The keystone triad

I. Anatomy, phylogenetics, and clinical references

ROBERT MURRAY RICKETTS, D.D.S., M.S.*

Los Angeles, Calif.

THE chin, point B, and the lower incisor merit discussion as a triad. A f ~
knowledge of all the influential factors in this unit is often the key to clinic~
success or failure. Sophistication in orthodontics depends upon an understand-
ing of the systematic totality of the behavior of this triad which is the keystone
of the lower jaw.
T o d a y concern over a receding chin is f r e q u e n t l y e n c o u n t e r e d b y the
orthodontist. This concern also has been m a n i f e s t e d b y m a n y cultures of the
past. ] n his writings K e i t h 1 mentions the conceit of certain groups as shown
b y their description of the " c u t " of the chin. He describes the m e n t a l state
which has impelled m a n to f a v o r his own k i n d and to be indifferent to all
others. M a n y philosophers h a v e held t h a t the chin was essential to facial
b e a u t y and thus was a significant f a c t o r in the desire f o r the m a t i n g of
"superior races."
D u B r u l and Sicher, ~ however, sober this ethnocentrism b y insisting t h a t
" t h e chin is but a blob of bone subject to all the laws of bone a n d muscula-
t u r e and is the result of the s h r i n k a g e of the d e n t i t i o n . " I n other words, the
chin has developed as the teeth became less p r o m i n e n t in the face a n d less
i m p o r t a n t to the life of the organism as a whole.
Downs 3 first described " B " as a clinical point in 1948, although the point
of deepest c o n c a v i t y at the chin alveolus on the a n t e r i o r portion was em-
ployed p r e v i o u s l y b y a n t h r o p o l o g i s t s a n d other investigators who called this
point s u p r a m e n t a l e . 4 I stopped using this point, except for descriptive pur-
poses, several years ago. P e r h a p s an explanation of m y reasons for not using it

Tho first of two essays to be published in the AMERICANJOUI~NALOF ORTHODONTICS,

based on material presented before the Middle Atlantic Society of Orothodontists
in Atlantic City, N'. 5., Oct. 28 and 29, 1963, and before the Jarabak Foundation in
Chicago, Ill., Feb. 1 and 2, 1963.
*Associate Professor of Dentistry, School of Dentistry, University of California.
244
vozume ~o Keystone triad 245
N'~mber 4

clinically will help to strengthen other points that arc used instead, or per-
haps my observations will provoke some interest and stimulate a controw,rsy,
which is good for the clarification of any subject.
The differences of opinion regarding the most proper measurement or
position of the lower incisor are as old as dentistry. As neophyte dentists, we
were taught to put teeth over the ridge in prosthetics. Yet we frequently
observe clinically healthy mouths in which these teeth arc far forward ,v
backward of the center of the chin. The resulting confusion has led many
clinicians into a dilemma about who is right (ir which technique they shouhl
follow. Some have come to use many techniques, i actually observed one
clinical procedure in which an orthodontist used four different analyses in
order to determine " w h i c h way to go." There has been little concrete found,-
tion because sophisticated research in large longitudinal samples, treated and
untreated, is only now forthcoming. Agreement will lie difficult because ,kl
the wide variation in nature and the differences in structure that any inveslL
gator of human biology quickly observes. The prol/lem of relating the h)wer
incisor should be defined and simplified, gemanties should be olarified, and
known facts should be recognized.

OSTEOLo,Y
Although the orthodontist deals daily with the chin, a review of the fine
anatomic points seems advisable in this discussion. The chin will be described
as it is viewed in the mandible as a whole aud as seen in detail at the sym-
physis (Pig. ] ).
When the dried mandil)le is held in the hand, one quickly realizes that
its greatest bulk is seen in the area of the molars immediately anterior to the
ramus. On elose inspection, it will be noted that a " c e n t r a l c o r e " of the man-
dible starts from the mandibular condyle and proceeds through the ramus and
is reinforced by the coronoid process at the external oblique ridge. The mass of
the bone at this point is extremely heavy, as any oral surgeon knows. Thb~
central core then terminates in the chin. Thus, the chin is directly connected
to the mandibular condyles, and the mandible is one long bent bone.
Looking on the medial side (Fig. 2), the outer heavy mass is eomple--
mcnted by the inner mylohyoid ridge which joins it to proceed around the
mandible toward the midline, forming a hard, compact internal and external
cortical surface. On the outside, the external oblique ridge proceeds forward
under the mental foramen and blends into a mass of bone which we call th~
chin. The two halves of the mandihle join at the mid]in(~ t . fm'm th~ sym-
physis.
AnterioHy, on the inside in th~ area of the symphysis (Fig. '3), 1lie fob
lowing landmarks should he noted: the inferior ridge of hone, slightly de-
pressed at the midline and terminating in tlhe interdigastric spine, and on
either side a depression called the digastric fossa. These points and surfaces
form the posterior border of the symphysis as traced eephalometHeally.
The inner surface of the chin is also of gre~lt interest for our pres,mt
consideration (Fig. 4~. Immediately above, on either si,le ,,f the afot'emen-
246 Ricketts ~t.~. J. O r t h o d o n t i v $
April 1964

Fig. 1. Lateral view of the mandible. 0 shows area of greatest thickness of this bone at
external oblique ridge. Stresses from condylar area (C) join with stresses from the coronoid
process (CD), and these combined vectors terminate in the chin at mental tubercles (I').
Buccal occlusion is Class I I (Angle) malocclusion.

