberOS>ly plane
which is perpendicular lo lhe MPR
and extends through the most dis-
tally pas1honed maxillary ruoeros-
ity
513 Symmetrograph
according lo Bemklau
Asymmetrical arch shape m trans·
verse and aruerooostenor direc.
11ons. can be assessed using ap.
propnale measuring IRSlf\lmen!s
which are 011enled lo !he mldpala-
The transparent measuring grid
of Bernldau is a plas!lc remplale
wnn a 2-mm square scale and IWo
me!al rods. The calibrated gnd can
therelore be sturdily fi>ed on the
mldpalalal raphe.
Left. Oblique Side VllNI of the
I measuung gucL
Analysis of Transverse Symmetry

The following findings are derived from this type or
intramaxillary assessment of the study casts.
- Symmetric/asymmetric width development between
right and left sides of the arch (malposition: sym-
metric, asymmetric, unilateral)
- Congruence/incongruence between dental midline
and skeletal midline of the arches (dental midline
shift)
The transverse distance of the Poat reference points to
the arch midline is determined and the actual measured
value is compared with the half value of the standard
width of the dental arch. According to Schmuth (1983).
measurements should not be taken from these reference
points but rather from the linguo-gingival margin of the
teeth, since erroneous measurements can occur in cases
of tooth rotation.
From a diagnostic paint of view, assessment of the
transverse symmetry is clinically relevant, particularly
in cases of transverse malocclusions (lateral cross-bite.
edge-to-edge occlusion, buccal/lingual nonocclusion).

Clinical importanceof
transverse symmetry anatysis
- case example -

514 Unilateral cro.ss ..;bite

Transverse malocclus100 tn !he
11gh1 pos1e11or region, with man-
dibular m«lhne shrtt ol aoprox»
ma1ely 1.5 mm to the nghL
Fo< assessing tne cause of !his
maltelauonsrup, !he transverse
symmeuy analysis should be ear-
ned oot first lodelermme the s;gnlf.
1cance of a nght-lel1 asymmetry in
the upper and tower arch w1dlh.

515 Symm&tric maxlttary arch

Companng lransverse symmetry,
lhe nght and leh aich sides are of
eoual width 1n retauon 10 tl>e rmd-
palalal raphe. Maxillary arch of !he
case example shown In Fill 514.

Right: Line-drawing ol the relevanl

midsag1rtal plane As a rule, trans·
verse symmetry rs assessed us1119
the Pont ieference points.

516 Asymmetric mandibular

arch
The lower arch shows asymmetnc
development between lhe lett and
nghl Sides.
The dlSlance of !he right post-
enor 1ee1h trom the mandibular
mldline Is greater than lhal at me
other Side.
Thus, according 10 ttus analysis,
tne untla1era1 cross-oue, shown 1n
Fig.51~.iscombined w•lh undate<al
exc:essNe width of the lower right
postenor arell.
 Midline shift

517 Mldllne shift in the

maxlllary arch
The contact point ot the mes1al
approJ<Jmalsurlaoes of the upper
central 1nc1sors does not comooe
with the nudsaqutal plane (= m1d-
palalal raphe) ol the upper arch,
~ but devoales to the nght (denlal
' mldlme slnlt to the nghll.

Left Lateral 11pp1ng oC the uppe<

mcrsors is a chnocal feature ot a
denial m1dhneshdt

518 Dental midline shill

I Dental rmdlme shifts are the result
ol tooth migration.

Leh· Denial m1dhnedeviation on the

upper S!Ch
~) The conlact pomt of the uppe•
cent•al 1nc1sa<s is shoheo to the
nght. In retauon to Lhe rrudsagmal
plane, Le. to the sode wnh lack of
space lor the canme

Right. Denial modhne sh1h on ltle

mandibular arcn The contact point
of the tow!!< ceotrat 1nC1SO<S IS de-
v1aled 10 the left as lhe resutt of
1 tOOlh dntl In an otherwise welt-
allgned areh, the fOwe< rogtlllaleral
mersor 1s LtnguaJfy blocked out
(according to ReJchenoach and
Btiick.e/, t96n

519 Differentiation between

dental and skeletal midline
shill in the mandible
ten: Ma)(.lllary and mandibular
arches with dental m1dhne devl!I·
lions in opposite dorec11ons 1n con-
[uncuon with tooth malpos1t1on1ng
1n the respective antenor 1eg1ons.

R1ghr· Skeletal mandibular mid line

shill, as a resull ol displacement of
the whole mandible to the left.
.J ) ~~
~ The MPA Is not useful lot d1ffer-
--1 entoahon between dental and man-
- dibular rmdlme devoa11on. The true

-'
~ skeletal mandibular m1dllnehas to
I
....,.__ ' '- be determined The anlelior skele-
) • -v tal m1dpom1 of the mandible is ei-
~'
•
'.)
ther determined with the help of the
menial spine View (see Fig. 4311 or
by assessing the pomt of msemon
of the lmgual frenum. The 1ad10-
graph1c method ss lhe most rel>-
able
216 Study Cast _A_na_Jy,_s_is _
Analysis of Anteroposterior Symmetry

The measurements reveal the following: distally!).

- Asymmetric rnesiodistal tooth position of correspon-
ding teeth in the right and left sides of the dental
arches
Jn practice, this involves drawing a line parallel to the
ruberosity plane. which runs through the posterior
surface of the distal-most first molar, and comparing
the sagirtal distances of the individual posterior teeth
(it is postulated that the first molars only seldom migrate
This analysis serves to diagnose first and foremost
any mesial tooth drift. lf there is no right - left asym-
metry, the teeth are correctly positioned or there has
been symmetric mesial migration. In this case, the
diagnosis of the rnesial tooth shift has to be made by
assessing other criteria (Fig. 523).
Asymmetry of a transverse arch form may result in a
relative mesial position of the more buccally placed
teeth (characteristic symptoms of mesial malposition-
ing are absent in such a case).

520 Analysis of
anterpaS1erior symmetry
Left Diagram of the nomially deve-
loped arch showing the m1dsag1nal
plane. the tuberos1ty plaoe. and the
d!Slance ol ihe lirsl premolars from
lhe tuberosrty otane

Rrgnr· R•ghHeh discrepancy of lhe

)
distance ol the first molars from the
tuberos.iy plane. The rnesral dntt of
tile upper leh first permanent molal
can be measured using this meth-
Od A Pterequ1site forth is IS thallhe
ooposne side of lhe den1al arch Is
___g_
no<mally developeC.

521 Correlation between

anleroposte.rior and transverse
tooth position
Asymmetnc position of the first
molar m the absence ol rnesiat dntt
of the right posterior teeth. The
cause ol this d1vergency m amero-
postenord11ectt001sa nght-lelt d1I·
ference m uansveese a{ch forrn.
The more buccally placed teetn
on the ngtu Side are relallwty posr-
11oned more mes1ally as a resull ol
the increased arch curvature.
I J l
• "t

522 Differentiation between

unilateral and bilateral shill ot
posterior teeth
Left: Smee the left arch ts normally
developed. m1gra1100 of the firSI
premolar and first mclar on lhe
nght stde can be measured m reia-
0
11onsh1p lo lhe luberos1ty plane

Right. tnthecaseolbllateral m19ra-

t>0nof poster tor teeth the position ol
the tuberOS<IY plane Is altered so
that lhe symmetry analysis does I
not drscoverthe malpos111omng An
exaa reconstructing of Ille ongmal
pos111on ol the tuberOS<ty plane rs
11ery d1fhcutl
 !:>ymmetry Assessment 217
523 Symptoms of bilateral
mesial position of posterior
Symptoms of Mesial Position of Posterior Teeth teeth
Ouahtat1ve and quantitative as-
sessment lor the dtagnosisol me-
• Crowding and space loss, espeClally In the supporting zones s•al m1gra11on o! nght and left POS-
• Dental midline shill with crowding and space loss ter1oc reetn
• Mes1al lipping of premolars
• Rotation of first permanent molars
• Relation of first pair of palatine rugae to the canine according to Hausser
(first palatonerugae distal to canine = mesial position)
• Relationship of the papilla-transverse plane to the canine (Schmuth)
(perpendicular through the posterior end of the Incisive papilla runs
distal to the canine= mesiaf position)

524 Rotation of molars

Bt1a1e1al mestal position of posse-
nor leeth, chn1calfy apparent by
mesiohngual rotauon ol first per.
manent molars.

525 Anteroposterior
symmetry in case of rotated
molars

Blue = Normal case

Red = In case ol IOOlh rctauoes

In cases wllh rotation ol Ille first

molars, 1he anteroposlemx sym-
metJy analysis shoukl not be ca«
ned out using the Pont relerence
po.ms.
In these cases. mesial m1grat1on
must be• assessed by measure-
meres 10 lhe mestal or distal lingual
surfaces ol lhe f1rS1 permanent mo-
lar.

