The quadrilateral analysis: A differential

diagnosis for surgical orthodontics Dr. Di Paolo

Rocco J. Di Paolo, D.D.S.,* Chris Philip, D.D.S.,**

Anthony L. Maganzini, D.D.S., M.S.D.,** and John D. Hirce, D.M.D.,
M.S.D.**
Hackensack. N. J.

The integration of the diagnostic and treatment skills of both the orthodontist and the maxillofacial surgeon has
become a standard procedure in the treatment of severe dentofacial dysplasias. Orthognathic surgery, surgery
without prior tooth movement, is being replaced by an interdisciplinary approach as the treatment of choice.
When a proper tooth-to-denture-base relationship is obtained, an ideal maxillomandibular relationship can be
achieved surgically. The quadrilateral analysis enables the practitioner to obtain an individualized skeletal, dental,
and soft-tissue assessment of each patient requiring treatment. It determines the direction and extent of the
skeletal dysplasia in millimeter measurements and allows the clinician to outline the appropriate surgical
orthodontic procedures. The quadrilateral analysis indicates that in a balanced facial pattern a 1 : 1 ratio exists
between the maxillary bony base length (Max.Lth.) and the mandibular bony base length (Mand.Lth.); also that
the average of the anterior lower facial height (ALFH) and the posterior lower facial height (PLFH) equals these
ALFH ” PLFH”
bony base lengths. Simply stated, the Max.Lth. = Mand.Lth. = An accurate diagnosis locates the
2
area and quantifies the magnitude of skeletal dysplasia. Then the correct placement of a dentition within the
denture bases and the appropriate surgery in the area of dysplasia can produce an individualized, balanced facial
pattern.

Key words: Balanced facial pattern, individualized skeletal assessment, incisor position, angle of
facial convexity, sagittal ratio

c ephalometric analysis is the common lan-
guage of the maxillofacial surgeon and the orthodon-
tist. It is used in the diagnosis of skeletal and soft-tissue
problems, in establishing proper tooth-jaw relations,
and in determining the method and magnitude of surgi-
cal correction. Unfortunately, cephalometric analysis is
not interpreted uniformly by all practitioners. Some
rely solely upon model surgery, while others rely on a
visual profile assessment. This practice may lead to a
less than optimum result.
Model surgery gives the clinician only an approxi-
mate, dimensional, and visual rendition of what the
jaw-to-jaw relationship would look like after surgery. It
does not locate or indicate the extent of the skeletal
dysplasia; nor does it permit the surgeon to position the
incisors accurately as related to the soft-tissue profile of
the patient.
At present, many cephalometric analyses are used
in surgical orthodontic diagnosis.‘, 2 Some of the
From Fairleigh Dickinson University.
*Rofessor and Chairman of Orthodontics
**Associate Professor of Orthodontics.
470
cephalometric measurements that are commonly uti-
lized are not as accurate or reliable as we would like
them to be. For example, in a retrognathic or prog-
nathic jaw relationship, measurements such as SNA,
SNB, Y axis, and mandibular plane angle do not differ-
entiate as to whether the dysplasia is due to size, posi-
tion, or a combination of both.
Some practitioners believe that certain standard-
ized, normal measurements should be applied to all
patients. Other clinicians dispute the usefulness of any
cephalometric analysis that compares patients to stan-
dardized norms. This poses a dilemma. Should the sur-
geon use cephalometric measurements which contradict
visual experience? The answer is obvious. If a cepha-
lometric analysis is not a diagnostic guide, it should not
be used.
In surgical orthodontics, the combination of vari-
ables in dentofacial deformities is so complex that
it becomes questionable whether all cases should be
treated to a standard norm. 3, 4 The clinician, therefore,
must seek a more individualized cephalometric analysis
that clearly determines the amount and the location of
the dysplasia. In this way, the appropriate surgical pro-
Volume 86 Quadrilateral analysis 471
Number 6

Table I. Comparison of skeletal patterns, adolescents (9 to 15 yr)