Fig. 2. On the medial side, the mylohyoid ridge (M) proceeds forward from the mandibular
foramen to blend into the plauum alveolar (P) at the midline at the symphysis (S).
voz~,~), Ket/stone ttqad 247
N~mber 4 "

Fig. 3. I n f e r i o r aspect of symphysis showing interdigastric spine (is), digastric fossa ( d / ' ,
an4 genial tubercles ( g t ) . Note also bulk at X and prominence at P.

Fig. 4. Inside view of symphysis showing the inferior torus (it), the superior t ransw~rs~
torus (st), and the planum alveolar (pl). (Note the thickness of bone in "trea as sho~v~ i~
Fig. 6.)
248 Ricketts A , , J. O,'thodontie.~.
April 1964

tioned digastric fossae, are p a i r e d spines os tubercles k n o w n as the genital

tubercles. Between these rounded extensions, in the midline, are m a n y foranl-
ina. Above the digastric fossa is a ridge of bone r e f e r r e d to as the inferior
t r a n s v e r s e t o m s . A p p r o x i m a t e l y m i d w a y up the slope of the lingual surl'ace
of the bone and in a direct line with the m y l o h y o i d ridge is a bridge of bone
called the superior t r a n s v e r s e torus. A b o v e this ridge is a flattened area
k n o w n as the p l a n u m alveolar, or the alveolar plane of the m a n d i b u l a r sym-
physis. Thus, the posterior surface has the s t r o n g e s t and most heavily s t r u t t e d
site in the chin.

Fig. 5. Frontal view of chin. The area from the mental tubercles (T) blends upward and
forward to meet the mental protuberance (Po) or pogonion to form the trigonum mentale
(T-Po-T). There is a slight ridge for the attachment of the mentalis muscle (m).

T u r n i n g the mandible and the chin to the f r o n t a l view and looking at the
mandible in strict detail, we see several points t h a t are of interest (Fig. 5).
Virchow s called the d o m i n a n t area of the chin the t r i g o n u m mentale. This
t r i g o n u m is composed of the tubercle of the p l a t y s m a as it comes f o r w a r d to
f o r m the mental tubercle. F r o m these lateral tubercles the bone bends u p w a r d
and f o r w a r d to meet at the midline of the mental protuberance which termi-
nates in a ridge of bone blending u p w a r d into the alveolus at the j u n c t u r e of
the two halves of the mandible. These points are often confused in the eephalo-
metric image.
I n a lateral direction, at a p p r o x i m a t e l y a midpoint from the lower border
to the m a r g i n of the alveolus, we see the ridge for the mentalis muscles. The
area above this ridge at the roots of the incisor teeth is called the mental fossa.
V'ot~,,~e :,~ Ke.~jsto~te triad 249

Details of the growth change of the ridge for the mentalis muscles are nol
known.
In cross section, in the midsagittal area (Fig'. 6), the symphysis is c h a r a c
~erized by a thick outer cortical layer of ahnost horseshoe shape which is heavivr
on its lingual surfaee than on its labial surface. The planum alveolar is con
sistently thick from the genial tubercles to the alveolar border. The oute:'
(;ompaet plate f r e q u e n t l y terminates in the r~gion of th~ m~ntal protuberanc~
and is quit~ thin at the curve leading up to the h~w~,r blcisor, esp~cially l~ll
~',ral to the midline.

Fig. 6. l , a t e r a l view. N o t e g e n i a l t u b e r c l e s (gt) a n d p l a n u m alveolar. Pogo~lion is lo,.at~d

at, g, point B at X, a n d m e n t o n at Z. N o t e m y l o h y o i d ridKe (ml). T h e occlusion as l:lnss t |
,, ta tact( risti,,s

The true chin'-' is " s t r u e t u r e d in relief oil th(~ u p w a r d and /)ackw~Jr~i

slanting outer surface of the jaw at the midline (protuberance) eantil~o:
sharply out of the hollow just below the sockets of the incisor teeth. A rid~(~
divides below to enclose a t r i a n g u l a r bulge with a concave base forming lh~
lower b o r d e r of the jaw and ending on either side in a blunt knob, the m~nt~l
tu, bercIe." A real subject of controversy is the area from the mental protuber-
anee to the lower incisor or the labial curve of the bone up to and includht~;
the incisor root.

