Planning Treatment on the Basis of the

Facial Pattern and an Estimate of Its Growth

ROBERT M. RICKETTS, D.D.S., M.S.

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

Pacific Palisades, Califoniia

PART I
CEPHALOMETRICS AND GROWTH
ESTIMATION

Cephalometric roentgcnography. like that the explanation of the variet\' of

all valuable tools. has found several facial changes lies within the temp.oro-
uses. At its beginning it was employed rnandibular complex.
primarily for growth studiPs of the skull. Three main factors seemed to ex-
It was not long, however, until it was plain these differences in beha\·ior \Fig.
rt'cognized as a method for eYaluating I). First to be considered, but perhaps
treated orthodontic cases. The study of least important during the time of
movements of the mandible and dy- treatment, were the changes in the
namics of occlusion became another cranial base (NSBa). The majority did
phase of its application, the method not change but some became more ob-
still being limited to research. tuse and some more acute, viz., the skull
Cephalometrics did not become popu- base flattening or shortening when re-
lar until it was adapted to routine clini- lated to the horizontal. Theoreticallv
cal practice as an aid in diagnosis and at least, since the glenoid fossa is lo'-
treatment planning. Through it. the de- cated in the general proximity of the
scription and communication of the na- middle cranial fossa. its reiation to
tme of the orthodontic problem became basion is presumed to remain relatively
possible. The application of cephalo- fixed. Bjork" has recently become skepti-
metric principles to laminagraphy cal of the importance of this relation-
helped to re\·eal the temporomandibular ship but Coben" found little change in
joint. These combined methods as- point articularc to point basion i~ his
sisted in the understanding of the \·aria- serial studies. At any rate, changes in
tion in jaws and disclosed the changes the cranial base or changes in the loca-
in treatment. tion of the fossa seemed to explain the
A study has been reported by the beha\·ior of certain ca,cs.
author 1 in which facial and denture Secondly, as had long heen suspected,
changes in fifty treated Class II cases the condyle \\'as obsen-ed to mO\T for-
\HTe analyzed with a combination of \,·ard. As describE·d in previous work
cephalometrics and lam'nagraph\'. It howeYer. one fourth of all Class II cast's
was shown that mam· similar malocclu- during treatment dl'monstrated a pos-
sions. recei,·ing id!'ntical treatment. re- terior positioning of the condyle. These
sµonded in en.tirely diffnent facial be- were obse1Yed to influl'nce the chin be-
ha\·iors, i.e.. the chin either camt· haYior in a dt'tinitc manner. contribut-
fo1ward. dropµed dm,·nward or ,n'.nt ing largely to an opening of thl' Y axis
backward \\·hen related to cranial land- or a downward and backward 1110\T·
marks. In that study it was concluded ment of the chin.
Thl' third factor. and that found to
Pn·:-.ont<•il l1t•fon' Tiu• l ◄:dw:1rd lf . . \11g·)p
~1H•inh· of Orfhodo11ti:1, ('lii(·:1g·o, ·.\:o\·i'IIIIH'l"
bt· thl' 111ost important. \,·as the growth
7. I !t;~,:-,. at thl' conddt· in a111n11nt and din·ction.
14
Vol. 27, No. I Growth Estimate IS

vature of the antegonial depression.

Growth of the condyle in a majority of
cases tended to follow this plane al-
though great variation was observed.

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

In a given case, all factors leading to
posterior movement of the glenoid fossa,
posterior positioning of the condyle,
growth of the condyle in an upward and
backward direction, and bite opening
( rotation of the mandible) could alter
the face in the manner seen in Fig. 2-
left. Conversely, all factors producing
the opposite effect contribute to changes
as seen in Fig. 2-center. A comparison
of the two conditions leads to an ex-
tremely great difference in the chin posi-
tion as a possibility for the individual
Fig. 2-right. These changes are not

~~ ~
unrealistic. Cases exhibiting such be-
havior have been observed. In spite of
these great differences in facial beha-
vior, some orthodontists still have the
AMOUNT ANO DIRECTION OF
temerity to ask, "What has growth to do
GRO'#TM AT Tl-l£ CONDYLE
with orthodontic treatment?"
Fig. 1 Changes in the face during treat- These studies suggested that facial
ment were thought to be influenced mainly
by three phenomena within the temporo- form was to a large degree determ:ned
mandibular complex. Top-changes in the by the position of the chin. In addition,
angle of the crania-1 base to a more acute or it appeared that the chin position was
obtuse cranial relationship. Bottom-For-
ward or backward condyle growth. mainly influenced in the developing
face by these three factors, viz., the
Upward and forward growth of the cranial base, the condylar position and
condyle tended to be consistent with in- condylar growth. Through a considera-
creased depth of the face (brachy- tion of these factors the changes in any
cephalic tendencies) while upward and given case could be analyzed and could
backward growth was found to be more be understood. It therefore was thought
consistent with increased length of the feasible and rational to attempt to prog-
face (dolichocephalic tendencies) . The nosticate the changes in a case by con-
mechanism of mandibular behavior ceiving the changes in each contributing
does not appear to be as simple as has part.
been inferred in the past. More was entailed in a growth esti-
This work introduced a new plane to mation procedure than .simply observ-
the orthodontic library. For want of. a ing a head plate or manipulating a
better name, it was termed the "condy- group of figures. Projecting the behavior
lar axis" (Figs. 1, 3, 5). Originally it was of the given case was noted to encom-
designed to represent the inclination of pass the careful analysis and considera-
the condylar head and neck. However, tion of the many individual parts that
for this work, it was selected by bisect- contribute to the total behavior. The
ing the condylar neck and connecting probability of change of each part was
this point to a point at the greatest cur- estimated on the basis of the similarity
16 Ricketts January, 195 7

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

SUMMATION OF CHANGES TOTAL CHANGES POSSIBILITY OF CHANGE
VERTICALLY FORWARD IN THE PROFILE
Fig. 2 Possibility of change in an individual case. Left-Crania<l base development in a
backward direction together with posterior positioning of the condyle in addition to obtuse
development of the mandible all contribute to dropping of the chin. Center-No cranial
base growth, forward positioning of the condyle plus acute development of the mandible
yields forward positioning of the chin. Right-Range of possibility when opposite extremes
are compared.

