American JoumaZ of ORTHODONTICS

ORIGINAL ARTICLES

Analysis of dentofacial vertical:

proportions
T 1 KEN S A S SO U NI, D .D . S., 1). S c.,’ ant1
SPREKDER NANDA, B.D.S., M.S.“”
Pittsburgh, Pa

FACIAL balance is of cardinal concern to health specialists, not only because

many vital organs are concentrated in a circumscribed area but also because
of the social value of the face. Artists, dentists, physicians, and anthropologists
have studied the face from diverse angles. Orthodontists, employing cephalo-
metric techniques, have investigated the relationship between dental occlusion
and skeletal balance of the face. As the most popular classification of maloc-
clusion (that introduced by Angle) was defined in the anteroposterior dimension
only, it was natural that the attention of investigators should be directed
chiefly toward the anteroposterior balance of the dentofacial complex. In recent
years clinical experience and research have brought to light the close inter-
dependence, in three dimensions of space, of facial proportions. At the samt’
time, the development of diversified orthodontic appliances has permitted
differential treatment of dentofacial deviations selectively in each of the thr(‘c.
dimensions.
Too often, however, treatment has been guided b>- the appliance in WC’.
rather than the appliance being selected according to a differential diagnosis.
This is probably due to the poor link established between diagnosis and treatment
planning, which, in turn, may be due to the fact that at present a systemat,iv
diagnosis is not made in the three dimensions of space. It is therefore prrmissihltl.
from this standpoint, for us to focus our attention on thr vertical proportions

Part of the material from which this investigation is dorivd has Iweu supportcti
by PHS-NIH Grant D-1102, and part comes from thr, film of the Child K~~R~c~I
Council, Denver, Colo.
Presented before the Great Lakes Society of Orthodontists, Toronto, Ontario, Octobrl 1
7963.
*Professor and Chairman, Department of Orthodontics, University of Pit~tslrurgh,
and Acting Chairman, Department of Orthodontics, West Virginia University.
““Research Associate, Department of Orthodontics, West Virginia University.
802 Sassouni and Nan&~

of dentofacial structures. A purely technical remark pertaining to roentgeno-

graphic cephalometry is that the vertical dimension is the common dimension-
the link-between the lateral and front,al films of the face.
To have a meaningful value for clinical purposes, a cephalometric analysis
must combine the basic knowledge of facial architecture with the functional
components of the masticatory apparatus, with the genetic growth potential,
and with the possibilities and limitations of orthodontic treatment, but at the
same time it must not exclude esthetic and social considerations.
A diagnostic analysis, therefore, should include the following:
1. Differential characteristics of the face associated with vertical maloc-
clusions, namely, open-bite and deep-bite.
2. Vertical changes due to growth.
3. Hereditary factors.
4. Vertical changes that could be brought about by orthodontic treat-
ment.

SKELETAL CHARACTERISTICS ASSOCIBTED WITH OPEN-BITE AND DEEP-BITE

A number of investigators have studied the variations in degree of incisor

overlap concomitant with the degree of changes in the skeletal components.
These variations, usually calculated by means of the coefficient of correlation,
do not preclude causal relationships but express mere associations. Probably
because of the differences in method and sampling in these studies, not all of
the findings are in agreement. As these findings are not derived from multiple
correlations, it still has not been established whether all the characteristics are
present simultaneously, whether they cancel each other, or whether some have
greater influence than others. Only those that seem to be well established will
be reported here.
Deep-bite is associated with the following:
1. Large cusp height of posterior teeth-l3
2. Small molar height.“, 5s13sI47 23
3. More upright incisors.13* I9
4. Small total anterior facial height.la 5
5. Small anterior lower face height.5, *, I7
6. Horizontal mandibular, occlusal, and palatal planes.*, 3l 5, 8
7. Small gonial angle.3l 5l 21
8. Larger free-way space.ll 8, I7
Open-bite is associated with nearly identical variations in an opposite
direction.
Some additional details are given in later parts of this article. Diagrams
illustrating these tendencies, as well as typical persons with these characteristics,
were presented in 195918” (Fig. I). A n important observation here is that the
skeletal differences are not confined to the vertical dimension but exist
simultaneously in the anteroposterior proportions.
Mullerg studied two groups of persons-one group with open-bite and an-
other with deep-bite. The contrast between the skeletal components of the two
groups confirms basically the preceding description.
 Dentofacial wrtical proportiom 803