MYOLOGY

It is impossible to consider the chin from a biologic point of view without

giving due consideration to the attached muscles and the total function p(r-
formed by the bone. Muscle pull wins out over bone and is a strong factor
in a consideration of point B and the lower incisor. I like D u B r u l and Sieh-
m"s ~ stat~'mcnt that bone can be r i g h t l y imagined as li~'i~tg calcified s~]st(:m,~
250 Ricketts A~n. J. O r t h o d o n t i c s
A p r i l 1964

of stress, and that these stresses may be elicited by forces acting directly upon1
the area or by the loading of a bone distant to the area. It is necessary, there-
fore, to remind ourselves of the muscles that are both directly and indirectly
related to the function of the lower incisors and of the chin as a whole.
In this study attention will be directed to only the pertinent muscle sys-
terns. Let us first examine the muscles most directly concerned with the chin
proper. The first of these is the mentalis muscle (Fig. 7), which arises from
that aforementioned slight ridge of bone just below the incisal fossa and extends
into the chin tissue where it is fused with the muscle of the opposite side. It
elevates the tissue of the chin immediately over the trigonum. In orthodontics
nearly all lip problems involving muscles have been rather loosely called "men-
talis habits." Space will not permit a discussion of functional problems in this
area; these vary extensively, and the reader is referred to my previous publi-
cations on classification of lip problems. 6
The second muscle of concern is the quadratus labii inferioris (Fig. 7),
which is sometimes called the depressor of the lower lip. It arises from the
slight ridge of bone posterior to the mental protuberance and extends
obliquely upward to join the orbieularis otis around the mouth. These fibers
cross at their insertion and blend with the same muscle of the opposite side.
What is not well known is that they sometimes connect in the midline to
form an almost horizontal band. We need to know much about the detail of
variation in this area. Is this band, which is sometimes present, the cause of
the sublabial furrow that we often see clinically ?
The next muscle is the triangularis (Fig. 7) which covers the origin of the
quadratus labii inferioris and is attached from a point just distal to the mental
tubercle backward to a point on the external oblique ridge, ahnost at the level
of the first molar. Its fibers converge toward the corner of the mouth and
are continued as a part of the orbicularis otis into the upper lip. This muscle
draws the mouth laterally and downward and is opposed by the caninus
muscle from the upper lip. In many patients a thin slip from this muscle runs
under the chin and joins a faseiculus from the opposite side to form a trans-
verse mental muscle. Can this be a problem in the extremely narrow chin
sometimes seen clinically? Anatomic research into the details of these chin
muscles is still needed.
We often forget the platysma muscle which originates in the lower part of
the neck, extends obliquely upward to the chin and corner of the mouth, and
inserts into the mental tubercle of the mandible and the inferior margin of the
mandible. It often fuses with the quadratus labii inferioris and the orbicu-
laris oris and can serve as a depressor of the integumental tissue and of the
mandible. We usually do not appreciate its influence until we see a case of
tortieollis in which the whole head is pulled to one sideJ
The muscle system of great concern to us in the present discussion is the
buccinator complex (Fig. 8). The buccinator muscle arises from the pterygo-
mandibular raphe and from the sides of the maxilla and the mandible and runs
forward to decussate at the commissure of the mouth, completely encircling
it. Its function is to pull the lips against the teeth and to flatten the cheek.
Volume 50 K e y s t o n e triad 251
Number 4

\
A

L/
@

f
f
f

/f
B
Fig. 7. A, Diagrammatic representation of pertinent muscles in the chin area as viewed from
tracing of frontal head film. Note mentalis muscles (m); quadratus ]abii iuferioris (Li);
triangularis (Tr); dotted line represents the plutysma. Quadratus muscles sometimes join at
X. Note area of cortical bone viewed in frontal head fihn at arrows and O. B, Muscles se(m
in lateral perspective.
252 Ricketts A,~. J. Orthodontics
April 1964

Fig. 8. Diagrammatic representation of buccinator complex as viewed from the lateral head
film. The orbicularis otis blends with these muscles, bu, Buccinator; ml, mylohyoid. The
digastric muscles are also represented. (da, Anterior belly; dp, posterior belly.)

This muscle literally wraps around the arch in the area of point B. It should
be added that one school of thought labels the buccinator in common with
the superior constrictor because they join posteriorly at the pterygomandibu-
lar raphe. This buccinator complex is of direct concern in the eruption of
teeth and the development of occlusion.
One might ask why the muscles of mastication should be related to the
chin. The fan-shaped temporalis, the thick masseter, and the pterygoid muscles
are of deepest concern to the biologist. In a discussion of the chin, the external
pterygoid comes into consideration because of its possible importance to the
bulk of the chin, although it is farthest removed from the chin at its insertion
(Fig. 9). The arrangement of the closing muscles is well known, but the exter-
nal pterygoid should be considered almost independently. This factor will be
discussed later in connection with the vectors of pull of these heavy muscles
and their influence on form of the mandible.
Of direct consideration are the muscles which are attached to the inner
aspect of the chin and the inside margins of the mandible : the muscles of the
tongue and the hyoid muscle (Fig. 8). Of first concern, possibly, is the digas-
tric muscle, particularly the anterior belly which originates in the digastric
fossa at the lower border of the chin toward the midline and proceeds down-
ward to a stirrup from the hyoid bone, only to go upward to the posterior belly
and to end in an area beneath the mastoid process. Deep to this muscle is the
mylohyoid muscle which, together with its twin on the opposite side, forms the
vozume ~O Keystone triad 253
lgumber 4

