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  • Cephlometric Evaluation For Incisor Position

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    ortodoncia

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    Cephlometric Evaluation for Incisor Position

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    8 Ansichten21 Seiten

    Cephlometric Evaluation For Incisor Position

    Hochgeladen von

    ChristianLambert
    ortodoncia

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    © All Rights Reserved
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    Cephalometric Evaluation of Incisor Position Edward Ellis 111 James A. McNamara, Jr. An evaluation of seventeen measurements of incisor angulation and position for their applicability in describing the incisor rela- tionship to maxilla and mandible. Most are better descriptors of other relationships that could confound interpretation of rela- tionships to the supporting bones. KEY WORDS: * Crenatomerrics * INcisoR * MANDIBLE * l he rise in the level of sophistication and precision of orthognathic surgical procedures during the last decade has increased the need for more accu- rate preoperative prediction of their outcome. Coordination of the dental arches prior to surgery is particularly important, so that the optimum anteroposterior, transverse and vertical changes in jaw position can be achieved. One important consideration is the positions of upper and lower incisors relative to each other and to their supporting bones. Incisor interferences can prevent the desired surgical repositioning of osseous components, as when retro- positicned upper incisors inhibit forward repositioning of the mandible. ‘Two general approaches to evaluating upper and lower incisor positions prior to surgery are commonly used. One is the hand articulation of original or progress casts. Although the relative positioning of the teeth in each arch can be readily determined in this way, the relationship of the teeth to their underlying bony bases is less obvious, and may be impossible to determine from dental casts alone. The lateral cephalograph provides a second source of information on the positions of the maxillary incisors, maxilla, mandibular incisors and mandible. Dr. Ellis, the Department of Oral and Maxillofacial Surgery, Co-director of the Dentofacial Author Address: Program and Research Investigator at the Center for Human Growth and Development at the University of Michigan in Dr. Edward Ellis, Itt Ann Arbor. He holds a D.D.S. degree and an M. in ‘School of Dentistry Maxillofacial Surgery from the University of Michigan. Department of Oral and Dr. McNamara is Professor of Orthodontics, Professor of Maxillofacial Surgery Anatomy and Cell Biology and Research Scientist at the The University of Michigan Center for Human Growth and Development at the The ‘Ann Arbor, Mi 48109 University of Michigan. He holds a D.D.S. degree and M.S. in Orthodontics from the University of California at San Francisco, and a Ph.D.in Anatomy from the Univer- sity of Michigan, 324 October, 1986 The Angle Orthodontis® Therefore a need has arisen for cephalo- metric measures which are sensitive not only to the position of the teeth within a given bone, but which are sensitive to the relationship of the jaw elements and cra- nial base structures to one another. This study considers only the relation of the teeth to their respective supporting bones. The determination of incisor position is a part of most cephalometric analyses. Downs (1948, 1952 AND 1956), STEINER (1953, 1959 AND 1960), TWEED (1953 AND 1954), RICK- ETTS (1960, 1972 AND 1981) and RIEDEL (1952) all present specific measures of incisor position, ‘Most of the popular analyses were con- ceived prior to the use of orthognathic surgical procedures for the three-dimen- sional repositioning of almost every bony structure in the face, so little considera- tion has been given to their appropriate- ness in those applications. Many of the measures of incisor position are based on osseous structures of the face that may be surgically repositioned. In addition, descriptive measures of relationships to specific bony landmarks are independent of measures that may indicate whether those landmarks are in a normal relation- ship to the remainder of the face. Maxillary Incisors A theoretical discussion of the following eight cephalometric measures of maxil- lary incisor (U1) position demonstrates their broad variation. 