SKELETAL MALOCCLUSION \ .
Open-bite
bi-dental

Fig. 1. Tracings of two patients, one exemplifying a skeletal open-bite and the other :k
skeletal deep-bite. The contrast is present at both the skeletal and dental levels. Notic,
particularly the vertical position of the condyles and the maxillary molars and the size 01
the ramus. In addition, in the deep-bite case, the palatal, occlusal, and mandibular planc~
are horizontal and nearly parallel to each other, while in the open-bite case these planc~s :I),’
sharply angulated. (From Sassouni, V. : The Face in Fire TXrncnsions, Philadelphia, I I)%,
Philadelphia Center for Research in Child Growth.)

-Deep-bits

-- -- Open-bite

Fig. 2. Comparison of the average tracings of eight adults with deep-bite and open-bite
(superimposed at sella-planum and optic plane). These averages were ohtained geometrically.
Two tracings were superimposed and the midline of all structures Iv-as traced, then two
others, and so on until four composites were obtained. Two ljy tlvo, these four composites
were superimposed and two composites were obtained; finallj-, these were superimposed,
and the last coverage tracing obtained represents the type.
8 04 Sassouni and Nanda

- Deep-bite

--.-Open-bite

C.

Fig. 3. Regional comparison between the average tracings of adults with open-bite and deep-
bite. A, Superimposition on the palatal contour with PNS registered. In open-bite the teeth
are more extruded than in deep-bite. B, Superimposition of the mandibular body with the
symphysis registered. In open-bite the teeth are more extruded and more protrusive; the
gonial angle is wider, and the ramus is shorter. C, Superimposition of the lower half of the
face, with articulare registered and the palates kept pamllcl. This shows the effect of the
vertical position of the molars, in relation to the eondyles, on the mandibular rotation.

In order to have a clearer picture, not only of dimensional or positional

differences but also of form, an investigation was undertaken. From a longitudi-
nal series of 250 patients* on whom cephalometric records had been kept from
birth to adulthood, eight adults with skeletal open-bite and eight adults with
skeletal deep-bite were selected by inspection to fit as close as possible to the fore-
going description. The lateral tracings were superimposed, and an average out-
line was derived from each group. Fig. 2 shows tracings of the average open-bite
and deep-bite types superimposed on the anterior cranial base. The basic
differences found by the previous investigators were confirmed again here. In
addition, when the palates were superimposed (PNS registered), it was apparent

*Child Research Council, Denver, Colo.

that the total maxillary dental height was greater in persons with open&W, at
both the incisor and molar levels (Fig. 3, A).
From this it is deduced that undereruption of the incisors vertically is
not a primary factor in open-bite. The same \vas true for the mandibular tecbtII.
but not as marked in the lower posterior segment, (Fig. 3, R). In this supc~~‘-
imposition (symphysis and lower border of the mandible) the posterior
divergence of the condyle in the open-bit,e average confirms that the ponial angic
is wider. In order to gain a better understanding of the mechanism involved in
t,he variation between open-bite and deep-bitt, we snperimposcd (art icula1.c.
registered) the condvles and kept the palatal planes parallel (Fig. 3, C’i Th(.
relationship between the molar level and the mandibular rotation is brought
into evidence here. It should be noticed also that the total length of the mandihl~~
is the same in both types. Also, the distance between the condyles and t,llc,
molars is the same. It is probable that the short ramus, high condyle, an(i
greater condyle-molar vertical distance are together instrumental in the make-ull
of the open-bite type as opposed to the deep-bite type. :2t the same time, if
Ah-G&

AOEw YEMII
Fig. 4. Percentage increment of nasion-gnathion (total facial hcbight in ten persons from 3
to 20 years of age). This is a kde individual variation in thr timing and velocity of vMica1
growth. Note the circumpubertal growth spurt. iFrom Nmda. Ii. S. : AM. .J. OKTIIODOSTI(~S,
September, 1955.)
 Am. 6. Ol‘thodmtics
80 6 Sassouni and Nanda November 19fi4

should be noted that the rotation of the tnandible has simultaneously an

anteroposterior and a vertical effect on the chin.