Fig. 9. Representation of geniohyoid (gh) and genioglossis (gg) traced from lateral head
film which was exposed lightly. The external pterygoid directions i)~ lateral perspective are
suggested ( P t ) .

floor of the mouth. It arises from the mylohyoid line in the mandible, which
extends from the symphysis to the last molar and the mandibular foramen.
The anterior portions are attached to a medial fibrous raphe, which often
runs backward to the hyoid bone. Deep to this muscle is the narrow genio.
hyoid muscle, which comes from the inferior genial tubercle and extends from
the chin to the hyoid bone on either side of the midline.
The tongue muscle with which we are mainly concerned in our study o~'
the chin is the genioglossus which arises from the superior genial tubercle (Pie'
9). Some fibers of this muscle extend upward a)~d forward into tile tongue:
others extend directly toward the dorsum of the tongue; and the lower fibers
run downward and backward to the medial part of the superior border of th( ~
hyoid bone. Although this muscle serves to change tongue form, its main put'
pose is to draw the tongue forward for protrusion from the mouth. In om
sense, the genio.qlossus muscle is, therefore, an antagonist of the buccinato)
muscle. There arises the question of whether these two very important muscles
have a reciprocal or synergistic relationship of value to the clinical orthodon-
tist. This is at the very vital center of clinical practice, for the lower incisor
lies in a state of equilibrium between the tongue and the lips.

ANTHROPOLOGIC CONSIDERATIONS
In their excellent work entitled The Adaptive Chin, DuBrul and Sieher:'
list six structural changes which occur in the development of forms from th(
254 Ricketts A,~. J. Orthodontics
April 1964

• Tupoio

~ Lemur
~Cercopithecu$
Cebus
~ Hyolbae
ts

Homo
Fig. 10. Six stages in alteration of the symphysis in the phylogenetic development of man.
Note the horizontal relationship of the chin in the Tupaia to the vertical relation in the
Homo. (From DuBrul and Sichcr: The Adaptive Chin, Springfield, Ill., 1954, Charles C
Thomas, Publisher.)

lower primates to modern man. Time will not permit a thorough discussion of
their outstanding work, but certain critical observations cannot be omitted. In
the lower forms, such as the Tupaia and the Lemur, the mandible is long and
V-shaped (Fig. 10). The lower teeth are seen to extend almost directly forward.
In these animals the chin is flat, forming an almost directly horizontal shelf.
Vol~tme 50
~V~tmber 4 Keystone triad 255

;...:..y

Fig. 11. One theory of the function of the symphysis is to bridge the mandible from both
of the external pterygoid muscles. A, Vectors of pull from superior view. B, Both are force-
fully contracted in protrusive movement of chin. C, Unilateral contraction observed in lateral
movement of chin. ( F r o m Dubrul and Sicher: The Adaptive Chin, Springfield, Ill., 1954,
Charles C Thomas, Publisher.)

I n the Cercophithecus, the p l a n u m alveolar is t u r n e d slightly upward, and the

inferior t r a n s v e r s e t o r u s has f o r m e d a slight shelf which is sometimes re-
fl, r r e d to as the simian shelf. A f t e r this stage has passed, the chin starts to
t u r n more u p w a r d and the teeth become more vertical in their relation to the
256 Ricketts A,~. J. Orthodontics
April 1964

