Camouflage in Orthodontics /fixed orthodontic courses by IDA

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INDIAN DENTAL ACADEMY Leader in continuing dental education

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Prologue Historical Development Points to consider. Who are the right patients for camouflage??? Who are not?? Contents Contd.....

Contents (Contd.):

Contents (Contd.) How to do it? Biologic Concerns.. Esthetic Concerns Steiner said……. Tweed said……. Merrifield said……. Ricketts said……. Holdaway said……. Arnett says……. Are the results stable??? Epilogue

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What is camouflage????!!!

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Disguise of guns, ships etc effected by obscuring outlines with splashes of various colours” -Oxford dictionary

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To deceive observation, or Plan as a false front -Webster’s dictionary..

Camouflage in orthodontics….?? :

Camouflage in orthodontics ….?? What are we masking……????

Different types of class II:

Different types of class II Class II with Maxillary dental excess Class II with Mand skeletal deficiency

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Class II with Maxillary skeletal excess Class II due to rotation

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The term “ Camouflage” is chosen to emphasize that successful treatment must produce “ acceptable” facial esthetics as well as an “ acceptable” dental occlusion.

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Camouflage by Extraction of Upper 1st premolar and Lower 2nd premolars:

Camouflage by Extraction of Upper 1 st premolar and Lower 2 nd premolars

History of Camouflage:

History of Camouflage Goal of Class II treatment in adolescents (in addition to correcting any other problem that are present) is to establish a correct overjet and buccal segment occlusion.


How was it achieved then????? How is it achieved now…..???

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Edward Angle was confident that if class II elastics were used, differential growth of the mandible would produce most , if not all the correction.

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(He Advocated Non- Extraction) Skull placed on Angle’s shelf in his surgery which he called “ old Glory ” He considered this as ideal and tried to finish the cases to this ideal

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But, he was proved wrong after the advent of Cephalometric data availability. It was showed that differential growth of the mandible rarely occurred and most of the correction was by tooth movement alone

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At the same time in Europe, the concept of Functional Jaw Orthopaedics developed, first by Pierre Robin with his mono bloc and later by Viggo Andersen by his Activator appliance.

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Extraction treatment was re introduced in the 1930’s and 1940’s. In that era, it was the major approach to treating skeletal problems since, at that time growth modification as a treatment approach had been largely rejected as ineffective,

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and surgical techniques to correct skeletal problems had barely begun to be developed. Thus, it seemed there fore appropriate for the Orthodontist to accept the limitations in skeletal relationships and concentrate on the dental occlusion.

Points to Consider:

Points to Consider

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For patients with mild to moderate skeletal class II problems, displacement of the teeth relative to their bony bases to achieve good occlusion is compatible with reasonable facial esthetics, and the camouflage can be quite successful.

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Considerable retraction of the upper incisors can be accomplished for most patients before an increasing prominence of the nose and an un-esthetically obtuse nasolabial angle signal the effective limits of camouflage.

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Camouflage can also be used in patients with mild skeletal class III problems in whom adjustment of incisor position can achieve acceptable occlusion and reasonable facial esthetics.

Camouflage treatment in Mild Class III with good results:

Camouflage treatment in Mild Class III with good results

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Unfortunately, even in moderately severe skeletal class III problems, camouflage is much less successful.

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Although extraction of lower premolars combined with class III elastics and extra oral force can produce good dental occlusion for most class III patients, the treatment rarely produces successful camouflage and frequently makes esthetics worse.

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Retraction of lower incisors makes the chin more prominent. Even minimal retraction often magnifies the facial esthetic problems associated with class III malocclusion

Moderate Class III with unacceptable results due to camouflage:

Moderate Class III with unacceptable results due to camouflage

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What about Vertical Problems....??? Can Camouflage be done to hide the vertical problems....??

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Effect of Class II elastics on Vertical Dimension :

Effect of Class II elastics on Vertical Dimension

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So, who are the right patients for camouflage……????

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Too old for growth modification??? Camouflage

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Mild to moderate skeletal Class II Jaw relationship……?? Camouflage

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Reasonably good alignment ( so that X n spaces can be used for retraction and not to relieve crowding) Good vertical facial proportions, neither extreme short face (skeletal deep bite) or long face (skeletal open bite)

And who are not ideal for camouflage????:

And who are not ideal for camouflage????