FACIAL GROWTH IN VERTICAL DIJIENSION

Having defined the open-bite and deep-bite types, our next problem is to
study the growth factor as it pertains to diagnosis. Bjiirkl and Brodie” have
found that, durin g growth, a number of patients do not keep exactly the
proportions of their initial facial patterns. These changes, however, do not
amount to a radical metamorphosis of the pattern. In the majority of cases
in which changes take place, the occlusal and mandibular planes have become
more horizontal. This means that, proportionately, the posterior vertical heights
increase more or faster than the anterior vertical facial heights. Nanda,” in
a longitudinal study, shows that facial growth curves proceed by spurts. In
other words, orderly growth should not be confused with uniform growth. r\janda
shows (Fig. 4) the circumpuberal growth spurt of facial height (r\saGn). In
addition, he demonstrates that in the same person different dimensions have
different velocities of incremental growth. Xeredith and associates’O find marked
differences in vertical facial growth curves among different, persons. In Fig. 5
they show that in one group (C) the upper to lower facial height proportion
has remained nea.rly constant, whereas in two other groups this proportion has
changed in different ways.

Fig. 5. Profile height proportions in three groups of children, indicating different trends of
change in proportion. (From Meredith, H. V., Knott, V. B., and Nixon, E. H.: AM J.
ORTHODONTICS, April, 1958.)
 Dentofacinl verticd propo,rtion.s 807

With reference to the open-bite and deep-bite types, it, was important l-o
establish whether a different growth pattern exists in association with each type.
Some clues were present in the study made by M~ller,~ but his sample was cross
sectional. He found that in the deep-bite type the posterior height gain was
relatively greater during growth, while in open-bite type there was a gr’eatctr
gain in anterior height.
The same investigation was conducted on a longitudinal basis. After thaw
eight adult patients with open-bite and deep-bite, previously illustrated, hacl
been selected, cephalograms of the same persons at around 6 years of age WCI’C
traced. At this age none of the permanent teeth were in contact. Fig. 6 sl~ows
their superimposed average tracings at the age of 6 years. The same basic
differences seen in the adult features are present at 6 years between the op,cn-bitts

,--__
,“7
and deep-bite types. However, these differences arr not, so accentuated as ill

.(’m .\--
‘*-Q
the adult patterns. The over-all facial growth was studied by superimposing

A.
I
\ L r',
\ -- .
\

-----Deep-bite

-Open-bite

Fig. 6. Average tracings, at 6 years of age, of the persons illustrated in Fig, 2. The super-
impositions are similar to those shown in Fig. 3. LI, Palatal superimposition; B, mandibular
superimposition on the symphysis and lower border; C, superimposition on articulare, wit It
the palatal planes kept parallel. The differences between the open-bite and deep-bite tt~t?
similar to those found in the adult averages; however, the charactf!rixtics are not as ar-
centuated.
8 08 Snssouni and Nmda

Fig. 7. Superimposition of the composite tracings of the same eight deep-bite patients at
the age of 6 years (solid line) and in adulthood (broken line). The lines represent the normal
variation during growth of the following landmarks: nasion, anterior nasal spine, incision
superius, gnathion, gonion, articulare, posterior nasal spine, and the mesiobuccal cusp of the
maxillary permanent first molar. The midpoint in these lines represents the landmarks at
the 12-year age level.

Fig. 8. Superimposition of the composite tracings of the same eight open-bite persons at
the age of 6 years (solid line) and in adulthood (broken line).
 c.

Fig. 9. Differential growth changes according to the open-bite and deep-bite facial patterns.
8, Deep-bite average superimposed on the palate, with ANS registered, showing that the
mandible (chin) has outgrown the maxilla anteroposteriorly. Furthermore, there is less grolvth
vertically at the profile than at the ramus, making t,he mandibular plane more horizontal.
R, The same superimposition for the open-bite composite shows that there has been more
vertical growth at the profile than at the ramus, making the mandibular plane steeper. .In
addition, in open-bite there is an increase in bidental protrusion. C, The differential growtll
pattern in open-bite and deep-bite is demonstrated when the composites shown in Figs. 7 and 8
are superimposed on the lower border of the mandible in thfa tracaings of thP G-year ~\-clragc~.

