Surgical analysis in orthodontics /certified fixed orthodontic courses by Indian dental academy

Surgical analysis and prediction

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Introduction
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In modern orthognathic surgery, the orthodontist
and oral surgeon need to work in complete
symbiosis to achieve the final objective of a
facial balance in harmony with the underlying
dental and skeletal structures.
The orthodontist is in a unique position to govern
the success of an orthognathic case by precisely
positioning the teeth (decompensation) prior to
surgery.


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Incorrect positioning of the incisors in either arch
can have a profound influence on the extent of
the overjet (reverse or positive), and thus on the
ability of the surgeon to produce the desired
profile changes.
It is, therefore, the responsibility of the
orthodontist to set clear goals before the start of
treatment and to communicate these to the
surgical colleague

Surgical analysis

Hard tissue analysis

Soft tissue analysis
SOFT TISSUE CEPHALOMETRIC
ANALYSIS - Legan, Dallas, Burstone et al

CEPHALOMETRICS FOR
ORTHOGNATHIC SURGERY
QUADRILATERAL ANALYSIS
MC NAMARA ANALYSIS

prediction

TOMAC: AN ORTHOGNATHIC
TREATMENT PLANNING SYSTEM
SOFT-TISSUE ANALYSIS- TONY G.
McCOLLUM,
SOFT TISSUE CEPHALOMETRIC
ANALYSIS- Arnett et al
VIDEO IMAGING


CEPHALOMETRICS FOR
ORTHOGNATHIC SURGERY
(COGS)
Burstone CJ, James RJ, Legan H,
Murphy GA, Norton LA.

J Oral Surg 1978


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CRANIAL
BASE –

Baseline for
comparison of most
data in this analysis
is HORIZONTAL
REFERENCE
PLANE.(HP)
Constructed plane ,
7˚from SN line.
Most
measurements are
made either parallel
or perpendicular to
horizontal plane.
Length of cranial
base – Parallel to
HP from Ar – N.

HP


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Should not be considered as absolute value, but a
skeletal baseline to be correlated to other measurements
such as maxillary and mandibular length to obtain a
diagnosis of proportional dysplasia
Patient with cephalometrically large maxilla & mandible
may have a normal appearance because of large cranial
base.
Ar – N is a relatively stable anatomical plane; however
it can be changed by cranial surgery that affects N, such
as Lefort II & III osteotomies. Or with auto correctional
rotations of the mandible where Ar moves closer to N.


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Ar – Ptm determines the
horizontal distance
between the posterior
aspects of mandible &
maxilla.
Greater the distance
between Ar- Ptm, more
the mandible will lie
posterior to maxilla,
assuming all other facial
dimensions are normal.
One casual factor for
prognathism or
retrognathism can be
evaluated by this
measurement


HORIZONTAL SKELETAL
PROFILE
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All the measurements are made parallel to
horizontal plane that’s why called so.


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Angle of facial
convexity :
formed by line N
– A and A-Pg.
Gives an
indication of
overall facial
convexity, but
not a specific
diagnosis of
which is at fault –
maxilla or
mandible.


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Positive angle – convex face.
Negative angle – concave face.
Clockwise angle is positive.
Counterclockwise is negative.


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Next a
perpendicular line
from HP is dropped
through nasion
the horizontal
position of point A &
B is measured to
this line
+ :anterior to line.
̶ : posterior to line


N

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It describes the apical base of
maxilla/mandible in relation to N.
Surgeon has a quantitative assessment of
A-P position of jaws and degree of
horizontal dysplasia and is important in
planning of treatment of anterior jaw
horizontal advancement / reduction or total
advancement / reduction.


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N – Pg is measured
in same manner.
Indicates the
prominence of chin.
Any unusual small or
large value must be
compared with N – B &
B – Pg., to determine if
discrepancy is in
alveolar process, the
chin or mandible
proper.
Helps to determine if
there is a horizontal
genial hyperplasia /
hypoplasia.
B
Pg

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The measurements of horizontal skeletal
profile represent facial convexity,
horizontal relation of apical base A & B
points, and chin as related to N.
After all the measurements are considered
the surgeon has a quantitative skeletal
cephalometric facial description of
horizontal anterior facial discrepancy.

VERTICAL SKELETAL
MEASUREMENTS.
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A vertical discrepancy may reflect an
anterior, posterior or complex dysplasia of
the face. therefore these measurements
are divided into –
Anterior &
Posterior components.