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Severe class II, Moderate or severe Class III, Vertical Skeletal Discrepancies. Patients with severe crowding or protrusion of incisors in whom extraction spaces would be required to align remaining teeth. Patients with excellent remaining growth potential Patients with severe skeletal Discrepancies

How to do it?:

How to do it?

Diagnosis :

Diagnosis Why diagnose….??? To define the nature of the problem. including etiology when possible To classify the problem To design a treatment strategy based on the specific needs of the individual

Find out the patients goals of treatment......:

Find out the patients goals of treatment...... Enhanced Dental esthetics Improved dental function Better facial esthetics Resolution or improvement of TMJ problems or muscle pain Improved long term maintenance of the dentition when factors such as periodontal problems are exacerbated by malocclusion


Classification Why classify…..? To treat any malocclusion, one must recognize it in all it’s forms and stages of development Based on this, the treatment plan is formulated Thus, it is important to diagnose the true nature of the individual skeletal abnormality as well as the underlying dental malrelation

Moyer’s classification of Class II ( AJODO Nov. 1980):

Moyer’s classification of Class II ( AJODO Nov. 1980) Six Horizontal types Five Vertical types Purpose To Localize and quantify any possible skeletal contributions to class II malocclusion To identify dental displacements associated with the class II malocclusion

Horizontal Types:

Horizontal Types Type A Normal skeletal profile Normal A-P Position of Jaw Maxillary dentition protracted Mandibular dentition placed normally on it’s base Class II molar relation Large Overjet & Overbite. Sometimes referred as “Class II Dental”

Type B:

Type B Mid face prominence Maxillary prognathism Mandibular length normal

Type C:

Type C Class II profile. Maxilla-Mandible back and beneath the anterior cranial base Smaller facial dimensions Upper incisor upright and/or labially tipped Lower incisor tipped labially Women > men

Type D:

Type D Class II skeletal profile which is retrognathic due to small mandible Midface is normal or slightly diminished Lower incisors are upright and/or lingually tipped. Upper incisor labially positioned

Type E:

Type E Class II skeletal profile Prominent midface Normal or prominent mandible Bimax Dento-Alveolar features

Type F:

Type F Large heterogenous group Mild skeletal Class II tendencies Combination of slightly abnormal variables

Vertical Class II types:

Vertical Class II types Type I Anterior Facial Height > Post Facial Height Clock wise tipping of the mandibular plane, occlusal plane (functional), palatal plane Anticlockwise tipping of anterior cranial base. Other names: high angle, steep mand. Plane, surgeon’s long face syndrome etc .

Type 2 :

Type 2 Square face Mandibular, occlusal and palatal planes are more horizontal than normal and are often parallel Small gonial angle Anterior cranial base is almost horizontal Incisors more vertically positioned showing deep bite

Type 3:

Type 3 Palatal plane tipped anticlockwise and upward anteriorly with a decreased anterior upper facial height and resultant predisposition to an open bite If mandibular plane is steep ---- a skeletal open bite is inevitable

Type 4:

Type 4 Mandibular, occlusal and palatal planes are tipped downward with mandibular plane almost normal High lip line ---- Gummy smile. Gonial angle relatively obtuse Upper incisor tipped labially. Lower incisor tipped lingually

Type 5:

Type 5 Mandibular and Occlusal plane normally positioned. Palatal Plane tipped downwards. Gonial angle smaller than normal Skeletal deep bite Lower incisor in labio version Upper incisor nearly vertical

Identifying Horizontal types:

Identifying Horizontal types Dental Class II – Type A Midface prognathic --- Type B and E Mandibular retrognathic --- Type C and D Combination of Mandible And Maxillary extreme skeletal features – Type F

Identifying vertical Types:

Identifying vertical Types Type I – shows large values for angles of PM vertical line with Mand. Occl. and palatal plane. Type II – smaller values for same angles Type III – Small Pal Plane angle with PM vertical Type IV – found in association with horizontal Type B Type V - Large Pal. Plane angles with Pm vertical, normal occlusal and mand plane angles, smaller gonial angles

Planning treatment. :

Planning treatment. How to plan? What is the basis of planning? What are the points to consider to plan treatment? What are the biologic concerns? What are the esthetic concerns? Will the results be stable ?

