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Comprehensive diagnosis-specific treatment
Comprehensive diagnosis-specify treatment* SCOTT
T.
Muskegon,
kiich.
HOLMES,
D.D.S.,
M.S.
THE Y ATERIAL that I am going to discuss comes under two general headings-diagnosis and treatment planning. These are two of the most “workedover ’ ’ subjects in the entire orthodontic literature. However, I feel that I am justified in reconsidering them at this time simply because I believe that we as orthodontists still have many problems to solve in relation to diagnosis and treatment planning. I have no illusion that this article will appreciably alter the situation. I have no panacea for diagnosis. I do believe, however, that from time to time all of us should record our ideas on these subjects in the hope that some day we may possess the cherished answers. At present we can only hope that sometime orthodontists will agree on a clear-cut yes or no answer to many of our highly controversial orthodontic problems. Maybe none of us will live to see the day when orthodontists will be in general agreement on even major diagnostic procedures, but it is certainly worth our while to work diligently toward that goal. I will start my discussion by considering the term diagnosis. Like many other American terms, this is rapidly becoming a word with numerous connotations. We of the orthodontic specialty originally borrowed the word from the medical vocabulary ; in its original context, the meaning was clear and the word was easy to define. Blakiston’s New Gould, Medical Dictionary (Philadelphia, 1949, The Blakiston Company) defines diagnosis as “the art or the act of determining the nature of a disease,” Disease is defined as “an illness or sickness. ’ ’ Presented before the 26 to Dec. 1, 1961.
Great
Lakes
Society
of Orthodontists,
Miami
Beach,
Fla.,
Nov.
*The first part of this paper, including the selected average normal pattern, was first read, in October, 1957, before the Middle Atlantic Society of Orthodontists in Philadelphia. Sometime later a detailed account of the development and construction of the Class II, Division 1 pattern was read before the Michigan Orthodontic Forum. This present paper is a combination and condensation of the two original papers, which have not been published.
727
728 Holmes
Am.
J. Orthodontics
October1962
Diagnosis as it relates to clinical orthodontics can mean an analysis of malocclusion, and many orthodontists no longer think of malocclusion as a sequela of disease. Many choose to think of certain forms of so-called malocclusion as natural manifestations of individual human form. Furthermore, diagnosis can mean a comparison of the individual with the ideal normal form to the end that the individual may be classified as showing one of a number of defined deviations from the ideal normal pattern. Thus, an orthodontic diagnosis may be called a descriptive and analytical comparison of individual facial and dental form with ideal normal form. Thus, today it is not generally accepted that a diagnosis of malocclusion necessarily constitutes a description of a certain form of dental disease as compared with dental health. It is in this connotation that an orthodontic diagnosis differs so great13 from a medical diagnosis. The physician is concerned primarily with the discovery and treatment of disease. The orthodontist is largely concerned with the evaluation of an individual pattern and the comparison of that pattern with the ideal normality. Should the presence of disease further complicate the problem, the orthodontist is then charged with the additional duty of diagnosis of disease in its usual sense. I belierc it is time that we as orthodontists place more emphasis on the difference between a medical diagnosis and an orthodontic diagnosis. Our problem is not to diagnose what is *‘wrong” with a person to the end that we can transform him into his “right” condition; rather our task is to evaluate the patient as he is and, with full cognizance of his anatomic limitations, to build into his pattern the greatest harmony and balance consistent with his individual potentialities. Thus, an orthodontic diagnosis is closely related to treatment planning, and in this connotation diagnosis can often be called case analysis. An orthodontic diagnosis has another rather peculiar characteristic in that two orthodontists can conceivably arrive at widely divergent diagnoses of a specific case, and it could be difficult at this particular stage of our specialty to prove positively that either one is right or wrong. The fact remains that an orthodontic diagnosis is still based to a very large degree on one’s individual concepts, and these concepts may or may not be scient,ifically sound. When one has practiced for a number of years, his individual concepts represent a combination of his original training, his accumulated study, and his clinical experiences. The beginning orthodontist,‘~ concepts are largely determined by the theories of his formal or informal teachers. If he has received formal orthodontic training, he will be influenced by a number of teachers, but the basic trend of his philosophy will probably be primarily that of the head of the orthodontic department. If he is preceptor trained, his concepts will be broad or narrow, depending on the philosophy of his preceptor. In any event, his diagnostic decisions will sooner or later become largely personal and will depend to a great degree on how he individually interprets the data available from diagnostic aids. As yet, we have no absolute answers to any appreciable number of our diagnostic problems. We cannot rely on laboratory tests, such as blood analyses, tissue studies, bacterial smears, and various other rather positive medical
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Comprehensive
diagnosis-specific
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diagnostic aids. True, some orthodontists do place rather positive diagnostic weight on specific measurements, but there is reasonable doubt as to the infallibility of these data. AR stated previously, most orthodontic diagnoses are individual concepts of a given problem, and two orthodontists may conscientiously arrive at diametrically opposite opinions of the same problem. The burning question is : “Which one is right ? ” I wonder if one of our major obstacles to uniform diagnosis lies in the fact that it is so difficult for most of us to develop a clear-cut visual image of ideal normality. True, even if we could visualize this rather evasive hypothetical form, not many of us would be foolhardy enough to attempt to remold all of our patients according to this preconceived form. However, if by some means we could construct a clear-cut visual image of ideal normality, that image might possibly serve as a backdrop against which we could project the individual in question. I have often wished that we could construct such a composite facial pattern and that it could be flexible and elastic enough to be applied to all facial sizes. Median values and average deviations of a large number of facial measurements are available to all of us, but, personally, I find it very difficult to keep all these items clearly in mind when studying the individual pattern. I am just visual minded enough to long for a composite pictorial comparison. I have a feeling that such a composite picture could be an additional diagnostic aid and that it could assist us in making a more comprehensive evaluation of the total facial problem. All of us have observed how easy it is to treat “good facial patterns,” both in the early “preventive treatment” stage and in the permanent dentition stage. We have also encountered the other extremes, where chance admixtures of divergent forms of human architecture have resulted in such severe facial disharmonies that they defy even a remote approach to harmony and balance. Accepting the existence of these extremes, it is only logical for us to recognize that varying degrees of harmony and disharmony occur between the extremes. A comparison of the individual patient with ideal proportions for one of his comparable size might help us in more effectively locating and visualizing the areas of deviation. Additional minute study of the areas could then lead to the final diagnosis and help us to decide upon specific treatment. In a sense, such a composite pattern could be utilized in much the same manner as the plaster cast which we now almost automatically compare with ideal normal occlusion. With this goal in mind, I have attempted the construction and synthesis of a hypothetical ideal normal facial pattern based on data available in the literature. I have relied mostly on the normal values presented by Downs, Wylie, Broadbent, and the Northwestern Group, and the result is a purely hypothetical ideal normal pattern based on the mean values of selected cases of good occlusion as described by these men. The purpose of this construction is to visualize pictorially a close approach to ideal normal proportions and to develop an image applicable to all facial sizes. The dental age of the pattern is approximately 12 years. I wish to emphasize that I am attempting to construct only the ideal normal pattern, with no attempt whatsoever to include normal variat.ion. I wish also to emphasize that this diagram is nothing more than
730
Holmes
AWL J. Orthodoatics October 1962
another possible diagnostic aid and that it should be considered only as such. The comparison of the individual patient with this ideal pattern will not constitute a total orthodontic diagnosis in any sense of the word. A complete diagnosis must be considered as a mosaic into which all diagnostic aids may be fitted. Any diagnostic aid can be considered as only an integral part of the whole. No one aid can be regarded as the miraculous crystal ball which will automatically solve all orthodontic problems. As yet we have no such thing as an orthodontic electronic brain or a diagnostic vending machine. I maintain that a complete orthodontic diagnosis still requires comprehensive study of the total problem to the end that specific therapeutic measures may be effectively and confidently carried out. Now that I have emphasized rather strongly what my synthetic ideal facial pattern is not, I will proceed to introduce you to this hypothetical creature and see if it can be of value to us. As orthodontists, we have traditionally placed a great deal of stress on the upper first molar, so suppose we start with this tooth. In ideal occlusion the lower first molar should be positioned mesial to the upper first molar, so we will draw it accordingly. Since we must select some given age group, suppose we pick the early permanent dentition at the age of approximately 12 years and place the second molars accordingly. An ideal occlusion would certainly include third molars, so we will include these developing crowns. Progressing forward from the molar area, we must design ample space for the premolars, cuspids, and incisors. To avoid confusion, I will not include the lateral incisor. It is now time to establish the occlusal plane and to be sure that the upper and lower incisors have the ideal inclination of 135 degrees and that the lower incisors are at an angle of 15 degrees with the occlusal plane (Fig. 1, A). Our next step will be to design bony bases of ideal size and form to carry these dental arches. In designing the mandible, we will select the mean values reported by Wylie (Fig. 1, B) : Length of body of mandible, 67.5 mm. Length of ascending ramus, 55 mm. Gonial angle, 122.5 degrees Total mandibular length, 103 mm. Lower incisors at angle of 93 degrees with GoGn plane It is now necessary to attach this ideal dentition and supporting bones to an ideal upper face. We will start this construction by using an NP 1 1 1 dimension of 5.5 mm. Taking the point pogonion and a point 5.5 mm. posterior to the in&al edge of the upper central incisors, we draw a line. Ideally, nasion should lie some where on this line. Wylie’s mean value for facial height is 113 mm., so we will establish N at this point. We can now construct lines NA and NB and the NS line at an angle of 82 degrees with NA. Sella should lie somewhere on this line. According to the Broadbent charts, porion at this age is posterior to and slightly higher than the head of the condyle. Using this point, we will construct a line at an angle of 88.5 degrees with NP. This will be line FH, and it will locate approximately orbitale and, in turn, the 88.5 degree facial angle of
Volume
Number
48
diagnosis-specific
Comprehensive
10
treatment
73 1
Downs. We are now ready to establish the position of S. To do this, we will measure 18 mm. anterior to the posterior border of the head of the condyle on the Frankfort horizontal plane of Wylie and construct a perpendicular. This line should intersect the SN plane at the center of S (Fig. 1, C). We will now complete the lines of the various angles and linear measurements and then cover the face with a layer of muscle, fascia, and skin. This represents my concept of A.
