Dr. Mridula Trehan Dr. Jatin Sahwal (Prof. & H.O.D.) P.G. 2nd Year Dept. of Orthodontics & Dentofacial Orthopaedics CONTENTS INTRODUCTION MOOREE’S MESH DIAGRAM TEMPLATE ANALYSIS REGIONAL SUPERIMPOSITION PROPORTIONATE TEMPLATE CONCLUSION REFERENCES INTRODUCTION- The cephalometric technique has been used in the field of orthodontics for over 60 years and has become an important diagnostic aid in the formulation of diagnosis and treatment plan as of today. Many a times clinicians take statistical mean as the norm and tend to treat the patients according to them which in all cases may not be the ideal treatment. To overcome this a template analysis was developed. A cephalometric template is a set of oriented rulers that permit size and position to be measured in terms of years of development. T he "Moorees mesh” which was developed in the 1960s, presents the patient's disproportions as the distortion of a grid.
The Mooree’s mesh can be used to compare growth changes in longitudinal studies where proportions can be visualized rather than the amount of growth.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
In recent years, direct comparison of patients with templates derived from the various growth studies has become a reliable method of analysis with the considerable advantage that compensatory skeletal and dental deviations within an individual can be observed directly.
Standardized lateral head radiographs of 46 men and 47 women from the greater Boston area, representing a broad range of normal occlusal variation, were used to construct male and female norms for the mesh diagram. These radiographs were obtained as part of the Longitudinal Studies of Child Health and Development by the Department of Maternal and Child Health, School of Public Health, Harvard University. Moorrees, Coenraad. Normal Variation and Its Bearing on the Use of Cephalometric Radiographs in Orthodontic Diagnosis. Am. J. Orthodontics. 1953;39:942–950. TEMPLATE ANALYSIS- Each template is a compact set of oriented rulers graduated in years (6 to 16 years). So a single template can be used for the analysis. There are no millimeter measurements or degrees.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Male and female dianostic templates. The incisor long axis (1/1) and Down’s occlusal plane (DOP) are depicted of 3 ages and articulare (Ar) for two.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
The lines perpendicular to DOP represent maxillary and mandibular 1st molar (M) terminal planes (distal of E and mesial of 6) and the dots represent the position of averaged mesial contact point of upper first permanent molars from ages 6 to 16. Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. One of the objectives of any analytic approach is to reduce the practically infinite set of possible cephalometric measurements to a manageably small group that can be compared with specific norms and thereby provide useful diagnostic information.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
From the beginning it was recognized that the measurements for comparison with the norms should have several characteristics. The following were specifically desired: (1) The measurement should be useful clinically in differentiating patients with skeletal and dental characteristics of malocclusion;
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
(2) The measurements should not be affected by the size of the patient (i.e., proportions should be preserved between small and large individuals). This means an emphasis on angular rather than linear measurements; and (3) The measurements should be unaffected, or at least minimally affected by the age of the patient. Otherwise, a different table of standards for each age would be necessary to overcome the effects of growth. Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. Any individual cephalometric tracing easily can be represented as a series of coordinate points on a (x,y) grid (which is done when a radiograph is digitized for computer analysis). But cephalometric data from any group also could be represented graphically by calculating the average coordinates of each landmark point, then connecting the points.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
The anatomically complete template, a different one for each age, are particularly convenient for direct visual comparison of a patient with the reference group while accounting for age.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
CRANIAL BASE SUPERIMPOSITION- The best plan usually is to select the reference template initially so that the length of the anterior cranial base is approximately the same for the patient and the template and then to consider developmental age by William R. Proffit, Contemporary Orthodontics, 4 th Edition, Elsevier Publications, 2007. moving forward or backward in the template age if the patient is developmentally quite advanced or retarded.
William R. Proffit, Contemporary Orthodontics, 4th Edition, Elsevier Publications,
2007. In almost all instances, correcting for differences between developmental and chronologic age also leads to the selection of a template that more nearly approximates the anterior cranial base length.
William R. Proffit, Contemporary Orthodontics, 4th Edition, Elsevier Publications,
2007. The sequence of superimpositions follows: 1. Cranial base superimposition, which allows the relationship of the maxilla and mandible to the cranium to be evaluated.
William R. Proffit, Contemporary Orthodontics, 4th Edition, Elsevier Publications,
2007. The most useful approach is to superimpose on the SN line, registering the template over the patient's tracing at nasion rather than sella if there is a difference in cranial base length.
William R. Proffit, Contemporary Orthodontics, 4th Edition, Elsevier Publications,
2007. 2. The second superimposition is on the maximum contour of the maxilla to evaluate the relationship of the maxillary dentition to the maxilla.