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What are the biologic concerns?

What are the biologic concerns?:

What are the biologic concerns? What are the limitations of orthodontic tooth movement..? How much can you move without harming the supporting structures.......?

Proffitt and Ackerman:

Proffitt and Ackerman “ Envelope of discrepancy” can help serve as a guide when selecting appropriate treatment modalities for patients with a variety of maxillofacial abnormalities of varying severity

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Outer envelope Inner envelope Orthodontic tooth movement alone Middle envelope Orthodontic tooth movt.+ Growth modification Orthognathic surgery

Envelope of discrepancy for Maxilla:

Envelope of discrepancy for Maxilla

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Envelope of discrepancy for mandible

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What are the esthetic concerns...???

What are the esthetic concerns??:

How much can we retract till we exceed the esthetic limitations…? What are the esthetic objectives to be met at the end of treatment….? What are the esthetic concerns??

In a newspaper article approved by the American Medical Association on Aug. 28, 1979 :

In a newspaper article approved by the American Medical Association on Aug. 28, 1979 “ Physical appearance is our calling card. An attractive and pleasant appearance opens doors. It is not merely vanity that prompts tens of thousands of Americans each year to turn to cosmetic surgery to seek improvement of physical appearance. Plastic surgical operations do not magically give new talents or personalities to people. Rather, they take away a liability so that the person's own natural talents and personality can develop normally.”

What did Steiner say???...:

What did Steiner say???...

Steiner said....(1952 AJO):

Steiner said.... (1952 AJO) Lips in well balanced faces should touch a line extending from the soft tissue contour of the chin to the middle of an ‘S’ formed by the lower border of the nose. This line is referred to as S - Line

Acceptable compromise:

Acceptable compromise Steiner said that in instances of skeletal discrepancy where it is not possible to achieve an ideal relationship of 4 mm and 22 or 25 degrees to NA and NB line, if the maxillary incisors were inclined a little more lingually and mandibular incisors little more labially , a well balanced and harmonious occlusion can be achieved.

Steiner’s acceptable compromise:

Steiner’s acceptable compromise

Steiner’s acceptable compromise for Class III:

Steiner’s acceptable compromise for Class III

Formula to remember….:

Formula to remember…. and lower incisor to NB increases by 0.25 mm and 1 degree For every degree increase in ANB Upper Incisor to NA decreases by 1mm and 1degree decreases increases

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What did Tweed say....???

Tweed said….:

Tweed said…. Keep the teeth upright on the basal bone….. Emphasis on the lower incisors Extractions may be necessary to achieve this

Tweed’s Diagnostic facial triangle :

FMIA – F rankfurt- M andibular I ncisor A ngle FMA – F rankfurt – M andibular plane A ngle IMPA – I ncisor M andibular P lane A ngle Tweed’s Diagnostic facial triangle ( The Angle orthodontist… 1954 )

FMA – 220 to 280:

FMA – 22 0 to 28 0 Indicates the direction of lower facial growth in both horizontal and vertical dimensions

FMIA = 680 for individuals with FMA 220 to 280:

Standard should be 65 0 if the FMA is 30 0 and above. FMIA should increase if FMA is lower FMIA = 68 0 for individuals with FMA 22 0 to 28 0 Tweed believed that this value was significant in establishing balance and harmony of the lower face

IMPA --880:

IMPA --88 0 Defines the axial inclination of mand. Incisor in relation to the mand. Plane If FMA is low, IMPA can be compensated by positioning more labial. If FMA is high, IMPA must be more upright



Merrifield...... Am J Orthod 1966; 52:804-22. :

Merrifield...... Am J Orthod 1966; 52:804-22. The profile line is universally used to give the orthodontic practitioner an idea of lip procumbency and balance. The ideal relationship of the profile line to the soft tissue is to be tangent to the chin, to vermilion border of both lips and to bisect the nose

Relative thickness of the upper lip and total chin thickness:

Relative thickness of the upper lip and total chin thickness Upper lip thickness should equal total chin thickness. If total chin thickness is less than upper lip thickness, a compensation must be made in anterior retraction that will result in a more ideal facial balance and harmony.