the 6 year average tracing on the adult one (Figs. 7 and 8). In order to show
more accurately the changes in the oral area, the palates were superimposed.
with ANS registered (Fig. 9, A and B). In open-bite the lower anterior vertical
facial growth (ANS-Me) exceeds the posterior vrrtical growth ( PNS-Go).
whereas in deep-bite the reverse is true. This is illustrated in Fig. 9. C by thcb
superimposition of the lower borders of the mandibles of deep-bite and open-hit,<.
patients at 6 years and tracing of their respective mandibles at adult. age,
From the preceding, it can be concluded that the growth pattern is different
in opposite facial types and, therefore, among individuals. Furthermore. sincci
the growth pattern is associated with different facia.1 types, if these facial
types could be recognized early their growth tendencies could be prcdic+e(l
to a certain degree. What, then, is the earliest time at which a facial t,ype can
be recognized? And what is the mechanism at the origin of its creation?
8 10 Sassouni and Nanda

As mentioned previously, in the 6 year sample only the deciduous teeth

were in occlusal contact. It could be postulated that the same basic facial pattern
was present when the first deciduous teeth (incisors) came into occlusal contact,
therefore, within the second half of the first year of life. Going a step further
in this discussion, it could be suggested that the deciduous incisors erupted only
up to a point established by the degree of jaw separation permitted by the
tongue and facial musculature. This brings us to the neonatal or prenatal age.
At this point, however, another question may be raised: Is the facial type
acquired or inherited?

HEREDITY OF FACIAL TYPES

Studies of twins and triplets have shown that certain parts are inherited
mostly as discrete units.? One should be cautious in speaking of the inheritance
of skeletal form, as it could be the result of muscular inheritance. This seems
to have some support in the work of Sarnas,17 who found a much greater intra-
family resemblance when the mandible was at rest than when it was in occlusal
contact. Similarly, the experiences of Washburn20 tend to show that the muscular
attachments give the mandible its ultimate shape. Studies of twins have a
limitation, for they cannot be applied to individual cases. The most practical
clinical method of defining the genetic make-up of an individual resides in the
study of the immediate family-parents and siblings.
Figs. 10 and 11 show the tracings and physioprints of a child and his
mother. Each has a typical deep-bite skeletal pattern. Their tracings can be
perfectly superimposed except for the anterior half of the palate. This is an
example of total inheritance. The problem is more complex when the child
inherits from both parents. Fig. 13 shows a child with all characteristics of an
open-bite skeletal pattern. In order to evaluate his growth potential, we com-
pared him to both parents (Figs. 12 and 14). His mandible is identical to that
of the father except for the symphysis, while the cranial base and palate are
like those of the mother. This is a case of mixed inheritance. Notice that, in the
father, a number of dentoalveolar adjustments have probably prevented a
Class III open-bite. In the treatment planning of both of these cases the
hereditary factor will be taken in consideration.

EFFECTS OF ORTHODONTIC TREATMENT IN THE VERTICAL DIMENSION

This brings us to a review of the effects of orthodontic treatment on the

teeth and the jaws.
TEETH AND ALVEOLAR BONE. Teeth could be depressed or elongated. It seems
that depression is more difficult to accomplish than extrusion. The mechanism
of depression is interpreted as holding the tooth while the alveolar process is
growing occlusally. I5 The limit of depression in this case is the potential of
growth of the alveolar process. However, it does not follow that the orthodontic
correction of deep-bite is necessarily due to depression of teeth; it may be the
result of changes in jaw relationship.
VoEume 50
Yumber 11

Fig. 10. Tracings of child (A) and his mother (Bj, each of whom has a skeletal deep-bite
pattern. Except for the premaxilla, these tracings can he superimposed almost perfectly with
respect to size, shape, and proportion. This is an example of total inheritance.

Fig. Il. Physioprints of the mother and child illustrated in Fig. 10 showing the similarities
of soft tissues of the face.
812
 Dentofacial vertical proportions 8 I :I

