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Differential Diagnosis
L. Levern Merrifield

Differential diagnosis enables the orthodontic clinician to completely ana-

lyze and study a malocclusion. The differential diagnosis protocol of analyz-
ing the face, the skeletal pattern, and the teeth enables the clinician to
ascertain the area with the greatest disharmony, prioritize the attainable
objectives, and arrive at a diagnosis and ultimately a treatment plan that will
allow him or her to treat the greatest number of attainable objectives. Any
differential diagnostic system must be used with an understanding of the
concept that there are anterior, posterior, lateral, and vertical limits of the
dentition. These boundaries are determined by bone and muscular limita-
tions. (Semin Orthod 1996;2:241-253.) Copyright © 1996 by W.B. Saunders
Company

u n d a m e n t a l to the delivery of a consistently 22 ° to 28 ° (Fig 1).3 T h e standard should be 65 ° if

F high-quality orthodontic service is accep-
tance by the clinician of the idea that there is a
finite dimension of the dentition. 1 T h e c o n c e p t
of dimensions of the dentition should be the
f u n d a m e n t a l basis for a diagnostic and t r e a t m e n t
philosophy.
After years of clinical study, a Differential
Diagnostic Analysis System, 2 has b e e n developed
by the Tweed Study Course teaching staff. Use of
the system enables the clinician to classify a
patient's p r o b l e m into: (1) facial, (2) skeletal, or
(3) dental, and to formulate an accurate differen-
tial diagnosis. Use of the diagnostic analysis
system allows the clinician to reach predeter-
m i n e d objectives.
An explanation and interpretation o f each o f
the values used in the analysis is p r e s e n t e d so
that the application o f this information can be
better understood. T h e values that are u s e d have
b e e n selected because of Foundation research,
study, and clinical evaluation.
Definition of Terms
FM/A. O n e of the three angles of Dr. Tweed's
diagnostic facial triangle, a standard of 68 ° has
b e e n established for individuals with an FMA of
From the Co-chairman of the Board of the Charles Tweed
International Foundation, Tucson, AZ.
Address correspondenceto L. Levern Merrifield, DDS, MSD, 111
Patton, Ponca City, OK 74601.
Copyright© 1996 by W.B. Saunders Company
1073-8746/96/0204-000455.00/00
the FMA is 30 ° or above. T h e FMIA will increase
if the FMA is smaller. Dr Tweed believed that the
FMIA value was a very significant indicator of
balance and h a r m o n y of the lower face.
FMA. This angle of the triangle that is per-
haps the most significant value of cranial analysis
because it indicates the direction of lower facial
growth in b o t h the horizontal and vertical dimen-
sions, has a range of 22 ° to 28 ° when the skeletal
p a t t e r n has a n o r m a l growth direction. 4 An FMA
above the n o r m a l range indicates greater vertical
growth, while an FMA below the n o r m a l range
indicates lesser vertical growth.
I M P A . This angular value establishes the posi-
tion of the m a n d i b u l a r incisors in relation to the
m a n d i b u l a r plane. 5 It is a g o o d guide to use in
maintaining or positioning the m a n d i b u l a r inci-
sor teeth in their relationship to underlying basal
bone. T h e standard of 88 ° indicates an upright
m a n d i b u l a r incisor position. If the patient has a
n o r m a l FMA, then upright m a n d i b u l a r incisors
should m a k e it possible to have the best balance
and h a r m o n y of the lower facial profile. If the
FMA is above normal, the orthodontist should
c o m p e n s a t e by further uprighting of the man-
dibular incisors, and if the FMA is below the
n o r m a l range, c o m p e n s a t i o n can be achieved by
allowing the incisors to be maintained in their
p r e t r e a t m e n t positions or positioned less up-
right. However, the m a n d i b u l a r incisor position
is limited to the original incisor inclination in
the patient who has n o r m a l muscular balance.