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Z- angle of Merrifield It is the chin/ lip soft tissue profile related to the frankfurt’s horizontal plane Normal range = 70 0 to 80 0 Ideal value is 75 0 to 78 0 depending on age and sex It was developed as an adjunct to FMIA More indicative of facial profile and is responsive to maxillary incisor position.

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Merrifield’s Z angle Maxillary incisor retraction of 4 mm allows 4 mm of lower lip retraction and approximately 3 mm of upper lip response. Horizontal mandibular repositioning will also affect this value Vertical facial height increase, both anterior and posterior can influence the Z angle. This enables the clinician to make a critical facial analysis

Robert Murray Ricketts.....the great contributor:

Robert Murray Ricketts..... the great contributor Esthetic plane: Is a tangent to the most anterior point on the nose and the most anterior point on the chin It is a basic reference line for evaluating facial balance. The lower lip should fall approximately 3 mm behind the esthetic line

Robert Murray Ricketts (AJO 1960):

Robert Murray Ricketts (AJO 1960) Lower incisor to A- Pog was a reference that aided repositioning of the dental arch.

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Cases treated to near +1 mm to A-Pog and an angle of 22 degrees to A-Pog seemed to remain stable Cases which diverged from these values tended to relapse.

Reidel (1950 Angle orthodontist ) :

Reidel (1950 Angle orthodontist ) Has shown a relationship between the lower lip and the esthetic plane. Subjects with Lower lip point ( LL ) falling immediately behind the E- line were regarded as most pleasing

Holdaway… the beautician..??? (1983 July.. AJODO ):

Holdaway… the beautician..??? (1983 July.. AJODO ) Came up with a cephalometric analysis on the soft tissue in view of the shortcomings observed in the conventional hard tissue analysis and the inability of those analyses to describe orthodontic treatment plan in terms of facial esthetics in most situations. He described soft tissues response in relation to incisor retraction

Soft tissue facial Angle:

Soft tissue facial Angle N’ – Pg’ to FH A measurement of 91 degrees is ideal, with an acceptable range of ±7 degrees .

Nose prominence.:

Nose prominence. Nose prominence can be measured by means of a line perpendicular to Frankfort horizontal and running tangent to the vermilion border of the upper lip. This measures the nose from its tip in front of the line and the depth of the incurvation of the upper lip to the line Those noses under 14 mm. are considered small, while those above 24 mm. are in the large or prominent range.

Upper lip thickness and strain:

Upper lip thickness and strain This is near the base of the alveolar process, measured about 3 mm. below point A. It is at a level just below where the nasal structures influence the drape of the upper lip. This measurement is useful, when compared to the lip thickness overlying the incisor crowns at the level of the vermilion border, in determining the amount of lip strain or incompetency present as the patient closes his or her lips over protrusive teeth .

Holdaway said…..:

Holdaway said….. The tissue will thicken as the incisors are moved lingually until the tissue approaches the thickness at point A . When the lip taper has been eliminated, further lingual movement of the incisor will now cause the lip to follow the incisors in a one-to-one ratio. ( 1 mm retraction of incisors will cause 1 mm of retraction of the upper lip ) EXCEPT in…………

Exceptions to the rule……:

If the tissue thickness at point A is very thin Even if there is lip taper, (for example, 9 to 10 mm.), the lip may follow the incisor immediately and still retain the taper. If the tissue at point A is very thick (for example, 18 to 20 mm.), the lip may not follow incisor movement at all. Adult tissue reaction is similar to the first exception. Even though there may be lip taper, the lips will usually follow the teeth immediately Exceptions to the rule……

Upper lip form or curl. :

Upper lip form or curl. A range of 1 to 4 mm. is acceptable in certain types of faces, with 3 mm. being ideal. During orthodontic treatment or surgical orthodontic procedures, we should strive never to allow this measurement to become less than 1.5 mm.

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However, in cases of high skeletal convexity, especially associated with mandibles that have obtuse gonial angles and long lower face dimension, or in cases of very thin lips, it may be necessary to settle for a 1 mm. measurement. 1 mm

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With less face height, more prominent chins, and longer or thicker upper lips, a measurement of up to 4 mm is acceptable.

Harmony line (H- Line):

Harmony line (H- Line) It is a tangent to the chin point and the upper lip.