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Anterior
component
subdivided into
a) Middle third
face height (NANS).
b) Lower third
face height (ANSGn).
Measured
perpendicular to
HP.

HP

N

AN
S

Gn

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Posterior component – a)
Posterior maxillary height
is length of a
perpendicular line from
HP intersecting PNS.
b) Divergence of
mandible posteriorly is
shown by MP-HP
angle.MP is formed by
Go-Gn.
It relates to posterior
facial divergence with
respect to anterior facial
height.
Both these
measurements define the
vertical dysplasia of the
posterior components.

HP


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Vertical skeletal measurements of anterior
& posterior components of face will help in
diagnosis of anterior , posterior , or total
vertical maxillary hyperplasia or
hypoplasia, and clockwise or
counterclockwise rotations of the maxilla &
mandible.


VERTICAL DENTAL
DYSPLASIA


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Divided into –
a) Anterior
b)Posterior
Anterior – Anterior
maxillary height is
measured by dropping
a perpendicular from
incisal edge to nasal
floor (NF).
Anterior mandibular
height – incisal edge
to mand plane ( MP).
These 2
measurements
determine how far
incisors have erupted
in relation to NF and
MP.

NF

MP


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POSTERIOR –
a) From maxillary
1st molar m-b cusp
a perpendicular
line is drawn to NF.
b) Similar line from
mandibular m-b
cusp to MP.
All these values
should be related
to ANS-Gn & MPHP to establish
whether the origin
of maxillary &
mandibular
discrepancies is
skeletal, dental or
both.


MAXILLA AND MANDIBLE
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Effective length
of maxilla is
distance from
PNS-ANS.
This distance
along with
measurements
N- ANS, N –
PNS gives a
quantitative
description of
maxilla in skull
complex.

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MANDIBLE –
1) Ar-Go quantitates
the length of
mandibular ramus.
2) Go-Pg gives length
of mandibular body.
3) Ar-Go-Gn angle
gives relation
between ramal plane
& mandibular plane.
4) B-Pg describes the
prominence of chin
related to mandibular
denture base.

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These measurements are helpful in
diagnosis of
variations in ramus ht., that effect open
bite/deep bite problems,
increased /diminished mandibular body
length,
acute or obtuse Go angle that also
contribute to skeletal open/closed bite.
Assessment of chin prominence.

DENTAL MEASUREMENTS


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Occlusal plane (OP)
is drawn from buccal
groove of both
permanent 1st molars
through a point 1mm
apical of incisal edge
of central incisors in
respective arch.
OP angle is angle
between OP and HP.
If the teeth overlap
anteriorly to produce
an overbite the OP
can be drawn as a
single line

HP


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If anterior open bite is present 2 OPs must be
drawn and measured separately. Each OP is
assessed as to its steepness or flatness in
relation to HP.
Vertical facial & dental heights should be
considered to determine which OP should be
corrected.


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INCREASED –
Skeletal open bite,
lip incompetence,
increased facial
height, retrognathia
or increased MP
angle.
DECREASED –
Deep bite,
decreased facial
height, lip
redundancy.

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Measurement AB –
OP is done by
dropping a
perpendicular line
to OP from points
A & B, then
measuring
distance between
two intersections.
It gives relation of
maxillary &
mandibular apical
base to OP.


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Angulation of
maxillary incisor to
NF and mandibular
incisor to MP is
measured.
They determine
the procumbency
or recumbency of
incisor & are vital
in assessing the
long term stability
of the dentition.

NF

MP


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A consultation with an orthodontist will be
helpful in trying to establish the most
stable relationship of the angulation of the
teeth to the denture base and to the lips
and tongue.


QUADRILATERAL ANALYSIS
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Formulated by Di Paolo in 1962.
It attempts to identify skeletal deviations,
in size and position, in both the horizontal
and the vertical dimensions, regardless of
dentoalveolar relationships. It provides an
individualized skeletal assessment of each
patient.
Proportional analysis which is based on
theorems in Euclidean geometry.
Sample – 245 subjects, mean age-12.6
yrs.

QUADRILATERAL ANALYSIS
OF LOWER FACE
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Maxillary bony arch length - measured,
horizontally between two points projected
onto the palatal plane.


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anterior limit projecting a
perpendicular from
Pt A upward to
the palatal plane
(ANS-PNS),
posterior limit projecting a
perpendicular from
the most inferior
portion of the
PTM downward to
the palatal plane.