526 Tran5"erse plane of

incisive papilla
Descr1p11on ol meS!al POS!llOfl ol
pastenor lee1h using lhclransverse
plane ot the masrve papilla ac-
c0<d1ng 10 Schmuth.
The perpendicular cooslrucied
on 1he m1dpaialal raphe al lhe PoS-
tenor po.nt ol the 1ncis1ve papilla
runs through the first premolars.
In normal retauons. the pap1lla-
transverse line extends to the ca-
nines.
218 Study Casi Analy<--S=--IS _
Palatal Height

Palatal height, according to Korkhaus. is defined as a
vertical line perpendicular to the midpalatal raphe
which runs from the surface of the palate to the level of
the occlusal plane. This is measured between the refer-
ence points of the Pont-Index for the posterior arch
width. Korkhaus (1939) evaluates palatal shape accord-
ing to the index:
. ht . d Palatal height X I 00
Palatal herg rn ex = . .
Posterior arch width
The average index value is 42%. The index figure is
increased when the palatal vault relati ve to the trans-
verse arch development is high, and decreased when the
palate is shallow.
A high palate is a principal feature of apical narrowing of
the maxillary alveolar process, which often occurs in
cases of chronic mouth-breathing, rickets, and in certain
types of sucking habits.

527 Palatal height index

accordingto Korkhaus
Diagram of relevant lines 10< neter-
m1n1ng lhe palatal heigh! rndex.
Palatal height is measured 1n lhe
m1dsagrrtal plane m rhe region~
lhe upper hrSI molars. on lhe level
of the occlusal plane The heighl rs
defined as the d1saance ot lhe per-
pendicular trom the connecting
tme berween the midpoint ol lhe tis-
sures ol bolh upper nrst molars to
the surface of the palare.

528 M~$urement of palatal

height
Using the K0<1<hauslhree-d1meos1·
onal ortllodonticdlVlder, the palatal
height can be measured,aswell as
OOS1e110< arch width

LJ

529 Palatal height in ease of

bilateral cross-bite
Irsnsverse section ol model casts
1n the hrst molar region.

Left B1ta!eral cross-buewdna h>gh

palate (palatal height index =
51.3%) The palatal conhgura11on is
cnaraetensuc ol bdateral narrow-
ing ol lhe maxillary arch Treatment
can onctudeexpansionol the upper
dental arch.

F11gnL B1ta1e<a1 cross-bite with a

Shallow palatal arch (index =
36.6%). Extensive e,pans1on ol me
upper dental arch woulcl De con-
lramd1cated
 Analysis of Supporting Zones 219

Analysis of Supporting Zones

Assessment of supporting zones (Fig. 530) is carried out
in the mixed dentition period to determine the differ-
ence between space available and space required for
the as yet unerupted permanent canines and first and
second premolars. Four different methods of evaluation
are described in the literature:
- A prediction method based on mean values for
supporting zones
- Proportionality tables taking into account size of the
anterior teeth
- Radiologic methods
- Combination of radiologic and prediction table
methods
The combined radiologic-prediction table method esti-
mates the width of the unerupted teeth most accu-
rately. The prediction from proportionality tables is the
next most accurate method. The radiologic determina-
rion is the least accurate, because of technical difficul-
ties. The prediction tables are the most widely used in
clinical practice.

530 Measurement of the

supporting zones
The oopportmg zone m lne mixed
cennuon ss defined as Ille distance
between the d1S1al surtace al tbe
lateral permanent incisor and the
mesiat surface al the f<rSI perrna-
nent molar. The area comptisesthe
deciduous canine and the hrsl and
second deciduous molars

_J
531 Supporting zones - mean
values
Average values of the supporting zone Lell. Companson of d•stances: d•s-
~ tat edge of Ihe 1a1eml permanenl 1n-
crsor to the rnessal edge of the firsa
;o " cl' Q permanen1 molar 1n !he m"'ed den-
"?, 1t110n (letr) and In lhe permanent
max mand max mand dentrtton (nghtJ. Mean values ac-
I v cording lo AM Schwarz.

I I Seipel 22.3 21.8 21.0 21.1 The aad111ona1 space whicn occurs
,...). (1946) m lhe supportmg zone dunng the
Moorrees 21.8 21.8 21 2 20.6 transitional penod is known as the
•teeway space- (Nance). It is large<
(1957) 1n Ille mand1bularthan sn the maxII·
Stahle 21.9 21.6 21.7 21.1 lary arch.
,. (1958)
""-"
.
t<, Garn
(1964)
21.9 21.5 21.0 20.6 Righi· Average values lor 1he
supp0<11ng zooes m mates and te
males according tod1tferen11nves-
• Mlethke 21.8 21 4 21.1 20.7 119at0rs (SchulZe 19821
'v=- (1972)
s-
f
IV
" •
~ Mean
21.9 21 5 21.1 20.7
value
220 StudyCastAnaly'-"s:. :. :is'------
Prediction from Proportionality Tables
The best known predication tables for estimating the
required space of unerupted permanent canines and
first and second premolars is that of Moyers (1967): it
is used as follows:
I) Determination of the sum ofmesiodistal tooth width
of lower permanent incisors (SIJ.
2) In the presence of incisor crowding: marking the
distance of incisor width in the line of arch for each
quadrant starting from the contact poiru of lower
central incisors (Fig. 532).
3) Measurement of the distance from the mark in the
anterior region (in a well-formed anterior arch from
the distal surface of the lateral permanent incisor)
to the mesial surface of the first molar (space avail-
able).
4) Reading off the probable space requirement for the
permanent canine and first and second premolars
from the prediction table using the column which
shows the measured width of lower incisors.
5) The difference between available space and space
required expresses the space situation in millime-
ters; in case of insufficient space, by a minus value.
6) Steps 2 lo 5 are repeated for the maxillary arch.

532 Measurement of
supporting zonesi_n case of ,_-
Incisor crowding
In each quadranl 1he sum ol 1he
width of cenl!al and lateral mcisors
,__\
IS measured w11h a loolh-measur·
1ng gauge lrom theconlaci l)Olnl ol
Ille central incisors and marked In
cases ol etowdrng lhe marking
may extend 10 !he canine.
TheaClual length ot lhesuppo<1·
ing zone is delrned as the d1S1ance
Detween !his mark and lhe mesial ,
edge ol lhe f1rs1 permanem molar.
The procedure 1s performed sepa-
1A1ely for !he nght and leh sides.

533 Prediction •alues from

proportionality tables
Prognosis of w1dlh ol permanenl
canine and f1rS1 and second pre·
molars rn retanon to lhe sum ol 1he
mandibular IOCISOrS (Sid. The level
ol probabolnywilh this melhOO is
75...
Based on the actual value of lhe
Sic. lhe predicted seace require-
ment fO< lhe unerup1ed teeth of the
supporting zones rn Iha rnandrbu-
lar and maxillary arch can be read
ol1 (Moyers IUSAJ. Droschl et al.
{Aus111a)l.
345 75 % -Level of prObabllil'(
SIL 19.5 20.0 20.5 21.0 21 5 22.0 22.5 23.0 23.5 24.0 24.5 25.0 25.5 26.0 26.5 27.0
Moyers 20.1 20.4 20.7 21.0 21 3 21 6 21.9 22.2 22.5 22.8 23.1 23.4 23.7 24.0 24.3 24.6
Droschl d'20.8 21.0 21.2 21.4 21.6 21.8 22.0 22.3 22.5 22.7 22.9 23. 1 23.3 23 5 23 7 23.9
Q 20.0 20.3 20.6 20.8 21.1 21.4 21.6 21.9 22.2 22.4 22.7 230 23.2 23.5 23.7 24.0
345 75'!!>-level ot probablhl'(
SIL 19.5 20.0 20.5 21 0 21.5 22.0 22.5 23.0 23.5 24.0 24.5 25.0 25.5 26.0 26.5 27.0
Moyers 20.6 20.9 21.2 21 5 21 8 22.0 22.3 22.6 22.9 23.1 23.4 23 7 24 0 24.2 24.5 24.8
Oroschl d' 21.3 21.5 21.7 21.9 22.0 22.2 22.4 22.6 22.7 22.9 23.1 23.3 23.4 23.6 23.8 24.0
Q 20.2 20.5 20.7 21.0 24.0 21.2 21.5 21.7 22.0 22.2 22.5 22.7 23.0 23.2 23.5 23.7

534 Chart for space analysii;

fn the mi•ed dentition using
proportionality tables Tooth 42 41 31 32
Thespaoeawllable correlates W111l Mesiodistal width
the values from thecaSIof soopon-
1ng zone lenglh. Total width (SIJ
Required space rs Iha pred1c1ed Lower arch Upper arch
wlue taken lrom Ille tables lor the right left right left
sum ol lhe widlh of 1he permanent
canone and the first and second Space available after
premolars. incisor alignment
Space required
Difference
.
Discrepancy/arch
 Analysis ot t>uppon1ng Lones 4!~1