Soft-tissue subnasale to H line:

Soft-tissue subnasale to H line Here the ideal is 5 mm., with a range of 3 to 7 mm. When the skeletal convexity of a case will be from – 3 to +5 mm. at retention, The lips can usually be aligned nicely along the H line when the superior sulcus measurement is at or near 5 mm.

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In longer and/or thicker lips, 7 mm. may be in excellent balance With short and/or thin lips, 3 mm. will be adequate

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If this measurement were 8 or 9 mm with thicker lips, with no evidence of lip strain or lack of harmony of facial lines, extraction of four premolars just to reach this goal would not be indicated. The measurement is a very useful guide, however, and is used routinely to visualize the best lip position for a case when a Visualized Treatment Objective (VTO) is constructed.

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In cases found to be on either extreme of the skeletal convexity spectrum, the ideal measurements to the H line lose their significance because of the change in the cant of the H line

H- Line angle:

H- Line angle This is an angular measurement of the H line to the soft-tissue Na-Po line or soft-tissue facial plane. Ten degrees is ideal when the convexity measurement is 0 mm

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Measurements of 7 to 15 degrees are all in the best range as dictated by the convexity present

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Ideally, as the skeletal convexity increases, the H angle must also increase if a harmonious drape of soft tissues is to be realized in varying degrees of profile convexity. These observations have been based on the patients in Holdaway’s practice, who are of predominantly northern European ancestry.

Formula to remember….:

Formula to remember…. = H – angle to be (in degrees) Convexity (in mm ) + 10

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H angle measures the prominence of the upper lip in relation to the over-all soft-tissue profile. When the profile convexity is outside that indicated as the best range in the chart, one may on occasion plan the denture orientation a little differently from the chart to attempt to mask skeletal problems and soft-tissue distribution problems.

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This must not be done, however, at the expense of leaving the lips without proper dentoalveolar support, in which case the upper lip would be left without the bare minimum of 1 mm. of curl or that the lower lip would be left located too far behind the H line.

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A 10-degree H angle is ideal when it is found with a 0-degree convexity figure, but it is evident from the excessive depth of the superior sulcus and from the roll of the lower lip outside the H line that a 10-degree angle for this concave skeletal pattern having a – 2.5-degree convexity is not harmonious. It may be noted in the 2nd tracing that a 6-degree H angle is indicated with a – 4 mm. convexity, and this was achieved with the removal of four premolars.

Pre treatment Facial angle = 83 degrees convexity = 12 mm H – angle = 32 degrees:

Pre treatment Facial angle = 83 degrees convexity = 12 mm H – angle = 32 degrees Post treatment Facial angle = 83 degrees convexity = 8 mm H – angle =19 degrees

Lower lip to H- line:

Lower lip to H- line The ideal position of the lower lip to the H line is 0 to 0.5 mm. anterior, individual variations from 1 mm. behind to 2 mm. in front of the H line are considered to be in a good range.

Case with lower lip ahead of H Line demonstrating unaesthetic appearance:

Case with lower lip ahead of H Line demonstrating unaesthetic appearance

Factors to consider to make a harmonious soft tissue balance:

Factors to consider to make a harmonious soft tissue balance H- angle Skeletal convexity Sulcus depth measurement

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The Arnett’s way

Arnett & Bergman.... (1993- Am. J. orthod. & Dentof Orthop. ):

Arnett & Bergman.... (1993- Am. J. orthod. & Dentof Orthop. ) Contributed 19 keys to facial esthetics Used for comprehensive treatment planning. Backed by Soft Tissue Cephalometric Analysis (1999 - Am. J. Orthod. & Dentof. Orthop. )

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“ We only treat what we are educated to see. The more we see, the better the treatment we render our patients ” - Arnett ....

Arnett and Bergman....... :

Arnett and Bergman....... “When attention is directed only to bite correction, facial balance may not improve and can deteriorate. The orthodontist's job is to balance occlusal correction, temporomandibular joint function, periodonal health, stability, and facial balance while moving the teeth to correct the bite.”

Format for examination of face:

Format for examination of face Natural head posture, Centric relation (uppermost condyle position), Relaxed lip posture True Vertical Line ( TVL )

Arnett and Bergman :

Arnett and Bergman By examining the patient in this format, reliable facial-skeletal data can be obtained that enhances diagnosis, treatment planning, treatment, and quality of results.