Normal Hypodivergent Hyperdivergent
Parameters
measured N X SD N X SD N X SD

Maxillary length 245 50.9 2.0 64 52.1 2.4 64 49.1 2.5

Mandibular length 245 50.0 2.5 64 51.4 2.6 64 49.6 2.2
Difference 245 .9 N/M 64 1.3 N/M 64 .5 N/M
ALFH 245 60.0 3.5 64 55.3 3.4 64 70.3 3.7
PLFH 245 39.4 2.2 64 37.8 2.1 64 42.3 2.3
LFH (average) 245 49.1 2.8 64 46.6 3.1 64 56.3 2.9
AUFH 245 49.2 2.3 64 51.5 2.5 64 52.4 2.6
Posterior LEG (max) 245 101.4 N/M 64 118.1 N/M 64 72.2 N/M
Total length (max) 245 152.3 N/M 64 170.8 N/M 64 121.3 N/M
PP-GoCn angle 245 23.1” 1.7” 64 19.8” 1.5” 64 31.6” 2.2”
Facial convex angle 245 169.5” 3.2” 64 172.8” 3.6” 64 163.8” 2.9”

N = Sample size.
X = Mean.
SD = Standard deviation.
N/M = Not meaningful.

Table II. Comparison of skeletal patterns, adolescents (9 to 15 yr)

Normal Hypodivergent Hyperdivergent
Raiio
established N X N X N X

Maxillary length/mandibular length 245 1: .99* 64 1: .98* 64 1 : 1.01*

Maxillary length/LFH (average) 245 1: .99* 64 I:.88 64 1: 1.15
ALFHiAUFH 245 1: 1.21 64 1: 1.07 64 1:1.34
Posterior LEG (max)itotal length (max) 245 1: 1.50 64 I : 1.41 64 1:1.61
(sagittal ratio)
PLFHiALFH (vertical ratio) 245 1: 1.52 64 1:1.46 64 1:1.66

N = Sample size.
X = Mean.
SD = Standard deviation ~0.05
*Denotes equal counterparts.

cedure can be selected to restore a harmonious relation-
ship of the jaws to the rest of the face.
In 1962 the quadrilateral analysis was formulated
by Di Pao1o.j It attempts to identify skeletal devia-
tions, in size and position, in both the horizontal and
the vertical dimensions, regardless of dentoalveolar re-
lationships. It provides an individualized skeletal as-
sessment of each patient. 6-g A statistical summary
comparing normal, hypodivergent, and hyperdivergent
adolescent skeletal patterns appears in Table I.
The mean age of these equally divided male and
female patients was 12.6 years. When no sex-related
differences were observed, the statistical data were
pooled. In order to group the patients into the different
skeletal patterns, the palatal plane angle was used.
Therefore, patients with a palatal plane angle of 22” to
25” were considered normal, while those below 21”
were classified as hypodivergent, and those above 29”
as hyperdivergent. The proportional relationship be-
tween various segments of the facial complex appears
in Table II.
QUADRILATERAL ANALYSIS OF THE
LOWER FACE
The maxillary base length is measured, in milli-
meters, horizontally between two points projected onto
the palatal plane. The anterior limit of maxillary base
length is determined by projecting a perpendicular from
subspinale (PtA) upward to the palatal plane (ANS-
PNS), while the posterior limit of maxillary base length
is determined by projecting a perpendicular from the
most inferior portion of the pterygomaxillary fissure
(PTM) downward to the palatal plane.
The mandibular base length is measured, in milli-
meters, horizontally between two points projected onto
the mandibular plane (GoGn). The anterior limit of the