B.
c. Fig. 1. A sequence normal pattern.
of
D.
drawings
demonstrating
the
constructions
of
the
selected
average
732
Am.
Holmes SN-A SN-0 OIFF NS L CO-CAN i NS-GO-GN NP- I
82 80 -2 IO3 93 30 55
FACIAL ANGLE ANGLE OF CONV AB PL TO FACIAL MAND PL ANGLE Y-AXIS
CANT IT0 i TO i TO IT0
OF OCCL i GO-GN OCCL PL AP PL
AI8 B18 c52 D15 E - 103
PL
PL
TOTAL FACIAL HT UPPER FACIAL HT LOWER BORDER OF RAMUS HT CONDYLAR ANGLE
J. Orthodontics October 1962
II3 MAND
675 I22
5
-4 22 5 60
05 135 93 I5 4
AVERAGE
NORMAL
PROPORTIONS
HOLMES
Fig. 2. The selected average normal pattern in constructions of the pattern.
and the data taken from the literature
and used
ideal normal proportions based on some representative mean values of selected normal facial patterns (Fig. 1, D) . I will grant you that this is an arbitrary design of ideal normal, and there are many other ways that it could have been constructed. A logical question is: “Now that it is constructed, does it really satisfy the mean values of selected normal as originally intended ? ’ ’ Fig. 2 may clarify this question. Considering that this is a composite, it could hardly be expected that it would absolutely satisfy the mean values of all the selected normal dimensions, but it is surprising to see how closely it does eonform to most of them. The chart shown in Fig. 1 was not adaptable to various facial sizes. The next step was to supply this flexibility. First of all, we placed a paper mask over all of the chart except the line drawing. A lens with a long focal length was used to make a photographic negative. This was placed in an enlarger and projected over the original drawing to check conformity. When no spherical aberration was detected, it was assumed that, for all practical purposes, varying degrees of enlargement would have the same relative proportions. \One exception to this generalization is that the smaller the NGn dimension of the facial chart, the greater is the degree of curvature of the facial profile. This is based on the fact that the curvature of the profile from N to ANS to incisal edge of upper central incisors to GN is essentially a portion of the circumference of a circle. The radius of the circle is approximately twice the depth of the face from ANS to the posterior border of the ascending ramus extended posteriorly from ANS
Volume ivwnber
48 10
Comprehensive
Fig. 3. The pattern as enlarged from the negative 140 mm., measured from N to On.
diaposis-specific
and printed
treatment
in sizes varying
733
from 90 to
on the palatal plane. Therefore, the smaller the facial height, the smaller will be the radius of the circle and, therefore, the greater the degree of profile curvature. Total facial height was considered to be a good comparative dimension, so NGn was selected as the indicator dimension and various enlargements were made, ranging in size from 95 to 140 mm. (Fig. 3). I will now show how I use these charts in evaluating individual cephalometric data. Again, I want to emphasize that comparison of the cephalometric tracing with these charts does not represent a total diagnosis. The first case is that of Patient B. O., an ll-year-old girl. Her general history indicated good health, and her dental health was also excellent. Frontface and profile photographs show an essentially well-balanced morphology with no indications of gross disharmony (Fig. 6, A and B) . The greatest deviation seems t,o be the position of the upper anterior teeth and the lingual positioning of the lower lip. These photographs do not suggest a diminutive or unusual mandible, and the relative size, shape, and type of the upper and lower face seem harmonious. Now let us examine the cephalometric tracing (Fig. 4, A), which shows no numerical data. Visuallg, it gives us essentially the same information as the lateral photograph, namely, good proportions, a well-developed mandible, protrusive upper anterior teeth, and lingual positioning of the lower lip; in addition, it suggests a tendency toward a Class II molar relationship. We will now select an ideal normal chart with the same NGn dimension for comparison (Fig. 4, B) . This chart is shown in dotted lines to help clarify the
734
J. Orthodontics
Am.
Holmes
1962
October
next illustration, which represents a superimposed comparison of the patient’s tracing (in solid lines) with t.he dotted lines of the ideal normal (Fig. 4, C) . Both tracings are oriented on the SN line, with S superimposed as the registration point. The shaded area gives us a visual picture of the difference in pattern A.
B. \
‘1 ‘\, I I ,,U:-----
--------q
____----
: /.L-,‘---,, ‘\ : \I ‘1 ;-
I‘\ ___--------
&;-‘:pj---
#’
-. -4.
-. .,‘\
1, ; 1; : >&-\ -Ix ‘( pT-1
‘;;, !;
,‘I’\ I ” ,’ a : =._
‘\ t, : ) : :, :
I:, I ’ ‘-1 I : ‘-‘\ >,1 :I ‘,,:;’ ‘1 I ‘; ,I :?K rt I>,
I ’ iI -k*,
j
j
\ >,; /’ c,,-: /,’ ‘,‘$t c : ‘, \? ,’ I* $J A, : ‘, : “‘>(Zf, y
-I. .=,.y
j .*.:r
/’
,
,/-
-----,
‘.
F -____ -*, I’
\
:
c.
D
Fig. 4. Cephalometric tracings of Patient B. 0. before treatment. A, Patient’s tracing before treatment. B, Selected normal pattern; same NGn dimension as patient. C, Superimposition of patient’s tracing over selected normal pattern oriented on SN and registered on S ; shaded area emphasizes differences in upper facial patterns. D, Superimposition of patient ‘s tracing over selected normal pattern oriented on NGn; shaded area emphasizes dif ferences in protiles.
Volume Number
48 10
Comprehensive
diagnosis-specific
treatment
73 5
between the patient and the ideal when oriented in this posit,ion. It is interesting to note that the major portions of these two patterns are quite similar except in the anterior pprtion of t,he upper Face ilrld premaxilla. Here WC hn~ :I A.