or dissimilarity to cases previously ob- mation 1s a projection of probable

served. changes in the basi-cranium ( Fig. 5) .
The basi-cranium includes points N. S,
THE PROCEUURE FOR GROWTH
ESTIMATION IDEAL ADULT NORMAL
It goes without saying that the first
requisite for growth estimation depends
upon an accurate tracing of the lateral
head plate ( Fig. 3) . Certain bilateral
structures, such as the angles of the
mandible and the pterygomaxillary fis-
sures are bisected to procure an imagin-
ary midsagittal image free of distortion.
For growth estimation work, the cranial
plane basion-nasion is employed. Basion
is observed by following the clivus from
the post-clinoid process to the anterior
border of foramen magnum to a point
which intersects the inferior border of
the basioccipital. The basioccipital
should not be confused with superim-
posing structures such as the tympanic
plate or other parts of the temporal Pig. 3 Head plate tracing of a 26 year old
female with excellent occlusion of all teeth.
bone. Good harmony of the mouth with the 1·e-
A Class II Div. 1 extraction case was maining features is ·demonstrated. The !owe!'
selected to demonstrate this procedure incisor is 1 mm. forward at 23° inclina-
tion to the APo plane. The FMIA angle is
( Fig. 4) . The first step in growth esti- 68°.
Vol. 27, No. I Growth Estimate 17

PLAN AND RESULT

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

PREDICTION
BEGINNING

CASI 110. !lll41

RETENTION COMPARISON
Fig. 4 The '' growth estimation treatment p'1an'' applied to a Class II Div. 1 patient
with crowding in both arches and treated "ith extraction of lower first and upper second
bicuspids. The growth prediction is seen in the upper right. Figures 5, 6 and 7 out.line
the steps in arriving at this estimation. Xote the accuracy of the growth plan in the
comparison tracings. (Lower 1·ight) Note how closely the case approaches the "ideal"
in denture and lip balance and facial harmony.
18 Ricketts January, 1957

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

m

I
i5
II.I
If

0
CD
Fig. 5 Steps in estimating the behavior of the cranial base and mandible during treat•
ment. A. Increases in SN and SBa projected and new BaN constructed. B. Location of
the condyle is selected. C. Pterygo-maxillary fissure and coronoid process are oriented.
D. The condyle axis (RR' plane) is seleeted. Degree of bite opening is evaluated and amount
of condyle growth is predieted. E. Growth is ailded to the mandible. Form of the ramus
and processes outlined. F. Changes in relation of the body to the ramus arn forecast
and increases from the condyle axis (point R) to the symphysis are estimated.
Vol. 27. No. I Growth Estimate 19

and Ba for purposes of this analysis. cases, during treatment, showed pos-
Employing point sella as a starting terior movements of the condyles. Such
point, the average expectancy for in- incidences produce a noticeable effect

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

crease along SN is plotted. During on behavior of the chin during treat-
vigorous growth, as in pubertal spurts, 1 ment. Superposing BaN and registering
mm. per year can be expected. 1 2 In Ba will reveal the prospective condylar
some children in the mixed dentition position relative to basion after the
stage .5 to .7 mm. per year will be ob- above factors have been considered.
served while many 13 year old females Following the construction of the
will demonstrate very little change. new basi-cranium and condylar loca-
The expected changes between sella tion, the pterygomaxillary fissure is out-
and basion are next plotted. The change lined (Fig. 5). The findings of Brodie5
in length of SBa is about three fourths are utilized in order to make this trans-
as much as anticipated on SN. It should formation. Superimposing of SN and
be mentioned that certain clues are registering at S shows a slight down-
suspected within the spheno-occipital ward dropping of this fissure of about 1
synchondrosis for this behavior. Wide mm. during the usual case. The loca-
open sutures are thought to be yet active tion of PTM is important to the evalua-
while closed sutures are not growing. tion of the maxillary growth and to help
A great deal of variation in closure establish the future position of the
probably exists at age twelve between coronoid process. The tip of the coro-
sexes. Our knowledge of this area is noid is usually, but not always, located
incomplete. It should also be mentioned about 3 mm. forward of the pterygo-
that in long term planning the expec- maxillary fissure at both the start and
tation should include possible changes completion of orthodontic treatment
in the angulation of NSBa although the unless dramatic rotation of the man-
average does not change. 1 • 2 Following dible is experienced, i.e., bite opening.
the plotting of estimated SN and SBa Behavior of this point was observed
behaviors, points Ba and N are con- from laminagraph sections.
nected to establish the expected basion- Following the construction of the
nasion plane and conclude the forma- condyle and the coronoid process, the
tion of the new basi-cranium. RR' plane or condylar axis is con-
The next step consists of predeter- structed (Fig. 5). This axis is deter-
mining the behavior of the condyle mined on the initial tracing by connect-
( Fig. 5) . Previous studies have indi- ing a point in the center of the neck of
cated that the condylar position during the condyle at the level of articulare
orthodontic treatment of Class II mal- with a point at the deepest curvature
occlusions remained the same in about of the depression on the body of the
60% of the cases. 4 During growth, the mandible anterior to the gonial angle,
downward and backward movement of or at the antegonial depression. It
articulare and basion are thought to be usually expresses the long axis of the
parallel after age six. Changes in the lo- condylar head and neck.
cation of the temporal bone and hence The observation of antegonial area
the glenoid fossae are presumed by is not new. Engel and Brodie6 noted
associating joint behavior with changes severe notching of the mandible in this
in point basion. In addition, condylar area in condylar growth arrest cases.
positional changes within the fossae are Broadbent 7 has hinted that a great deal
equally important considerations. As of significance might be found in growth
stated previously one of four Class II of the mandible at about this junction
20 Kicketts January, 1957
between the ramus and the body of the are observed, particularly in males, at
mandible. This is possibly a great ad- which time three and sometimes four
justment zone, particularly as resorp- mm. per year may be expected. Many