William R. Proffit, Contemporary Orthodontics, 4th Edition, Elsevier Publications,
2007. 3. The third superimposition is on the symphysis of the mandible along the lower border, to evaluate the relationship of the mandibular dentition to the mandible.
William R. Proffit, Contemporary Orthodontics, 4th Edition, Elsevier Publications,
2007. lf the shadow of the mandibular canal is shown on the templates a more accurate orientation can be obtained by registering along this rather than the lower border posteriorly. Both the vertical and the anteroposterior positions of the anterior and posterior teeth should be noted.
William R. Proffit, Contemporary Orthodontics, 4th Edition, Elsevier Publications,
2007. REGIONAL SUPERIMPOSITION- The template is placed over the cephalogram or a tracing of the cephalogram, and the pair of points that define the measurement is compared with the template scales at symmetric ages (6 and 6, 8 and 8, 10 and 10, etc) until a match is achieved.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
1. Cranial base length- Anterior - Register on S, read age at N Posterior - Register at S, read age at Ba Total - Ba to N
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
2. Facial height- Upper anterior - ANS to N Upper posterior - PNS to S Lower anterior - ANS to Gn Anterior - N to Gn Posterior - S to Go
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Maxillary size- Length - PNS to ANS or point A Effective length - Ar to point A
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Mandibular Size- Ramus height -Ar to Go Body length -Go to Gn/ Pog/ or point B Overall - Ar to Gn/ Pog/ or point B Effective length - Ar to Gn
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Dental position- Maxillary dentition - Orient on palatal plane, register at A, read molar position at upper contact-point dots (M) and incisor position at 1 /1 Mandibular dentition - Orient on mandibular plane (GoGn), register at point B, estimate molar position by interpolation at lower terminal planes (M) and incisor position at 1 /1
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Dental Extrusion- Maxillary: Palatal plane registered at A to Downs occlusal plane (DOP) Mandibular: Mandibular plane (Go-Gn) registered at B to DOP or 1/1 Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. PROPORTIONATE TEMPLATE- The proportionate template is based on the principle of the visual comparison of lateral cephalometric tracings with average normal tracings. A single template cannot be used for all individuals because of variations in body height.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
To compare lateral head film tracings of persons with craniofacial skeletal dysplasia, a template having average skeletal proportions was developed from the data of Broadbent and coworkers. These data were based on the recordings of 5,000 individuals.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. To accommodate variations in skull size, four templates were designed. The average template was developed by averaging geometrically the dimensions of the sample.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
The large template was intended for larger than average persons, and the small template for persons with smaller than average craniums and jaws. In addition, an extra-large template was designed for much larger than average individuals.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Cephalometric Landmarks and Planes-
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Method of Application- Selection of the appropriate template. 1. The mid S-J point of the template is superimposed on the tracing, and the template is adjusted to the point where the Ba-N lines on the template and the tracing are parallel to each other. Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. 2. Points basion and nasion in the correctly selected template will approximately overlie the same points on the tracings. When superimposing Ba-N, both S-J lines will be parallel to each other. The template is then raised or lowered, keeping the Ba-N lines parallel until both of the mid S-J points are equidistant from the Ba-N line. Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. Interpretation – The following can be interpreted by the proportionate analysis- The relative spatial position of maxilla and mandible. Length of maxilla. Length of mandible. Vertical dimensions Incisor inclination. Cant of mandibular plane.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
TEMPLATE ANALSIS FORM
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995.
Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. Relative position of maxilla and mandible- State whether maxilla and mandible are anteroposteriorl protrusive or retrusive. Whether the mandibular plane is steep or low. Measure the distance between the incisal edge of upper teeth and lower border of upper lip. On an average the lip embrasure is 2-3 mm above the incisal egde. Soft Tissues- Lips- comment on thickness, competence and strain. Nose- comment on size and shape. Chin- comment on thickness, prominence and deficiency. CONCLUSION The expanding scope of orthodontic treatment would seem to demand meaningful diagnostic procedures. Template analysis provides a simple and flexible alternative to the conventional methods. It demands the active participation of the clinician and forms more of a decision tree when compared to the conventional numerical analysis. REFERENCES Proffit WR. Contemporary Orthodontics, 4th Edition, Elsevier Publications, 2007. Jacobson A. Radiographic Cephalometry, Quintessence Publications, 1995. Athanasiou AE. Orthodontic Cephalometry, Mosby- Wolfe Publications. Moorrees, Coenraad. Normal Variation and Its Bearing on the Use of Cephalometric Radiographs in Orthodontic Diagnosis. Am. J. Orthodontics. 1953;39:942–950.