symphysis. In Homo sapiens, the main body of the synlphysis is usually in-
clined posteriorly (Fig. 11).
DuBrul and Sicher offered four principal theories in explanation of these
phylogenetic changes in the chin: (1) the shifting theory, (2) the development
of articulate speech, (3) the mechanical effects of reduction and retrusion of the
teeth, and (4) the influence of muscle activity. After a rather complete critique,
DuBrul and Sicher concluded that probably the best explanation that could be
offered involved the effects of muscle activity; thus, they agreed with the theories
of Weidenreich s and Grunewald2 By means of a stress coat painted on the man-
dible, it was shown that the compressive strength exerted by the external ptery-
goid muscle in the normal lateral and protrusive movements of the lower jaw
was enough to produce a strain in the symphysis (Fig. 11). In the protrusive
movement of the mandible, DuBrul and Sicher were able to demonstrate a
0.5 ram. contraction in the width of the intermolar distance. They concluded
that this force was probably important in the formation of the chin. Thus it
is strongly hinted that the development of the chin is linked with good lat-
eral function of the mandible.
DuBrul and Sichcr favored this theory rather than that of Klaatseh, 1° who
claimed that the form of the chin was due to the inward or outward rota-
tional effect of the temporalis or masseter muscles. In patients with large
mental tubercles, Klaatsch had reasoned a temporalis dominance, while patients
with large mental protuberances were thought to reflect masseter dominance.
DuBrul and Sicher agreed with Weidenreich s that the human chin was the
result of a long evolutionary process and that the triangular form of the chin
was due to a buckling of the alveolus which was filled in with bone as a result
of the total transformation principle. They pointed out that the chin was not
developed as an isolated factor and showed that it was consistent with the up-
righting of posture and the change in locomotion of the animal (Fig. 12).
Thus, the development of the chin is consistent with a long line of structural
changes in the whole body and is not a single entity unto itself.
From a clinical point of view, I would readily accept the thesis of DuBrul
and Sicher. However, I tend also to inspect in a very critical nlanner the shift-
ing theory developed by Bolk 11 in 1924, especially in light of more recent
cephalometric growth findings and certain conclusions of Brodie. 12
Bolk described various forms of the chin. A chin with an angle greater
than 90 degrees, or no chin, was termed ageniotic. This would be represented in
our current thinking by chins in which point B lies anterior to the body of the
symphysis. Chins with a 90 degree relation to the body of the mandible were
described as neutral, or nlesogeniotic. Definitive chins, or those with angles less
than 90 degrees, were described as eugeniotic. These types delight those fol-
lowing the Tweed school of thought and demonstrate what is called a " b u t -
t o n . " Bolk pointed out that in fetal life most chins are mesogeniotic and that
in the ape, since the second molars erupt prior to the shedding of the decidu-
ous teeth, the chin tends to become ageniotic. In man, however, the basilar
part grows faster than the tooth-bearing parts, and the second molar does
not erupt until after the deciduous teeth are shed; hence, man becomes more
~*ozu.~e~,o Keystone triad 257
Nit~bev 4

7"
Homo
/F

/
/
1 I
I

II
p
.

I Hylobates
i t
i tI
l I

I i

I
t

~'
J Cebus

'4, Lemur

,,,~~'t ~ ' ~ Tupaia

Fig. 12. Changes in the chin are associated with deep underlying structural and funetion~l
phenomena, such as uprighting of posture and vertical locomotion of the organism. Diagram
~hows direction of opening of foramen magnum, change in the angle of the ramus, and
change in cant or inclination of symphysis. (From ])uBrul and Sicher: The Adaptive Chin.
Springfield, Ill., 1954, Charles C Thomas, Publisher.)

e,ageniotie. Thus, although it has not been stated directly, one eouhl infer
t h a t f o r w a r d positions of point B were eharaeteristie of more primitiw~ races.
Both H u x l e y '~ and Cuvier 14 described a flattening of the faee during th,:
individual life cycle, and this idea has been accepted by m a n y anatomists and
258 Ricketts A.~. J. Orthod(mt~os
April 1964

anthropologists. ]'he inference is that the face becomes less convex and the
denture less prominent. ~ ut it has also been observed that some of the lower
creatures, born with a shortened maxilla, grew alveolar processes on the
lower jaw which leaned backward so that the teeth could work against the
upper opponents. Thus, in an ahnost pt~ssive manner the lower border of the
mandible has come to lie in an advance position in the lower jaw. These
structural stages of development are a prologue to the beautiful act of Nature
in the ontogeny of the human face. Knowledge of these observations from
studies in basic science helps the clinician to become better qualified for mak-
ing decisions at the chair.

CEPHALOMETRIC LANDMARKS AND DESCRIPTIONS

Studies of mandibular growth are usually started postnatally or after in-

fancy, and various tools for measurement are needed. With the advent of cepha-
lometrics for growth studies, the description of various landmarks in the lateral
x-ray film has been controversial. Certain points of reference have come to be
accepted, although frequently they are given different names. One subject of
our present study is point B, which Downs described as a point at the deepest
curvature of the outline of the symphysis in the chin. This point allegedly
was to separate or to be located at a junction between the basal bone and the
alveolar bone (Fig. 6). Downs was concerned with the relationship of the
alveolar bone, since at that time he feared the alteration of tooth position on
the mandible because of experience with so-called " s t r i p p i n g " or recession
of the investing gingival tissues when the lower incisor' was moved forward.
The use of point B was simply a convenient device for description.
A vertical deepening of the body of the symphysis occurs with eruption
of the teeth. The bony tissue that is alveolar in the young becomes incorpo-
rated in the body and becomes basilar in the adult, so that point B moves
both vertically and horizontally. The need for description, however, makes
necessary the identification of one area to separate it from another, at least
for purposes of measurement. Point B was referred to earlier by BjSrk as
supramentale, which was the anthropologie nomenclature described by Martin
and Salles. 15 Therefore, either SM or B will suffice as a symbol for our use.
There seems to be little disagreement that the most anterior point on the
curve of the outline of the symphysis can be termed pogonion. This is a point
on the n|ental protuberance at the midline and should not be confused with the
mental tubercles, which are lateral structures. Different symbols have been used
to designate pogonion, including PG, POG, pg, Po, Pg, P, Pgo, and pgo. I
choose to label it Po, following the original work of Downs. The simple P has
been employed for porion, so I hope to implement the understanding of this
point with the continued use of Po.
The selection of gnathion (Gn) has become confused by various state-
ments of different authors. Brodie 16 selected gnathion as the lower anterior
point on the chin by bisecting the distance between the most anterior and
inferior points on the bony chin. Its use became confused as Brodie selected
the most inferior curve on the body of the mandible at the angle and at the
roZume,~o Keystone triad 259
~Vumber 4

