Assessment of the skeletal pattern and its relevance in treatment planning

Knowing how to see Leonardo da Vinci

We only treat what we are educated to see. The more we see, the better the treatment we render our patients Arnett and Bergman AJODO 1993

Terms of reference
Frankfort plane Zero meridian True vertical (plumb line) Mandibular plane Maxillary plane Horizontal(Transverse) 1/5ths Vertical 1/3rds Midline(s) Dentoalveolar compensation

Frankfort Plane

Skeletal Class I, II or III?

Zero Meridian

True Vertical

Maxillary and Mandibular Planes

Maxillary plane
ANS PNS

Mandibular plane
Me Go
Constructed Gonion Go Lower border

Horizontal 1/5ths
Rule of 1/5ths Divided into equal fifths Each the width of an eye Alar base = intercanthal Mouth = medial iris margins

Vertical 1/3rds
Equal thirds
Trichion to glabella Glabella to subnasale Subnasale to s.t. Menton

Lower third
Subnasale to stomion 1/3rd Stomion to s.t. Menton 3/2rds

Midline
Facial midline
Philtrum, glabella

Maxillary dental midline Mandibular dental midline Relation to each other Displacement
A functional movement ICP to RCP

Deviation
A dynamic movement

Dentoalveolar compensation
A mechanism where the position of the teeth has altered in an attempt to maintain a normal inter-arch relationship

Dentoalveolar compensation for skeletal Class II

Soft tissues have caused proclination of the lower incisors

Aetiology
95% Complex interaction
Genetic Environmental influence

5% Specific cause
In-utero disturbances Syndromes Trauma Growth disturbances

Importance
Greater genetic component: worse prognosis Mode of treatment
Interceptive Camouflage Orthognathic

Skeletal pattern
Antero-Posterior Vertical Transverse

Clinical assessment Radiographic assessment

1. 2. 3. 4. 5. 6. 7. 8. 9.

Nasomaxillary complex Maxillary alveolus Maxillary incisors Mandibular incisors Mandibular alveolus Ramus Body Symphysis Spheno-ethmoidal synchondrosis 10. Anterior cranial base 11. Spheno-occipital synchondrosis 12. Posterior cranial base

Cranial base angle

CLINICAL ASSESSMENT

Clinical assessment: How

Sat upright in chair
Why? Class I, II or III Natural Head Position(NHP)
Standard reproducible( 2) head orientation Relaxed Looking at distant object or own eyes in mirror Individual variation Frankfort plane may not be horizontal

Asymmetry; from above

Clinical assessment: ANTERO-POSTERIOR

Soft tissue point A: Soft tissue point B Kettles method Soft tissue pogonion to zero-meridian Profile convexity

Sat upright in chair Natural Head Position Frankfort plane horizontal

Soft tissue point A: soft tissue point B

Class I; 2-3mm Class II; Mandible retrusive to maxilla Class III; Mandible protrusive to maxilla

A B

Kettles Method

Zero Meridian

Profile contour
Straight Convex
II
Max excess Mand def combination

Upper facial plane; Glabella to Subnasale Lower facial plane; Subnasale to Pogonion

Concave
III
Max def Mand excess combination

Clinical assessment: VERTICAL

FMPA Vertical 1/3rds
LAFH

Clinical assessment: Transverse

Vertical 1/3rds Horizontal 1/5ths Ask pt to bite on a spatula

Crossbites
Displacement? Skeletal versus dental? Age?

RADIOGRAPHIC ASSESSMENT

Indications for radiographs

BOS Guidelines

Radiographic assessment: Antero-posterior

ANB Eastman correction Wits analysis Ballard conversion

ANB
Class I Class II Class III ANB 2-4 ANB > 4 ANB < 2

Eastman Correction
ANB assumes
SN is reliable Points A and B reflect basal bone Variation in position of Nasion affects SNA, SNB and therefore ANB

Providing SN-Max plane is within 5-11

For every degree SNA >81, subtract 0.5 from ANB For every degree SNA <81, add 0.5 to ANB

Wits Analysis
Compares maxilla and mandible to occlusal plane Drop perpendicular lines from points A and B Measure AO to BO Male -1mm Female 0mm

Ballard Conversion
Rotate the upper incisors to 109 Rotate lower incisors to 120 MMPA Residual OJ reflects underlying skeletal pattern

Radiographic assessment: Vertical

MMPA LAFH:TAFH Posterior face height: Anterior face height

MMPA

MMPA
Ratio of posterior to anterior face heights Average value 27 +/- 4

LAFH
Max plane to Me x 100 MxPl to Me + MxPl to N Average value 55%

Jarabak ratio
Posterior face height(S Go) X 100 Anterior face height(N Me) < 59% 59-63% vertical growth neutral growth

Females Class I, Class II div 1

> 63%

horizontal growth

Males Class II division 2, Class III

Radiographic assessment: Transverse

OPG PA skull

TREATMENT

Treatment planning
Facial concerns Dentoalveolar compensation Influence of soft tissues Mechanics
Compensation High/low angle

Growth
Expected future growth Influence it?