Why the Natural head position?:

Why the Natural head position?

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Natural head posture is preferred because of its demonstrated accuracy over intracranial landmarks. Natural head posture has a 2° standard deviation compared with a 4° to 6° standard deviation for the various intracranial landmarks in use.

Why Centric Relation??:

Why Centric Relation??

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All examination data should be recorded in centric relation since orthodontic and surgical results are strictly in this position to produce precise function.

Why relaxed lip position??:

Why relaxed lip position??

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The patient should be in the relaxed lip position because it demonstrates the soft tissue, relative to hard tissue, without muscular compensation for dentoskeletal abnormalities. Vertical disharmony between lip lengths and skeletal height (vertical maxillary excess, vertical maxillary deficiency, mandibular protrusion, mandibular retrusion with deep bite) can not be assessed without the relaxed lip posture.

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Existing positions and needed changes in upper incisor exposure, interlabial gap, lip length, and proportion are lost in the closed lip position. Closed lip position may be adequate for normoskeletal cases but is totally inadequate for skeletal disharmony assessment

What is TVL and Why TVL??:

What is TVL and Why TVL??

True Vertical Line ( TVL ):

True Vertical Line ( TVL ) It is a Vertical line passing through the Subnasale with natural head posture. It may be used to quantify favorable or unfavourable change in the profile after overjet reduction and has a potential role in post treatment analysis and research

Arnett says...:

Arnett says... Shift emphasis from lower incisors to Upper incisors .

Concept of ‘ideal’ incisor position.:

Concept of ‘ ideal’ incisor position. Base treatment planning on position of upper incisors instead of using molars and / or lower incisors Envision an ‘ideal’ incisor position for upper incisors and subsequently fit all other teeth around the ideal position.

Planned Incisor Position ( PIP ):

Planned Incisor Position ( PIP ) “ The intended end of treatment position for the upper incisors”

Four stage treatment planning process. :

Four stage treatment planning process. Stage I ---- Setting a PIP for upper incisors Stage II ---- Fitting the lower incisors Stage III ---- The remaining lower teeth Stage IV ---- The remaining upper teeth

Stage I- Setting PIP for upper incisors:

Stage I- Setting PIP for upper incisors At the start of treatment planning, it is necessary to determine the PIP for upper incisors. In some cases, the perceived ideal upper incisor position is a realistic treatment goal and can be used as the PIP In other cases, a PIP can be accepted which is not ideal, but which is acceptable for the case .

Stage II – The Lower Incisors:

Stage II – The Lower Incisors The second stage of treatment planning concerns the lower incisors, and how to position them in good relationship to the PIP of the upper incisors If this cannot be achieved by orthodontics alone, it will be necessary to modify the PIP for the upper incisors, or consider mandibular surgery

Stage III – The remaining lower teeth:

Stage III – The remaining lower teeth It concerns the planning of positioning of the rest of the lower teeth to fit the planned lower incisor position The dental VTO can be used to plan this stage of the treatment planning. Primary factors are crowding, curve of spee and midlines

Stage IV – The remaining upper teeth:

Stage IV – The remaining upper teeth It concerns the planning of positioning of the rest of the upper teeth to fit the planned upper incisor position The dental VTO can be used to plan this stage of the treatment planning.

PIP components in class II treatment :

PIP components in class II treatment For each case, it is necessary to set a PIP as a treatment goal which will result in the upper incisors having Correct Antero-Posterior positioning Vertical positioning , Appropriate torque

Antero – posterior component of PIP in Class II treatment:

Antero – posterior component of PIP in Class II treatment Upper incisor position is related TVL ( MXI – TVL) Linear measurement from the tip of upper incisor to TVL. Ideal values Male = -12 mm Female = - 9mm

Vertical Component of PIP:

Vertical Component of PIP Overbite should be 3 mm. Upper incisor exposure should be 4 mm below the relaxed upper lip for males and 5 mm for females

Torque component of PIP:

Torque component of PIP Arnett’s analysis relates upper incisor torque to the maxillary occlusal plane and the lower incisor torque to the mandibular occlusal plane , Male upper incisor torque being ideally 58 degrees Female upper incisor torque being ideally 57 degrees

Fastlight..... (June 2000 JCO):

Fastlight..... ( June 2000 JCO ) Upper incisor to palatal plane Lower Incisor to mandibular plane Interincisal angle Maxillary / Mandibular plane angle Presented the facial tetragon consisting of four angles

Different tetragons for different malocclusions :

Different tetragons for different malocclusions

Class II tetragon:

Class II tetragon

Class III tetragon:

Class III tetragon

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How stable are the results????