472 Di Paolo et ul.
Fig. 1. Dental assessment.
Fig. 2. Sagittal ratio.
mandibular base length is determined by projecting a
perpendicular from supramentale (PtB) downward to
the mandibular plane (GoGn), while the posterior limit
of the mandibular base length is determined by project-
ing a perpendicular from point J downward to the
mandibular plane (GoGn).
Point J is located at the deepest point of the curva-
ture formed at the junction of the anterior portion of the
ramus and the corpus of the mandible. Point J is the
cephalometric representation of the posterior limit of
the denture base.
A line is drawn from articulare tangent to the most
posterior point on the ramus. A parallel line is then
drawn through the innermost point on the curvature of
the anterior aspect of the ramus. At a point where
the remaining alveolar crest contacts the last molar,
a line is drawn parallel to the gonion-gnathion plane.
Am. .I. Orthod.
December 1984
Fig. 3. Variation of facial convexity due to relative size of the
maxilla and mandible.
The angle formed is then bisected, and point J is lo-
cated where this line crosses the inner curvature of the
mandible.
Anterior lower facial height (ALFH) is measured,
in millimeters, from the projection of point A onto the
palatal plane to the projection of point B onto the
gonion-gnathion plane. Posterior lower facial height
(PLFH) is measured, in millimeters, from the projec-
tion of PTM onto the palatal plane to the projection of
point J onto the gonion-gnathion plane. These four
measures (maxillary bony base length, mandibular
bony base length, anterior lower facial height, and
posterior lower facial height) form the basis for the
quadrilateral analysis of the lower face.
Anterior upper facial height (AUFH) is measured,
in millimeters, from the projection of point A onto the
palatal plane to nasion on the cranial base plane (S-N).
In reviewing Table II, the basic concept of lower
facial proportionality is illustrated. The quadrilateral
analysis indicates that in a balanced facial pattern
a 1: 1 ratio exists between the maxillary bony base length
(Max.Lth.) and the mandibular bony base length
(Mand.Lth.); also, that the average of the anterior lower
facial height (ALFH) and posterior lower facial height
(PLFH) equals these bony base lengths. Simply stated,
the Max.Lth. = Man.Lth. = ALFH k PLFI-I’O
2 .
Enlow” has described a similar dimensional bal-
ance that exists between the various parts and counter-
parts of the face. He indicates that the counterpart
principle is “ . . . the actual design basis upon which
the face is constructed and which underlies the plan of
its intrinsic growth process. ”
Volumv 86 Quadrilateral analysis 473
Number 6

Fig. 4. Variation of facial convexity due to relative position of the

maxilla and mandible.