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Mandibular bony
arch length horizontally between
two points projected
onto the mandibular
plane (GoGn).
anterior limit determined by
projecting a
perpendicular from Pt
B downward to the
mandibular plane (Go
Gn),
posterior limit determined by
projecting a
perpendicular from
point J downward to
the mandibular plane www.indiandentalacademy.com

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Point J -

deepest point of
the curvature formed at the
junction of the anterior portion
of the ramus and the corpus of
the mandible.
A line is drawn from articulare
tangent to the most posterior
point on the ramus.
A parallel line is then drawn
through the innermost point on
the curvature of the anterior
aspect of the ramus.
At a point where the remaining
alveolar crest contacts the last
molar, a line is drawn parallel
to the gonion-gnathion plane.
The angle formed is then
bisected, and point J is located
where this line crosses the
inner curvature of the
mandible.

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Anterior lower
facial height
(ALFH) is
measured, as
vertical linear
measurement
from the
projection of
point A onto the
palatal plane to
the projection of
point B onto the
gonion-gnathion
plane

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Posterior lower
facial height
(PLFH) is
measured, from
the projection of
PTM onto the
palatal plane to
the projection of
point J onto the
gonion-gnathion
plane


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These four
measurements –
maxillary bony
base length,
mandibular bony
base length,
anterior lower facial
height,
and posterior lower
facial height form
the basis for the
quadrilateral
analysis of the
lower face.


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The quadrilateral analysis indicates that in
a balanced facial pattern a 1:1 ratio exists
between the maxillary bony base length
(Max.Lth.) and the mandibular bony base
length (Mand.Lth.);
Average of the anterior lower facial height
(ALFH) and posterior lower facial height
(PLFH) equals these bony base lengths.
Max.Lth. = Man Lth = ALFH + PLFH
2

Dental Analysis
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Maxillary incisor
position : determined
by drawing a line
through point A
parallel to the anterior
lower facial height
(ALFH).
A perpendicular from
this line to the most
anterior point on the
maxillary incisor
should result in a
measurement of 5 mm
± 1 mm.

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Mandibular
incisor
position -

drawing the line
through point B
parallel to
anterior lower
facial height
(ALFH).
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The
perpendicular
distance to the
most anterior
point of the
lower incisor is
2 mm ± 1 mm.


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Pogonion line drawing a line tangent
to pogonion, parallel
to anterior lower facial
height (ALFH).
The most anterior
point of the
mandibular incisor
should be ± 2 mm to
this line.
This measurement will
indicate if the chin is
excessive or deficient
in size

Sagittal Ratio
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Important in assessing the relative anteroposterior
position of the maxillary and mandibular bony bases.
Skeletal malformations of the jaws may be either in the
bony bases or located posteriorly. Therefore, pinpointing
the area of the deformity will have a significant impact on
whether or not certain surgical procedures are indicated.
For example, if we are to perform a surgical correction of
a mandibular prognathism, it would be necessary to
determine whether we should reduce the bony base
lengths (body ostectomy or sagittal split setback) or
whether we should perform mandibular surgery posterior
to the bony base area (vertical osteotomy, etc.).


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The lines used to
measure the bony
base lengths in are
extended posteriorly to
point x, which is the
sagittal angle
When the anterior
and posterior lower
face heights are
parallel and the
maxillary and
mandibular bony
bases are equal, a
proportional relation
exists with sides A, B,
C, and D of the similar
isosceles triangles.
The ratio of A to B
and C to D is
called the sagittal www.indiandentalacademy.com

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Any forward or
retroposition of the
bony base will cause
unequal lengths of
the posterior legs
(lines A and C).
In balanced skeletal
patterns the sagittal
ratio in adolescents
is 1.0:1.50 ± 0.05;
in adults it is
1.0:1.45 ± 0.05
sagittal angle is 23°
± 1°.

Angle of facial convexity
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Measurement of
the skeletal profile.
This angle is
formed by the
intersection of
anterior lower
facial height with
anterior upper
facial height and
relates the
quadrilateral to the
upper face.(165 178˚)

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It shows possible areas of skeletal
discrepancies, such as posture of the
lower facial complex, cranial base
deflections, and bony base discrepancies.
The degree of facial convexity will vary,
depending upon the skeletal type and the
position of the quadrilateral pattern as it
relates to the upper face

Facial Types
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Type 1. This face has a normodivergent pattern
showing a favorable vertical growth .
In the majority of Type 1 cases, the maxillary
and mandibular basal arch lengths are equal
and the average vertical height is equal to the
arch length. This balance indicates a
harmonious skeletal development of the lower
face.