lateral area of the chin as a mandibular plane. To confuse the issue further,
Downs selected the mandibular plane from the lower border at its angle to
the lower border of the symphysis and, at the intersection of this mandibular
plane with the facial plane (nasion--pogonion), erected a point in space som(~-
times referred to as gnathion.
]n an effort to straighten out this protflem of description, some writer's
have chosen to refer to the lower border of the symphysis as mentott (M),
the anterior-inferior point at the crossing of the Y axis as gnathion, and the
anterior border as pogonion. BjSrk, Jensen, and Palling '7 suggested the term
prognathio~ for that point selected at the crossing of the Y axis and reserved
the use of gnathion for the inferior border. Menton was to be employed for
lateral structures usually seen at the mental tubercles rather than at the men~al
protuberance and thus would represent a lateral structure. I suggest that H~ese
points be labeled Mt for mental tubercles.
Swartz used a point at the anterior curve of the symphysis and called it
the SM or spina-mentalis (Fig. 13). He drew a distinction between crista men-
talis (CR) and tubercle mentalis (T) in the outlines seen cephalometrieally.
Studies using the posterior border have been conducted by Bench, 's who
termed this point genial (G). In actual practice most authors describe their"
reference points at the start of their studies, which has helped to reduce ~]~e
confusion, but many have not done this.
Another reference point has been suggested by Steiner2 ~' The eenter of the'
symphysis wets picked by inspection, in nmeh the same manner that the center
of sella-tureiea was selected. Recognizing the inadequacies of using point 1~
for changes in the chin, Steiner employed it as a reference point which h~
called point D for the purpose of evaluating serial behavior of the chin 1o SN.
Several arguments have been offered against the use of pogonion or

A B C D E
Fig. 13. Concepts of A. M. Sehwarz on the bone of the chin and lower incisor. A, tlorizontal
lines represent retroposed alveolar bone. Vertical hatched portion is area of spongiosa.
B , Vertical hatch shows sylnphysis spongiosa; horizontal small hatched area lateral to mid-
line shows prominent tubercles and yields double line for anterior border of the symphysis.
True midline is posterior contour. C, Lower incisor can be 90 degrees vertical and be either
forward or backward. The angle does not describe its anteroposterior position. D, Lingually
inclined lower incisor at 70 degrees can still be either forward or backward. E, Labially
inclined lower incisor (110 degrees) also can be either forward or backward. Note that point
B is determined by the lower incisor position.
260 Ricketts ~ m . J. O r t h o d o n t i c s
April 1964

gnathion for the growth reference, since it was believed that both of these
structures reflected secondary growth characteristics, particularly in males;
however, these objections have not been based on direct study but are simply
hypothetical ones based on a few cases thought to grow buttons. Thus, the
so-called " b u t t o n " on the chin has sometimes been referred to in the litera..
ture. In actual practice, some refer to the button (or spina mentalis) as any
bone anterior to point B. Since little concrete work has been done in this
regard, it will be necessary to review some of the studies of growth in a
longitudinal manner to reflect some bona fide information on the subject.

CLINICAL REFERENCES

Cephalometric references vary among different authors. Several planes of

reference have been constructed in order to study the chin, point B, and the
lower incisor in morphologic analysis and for growth and change. The man-
dibular plane has been the one most commonly employed for growth reference
(Fig. 14). Brodie used a line tangent to the inferior border in discussing the
growth of the mandible, but for analysis he used a plane between Go and Gn.
This method was modified by Steiner. With the advent of Downs' analysis, a
line from the inferior border of the angle of the mandible to the lower border
of the symphysis or point M has become most popular. For routine measure-
ment, I have selected this plane by superimposing on the " h o r s e s h o e " out-
line of the chin with the mandibular plane parallel, hereinafter called the
mental osseum.
In 1960 I started using still another plane of reference for growth of the
mandible and behavior of the chin after viewing BjSrk's '~° studies on im-
plants, discussing it with him personally, and reviewing my own series of
mandibular growth problems. 2~ With laminagraphy, the mandibular canal and
the mandibular foramen could be located. Therefore, I registered on the sym-
physis at the anterior border of the mental osseum and superimposed with
the mandibular foramen parallel. My impression was that this technique
closely followed the pattern expressed by BjSrk's implants. More recently
BjSrk 22 has advised superimposing over the inferior border of the crypt for
the third molar in line with the mental osseum or area of pogonion.
In assessing development of the chbb the use of the ~'acial plane (N-Po)
has also been popular because nasi(m represents the terminus of the anterior
limits of anterior cranial base as pogonion represents this point on the ma~l-
dible (Fig. 14). The lower incisor and point B have been related to this line.
The line N-B has also been employed by Reidel and was adapted for
measurement of the lower incisor by Steiner. ~ When point B is in line with
the facial plane, the two would be synonymous and recordings would be
identical for either NB or NPo. As a reference for the spatial position of the
lower incisor, I have continued to use the point A--pogonion plane (Figs. 6
and 14). In a perfectly straight face, with point B forward on the facial
plane, all three planes (NB, NPo, and APo) would be identical.
Downs employed a line from point A to point B in an effort to relate the
denture bases to the facial plane. So-called " b a d " A-B relationships were
voZum~ ~o K e y s t o n e triad ,,°61
.V~ber 4