B.
c.
D.
Fig. 5. Cephalometric tracings of Patient B. 0. after treatment. A, Patient’s tracing after treatment. B, Superimposition of traaings before treatment (dotted line) and after treatment (solid line) ; shaded areas &OF dimensional changes that have taken place during treatment. C, Tracing of finished ease (solid line) superimposed over corresponding selected normal (dotted line), oriented on SN and registered on S. D, Tracing of finished case (solid line) superimposed over corresponding selected normal pattern (dotted line), oriented on NGn.
parallel doininancc OF all liwizontal dimensions frwl t,lw occlusal ~~laiic upu3~d~ including tlrt: frontal hone. This would irrdivatv tlrilt \vc are tlealing I\-ith 2 pattC?lTl in whic*lr \V(’ fintl IlOt 1~roli~usiorl Ot’ the, Ul,[JC’l’ IWtlL iIlOTlC’ ljllt, riltll(‘l*, il larger horizont;r I fiimension 01’ the critirc~ upper’ 1’ilCt’ \vith only sliglil nrcsial axial tipping of the upper’ antvr4or tcrth. II suggests a mandilrlc ot’ a~~~r;rgosize. Tlrvt*c~ is slight, distal positionin g Ot’ thtl IO\\-W I~~Olil12S ilild ;Ilrl)rosirlratc~l!- the Sil111C amount of I~~C?Siill positioning of thv uppt~t’ fir+ tnolat*s. ln otllcY nvrtls, we ilw dealing with a morphologic pat,tcrx that is distinctly Mf’ercnt from the ide;\I normal Class T hut deviating onl?- slightly in IIN~~;II*relation. It is obvious tlrilt we cannot do much about the Irony pattern superior to the maxilla, but we arc deeply interested in tllc t’:lCiill profile ’ i!Hd in its irrtc~~rclationshi~~ to the dentition. Therefore, let us riot’ r’eor’icnt our rephahnf~tr’ic trxcings on %(‘I’0 rvfcrcnce with regard to the txo ltrofilcs and eonsidcr 1110two tracirrgs \\hcn snpc~imposc~tl on SGn (Fig. 4, U) Now \vt’ sc(’ sonicthin g quite difl’orcvrt. In this position, \v(’ find considerah1.v Irsn diffcrcnce bet wv(ln the t\\-o profiles :lrld a grocwt,cuemphasis on the differencr in position of’ tlrc: upper ;Irrter*ior t&h. Thcrcl is a high degrcv of conformity in tllcl wst ol’ tlw filVi;ll p:lttfrn aritl. if the \* axis c’iui h wlityl upon for direction of growth, thrln the usualI\- acccptcd (‘lass II therapy in which ilI1 att,Plnpt is rnadcl to rc~t:~lYli’O~\~:~Klprogression of the IIlilXillZil’y trcth and stimuhtc masimLlJl1 pOtfwtii1~ ilwsiill dc\vhpmcwt oi’ the In;rndihlf~ would seem feasihlc. In othcy words, the c~losc~thr al~prowch to idealism in the individual pattern, the hcttcr the opl~oi~tunity one 1lilS of obtaining tht~aretical idealism in tlrc finishcvl result. In this KISP tlrc individual tl~~riatiorr \\‘irs not great. Thcrcforc~, this analysis, plus such additional aids as vasts, intraora I roentgenograms, fundional analysis, 0.. dic*i atcvl routine trcatmcnt~ with Class IT mechanics. li’ig. 5, .1 SIIOWS tlw patient,‘s tracing aftna tr*~~;rtrnerrt was completed. Fig. 5, II shows snl)(lrirrrl,ositiurr 01’ the Marc>- ;lrltl ;rftc~-t~catmt~rrt tracaings superimposed on SN \vith S as thch YcKisttxtiotr point. Sinvc the original st,Udp and tracing SllO\~~Vl il. C~lOSC :I~~~)lYJilc’tl to t t1(> iClC?ll~1Olnlill pattern, \vc Eclt that we could rvasonahly c>xp(lct,the usual do\\-nward and l’orward increase in lower facial dimension. Nature was kind, and a pltlasing rrsnlt, was obtained Now let us c~ompar~c011~final tracing with an ideal nor,nral tracing of (yrr*responding size, or+nted on SN, and rcgistercd on S (Fig. 5, c’). We find that we now have a. pattern which is uniformly la~gc~ in all horizontal dimensions than the rorresponding idcal lj()t~llliIl, including the length of the mandible. Homeyer, I haye no illusions that, if left alone, this cast would have transformed itself into the well-locked (!lass I r~clationship of the finished case. Without appliance therapy, it would have c~ontinucd in its natural pattern, hut cornl)rehensivr diagnosis enabled me to plan and csrrutr specific c4f&tive treatment. Again let us reorient the two tracings on ZCYOr*cfcrc>nce with regard to the profiles and superimpose tlrcm on NOn (E’ig. 5, D) \\‘c no\v find that we have almost complete superimpositions of’ the pr40files, indicating that in this instance the treatment plan was either in accordanrv \vitll the patient’s potential or that we were just plain lucky. Intraoral and final photographs give additional \-isual data on the final pattern (Fig. 6, C’ and U, and Fig. 7).
c.
Fig.
ti. Facial
photographs
11.
of patient
Iwforc
(.I
and
B)
and
after
(C and
D)
treat
1ntwt.
111 the next cast, which is also classified a~ Cllass II; Dirision 1, the patient is J. J an II-year-old girl. The general health history was good, and tht : dental health “and I ~~glrne _’ WE also good. The front-fare photograph shoxvs a rather Gfie 1?.mygornatic width, and the vxtical depth of the lowr portion of t11c 1owrr face from the prominent upper incisors to tlrc tip of the chin scms a little long ( Fig. 10, .I and K). The upper lip seems shortmctd and protrusi vc. arid the 101wr lip is severely locked untlw the upper incisom. The face is synrr wtrical, and it sccrns to me that it is growing in accordance with its natural l)iltt(l rm. The photograph emphasizes the lip ~norpllolog~ arld also indicates am pie size rnandihlc. It snggcsts that t,hprc may 1~ a forwar~tl hodil,v I>lircCIriimt of lilteEl of
t11c
Fig. after
7. Before and after intraoral (I?, D, and F) treatment.
photographs
of
Patient
B.
0.
before
(.4,
C, and
E)
and
the upper incisors rather than just mesial axial inclination of hhese teeth. The lateral head cephalometric tracing (Fig. 8, A) emphasizes the wide A-B difference and the long vertical dimension from the incisal edges of the lower incisors to Gn. There is a positive Class II molar relationship the full width of a premolar. It, is also interesting to note how much shorter the dimension is from the lower border of the mandible to the occlusal plane of the molars t.han from the lower border of the mandible to the incisal edges of the lower incisors. At this point let us select an ideal normal tracing with the same NGn dimension (Fig. 8, B, in dotted line) and superimpose it over the patient’s tracing (solid line).
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Number
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Comprehensive
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73 9
Orientation is on SNa, registered on S (Fig. 8, 15’). The shaded area emphasizes the differences in horizontal dimensions in the upper portion of the face. The SnGoGn angle is relatively large. The dimension from Go to S is short, indicating a relatively short posterior facial height, The position of ANS shows A.
B.
Fig. 8. Cephalometric tracings of Patient J. J. before treatment. A, Patient’s tracing before treatment B, Selected normal pattern; same NGn, dimension as patient. C, Superimposition of patient’s tracing over selected normal pattern oriented on SN and registered on S; shaded area emphasizes differences in upper facial patterns. D, Superimposition of patient’s tracing over selected normal pattern, oriented on NGn; shaded area emphasizes differences in profiles.
A.
c. Fig. 10. mcnt.