Combined Radiologic-Prediction Table Method 2) Determination of mesiodistal tooth width of the

lower central and lateral incisiors on the study cast
This procedure combines measurements from the corresponding to the side of the radiograph.
denial cast and width measurements from the periapical 3) After adding together both figures, the probable
radiograph in order to improve accuracy of prediction width of the permanent canine and first and second
for each individual case. premolars for the corresponding quadrant can be
The method of Hixon and Oldfather(1956),modified read off in the prediction graph under the column of
by Staley and Kerbers (1980) is restricted to the analysis the calculated sum total (Fig. 536).
of the supporting zone in the mandible. An optimal periapical radiograph taken with the long-
The procedure is as foUows: cone technique under standard conditions (head and
1) Measurement of size of unerupted first and second tube position), is necessary for this rype of analysis of the
premolars in one mandibular quadrant from a peri- supporting zone.
apical radiograph.
535 Chart for combined
radiologic-prediction table
Measurement on dental cast Radiologic measurement method.
From 1he same side ol the mand11>
ular cast, lhe tOlalwtdlh ol lhe cen-
Tooth width· mand 1: mand 2: Tooth width: mand 4: mand 5:
tral and lateral 1nc1sors Is mea-
sured From lhe rad1ograph,the lo-
Total width: mm Total width: mm ral saze of lhe first and second pre-
molars is determined
usirio lhe summed-up value of
Total width model/film measurement: mm bolh measuremen1s, tne pred1Cllon
graph gives lhe figures ot lhe to-
Space required: mm 131 w1d1h ol canine and oremotars
Space available: mm ol lhe same side tsoace reqwred).
Space available IS the measured
Difference/Quadrant: mm value of 1he length of lhe support·
ing zones

536 Prediction graph for

space analysis of the
''. I '.
.. • • ...:.+.
. ... ,.....,_..
supporting zone, according to
Hixon and Oldfather, modified
by Staley and Kerbe<
mm
24 X-aJas: Sum ol mandtbulat incisor
e : '. width measured on lhe denial cast
and ine 101al w1dlh ot the lirst and
~ . ............' ..--
E
.
t __ :::: • • -
- - •i ' . second premolars measured on
"~ 23a .. .. 1.........: Iha penapical film. (Unllaleral mea-
:~ - - I :-~.:::J .. . ........... suremeo1; e11her 1he nghl OI lett
j •• side or lhe mandible is analyzed).
-e •
'
' ...
ii; 22
..
m
e
c
.. j
- .: :
~ Y·/lXIS: PtedlCled total Wldlll ol
permanentmandibular canine and
first and second premolars.
~ 21
•••• =
.......
~ The formula IOI calculallon ol the
2
' ' ."J
........
+- •
regression equanon 1s as follows
0 I. 1: 3 + 4 + 5 = ([l: I+ 2 + X4 + X5] x
0. 7158) + 2-1267
' - . - (X - measurements from red•o-
§
..
"C 19 -·
. graph)

j ···--
• ~+-

-- - -- - ~-:..,;: .•.....•

--
...
. •···
' .L...-

.. . . . ---
18
....... ,,,, ·1 •• ' -~~-~

. . . n,:~ . . ,. . ·----- . . . . ' .t ••

. . '·. -. . . . ...
-1'.i
• •

ti ..
r :
,- I .
.. . . ..
o+
·- :~--.
- -

. . . '
. .. ,

17
22 23 24 25 27 28 29 30 31 mm
Wtdth ot bothk>wer incisof$ on the dental cast aod, ol the same
quadrant, both lower premolars measured on the radiograph
222 Study Cast Analysis

Space Analysis in the Permanent Dentition

For patients with malalignrnent of teeth resulting from
lack ofspace. it is important 10 determine from the study
casts the amount of crowding in the maxillary and
mandibular arches. The purpose is 10 determine the
difference between space available and space required
for tooth alignment. This means that two measurements
are required in each arch for intrarnaxillary analysis of
space requirement:
I) calculation of space required and
2) calculation of space available.
The analysis can be carried out by two methods:
The Nance Analysis (Figs. 537 -539)
The steps are as follows:
I) Recording the mesiodistal width of each tooth mesial
to the first permanent molar. The sum total of the
width corresponds to the necessary space required
(ideal dental arch length).
2) Recording the acrual arch length using a soft wire.
This is contoured to the individual arch shape and
placed on the occlusal surfaces over the contact
points of the posterior teeth and the incisal edges of
the anteriors. The distance between the mesial con-

Recording space available in

the permanent dentition.
according to Nance

537 Measurement of the

maxillary arch
The actual arch length is measured
with the aid ol a soh wire. •
This IS contoured to the mdM·
dual arch lorm. In the poslenor re-
gion 11 crosses the contact porns r
and an1eriorty11loflows1t>e 1nasal-
edges.
The actual arch length is ob-
lained by measuring the arch pen-
meter meS1al 10 the ftrst permanent
molars

538 Measurement of the

mandibular arch
De1erm1na11on of Jhe actual arch
length IS earned 001 m lhe same
way as tor the maxillary arch.

Righi Schema11c 111us1ra11on ol the ~--

measuremera,

539 Calculation of space

required using the Nance Max: Tooth 15 14 13 12 11 21 22 23 24 25
analysis Tooth width 7.5 8 7.5 7 8.5 9 7 7.5 7.5 7.5
Reoord1ng the measurements for v
the maxillary end mandibular arch Space required 177 mml
Jrom Figs. 537. 538 onto the chart
Space available l1omml
and determining the d1tterence be-
tween space required and space Difference l-7mm(
available.
Mand: Toolh 45 44 43 42 41 31 32 33 34 35
Tooth width 7 7 6 5 5 5 5 6 7 7
v
Space required l60mml
Space available l62mm(
Difference l+2mm(
 soace Analysis 22;$

tact points of the first permanent molars - recorded
from the straightened wire - is the amount of space
available in the dental arch (actual arch length).
3) The assessment of space relationship is the result of
the difference between the ideal and actual arch
length (negative value = space deficiency, positive
value= space excess) (Fig. 539).
The Lundstrom Segmental Analysis (Figs. 540-542)
The segmental analysis involves an indirect assessment
of the dental arch perimeter, which can be carried out in
the following way:
I) Division of the dental arch into six straight line
segments of two teeth per segment, including the first
permanent molars (Fig. 540).
2) Recording the mesiodistal width of the twelve teeth.
3) Summing the individual tooth width ofeach segment.
4) Recording the available mesiodistal space on the
study cast separately for each segment.
5) The sum of the difference between ideal and actual
length of each segment expresses the space rela-
tionship (Fig. 542).

,_ SJ -\ 1~
v Determination of space
available in the permanent
dentition, according to
Lundstrllm

540 Segmf!nlal division of the

S2 SS

S1
- maxillary arch
Schemauc 1llustrat1on and study
cast showing the melhod of analy-
sis for calculating the actual arch
length in the permanent denuuon
I (Saugut, 1983).
-1'7'-"'
-
In this analysis, the measure-
ment includes the hrSI permanenl
molar.

541 Segmental division of the

mandibular arch
Segmental division for the lund-
s110m analysis lo derm1ne the
'
I
I
- amount ol space required 1n the
permanent dent11100 is 1den11cal m
the upper and lower arch.

51 S6

52
-
'

542 Calculation of space

required using the segmental
Tooth 16 15 14 13 12 11 21 22 23 24 25 26 analysis of Lundstrom
Tooth width 11 7.5 8 7.5 7 8.5 9 7 7.5 7.5 7.5 11 Record mg the ind1v1dual measure-
ments lor analysis of space re-
quired in the upper arch lrom Fig.
540.
224 srocv Gast Analysis

Discrepancy Calculation
Limiting the assessment of space relationships to the
analysis of study casts is insufficient in itself. The differ-
ence between space required and the amount of space
available for alignment of the teeth is determined by two
different parameters:
I) Amount of dental crowding
2) Anteroposterior position of the incisors in relation to
the facial skeleton.
Comprehensive space analysis must therefore consist of
a combined analysis including measurements from the
cephalogram and study casts. The steps in this overall
discrepancy calculation in upper and lower arches are:
1. Determination of dental discrepancy
On the study cast are calculated: a) the difference
between the actual and ideal dental arch length (p. 220)
and b) the amount of curve of Spee separately on the left
and right side (p. 227). (To level the curve of Spee by
I mm requires I mm of arch length).
The sum of the measurements of a) and b) is known
as the dental discrepancy (DD).

543 Discrepancy calculation

Uppet tetr· The dental discrepan-
cy {DO) combines the difference
between !he actual and ideal arch
length and the degree ot dev1ahon
ol lhe curve ol Spee from tne stan-
dar<I. The lanet is determined by
the sum tOOll ol the 1ndMduat mea-
surements tor the left and right side

Upper nght. The sag1ttal d1screp·

ancy (SDI represents lhe deviahoo
1n lhe rela1toosh1ps berween !he
upper and lower 1oosal edges 10
!he N-l'og-hne (standard value 1n
lhe maJ(lllary arch +2 IO +4 mm,
standard vatue in 1he mandibular
arch -2 to +2 mm).
II the 1nc>SC>r$ are 100 far labial
wilh r~ to the Slandard value.
1n order to achieve a correct ruoal
1nd1nauoo, dental arch leng1h IS
required m a t:t relalloo
In the opposrte case. where the
1oosal edges he too lar posteriorly
~1ngual), an merease in dental arch
length IS gamed to the same de-
gree..