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

tion of the medial and anterior aspect females after puberty display very little
of the ramus makes way for the de- growth. A consideration of the physical
veloping molars during growth. type and endocrine pattern of the in-
Interpretation of the character of dividual patient, together with his
muscle in the particular case is neces- hereditary dispo3ition offers assistance
sary at this time. This consideration in this prognosis. In the entire scope of
sheds light on the possible effects of bite facial estimation, this factor, the amount
opening as a consequence of rotation of of growth of the mandible, seems to be
the mandible during treatment. Muscle the m9st difficult aspect to predeter-
patterns are often correlated with spe- mine accurately.
cific types of morphologic patterns. The as~essment of condylar growth
Cases with high mandibular plane permits the construction of the pos-
angles, small gonial prominences, thin terior border, gonial angle, sigmoid
rami and short condyle heads frequently notch and the anterior border of the
display excessive opening during treat- ramus. This yields the projected rough
ment.1 On the other hand, cases pos- form of the mandible with the excep-
sessing acute gonial angles, well-de- tion of the body and symphysis.
veloped bodies, thick rarrii and well-
formed condyle heads will resist bite As a start to estimation pf the re-
opening rather dramatically. Treat- mainder of the mandible the possible
ment, if slow in this type, will usually changes in the angulation of mandibu-
result in depression of teeth in correc- iar planes to the condylar axis are as-
ti.on of overbite rather than rotation of certained (Fig. 5). In Class II cases the
the mandible and lengthening of the average angle formed by the mandibu-
face. During treatment with Class II lar plane with the condylar axis was
intermaxillary elastics in "weak man- observed to change very Ii ttle; however,
dible" severe overbite cases, the rela- a tendency for forward inclinations
tionship of the condyle axis to basion- was suggested. 4 In excellent facial pat-
nasion plane will open about 1 degree terns a definite forward tendency of one
or more. In prolonged head gear cases, degree or more was noted. In certain
rotation of the mandible is even greater. cases, the mandibular plane-condylar
Greater knowledge is needed in this re- axis angle becomes greater, in others
gard; however, the condyle axis can be it clmes rather markedly.
sensibly estimated based on present in- Changes in the form of the ramus and
formation. the condyloid and coronoid processes
• A contemplation of the important give clues to the behavior of the gonial
factor of the amount of growth of the angle and body, i.e., increases in depth
condyle is next in sequence. This is esti- of the ramus tend to develop more
mated on the condyle axis that has been acute gonial angles and vice versa. The
constructed and is measured off the procedure is simply to rotate the man-
condyle axis at the point it crosses BaN. dibular plane of the original tracing at
During treatment of the average case at its intersection of the condyle axis until
age seven to nine years, both sexes the change agrees with the estimate of
usually exhibit approximately two mm. change for that case. Once the direc-
of growth per year in the lengthen:ng tion of effective growth of the condyle
of the condylar axis. During puberty, has been determined, a line is con-
slightly greater increases in this line structed for the mandibular plane. It
Vol. 27, No. I Growth Estimate 21

should be remembered that a forward Secondly, the horizontal position of

direction of condylar growth is consis- the maxilla is postulated from the ten-
tent with lower mandibular plane dency of SNA to remain constant to
angles, while backward condylar incli- BaN. Therefore, point A is dropped

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

nations usually result in higher man-- parallel with the beginning line NA. In
dibular plane angles. cases needing a great amount of bodily
A determination of increases in length retraction of the upper incisor and the
of the body of the mandible from the upper arch, point A will be moved back
intersection of the condylar axis to the as much as three to five degrees de-
symphysis is the next step (Fig. 5). pending upon the amount of retraction
Lengthening of the body on the average necessary or thought possible for that
is slightly greater than lengthening of individual (Fig. 6).
the SN line, i.e., about 1.5 mm. per year In cases exhibiting bizarre facial pat-
during active growth. Cases with acutP terns, a second check on the behavior of
gonial angles and well-formed man- the maxilla is sometimes used to help
dibles will show this dimension rnme- predict the strongest tendency and
times to increase more than 1.5 mm. per evaluate the case. This is a good adjunct
year. The lengthened dimension of the in cleft palate cases. A point on the
body of the mandible is estimated and most superior curvature of the glenoid
the changes in the position of the sym- fossa (K) is selected as a cranial refer-
physis during treatment are plotted. ence point. The anterior end of the
The facial plane and the Y axis can zygomatico-frontal suture (Z) and a
now be constructed and the superposi- point at the most inferior curvature of
tioning on the basion-nasion plane will the key ridge (J) represent landmarks
indicate the direction and magnitude for zygomatico-maxillary relationships
of growth of the mandible (Fig. 6). (Fig. 6). A triangle is constructed con-
necting these three points. In the aver-
Changes in the position of the maxilla
age Class II case, the distance from
are approached in three ways but an
point K to Z increases 2 mm. during
application of the findings of Lande 8
treatment, while that of K to J in-
is used for the total tendencies. How-
creases only 1.5 mm. Therefore, some
ever, the basion-nasion plane is super-
indication of the relative position of the
imposed and registered on N rather
jugal process can be visualized, but this
than SN or the Frankfort plane. First,
needs further investigation in light of
in order to predict vertical changes, the
more recent treatment techniques.
facial planes are superimposed and reg-
istered on N. About sixty percent of the Total palatal behavior can be
total facial height increase is credited checked by the fact that the posterior
to the denture area. Therefore, about nasal spine drops parallel to the ptery-
forty percent of total facial increase is gomaxillary fissure under usual condi-
allotted to the upper face, which lo- tions. However, the palatal plane is
cates the level of the anterior nasal tipped in some cases receiving strong
spine (Fig. 6). An estimate of treatment traction to the maxilla!)' teeth in either
effects on facial height alters this pre- direction (Fig. 6). Here again, rela-
diction, however. In conditions in which tions of the cranial base give indications
it is planned to employ intermaxillary of its relative behavior.
elastics and cervical anchorage over a With the construction and position-
long period of time, Watson 9 showed ing of the maxilla in the face, the bony
showed that a dight tipping down of the framework is completed. It should be
palatal plane is to be expected. remembered that facial variation in
22 Ricketts January, 1957

PREDICTION OF SKELETAL FACIAL PATTERN

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

.... ---'~-

CHIN MAXILLA

·--~~<
I
'
:
'
-- '
"'\\
•,
.......