Seminars in Orthodontics, Vol 2, No 4 (December), 1996: pp 241-253 241

<< ~,t-'.t,. a >>
242 L. Levern Merrifield
Figure 1. Definition of terms. A drawing that illus-
trates the cephalometric values used in the Differen-
tial Diagnostic Analysis System. 1 FMA, 2 IMPA,
3 FMIA, 4 SNA, 5 SNB, 6 ANB, 70CC-FH, 8 Z-angle,
9 UL, 10 TC, 11 PFH, 12 AFH.
Original incisor inclination seems to be the limit
because o f tissue health a n d stability.
SNA. This a n g u l a r value gives g u i d a n c e in
d e t e r m i n i n g the relative h o r i z o n t a l position o f
the maxilla to cranial base. 6 A r a n g e o f 80 ° to 84 °
is n o r m a l at the e n d o f growth a n d d e v e l o p m e n t .
SNB. This value expresses the horizontal rela-
tionship o f the m a n d i b l e to cranial base, a n d a
r a n g e o f 78 ° to 82 ° indicates n o r m a l h o r i z o n t a l
m a n d i b u l a r position. 6 If the value is below 74 °, it
m i g h t indicate that o r t h o g n a t h i c s u r g e r y w o u l d
be a valuable a d j u n c t to treatment. T h e same
c o n c e r n s h o u l d be a c c o r d e d a value o f over 84 °.
ANB. T h e n o r m a l r a n g e is 1 ° to 5 ° . This
significant value expresses a direct h o r i z o n t a l
relationship o f the maxilla to the mandible. As
the Class II malocclusion b e c o m e s p r o p o r t i o n -
ally m o r e difficult, the h i g h e r the ANB. A n A N B
above 10 ° usually indicates that s u r g e r y s h o u l d
be a possible a d j u n c t to treatment. A negative
ANB value is p e r h a p s even m o r e indicative o f
h o r i z o n t a l facial d i s p r o p o r t i o n . For example, an
ANB o f - 3 ° or m o r e , if the m a n d i b l e is in its t r u e
position, s h o u l d indicate careful m o n i t o r i n g with
the possibility o f surgical assistance for Class III
correction.
AO/BO. This relationship 7,8will verify the hori-
zontal relationship o f the maxilla to the m a n -
dible a n d is p e r h a p s m o r e sensitive to malrelation-
ships t h a n ANB b e c a u s e it is m e a s u r e d a l o n g the
occlusal plane. T r e a t m e n t b e c o m e s m o r e diffi-
cult if the value is b e y o n d the n o r m a l r a n g e o f 0
to 4 m m . A O / B O is affected by the steepness o r
Home [ TOC [ Bndex
flatness o f the occlusal plane since the measure-
m e n t is m a d e f r o m a p e r p e n d i c u l a r to occlusal
plane f r o m Point A a n d P o i n t B.
Occlusalplane. This is a dental-skeletal relation-
ship 9 value o f the occlusal plane to F r a n k f o r t
H o r i z o n t a l plane. A r a n g e o f 8 ° to 12 ° is n o r m a l .
It varies a b o u t 2 ° b e t w e e n male a n d female
patients. T h e female p a t i e n t usually averages
a b o u t 9 °, a n d the male a b o u t 11 °. Values above
a n d below the n o r m a l r a n g e indicate m o r e
difficulty in treatment. T h e original value s h o u l d
be m a i n t a i n e d o r lowered with t r e a t m e n t m a n -
a g e m e n t . A n increase in the occlusal plane value
indicates a loss o f vertical control, a n d it is
usually unstable b e c a u s e the occlusal plane is
d e t e r m i n e d by the m u s c u l a r balance, primarily
the muscles o f mastication. T h e original occlusal
plane value usually r e t u r n s following active orth-
o d o n t i c treatment, resulting in a d e t r i m e n t a l
interdental relationship c h a n g e if this plane was
t i p p e d d u r i n g t r e a t m e n t to aid in occlusal correc-
tion.
Z-angle. This chin lip profile line 1° related to
F r a n k f o r t H o r i z o n t a l has a n o r m a l angular r a n g e
o f 70 ° to 80 ° . T h e ideal value is 75 ° to 78 ° ,
d e p e n d i n g on age a n d sex. This a n g u l a r measure-
m e n t was d e v e l o p e d to f u r t h e r define facial
esthetics a n d is an a d j u n c t to the FMIA. It is
indicative o f the soft tissue profile a n d is respon-
sive to maxillary incisor position. Maxillary inci-
sor retraction o f 4 m m allows 4 m m o f lower lip
retraction a n d a p p r o x i m a t e l y 3 m m o f u p p e r lip
response. H o r i z o n t a l m a n d i b u l a r repositioning
will affect this value. Vertical facial h e i g h t in-
crease, b o t h a n t e r i o r a n d posterior, can influ-
ence the Z-angle. T h e Z-angle value facilitates a
critical facial analysis.
Upperlip thickness. T h e thickness o f the u p p e r
lip 1° influences the Z-angle. T h e u p p e r lip usu-
ally thins with m a t u r a t i o n b u t thickens with
maxillary incisor retraction. A p p r o x i m a t e l y 1
m m o f t h i c k e n i n g occurs with e a c h 4 m m o f
incisor retraction.
Total chin thickness. T h e b o n y chin a n d the
soft tissue overlay at p o g o n i o n greatly influence
the soft tissue profile a n d the Z-angle. 1° Pogo-
n i o n increases with m a t u r a t i o n , m o r e in male
t h a n in female patients. T h e thickness o f the
total chin s h o u l d be equal to the thickness o f the
u p p e r lip. If this p r o p o r t i o n is n o t a o n e to o n e
ratio, the o r t h o d o n t i s t s h o u l d c o m p e n s a t e by
incisor positioning. A deficient total chin or an
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DifferentialDiagnosis 243

excessive value for total chin will be reflected in
the Z-angle and will increase the difficulty of
treatment management.
Posterior facial height. PFH 11 is a millimetric
m e a s u r e m e n t of ramus height m e a s u r e d f r o m
articulare, tangent to the ascending ramus, to
m a n d i b u l a r plane. It is a vertical value that is
i m p o r t a n t in cranial analysis. It influences facial
form, both vertically and horizontally. PFH in-
crease is essential for counterclockwise mandibu-
lar response. Its relationship to anterior facial
height determines the FMA and the lower facial
proportion. In the growing child who has a Class
II malocclusion, ramal growth change in relation
to anterior facial height in b o t h p r o p o r t i o n and
in volume is critical.
Anterior facial height. AFH 12 is a millimetric
m e a s u r e m e n t which is m e a s u r e d f r o m palatal
plane to menton. A value of a b o u t 65 m m for a
12-year-oldindicates that anterior facial height is
normal. This vertical value must be m o n i t o r e d
carefully if it is m o r e than 5 m m greater or lesser
than normal. In Class II malocclusion correc-
tion, it is essential to limit the increase in
anterior facial height by controlling maxillary
and m a n d i b u l a r m o l a r extrusion and by using an
intrusive force on the anterior s e g m e n t of the
maxilla.
Facial disharmonies are often the result of
a b n o r m a l skeletal relationships. T h e clinician
must u n d e r s t a n d the skeletal pattern and have
the ability to c o m p e n s a t e for a b n o r m a l skeletal
relationships by changing the positions of the
teeth. T h e Frankfort m a n d i b u l a r plane angle
(FMA) is a skeletal angular value that is critical in
differential diagnosis. Dental c o m p e n s a t i o n for
the high FMA requires additional uprighting of
the m a n d i b u l a r incisors. Lower facial balance
can be dramatically improved by using this knowl-
edge. Figures 2 and 3 illustrate a patient's man-
dibular incisors being overuprighted to compen-
sate for the high Frankfort m a n d i b u l a r angle. If
the m a n d i b u l a r incisors are not placed in an
overly upright position, there will be lip protru-
sion a n d lack o f facial balance (Figs 4 and 5).
Conversely dental c o m p e n s a t i o n for the low