• In the majority
of Type 1 cases,
the maxillary
and mandibular
basal arch
lengths are
equal and the
average vertical
height is equal
to the arch
length.
•This balance
indicates a
harmonious
skeletal
development of
the lower face.

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Other possibilities of Type 1 cases are
(B) maxillary denture base length larger than the
mandibular denture base length and
(C) mandibular denture base length larger than
the maxillary denture base length
Malocclusions in this group are dentoalveolar in
origin. Tooth size— arch length discrepancies or
anterior or posterior position of the teeth on their
respective denture bases account for the
majority of problems

•Type 2. This face is
hypodivergent,
predominantly horizontal
growth pattern .
•There is a reduction in
lower face height with an
undesirable growth
pattern, resulting in a
skeletal deep-bite
•In these patients the
average vertical height is
deficient when compared
to the denture base
lengths.

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3 possibilities: (A)
Maxillary and
mandibular denture
base lengths are
comparable in size,
(B) maxillary base
length is larger than
the mandibular base
length, and
(C) mandibular base
the maxillary base
length.
The significance is
that anteroposterior
skeletal
malrelationships can
exist in skeletal deepbite patterns.

Type 2 A


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Type 3. This face is
hyperdivergent,
predominantly vertical
growth pattern .
There is an increase
in lower face height
with an undesirable
growth pattern,
resulting in a skeletal
open-bite.
In these patients the
average vertical
height is excessive
when compared to the
denture base lengths.


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These cases
usually present
with a deep curve
of Spee and a lack
of posterior
alveolar
development.
CLINICAL
SIGNIFICANCE
Posterior alveolar
compensation may
prevent a dental
open-bite in some
cases .
Leveling
mechanics in these
patients will cause
the underlying
skeletal open-bite
to be manifested
dentally.

3 possibilities:
(A) Maxillary and
mandibular denture
base lengths are
comparable in size,
(B) maxillary base
the mandibular
base length, and
(C) mandibular base
length is larger

than the
maxillary base
length.

TYPE 3 A


Mc Namara Analysis
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Presented by Dr. James A Mc. Namara as
an original article in the December 1984
issue of the American Journal of
orthodontics.
This method of analysis is derived in part
from the principles of the Ricketts’ and
Harvold analyses.


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Basis : The Mc Namara analysis is useful
in diagnosis and treatment planning of
the individual patient when values
derived from the tracing of the patients’
head film are compared to established
norms;
the norms from 3 groups have been
derived:
The Bolton study
The Ann Arbor sample (200 adults)
The Burlington sample Composite norms.


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This analysis consists of 5 major
sections:

 Relating

maxilla to cranial base
 Relating maxilla to mandible
 Relating mandible to cranial base
 The dentition
 Airway analysis


I.Relating the maxilla to
cranial base:
soft tissue evaluation:
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The nasolabial angle is
formed by the intersection
of a line tangent to the
base of the nose with a
line tangent to the upper
lip.


Norms
110 ° (Scheidemann et al)
102 ° ± 8 ° (Ann Arbor sample)
 Acute naso Labial
angle=Dentoalveolar Protrusion
/ orientation of the base of the nose.


B) Cant of upper lip:
The cant of the upper lip
should be evaluated
relative to the vertical
orientation of the face.
The upper lip to nasion
perpendicular angle
should be:
14°± 8° in females
(Ann Arbor sample)
8°± 8° in males (adult)


Hard tissue evaluation:
The antero-posterior
position of the
maxilla is
determined by
Constructing the Nasion
perpendicular.
The Linear distance from
point A to Nasion
Perpendicular is Measured

Ann Arbor
Norm=0.4mm(male)
Comp
Norm=0mm(Mixed D)
.

1mm(adult)

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Data derived from the Bolton standards indicate
that the SNA angle increases minimally with age
(approximately 1° from ages 6 to 18).
Since a 1° change at point A is equivalent to a 1
mm linear change in the position of point A
relative to nasion, one can extrapolate the
position of point A relative to the nasion
perpendicular during the mixed dentition

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Thus, the
composite
norm for the
relationship of
point A to the
nasion
perpendicular
is 0 mm in the
mixed-dentition
person and 1
mm in the adult
female and
the adult male .