Facial
photographs
D. of
Patient
J. J.
before
(.4
and
13)
and
after
(C and
II)
treat-
in the osseous structures are reflected in the soft structures, with corresponding anterior placement of the upper facial soft structures. With this degree of rariation from the ideal pattern, we would hesitate to alter the patient to conform to the ideal tracing, so now let us focus our at,tention on the profile alone by reorienting the tracings on NGn as shown in Fig. 8, D. In this relat,ionship we have quite a different picture. The relative position of the mandible seems quite satisfactory, and even the occlusal plane of the molars is quite harmonious. The incisal edges of the lower incisors are still much highrr than in the ideal tracing, and the mandibular bone surrounding t,he lowr incisors and in the menton region is considerably larger.
742
IIolmcs
Pig. Il. Intraoral F) treatment.
photographs
of
Patient
.T. J. Iwfore
i-4,
C. and
E> and aftrr
(R, D, an11
Pogonion is also quite prominent. The lower first molars are completely distal to the upper first molars, but the prominent menton compensates for this. Vertical dimensions in the maxilla correspond very closely, but all horizontal dimensions are greater. Were these tracings to be reoriented again on the Frankfort horizontal of Wylie, registered on PTM, the relative oversizing of horizontal dimensions of the maxilla would be even more evident. In fact, at this stage of comparative study, the individual deviations from ideal become more and more obvious, and many reorientations to the two tracings in zero reference to the characteristics to be studied are very much in order. However, to conclude our
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Comprehensive
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743
evaluation of this orientation, it appears as though the three greatest variations from the ideal normal chart are in the region of S, the premaxillary and subnasal region, and in the molar relation. Obviously, we could not change S, so we could disregard that. As far as the molar relationship was concerned, the casts and additional aids in this case showed a good lower arch, and there was no disturbance of function in the molar region. Functional and occlusal analysis did not indicate any distal locking of the mandible and, from the standpoint of the posterior and lower part of the face, it did not seem imperative to change the molar relation unless such a change could be considered beneficial to the premaxillary region. From the standpoint of growth potential, the great height of the mandible in the lower anterior region and the facial appearance of excessive vertical dimension in the lower face suggested continued emphasis on vertical development in this area. All in all, I decided that t,he deviation from the ideal pattern was such that the usual Class II approach to therapy, as utilized in the first case, would not result in sufficient change in the natural characteristics of this face to bring about a satisfactory result. Therefore, I decided to try to maintain the natural balance throughout, except for the deviating premaxillary region. For the benefit of this area, I elected to extract two upper first premolars and subsequently attempted to retract the premaxillary structures into closer conformity to my concept of ideal pattern. This is the point at which many of us can very logically come to entirely different conclusions in the selection of the most desirable appliance therapy. My purpose here is not to dictate or even knowingly to direct appliance therapy but, ra,ther, to present available case study data in a manner that will enable all of us to evaluate and correlate our data to the end that our final decisions will be objective, constructive, and sound. In other words, I propose a comprehensive diagnosis, leading to specific treatment with the appliance of your choice. Now let us continue with our case study and analysis. As stated earlier, I treated this case will full-banded technique, which included the extraction of the upper first premolars, and used Class II elastics and a neck strap for distal stress on the maxilla. Fig. 9, il shows the tracing following treatment. I might just as well call attention to it, because some of you will surely see it anywaythe upper anterior teeth are excessively vertical. In the final photographs you can draw your own conclusions as to whether or not this has det~rimentallp affected the facial profile. Much more can be seen by superimposing original and final tracings as shown in Fig. 9, B. First I would like to call attention to the harmonious downward and forward dimensional change of the molars and to the considerable increase in the size of the mandible. However, the dimensional change has been dominantly in a vertical direction, rather than horizontal, and to me this is further evidence of an individuality of pattern growth divergent from ideal normal. Now let us superimpose the final tracing (solid line) over the corresponding ideal normal pattern (dotted line), as shown in Fig. 9, C. Orientation is on SN, registered on S. Here again we see a considerable deviation of the individual pattern from ideal normal, but I feel that it also demonstrates how, even in the highly divergent form, certain selected changes can be made
toward a greater degree of harmony and balance. Fig. 9, 17 sho\vs comparison of the profile with the ideal pattern by superimposition on NGn. Fig. 10, Cr and D shows final facial photographs, and iTin. 11, -1 to P sho\vsbefore- ad aftertreaknent intraoral photographs. If the data pl.cscnted indicate to you that this case should have been treated without &ractions or with four premolar estractions, t,hat decision is certainlp your privilcgc. Jly only hope is that this a~)preach to diagnosis may hc all additional 11~11)to all of LIS in our pretr
Fig. 12. Composite mrasurements taken
Class II, Uvision in seventy nine
1 facial pattrru Class II, Division
based 011 the I cases.
averages
of
fort,y-tiv
zontal dimensions of the upper face rather than a diminuti\-e, posteriorly placed mandible. As I have compared mang such cases with my Class I pattern, I havc~ become increasingly aware of the fact that Class II, Division 1 facial morpholog! is quite different from Class I in a number of ways, not the least of which ma?be this oversizing of the upper face. Accordingly, I have made a rather detailed study of seventy-nine Class 11, IXvision 7 cases for comparison with my Class I pattern. Cephalometric tracings were made in c~ch of the seventy-nine cases, and photographic negatives were made of these tracings. The negatives WTP rnlarged and printed so t,hat each tracing photograph had a common N(:n dimension of 113 mm. to correspond with the Class I pattern. Fort,y-five measurcmerits were then made of each photograph and recorded. Average readings for all dimensions were determined, and from these data a composite Class II,
1 pattern wax spnthe&ed. This pattern is shown in Fig. 12. The C&n II pattern is purposely designed so that it can be compared directly with the Class I pattern. Fig. 13, 11 to 11 shows this comparison and superimposition. Fig.
~)i&on
A.
c.
R.
u.
F’ig. 13. Comparison of Class II, Ibision 1 composite facial pattern with selected normal pattern. A, Class II, Ijivision 1 pattern. B, Class I pattern. C, Superimposition of Class I pattern (dotted line) over Class IL, Division 1 pattern (solid line), oriented on S.N. and registered on S; shaded area emphasizes diflrrences in upper facial patterns. D, Superimposition of Class I pattern (broken line) over Class II, Division 1 pattern (solid line), oriented on NGn; shaded area emphasizes differences in profiles.
746
Holmes
Am.
J. Orthodontics October 1962
13, C shows that orientation is on SN, registered on 8. Many interesting comparisons can be made, but I think that one of the most interesting observations is that a good portion of the Class II? IJivision 1 pattern very closely conforms to the Class I pattern except for the horizontal oversizing in the upper anterior portion of the face. Fig. 13, D shows the two patterns superimposed on NGn for profile comparison. For the sake of clarity, remember that I did not say that Class II, Division 1 cases nezfer show a diminutive or distally locked mandible. I am stating only that the average pattern of this sample of seventy-nine Class II, Division 1 cases seems to show horizontal dimensional oversizing in the upper face as compared with my Class I pattern. To me! this is an interesting observation which could well stand some further investigation. I also recommend for your consideration the method of this investigation and study. I can assure you that it is a very fascinating extracurricular activity which offers an interesting method of studying some of our unsolved orthodontic problems. Briefly, the technique suggesm a method of studying similarities and dissimilarities of facial forms of all sizes and configurations. The faces are first reduced or enlarged so that one indicative measurement is common to all faces studied. The faces are then compared individually and collectively with each other. To date two standard patterns-the ideal normal and the Class II, Division 1 pattern-have been synthesized and partially studied. I have given you only a very few of these observations and comparisons. The data have been studied not only for determination of average dimension but also for probable deviations, relative variations, and other purposes not included in the scope of this article. CONCLUSION
In this article I have presented my concept of a Class I selected normal pattern, and I have shown how I utilize this pattern as a measuring stick for comparison of the individual with the ideal pattern. I have presented a method of comparative study of similarities and dissimilarities of facial forms of various sizes and configurations. I have presented a composite pattern of a group of Class II, Division 1 cases and have compared this pattern with the Class I pattern. This study is continuing in the hope that additional investigation may eventually help clarify some of our mutual orthodontic problems.