1. UWS-N + (Fig. 1) The angle between the axis of the maxil- lary incisor and the S-N plane (Riepet 1952, DRUMMOND 1968, WAITE ET AL. 1971 AND BisHara 1981) relates maxillary incisor position to the anterior cranial base, ©The Angle Orthodontist independent of maxillary and mandibular positions. However, tilting of the maxilla causes a comparable change in the U1/S- N angles. 2, UI/FH (Fig. 1) The angle between the maxillary incisor axis and the Frankfort plane (RrEpEt 1952 AND 1957) is also based on a superior skel- etal reference plane, similar in applica- tion to the UI/S-N measure (Fig. 1). 3. UI/PP (Fig. 2) ‘The angle between the upper incisor axis and the palatal plane (Anterior Nasal Spine to Posterior nasal Spine) (Burstons ‘T AL. 1978) is an excellent indicator of orientation within the maxilla. Although the palatal plane may vary in angulation, many of the maxillary deformities cor- rected by orthognathic surgery are den- toalveolar in nature. In these patients, the U1/PP measure is very useful. 4. UI/N-A (angular) and U1“N-A (lin- ear) (Fig. 3) The nasion-A line (Sretwer 1953, RrEDEL 1957, MacIntosi 1970, AND KHOUW ET AL. 1970) is used as both an angular and lin- car reference. The angular measure shows the axial procumbency of the inci- + ‘Cephalometric Notations Lines and planes are indicated by a short dash ‘between terminal points, as A-B. Angles where two lines intersect at an identi- fied landmark are indicated by the two lines that form the angle, as A-N-B. Angles where the intersection is not a named point, and angles between lines that do not intersect, are indicated by a slash between the two lines, as FH/N-B or FH/MP, Linear measurements ate indicated by a double arrow between the landmarks that define the measurement, as At+N-Po. October, 1986 = 325 Ellis and McNamara Fig. 1 A — acephalometric tracing showing the upper incisor to sella-nasion (U1/ $-N) and upper incisor to Frankfort horizontal (U1/FH:) measures. B — altering the maxillary skeletal position in the horizontal plane (dashed lines) has no effect on these measures because the lines are parallel. C — the effect of tilting the maxilla (dashed lines). Both measures change in direct relationship to the amount of maxillary tilt. Fig. 2 The upper incisor to palatal plane measure (U1/PP). Note that this measure is based on maxillary points; altering the petition of the maxilla will not affect this measure. sor, and the linear measure shows the horizontal distance between the facial surface of the maxillary incisor and the N-A line, independent of the axial inclination. Although these have become two of the most accepted measures of maxillary incisor position, an examination of the N-A line shows a need for careful inter- pretation. When the maxillary skeleton (and therefore point A) is positioned pos- teriorly without changing the position of the incisor within the maxilla, the change in the angulation of N-A causes the UI1+N-A measures to become larger. 326 October, 1986 5. Ul to Point A Vertical (Ui AVERT) (Fig. 4) The U1++AYERT measure, as defined by McNamara (1983) is another way to relate the maxillary incisor to the maxilla. The UI+AYERT measure is the horizontal distance between the facial surface of the maxillary incisor and a perpendicular erected from point A to the Frankfort horizontal plane. Because its angulation is unaffected by the position of the max- illa or the mandible, this is a sensitive measure even in patients with maxillo- mandibular disharmonies. Although it The Angle Orthodontis® Incisor Position Fig. 3 The upper incisor to nasion-A measures (U1/N-A and U1“N-A). Altering the horizontal position of the maxillary skeleton changes these measures, As the maxilla is brought forward, they are decreased (and vice- versa). These changes in the U1 to N-A measures occur even though the position of the upper incisor within the maxilla may remain unaltered, ex Fig. 4 The upper incisor to point A vertical (U1 A¥#*") measure. This measure is the horizontal distance between the facial aspect of the upper incisor and a perpendicular erected to the Frankfort horizontal plane through point A. Note that this measure is unaffected by horizontal movements of the maxillary skeleton. ©The Angle Orthodontist October, 1986 327 Ellis and McNamara Fig.5 The upper incisor to facial plane measure (U1+N-Pog), and the effects of altering the horizontal position of the maxillary or mandibular skeleton. The U1+N-Pog measure is increased by anterior movement of the maxilla, and decreased by anterior movement of the mandible. utilizes cranial landmarks for reference (porion and orbitale), it relates the maxil- lary incisor to the bony maxilla. 