Extrusion of teeth could be accomplished more readily, but we lack informa-

tion as to the extent of possible and permanent extrusion. It is common experi-
ence that, in skeletal open-bite cases, vertical extrusion of the incisors brought:
by elastics ends in relapse. Conversely, extrusion of molars in open-bite cases
seems to be stable but worsens the facial pattern by rotating the mandible down-
ward and backward.
In deep-bite cases extrusion of the molars or an increase in molar crown
height (onlays) does not seem to hold all the gain permanently as far as opening
of the bite is concerned.
From these observations, the following theory is advanced: In open-bite thti
posterior vertical chain of muscles (internal pterygoid, masseter, temporalis‘
exerts an oblique force posterior to the molars’ resistance and creates a mesiaL
component of force between the steep palate and the mandible. In deep-bite.
on the contrary, the vertical chain of muscles is perpendicular and more’
anteriorly situated, thus exerting its major force against the molars and keeping
them depressed. It follows from this that a different treatment should be insti-
tuted according to skeletal types. In open-bite cases the molars should be brough:
posteriorly so as to be under the field of forces of the posterior vertical ellaill
of muscles. Clinically, however, this movement is difficult to accomplish becaustb
of space limitations. Furthermore, when molars are moved posteriorly one 01
the probable effects is an increase in the posterior vertical height and, therefore,
further opening of the bite. Theoretically, the alternate solution is to bring the
muscles attached to the gonial area of the mandible more anteriorly by surgical

Fig. 14. Physioprints of Family M.G. If the resemblance between child and parents w-er~*
evaluated only on the basis of the soft tissues of the face, this child would srern to I)*.
primarily of maternal lineage and the resemblance of the child’s mandible to t,hat of ttrn,
father would be missed.
814 Xassouni and Nan&

Fig. 15. Deep-bite skeletal type treated with activator, showing a large amount of vertical
growth of the lower face. (Redrawn after BjSrk in LundstrBm: Introduction to Orthodontics,
New York, 1960, McGraw-Hill Book Company. Used hy permission.)

means (reinsertion of masseter and internal pterygoid) . As for the deep-bite,

a possible solution is to bring the posterior teeth more anteriorly, avoiding to
a degree the impact of the force of the posterior vertical chain of muscles.
Clinically, this is possible to achieve. Furthermore, to give the dentition a greater
resistance, the incisor should be angulated in a bidental protrusion.
THE MANDIBLE. When the skeletal components of the face are under con-
sideration, it is extremely difficult to dissociate the effect of orthodontic treat-
ment from that of natural growth. The closest to an ideal design would be a
sample of identical twins of which only one would receive treatment while the
other would represent the control. As this test has not been made, the following
statements have to be accepted with reservations.
It is not demonstrated that the size of the mandible can be influenced at
the age when orthodontic treatment is common. The direction of growth can be
modified, however, mostly by vertical modification of dental structures. Fig. 15
illustrates a case treated by Bjijrk with an activator, showing an unexpected
increase of the anterior and posterior lower facial heights. A case presented by
R,ickettP shows a marked mandibular rotation (Fig. 16). Notice the amount of
vertical growth of the palate, the extrusion of both upper and lower molars, and
the disproportionate changes between upper and lower vertical heights. The
rotation of the mandible is attributed to the treatment and not to growth alone.
THE MAXILLA. Recent investigation9, I2 have shown that, under strong head-
cap traction, the palatal plane changes its inclination by opening anteriorly.
Fig. 16. Major changes in skeletal pattern concomitant with orthodontic trmtnwnt. Sotl’
rotations of palate and mandible, changing facial proportions. c From R,icketts, R. N.: .\l~ylv
Orthodontist, .Julp 7960.)

Klein6 finds that, at the same time, the mandible is rotated downward and back..
ward and that the maxillary first molars are clongat,cd. \Vinslander’2 and
Ricketts1G confirm the basic findings of Klein.
FACIAL HEIGHTS. Meredith and associates’” have illustrabrd the disturhallc~c~
ot’ facial proportions concomitant with orthodontic treatment (Fig. 17).

DIAGNOSIS AND TREATMENT I'LANNISG

The previous findings concerning facial types, facial growth, facial heredit)-,
and the new knowledge of the effects of orthodontic treatment on the skeletal
pa.ttern permit us now to adopt diagnostic procedures leading to t,reatmcnt
planning.
Heretofore deep-bite and open-bitt were described as being associated with
neutroclusion. These vertical variations are also present with anteroposteriol.
variations in facial proportions and malocclusions (mesioclusion and distoclu-
sion). On this basis, it is possible to draw a map of simple (unidimensional) and
complex (multidimensional) malocclusions. At the poles of a vertical axis (Fig.
78) are placed the deep-bite and open-bite sk(alctal types. At the oxtrerncn o-f a
horizontal axis, the skeletal Class II and Class I11 arc rqrcsentcd. i A skeletal
Class II malocclusion is defined as one in which there is a maxillary protrusion,
a mandibular retrusion, or a combination of both. A skeletal (‘lass II 1 ~naloc~-
elusion is defined as a maxillary retrusion, a rnmdihnla~* protrusion. or ;I wm-
8 16 Xassouni and Nanda Am. J. Ortlwxbatics
November 1964