Below To calculate lhe total

Mandibular discrepancy calculation
discrepancy (sum total of the dis·
crepancres trom the study cast and Space available: mm
roentgenocephalometnc analy- Space required: mm DD= mm
ses) the bilateral measurement ol Curve of Spee: mm
denial dlSCrepancy (DD) and ol the
Distance from
unilateral measuramenl ot sag111al
lower Incisors mm SD= mm
d1SC1epancy (SO) must be reduced
to N-Pog:
1oacommondenomlnat0<. To cal-
culate lhe to1al dtserepancy for one Discrepancy per
arch srde the value ol the dental arch side
{020 +so) mm Total= mm
discrepancy is d1111ded by rwo and
then thlS hgure added 10 the value
ot !he sag111al discrepancy. Maxillary discrepancy calculation

The analysJs can be perlormed in Space available: mm

lhe permanent dennnon as well as Space required: mm DD= mm
in the moxed denlltion. It d11lets only Curve of Spee: mm
1n lhe drvergent calcutauon or ac- Distance from
tual and Ideal arch length. Howev· upper incisors mm $0= mm
er when caleulahng the sa911tal to N-Pog:
dlSClepancay tn adolescents, al·
tenroo mus be pard 10 the expect. Discrepancy per ( o2o+ so) : mm Total= mm
ed growth-related changes 1n posi- arch side
tion ot the N-Pog-line.
 urscrepancy 22~

2. Determination of sagittal discrepancy
The distance of the incisal edge of the central incisors to
the N-Pog-line is measured on the lateral cephalogram.
The degree to which incisor position varies from the
standard value represents the sagittal discrepancy (SD).
A forward position of the incisors signifies a need of
denial arch length. retroposition signifies an increase in
denial arch length (I mm change of incisor position in
the lateral cephalograrn = I mm arch length).
3. Determination of total discrepancy
Total discrepancy (TD) is the sum of the dental and
sagittaldiscrepancy and -since the measurement which
is for both sides of the dental arch on the study cast but
only on one side on the radiograph - is calculated as
follows:
I TD per arch side= SD + 112 DD
The amount of the total discrepancy is a significant para-
meter for deciding whether extractions are necessary.
If the discrepancy calculation is carried out in the
mixed dentition, growth-related changes in the position
of'the N-Pog-line must be taken into account, most of all
the type of mandibular rotation (p. 192).

Olscrel)ancy calculation
- 1st case example -

544 Dental discrepancy

Lett. In lhe uppe1 111ch lhe actual
srcn leng1h is 8 mm shoner ltlan
the 1<1eal arch lenglh (measured
lrom the rnesial contact poml of
lhe firs! molar 10 lhe mesiaJ ot 1he
cpposue molru).

Righi In !he lower arCh. avallable

space 1s 8 mm less man space
requued, The curve ol Spee is
excessive by 2 mm on each Side

v 545 Sagittal discrepancy

The value ol lhe d1slance ol the up·
per central 1nc1sors (- + 3 mm}
equals 1he siandrud value.
The rncJSal edge of Ille most
labrally placed lowe• central inci-
sor is 5 mm 100 far posteflO<.
Talung !he average Slandard
value (-210 +2 mm} as a baseline
for discrepancy calculahon. one
gams 5 mm 1n arch tenglh on each
side If !he 1nosal edge rs placed on
lhe N-Pog-hoe.

N·Pog
1 - 3 ITIT1
T -Smm

546 Calculatlon of total

Discrepancy calculation diSCTel)ancy
The separate measorernerus of
Upper jaw Lower jaw dental and sag111a1 dlSCfepanoes
are recorded on !he chart
Dental discrepancy Dental discrepancy
Alter calcula11ng !he lolal di$·
Space available: 59mm Space available : 50mm crepancy. laci< ot maJOllary 111ch
Space required : 67 mm Space required : 58mm space 1s clearly moll! marked than
Curve of Spee : Omm Curve of Spee : --4 mm m the mandible. as m the lowe•
Sum DD -8mm Sum DD -12mm arch !he denial discrepancy is
compensated by lhe more favor·
Sagittal discrepancy Segitlal discrepancy able 1rn1ial pos111-0n ol !he lower
.!_-N-Pog +3mm T-N-Pog -Smm 1oosors 10 !he N-Pog-tme.
SD Omm SD .
. +5mm
Total discrepancy/ Total discrepancy/
Arch side -4mm Arch side -1mm
226
Discrepancy calculation
- 2nd case example -

547 Occlusal findings

Class I rela11ons1>1p wilh m1mmal
antenoroverbrte. The anterior teeth
are ma10119ned due 10 lack of space
ano 1he upper cen11aJ 1oosors are
lab.ally inclined.
- ... - •

548 Dental discrepancy

Oclosal view of tne upper and
IOwer dental arches.
In the maxJllary arch. the actual
arch leng1h rs 7 mm tOO short.
In 1he mandible, the amoun1 of
space requ11ed Is 5 mm
The curve ol Spee shows no
marked abnomial1ty.

S49 Sagittal discrepancy

ConSldenng lhe upper hm11 ol
u
the s1andard value (maxillary arch
"4 mm, mandibular arch +2 mm),
t3 mm of arch length Is required in
the maxillary arcn m order to cor-
teciJy posauon lhe meisal edges to
me N-Pog-lme.
Mandibular sag1llal d1SCtepancy
amounts 10 -8 mm

N·Pog
1 .. 17rmi
I •10nwn

550 calculation ol total

discrepancy Discrepancy calculation
The 1ndMdual measeremeets for
dental and sag meI discrepancy are Maxillary arch Mandibular arch
shown m lh1s chart Dental discrepancy
Dental discrepancy
In oroer IO achieve ideal occlusal 65mm
Space available: 69mm Space available :
1elabonsh1ps, 16.5 mm are required
Space required : 76mm Space required : 70mm
pe< ma><1llary arch Side, and 10.S
Curve ol Spee . . Omm Curve of Spee .. Omm
mm 001 mandibular arch side.
The d•sciepancy signifies 1tia1 a Sum DD -7mm Sum DD -Smm
compromise result is only possible
Sagittal discrepancy Sagittal discrepancy
d pu1ely cnnooonnc measures are
J..-N-Pog +17 mm 1-N-Pog +10mm
pertormed. even in oomb1na11on
Wllh ex1taC110n lherapy SD -13mm SD .- -8mm
Total discrepancy/ Total discrepancy/
Arch side -16.5 mm Arch side .- -10.5 mm

Analysis in the Vertical Plane
The degree of malposition of individual teeth and
groups of teeth in the vertical plane is measured in rela-
tionship to the ocdusal plane, and is described as
follows:
Supraversion = overeruption in relation to the occlu-
sal plane
lnfraversion = insufficient eruption in relation to the
occlusal plane
The occlusal plane is a fictitious, constructed plane
verucai Helattons zz t
which does not actually exist, as the occlusal surfaces
of the teeth do not lie on one plane. Therefore, precise
measurements cannot be made and ii only serves as a
point of reference when describing vertical anomalies.
Examination in the vertical plane also involves analy-
sis of the sagittal compensating curve (curve of Spee).
This can be steep, flat, or reverse. A steep curve
of Spee is often combined· with crowding, whereas a flat
curve allows a good occlusion. Overeruption of inci-
sors in a deep bite case can be combined with a
pronounced transverse compensating curve.
551 Vertical plane - normal
incisor position
In a corr eel vertical relal•onshrpthe
mctsal edges comact lhe ocelusal
plane.
Lett: Sc:hemauc 1llusuation show-
ing the ocdusal plane and 1he tu-
beros1ty plane perpend>eular 10 IL
The ecctusal plane rs defined by
the 1angen1 which runs 1hrough ine
tips o1 the mesioooccet cusps o1
the hrsl molars and lhe buccal
cusps ol the premolars,
552 Supraversion ot the
anterior teeth
Supravers1on o1 lhe rnosors w11n
overerupbon 1n retationsn1p lo me
occlusal plane
553 Measurement of the
curve of Spee
The dep1h ol lhe curve ol Spee is
defmed as the distance lrom the
venexol 1he curvaune 10 lhesideol
a plastic template placed over Ille
lower arch. The template touel>es
anleriorty lhe 1nc:isal edges ano
oostenonv lhe diswl-mC>SI mOlar
cusps The measurement 1s earned
out separately on bolh lhe lelt and
right Sides ol the denial arch
Left. Diagram 1lluslratmg lhe mea·
soremem,
228 Study Cast Analysis

Bolton Analysis For this analysis it is postulated that the relatively

The Bolton analysis (Bolton. 1958) determines the ratio
of the mesiodistal widths of the maxillary versus the
mandibular teeth (i.e.• tooth size discrepancy). Jn the
analysis of the overatl ratio the relationship of the 12
mandibular teeth to the 12 maxillary teeth is assessed
(second and third molars are excluded). On account of
the importance for the canine relations as well as for
overbite and overjet relationships. a further analysis is
performed to evaluate the ratio between the six upper
and lower anterior teeth (anterior ratio).
smaller tooth material is the correct one. The tooth
width that is perfectly related to this size in the opposite
arch is found in the correlation table of standard values.
Only index deviations of more than rwo standard
deviations are of clinical relevance. In normal occlusal
relationships and good incisor position tooth size
discrepancies are often the cause of rotations, space
formations, crowding and incorrect intercuspaiion,
Disharmony between the width of upper and lower
teeth can be improved by: I) extractions, 2) interdental
stripping, 3) in extreme cases. by increasing the mesio-
distal tooth size.