6. ULlON-Pog (Fig. 5) This reference line for maxillary incisor Position, popularized by RrEpEL (1952 AND 1957), is similar to the Ul A~Pog line measure described below. It is the dis- tance between the incisal edge of the upper incisor and the nasion-pogonion line (facial plane). However unlike the A-Pog measure, it eliminates one of the highly variable points (point A) from the analysis. Although nasion may also be abnormal in position, it is certainly more constant than the maxilla, which is fre- quently affected in malocclusions (Euuts ET AL. IN PRESS, LAWRENCE ET AL. IN PRESS). However, the mandible is one terminus 328 October, 1986 of the N-Pog line, and is also affected in many malocclusions, z 8 ( The distance from the incisal edge of the maxillary incisor to the A-Pog line (Downs 1948, 1952 AND 1956; RICKETTS 1960, 1972 AND 1981; RIEDEL 1952, 1957; SCHEIDE- MAN ET AL. 1980; BIsHARA 1981) obviously demarcates jaw structures which may themselves be in abnormal relationships to each other. A retruded mandible with a retruded maxillary incisor may result in a normal Ul1+*A-Pog measure. Con- versely, a protruded mandible with a pro- truded maxillary incisor may also produce a normal value. Endless combi- nations of U1+*A-Pog values are possi- ble when various maxillary (Point A) and mandibular (Pogonion) positions are combined. The Angle Orthodontist® Incisor Position dd .65). The UM/L1 measure also corre- lated (p<0.01) with mandibular plane angle measures (S-N/MP, FH/MP). Maxillary Position (NAD z u ULIS-N +355 a3 ULFH =.060 1781 wuPP -040 644 ULIN-AC) 516 361 ULs=N-A (mm) 367 B19 ULs°A vertical +032 1543 UL++N-Pog. +2 1547 Ul-+A-Pog +0130 1672 uit -.050 1653 1 ~ Spearman's Rank Correlation Coefficient U— Mann-Whitney U-test ‘Significant at 0.01 level Mandibular Position TFHIN-Poe) : u 41st 1663 +s 1701 os 16 mine 1546 =027 1606 Hin ans =e 360 =r ie pot we October, 1986. The Angle Orthodontis® Incisor Position 105 325 % 90 soo} * £ _ aes B sof. £280 =< = rs ast : Sas F 205 & 30 8 200 ® 5 5 1s 2 ns 2 oo . B iso : Bas es 30 100 7 Fs eS "8s S-N-A(*) ‘S-N-A(*) Fig. 14 Scatter plots of the measures U1-AY#*? and U1/N-A versus S-N-A. The distribution for U1-A¥#*" appears to be random, while an inverse linear relationship is seen in the U1/N-A plot (a more protrusive maxillary skeleton gives smaller U1/N-A angular values). 60 135 0 as 60 35 15 -40 Upper incisor 10 Poin!“ Pogonion Line (en) 00 “65 78 84 90 96 02 7 84 90 «96 ~~ Foci! Angle (*) Facial Angle (°) Fig. 15 Scatter plots of the measures U1/N-A and U1 A-Pog versus FH/N-Pog. No linear relationship is seen in the U1/N-A plots, whereas an inverse linear relationship is seen for U1 A-Pog. This indicates that the U1/N-A angular measure is not affected by mandibular skeletal position, and the U1++A-Pog measure is inversely related to mandibular skeletal position (a more protrusive mandible gives smaller U1+ A-Pog values). ©The Angle Orthodontist October, 1986 337 Ellis and McNamara Those measures of maxillary incisor position not involving a mandibular ref erence point did not show any correla- tion with mandibular skeletal position. The results of the Mann-Whitney U-test where the sample was subdivided by the median FH/N-Pog angle value (88.3°) were the same as found in the rank correlations. suspect. The facial plane angle (FH/N- Pog) was used as a measure of horizontal mandibular skeletal position, and the mandibular plane angle was used as an indicator of vertical mandibular skeletal position. The Spearman’s rank correlation coef: ficient for the measures of mandibular incisor position versus horizontal mandi- bular skeletal position are listed in Table Mandibular Incisors 2. The results reveal the following: The number of individuals who had a “normal” relationship of the mandibular _ Correlation Correlation incisor to the mandible, with LI/MP Not Significant Significant angle within the 89°-93.5° range, was (p<0.05) 102, and these were used for the remain- a der of the calculations. thine eae A measure of mandibular incisor posi- LIN-B LUOP tion on the mandible that correlated with L1-BPERP LleN-B changes in mandibular position would be Table 2 Relationship of Mandibular Incisor Measures to Facial Angle FH/N-Pog and to FH/MP in 102 Subjects with a Neutral Relation of the Lower Incisor to the Mandible (89°

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