INCISAL POSITIONING
Fig. 5. Variation of facial convexity due to increased lower facial
Variations in the cant of the cranial base make the height.
use of SNA and SNB angles unreliable; the greater the
degree of dysplasia, the less the reliability of these
measurements.12 The positioning of the incisor teeth in
relation to the nasion-point A line and the nasion-
point B line, therefore, also becomes questionable.13
The musculoskeletal pattern present, the relation of the
bony bases, and the convexity of the face are factors
that influence incisal positioning. It is essential that an
individualized balanced relationship exist between inci-
sal position, angle of facial convexity, and size of the
chin.14 This interdependence becomes very important
in surgical orthodontics. The malposition of the maxil-
lary and mandibular incisors can result in a surgical
malalignment of the maxillary and mandibular bony
base lengths. Although an acceptable dental occlusion
may be obtained, a Class II or Class III facial pattern
may result. l5 In order to determine proper maxillary
and mandibular incisor position, it is important first to Fig. 6. Variation of facial convexity due to spatial rotation (cant)
obtain normal denture base relationships cephalometri- of the lower face.
tally in the quadrilateral, in this way achieving a pro-
portionally balanced lower facial pattern.
to the most anterior point of the lower incisor is 2
Dental analysis (quadrilateral) mm 2 1 mm. The pogonion line is constructed by
Maxillary incisor position can be determined by drawing a line tangent to pogonion, parallel to anterior
drawing a line through point A parallel to the anterior lower facial height (ALFH). The most anterior point of
lower facial height (ALFH). A perpendicular from this the mandibular incisor should be + 2 mm to this line.
line to the most anterior point on the maxillary incisor This measurement will indicate if the chin is excessive
should result in a measurement of 5 mm -+ 1 mm. This or deficient in size (Fig. 1).
was derived from the same normal study of 245 patients
Sagittal ratio
previously stated. This analysis has an advantage be-
cause it relates the teeth to the lower facial convexity The sag&al ratio is important in assessing the rela-
rather than to a cranial base measure outside the lower tive anteroposterior position of the maxillary and man-
face. The same procedure is used for the mandibular dibular bony bases. Skeletal malformations of the jaws.
incisor by drawing the line through point B parallel to may be either in the bony bases or located posteriorly.
anterior lower facial height (ALFH). The perpendicular Therefore, pinpointing the area of the deformity will
474 Di Paolo et ul
Fig. 7. Presurgical diagnostic
have a significant impact on whether or not certain
surgical procedures are indicated. For example, if
we are to perform a surgical correction of a mandibular
prognathism, it would be necessary to determine
whether we should reduce the bony base lengths (body
ostectomy or sagittal split setback) or whether we
should perform mandibular surgery posterior to the
bony base area (vertical osteotomy, etc.).“j, l7
To determine differences in the sagittal relation of
the maxillary and mandibular bony base lengths, the
lines that are used to measure the bony base lengths in
the quadrilateral pattern are extended posteriorly to
point x, which is the sagittal angle (Fig. 2). When the
anterior and posterior lower face heights are parallel
and the maxillary and mandibular bony bases are equal,
a proportional relation exists with sides A, B, C, and D
of the similar isosceles triangles. The ratio of A to B
and C to D is called the sagittal ratio. Any forward
or retroposition of the bony base will cause unequal
Am. J. Orthod.
December 1984
records of Class III skeletal malocclusion
lengths of the posterior legs (lines A and C). In bal-
anced skeletal patterns the sagittal ratio in adolescents
is 1.0: 1.50 -C 0.05;inadultsitis 1.0: 1.45 ? 0.05and
the sagittal angle is 23” ? 1”.
Angle of facial convexity
The angle of facial convexity is a measurement of
the skeletal profile. This angle is formed by the inter-
section of anterior lower facial height with anterior
upper facial height and relates the quadrilateral to the
upper face.
It shows possible areas of skeletal discrepancies,
such as posture of the lower facial complex, cranial
base deflections, and bony base discrepancies. The
degree of facial convexity will vary, depending upon
the skeletal type and the position of the quadrilateral
pattern as it relates to the upper face. However, this
angle of facial convexity may be the same with differ-
ent skeletal patterns. r8 (Various rotations of the lower
Volume 86 Quadrilateral analysis 475
Number 6

Fig. 8. Postsurgical diagnostic records (sagittal split set-back)

Fig. 9. Quadrilateral analysis indicates both anteroposterior and Fig. 10. Prediction tracing indicates that mandibular set-back
vertical skeletal discrepancies. alone would result in an anterior open bite.

476 Di Paolo et al.
Fig. 11. Presurgical diagnostic
facial complex result in different profiles yet lower
“balanced” relationship of the dental arches.) This is
the result of:
1. Relative size differences of the maxillary and
mandibular bony bases. This is determined by mea-
suring the point A-PTM and point B-point J lengths
(Fig. 3).
2. Relative position of the maxillary and mandibu-
lar bony bases. This is determined by examining the
sagittal ratio of the anterior and posterior legs (Fig. 4).
3. Vertical dysplasia of the lower face. This is de-
termined by examining the average of the anterior and
posterior lower facial heights as they relate to the bony
bases and further by examining the ALFH to PLFH
ratio (Fig. 5).
Am. J. Orthod.
Lkmzbw 1984
records of a Class III open-bite skeletal malocclusion
4. The spatial rotation of the lower face (quad-
rilateral) to the upper anterior face height. This is de-
termined by the cant of the palatal plane to anterior
upper facial height (Fig. 6).
In examining Figs. 3 to 6, each patient has approx-
imately the same angle of facial convexity but exhibits
different skeletal problems.
Hard- and soft-tissue profile analyses are important
in assessing the role of surgical procedures necessary for
patients with skeletal dysplasias.lg Surgery, however,
based only on a profile assessment, arbitrarily adjusting
cranial base, visual treatment objectives, or template
analysis, may not result in an acceptable result.
Enlow has demonstrated that there is a wide variety of
skeletal compensations that can exist within similar
Volume 86 Quadrilateral analysis 477
Number 6