Differential Diagnosis
Facial Disharmony
A study of the face, its balance or lack of balance,
must be the first c o n c e r n during a differential
diagnosis. T h e clinician must have an intuitive
concept of a balanced face. T h e r e are essentially
three factors which influence facial balance or
the lack thereof: (1) the positions of the teeth,
(2) the skeletal pattern, and (3) the soft tissue
thickness.
Facial balance is affected by m a r k e d protru-
sion a n d / o r crowding of the teeth. T h e lips are
s u p p o r t e d by the maxillary incisor teeth. T h e
u p p e r lip rests on the u p p e r two thirds of the
labial surface of the maxillary incisors, and the
lower lip is s u p p o r t e d by the lower one third of
the labial surface of the maxillary incisors, thus
lip protrusion is a reflection of the a m o u n t o f
maxillary incisor protrusion. Maxillary incisor Figure 2. (A) Pretreatment facial photographs of a
patient with an FMA of 34 °. (B) Pretreatment cephalo-
position is, of course, directly related to the gram with IMPA and the Z-angle drawn. Note that the
position of the m a n d i b u l a r incisors. P r o t r u d e d incisors are upright, but the Z-angle remains too low
teeth cause facial imbalance. because of the high FMA.
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244 L. Levern Merrifield

t e n d e d to soft tissue p o g o n i o n (Fig 6). Total chin

thickness should equal u p p e r lip thickness. If it is
less than u p p e r lip thickness, the anterior teeth
must be uprighted further to facilitate a m o r e
balanced facial profile because lip retraction
follows tooth retraction.
Careful consideration o f the positions of the
teeth, of the skeletal pattern, a n d of the soft
tissue overlay will give the orthodontist critical
information a b o u t the face and will enable the
clinician to d e t e r m i n e whether dental compensa-
tions will improve facial balance. Before initiat-
ing tooth m o v e m e n t , its impact on the overlying
soft tissue must be clearly understood.
T h e profile line, which originates from the
chin and is drawn tangent to the most p r o m i n e n t
lip, is a useful tool when facial balance is studied.
T h e Z-angle, the inferior angle f o r m e d by the
Frankfort horizontal line and the profile line
(Fig 7), quantifies facial balance. T h e Z-angle

Figure 3. (A) Posttreatment facial photographs. Note

the facial balance exhibited in this high angle patient.
(B) Posttreatment cephalogram of the patient follow-
ing premolar removal and treatment. The mandibular
incisors are over upright to give the patient facial
balance.

FMA requires less m a n d i b u l a r incisor upright-

ing. Decisions regarding tooth position objec-
tives must be m a d e after a t h o r o u g h study of the
skeletal pattern.
Facial disharmonies that are not the result of
skeletal or dental distortion are generally the
result of p o o r soft tissue distribution. This prob-
lem needs to be identified during differential
diagnosis so that n e e d e d dental compensations
can be planned. T h e millirnetric m e a s u r e m e n t s
of total chin thickness and u p p e r lip thickness
are essential c o m p o n e n t s in any study of facial
balance. U p p e r lip thickness is m e a s u r e d f r o m Figure 4. (A) Pretreatment photographs of a high
the greatest curvature of the labial surface of the angle (31 °) patient. Note the facial imbalance and the
mentalis strain. (B) Pretreatment cephalogram exhib-
maxillary central incisor to the vermilion b o r d e r iting mandibular incisors that are 90 ° to mandibular
of the u p p e r lip. T h e total chin thickness is plane. However the FMIA and the Z-angle are low
m e a s u r e d horizontally f r o m the NB line ex- because of the high FMA.
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DifferentialDiagnosis 245

UPPER LIP THICKNESS

TOTAL CHIN THICKNESS

Figure 6. Drawing that illustrates how upper lip thick-

ness and total chin thickness are measured.

Figure5. (A) Posttreatment facial photographs. Note
the worsened facial esthetics. Mentalis strain has
increased. (B) Posttreatment cephalogram that exhib-
its mandibular incisors that have been maintained in
their pretreatment position. They could not be overly
uprighted because the patient was treated without
extractions. Facial balance suffered because of the
diagnostic decision not to extract.
Differential Diagnosis
Skeletal Disharmony
Skeletal d i s h a r m o n i e s are evaluated by observ-
ing the occlusal relationships o f the casts, by
studying the facial p h o t o g r a p h s , a n d m o s t impor-
tantly, by a careful analysis o f the c e p h a l o m e t r i c
m e a s u r e m e n t s . T h e Charles H. Tweed I n t e r n a -
tional F o u n d a t i o n has u n d e r t a k e n several clini-
cal c e p h a l o m e t r i c studies that have yielded infor-
m a t i o n that has b e c o m e an integral p a r t o f the
Differential Diagnostic Analysis System. These
studies led to the d e v e l o p m e n t o f the Cranial

gives an a n g u l a r value that is indicative o f lip

protrusion. A Z-angle that reflects optimal facial
balance ranges f r o m 72 ° to 78 ° .
T h e Z-angle quantifies the c o m b i n e d abnor-
malities in the values o f FMA, FMIA, a n d soft
tissue thickness, a n d all have a direct b e a r i n g o n
facial balance. T h e Z-angle gives i m m e d i a t e guid-
ance relative to a n t e r i o r t o o t h repositioning. I f
the patient has a n o r m a l FMA o f 25 °, a n o r m a l
FMIA o f 68 °, a n d g o o d soft tissue overlay distribu-
tion, the Z-angle value s h o u l d be a p p r o x i m a t e l y
78 °. If any o f the three c o m p o n e n t s is n o t within
its optimal range, differentiation can be m a d e to
d e t e r m i n e which values are n o t optimal a n d why. Figure 7. The Z-angle quantifies facial balance. It is
T o o t h positions can subsequently be altered to very sensitive to lip position. A Z-angle range which
favorably influence facial balance. exhibits optimal facial balance is 72° to 78 °.
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246 L. Levern Merrifield