Fig. 17. Effect of orthodontic treatment on vertical facial proportions. Individual curves
for seven children receiving I ‘bite-opening ’ ’ therapy. OZZ, Overlay crowns on deciduous
molars for Class II elastics; OX, overlay crowns on deciduous molars for cross-bite; BP,
bite plate; CT, cervical traction; CZZ, Class II elastic traction; &Z, monobloc (Andresen) ;
E, extraction (premolar) with retraction of anterior teeth; L, leveling arch wires. Black
triangle indicates point obtained with subject wearing bite plate. (From Meredith, H. V.,
Knott, V. B., and Hixon, E. H.: A&L J. ORTHODONTICS, April, 1958.)

bination of both.) In a zone situated at the intersection of the vertical and

horizontal axes are located normal occlusions or malocclusions with well-pro-
portioned facial balance. In other words, the malocclusions found in this area
are purely “dental malocclusions” as opposed to the extreme “skeletal maloc-
clusions ’ ’ situated at the four poles.
The first distinction is of clinical importance. Because of our better knowl-
edge and skill in controlling tooth movement versus skeletal modifications, a
“dental malocclusion” has a better prognosis than a “dentoskeletal malocclusion”
of the same severity. In the first instance, the plan of treatment will consist of
correcting the dental occlusion while maintaining the skeletal balance, and this
can be achieved successfully. In the second category, it is necessary to modify
both dental and skeletal relationships. It is not always possible and feasible to
 Dentofacial vertical proportions 8 1.7

CLASS I-OPEN BITE

CLASS III-OPEN

Fig. 18. Facial types and malocclusions (see text). (From Sassouni: The Faw in P’ivl*
Dimensions, ed. 2, Morgantown, W. Va., 1962, West Virginia University Press.)