Fig. 12. Postsurgical diagnostic records (mandibular subapical set-back).

overall skeletal patterns. 2oBecause ofthe multiple sites of

facial growth and the compensatory variations that can
occurineach area, it would bemisleadingtocategorizeall
anteroposterior skeletal dysplasias as having small or
large bony bases or that all high mandibular plane angles
have open-bite skeletal patterns. Consequently, prog-
nathic, retrognathic, or vertically aberrant skeletal pat-
terns are difficult to differentiate with most of the cepha- Fig. 13. Diagrammatic depiction of surgical shortening of man-
lometric standards and norms that are presently being dibular posterior leg.
used. We are giving a cephalometric means of analyzing
wherever these growth compensations are occurring. ment planning of skeletal malocclusions. The first three
cases present an interesting diagnostic problem. They
DISCUSSION all have crossbite relations of the maxillary and man-
The following cases are presented to illustrate the dibular incisors, concave facial profiles, and negative
use of the quadrilateral analysis in diagnosis and treat- ANB angles. However, the quadrilateral analysis indi-
478 Di Paolo et al.
Fig. 14. Presurgical diagnostic
cates that we are treating very different problems, each
requiring a different surgical approach.21a 22
CASE 1
A 1&year-old white girl presented clinically with a Class
III malocclusion and a complete anterior crossbite. There was
minimal vertical overbite of the central incisors with an open
bite extending bilaterally from the lateral incisors to the sec-
ond premolars. Cephalometrically, the patient had an angle of
facial convexity of 183” with a concave profile.
This skeletal malocclusion could be classified as a Class
III maxillary retrusion with vertical excess. The SNA was 74”
and the SNB was 70”. The ANB difference was -4”, and the
records of a Class Ill skeletal malocclusion.
GoGn-SN angle was 41”. If surgery were performed on the
basis of this diagnostic information, the procedure would
most likely be a combination of maxillary advancement and
impaction. However, these cephalometric measurements did
not indicate the location of the deformity and the amount of
surgical correction needed.
With the severe lingualization of the mandibular incisors
and the excessive curve of Spee, it would be difficult to create
an acceptable occlusion without some preoperative orthodon-
tic treatment to establish proper incisal positioning.
Examination of the quadrilateral analysis indicated that
the maxillary bony base length was 50 mm and the mandibu-
lar bony base length was 59 mm. There was a 9 mm discrep-
Volume 86 Quadrilateral analysis 479
Number 6

Fig. 15. Postsurgical diagnostic records (vertical osteotomy)

ancy anteroposteriorly between maxillary and mandibular

bony base lengths. If the mandibular bony base length were
reduced 9 mm, the average of the ALFH and PLFH would be
proportional (? 1.S mm) to the maxillary bony base length

(50 mm = 59 - 9 mm = v mm). In examining the

posterior legs of the quadrilateral, we see a harmony of maxil-

-J
lary and mandibular bony base positioning (71 mm = 71
mm), indicating that the skeletal dysplasia was within the Fig. 16. Diagrammatic depiction of surgical shortenil of man-
bony base length and not located posteriorly (ramus, gonial dibular posterior leg.
angle, etc.).
The plan of treatment consisted of 18 months of presurgi-
CASE 2
cal orthodontic correction to align the maxillary and mandibu-
lar teeth within each jaw. A sagittal split procedure resulted in A 16%-year-old white girl presented clinical 1Y with a
a mandibular reduction of 7 mm. The angle of facial convex- Class III malocclusion, a complete anterior crossh bitt:, and a
ity was improved to 171” (Figs. 7 and 8). minimal vertical overbite. There were congenital1 Y missing