Facial Analysis, the c o m p o n e n t of the Differen- Table 2. The Probability Index Variables With the
tial Diagnostic Analysis system that identifies the Statistically Computed Difficulty Factors
skeletal disharmony. Variation
FMA 5 points
Backgroundm The Cranial Facial Analysis ANB 15 points
FMIA 2 points
For a period of approximately 15 years, until his OcP1 3 points
untimely death in J u n e of 1993,Jim Gramling of SNB 5 points
Jonesboro, AR, was the research director for the Note. This was Gramling's initial attempt at a Probability
Foundation. During the years he was the re- Index.
search director, Dr Gramling compiled a rather
large sample of successfully and unsuccessfully
treated Class II malocclusions, 13,14 all of which 1. to a u g m e n t diagnostic procedures,
were treated by members of the Foundation. 2. to guide treatment procedures,
The results of these studies of unsuccessful 3. to predict possible treatment success or fail-
and successful treatment were c o m p a r e d and ure.
can be seen in Table 1. In the successful sample,
FMA was reduced, FMIA was increased, and It was h o p e d that the index would be of value in
IMPA was reduced. In the unsuccessful sample, isolating those Class II malocclusions that might
FMA increased, FMIA remained the same or need alternate treatment procedures or those
decreased a m i n i m u m amount, and IMPA in- that might require surgical correction to achieve
creased or remained the same. There was not as complete correction. Gramling's probability in-
much Z-Angle increase in the unsuccessful sample dex was based on the premise that control of the
as there was in the successful sample. SNA FMA, the ANB, the FMIA, the occlusal plane,
reduction was similar, but A O / B O reduction for and the SNB were the keys to success or failure of
the unsuccessful sample was not as g o o d as for the orthodontic correction of a Class II malocclu-
the successful sample. Y-Axis values and SNB sion. The Probability Index suggested that the
values remained the same for both samples. By following pretreatment conditions might be nec-
studying the collected data from these two essary for Class II treatment success.
samples, it can be concluded that in unsuccessful 1. FMA should be 18 ° to 35".
Class II treatment, the mandibular incisor posi-
2. ANB should be 6 ° or less.
tion was not corrected, or if it was corrected, the
3. FMIA should be greater than 60 °.
correction was subsequently c o m p r o m i s e d by
4. Occlusal plane should be 7° or less.
excessive, unreciprocated use of Class II elastics 5. SNB should be 80 ° or more.
in an attempt to establish the p r o p e r anteropos-
terior maxillo-mandibular dental relationships. Gramling statistically established a difficulty
From the b a c k g r o u n d of evidence gathered factor and assigned a specific n u m b e r of points
from these studies, Gramling formulated a Prob- to each variable (Table 2).
ability Index 15 for three specific purposes: In 1989 Gramling studied a different sample
of 40 successful and 40 unsuccessful Class II
malocclusion correctionsJ 6 After this study, he
Table 1. A Comparison of Gramling's Studies of revised only one of the five premises of the
Successful and Unsuccessful Class II Correction Probability Index. He c h a n g e d the successful
Successful Unsuccessful FMA range from 18 ° to 35 ° to 22 ° to 28 ° (Table 3).
Pre Post Pre Post In a later study o f successful and unsuccessful
Class II treatment, Gebeck 17 and Merrifield is
FMA 27 27 29 30
FMIA 58 63 56 55 studied a successfully treated Class II sample, an
IMPA 95 90 95 95 unsuccessfully treated Class II sample, and a
Z-angle 66 75 62 69 control Class II sample. As a result of their
Y-axis 62 62 65 65
SNA 82 79 81 79 studies, Merrifield and Gebeck concluded that
SNB 76 76 75 75 important to successful Class II correction was
ANB 6 3 6 4 control of anterior facial height and posterior
A.B. 4 - 1 7 5
facial height, or as Gramling concluded by using
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Differential Diagnosis 247

Table 3. The Probability Index After the
Pretreatment Range for FMA was Adjusted
Downward to 22° to 28°
Point Cephalometric Probability
Value Value
FMA 22 ° to 28 ° 5 areas were weighted, taking into consideration
A N B 6 o r less 15
F M I A 60 o r M o r e 2
O C C PL 7 o r Less 3 plexity and importance of treatment manage-
SNB 80 o r M o r e 5 ment.
Total
FMA and occlusal plane, control of the vertical
dimension.
In 1989, Andre H o r n studied the ratio o f
anterior facial height to posterior facial height.
H o r n suggested a Facial Height Index or FHI. 19
The normal anterior facial height to posterior
facial height ratio was f o u n d by H o r n to be 0.65
to 0.75. If the FHI value was below or above this
range, the malocclusion was a great deal more
complex and the difficulty e n c o u n t e r e d in its
correction was increased. For example, an index
of 0.85 was severe and was usually f o u n d on a
patient with a low FMA and with either too m u c h
ramal growth or too little vertical anterior facial
height development. As the index a p p r o a c h e d
0.60, the cranial facial pattern was one that
showed too little ramal height or too m u c h
anterior facial height, both of which are also
c o m p o n e n t s of a severe vertical skeletal prob-
lem.
Cranial Facial Analysis
Using information from the previously described
clinical research, the Cranial Facial Analysis
(Table 4), an integral c o m p o n e n t of the Differen-
tial Diagnostic Analysis system, was developed.
Each of the six cephalometric values used has
been d e t e r m i n e d to have significant merit. The
interrelationship of each of the values has been
statistically weighed in relationship to its indi-
vidual significance and mathematical value. In
Index
determining the difficulty of correction, the
the necessary diagnostic decisions and the com-
The FMA, the A F H / P F H ratio, and the occlu-
sal plane to Frankfort angle, are significant when
used as a group. These values comprise the
vertical skeletal c o m p o n e n t of the cranial facial
analysis. The vertical skeletal pattern can be a
problem of excessive anterior facial height in the
presence of a decreased posterior facial height,
or conversely, a problem of excessive posterior
facial height and a decreased anterior facial
height. If facial height, either anterior or poste-
rior, is out of p r o p e r proportion, correction of
the malocclusion is most difficult, and great care
must be taken with treatment procedures so that
the vertical disharmonies do not significantly
worsen.
The horizontal skeletal c o m p o n e n t of the
cranial facial analysis is c o m p o s e d of the SNB
and the ANB. A high ANB caused by a low SNB
makes the horizontal skeletal disharmony m u c h
more difficult to manage than it would be if the
high ANB were caused by an excessive SNA. The
low SNB requires a treatment compromise or, if a
more ideal result is desired, orthognathic sur-
gery.
The previously described Z-angle value is the
only non-skeletal m e a s u r e m e n t in the cranial
facial analysis. It was included because it is a
facial indicator of skeletal imbalance.