''I '
I

ZYGOMA PALATE
PROFILE
Fig. 6 Estimation of the !Jouy fa~ial pattern. A. 'l'lte composite of all factors covered
in Fig. 5 yields the predicted behavior of the Y axis and facial plane and location of the
chin. B. The vertical relationship of the m:1xilla is estimated by proportioning total vertical
growth. C. Future facial convexity is determined by prPdieted behavior of point A. D. Zygo-
matico-maxi'1lary temporal relations are anticipated. E. Descent of the palate is forecast.

height, depth and breadth are to be ship of the denture for each case.
expected, together with profiles that
exhibit convexity or concavity in dif- Planning the Arrangement of Teeth
ferent degrees. The skeleton or the bony and Determining Anchorage Values
frame of reference for the denture is not The arrangement of teeth is planned
alike in all cases. It becomes an archi- from the occlusal plane (Fig. 7a). Dur-
tectural problem to plan the relation- ing normal growth the cant of the oc~
Vol. 27, No. I Growth Estimate 23
ARRANGEMENT OF TEETH AND LI PS

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

130°

A B C

Fig. 7 Methotl for arrnngillg tht> teeth for ideal relationship . .-\. Palatal urnl mandibular
planes are bisected and the occlusal plane is tilted in respect for the coneeived changes
brought about by intermaxillary tradion. The new A.Po is established for reference for the
teeth. B. The lowe1· incisor is arranged at 22° 1 mm. forwnrd of the A.Po plane. C. The upper
incisor is oriented at 130° to the lower incisor. D. Molar anrhorage value is determined and
the behavior of the ,1ower lip is predirted. }:. Reaction of the upper arch is estimated and
,election of the teeth to be removed in this instance ran b<.' mad<.' .. Gro\\·th of the nosP and·
e.hnnges in the lip can be estimnted. The romplete planniug is seen in Fig. 4.

clusal plane will decrease, i.e., it will teeth.

drop faster in the back than in front. Once the occlusal plane is estab-
Cervical elastic traction applied at the lished, the new point A-pogonion plane
maxillary molars will be in accordance is erected and the lower incisor is placed
with this tendency. The application of one mm. forward to it and at a 22°
intermaxillary Ciass II elastic works in inclination by using the original tracing
a reverse direction and tends to rotate as a template (Fig. 76). The upper
the plane an average of :~ 0 from the incisor is arranged ideally at 130 de-
mandibular plane. This action elevates grees to 'the lower incisor ( Fig. 7c) . If
the lower first molar an average of 2.5 conditions of the lips or the tongue
mm. while the anterior teeth elevate contraindicate such movement or the
more slowly, are held in place vertically amount of trauma thought to accom-
or are depressed, depending upon pany this arrangement be too great,
growth factors and anchorage values. some compromise from the ideal posi-
Simply bisecting the height increase of tion of the teeth must be made at this
the lower face and assuming changes time. At any rate, the relationship of
in one way or another depending upon the incisors should be made to accom-
the avenues of treatment provides a plish a functional equilibrium together
base line for the arrangement of the with esthetic balance and harmony.
24 Ricketts January, 1957

Having arranged the incisors to fit incisors are not going to be moved ex-
the face as indicated from the x-rays, cessively.
models, photographs, etc., it is time that Estimation of changes in the lower
full consideration of anchorage be lip are made by bisecting the overbite

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

made. The forces necessary to arrange and overjet change and drawing in the
the posterior teeth can be determ:ned. superior portion of the lower lip at this
Herein various factors that affect an- level (Fig. 7d). Almost the same thick-
chorage of teeth can be evaluated (Figs. ness of lip will be present after treat-
7d, 7e). Different growth patterns give ment. The sub-labial area seems to
clues to different types of anchorage behave in conformity to the roots of the
behavior. The possibilities of headgear lower incisor. Therefore, if the roots
therapy on either or both the upper and of the lower incisors are retracted, an
the lower arch can be considered. The increase in sub-labial depression will en-
amount of anchorage offered by teeth sue. If the lower incisors are brought
in the event of extraction can be en- forward, this portion of the lip will be
visioned. Anchorage values and their built out. Cases demonstrating active
preparation are a separate topic and mentalis habits with the soft portion of
will not be discussed here. the chin rolled upward and forward will
Speculation on Soft Tissue Behavior often be relaxed by treatment and the
soft tissue of the chin will come to oc-
Soft tissues of the face can be modi- cupy a normal position. Therefore, it
fied a great deal by orthodontic therapy. should be constructed accordingly.
The next procedure is to evaluate the
This then constitutes the complete
soft tissue changes for esthetic im-
procedure for estimating the changes
provement and to <lelerrnine the indi-
that can be expected in any given case
cations for myo-therapy. Superposi-
prior to treatment.
tioning of the palatal planes and regis-
tering on ANS has indicated that, on
the average, 2 mm. of growth of the PART II
nose can be expected during the course
ESTHETIC CONSIDERATIONS AND
of orthodontic treatment ( Fig. 7e). In
TREATMENT PLANNING
rapidly growing faces this figure will be
greater, while in already well-developed, Because an appreciation of tooth
non-growing individuals this figure will position is an integral part of growth
be smaller. The profile outline is then estimation and treatment planning, a
constructed to the area below the nose, "prescription" for the arrangement of
including the nares, using the palatal teeth has been included. However, it
plane as a reference. Following this could be asked, "What evidence avails
procedure, the changes in the upper lip to justify the relationship so described?"
are determined. In excessively protrud- A search through the literature on
ing cases, the upper lip may appear to esthetics yielded little but perwnal opin-
be thin and stretched but as the teeth ion in this regard. It was agreed that
are retracted a thickening of the lip one of the primary objectives of ortho-
will occur due to its relaxation. In ad- dontic treatment is that of esthetic
dition to this, the upper lip actually facial balance and harmony. However,
grows in thickness. Therefore, a two "balance" and "harmony" should be
to four mm. increase in thickness of more clearly defined.
the lip can be expected in severely pro- The word "balance" implies evenness
truding cases and about a one to two or proper proportion of parts or ele-
mm. increase in cases wherein the upper ments. The word "harmony" denotes a
Vol. 27, No. I Growth Estimate 25
fitting together or a smoothness; a classification of "poor," "fair," or
blending, or that which is pleasant. "good" was all that could be gained.
In his chapter on facial art, Angle 10 Reidel found certain skeletal consisten-