554 Index of overatt ratio

Formula toderorm1ne !he 1n1ermax-
111aJy mes10d1S1al congruence ot
ovetall tooth w1d1hs, 1nciudmg me
first permanent molars.
If the calculated r31Jo IS greater
than 91.3 'lo. !he mandibular teeth
are too wide compared to the ma-
><Jllary teeth. II !he ra110 is reduced,
lhe maxillary teelh are relatively IOO
large.

For analysis of dental matenal the Overall ratio:

12 uppe• and 12 lower Leeth are
measured at lheu widest mes10d1s· Sum mand., (m-cl)
X100•91.3~
la! points. The melhOd 1s conhned Sum max., (m-d) +0.26
to the permanont dennnon
6
The mam cause ot 1001h Wldth d•s·
crepancy 1s a 11gh1-leh asymmetry
ol meSIOd1SUll tooth size.

555 Index of anterior ratio

Formulatodeterm1nethe1mermax-
tllary tooth w1dlh congruen<:e m
the aruenor region. If the 111110 is
greater tllan n.2% the total wtdth
of 1helower S1Xantenor leelh rs reia-
nvely too large. II the mdex value rs
reduced, the discrepancy rs due to
an excess 1n 1118Xlllary looth mate-
nat,
The relevance ol the an1enor in-
dex value is greally reduced in 1he
follOW1ng SltU8ll0!1S Anterior ratio:
- severe labfoversion of lower mer·
Sum mend, (m·d)
X100=n.2~
- abnormally large 1ab1ol1ngual Sum ma.. (m-cl) +0.22
diameter ol lhe tncrsal edges.

1 1

' J.
Excessive Meslodistal Tooth Material
In the maxillary arch
• increased overbite
• increased overjet
• crowding in the maxillary arch
• spacing in the mandibular arch
• linguoversion of upper incisors
• labioverslon of lower
Incisors
Botton Analysis
in the mandibular arch
• reduced overbite
• reduced overjet
• crowding in the mandibular arch
• spacing in the maxillary arch
• labioversion of upper incisors
• linguoversion of lower
incisors
229
Discrepancy in the anterior
ratio
- case example -
556 Anterior view cl the study
casts
Maxillary aoc mana1ou1ar antenor
arches w11h light contacts. in rhe
lower dental arch mild 1nc1sor
crowding and m1dllne deviahon to
the nghl
The overall rauo is 91.9%. the
anterror ra110 rs 82%: i.e. me 1oom
size discrepancy tS localized 1n the
anterror region The summed width
ot rhe sox mand1t>utar1ee1h is 2.4
mm retauvely enlarged
557 Occlusal relationships
B1la1eral neu1roclusoon ol nrst per-
rnanern molars wrlh slight d1Slodu·
soon 1n lhe canrne regron
In add111on lo malahgnment ol
lower an10110< teeth, lhe anleno.
IOOlh size discrepancy prevenis
coned 1n1ercuspauon ol me ca-
nines
558 lntermaxillary tooth size
diSCTepancy and malalignment
ol teeth
A dlSJ)roponion between upper
and lower tooth size has ce11a1n
effects on 1001h pos111on and occlu-
sion !'he deviation depends on the
tocabzanon of the excesswe loom
mateual: maxillary 0< mand1bu1ar
arch
5~0 Disproportionate
1nterma}l:illary tooth size as
a result of morphologic
anomalies
Hypoplast1c upper lateral 1nctS01S
which maikedty affect lhe ratio be·
tween upper and lower toorh width.
In these extreme cases a deosron
must be made pnor lo l!ealment as
to whether the dosproporuon can
be co-rectec by mlerprox1mal ena-
mel stnppmg ollheopposmgteeth
0< whether !tie d1setepancyneeds
to be corrected by 1estora11onolthe
hypoplasl1c teeth.
230 Study Cast Analysis
56-0 Ideal relationship of
maxillary and mandibular tooth Overall retio
widths according lo Bolton
Ta Ole of average valul!$ lor the mand12
max12 mandt2 max12 mand12 max12
(Mlrall and anlenm rano tl1guresrn
mm) 85 77 6 94 85.8 103 94.0
86 78.5 95 86.7 104 95.0
Mer caieuranon of tne BOiton ratio. 105 959
87 79.4 96 87.6
the arch with Ille relaJ1voly smaller
:oath matenal is determined and 88 80.3 97 88.6 106 96.8
the actual bgure CO< responding to 89 81.3 98 89.5 107 97.8
ltle arch tooltl StZe located in the 90 82.1 99 90.4 108 98.6
table The •deal value tor the size ol 91 83.1 100 91.3 109 99.5
the opposing teetn IS read olf from 100.4
92 84.0 101 922 110
the aecompanymg COiumn
The d1Herence between the ac- 93 84.9 103 93.1
tual value and 1he ideal value tac·
cording 10 the tat>le) tor the relative-
Anterior ratio
ly c-nlarged tooth matenal repre-
sems 1n mm the amount ol excess
looltl size in lhts ard>. maxs mands maxs mand6 maxs mands

40.0 30.9 45.5 35.1 50.5 39.0

40.5 31.3 46.0 35.5 51.0 39.4
41.0 31.7 46.5 35.9 51.5 39.8
41.5 32.0 47.0 36.3 52.0 40.1
42.0 32.4 47.5 36.7 52.5 40.5
42.5 32.8 48.0 37, 53.0 40.9
43.0 33.2 48.5 37.4 53.5 41.3
43.5 33.6 49.0 37 8 54.0 41.7
44.0 34.0 49.5 38.2 54 5 42.1
44.5 34.4 50.0 38.6 550 42.5
45.0 34.7

561 Evaluatlon chart for the

Bolton analysis
Mesiodistal tooth sizes:

R
I L

Sum mand12 mm
Overall ratio: x 100=
Sum max12 mm

Summands mm
Anterior ratio: x 100=
Sum max5 mm

Overall ratio > 91 .3 'lb Overall ratio < 91.3 'lb

----'m~m mm = _ _:.m:.::m"-' mm ____ m""'"m__ _:.m;:.m:.::.

Actual mand12 Ideal mand12 DiH. Actual max12 Ideal max 12 Diff.

Anterior ratio> 77.2% Anterior ratio < 77.2 Ofo

mm ____m-"-"-m = _ _,m;:.m::.; mm mm __ __:mc:..::.:.:m

--- Ideal mand6 Diff. Actual max5 Ideal max5 Dill
Actual mands
Analysis of the Apical Base, According to Rees
The relation between the overall extent of the apical
base and the length of the dental arch is expressed metri-
cally for the upper and lower jaws, The analysis is
carried out as follows:
I) Erasing of the lip and cheek frena on the casts.
2) Construction of three perpendiculars to the occlusal
plane (mesial to the first permanent molars and at the
contact point of the central incisors). These lines are
extended by 8-10 mm from the dental papilla toward
the vestibular fold.
3) Measuring the distance from the rnesial of the first
permanent molar on one side to that on the other side
through the tips of the vertical lines with the aid of a
piece of thin adhesive tape.
4) Determining dental arch length by measuring the
arch perimeter mesial to the first permanent molars
using a piece of brass wire.
The individual values are compared to one another
within the same arch and to the opposing arch (Fig.
564) and the calculated figures compared to the stan-
dards according to Rees (1953).This method is confined
to the permanent dentition.
A.ssessing the slze of the apical
base

562 Marlting the reference

points
Leh The IRC1sal relerence l)()lnJ 1s
marked on avert1cat llnewhlChex·
8mm lends lrom the oc:clusal plane
through me contact oovu ol 11\e
cen1ral incisors towardthe vest•bu·
lar lold. 8 mm lrom lhe gmg1val
margin
8mm
Righi Usmg the same ct11ena the
molar porru is marked Oilatetally
lhrough the rnesiat contact l)Olnt of
!he l11st molar.8 mm lromllleg•ng•·
val margin on the alveolarprocess.
563 Measuring the apical
base
Measuremenl ol Jhe apical Dase IS
earned out using a lh1n adhesive
tape, extending from !he d•Slal re-
tereoce point on one side 11\rough
lhe 1nc1sal reference POIRI lO lhe
distal ma.king on lhe Olhersl<le
• The adnes1ve tape is tnenremovec
horn lhe Sludy casa and its lenglh
measured

564 Ideal relations according

Measurement Ideal values (Rees)
Maxillary apical base Maxillary dental arch: +1.5
Mandibular apical base Mandibular dental arch. +20
Maxillary apical base Mandibular apical base +3.0
to Ress
For these measurements Ille se-
cond parameterIs sub1racted from
the lirSI. The arrangemen1ol com-
parosonsIS made in such a way 1ha1
1n !he no<mal case lhe f•rSI measu-
rement is larger lhan tile second.
+ 5.0mm
In bOrderllne cases the analJ'Sls
+ 7.0 mm prov•des 1ntormaJJonto' trea.tmenJ
planning 1m part•cularextrai;iiooor
+ 9.5 mm nooe)'tract1on1