Table 4. The Cranial Facial Analysis was Developed Differential Diagnosis

from Gramling's Probability Index
The Dentition
Cranial Facial Analysis
Ceph Difficulty For most patients, a dental disharmony is manage-
Normal Range Value Factor Difficulty able. To correctly diagnose the dental problem, a
careful total dentition space analysis 2° (Table 5)
F M A 22 ° to 28 ° 5
A N B 1 ° to 5 ° 15 and a study o f the occlusal relationships is
Z A n g l e 70 ° to 80 ° 2 essential. The dentition is divided into three
O c c P l a n e 8 ° to 12 ° 3
areas: anterior, midarch, and posterior. This
SNB 78 ° to 82 ° 5
F H I ( P F H - A F H ) .65 to .75 3 division is made for two reasons: simplicity in
C.E Difficulty T o t a l identifying the area of space deficit or space
N o t e . T h e Z-angle was s u b s t i t u t e d f o r t h e F M I A a n d t h e
surplus, and the possibility of arriving at a more
A F H / P F H r a t i o was a d d e d . accurate differential diagnosis.
<< :,¢J,. ~ >> Home I TOC I Bndex

248 L. Levern Merrifield

Table 5. Total Dentition Space Analysis Divides the t r i a n g l e is d r a w n o n t h e h e a d p l a t e with white

Dentition into Three Distinct Areas ink. A d o t t e d line s t a r t i n g at t h e a p e x o f t h e
Oifficu~ m a n d i b u l a r i n c i s o r is d r a w n u p w a r d to i n t e r c e p t
Value Factor Difficulty t h e F r a n k f o r t p l a n e at a n a n g l e o f 65 ° . T h e
Anterior d i s t a n c e b e t w e e n t h e solid line, w h i c h is t h e
Tooth arch disc 1.5 e x i s t i n g i n c l i n a t i o n o f t h e m a n d i b u l a r incisor,
Headfilm disc 1 a n d t h e d o t t e d line, w h i c h is t h e d e s i r e d incisal
Soft tissue mod 0.5
Total i n c l i n a t i o n ( m e a s u r e d at t h e incisal e d g e o f t h e
Midarch m a n d i b u l a r i n c i s o r ) , is t h e d i s t a n c e in m i l l i m e -
Tooth arch disc ters t h a t t h e m a n d i b u l a r incisors m u s t b e t i p p e d
Curve of Spee
Total l i n g u a l l y to satisfy t h e m i n i m u m r e q u i r e m e n t f o r
Occlusal disharmony (Class a n F M I A o f 650. "25 T h e n u m b e r o f m i l l i m e t e r s
II or Class III) from the desired position of the mandibular
Posterior
Tooth arch disc i n c i s o r e d g e to t h e a c t u a l p o s i t i o n o f t h e m a n -
Expected increase ( - ) d i b u l a r i n c i s o r e d g e is m u l t i p l i e d by " 2 " b e c a u s e
Total 0.5 b o t h sides o f t h e a r c h have to b e c o n s i d e r e d . F o r
Space analysis total Space analysis
difficulty total t h e p a s t 30 years, this p r o c e d u r e h a s b e e n d o n e
o n t h e c e p h a l o m e t r i c tracing, n o t f r o m t h e
Note. Calculations can be made that reflect space surpluses
or deficits in each area. Abbreviations: disc, discrepancy; a c t u a l x-ray as it was d o n e in T w e e d ' s day (Fig 8).
mod, modification. T h e t h i c k n e s s o f t h e soft tissue ( u p p e r lip
versus total c h i n ) m u s t also b e c o n s i d e r e d as p a r t
Anterior Space Analysis o f t h e a n t e r i o r s p a c e analysis. Total c h i n thick-
T h e a n t e r i o r s p a c e analysis i n c l u d e s t h e differ- ness s h o u l d e q u a l u p p e r lip thickness. I f it is less
e n c e in m i l l i m e t e r s b e t w e e n t h e s p a c e available t h a n u p p e r lip thickness, t h e a n t e r i o r t e e t h m u s t
in t h e m a n d i b u l a r a r c h f r o m t h e distal o f t h e b e u p r i g h t e d f u r t h e r to c r e a t e a m o r e b a l a n c e d
c a n i n e t h r o u g h t h e distal o f t h e c o n t r a l a t e r a l p r o f i l e b e c a u s e lip r e t r a c t i o n follows t o o t h u p -
c a n i n e a n d t h e m e s i o d i s t a l w i d t h s o f t h e six righting.
a n t e r i o r teeth. T h e d i f f e r e n c e b e t w e e n t h e s e The sum of the anterior tooth arch surplus or
m e a s u r e d values is r e f e r r e d to as a s u r p l u s o r a
deficit.
A head-film discrepancy, or a calculation of
h o w m u c h s p a c e is n e c e s s a r y f o r m a n d i b u l a r
i n c i s o r u p r i g h t i n g , m u s t b e a d d e d to t h e a n t e -
q5
r i o r s p a c e s u r p l u s o r deficit. C e p h a l o m e t r i c dis-
c r e p a n c y is a t e r m w h i c h o r i g i n a t e d with C h a r l e s
T w e e d . H e s t u d i e d t h e c e p h a l o g r a m s o f 37
c o n s e c u t i v e l y t r e a t e d p a t i e n t s a n d i n t e g r a t e d his
f i n d i n g s with t h o s e o f B r o d i e , 21 Downs, z2 a n d B.
H o l l y B r o a d b e n t . 23 H e f o u n d t h a t t h e p a t i e n t s
w h o e x h i b i t e d p l e a s i n g facial esthetics h a d a n
F M I A b e t w e e n 62 ° a n d 70 °, n o m a t t e r w h a t t h e i r
FMA. This l e d T w e e d to p r o p o s e his f o r m u l a f o r
c e p h a l o m e t r i c c o r r e c t i o n z4 ( m a n d i b u l a r i n c i s o r
u p r i g h t i n g ) to arrive at a f a v o r a b l e F M I A f o r
each patient. Tweed's formula:

F M A 21 ° to 29°: F M I A s h o u l d b e 68 °
F M A 30 ° o r g r e a t e r : F M I A s h o u l d b e 65 °
F M A 20 ° o r less: I M P A s h o u l d n o t e x c e e d 92 °.
T w e e d m e a s u r e d his c e p h a l o m e t r i c c o r r e c -
t i o n o n a n x-ray by d o i n g t h e following: " A
l a t e r a l h e a d p l a t e is m a d e o f t h e p a t i e n t a n d t h e
Figure 8. This drawing illustrates the method used by
Tweed to calculate a cephalometric correction. The
number of millimeters from the actual position of the
incisal edge of the mandibular incisor to the desired
position is multiplied by two.
<< :a-'J,. a >> Home I TOC I [ndex