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

used such terms as harmony or inhar- cies with those cases classed as "poor"
mony, beauty or ugliness, and perfection but offered no suggestions for an im-
or deformity. He also stated emphati- proved method of evaluating esthetic
cally that the study of orthodontia was balance and harmony of the face. The
indissolubly connected with that of desire for a method to explain facial
facial art. Angle further inferred that improvement was currently noted by
the orthodontist must look toward an Tweed. 13
ideal. He held that poor results could Downs' cephalometric analysis,"'
be prevented by the proper application which has gained almost universal ac-
of wund principles and guides. How- ceptance, provides a classification of
ever, many clinicians will not agree that facial and denture patterns that may be
the facial esthetic results he showed in compared with Angle's classification of
some cases were the best that can be malocclusion as a contribution to den-
achieved today. Angle made one point tistry. His report was based on patients
clear that should be considered in the exhibiting normal occlusion together
analysis of any profile view and that is, with those with malocclusion, and con-
that it is the upper teeth, not the lower, stitutes an excellent yardstick to evalu-
that establish the curve of the lower ate facial types and the relationship of
lip. The dearth of discussion of the chin the teeth. However, a cephalometric
contour was noted in his writings as analysis should include two additional
greater heed was paid to the upper cus- considerations in the author's opinion.
pid area. Severe· retrognathic pattern One is that the soft tissues of the nose,
cases were dismissed as rare. lips and chin be considered: and sec-
Attempts to establish i·ules for the at- ondly that additional information must
tainment of the ideal were made by be gained in order to guide the clinician
Simon, 11 · who established the orbital in treating malocclusion in facial pat-
plane as a reference line. Later, Tweed" terns which lie outside the range of
concluded that facial esthetics were those demonstrating harmonious rela-
clo:ely related to the axial inclination of tions. This need was noted by Steiner'"
the lower incisors to the mandibular who has published his recommendations
plane. Tweed'" more recently has cor- using a slightly different approach than
related the lower incisor to the Frank- that of Downs. However, neither does
fort plane. Although many do not agree Steiner's analysis include a considera-
with Tweed's concept of beauty of a tion of the soft tissues. The clinical ap-
face, he must be given credit for re- plication of both methods are restricted
awakening the profession to the con- in the seme that both constitute a static
sideration of facial lines, beauty and analysis of the immediate condition.
harmony. Neither takes into consideration growth
Probably the most recent systema- factors that ultimately must be con-
tized study of facial esthetics was that sidered in the full application of any
of Reidel1' who obtained soft tis3ue treatment planning procedure.
profile outlines and submitted them to
seventy-two orthodontists for esthetic METHOD OF SoFT T1ssu:E
evaluation. It was evident that the pro- DETERMINATION

fession lacked objective criteria for The method of arriving at an ideal

('valuation of the profile. The nebulous face must necessarily be purely subjec-
26 Ricketts January, 195 7
tive. Therefore, a search was made to mony for children? Previous growth
observe as many photographs from any studies are referred to in this regard.
source as were readily available. Atten- The findings of Schaeffer'' and those

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

tion was ultimately limited to the parts of Baum 18 both suggested normal re-
of the face that were thought to be traction tendencies of the denture area
greatly modified or changed by ortho- during the growth span. Clinical ob-
dontic treatment. The conclusion was servation suggested that the lower lip
finally reached that the most conveni- should be on or slightly posterior to the
ent points from which the lips could chin-nose line in order to attain pleasing
be related were the end of the nose and relationship for the age range from
the chin. A line was drawn between seven to twelve. Reidel's work, con-
these two points and the lips were mea5- ducted on children in the mixed denti-
ured anterior or posterior to this line. tion age, demonstrated that all cases
For want of a better name this line "poor" in facial balance possessed lips
was termed the "esthetic plane." located forward of a line drawn from
By fortuitous circumstance, three pic- the nose to the chin. This observation
tures appeared on the covers of leading emphasized the reliability of using the
magazines within a month's time. All line from nose to chin for purposes of
were nearly true profile views of the reference.
heads of popular starlets in almost life- These impressions were gained almost
size. An analysis of these portraits, un- entirely from clinical observation and
doubtedly picked for their close ad- through the careful evaluation of pho-
herence to the prevailing idea of beauty tographs. Recourse to x-ray analysis is
of nrofile. revealed that the lower Jin
needeu lo sluuy fully the reiationships
wa; appr~ximately two millimeters and
of tooth and skeletal structures to the
the upper lip approximately four mm. soft tissues. A hard and soft tissue trac-
posterior to a line from the nose to the
ing is seen in Fig. 3. Thus cephalometric
chin. It should be mentioned that the
procedure permits the correlation of lip,
majority of still models, as evidenced
nose and chin relationships with the
by some magazines, are selected for a
teeth.
prominent chin and a "hungry look."
The animation of movies apparently RELATIONSHIP OF THE ANTERIOR
requires a more prominent denture. TEETH
The consideration of the faces in a For a long time the author had
group of males exhibiting normal rela- shared in the general interest that had
tionships of the teeth and again a sub- been focused on the lower incisor and
jective impression of what was con- was aware of the skepticism that pre-
sidered to be desirable revealed the lips vailed regarding the relationship that
of the male to be slightly more re- the lower incisor tooth bore to refer-
tracted in relationship to the nose and ence planes such as the mandibular
chin. This is probably because the fea- plane,- the Frankfort plane and the
tures of the male are slightly more orbital plane. However, two important
rugged, the chin is more prominent and factors continued to attract attention
the nose somewhat greater in length. toward this tooth; viz., ( 1) orthodontic
A study of the lip relationship in the treatment planning most frequently re-
face of the Appollo bears out this con- volved about the relationship of the
clusion. lower incisor; ( 2) success or failure
The above has reference to adults; often was measured in the degree of
what might determine balance and har- stability of correct incisor relationship.
Vol. 27, No. 1 Growth Estimate 27