Maxillary dental arch Mandibular dental arch· + 5.0 +10.0 mm

232 Study Cast_A_n--'a'--'ly'-'s--'is'---------------
Examination of Occlusion

This three-dimensional analysis estimates the inter- Anteroposterior Malocclusions

maxillary relationship between the upper and lower - Anterior:increased overjet, negative overjet
dental arches in habitual occlusion. - Posterior:distoclusion, mesioclusion

Transverse Malocclusions Vertical Malocclusions

- Anterior: Anterior cross-bite. skeletal mandibular
midline shift (displacement of the entire mandible in
relation to the facial midsagittal plane)
- Posterior: posterior cross-bite (uni-, bilateral), non-
occlusion (buccal, lingual)
Unsupported overbite, deep bile (dentallylgingivally
supported), open bile (anterior, lateral, complex).
When examining the occlusion, a distinction has to be
made between the occlusal relations and the maxillo-

565 Measuring the overjel

Determination ol lhe overiet with
a graduated ruler. (for Clallly. the
ruler markings are v1s1ble)

R gnr· Tne ove~el rs dehned as the

dlSlance between the labial sur-
lace of the lower central incisor and
lhe upper 1ncisal edge. The mea-
surement ts performed parallel lo
the occiusal plane.

Reconstructlon of occlusal
r&lationships

566 Class I maloeclusion

Lelt: Oistoclusoon Of the lirst molais
by ane oremolar width In the pres-
ence of a normal iaw rela1Jonsh1p.
The dlSIOCluSIOfl has occurred on
accounl al mesial m1grahonol the
upper hrst molar with loss ol space
tor the second premolar

Rtg/11" M8Slociusion ol the hrst

molars by 3, premolar width. Re-
construct1onOI the mesial d11h ot
Ille tower molar reveals a Class I
iaw retallonst11p.

567 Class II and Class Ill

malocclusions
ten. Neuirocluslon Of the firs!
molars m a Class Ill malrelahon-
srup ol lhe 1aw bases by 1 '1 premo-
lar width 1esu1ung l1om rnesiat dnh
ol upper firsi molar.

Righi MesiocluSIOn ot first molars

by one premolar width 1n lhe pres-
ence ot a Class II Jaw 1elat1onSh1p.
Tne discrepancy between the oc-
ciusal relationship and the dental
base relauonsh1p results lrom me·
sial m1gra11on of the lower first
molar w11h space loss for the se-
cond premolar (Eschler et al, 1971)

mandibular jaw relationships. This difference is particu-
larly important for sagittal analysis of intermaxillary
relations as there is a clear distinction between the
occlusal rnalrelationships and the anteroposterior jaw
maJrelationships. lntermaxillary skeletal discrepancies
can only be assessed directly from the occlusal relations
if no tooth migration has occurred. This finding can be
ascertained by intramaxillary symmetry measure-
ments. If teeth have been displaced in mesial or, less
often. in distal direction as a result of tooth drift,
• oonstruCled occlusal relatJoosh1ps,
I represents the degree of overbne.
exarmnanon or occiusron ;i!;;s;;s
then the amount of these dental shifts have to be evaluat-
ed first ("reconstruction of the occlusion," according to
Grunberg, "thinking back," according to Schwarz).
Taking the dental malpositions into account the thus
reconstructed occlusal relationships reveal the true
anteroposterior skeletal discrepancy ofjaw relations.
The anterior overbite is regarded as excessive if it
measures more than 2-3 mm. A nondentally or non·
gingivally supported overbite in the presence of a posi-
tive overjet signifies an orofacial dysfunction.
Reconstruction of occlusion
- Case example -
568 Mesial migration ln the
maxillary and mandibular arch
Left: Mes1al position or the uppet
nght posterior teeth by about 1 mm.
and about 2.6 mm on the leh side
Righi Mesia! drift of the lower
postenor teeth as a result prema-
ture loss of deciduous teeth m Ille
supporong zones: on lhe right
sde about 5 mm, on lhe leh &de
aboot 6 mm.
569 OcclusaJ relations versus
anteroposteriorjaw relation·
ships
B11a1eral neuuoclUS>on ol f1rs1
molars. Aher analyzing the degree
of mooal m1grat1on. which has
been more extensive 1n the man-
dibular than 1118JOtlary arch. the re-
reveal a skeletal Class II matocdu-
StOll
570 Oetermi.nation of overt>ite
The upper 1nc1sal edge is proiecled
withe l)eflCll mark on lhe labial sur·
lace of lhe rowei cenuaJ 1nctSO<
parallel lo the occfusal plane
Left. The distance between thlS
mark and the lower 1nc1Sal edge
In an open bile case, the vertlCal
d1s1anoe between the 1nasal edges
1s measured.
234 Study Cast Analysis _

Study Cast Analysis - Record Sheet

Three-dimensional analysis of the dentition.

S I (Sum of incisors) Upper arch Lower arch mm

Transverse Sag1ttaJ Vertical

I
I Antenor area: Anterior area: Suprapositlon!OvereruptJon
Denial rmdhne shift:
Diastema:
mm nghVleft
mm Lu
I I
Actual Standard I Dill. .
lnd1v1dual tooth:

Posterior region: Posterior area:

Groups of teem:
Actual Standard Dill. Supporting zones:
li]: MPR Actual Standard Diff.
~:MPR /nfraposillon/Submergence
right
x ~:~ tell
~"' .l§J: MPR Individual tooth.
Space required: mm
g§j: MPR
Space available: mm
.l§J: Lg§ Groups of teeth:
Difference: mm

Compensating curve: Compensating curve:

right lefl right left Palate height 616:

Anterior area: Antenor area: Suprapos11Jon!Overerupt1on

Dental rmoune shitt:

D1astema:
mm nghVleft
mm Lu
I Actual !Standard I Dill
Individual tooth:

Posterior area: Posterior area:

Groups or teeth:
Actual Standard Ditf. Supporting zones:
44 I: MPR Actual Standard Dill.
~:MPR right
~:~
§_]: MPR
left I lnfravers1on!Submergence
Space required: mm
~:MPR
Space available: mm
ill :l]§
Difference: mm
Individual tooth:

Compensaling curve: Cornpensatmq curve: Groups of teeth:

nghl fell right left

Overiet mm Overbee mm

Cross-oite Occlusion
Open bile mm
Nonocclusion

buccal hnguaf
~I ~ 83 anterior/lateral righVlefl

Deep bile:
~ 6 ~ 3 supported/unsupported
/
Midhne shift: mm righVlelt Jaw relanonsrup: dentally gmgivally

• For Rees and Bolioo measurements. special evaJuahon sheeis are used.

Treatment Plan
The individual findings are compiled to form the
comprehensive diagnostic assessment. This compre-
hensive diagnosis describes those features of the mal-
occlusion which must be considered when planning
treatment. These include abnormalities of the maxilla,
mandible. and the occlusion. as well as the functional
and craniofacial relationships.
Finally, a detailed treatment plan is prepared, subdi-
vided into chronological treatment stages. For each
Treatment Planning 235
stage the necessary treatment measures and appliances
are recorded. Such a plan serves as a guide for therapy
which may extend over a 3- to 4-year period. At the end
of the individual treatment stages, the plan - depending
on the intermediate results - may have to be confirmed
or changed. At the end of treatment, a critical appraisal
is made in order lo compare the result of treatment with
the original goals. From p. 238 onward three examples
can be found which illustrate such planning.

571 Chart of orthodontic

treatment pfan
Comprehensive diagnostic assessment: Aller lhe diagnosis ot the 011era11
problem, the 1nd1V1dual treatment
stages are listed chronolog1cally
together wllh any planned tootn ex·
tracnoos and onnodoone or deoto-
tac1al O<tlloped'c apploarn:es

Undet 1he heading ·cnanges~

Maxilla: Mandible: possible alterations lrom rne
above-men11oned lrearment plan
should be recorded since !hey may
be necessary, depending on reac-
lion lo treatment especially w1111
resoect to the 1ntermedoate results.
Occlusion:
Undet theheadong "prognosrieas·
sessmen1. •favorableand unfa<'OI·
able iaetors concerning 1he
planned treatmenl are descnbed

The section "final cr11tcal assess-

meni· includes a companson ol
Treatment plan in stages: Iha intended treatment fa< lhe case
on quesllon and olher lherapeut1c
Treatment stages: Extractions: Treatment measures: poss1bd1bes.