Skeletal Class I
Treatable Be aware of vertical and transverse problems Eliminate any unfavourable soft tissue influences Soft tissue profile Dentoalveolar assessment
Degree of crowding Incisor protrusion
A-Pog line (Raleigh Williams) Aesthetic not for stability(Houston and Edler) Lower labial segment position (Mills)

Skeletal Class II
Where is the problem?
Prominent maxilla Retrognathic mandible Combination

Mild, moderate or severe? Influence of the soft tissues Anchorage requirements

Look at A-P position of canines and molars

Degree of dentoalveolar compensation

Compensated Class II
Retroclined upper incisors Proclined lower incisors Both

Skeletal Class II
Mild, treatable Moderate
Growth modification Camouflage Associated vertical or transverse problems?

Severe
Usually orthodontic/surgical treatment

Class II; Growth Modification

Ideal class II functional case
Growing patient Non xl with well-aligned arches Skeletal mandibular retrusion MM angle reduced or average Increased overbite Maxillary incisors proclined Mandibular incisors retroclined

Class II; Camouflage

Retraction of upper incisors
Relative prominence of nose Nasolabial angle Palatal bone to retract into to achieve edge centroid

Proclination of lower incisors

Labial bony support and gingival recession Stability

Use of class II elastics Facial profile considerations

Common xl patterns
Finish to Class I molars
Upper 4s Lower 5s

Finish to Class II molars

Upper 4s Lower non-xl

Class II; Orthognathic

OJ > 10mm Short mandible Proclined lower incisors Long face

Skeletal III
Mild, treatable especially if simple interceptive treatment GROWTH BEWARE. Can be very unpredictable Refer early for growth monitoring Treat once growth has slowed Treat upper only? Degree of dentoalveolar compensation
Compensated Class III
Proclined upper incisors retroclined lower incisors both

Class III; Growth modification

Facemask therapy Mandell 2011
Early class III protraction HG in patients under 10years is skeletally and dentally effective in short term and does not result in TMD 70% successful, positive OJ No clinically significant psychosocial benefit

Awaiting results of long term follow up

Class III; Camouflage

Less successful than Class II camouflage Proclination of upper incisors Retroclination of lower incisors
If excessive, increases chin prominence

Use of class III elastics Achieve edge to edge

Common extraction patterns

Finish to Class I molars
Upper 5s Lower 4s

Possibility of future orthognathic treatment

LOWER non-XL?

Class III; Orthognathic

Kerr; Limits for Class III

ANB below -4 Holdaway angle below 3.5 Lower incisors retroclined more than 78.5

Vertical; Low MMPA

Reduced anterior face height Increased OB Forward rotation of mandible Excessive eruption of lower incisor teeth Extractions avoided as space closure retracts lower labial segment and worsens OB

Vertical; High MMPA

Increased anterior face height Reduced OB and mild AOB, treat Anchorage rapidly lost but ?stability? Increased AOB, orthognathic Care with excessive eruption of posterior teeth
High pull headgear Buccal bite blocks microscrews

VME

Transverse problems
Displacement?
Eliminate

True mandibular asymmetry

Refer Growth potential Accept? Surgical approach

Tx options
Grinding premature contact in deciduous dentition Asymmetric XLs URA QH RME SARPE Functional Headgear Fixed Orthognathic surgery

Growth
Growth rotations;
reflection of differential growth between anterior and posterior face heights(Bjork 1955, 1969)

Backward
Type I Type II

Forward
Type I Type II Type III

Signs of direction of growth

Inclination of condylar head Curvature of ID canal Shape of lower border Inclination of mandibular symphysis Inter-incisal angle Inter-molar angle Anterior face height

Proffit; Limitations for camouflage

Acceptable results likely Average/short facial pattern Mild A-P discrepancy Crowding < 4-6mm Normal soft tissues No transverse skeletal discrepancies Poor results likely Long vertical facial pattern Moderate or severe A-P skeletal discrepancy Crowding >4-6mm Exaggerated facial features Transverse skeletal discrepancies

Summary
Camouflage Too old for successful growth modification Mild/Moderate Class II Mild Class III Good alignment Average vertical proportions Avoid camouflage Still potential for growth modification Severe Class II or Class III Significant vertical discrepancy Severe crowding and protrusion Adults better managed with orthognathic surgery