X-ray examination of a small sample can be specified by relating the lips to

of children with normal occlusion and a line connecting the chin and nose. An
of those with malocclusion in a variety evaluation of the inclination and loca-
of facial patterns suggested that the tion of the incisors will indicate the con-

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

lower incisor angulation was related tribution of the teeth to the total effect.
in some manner to a line from point A The needs of the individual can read-
to pogonion (Fig. 3) . This suggested ily be determined by placing the lower
that the lower half of Downs' angle of incisor in proper position ( 22 degrees to
convexity alone might serve as the point A Po at plus 1 mm.) and arranging the
of departure for the evaluation of this upper incisors to it at 130 degrees to
tooth in all types of faces. Subsequently, 135 degrees. Fig. 8 shows eight distinct
Dr. Downs was kind enough to measure types of imbalance of the lips that are
the axial inclination of the lower in- commonly seen in orthodontic practice.
cisor to the APo plane in his normal Note the relationship of the individual
sample. The findings indicated an aver- lips to a line connecting the chin and
age of 23 degrees, with a range from nose.
16 to 33 degrees. The standard devia- It should be pointed out that normal
tion was strikingly low ( 3 degrees) . occlusion of the teeth is not necessarily
However, the mere inclination of this a criterion for beauty in the face. Cases
tooth was not sufficient for any conclu- are sometimes seen in which the teeth
sion because its antero-posterior posi- are normal, yet the face is not within
tion also had to be considered. There- an accepted esthetic range. However, it
fore, a sample of forty esthetically ac- should be pointed out that the abandon-
ceptable faces was selected and the in- ment of common sense toward the at-
clination and position of the lower in- tainment of the ideal is not justified.
cisor to the APo plane was studied. The amount of tooth movement, dam-
In addition to this, the actual thick- age to tissues, and risk of relapse may
ness of the upper and lower lip was read contra-indicate an attempt to gain the
from the head films. The conclusions strict cosmetic ideal. The acceptable
reached were as follows: range is great enough to permit the ma-
A. The ideal lower incisor is inclined jority of cases to be brought within the
22-23 degrees forward of the APo plane prescribed limits. A question may be
and is located 0-1 mm. anterior to it. asked regarding functional balance
B. Axial inclinations below 16 degrees without concomitant balance of the
or above 28 degrees with positions of 3 musculature. Again, it is the author's
mm. or more posterior or 4 mm. or opinion that the orthodontist should
more anterior to the point A pogonion recognize such conditions and employ
plane are undesirable. orthopedic measures for muscle cor-
C. Interincisor relationship of 130 rection to permit stability of the case.
degrees is advisable in the treated case Tongue and lip exercises have proven
in order to promote stability and allow of value. Equilibration of occlusion and
for uprighting with later vertical de- chewing exercises also should be in-
velopment. cluded in a complete care. Neither poor
D. Both the upper and lower incisors muscle balance, habits nor even facial
contribute to facial esthetics depending type should be a definite obstacle to-
upqn the case. ward attainment of the ideal.
Typical cases demonstrating severe
imbalance of the lips are seen in Fig. 8. CLINICAL APPLICAT!Ol\'

The undesirable qualities in each case With that background for esthetic
28 Ricketts January, 1957

VARIATION IN LIP BALANCE ANO INCISOR RELATIONSHIP

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

G D
A B

E F G H
Fig. 8 A variety of cases demonstrating lip imbalance and poor facial harmony. The
relationship of the teeth to the •lips can be studied. A. A bimaxillary protrusion case--
needs 3 mm. and 8° retraction of the lower incisor. B. A bimaxillary retrusion. The entire·
denture should be located 6 mm. forward. "Button" apparently is present due to
mandibular growth and tight buccinator complex that restrains the denture. C. The
upper lip is forward and the lower lip is back. The lower incisor should be located 5 mm.
forward. D. Poor balance and harmony due to mesial thrust and lingually locked upper
incisors. The lower incisor is 2 mm. forward of the ideal. E. A similar lip imbalance is
seen in D. This, however, is due to almost 20° and 7 mm. forward relation of the lower
incisor. F. Opposite lip imbalance is seen in E but similar to C. For purposes of facial
harmony this case needs forward movement of the lower incisor. See l<'ig. 12 and 13. G.
Primarily protrusion of the upper incisor. The lower is almost ideal except supraerupted.
This case called for bilateral extraction in both arches. Case C has a similar relationship
of teeth ou the plaster cast but was treated without extraction. H. High convexity and
severe retrognathic pattern. Sucress in uprighting lower incisor depends upon the ability
to retract point A.
Vol. 27, No. I Crowth Estimate 29

and functional consideration let us re- ANALYSIS OF TREATMENT

turn to growth estimation and treat-

ment planning as applied clinically.

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

The reliability of this estimation pro-
cedure is tested in the application to the
forty-five almost consecutively treated
cases exhibited here* and in particular
to the first clinical case involving a
multitude of orthodontic problems. This
case was selected to be representative of
typical behavior during space closure
and intermaxillary traction. It is a Class A B
II malocclusion in a female aged eleven
years in which the analysis calls for the
extraction of four bicuspids. The lower
first and upper second bicuspids were
extracted on the basis of anchorage
values, the overbite conditions, tight
lips, small mandible and the growth
pattern. 0
The estimation of the growth of the Fig. 9 The analysis of treatment for the
face was accurate to within the width estimated case. Note the accuracy of the
of a pencil line. Slightly greater retrac- plan by referring to Figs 4 to 7. A. Note
the opening of the Y axis together. with
tion was found than was desired but vertical facial development. Note pomt A
the case is still considered to be in has been retracted. B. Superpositioning on
pleasing balance from an esthetic stand- the facial plane and registering on the palate
reveals the changes in lip balance and facial
point and ideal balance from a func- harmony. Retraetion of the lip is seen as
tional standpoint. well as the lower lip being filled out in the
sublabial area. Relaxation of the chin has
The analysis of treatment (Fig. 9) occurred. C. The lower incisor was moved
indicated that the Y axis opened 2 forward in spite of the extraction of the
degrees as estimated. The anchorage lower first bicuspids. The lower moved for-
ward about one-half its width which is the
values, rotation of the occlusal plane, typical finding in extraction cases. D. The
etc., were almost identical to the treat- upper molar was held in place while good
bodily movement of the upper incisors was
ment plan (Fig. 7). The retraction of accomplished.
the roots of the upper incisors was at-
tained by continuous torque action detracts from this face g1vmg the im-
throughout treatment. pression of slight retraction to the den-
The facial improvement is seen in ture area. However, the lower incisor is
Fig. 10. The severe sublabial depres- only 1 mm. posterior to an ideal re-
sion has all but disappeared. The upper lationship and the case is thought to be
lip is in balance with the lower lip and stable.
the mouth is now in better harmony The second case is a boy, aged twelve
with the chin. A slightly pointed nose ( Fig. 11), for whom the analysis indi-
cated extraction in the upper arch
* The models, photographs, intraoral x- only. A low facial angle and high facial
ra.ys, head plates and ink tracings of the
headplates of the before treatment cases, convexity with maxillary protrusion
the planned and estimated cases and the characterized the case. ( This type seen
after treatment case, together with the
analysis of treatment were all exhibited at in Fig. 8.) Growth estimation and the
this meeting. treatment plan proved accurate to the
30 Ricketts January, 1957