DifferentialDiagnosis 249

deficit, the cephalometric discrepancy, and the Movement of these posterior teeth requires space
soft tissue thickness imbalance is referred to as management.
the anterior discrepancy. Each of the three
values in the anterior discrepancy calculation has
been given a difficulty factor so that an anterior
Posterior Space Analysis
space analysis difficulty value can be calculated. This area of the dentition has great importance.
Before any m e a s u r e m e n t of posterior space can
be made, it must be u n d e r s t o o d that there is a
Midarch Space Analysis posterior limit of the dentition. Rarely are healthy
functioning teeth located posterior to the ante-
The midarch area includes the mandibular first
rior b o r d e r of the ramus. Regardless of age, the
molars, the second premolars, and the first
anterior b o r d e r of the ramus appears to be the
premolars. Careful analysis of this area can show
posterior limit of the dentition.
mesially inclined first molars, rotations, spaces, a
The required space is the sum o f the mesiodis-
deep curve of Spee, cross bites, missing teeth,
tal widths of the mandibular second molars and
habit abnormality, blocked-out teeth, and occlu-
third molars. The available space is more diffi-
sal disharmonies. This is an extremely important
cult to ascertain on the immature patient. It is
area of the dentition because it allows for space
(1) a m e a s u r e m e n t in millimeters of the space
m a n a g e m e n t for posterior malocclusion correc-
distal to the mandibular first molar, along the
tion. A careful m e a s u r e m e n t of the space from
occlusal plane, to the anterior b o r d e r of the
the distal of the canine to the distal of the first
ramus and, (2) an estimate of posterior arch
molars should be recorded as available midarch
length increase based on both age and sex.
space. An equally accurate m e a s u r e m e n t of the
A literature study 27-29 suggests that 3 m m o f
mesio-distal widths of the first premolar, the
increase occurs per year until age 14 for girls and
second premolar, and the first molar should also
until age 16 for boys. This would be 1.5 m m of
be recorded. The lesser value is subtracted from
increase on each side each year after the full
the greater value. To the space surplus or deficit
eruption of the mandibular first molars. In
is added the space required to level the curve of
y o u n g e r patients these guidelines should be
Spee. To calculate the a m o u n t of space required
used after 8 years of age. In mature patients, girls
to level the curve of Spee, the greatest depth of
over 15 years old and boys over 17 years old, one
the curve is measured on both sides, averaged,
can measure from the distal of the first molar to
and then divided by two. ",6 From these measure-
the anterior b o r d e r o f the ramus at the level of
ments, one can determine the total space deficit
the occlusal plane and have an accurate determi-
or surplus in the midarch area.
nation of the space available in the posterior
Occlusal disharmony, a Class II or Class III
area. It is of extreme importance in diagnosis
buccal segment relationship, t h o u g h not a part
and treatment planning to know whether there
of the actual midarch space analysis, must be
is a space surplus or deficit in this area. The
measured because an occlusal disharmony adds
orthodontist should n o t create severe posterior
a great deal to the difficulty of correction of any
discrepancies while making adjustments in the
malocclusion and requires a careful treatment
midarch and anterior areas. Conversely, the clini-
strategy as well as space management.
cian should utilize a posterior space surplus to
Occlusal disharmony is measured by articulat-
help alleviate midarch and anterior arch deficits.
ing the casts and using the maxillary first premo-
The posterior space analysis surplus or deficit
lar cusp as a reference. Measure mesially or
has been given a low difficulty factor of 0.5
distally from the maxillary first premolar buccal
because a posterior space deficit can be easily
cusp to the embrasure between the mandibular
resolved by third molar removal.
first and second premolars. This m e a s u r e m e n t is
made on both sides and is then averaged to
determine the occlusal disharmony. The diffi-
The Differential Diagnostic
culty factor is "2," so the averaged disharmony is
Analysis System
doubled and added to the midarch difficulty
because it has to be corrected by moving teeth The cranial facial analysis and the total dentition
which are in the midarch area of the dentition. space analysis, used together, comprise the Differ-
<< ~,r'J,. a >> Home I TOC I Bndex

250 L. Levern Merrifield

Table 6. Differential Diagnostic Analysis System facial difficulty a n d the total dentition space
C~ph Difficulty analysis difficulty is the total difficulty. This
Value Factor Difficulty figure gives the clinician a quantitative m e t h o d
Cranial Facial Analysis o f evaluating the difficulty o f c o r r e c t i o n o f each
Normal Range malocclusion. T h e analysis identifies the specific
FMA 220-28° 5 areas o f m a j o r disharmony, ie, facial, skeletal, o r
ANB 1°-5° 15
Z-angle 700-80° 2 dental, a n d gives g u i d a n c e for t r e a t m e n t strat-
Occ Plane 8°-12° 3 egy. O t h e r clinical relationships a n d values such
SNB 78°-82° 5 as habit evaluation, j o i n t health, muscle balance,
FHI (PFH-AFH) .65-.75 3
C.E Difficulty Total dental malrelationships, a n d the o t h e r cephalo-
Total Dentition Space metric values m u s t be duly n o t e d a n d evaluated
Analysis
Anterior by the o r t h o d o n t i s t . T h e o r t h o d o n t i s t m u s t also
Tooth Arch Disc. 1.5 evaluate the patient's motivation a n d desire for
Headfilm Disc. 1 o r t h o d o n t i c correction. T h e r a n g e o f values for
Soft Tissue Mod. 0.5
Total the total difficulty that have b e e n f o u n d to be
Midarch most appropriate when malocclusion correction
Tooth Arch Disc. difficulty is studied are: mild, 0 to 60; m o d e r a t e ,
Curve of Spee
Total 1 60 to 120; severe, 120 plus.
Occlusional Disharmony T h e use o f the Differential Diagnostic Analysis
(Class II or Class system will be illustrated with the analysis o f
III) 2
Posterior p r e t r e a t m e n t r e c o r d s o f a patient with a Class II,
Tooth Arch Disc. division I malocclusion.
Expected Increase T h e p r e t r e a t m e n t facial p h o t o g r a p h s (Fig 9)
(-)
Total 0.5 indicate a convex facial profile with maxillary
Space AnalysisTotal Space Analysis p r o t r u s i o n , m a n d i b u l a r retrusion, lip eversion,
Difficulty Total
C.E Difficulty Total 54.0 a n d strain o f the mentalis musculature. T h e
S.A. Difficulty Total 34.0 p r e t r e a t m e n t casts (Fig 10) illustrate the Class II
Total Difficulty 88.0 dental occlusion, a d e e p overbite, mild crowd-
Index Difficulty: Mild 0-60 Moderate 60-120 Severe
120+ ing, a n d a m o d e r a t e curve o f Spee. T h e pretreat-
m e n t p a n o r a m i c r a d i o g r a p h (Fig 11) shows a
This system combines the cranial facial analysis difficulty and healthy dentition. T h e p r e t r e a t m e n t cephalo-
the total dentition space analysis difficulty to arrive at a total
difficulty for malocclusion correction. Use of the system g r a m (Fig 12A) a n d its tracing (Fig 12B) c o n f i r m
identifies the major areas of disharmony and quantifies this a dental i m b a l a n c e because o f flaring o f the
difficulty of the malocclusion. maxillary a n d m a n d i b u l a r incisors. T h e third
m o l a r b u d s are present. T h e A O / B O value o f 8
ential Diagnostic Analysis System (Table 6). Use m m a n d the ANB o f 6 ° are indicative o f a
o f this diagnostic m e t h o d o l o g y will significandy horizontal skeletal imbalance.
i m p r o v e the clinician's ability to diagnose, plan, T h e patient's cranial facial difficulty was calcu-
a n d e x e c u t e treatment. T h e s u m o f the cranial lated (Table 7). E a c h c e p h a l o m e t r i c value that is