T.
Muskegon,
kiich.
HOLMES,
D.D.S.,
M.S.
THE Y ATERIAL that I am going to discuss comes under two general headings-diagnosis and treatment planning. These are two of the most “workedover ’ ’ subjects in the entire orthodontic literature. However, I feel that I am justified in reconsidering them at this time simply because I believe that we as orthodontists still have many problems to solve in relation to diagnosis and treatment planning. I have no illusion that this article will appreciably alter the situation. I have no panacea for diagnosis. I do believe, however, that from time to time all of us should record our ideas on these subjects in the hope that some day we may possess the cherished answers. At present we can only hope that sometime orthodontists will agree on a clear-cut yes or no answer to many of our highly controversial orthodontic problems. Maybe none of us will live to see the day when orthodontists will be in general agreement on even major diagnostic procedures, but it is certainly worth our while to work diligently toward that goal. I will start my discussion by considering the term diagnosis. Like many other American terms, this is rapidly becoming a word with numerous connotations. We of the orthodontic specialty originally borrowed the word from the medical vocabulary ; in its original context, the meaning was clear and the word was easy to define. Blakiston’s New Gould, Medical Dictionary (Philadelphia, 1949, The Blakiston Company) defines diagnosis as “the art or the act of determining the nature of a disease,” Disease is defined as “an illness or sickness. ’ ’ Presented before the 26 to Dec. 1, 1961.
Great
Lakes
Society
of Orthodontists,
Miami
Beach,
Fla.,
Nov.
*The first part of this paper, including the selected average normal pattern, was first read, in October, 1957, before the Middle Atlantic Society of Orthodontists in Philadelphia. Sometime later a detailed account of the development and construction of the Class II, Division 1 pattern was read before the Michigan Orthodontic Forum. This present paper is a combination and condensation of the two original papers, which have not been published.
727
728 Holmes
Am.
J. Orthodontics
October1962
Diagnosis as it relates to clinical orthodontics can mean an analysis of malocclusion, and many orthodontists no longer think of malocclusion as a sequela of disease. Many choose to think of certain forms of so-called malocclusion as natural manifestations of individual human form. Furthermore, diagnosis can mean a comparison of the individual with the ideal normal form to the end that the individual may be classified as showing one of a number of defined deviations from the ideal normal pattern. Thus, an orthodontic diagnosis may be called a descriptive and analytical comparison of individual facial and dental form with ideal normal form. Thus, today it is not generally accepted that a diagnosis of malocclusion necessarily constitutes a description of a certain form of dental disease as compared with dental health. It is in this connotation that an orthodontic diagnosis differs so great13 from a medical diagnosis. The physician is concerned primarily with the discovery and treatment of disease. The orthodontist is largely concerned with the evaluation of an individual pattern and the comparison of that pattern with the ideal normality. Should the presence of disease further complicate the problem, the orthodontist is then charged with the additional duty of diagnosis of disease in its usual sense. I belierc it is time that we as orthodontists place more emphasis on the difference between a medical diagnosis and an orthodontic diagnosis. Our problem is not to diagnose what is *‘wrong” with a person to the end that we can transform him into his “right” condition; rather our task is to evaluate the patient as he is and, with full cognizance of his anatomic limitations, to build into his pattern the greatest harmony and balance consistent with his individual potentialities. Thus, an orthodontic diagnosis is closely related to treatment planning, and in this connotation diagnosis can often be called case analysis. An orthodontic diagnosis has another rather peculiar characteristic in that two orthodontists can conceivably arrive at widely divergent diagnoses of a specific case, and it could be difficult at this particular stage of our specialty to prove positively that either one is right or wrong. The fact remains that an orthodontic diagnosis is still based to a very large degree on one’s individual concepts, and these concepts may or may not be scient,ifically sound. When one has practiced for a number of years, his individual concepts represent a combination of his original training, his accumulated study, and his clinical experiences. The beginning orthodontist,‘~ concepts are largely determined by the theories of his formal or informal teachers. If he has received formal orthodontic training, he will be influenced by a number of teachers, but the basic trend of his philosophy will probably be primarily that of the head of the orthodontic department. If he is preceptor trained, his concepts will be broad or narrow, depending on the philosophy of his preceptor. In any event, his diagnostic decisions will sooner or later become largely personal and will depend to a great degree on how he individually interprets the data available from diagnostic aids. As yet, we have no absolute answers to any appreciable number of our diagnostic problems. We cannot rely on laboratory tests, such as blood analyses, tissue studies, bacterial smears, and various other rather positive medical
Volume Number
4s 10
Comprehensive
diagnosis-specific
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7 29
diagnostic aids. True, some orthodontists do place rather positive diagnostic weight on specific measurements, but there is reasonable doubt as to the infallibility of these data. AR stated previously, most orthodontic diagnoses are individual concepts of a given problem, and two orthodontists may conscientiously arrive at diametrically opposite opinions of the same problem. The burning question is : “Which one is right ? ” I wonder if one of our major obstacles to uniform diagnosis lies in the fact that it is so difficult for most of us to develop a clear-cut visual image of ideal normality. True, even if we could visualize this rather evasive hypothetical form, not many of us would be foolhardy enough to attempt to remold all of our patients according to this preconceived form. However, if by some means we could construct a clear-cut visual image of ideal normality, that image might possibly serve as a backdrop against which we could project the individual in question. I have often wished that we could construct such a composite facial pattern and that it could be flexible and elastic enough to be applied to all facial sizes. Median values and average deviations of a large number of facial measurements are available to all of us, but, personally, I find it very difficult to keep all these items clearly in mind when studying the individual pattern. I am just visual minded enough to long for a composite pictorial comparison. I have a feeling that such a composite picture could be an additional diagnostic aid and that it could assist us in making a more comprehensive evaluation of the total facial problem. All of us have observed how easy it is to treat “good facial patterns,” both in the early “preventive treatment” stage and in the permanent dentition stage. We have also encountered the other extremes, where chance admixtures of divergent forms of human architecture have resulted in such severe facial disharmonies that they defy even a remote approach to harmony and balance. Accepting the existence of these extremes, it is only logical for us to recognize that varying degrees of harmony and disharmony occur between the extremes. A comparison of the individual patient with ideal proportions for one of his comparable size might help us in more effectively locating and visualizing the areas of deviation. Additional minute study of the areas could then lead to the final diagnosis and help us to decide upon specific treatment. In a sense, such a composite pattern could be utilized in much the same manner as the plaster cast which we now almost automatically compare with ideal normal occlusion. With this goal in mind, I have attempted the construction and synthesis of a hypothetical ideal normal facial pattern based on data available in the literature. I have relied mostly on the normal values presented by Downs, Wylie, Broadbent, and the Northwestern Group, and the result is a purely hypothetical ideal normal pattern based on the mean values of selected cases of good occlusion as described by these men. The purpose of this construction is to visualize pictorially a close approach to ideal normal proportions and to develop an image applicable to all facial sizes. The dental age of the pattern is approximately 12 years. I wish to emphasize that I am attempting to construct only the ideal normal pattern, with no attempt whatsoever to include normal variat.ion. I wish also to emphasize that this diagram is nothing more than
730
Holmes
AWL J. Orthodoatics October 1962
another possible diagnostic aid and that it should be considered only as such. The comparison of the individual patient with this ideal pattern will not constitute a total orthodontic diagnosis in any sense of the word. A complete diagnosis must be considered as a mosaic into which all diagnostic aids may be fitted. Any diagnostic aid can be considered as only an integral part of the whole. No one aid can be regarded as the miraculous crystal ball which will automatically solve all orthodontic problems. As yet we have no such thing as an orthodontic electronic brain or a diagnostic vending machine. I maintain that a complete orthodontic diagnosis still requires comprehensive study of the total problem to the end that specific therapeutic measures may be effectively and confidently carried out. Now that I have emphasized rather strongly what my synthetic ideal facial pattern is not, I will proceed to introduce you to this hypothetical creature and see if it can be of value to us. As orthodontists, we have traditionally placed a great deal of stress on the upper first molar, so suppose we start with this tooth. In ideal occlusion the lower first molar should be positioned mesial to the upper first molar, so we will draw it accordingly. Since we must select some given age group, suppose we pick the early permanent dentition at the age of approximately 12 years and place the second molars accordingly. An ideal occlusion would certainly include third molars, so we will include these developing crowns. Progressing forward from the molar area, we must design ample space for the premolars, cuspids, and incisors. To avoid confusion, I will not include the lateral incisor. It is now time to establish the occlusal plane and to be sure that the upper and lower incisors have the ideal inclination of 135 degrees and that the lower incisors are at an angle of 15 degrees with the occlusal plane (Fig. 1, A). Our next step will be to design bony bases of ideal size and form to carry these dental arches. In designing the mandible, we will select the mean values reported by Wylie (Fig. 1, B) : Length of body of mandible, 67.5 mm. Length of ascending ramus, 55 mm. Gonial angle, 122.5 degrees Total mandibular length, 103 mm. Lower incisors at angle of 93 degrees with GoGn plane It is now necessary to attach this ideal dentition and supporting bones to an ideal upper face. We will start this construction by using an NP 1 1 1 dimension of 5.5 mm. Taking the point pogonion and a point 5.5 mm. posterior to the in&al edge of the upper central incisors, we draw a line. Ideally, nasion should lie some where on this line. Wylie’s mean value for facial height is 113 mm., so we will establish N at this point. We can now construct lines NA and NB and the NS line at an angle of 82 degrees with NA. Sella should lie somewhere on this line. According to the Broadbent charts, porion at this age is posterior to and slightly higher than the head of the condyle. Using this point, we will construct a line at an angle of 88.5 degrees with NP. This will be line FH, and it will locate approximately orbitale and, in turn, the 88.5 degree facial angle of
Volume
Number
48
diagnosis-specific
Comprehensive
10
treatment
73 1
Downs. We are now ready to establish the position of S. To do this, we will measure 18 mm. anterior to the posterior border of the head of the condyle on the Frankfort horizontal plane of Wylie and construct a perpendicular. This line should intersect the SN plane at the center of S (Fig. 1, C). We will now complete the lines of the various angles and linear measurements and then cover the face with a layer of muscle, fascia, and skin. This represents my concept of A.