achieve the skeletal changes desired, because of lack of knowledge, lack of abilit.y,
or simply because of inherent limitations of orthodontics. It is in this respce+
that the prognosis of “skeletal malocclusions” is relatively poor.
The next problem is to know whether the prognosis is equally poor in a11
types of skeletal malocclusions. Here the classification given in Fig. 18 assumes
a particular importance when the complex malocclusions (multidimensional) arch
added. The skeletal Class II malocclusion is thus divided as skeletal ‘*Class I I
deep-bite, ” and “ Class II open-bite, ” while the skeletal Class III is divided into
“skeletal Class III deep-bite” and “skeletal Class III open-bite.” The prog-
nosis is different in these complex types. The worst prognosis is in the:
skeletal Class II deep-bite and the skeletal Class III open-bite. The skeletal C!ilss
II open-bite and the skeletal Class III deep-bite have the best prognosis. This
differential prognosis is derived from our knowledge (described previously) of
the effects of orthodontic forces on the skeletal components of the face. Of thesca,
the most critical are the rotation of the mandible and the tipping of the palate.
In L’luss III open-bite (Fig. 18) we are confronted wit,h a dilemma.: Tf w
want to correct the skeletal open-bite by rotating the mandible in a closing dire+
tion, the chin will become more protrusive and increase the prognathic appear-
ance; if we want to correct the prognathism by rotating the mandible downward
and backward, the open-bite will be increased. This is whp it. is common clinical.
practice to regard the Class 111 open-bite case as the one least successfully
treated by orthodontic means. It is proposed either that nothing be done to these
cases or that the surgical approach be adopted. The preceding is particularly
true in the permanent dentition. In the early mixed dentition the prognosis is
not so bad if the mandibular prognathism is not hereditary. The plan at this
age, after growth has been evaluated, is to proceed to serial extraction and cor-
rection of the dental relationships. The expectation here is that after the incisors
are in proper lock the further forward growth of the mandible will carry the
maxillary teeth and the maxilla to a certain extent. During the active phase of
serial extraction, intermaxillary elastics should be avoided in order to avoid
opening the bite.
In Class III deep-bite (Fig. 19)) on the contrary, intermaxillary elastics
will extrude the maxillary molars, which will rotate the mandible, which will
open the bite, thus permitting the simultaneous correction of the deep-bite and
the Class III relationship. Bite planes or activators would be similarly successful
in these cases. The good prognosis is due primarily to the achievement of a
vertical change in skeletal position. Once this is achieved, the correction of
incisor cross-bite will add support to the vertical dimension. If, even after
treatment, there is a tendency for the incisor overlap to increase, this would
be beneficial in maintaining the correction. In this type of case, nonextraction
is the rule, as we are starting with a skeletal deep-bite where multiple extractions
are contraindicated. Only in cases of the most severe degree of crowding should
extraction be considered. Finally, if this type of malocclusion is recognized in
the mixed dentition, treatment should not be delayed, as the maxilla will respond
favorably at this age to the stimulus of the mandible. Furthermore, the vertical
growth of the alveolar processes, active at this age, is a major factor in the
maintenance of the vertical-dimension increase obtained by treatment.
In Class II deep-bite with mandibular ,retrusion (Fig. 18), the prognosis
is poor but not as poor as in Class III open-bite. The dilemma that, we face here
is opposite the situation in Class III open-bite. If we try to open the bite by
rotating the mandible in a downward and backward dire&ion, the chin is carried
posteriorly, increasing the retrognathism. If we try to bring the chin forward
by rotating the mandible in a closing direction, we increase the skeletal deep-bite.
The first alternative when there is a severe degree of disproportion is to resort
to surgical anterior repositioning of the corpus mandibularis. The second alter-
native is to accommodate the maxilla to the mandibular retrusion, in effect
creating a true skeletal “bimaxillary retrusion.” This total lower facial retrusion
usually produces a poor esthetic result by creating a greater nasal projection.
What complicates the planning of these cases is that crowding of the teeth is
the rule while, at the same time, extraction is contraindicated because of the
deep-bite skeletal pattern. These are truly compromise cases in the sense that
the orthodontist will not be able to achieve good results at the dental and skeletal
levels simultaneously. The compromise resides in evaluating which is, for a
Volume 50 Dentofacial ~zwticnl proportions H 1 !!
Number 11

Fig. 19. Superimposition of before- and after-treatment tracings of a cleft palate child,
showing correction of upper incisor cross-bite associated with rotation of mandible and increase
in lower facial height (AN&Me).

E’ig. 20. Physioprints of patient shown in Fig. 19, before and after orthodontic tnatmcut.
8 20 Sassouni and Nanda

given case, the most important consideration: the dental occlusion or the facial
balance. The closer a patient with this facial type is to adulthood, the worse the
prognosis. In the younger patient, at the mixed-dentition level, the prognosis
differs on one point. As the mandible grows more and for a longer period of
time than the maxilla, it is normal to expect that a number of patients will
naturally become less rctrognathic with age. At the individual level, thercforc,
it is critical to evaluate the potential of mandibular growth as a factor in the
treatment plan, The best source for this prediction, when an individual is con-
sidered, is the careful analysis of the facial balance and similarities of the
child’s parents and siblings. The prognosis depends, then, on the predicted
amount and direction of the growth potential of the mandible.
In Class ZZ deep-bite with maxillary protrusion (Fig. 21) the prognosis is
better if the proper treatment is instituted. The ideal case in this category is the
one without crowding. Headcap treatment with bite plane will correct the
anteroposterior and vertical dentofacial imbalance simultaneously. The maxilla
and the maxillary teeth are reduced posteriorly. At the same time, the palate
and the mandible are rotated. In cases in which there is crowding the basic treat-
ment is the same. The degree of crowding should be assessed on its own merit,
and extraction should be avoided except in the most severe cases.
In Class ZZ open-bite the prognosis is good if certain rules are followed. The
strategy involves rotating the mandible in a closing direction and lowering the
premaxilla but not the posterior half of the palate. All intermaxillary elastic

nc. ?
- Age 8:L
-- - Age 10:3

Fig. 21. Skeletal and dental changes brought about by orthodontic treatment in which a
face-bow was used, with cervical anchorage applied against the maxillary molars. No other
appliance was used. Note posterior repositioning of palate as a. whole and simultaneous
rotations of palate and mandible.
 Den tofacial vertical proportions $2 I