Changes:

Prognostic assessment

Flnal critical assessment

238 Examples of Treatment Planning

Treatment Planning Case Example 1

I 71/2-year-old girl with anterior open bite ..
in conjunction with maxillary prognathism
and bin1axillary dental protrusion.
~.;._~~~~~~~__J

History Infant feeding: Breast: 2 months, bottle till 6 months

Postnatal development: First teeth: 6 months. firsi steps: 11 months,

talking: started 13 months

Orofacial dysfunctions: Pacifier up to the age of 4 years, thumb-sucking up

to 6 years, also during day-time

Illnesses: Coughs and colds

Etiology of malocclusion Orofacial dysfunctions (tongue-thrusting, lip-sucking}

General examination Extraoral examination: Shape of skull: Broad

Shape of face: Broad

Lips: Everted

Nasal profile: Reduced nasolabial angle

572

17 15 14 13 23 24 25 27 X-
Dental status X- rav
rav
Absence of 16 55 54 53 12 11 21 122 63 64 65 26
third molars L
R
46 85 84183 42 41 31 32 73 74 75 36

47 45 44 43 33 34 35 37 X-
X- ray
ray
t Tooth not to be matntajned " Tooth elC:lr4C1.ed m Tooth maltormatlon
c Tooth carious
a Nonvltal 1ooth f Large A!Storadon s Weat tacet&

Examination of the oral cavity

Frenum attachments: deep insertion in the upper arch

Gingiva: normal, no inflammation
Periodontal disease: none
Oral mucosa: normal
Palate: average height
Apical base: maxillary arch - large sagittally, normal transversally.
mandibular arch - normal
Case Example 1 - D1agnos1s 239
573

Frontal and profile

facial photographs

574

Occlusal relationships

575

The dental arches

576

Panoramic radiograpb
240 Examples of Treatment Planning
577
AS. 0 SNA 88"
Original cephalogram 7..5 years SNB 82"
ANB 6"'
SN-Pog 82"
Cephalornetric tracing 69,6%
6Jmm
11 as- ( ~-r:=:;::..;::..::..:-=--=---...,..-1

144'

1 4- 6rnm

Results of the Prognathic facial type with horizontal growth tendency.

cephalometric analysis Skeletal Class II relationship with skeletal imbalance the of maxilla. Bimaxillary
dental protrusion of incisors and dentoalveolar open bite.

Craniofadal skeleton: Sagittal: prognatic,

small seUa angle,
low position of glenoid fossa,
Vertical: horizontal growth pattern and decreased
sum of posterior angles.

Maxilla: Prognathic with anteinclination,

short base.

Mandible: Prognathic, short base,

wide symphysis,
sagirtal discrepancy 6 mm.

Incisors: Labial tipping and anteposition to N-Pog-line

of upper and lower incisors.

Lip profile: Lips everted and protrusive to the esthetic line.

Profile analysis

Backward-slanting anteface.
Enlarged lip step
 L..ase cxarnpie 1 - u1agnus1s ~'+1

578
Analysis of study casts

Upper arch: Lower arch:

- Asymmetric narrow - Asymmetric narrow

arch arch
- Spacing of the - Midline shift of2 mm
anterior teeeth to the right
- Midline diastema - Supporting zones intact
- Upper right central - Infraversion of incisors
incisor tipped distally - Supraversion (over-
- Supporting zones intact eruption) of posterior
- lnfraversion of incisors teeth

Ocdusion: Ocdusal relationships:

Anterior open bite: 4 mm - first molar region - Canine region

Overjet: 4 mm left: 1 premolar left: '14 premolar
width distal width distal
Anteroposterior jaw
relationship: distal. right: '12 premolar right: Class J
Occlusal interference at the upper width distal relationship
right deciduous canine.
bilateral Class n relationship, more pronounced
on the left than on the right side;
abrasion of deciduous canines

579 580

-- - '

581 582
242 Examples of Treatment Planning
583
trontal lateral
Occi
A
Functional analysis •l
I
Occlusal position: forward I
l
Postural rest position: posterior I
I
I
I I
Mandibular sliding I I
movement: 2 mm anteriorly I
I
I
I
Temporomandibular joint: amount of maximal inter- I
I I
I
incisal opening: 5 cm, x. 0.
ng '
path of opening et opening
C-shaped to the right Patti of closure--
-----
Orcfacial dysfunctions Swallowing pattern: visceral, with contraction
of the perioral muscles
Tongue dysfunctions: tongue-thrusting with forward
posture of tongue
Lip dysfunctions: lip-sucking with tongue-lip
contact
Speech defects: interdental lisping,
peripheral disturbance of sound
formation
Breathing: nasal-breathing

Comprehensive diagnosis Morphology: Prognathic facial type with anterior open bite,
arueinclinarion of the maxilla,
and horizontal growth tendency.

Function: Tongue and lip dysfunctions,

visceral swallowing pattern.

Treatment plan in stages

Req11iren1e111S Appliances

Elimination of Oral screen with

/. Stage
orofacial dysfunctions tongue crib

Correction of maxillary Bracketing and banding

2. Stage
incisor position of max illary incisors
and upper first molars

Correction of antero- Activator, combined

3. Stag«
posterior jae discrepancy. with headgear
retraction of anterior teeth.
Guidance of tooth eruption
including retention
Course of Treatment

First stage. 12 months; second stage, 6 months; third Duration

stage (retention) until full eruption of permanent
dentition.

Myofunctional therapy may be indicated if

compensatory tongue-thrust persists following
correction of open bite.

584

Treatment was carried Details on treatment

out according to the mechanics will be
original treatment plan. discussed in the second
/ 1 volume "Orthodontic
' Treatment".

585

Panoramic radiograph
at the end of
treatment

se• 586
A. s. Q 69.2'!1. SNA
SNB 82"
12 5 v•a;~9' _ _ _6f!.S_"'.!!' ANB 4•
SN·Pog 82" Treatment finished
30~ at 12 years of age
after the retention period.

N·Pog
! ..- 7,5 mm
T -1-4,0mm
244 Examples of Treatment Planning

Treatment Planning Case Example 2

U-year-old girl with mesioclusion.
Bilateral cross-bite, slight anterior open bite, and crowding in upper arch.

History Infant feeding: Breast: LS months, bottle: 12 months,

spoon: started 6 months

Postnatal development: First tooth: 8 months, first steps: 11 months,

talking: started 12 months

Orofacial dysfunctions: Pacifier till 2nd year, nail-biting still continues:

sleeps with open mouth

Illnesses: Coughs and colds, hyperplasia of adenoids

and tonsils

Etiology of malocclusion Heredity (craniofacial morphology, hyperplasia of tonsils)

Orofacial dysfunctions (tongue-thrusting, oronasal breathing)

General examination Extraoral examination: Shape of skull: Narrow

Shape of face: Narrow, oval
Lips: Dry and narrow upper lip, competent
lip morphology, negative lip step
Chin: Well developed
587

Dental status 28 X-
X-
ray ray
Hypoplasia of occlusal
17 16 15 14 13 12 11 21 22 23 24 25 26 27
surfaces of upper first
permanent molars R L
47 46 45 44 43 42 41 31 32 33 34 35 36 37
I I

48 38 X-
X-
ray ray
c Tooth carious z Tooth not to be malnta_lned x Tooth extracted m Tooth mattormauon
a Nonvital tooth t Lilrge re$10ralion s Wear facebi

Examination of the oral cavity

Frenum attachments: weak in both arches

Gingiva: hyperplastic in upper anterior region
Periodontal disease: none
Oral mucosa: normal
Palate: high
Apical base: maxillary arch - large
mandibular arch - small
Case Example 2 - LJ1agnos1s 245
588

Frontal and profile

facial photographs

589

Occlusal relationships

590

The dental arches

591

Panoramic radiograph
246 Examples of Treatment Planning
S92
HS SNA rrs:
12 years SNB 76"
Original cephalogram ANS 1.5"
SN·Pog 76"
58,7%
Cephalometric tracing 64mm

'"44• 130!!74-:--~~,-7~
135"
--1~--'--IC::::~~~
HI"
ss-
139"
84'

N-Pog
1 -+ 6 ITWTl
1 2.5 mm

Results of the Retrognathic facial type with extreme vertical growth pattern.
cephalometric analysis Class lll tendency. partly compensated by posterior position of the glenoid fossa
and backward rotation of the mandible.

Cranicfacial skeleton Sagittal: retrognathic,

large seUa angle,
posterior position of glenoid fossa.
Vertical: vertical growth tendency with
increased sum of posterior angles
and lower genial angle.

Maxilla: Rerrognathic, anteinclination, normal base length.

Mandible: Normal arch form with lower incisors tipped

lingually, sagittal discrepancy I mm,
total discrepancy 3 mm.

Incisors: Linguoversion of lower incisors,

maxillary incisors labial to N-Pog-line with
normal axial inclination.

Lip profile: Upper and lower lips retrusive, behind the

esthetic line; large nasolabial angle.

Profile analysis

Average (- biometric) face.