Fig. 14. Cephalometrie scheme employed by Rieketts. Mandibular plane for cephalometri(~
work is constructed from lower border of angle of mandible to lower border of symphysis at,
midline, labeled M. Go is located at the arrow at the angle. In clinical usage, Gn is located
in space at point of intersection of facial and mandibular planes and sometimes labeled point
M. Technically, it is downward and forward in position on chin at crossing of Y axis (S-Gn).
N-Po, Facial plane; A-Po, denture plane. Tip of lower incisor related at distance from A P,
plane (4).

those in which either A or B, or both, was distant to the ~acial plane or :from
a s t r a i g h t line. I n an a t t e m p t to simplify this description, Reidel measure~l
the angle A-N-B. Thus, " b a d " A-B relationships have come to mean dishar-
mony of maxilla and mandible. W e have expressed skeletal c o n v e x i t y with ~1
straight linear measurement of point A to the facial plane, with no a t t e m p t
to consider point B per se.
One might ask why we use point A as a reference in the maxilla and
object to point B in the mandible. The answer is t h a t we simply cannot find
a better anterior terminus of basal bone in the u p p e r jaw. The anterior nasal
spine is definitely a process and so, of course, is the alveolar process. A junc-
tion between these two, therefore, represents basal bone and allegedly com-
pact bone. W e k n o w t h a t " A " is influenced by movement of the upper'
incisor, but still we must accept it as the best reference point. Bone p r o p e r
in the maxilla and the mandible is vastly different in c h a r a c t e r and functiom
and this is a f u r t h e r consideration.
I have r a t h e r serious objections to the common interpretations of point
B, p a r t i c u l a r l y to the use of NB as a reference for the lower incisor. This is
due to the fact that point B is determined by the position of the incisor in
the fir.st place. Consequently, relating the incisor to point B is relating it to
itself. Point B will not relate a t o o t h ' s incorrectness in the same light ~ls
262 Ricketts ilm. J. Orthodontics
A p r i l 1964

basal landmarks, because point B is an alveolar point after the mixed-

dentition period.
Holdaway '-'~ recognized the weakness of B point and has suggested that a
certain relationship of B to the bony chin be established its treatment. In the
final analysis, he was referring back to pogouion, ltoldaway went further to
extend the NB line through the chin. He strove to establish a relationship of
the lower incisor which was consistent with the distance from pogonion;
hence, a one-to-one relationship. It should be added that Holdaway did not
rigidly prescribe these measurements but was flexible with respect to indi-
vidual variation.
Lower incisor measurements have also been subject to great controversy.
Downs and BjSrk measured the incisal tip of the lower incisor to established
planes, from a point on the incisal tip. Steiner chose a point on the most
labial surface of the crown of the tooth to measure it in space. Probably the
biggest error ever to appear on the orthodontic scene, and one which affected
the course of orthodontics for many years, was the mistaken notion that the
angle or axis of the lower incisor was a measure of its forward or backward
position in the mandible or to the face.
The occlusal plane has been employed to measure the lower incisor and
points on the chin. The relationship of the A-B plane to the occlusal plane
has been taken as a measure of denture base problems. Changes with growth
have also been measured for this plane. Time will not permit a discussion of
the occlusal plane; however, this plane is vastly important to clinical ortho-
dontic understanding, especially its change with certain types of treatment.
Finally, the axis of the lower incisor has been related to the upper incisor
by the so-called interincisal angle. While this describes their mutual relation-
ship, it cannot be taken as a value for lower incisor behavior, since the upper
incisor can change radically with growth and treatment.
One final means of relating the lower incisor is its angle to the F r a n k f o r t
horizontal. While this value reflects the lower incisor's position to a horizontal
plane and serves as a guide for orientation to the earth's surface, it is a poor
criterion for measuring its spatial relation forward or backward.