Figure 9. Pretreatment fa-

cial photographs that ex-
hibit lip eversion and maxil-
lary protrusion.
<< At-'.t~ e >>
Differential Diagnosis
utilized in the cranial facial analysis was placed in
the " c e p h value" column. The difficulty factor
was calculated for each cephalometric measure-
m e n t that was outside the normal range. The
Figure 11. Pretreatment panoramic radiograph illus-
trates a healthy dentition.
Home I TOC I Bndex
251
Figure 10. Pretreatment casts reflect a Class II occlu-
sion, a deep overbite, and some anterior dental
crowding.
total cranial facial difficulty for this patient
was 41.
The total space analysis and the space analysis
difficulty were calculated (Table 8). The anterior
tooth arch discrepancy for the six mandibular
anterior teeth was 4 ram. Since the anterior
crowding was 4 m m and its difficulty factor is
held to be 1.5, the resultant difficulty column was
calculated to be 6. The head-film discrepancy
measured 12. There was no soft tissue modifica-
tion because the total chin m e a s u r e m e n t s
equaled the u p p e r lip measurements. The total
anterior space analysis difficulty was 18.
The tooth arch discrepancy for the midarch
was 1 ram. The curve of Spee required 1 m m of
space for leveling. The difficulty factor for the
midarch is 1, therefore, the total space require-
m e n t for correction o f crowding and the leveling
of the curve of Spee was 2.0 m m (1 + 1 × 1).
<< :,FJ,. ~ >> Home I TOC I Bndex

252 L. Levern Merrifield

Table 7. Cranial Facial Analysis

Ceph Difficulty
Normal Range Value Factor Difficulty
FMA 22°-28° 26 5 0
ANB 1°-5° 6 15 15
Z-angle 700-80° 71 2 0
Occ Plane 8°-12° 10 3 0
SNB 780-82° 77 5 5
FHI (PFH-AFH) .65-.75 0.82 3 21
C.E DifficultyTotal 41
Note. The patient's cranial facial difficulty was only 41. The
patient had an excessive AFH/PFH ratio and a horizontal
skeletal imbalance.