B.
c. Fig. 1. A sequence normal pattern.
of
D.
drawings
demonstrating
the
constructions
of
the
selected
average
732
Am.
Holmes SN-A SN-0 OIFF NS L CO-CAN i NS-GO-GN NP- I
82 80 -2 IO3 93 30 55
FACIAL ANGLE ANGLE OF CONV AB PL TO FACIAL MAND PL ANGLE Y-AXIS
CANT IT0 i TO i TO IT0
OF OCCL i GO-GN OCCL PL AP PL
AI8 B18 c52 D15 E - 103
PL
PL
TOTAL FACIAL HT UPPER FACIAL HT LOWER BORDER OF RAMUS HT CONDYLAR ANGLE
J. Orthodontics October 1962
II3 MAND
675 I22
5
-4 22 5 60
05 135 93 I5 4
AVERAGE
NORMAL
PROPORTIONS
HOLMES
Fig. 2. The selected average normal pattern in constructions of the pattern.
and the data taken from the literature
and used
ideal normal proportions based on some representative mean values of selected normal facial patterns (Fig. 1, D) . I will grant you that this is an arbitrary design of ideal normal, and there are many other ways that it could have been constructed. A logical question is: “Now that it is constructed, does it really satisfy the mean values of selected normal as originally intended ? ’ ’ Fig. 2 may clarify this question. Considering that this is a composite, it could hardly be expected that it would absolutely satisfy the mean values of all the selected normal dimensions, but it is surprising to see how closely it does eonform to most of them. The chart shown in Fig. 1 was not adaptable to various facial sizes. The next step was to supply this flexibility. First of all, we placed a paper mask over all of the chart except the line drawing. A lens with a long focal length was used to make a photographic negative. This was placed in an enlarger and projected over the original drawing to check conformity. When no spherical aberration was detected, it was assumed that, for all practical purposes, varying degrees of enlargement would have the same relative proportions. \One exception to this generalization is that the smaller the NGn dimension of the facial chart, the greater is the degree of curvature of the facial profile. This is based on the fact that the curvature of the profile from N to ANS to incisal edge of upper central incisors to GN is essentially a portion of the circumference of a circle. The radius of the circle is approximately twice the depth of the face from ANS to the posterior border of the ascending ramus extended posteriorly from ANS
Volume ivwnber
48 10
Comprehensive
Fig. 3. The pattern as enlarged from the negative 140 mm., measured from N to On.
diaposis-specific
and printed
treatment
in sizes varying
733
from 90 to
on the palatal plane. Therefore, the smaller the facial height, the smaller will be the radius of the circle and, therefore, the greater the degree of profile curvature. Total facial height was considered to be a good comparative dimension, so NGn was selected as the indicator dimension and various enlargements were made, ranging in size from 95 to 140 mm. (Fig. 3). I will now show how I use these charts in evaluating individual cephalometric data. Again, I want to emphasize that comparison of the cephalometric tracing with these charts does not represent a total diagnosis. The first case is that of Patient B. O., an ll-year-old girl. Her general history indicated good health, and her dental health was also excellent. Frontface and profile photographs show an essentially well-balanced morphology with no indications of gross disharmony (Fig. 6, A and B) . The greatest deviation seems t,o be the position of the upper anterior teeth and the lingual positioning of the lower lip. These photographs do not suggest a diminutive or unusual mandible, and the relative size, shape, and type of the upper and lower face seem harmonious. Now let us examine the cephalometric tracing (Fig. 4, A), which shows no numerical data. Visuallg, it gives us essentially the same information as the lateral photograph, namely, good proportions, a well-developed mandible, protrusive upper anterior teeth, and lingual positioning of the lower lip; in addition, it suggests a tendency toward a Class II molar relationship. We will now select an ideal normal chart with the same NGn dimension for comparison (Fig. 4, B) . This chart is shown in dotted lines to help clarify the
734
J. Orthodontics
Am.
Holmes
1962
October
next illustration, which represents a superimposed comparison of the patient’s tracing (in solid lines) with t.he dotted lines of the ideal normal (Fig. 4, C) . Both tracings are oriented on the SN line, with S superimposed as the registration point. The shaded area gives us a visual picture of the difference in pattern A.
B. \
‘1 ‘\, I I ,,U:-----
--------q
____----
: /.L-,‘---,, ‘\ : \I ‘1 ;-
I‘\ ___--------
&;-‘:pj---
#’
-. -4.
-. .,‘\
1, ; 1; : >&-\ -Ix ‘( pT-1
‘;;, !;
,‘I’\ I ” ,’ a : =._
‘\ t, : ) : :, :
I:, I ’ ‘-1 I : ‘-‘\ >,1 :I ‘,,:;’ ‘1 I ‘; ,I :?K rt I>,
I ’ iI -k*,
j
j
\ >,; /’ c,,-: /,’ ‘,‘$t c : ‘, \? ,’ I* $J A, : ‘, : “‘>(Zf, y
-I. .=,.y
j .*.:r
/’
,
,/-
-----,
‘.
F -____ -*, I’
\
:
c.
D
Fig. 4. Cephalometric tracings of Patient B. 0. before treatment. A, Patient’s tracing before treatment. B, Selected normal pattern; same NGn dimension as patient. C, Superimposition of patient’s tracing over selected normal pattern oriented on SN and registered on S ; shaded area emphasizes differences in upper facial patterns. D, Superimposition of patient ‘s tracing over selected normal pattern oriented on NGn; shaded area emphasizes dif ferences in protiles.
Volume Number
48 10
Comprehensive
diagnosis-specific
treatment
73 5
between the patient and the ideal when oriented in this posit,ion. It is interesting to note that the major portions of these two patterns are quite similar except in the anterior pprtion of t,he upper Face ilrld premaxilla. Here WC hn~ :I A.