Predominance of lower face height
 case example~ - uiaqnosis "L.4/
Analysis of study casts 593

Upper arch: Lower arch:

- Anterior crowding - Rotation and bucco-
- Asymmetric narro\v version of lower canines
arch - Rotation and expanded
- Buccoversion of width of premolars
.
upper canines
- Arch length deficiency
-b - Adequate arch length
- Overerupiion of
- Midline shift of2 mm incisors
to the right - I nfraversion
- lnfraversion of of posterior teeth
anterior teeth
- High palate

Ocdusion: Ocdusal relationships:

Bilateral cross-bite - Isl molar region - canine region

Cross-bite of upper lateral incisors and left: Y2 premolar left: Y2 premolar
lower canines width distal width distal
Overjet: 4 mm right: Y2 premolar right: 1/~ premolar
Anteroposterior jaw relationship: mesial width distal width distal
Open bite: I mm Mesial migration of upper posterior teeth.
Occlusal interference at lower Reconstruction of dental shills reveal
second molars a Class Ill relationship
Working side on the right
594 595

596 597
248 Examples of Treatment Planning
598
trontal JatetaJ
I
I oect
Functional analysis
Occlusion position:
Postural rest position:
forward
posterior
I

I ·-
I
I
I
R

I
Temporornandibular joint: amount of maximal I I
I
interincisal opening: I
I
5.3 cm '' I
I
muscle palpation: ' I
I
pain on pressure left and right left post! anL mait.0
right lateral ptyerygoid Path of opening --
muscles Path of closure - - - -
Occlusal interferences: at lower second molars

Orofacialdysfunctions Swallowing pattern: complex tongue-thrust swallow

Tongue dysfunction: thrusting. large tongue, postured anteriorly
Speech defects: interdental lisping
Breathing: mouth-breathing

Comprehensivediagnosis Morphology: Bilateral cross-bite, mesioclusion, retrognathic

facial type, vertical growth tendency.

Function: Orofacial dysfunctions, mouth breathing, abnormal

tongue function, nail-biting.

Treatment plan in stages

Requirements Appliances

I. Stage Correction of Rapid maxillary

bilateral cross-bite expansion appliance

2. Stage: Extraction of all four Full ftxed appliances in

first premolars and upper and lower arch,
alignment of dental arches high-pull headgear

3. Stage: Retention Removable retainers

 ~ase example L - 1 reatment 249
Course of treatment

Active treatment 2 years; long-term retention until 16 years of age. Duration

Following rapid maxillary expansion, a reevaluation of the case is indicated; Changes

should this reveal presence of the upper right third molar, the extraction of
first molars can be considered.

599

Treatment was Details on treatment

carried out according mechanics will be
to the original discussed in the second
treatment plan. volume "Orthodontic
Treat rnenr".

600

H. $. q 601
SNA 17' ANB o.s•
16 years SNS 76,s• SN·Pog 71'
61% End of treatment at
age 16 after the
retention period.

1 t 1 mm
zeu examples or 1 reatment l-'Jann1ng

Treatment Planning Case Example 3

25-year-old female patieni with anterior open bile, distoclusion, and cro\vding in the upper and lower arch

Treating an adult patient. certain age-related problems must be taken into account,

These are: - Periodontal condition, which must be especially examined and if necessary improved prior to adult
orthodontic treatment.
- Decreased bone elasticity, remodeling potential and reduced turnover rate.
- Treatment without damaging the related tissues.
- Absence of growth; therapy cannot effect skeletal changes.
Treatment is restricted to the dentoalveolar base.

History 7-year history of thumb-sucking; orthodontic treatment with active removable

appliances from the age of 9 to U years.
Treatment included extraction of lower right central incisor, After eruption of all
permanent teeth, the molars were "adjusted" by grinding (the patient was treated
at a different place).
Etiology of malocclusion Heredity: vertical configuration of the craniofacial skeleton, primary crowding
Orofacial
dysfunctions: long-standing digit-sucking habit, compensatory tongue dysfunction
General examination Extraoral Shape of skull: narrow
Examination: Shape of face: narrow, oval, long
Lips: narrow upper lip, lower lip everted and tense,
deep rnentolabial sulcus
Chin: fiat, receding
602

Dental status X-
rav
I I I I x-
ray
Deep restorations 18 17 16 15 14 13 12 1 1 21 22, 23 24 25 26 27 28
in the molars f I f I I f
R L
48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38
I f x f I I

I
X-
ray
c Tooth carious z Toothnot lo be rnalnl.llned x Toothextnictcd
I X-
ray
m Tooth maJformation
a NonvwtaJ tooth t large rutoratlon s Wearlace&s

Examination of the Frenum attachments: narrow in both arches

oral cavity
Gingiva: hyperplastic in upper and lower anterior region

Periodontal disease: Hygiene-index 50%

Papilla-bleeding-index 2.8 in upper arch,
3.1 in lower arch.
Pocket formation in the lower arch and upper
molar region
Sub- and supragingival calculus
Tooth mobility 0 in upper arch, 2 in lower arch
Pocket depth 4 mm in upper arch approximately,
4 mm in lower arch approximately.
Gase cxarnpie .j - uraqnosrs ze 1
6D3

Frontal and profile

facial photographs

6D4

Occlusal relationships

6D5

The dental arches

6D6

Panoramic radiograph
252 Examples of Treatment Planning
607
G.• 9. SNA 79,0-
26 years SNB 68.S'
Original cephalogram ANB 10.S'
SN-Pog 67,0'

Cephalometric tracing

I
I

~lr-~·~b,;,~~=l:,:~
39'
127°

N-Pog
1 +23mm
1 + 13 mm

Results of the Retrognathic facial type with extreme vertical configuration and extreme
cephalometric analysis mandibular retrognathism.

Craniofacia/ skeleton: Sagittal: retrognathic,

acute sella angle,
very large articular angle.
Vertical: vertical growth pattern with normal
genial angle, but very large lower gonial
angle.

Maxilla: Slight rerrognathism, slight retroinclination,

normal base length.

Mandible: Retrognathic, short base, normal symphysis, short

ramus, increased antegonial notching.

Incisors: Anteposition in both arches,

linguoversion of upper incisors and labial tipping
of lower incisors.
Mandibular sagirtal discrepancy of ll mm.

Lip profile: Upper and lower lips everted and protrusive

to the esthetic line.

Profile analysis

Backward-slanting anteface.
Excessive lower face height
 Case Example 3 - Diagnosis 253
Analysis of study casts 608

Upper arch: Lower arch:

- Asymmetric nar'rOw - Arch anteriorly

arch flattened, and widened
- Midli:neline shift of posteriorly
2 mm to the left - Anterior crowding
- Anterior crowding - Mesial migration of
- Buccoversion of posterior teeth
tooth 13 - Mesia! tipping of 1001h
- Linguoversion of 31 and tooth 32
tooth 14 - Tooth 41 extracted

Ocdusion: Ocdusal relationships:

Bilateral distoclusion with - first molar region: - Canine region:

anterior open bite from upper right first left: I premolar left 1ti premolar
premolar to upper left second premolar. width distal width distal
Overjei: 8 mm.
Occlusal interference at lower right second right: '14 premolar right: Class I
premolar and lower left third molar. width distal relationship

Mesia! migration of upper and lower

posterior teeth

609 610

611 612
254 Examples of Treatment Planning
613
lronlAI lateral
Occl
R
Functional analysis Mandibular path from postural rest position to
I
habitual occlusion with anterior sliding component I
I
I
I
Temporo- amount of maximal interincisal I

mandibular opening: 4.5 mm;

I
,
joint: muscle palpation: pain on pressure of ••
both lateral pterygoid muscles, rig
• ant. max.0
S-shaped opening movement,
Path of opentno
intermediate clicking of left joint. Path of ck>sure ---
Orofacial dysfunctions Swallowing pattern: visceral, with contraction
of perioral musculature
Tongue dysfunctions: tongue-thrusting and
forward posture
Lip dysfunctions: incompetent lips,
lower lip-sucking,
tongue-lip contact
•

Comprehensive diagnosis: Morphology: Skeletal anterior open bite, crowding,

mandibular retrusion, increased overjet,

Function: Orofacial dysfunctions, abnormal tongue and lip

function, symptoms of temporomandibular joint
dysfunction.

Treatment plan in stages

Requirements Appliances

1. Stage Extraction of upper Iirst Full fixed appliances in the upper

premolars and lower arch.
Levelling and alignment Insertion of flexible arch wires
of the arches

2. Stage Correction of open bite Insertion of heavy arch wires, use

of intermaxillary elastics

3. Stage Retention Positioner,

removable retainers, possibly
permanent retention in mandibular
dental arch

4. Stage Improving facial profile Genioplasry

 Case Example 3 - Treatment 255
Course of Treatment 614

Alignment and space

First treatment stage closure in the upper arch
using highly flexible,
Duration 11 months so-called exotic arch
wires.

615

The open bite is

corrected, using heavy
Second treatment stage archwires and short
intermaxillary elastics.
Duration 7 months Note:Labial stripping of
lower anterior teeth.

616

Retention stage.
Retention with a
Third treatment stage positioner, and following
genioplasty continued
Retention stage with removable retainers.
Periodontal care, with
possible gingival grafts.

617

Intraoral photographs
at the end of the third
treatment stage
256 Examples of Treatment Planning
618

Panoramic radiograph at
the end of the active
rreatment stage prior to
extraction of the lower
left third molar

619

Lateral cephalograms at
the end of active
treatment and after
genioplasty.

620

Frontal and profile

facial photographs after
genioplasry