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

.l<'ig. 10 The facial improvement for the case outlined iu Figs. -± thruugh 7. Bxcclleut lip
balance is seen ancl harmony er.mid bp i1uproved only with ,,,Jight forward position of the
denture (1 mm. according to ide:d). Tight thin lips am! a pointed nose limit the csthetic
value but, the fa<"ial lines are good. :\",,te the' 11,ino,rnt>ss of the mouth.
Vol. 27, No. 1 Growth Estimate Jl

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

:l<'ig. 11 :X ute the c.om e:oty of the fo,·,· allll tlie retrognathi,· pattern. Case "·a~ consiclerecl
in ideal bala11ce frum a fo11diu11:tl :111d esth,•tic sbll<lpoint for 1-l ~·ear old male after
treatment.
 Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

I
\

7
NO, 0
C.ASE
31.
Vol. 27. No. I Growth Estimate 33
same degree as in the first case. The the lower teeth forward, they remained
upper first molars were extracted be- 2 mm. posterior to the ideal position.
cause of severe caries. They were, however, inclined about 3
The analysis of treatment ( Fig. 12) degrees too far forward. Much greater

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

revealed rapid mandibular growth as retraction of the entire upper arch was
expected in a boy at puberty. Opening accomplished than was thought pos-
of the Y axis was seen. Maximum bod- sible. The growth pattern ( note no bite
ily retraction of the upper incisors was opening) together with the strong lower
accomplished. The lower arch main- lip were held to account for the tre-
tain its stability; the incisors were mendous anchorage of the mandibular
held upright during a period of twelve arch.
months of light elastic traction. The The photographs (Fig. 13) show a
case after treatment is considered to be gratifying result. A critical analysis re-
in almost perfect balance for this type veals that still better harmony could be
of face and age of patient (Fig. 11). accomplished with the uprighting and
The lower incisor is located 1 mm. for- forward movement of the lower an-
ward of APo at 20 degrees inclination, teriors, together with greater lingual
and the interincisor angle is 133 de- root torque on the upper incisors. This
grees. would place the lower lip slightly more
The lip imbalance of the third case is forward toward the esthetic plane and
seen in Fig. 8 and Fig. 13. The skeletal set the upper lip farther back to create
pattern is within normal limits and the better balance and harmony.
upper incisor is almost ideally situated
but a severe Class II molar relation is COMMENTS
present. A part of the etiology in this
Certain critical observations seem to
case is perhaps tongue and lip habits.
warrant a short comment. They are:
The prediction and plan indicated the
need for forward movement of the 1. This procedure has been routinely
lower arch ( Fig. 14) . used for four years and has been
The treatment consisted of strong sensibly accurate in more than
intermaxillary elastic traction for a pe- ninety percent of the cases.
riod of thirteen months. No caution was 2. This method of planning suggests
used to maintain mandibular anchorage that lingual root torque of the up-
because forward lower arch movement per central incisor should require
was desired. The analysis of treatment the utmost attention. (See Fig.
indicated that forward movement of the 12).
chin had occurred as expected. Less 3. In order to satisfy the range of re-
growth occurred than was anticipated quirements prescribed for lip bal-
in a 14 year old male for 20 months ance and facial harmony it was
period. In spite of all efforts to drag found necessary to extract in one

(
Fig. 12 Analysis of treatment of case ;;ePn in }'ig. 11. '£he case was characterized by high
convexity and a retrognathic pattern and the prediction called for compromise in the
upper arch. The prediction was accurate to "ithin 2 mm. in direction and magnitude of
mandibular g1·owth. The ca:;e at cont'lusion was in ideal balance and harmony for this
face. Notiee tlie extreme thitkening· (7 mm.) of the upper lip. Note the great amount of
growth experienced and that grnwth permitterl an elevation of the entire occlusal plane.
The upper first molars were remove<l for reasons of ilecay and the second molar was em-
ployed for anchorage. The incisor experieneed the maximum bodily retraction. In fact the
roots could be palpated on the palatal aspec.t at the conclusion of the torquing action.
34 Ricketts January, 1957

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

,

Fig. 13 The rewarding r es ult in facial harmony and lip bafance of case analyzed in Fig.
14. Slightly more retractiou of the upper lip would still improve tisthetics. The patient
was placed on lower lip '' puffiui.r'' exe1·cises 1-1ft,-.r treatment to gain relaxation of a
severely tight mentalis muscle.
Vol. 27, No. 1 Growth Estimate 35

ANALYSIS OF TREATMENT

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

CASE NO. 5337

Fig. 14 Analysis of a ease diagnosed to need forward movement of the lower arch.
Ooutinuous elastics were wom for 13 months. The upper lip was retracted, the lower
was built out in the sublabia'1 area and the chin became relaxed. Note that a slight change
in the occlusal plane is seen with depression of the lower incisor being accomplished. The
lower incisor is tipped forward excessively 2°. The amount of retraction of the upper
arch is the most ever observed with iutermaxillary elastics. No second order bends were
employed and continuous torque was applied to the incisors. Note that the root tip was
retracted more than the crown,
36 Ricketts January, 1957

or both arches in approximately changes in the form of the man-

thirty-five to forty percent of the dibular ram us and body)
cases experienced. D. The effects of treatment on the