B.
c.
D.
Fig. 5. Cephalometric tracings of Patient B. 0. after treatment. A, Patient’s tracing after treatment. B, Superimposition of traaings before treatment (dotted line) and after treatment (solid line) ; shaded areas &OF dimensional changes that have taken place during treatment. C, Tracing of finished ease (solid line) superimposed over corresponding selected normal (dotted line), oriented on SN and registered on S. D, Tracing of finished case (solid line) superimposed over corresponding selected normal pattern (dotted line), oriented on NGn.
parallel doininancc OF all liwizontal dimensions frwl t,lw occlusal ~~laiic upu3~d~ including tlrt: frontal hone. This would irrdivatv tlrilt \vc are tlealing I\-ith 2 pattC?lTl in whic*lr \V(’ fintl IlOt 1~roli~usiorl Ot’ the, Ul,[JC’l’ IWtlL iIlOTlC’ ljllt, riltll(‘l*, il larger horizont;r I fiimension 01’ the critirc~ upper’ 1’ilCt’ \vith only sliglil nrcsial axial tipping of the upper’ antvr4or tcrth. II suggests a mandilrlc ot’ a~~~r;rgosize. Tlrvt*c~ is slight, distal positionin g Ot’ thtl IO\\-W I~~Olil12S ilild ;Ilrl)rosirlratc~l!- the Sil111C amount of I~~C?Siill positioning of thv uppt~t’ fir+ tnolat*s. ln otllcY nvrtls, we ilw dealing with a morphologic pat,tcrx that is distinctly Mf’ercnt from the ide;\I normal Class T hut deviating onl?- slightly in IIN~~;II*relation. It is obvious tlrilt we cannot do much about the Irony pattern superior to the maxilla, but we arc deeply interested in tllc t’:lCiill profile ’ i!Hd in its irrtc~~rclationshi~~ to the dentition. Therefore, let us riot’ r’eor’icnt our rephahnf~tr’ic trxcings on %(‘I’0 rvfcrcnce with regard to the txo ltrofilcs and eonsidcr 1110two tracirrgs \\hcn snpc~imposc~tl on SGn (Fig. 4, U) Now \vt’ sc(’ sonicthin g quite difl’orcvrt. In this position, \v(’ find considerah1.v Irsn diffcrcnce bet wv(ln the t\\-o profiles :lrld a grocwt,cuemphasis on the differencr in position of’ tlrc: upper ;Irrter*ior t&h. Thcrcl is a high degrcv of conformity in tllcl wst ol’ tlw filVi;ll p:lttfrn aritl. if the \* axis c’iui h wlityl upon for direction of growth, thrln the usualI\- acccptcd (‘lass II therapy in which ilI1 att,Plnpt is rnadcl to rc~t:~lYli’O~\~:~Klprogression of the IIlilXillZil’y trcth and stimuhtc masimLlJl1 pOtfwtii1~ ilwsiill dc\vhpmcwt oi’ the In;rndihlf~ would seem feasihlc. In othcy words, the c~losc~thr al~prowch to idealism in the individual pattern, the hcttcr the opl~oi~tunity one 1lilS of obtaining tht~aretical idealism in tlrc finishcvl result. In this KISP tlrc individual tl~~riatiorr \\‘irs not great. Thcrcforc~, this analysis, plus such additional aids as vasts, intraora I roentgenograms, fundional analysis, 0.. dic*i atcvl routine trcatmcnt~ with Class IT mechanics. li’ig. 5, .1 SIIOWS tlw patient,‘s tracing aftna tr*~~;rtrnerrt was completed. Fig. 5, II shows snl)(lrirrrl,ositiurr 01’ the Marc>- ;lrltl ;rftc~-t~catmt~rrt tracaings superimposed on SN \vith S as thch YcKisttxtiotr point. Sinvc the original st,Udp and tracing SllO\~~Vl il. C~lOSC :I~~~)lYJilc’tl to t t1(> iClC?ll~1Olnlill pattern, \vc Eclt that we could rvasonahly c>xp(lct,the usual do\\-nward and l’orward increase in lower facial dimension. Nature was kind, and a pltlasing rrsnlt, was obtained Now let us c~ompar~c011~final tracing with an ideal nor,nral tracing of (yrr*responding size, or+nted on SN, and rcgistercd on S (Fig. 5, c’). We find that we now have a. pattern which is uniformly la~gc~ in all horizontal dimensions than the rorresponding idcal lj()t~llliIl, including the length of the mandible. Homeyer, I haye no illusions that, if left alone, this cast would have transformed itself into the well-locked (!lass I r~clationship of the finished case. Without appliance therapy, it would have c~ontinucd in its natural pattern, hut cornl)rehensivr diagnosis enabled me to plan and csrrutr specific c4f&tive treatment. Again let us reorient the two tracings on ZCYOr*cfcrc>nce with regard to the profiles and superimpose tlrcm on NOn (E’ig. 5, D) \\‘c no\v find that we have almost complete superimpositions of’ the pr40files, indicating that in this instance the treatment plan was either in accordanrv \vitll the patient’s potential or that we were just plain lucky. Intraoral and final photographs give additional \-isual data on the final pattern (Fig. 6, C’ and U, and Fig. 7).
c.
Fig.
ti. Facial
photographs
11.
of patient
Iwforc
(.I
and
B)
and
after
(C and
D)
treat
1ntwt.
111 the next cast, which is also classified a~ Cllass II; Dirision 1, the patient is J. J an II-year-old girl. The general health history was good, and tht : dental health “and I ~~glrne _’ WE also good. The front-fare photograph shoxvs a rather Gfie 1?.mygornatic width, and the vxtical depth of the lowr portion of t11c 1owrr face from the prominent upper incisors to tlrc tip of the chin scms a little long ( Fig. 10, .I and K). The upper lip seems shortmctd and protrusi vc. arid the 101wr lip is severely locked untlw the upper incisom. The face is synrr wtrical, and it sccrns to me that it is growing in accordance with its natural l)iltt(l rm. The photograph emphasizes the lip ~norpllolog~ arld also indicates am pie size rnandihlc. It snggcsts that t,hprc may 1~ a forwar~tl hodil,v I>lircCIriimt of lilteEl of
t11c
Fig. after
7. Before and after intraoral (I?, D, and F) treatment.
photographs
of
Patient
B.
0.
before
(.4,
C, and
E)
and
the upper incisors rather than just mesial axial inclination of hhese teeth. The lateral head cephalometric tracing (Fig. 8, A) emphasizes the wide A-B difference and the long vertical dimension from the incisal edges of the lower incisors to Gn. There is a positive Class II molar relationship the full width of a premolar. It, is also interesting to note how much shorter the dimension is from the lower border of the mandible to the occlusal plane of the molars t.han from the lower border of the mandible to the incisal edges of the lower incisors. At this point let us select an ideal normal tracing with the same NGn dimension (Fig. 8, B, in dotted line) and superimpose it over the patient’s tracing (solid line).
Volume
Number
48 10
Comprehensive
diagnosis--specific
treatment
73 9
Orientation is on SNa, registered on S (Fig. 8, 15’). The shaded area emphasizes the differences in horizontal dimensions in the upper portion of the face. The SnGoGn angle is relatively large. The dimension from Go to S is short, indicating a relatively short posterior facial height, The position of ANS shows A.
B.
Fig. 8. Cephalometric tracings of Patient J. J. before treatment. A, Patient’s tracing before treatment B, Selected normal pattern; same NGn, dimension as patient. C, Superimposition of patient’s tracing over selected normal pattern oriented on SN and registered on S; shaded area emphasizes differences in upper facial patterns. D, Superimposition of patient’s tracing over selected normal pattern, oriented on NGn; shaded area emphasizes differences in profiles.
A.
c. Fig. 10. mcnt.