traction should be avoided, as this will extrude the molars, thereby rotating the
mandible downward and increasing the open-bite and the mandibular retrusion.
Similarly, all forces that would tend to extrude the molars (for example, certain
types of cervical face-bow) should be avoided. As we have seen, a. headcap will
t,end to tip the palate and to position it posteriorly, but this should be done
with a high-pull force (anchorage at vertex of cranium). In this way not only
are the maxillary molars not extruded, but they are held in a higher position
while the face is growing downward and forward. In i&elf, this is a factor
which promotes the closing positional change of the mandible. These cases, par
excellence, call for reduction of tooth material. In the most severe cases, up to
eight, teeth could be removed; these are the first premolars, the mandibular
second molars, and the maxillary permanent first molars. All tooth movement
should be done by intramaxillary forces. Differential light-wirr tcchniqncs seem
to have their best indications in these cases.
The previous classification and this statement of the objectives have led its
to enunciate a certain treatment plan. These are necessarily generalities. When
an individual patient is considered, all of the factors mentioned here should 1~.
carefully analyzed. It was shown that a cephalometric analysis should be abh
to distinguish between the different facial types as defined in the preceding
paragraphs. With some prejudice probably, the arch&l analysis ( Qassouni’F21
has been the one with which this differential diagnosis has been made. The
prime requirement is that such an analysis should incorporate all structures
influenced by orthodontic treatment, all structures whose genetic make-up pl;lys
a part in prognosis and planning. Too many of the ccphalometric analysts<
proposed in the literature are incomplete, rather than wrong. The large majorit:,
consider only t,he dentofacial balance in one dimension-the antcroposterior
proportions and position. It was dcrnonstratrd that many anteropostcrior inl-
halanccs are only symptoms, the cause of which is found in t,hc vtlrtic”;ll
dysplasias. It is in this sense that particular attention has been focusccl hcrc 011
the vertical components of the dentofacial complex.

SU31MBRY AXD COSCLUSIONS

The thesis that vertical facial disproportions were at. the origin of some
anteroposterior disharmonies was presented.
Eight persons with skeletal deep-bite and eight persons with skeletal open-bits
wrrc followed longitudinally from the age of 6 years to adulthood. In each type
the basic facial pattern remained different. However, the intensity of expression
of each trait composing the open-bite and deep-bite was less marked at the fi
year level than at. adulthood.
There a.re three significant differences with rrspect to the origin of tile
mechanism of the open-bite versus the deep-bite type. The position of tile
condyles is higher in open-bite than in deep-bite. The ramus is shorter in open-
bite than in deep-bite. The maxillary molars are lower in position in open-bite
than in deep-bite. These fundamental differences probably cause the other
symptoms-a steeper mandibular and occlusal plane in open-bite, a larger lower
anterior face height and a smaller lower posterior face height in open-bite, and
a greater interincisal angle and bidental protrusion in open-bite.
The genetic resemblance of the individual orthodontic patient is best
assessed by comparison of the propositus with the parents and siblings. It was
shown that it is possible, by roentgenographic cephalometric means, to tract
paternal or maternal contributions in the make-up of the facial type of the child.
The effects of orthodontic treatment were critically reviewed to stress par-
ticularly that it is possible to change the skeletal pattern by modifying the size
and position of the maxilla and the position of the mandible.
Diagnostic and treatment procedures were outlined on the basis of the
previous findings. A classification of malocclusions as associated with skeletal
type was proposed. Of special importance was the distinction in a skeletal Class
II malocclusion when associated with deep-bite or open-bite. Similarly, Class III
was subdivided as skeletal Class III deep-bite and skeletal Class III open-bite.
It was demonstrated that the worst cases seen by the orthodontist are those
involving the skeletal Class II deep-bite with mandibular retrusion and the Class
III open-bite.
In the over-all discussion it was demonstrated that vertical disproportions
were in many cases at the origin of anteroposterior dysplasias. The treatment,
therefore, should be primarily in the vertical direction to correct anteroposterior
disharmonies. The critical point is that the t,reatment should be centered on the
cause and not on the effects.
It was concluded that a cephalometric diagnostic analysis should include a
discriminating analysis of vertical proportions.

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