Hixon. E.H. ( AJO 1962):

Hixon. E.H. ( AJO 1962) Majority of cases in which mandibular arches have been advanced will relapse to the original position. If crowding is present, extraction is the only treatment which will provide stable results……

Weinstein (Equilibrium theory of tooth position Angle Orthod. 1963):

Weinstein (Equilibrium theory of tooth position Angle Orthod. 1963) Teeth are in a state of equilibrium with the musculature. If treatment results are to be stable, teeth must be within the form of the arch as presented. The Opinion was backed by Miller (1971)

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As time passed, more sophisticated analyses showed that in many cases, the lower incisor could be moved. The secret was to predict proper lower incisor placement prior to treatment on an individual case basis

Posen (Angle Orthod. 1976):

Posen (Angle Orthod. 1976) Measured perioral musculature and found that the strength of the musculature co related with the position of the incisors. Class II div 2 had the strongest perioral musculature; Class I bimax had the weakest .

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He also observed that in treatment, a change in oral environment as a result of normal denture position was accompanied by a change toward normal to create a more normal lip tonicity and hence reduce the chance of incisor relapse

Robert Murray Ricketts (AJO 1960):

Cases treated to near +1 mm to A-Pog and an angle of 22 degrees to A-Pog seemed to remain stable Cases which diverged from these values tended to relapse. Robert Murray Ricketts (AJO 1960)


The range of orthodontic tooth movement for lower incisors within the bony housing of the mandible is limited. Mesial movement of the lower incisor tips is mainly as a result of change in torque .

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A rule of thumb for this proclination is 100 degrees to mandibular plane as set in class II mandibular triangle . As these arbitrary limits are exceeded, there comes a percieved risk of instability, poor esthetics or gingival problems

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In class II div I cases with class II skeletal bases, it is becoming more acceptable to procline lower incisors beyond the traditional 95 0 to mandibular plane and + 2 mm to the A Po line Conventional Orthodontic thinking was against this because of the risk of gingival recession and relapse.... However............

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Gingival recession or periodontal disadvantage has been shown NOT to occur... Long term effect of thin interdental alveolar bone on periodontal health after Orthodontic treatment (Artun J. Osterberg S. Journal Of Periodontology.. 1986) Does Orthodontic proclination of lower incisors in children and adolescents cause gingival recession.. H Pancherz , Ruf. S . AJODO 1998

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Does labial movement of lower incisors influence the level of the gingival margin? – A case control study of adult orthodontic patients` Birte Melsen....Delfino Allais …. Europeon. J Of Orthodontics August 2003

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Dental Chess....:

Dental Chess.... Orthodontics may be thought of as the dental equivalent of chess. The analogy is appropriate in many respects . The game is played with 32 ivory pieces that are arranged symmetrically about the midline on a board in two equal and opposite armies

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The opening moves are crucial in determining the strategy of the game. From the outset, the game is won or lost depending on the strategy of development of the individual pieces. Indeed these opening moves can determine whether the game is eventually won or lost.

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It is a mistake in chess to become obsessed with the individual pieces. Rather, one must take a broader view and look at the game plan as a whole to maintain a balanced position of the pieces on the board in order to achieve mutual protection and support.

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In dental chess, the board is analogous to the facial skeleton which is of fundamental importance in supporting the individual pieces.

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As the orthodontic chess game progresses, and the dental pieces are developed, the board may become overcrowded with pieces converging upon each other so that even the most experienced player at times sacrifices pieces only to realize as the game progresses that the gambit was miscalculated

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Only after the passage of time, on proceeding to the end game can the success of the strategy be evaluated. Successful treatment is judged in terms of facial balance, aesthetic harmony, and functional stability in the end result

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One may conclude that the objectives of treatment have been achieved only when the final post treatment balance of facial and dental harmony is observed.

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Thank You Leader in continuing dental education

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