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Drawbacks:
1) It is affected by position of
nasion, which is itself affected by
cranial base length.
2) There is displacement of point
A labially when the roots are
anteriorly tipped.


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II) Relating the mandible to the maxilla

(midface):


• Effective midfacial
length determined by
measuring a line
from
condylion to point A.
•An Effective
mandibular length is
derived by
constructing a line
from condylion to
anatomic gnathion.

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A given effective midfacial length
corresponds to an effective mandibular
length within a given range. “these are
not directly related to patient’s age or
sex”
A geometric relationship exists between
the effective length of the midface and
that of the mandible. Any given effective
midfacial length corresponds to a given
effective mandibular length.

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If the effective midfacial length is
subtracted from the mandibular length, the
maxillomandibular differential can be
determined.
Ideally this differential is 20 mm for small
sized persons, 25 -27mm for medium
sized persons and 30-33 mm for large
sized persons.


B) Vertical
Dimension:
•The clinical
appearance of the
relation between
upper and lower jaws
is affected greatly by
lower anterior facial
height (measured from
ANS to mention).
•This linear
measurement
increases with age
and is correlated to
the effective length of
the midface .

E.g.: In Mixed dentition Analysis
Mid face Length= 85mm
Lower Anterior Facial Height= 60-62mm
In Medium sized individuals
Mid face Length= 94
In Large sized individuals
Mid face Length= 100


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Significance:

Increase in Lower anterior Facial Height -Mandible appears retrognathic
Decrease in Lower anterior Facial Height
--Mandible appears prognathic


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In growing persons, an increased LAFH
camouflages a similar increase in
mandibular length, resulting in the
appearance that the chin is in the same
position A-P, with respect to cranial base
structures.
This analysis also includes two other
measurements:
· 1) Mandibular plane angle:
2) Facial axis angle of Ricketts:

•Mandibular Plane
Angle: Angle between
F-H plane and GoMe
•Normal Value:22°+/- 4°
• Adult south indian-18.9
•Adult north indian-19
( Elbe Peter, Valiathan
Ashima et al JPFA 2000)
•Higher Value: Excessive
Lower Facial height
•Lower Value: Deficiency
in Lower Facial Height www.indiandentalacademy.com

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Facial axis Angle:
Angle between
a)Posterosuperior
aspect of
pterygomaxillary
fissure to gnathion
b)Line joining
Basion to Nasion
Balanced Face
=90°


Excessive vertical development , =Less than
90°(negative value)
 Deficient vertical development, =Higher than
90°(positive value)
Thomas and Valiathan (June 1993) reported
normal directed growth of chin
90.65+/- 3.33
89.64 +/- 5.06 (Adult South Indians )
90.07 +/- 3.16 (Adult North Indians)


III. Relating the mandible to the
cranial base :


•The relationship of the
mandible to the cranial base is
determined by measuring the
distance of the pogonion to the
Nasion perpendicular.
•According to the composite
norms:
•In a mixed dentition (balanced
face) pog lies 8mm to 6mm
(i.e., posterior) with respect to
Nasion
• In adult male the chin position
is usually -2mm to +2,, relative
to Nasion perpendicular.

Dentition Analysis:
A.Relating Upper
Incisor To maxilla

A vertical line is
drawn through point A
parallel to nasion ⊥
The distance from
point A to the facial
surface of Upper
incisor is measured 
A-P position of Upper
incisor
Comp Norms=
6mm(Adults)

4www.indiandentalacademy.com

VERTICAL POSITION Upper Incisor
Clinically, and typically, the incisal edge of
upper incisor lies 2-3 mm below upper lip at rest.
This is subject to adjustment depending on
functional state of lip musculature and axial
inclination of the tooth prior to treatment.


•B. Relating the lower
incisor to the mandible:
•Anteroposterior position of
Lower Incisor:
•Determined by using a
traditional version of the
Ricketts measurement of
the facial surface of the
lower incisor to the A-Pog
line.
•Bolton study Norms: 1.5
mm anterior to the A Pog.
Line.
•Ann Arbor Norms :2.32.7mm anterior to the A
Pog. Line.