Fig. 17. Presurgical diagnostic
maxillary lateral incisors with slight lower incisor crowding.
Cephalometrically, the maxillary and mandibular incisors
were well positioned to the individual bony bases; the
posterior legs were in harmony; and the angle of facial con-
vexity was 175”.
The quadrilateral analysis indicated a 7 mm discrepancy
of the maxillary and mandibular bony base lengths (47
mm = 54 mm). If the mandibular bony base length were
reduced 7 mm, the average of the ALFH and PLFH would
be not proportional but excessive (47 mm = 54 mm - 7
46 + 68
mm = p). This indicated that we were dealing with an
2 Ill malocclusion, a complete anterior crossbite, and 3 to 4
anteroposterior and vertical skeletal discrepancy (Fig. 9).
These findings should significantly influence our surgi-
cal approach. If we were to perform a vertical ostectomy or
sagittal split and maintain the occlusal and mandibular plane
Am. .I. Orthod.
December 1984
records of a Class II skeletal malocclusion.
angles, an anteroposterior reduction would be achieved but an
anterior open bite would occur (Fig. 10).
The plan of treatment consisted of presurgical orthodontic
correction. Mandibular first premolars were removed and a 7
mm subapical reduction was performed. This developed an
anteroposterior bony arch balance and created a chin that was
in balance with the lower incisor position. The angle of facial
convexity was improved to 169” (Figs. 11 and 12).
CASE 3
A 17.year-old white girl presented clinically with a Class
mm of vertical overbite. The maxillary first premolars were
missing and the mandibular first premolars were malformed.
The maxillary arch was constricted, and there was moderate
lower incisor crowding.
Volume 86 Quadrilateral analysis 481
,Yumbrr 6

Fig. 18. Postsurgical diagnostic records (mandibular advancement)

Cephalometrically, the maxillary and mandibular incisors
were well positioned to the individual bony bases. The angle
of facial convexity was 179’ with a concave profile.
The quadrilateral analysis indicated that the maxillary
bony base and mandibular bony base lengths were 51 mm.
There was no anteroposterior discrepancy in these lengths,
and yet a skeletal Class III malocclusion did exist! In ex-
amining the posterior legs, we see a disharmony between
skeletal positioning of the maxilla and mandible (128 mm =
136 mm). This indicates that the skeletal dysplasia was
posterior to the mandibular bony length.
The plan of treatment consisted of removal of the man-
dibular first premolars and 14 months of presurgical ortho-
dontic correction. A vertical osteotomy was performed, re-
sulting in an 8 mm reduction pnsrerior to the bony base
lengths (Fig. 13). The angle of facial convexity was improved
to 168” (Figs. 14 and 15).
CASE 4
A 19.year-old white woman presented clinically with a
Class II malocclusion, a 10 mm horizontal overjet, and a deep
vertical overbite. All teeth were present, and there was minimal
lower incisor crowding. Maxillary width was constricted in the
canine region with 3 to 4 mm of maxillary incisor spacing.
Cephalometrically, the mandibular incisors were well
positioned to the mandibular bony base while the maxillary
incisors were 10 mm anterior to the maxillary bony base. The
angle of facial convexity was 164” with a convex profile and
retruded chin prominence.
The quadrilateral analysis indicated that there was no an-
teroposterior discrepancy in the bony base lengths (49 mm =
49 mm). However, there was a severe Class II skeletal
malocclusion! In examining the posterior legs, we see that a
skeletal disharmony posterior to the denture base is evident
(125 mm = 118 mm).
482 Di Pa010 et al. Am J Orthod.
Drwmher 19x4

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SUMMARY
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Because of the increase in the scope of surgical Graduate Orthodontic Department, Fairleigh Dickinson Univer-
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films has become obsolete. Surgical orthodontics re-
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