Facial
photographs
D. of
Patient
J. J.
before
(.4
and
13)
and
after
(C and
II)
treat-
in the osseous structures are reflected in the soft structures, with corresponding anterior placement of the upper facial soft structures. With this degree of rariation from the ideal pattern, we would hesitate to alter the patient to conform to the ideal tracing, so now let us focus our at,tention on the profile alone by reorienting the tracings on NGn as shown in Fig. 8, D. In this relat,ionship we have quite a different picture. The relative position of the mandible seems quite satisfactory, and even the occlusal plane of the molars is quite harmonious. The incisal edges of the lower incisors are still much highrr than in the ideal tracing, and the mandibular bone surrounding t,he lowr incisors and in the menton region is considerably larger.
742
IIolmcs
Pig. Il. Intraoral F) treatment.
photographs
of
Patient
.T. J. Iwfore
i-4,
C. and
E> and aftrr
(R, D, an11
Pogonion is also quite prominent. The lower first molars are completely distal to the upper first molars, but the prominent menton compensates for this. Vertical dimensions in the maxilla correspond very closely, but all horizontal dimensions are greater. Were these tracings to be reoriented again on the Frankfort horizontal of Wylie, registered on PTM, the relative oversizing of horizontal dimensions of the maxilla would be even more evident. In fact, at this stage of comparative study, the individual deviations from ideal become more and more obvious, and many reorientations to the two tracings in zero reference to the characteristics to be studied are very much in order. However, to conclude our
Volume Number
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Comprehensive
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treatment
743
evaluation of this orientation, it appears as though the three greatest variations from the ideal normal chart are in the region of S, the premaxillary and subnasal region, and in the molar relation. Obviously, we could not change S, so we could disregard that. As far as the molar relationship was concerned, the casts and additional aids in this case showed a good lower arch, and there was no disturbance of function in the molar region. Functional and occlusal analysis did not indicate any distal locking of the mandible and, from the standpoint of the posterior and lower part of the face, it did not seem imperative to change the molar relation unless such a change could be considered beneficial to the premaxillary region. From the standpoint of growth potential, the great height of the mandible in the lower anterior region and the facial appearance of excessive vertical dimension in the lower face suggested continued emphasis on vertical development in this area. All in all, I decided that t,he deviation from the ideal pattern was such that the usual Class II approach to therapy, as utilized in the first case, would not result in sufficient change in the natural characteristics of this face to bring about a satisfactory result. Therefore, I decided to try to maintain the natural balance throughout, except for the deviating premaxillary region. For the benefit of this area, I elected to extract two upper first premolars and subsequently attempted to retract the premaxillary structures into closer conformity to my concept of ideal pattern. This is the point at which many of us can very logically come to entirely different conclusions in the selection of the most desirable appliance therapy. My purpose here is not to dictate or even knowingly to direct appliance therapy but, ra,ther, to present available case study data in a manner that will enable all of us to evaluate and correlate our data to the end that our final decisions will be objective, constructive, and sound. In other words, I propose a comprehensive diagnosis, leading to specific treatment with the appliance of your choice. Now let us continue with our case study and analysis. As stated earlier, I treated this case will full-banded technique, which included the extraction of the upper first premolars, and used Class II elastics and a neck strap for distal stress on the maxilla. Fig. 9, il shows the tracing following treatment. I might just as well call attention to it, because some of you will surely see it anywaythe upper anterior teeth are excessively vertical. In the final photographs you can draw your own conclusions as to whether or not this has det~rimentallp affected the facial profile. Much more can be seen by superimposing original and final tracings as shown in Fig. 9, B. First I would like to call attention to the harmonious downward and forward dimensional change of the molars and to the considerable increase in the size of the mandible. However, the dimensional change has been dominantly in a vertical direction, rather than horizontal, and to me this is further evidence of an individuality of pattern growth divergent from ideal normal. Now let us superimpose the final tracing (solid line) over the corresponding ideal normal pattern (dotted line), as shown in Fig. 9, C. Orientation is on SN, registered on S. Here again we see a considerable deviation of the individual pattern from ideal normal, but I feel that it also demonstrates how, even in the highly divergent form, certain selected changes can be made
toward a greater degree of harmony and balance. Fig. 9, 17 sho\vs comparison of the profile with the ideal pattern by superimposition on NGn. Fig. 10, Cr and D shows final facial photographs, and iTin. 11, -1 to P sho\vsbefore- ad aftertreaknent intraoral photographs. If the data pl.cscnted indicate to you that this case should have been treated without &ractions or with four premolar estractions, t,hat decision is certainlp your privilcgc. Jly only hope is that this a~)preach to diagnosis may hc all additional 11~11)to all of LIS in our pretr
Fig. 12. Composite mrasurements taken
Class II, Uvision in seventy nine
1 facial pattrru Class II, Division
based 011 the I cases.
averages
of
fort,y-tiv
zontal dimensions of the upper face rather than a diminuti\-e, posteriorly placed mandible. As I have compared mang such cases with my Class I pattern, I havc~ become increasingly aware of the fact that Class II, Division 1 facial morpholog! is quite different from Class I in a number of ways, not the least of which ma?be this oversizing of the upper face. Accordingly, I have made a rather detailed study of seventy-nine Class 11, IXvision 7 cases for comparison with my Class I pattern. Cephalometric tracings were made in c~ch of the seventy-nine cases, and photographic negatives were made of these tracings. The negatives WTP rnlarged and printed so t,hat each tracing photograph had a common N(:n dimension of 113 mm. to correspond with the Class I pattern. Fort,y-five measurcmerits were then made of each photograph and recorded. Average readings for all dimensions were determined, and from these data a composite Class II,
1 pattern wax spnthe&ed. This pattern is shown in Fig. 12. The C&n II pattern is purposely designed so that it can be compared directly with the Class I pattern. Fig. 13, 11 to 11 shows this comparison and superimposition. Fig.
~)i&on
A.
c.
R.
u.
F’ig. 13. Comparison of Class II, Ibision 1 composite facial pattern with selected normal pattern. A, Class II, Ijivision 1 pattern. B, Class I pattern. C, Superimposition of Class I pattern (dotted line) over Class IL, Division 1 pattern (solid line), oriented on S.N. and registered on S; shaded area emphasizes diflrrences in upper facial patterns. D, Superimposition of Class I pattern (broken line) over Class II, Division 1 pattern (solid line), oriented on NGn; shaded area emphasizes differences in profiles.
746
Holmes
Am.
J. Orthodontics October 1962
13, C shows that orientation is on SN, registered on 8. Many interesting comparisons can be made, but I think that one of the most interesting observations is that a good portion of the Class II? IJivision 1 pattern very closely conforms to the Class I pattern except for the horizontal oversizing in the upper anterior portion of the face. Fig. 13, D shows the two patterns superimposed on NGn for profile comparison. For the sake of clarity, remember that I did not say that Class II, Division 1 cases nezfer show a diminutive or distally locked mandible. I am stating only that the average pattern of this sample of seventy-nine Class II, Division 1 cases seems to show horizontal dimensional oversizing in the upper face as compared with my Class I pattern. To me! this is an interesting observation which could well stand some further investigation. I also recommend for your consideration the method of this investigation and study. I can assure you that it is a very fascinating extracurricular activity which offers an interesting method of studying some of our unsolved orthodontic problems. Briefly, the technique suggesm a method of studying similarities and dissimilarities of facial forms of all sizes and configurations. The faces are first reduced or enlarged so that one indicative measurement is common to all faces studied. The faces are then compared individually and collectively with each other. To date two standard patterns-the ideal normal and the Class II, Division 1 pattern-have been synthesized and partially studied. I have given you only a very few of these observations and comparisons. The data have been studied not only for determination of average dimension but also for probable deviations, relative variations, and other purposes not included in the scope of this article. CONCLUSION
In this article I have presented my concept of a Class I selected normal pattern, and I have shown how I utilize this pattern as a measuring stick for comparison of the individual with the ideal pattern. I have presented a method of comparative study of similarities and dissimilarities of facial forms of various sizes and configurations. I have presented a composite pattern of a group of Class II, Division 1 cases and have compared this pattern with the Class I pattern. This study is continuing in the hope that additional investigation may eventually help clarify some of our mutual orthodontic problems.