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INDIAN NORMS ( Elbe Peter,
Valiathan Ashima et al JPFA 2000)
ADULT SOUTH INDIAN-2.87mm
ADULT NORTH INDIAN -2.85mm


•Vertical position of Lower Incisor
•Evaluated on basis of existing lower anterior
facial height.
• First, the lower incisor tip is related to the
functional occlusal plane.
•If curve of Spee is excessive:
•a) lower incisor is to be intruded (if LAFH is
normal/excess) OR
• b)lower molar is allowed to erupt and lower
incisor extruded. (when LAFH is inadequate).


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V. Airway analysis:
Two measurements are used to
examine airway impairment.


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Upper pharynx:

The upper pharyngeal
width is measured from a
point on the posterior
outline of the soft palate to
the closest point on the
posterior pharyngeal wall.
This is because the area
immediately adjacent to
the posterior opening of
the nose is critical in
determining upper
respiratory patency.


Apparent airway
obstruction, as
indicated by an
opening of 2mm or
less in the upper
pharyngeal
measurement is
only an indicator of
possible airway
impairment.
 For a more
accurate diagnosis,
an ENT examination
is required.

• Lower

pharynx:

• Lower pharyngeal width
is measured from the
intersection of the
posterior border of the
tongue and inferior border
of the mandible to the
closest point on the
posterior pharyngeal wall.
•Ann Arbor sample =1012mm ( average value)
does not change
appreciably with age.






Smaller than average values are not
significant,
Greater than average value,15mm suggests
anterior positioning of the tongue, either as
a result of habitual posture, or due to
enlargement of tonsils.


Certain conditions associated with greater than
average Lower pharyngeal width are:


Mandibular prognathism



Dento-alveolar anterior crossbite



Bialveolar protrusion of teeth


Bhat M, Sudha P, Tandon S.(June 2001)
•Used Computerized cephalometrics, in measuring skeletal and
dental relationship in order to establish norms for Bunt and
Brahmin children of Dakshina Kannada using McNamara's
analysis.
•The experimental group consisted of 40 children 20 Brahmins
and 20 Bunts with equal distribution of sex for both the groups.
•Age-10-14 years


The following conclusions were
drawn









Advanced maxillary growth in Bunt boys and
girls
Longer mid facial length in Bunt boys than
Brahmin but overall shows bunts to have longer
mid facial length.
Proclination of upper incisors in Bunt girls than
Brahmin girls
Prominent chin in Brahmin girls than in Bunt girls
Longer mandible in Bunt boys than in girls.






The present study indicate that different
racial or ethnic groups tend to have a
different craniofacial features establishing
their own norms for the individuals.
Therefore the knowledge of the racial and
ethnic origin is essential requisite for an
accurate evaluation of orthodontic
problem and skeletal discrepancies for
success of treatment modalities.

REFERENCES:_
1.

2.

3.
4.

Burstone CJ, James RB, Legan H:
Cephalometrics for orthognathic surgery.J Oral
Surg 1979 (36);269-77.
Legan H, Burstone CJ: Soft tissue
cephalometric analysis for orthognathic
surgery.J Oral Surg 1980 (38);744-751.
Burstone CJ: Integumental Profile. AJO 1958
(44); 1-25.
Di Paolo RJ, Philip C, Maganzini A: The
quadrilateral analysis: An individualized
skeletal assessment. AJO 1983 (83),1;19-32.

5.

6.

Albert Chinappi, Di Paolo RJ: A
quadrilateral analysis of lower face
skeletal patterns. AJO 1970 (58),4;341350.
Di Paolo RJ, Philip C, Maganzini A: The
quadrilateral analysis: A differential
diagnosis for surgical orthodontics. AJO
1984 (86) 6;470-482.

7.

8.

Mc Namara JA Jr. A method of
cephalometric evaluation. Am J Orthod.
1984; 86: 449-469
Peter Elbe, Ashima Valiathan, Suresh M.
Cephalometric comparison of South
Indians and North Indians using
Ricketts lateral cephalometric analysis.
Journal of Pierre Fauchard Academy
2000; 14(3):113-118.

9.

10.

Thomas G M, Valiathan A: A Cephalometric
comparison of South Indian and North Indian
population using six analysis. Dissertation
submitted to Mangalore university, June 1993
.Bhat M, Sudha P, Tandon S: Cephalometric
norms for Bunt and Brahmin children of
Dakshina Kannada based on McNamara’s
analysis. J Indian Soc Pedo Prev Dent ,June
2001 pg 41- 51

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