SUMMARY

For purposes of convenience, we have used the term keystone triad in re-
ferring to the chin or symphysis, the lower alveolar process or point B, and
the lower incisor.
In order to understand the chin, the clinician should know the biologic
forces that produce the growth and make the chin of man what it basically
is--functioning bone serving nlany purposes.
]t is important to conceive of the t rigonum mentale in order to under-
stand the difference between mental tubercles and the mental protuberance
for the purpose of identification and tracing for serial comparison. In addi-
tion, the function of the heavy bone on the lingual side must be recognized
as supporting bone for the lower incisor.
Muscles are important in the production of an esthetically effective chin.
vozum~o
Number 4
Keystone triad 263

The immediate facial muscles are important, but of greatest importance are
those of the tongue and of mastication. The external pterygoid has been con-
sidered a very important single muscle.
Authors differ with respect to nomenclature and planes of reference for
the study of morphology and growth of the chin. Recent implant studies hay( ~
shed much light on the true nature of proper references for study, 1)m
investigations are still under way.
Anthropologic, osteologic, myologie, and eephalometric principles haw,
been related to the "keystone triad" located at the keystone of the dental
arch and the arc of the mandible.
[ have found the A-pogonion plane most useful as a plane of reference
for the lower incisor. However, growth and treatment behavior of this wilt
be discussed later. Clinical interpretation and use will be described in Part
[I of this study.

REFERENCES

1. Keith, A.: A New Theory of H u m a n Evolution, 1949.

2. DuBrul, E. L., a n d Sicher, H.: The A d a p t i v e Chin, Springfield, Ill.. 1954, Charles (:
Thomas, Publisher.
3. Downs, W. B.: V a r i a t i o n s in Facial Relationships: T h e i r Significance in T r e a t m e n t
a n d Prognosis, AM. J. ORTHODONTICS 34: 812, 1948.
4. BjSrk, A.: The Face in Profile, Lund, B e r l i n g s k a B o k t r y c k e r i e t .
5. Virchow, It.: M u s k e l m a r k e n am Schadel, Itsder. Ethnol. 42: 638, 1910.
6. Ricketts, R. M.: A F o u n d a t i o n for Cephalometric Communication, AM. J. ORTHO-
DONTICS 46: 330, 1960.
7. P r u z a n s k y , S.: The Application of E l e c t r o m y o g r a p h y to Dental Research, J. Am. Dent.
A. 44: 49-68. 1952.
8. Weidenreich, F.: Das M e n s c h e n k i n n und seine E n t s t e h u n g . Eine Studie und Kritik.
Ergetm. d. Anat. u. Entwcklngsgesch. 31: 1-124, 1934.
9. Grunewald, J.: i2ber die B e a n s p r u c h n u n g und den A u f b a u des menschlichen Unter-
kiefers and die mechanlsche B e d e u t u n g des Kinnes, Arch. f. Anthropol. 46: 100, N.F.
18, 1921.
10. Klaatsch, H.: Kraniomorphologie and K r a n i o t r i g o n o m e t r i e , Arch. f. Anthropol. 36:
101, N.F. 8, 1909.
11. Bolk, L.: t?ber Lagerung, Verschiebung und Neigung des Foramen Magnum ant
Schadel der P r i m a t e n , Ztschr. f. Morphol. u. Anthropol. 17: 611, 1915.
12. Brodie, Allan: Muscular Factors in the Diagnosis and T r e a t m e n t of Malocclusiolls,
Angle Orthodontist 9.3: 71-77, 1953.
13. Huxley, T. H.: Evidence as to M a n ' s Place in Nature, London, 1862, Williams & Nor ~
gate, Ltd.
14. Cuvier, The Baron: The Animal K i n g d o m - - T h e ('.lass Mammalia, E d w a r d Grittitb
et al., London, 1827, Geo. B W h i t t a k e r .
15. Martin, R.y and Salles, K.: L e h r b u c h der Anthropologi% ed. 3. S t u t t g a r t , 1956, Gustav
Fischer Verlag.
16. Brodle, A. G.: On the Growth and P a t t e r n of the H u m a n Head From the Third Month
to the E i g h t h Year of Life, Am. J. Anat. 68: 209, 1941.
17. BjSrk, A., Jensen, E., and Palling, M.: M a n d i b u l a r Growth and T h i r d Molar ]mpac.
tion, Acta odont, scandinav. 14: 231, 1956.
18. Bench, R. W.: Growth of the Cervical Vertebrae as Related to Tongue, Face, ami
Denture Behavior, AM. J. ORTHODONTICS 49: 183, 1963.
19. Steiner, C. C.: Cephalometrics in Clinical Praeti~e, Angle Orthodontist 29: ~, 1959.
264 Ricketts A.~. J. Orthodontics
April 1964

20. Bjbrk, A.: Facial Growth in Man, Studied With the Aid of Metallic Implants, Acta
odont, scandinav. 13: 9, 1955.
21. Ricketts, R. M.: Facial and Denture Changes During Orthodontic Treatment as Ana-
lyzed From the T e m p o r o m a n d i b u l a r J o i n t , A~. J. ORTHODONTICS 41: 163, 1955.
22. BjSrk, A.: Variations in the Growth P a t t e r n of the Human Mandible: Longitudinal
Radiographic by the I m p l a n t Method, J. Dent. Res. 42: 400, 1955.
23. Steiner, C. C.: Cephalometrics for You and Me, AM. J. ORTHODONTICS 39: 729, 1953.
24. Holdaway, R.: Personal Communication, 1963.