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

4. It is extremely important to have musculature (bite opening versus
a definite objective. The ortho- muscle patterns)
dontist should be wary of the trap E. The effects of treatment on the
of falling into the acceptance of maxilla ( changes in point A and
one fixed idea of tooth arrange- tipping of the palatal plane)
ment for all individuals. F. The effects of intra and extraoral
anchorage (anchorage of teeth,
SUMMARY tip of the occlusal plane versus
For purposes of organization and growth patterns and musculature)
clarity of presentation, this subject was G. The changes in the soft tissues
divided into two parts. (Ii ps, nose and chin) .
The first part dealt with cephalo- Part two dealt with a study of facial
metric procedures and findings, cul- esthetics. A line drawn from the en:! of
minating in the application of a single the nose and the chin was employed for
head film for the estimation of growth reference. This was called the "esthetic
and treatment changes. Studies employ- plane." The upper and lower lips were
ing a combination of cephalometric and studied in relation to that plane. De-
laminagraphic technique had revealed scriptions were made for lip balance
several pertinent findings. The main and facial harmony in adults and chil-
factors held to effect changes in the chin dren. It was observed that most ortho-
position were located within the tem- dontists tf'rmf'cl a casf' "disharmonious"
poromandibular complex. That work or "imbalanced" when the lip-; ex-
further suggested that- these findings to- tended forward of this plane.
gether with other available information Recourse to the x-ray film was made
could be utilized to predetermine indi- in order to determine the tooth relation-
vidual growth and treatment behavior. ship comistent with cases exemplifying
The basion-nasion plane was em- ideal lip balance and facial harmonv.
ployed for reference. In addition the Great ~ignificance was placed on the
work introduced a new plane termed point A-pogonion plane as a reference
the "condylar axis". This plane was line. The lower incisor was related in
selected from a point bisecting the con- angulation and anteroposterior posi-
dylar neck to a point at the deepest tion to this plane. The author's range of
curvature of the antegonial depression. acceptable variation was described. In
A specific case was selected to demon- addition, the undesirable characteristics
styate the estimation procedure. The in unacceptable esthetic conditions were
steps in the method included the pre- enumerated (Fig. 10). The ideal posi-
determination in the following cate- tion was held to be a lower incisor re-
gories: lated at 22-23 ° and 0-1 mm. anterior
A. The cranial base (SN, SBa and to the APo plane. The results in three
BaN) radically different cEnical problems
B. The temporomandibular joint (lo- were shown in order to demonstrate the
cation of the glenoid fossa, application of the method. The tech-
changes in condylar position) nique appeared to be sensibly accurate
C. The mandible (amount of growth in more than ninety percent of routine
of the condyle, changes in direc- clinical cases to date.
tion of growth of the condyle and 15247 Sunset Blvd,
Vol. 27, No. I Growth Estimate 37
REFERENCES Washington Univ., St. Louis, 1954.
1. Ricketts, R. M.: Facial and Denture l 0. Angle, E. H.: Ma.locclusion. of the Teeth,
Changes During Orthodontic Treatment Seventh Edition, 1907.
as Analyzed from the Temporomandibu- 11. Simon, Paul W.: Diagnosis of Dental
lar Joint, Am. ,T. Ortho., March 1955. Anomalies, Boston Stratford Co., 1920

Downloaded from http://meridian.allenpress.com/angle-orthodontist/article-pdf/27/1/14/1365334/0003-3219(1957)027_0014_ptotbo_2_0_co_2.pdf by guest on 28 June 2021

2. Bjork, Arne: Cranial Base Development, (Reviewed in Salzmann Principle.~ of
Am. ,T. Ortho., Vol. 41, No. 3, 198-225, Orthodontics, Second Edition, pp. 482-
"'.\fareh 1955. 488).
:1. Cohen, S. Eugene: The Integration of l 2. Tweed, C. H.: Indications for the Extrat·-
Facial Skeletal Variants, Am. J. Ortho .. tion of Teeth in Orthodontic Procedure,
-11: 6, 407-434, ,Tune 1955. Am. J. Ortho., 30: 8, 1944.
~- R.icketts, R. M : A Study of Changes in 13. Tweed, C.H.: The Frankfort-Mandibular
Temporomandibular Relations Associ- Incisor Angle in Orthodontic Diagnosis,
ated with the Treatment of Class II Mal- Treatment Planning and Prognosis,
occlusion, Am. ,T. Ortho., 38: 12, 918- Angle Ortho., 24: 3, 1954.
933, 1952. 14. Reidel, R. A.: Esthetics and Its R{'lation
fi. Brodie, A. G.: Late Growth Changes in to Orthodontic Therapy, Angle Ortho.,
the Human Face, Angle Ortho., 23: 3, 20: 3, 168-198, 1950.
146-157, July 1953. Hi. Downs, W. B.: Variations in Fat•ial
ti. Engel, M. B. and Brodie, A. G.: Condy- Relationship: Their Significance in
lar Growth and Mandibular Deformi- Treatment and Prognosis, Am. ,l. Ortho.,
ties, Surgery, 22: 976-992, 1947. 34: 812, 1!)48.
7. Broadbent, B. H.: The Face of the ltl. Steiner, C. C.: Cephalometrics for You
Normal Child, Angle Ortho., 7: 183-208 and Me, Am. J. Ortho., 39: 10, 729-7/'ifi,
1937. ' 1953.
8. Lande, M. J.: Growth Behavior of the 17. Schaeffer, A.: Behavior of the Axis of
Human Bony Facial Profile as Revealed Human Incisor Teeth During Growth,
by Serial Cephalometric Roentgenog- Angle Ortho., 19: 2-54-275, 1949.
raphy, Angle Ortho., 22: 2, 78-90, 1952. 18. Balllll, A.: A Cephalometric Evaluation
9. Watson, Thomas J.: Extra-Aheolar of the Normal Skeletal and Denture Pat-
Cephalometric Appraisal During Ther- tern of Children with Excellent Occlu-
apy: A New Approach, Master's Thesis, sion, Angle Ortho., 21: 2, 96-103, 1951.