factor is lower i n the p o s t e r i o r p a r t o f the m o u t h

b e c a u s e p o s t e r i o r space r e q u i r e m e n t s can b e
@ resolved with t h i r d m o l a r extraction.
T h e actual space r e q u i r e d to c o r r e c t the
c r o w d i n g of the d e n t i t i o n was 37 m m . However,
the total space analysis difficulty was 49.5. This
figure i n c l u d e s the space m a n a g e m e n t for the
occlusal d i s h a r m o n y c o r r e c t i o n as well as space
r e q u i r e m e n t s for c o r r e c t i o n o f c r o w d i n g a n d
u p r i g h t i n g of m a n d i b u l a r incisors.
T h e c r a n i a l facial difficulty was a d d e d to the
space analysis difficulty to yield a total difficulty
(Table 9) of 90.5. U s i n g the criteria already
e s t a b l i s h e d for difficulty o f m a l o c c l u s i o n correc-
tion, this p a t i e n t ' s m a l o c c l u s i o n fits i n t o the
c a t e g o r y o f m o d e r a t e difficulty o f c o r r e c t i o n .
D i f f e r e n t i a l diagnosis e n a b l e s the o r t h o d o n -
tic c l i n i c i a n to c o m p r e h e n s i v e l y analyze a maloc-
Figure 12. (A & B) Pretreatment cephalogram and its clusion. T h e p r o t o c o l o f a n a l y z i n g the face, the
tracing exhibits bialveolar protrusion and a horizontal
skeletal imbalance. (B) FMIA 52 °, FMA 26°, IMPA
102°, SNA 83 °, SNB 77 °, ANB 6°, A O / B O 8mm, OCC Table 8. Total Space Analysis
10, Z 71 °, UL 10ram, TC 17ram, PFH 45ram, AFH Difficulty
55ram, Index .82. Value Factor Difficulty
Anterior
T h e p a t i e n t h a d a Class II o c c l u s i o n o n b o t h Tooth Arch Disc. 4 1.5 6
r i g h t a n d left sides. Five m i l l i m e t e r s o f space p e r Headfilm Disc. 12 1 12
Soft Tissue Mod. 0 0.5 0
side was n e c e s s a r y for occlusal c o r r e c t i o n . Be-
Total 16 18
cause occlusal d i s h a r m o n y has a difficulty factor Midarch
o f 2, the total difficulty for Class II c o r r e c t i o n was Tooth Arch Disc. 1
20 (5 + 5 × 2). T h e total m i d a r c h difficulty was, Curve of 8pee 1
Total 2 1 2
t h e r e f o r e , 22. Occlusal Disharmony {Class
T h e t o o t h arch d i s c r e p a n c y i n the p o s t e r i o r II or Class III) 10 2 20
p a r t o f the arch, m e a s u r e d f r o m the distal o f the Posterior
Tooth Arch Disc. 22
first m o l a r to the a s c e n d i n g b o r d e r of the r a m u s , Expected Increase ( - ) 3
was 22 m m . Because the p a t i e n t was 13 years old, Total 19 0.5 9.5
she c o u l d e x p e c t a n i n c r e a s e i n p o s t e r i o r space Space Analysis Total 37 Space analysis 49.5
difficulty total
of 3 m m . T h e r e f o r e , the space deficit was 19 m m .
Because the difficulty factor is 0.5 for the poste- Note. The patient's total space analysis and space analysis
difficulty calculations are illustrated. Anterior difficulty was
rior area, the total space analysis difficulty for the 18. Midarch diffÉculty,due to the Class II occlusion, was 22.
p o s t e r i o r d e n t u r e area was 9.5. T h e difficulty The posterior difficultywas 9.5.
<< Ar'J~: e >>
DifferentialDiagnosis
Table 9. T h e Patient's Total Difficulty
C.E Difficulty Total 41.0
S.A. Difficulty Total 49.5
Total Difficulty 90.5
Index Difficulty: Mild 0-60 Moderate 60-120 Severe
120+
Note. Cranial facial difficulty plus space analysis difficulty
equals a total difficulty of 90.5. This figure quantifies the
malocclusion and gives guidance for diagnostic decisions.
skeletal pattern, and the teeth enables the clini-
cian to ascertain the area with the greatest
disharmony, prioritize the attainable objectives,
and arrive at a diagnosis and treatment plan that
will enable h i m / h e r to address the greatest
n u m b e r of these treatment objectives.
T h e information derived from the Differen-
tial Diagnostic Analysis system can be invaluable
to the clinician during the diagnosis process. It is
a tool, but a tool that has clinical importance. It
gives the orthodontic specialist useful informa-
tion that can lead to proper diagnostic decisions
that will most advantageously facilitate correc-
tion o f the malocclusion.
References
1. Merrifield LL. Dimensions of the denture: Back to basics.
AmJ Orthod Dentofacial Orthoped 1994;106:535-542.
2. Merrifield LL, Klontz HA, VadenJL. Differential diagnos-
tic analysis systems. Am J Orthod Dentofacial Orthoped
1994;106:641-648.
3. Tweed CH. The Frankfort Mandibular Incisor Angle
(FMIA) in Orthodontic Diagnosis, Treatment Planning,
and Prognosis. Am J Orthod 1954;24:121-169.
4. Tweed CH. The Frankfort Mandibular Incisor Angle
(FMIA) in orthodontic diagnosis, classification, treat-
ment planning, and prognosis. AmJ Orthod 1946;32:175-
221.
5. Tweed CH. A philosophy of orthodontic treatment. AmJ
Orthod Oral Surg 1945;31:74-103.
6. Reidel R. The relation of maxillary structures to cranium
in malocclusion and in normal occlusion. Angle Orthod
1952;22:142-145.
7. Jacobson A. The "Wits" appraisal of jaw disharmony. Am
J Orthod 1975;67:125-138.
8. Jacobson A. Radiographic Cephalometry. Chicago, IL:
Quintessence 1995:97-112.
9. Downs WB. The role of cephalometrics in orthodontic
case analysis and diagnosis. AmJ Orthod 1952;38:162-82.
Home I TOC I Index
253
10. Merrifield LL. The profile line as an aid in critically
evaluating facial esthetics. AmJ Orthod 1966;11:804-822.
11. Riolo M, Moyers RE, McNamara J, et al. An Atlas of
Craniofacial Growth Center for Human Growth and
Development. Ann Arbor, MI University of Michigan,
1974:116.
12. Merrifield LL. Z-angle maturity study. Unpublished Lec-
ture, Tweed Study Course, Tucson, AZ.
13. GramlingJE A cephalometric appraisal of the results of
orthodontic treatment on one hundred fifty successfully
corrected difficult class II malocclusions.J Charles Tweed
Foundation 1987;15:102-111.
14. GramlingJE A cephaloinetric appraisal of the results of
orthodontic treatment on fifty-five unsuccessfully cor-
rected difficult Class II malocclusions. J Charles Tweed
Foundation 1987;15:112-124.
15. Gramling JE The probability index. J Charles Tweed
Foundation 1989;17:81-93.
16. GramlingJ. The probability index. AmJ Orthod Dentofa-
cial Orthopedics 1995;107:165-171.
17. Gebeck TR, Merrifield LL. Orthodontic diagnosis and
treatment analysis: Concepts and values, part I. Am J
Orthod Dentofacial Orthop 1995;107:434-443.
18. Merrifield LL, Gebeck TR. Orthodontic diagnosis and
treatment analysis: Concepts and values, part II. Am J
Orthod Dentofacial Orthop 1995;107:541-547.
19. Horn A. Facial height index. Am J Orthod Dentofacial
Orthop 1992;102:180-186.
20. Merrifield LL. Differential diagnosis with total space
analysis.J Charles Tweed Foundation 1978;6:10-15.
21. Brodie AG. Some recent observations on the growth of
the face and their implications to the orthodontist. Am J
Orthod Oral Surg 1940;26:740-757.
22. Downs WB. Variations in facial relationships: their signifi-
cance in treatment and prognosis. AmJ Orthod 1948;34:
812-840.
23. Broadbent BH. Ontogenic development of occlusion.
Angle Orthod 1941;11:223-241.
24. Tweed CH. Clinical Orthodontics, vol I. St. Louis, MO:
Mosby, 1966:59.
25. Tweed CH. The Frankfort Mandibular Incisor Angle
(FMIA) in orthodontic diagnosis, treatment planning,
and prognosis. AmJ Orthod 1954;24:139-140.
26. Baldridge D. Leveling the curve of spee: Its effect on
mandibular arch length. Unpublished Master's Thesis,
June, 1960, University of Tennessee.
27. Richardson ME. Development of the lower third molar
from ten to fifteen years. Angle Orthod 1973;43:191-193.
28. Ledyard BC. A study of the mandibular third molar area.
AmJ Orthod 1953;39:366-374.
29. Bjork A, Gensen E, Palling M. Mandibular growth and
third molar impaction. Eur Orthod Society Trans 1956:
164.