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Mc Namara Analysis

Ricketts Analysis

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Introduction
Since the introduction of cephalometrics
by Broadbent in 1931, a number of
different analyses have been devised.
Most of the analyses were conceived
during the period (1940 to 1970) when
significant alterations in craniofacial
structural relationships were thought
impossible...
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But from 1970s clinical orthodontics
has seen the advent of numerous
orthognathic surgery procedures which
allow three-dimensional repositioning of
almost every bony structure in the facial
region. Therefore, a need has arisen for a
method of cephalometric analysis that is
sensitive not only to the position of the
teeth within a given bone but also to the
relationship of the jaw elements and
cranial base structures one to another.
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Mc Namara Analysis
In this method of analysis described by
Mc Namara in his article on AJO-DO 1984
represents an effort to relate
teeth to teeth
teeth to jaws
each jaw to the other
the jaws to the cranial base.
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Advantages
1. This method depends primarily upon
linear measurements rather than angles,
so that treatment planning (particularly
treatment planning for the orthognathic
surgery patient) is made easier.
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Advantages (contd.)
2. This method of analysis is more sensitive to
vertical changes than is an analysis which relies
on the ANB angle, such as that of Steiner. The
use of the ANB angle can be misleading, since it
tends to be insensitive to the vertical component
of jaw discrepancies. Similarly, changes in
growth pattern, which include both horizontal
and vertical adaptations, may be completely
missed if only a change in the ANB angle is
measured.


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3. This analytical procedure provides
guidelines with respect to normally
occurring growth increments. Therefore,
the norms derived from the Bolton
standards, the Burlington sample, and the
Ann Arbor sample and the composite
norms presented in this article can be
used to evaluate treatment results.

Advantages (contd.)
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4. The principles of this analysis are easily
explained to nonspecialists and to lay
persons such as patients and parents.


Advantages (contd.)
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Normative Standards
Normative standards were determined
by arbitrarily combining comparable
average values of three samples.
The first sample contains normative data
derived from lateral cephalograms of the
children comprising the Bolton standards,
the longitudinal records of whom were
retraced and digitized by Behrents and
McNamara to include all the landmarks
necessary for the present analysis.
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The second sample contains selected
values from a group of normal children
from the Burlington Orthodontic Research
Centre who also were followed
longitudinally.
The third group considered is the Ann
Arbor sample of 111 young adults who
had good to excellent facial configurations.
Patients in this latter group had a Class I
occlusion and good skeletal balance with
an orthognathic facial profile.

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Contents
1. Relating Maxilla To Mandible
2. Relating Mandible To Maxilla
3. Relating the mandible to the cranial base
4. Relating the upper incisor to the maxilla
5. Relating the lower incisor to the mandible
6. Airway analysis
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Relating Maxilla To Mandible
1. Hard Tissue Evaluation
2. Soft tissue Evaluation
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Hard Tissue Evaluation
The anteroposterior orientation of the
maxilla relative to the cranial base can be
determined by measuring the linear
distance between Nasion perpendicular
and point A.
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F-H Plane is drawn
from superior aspect
of the external
auditory meatus to
the lower border of
the orbit
Nasion Perpendicular
is a veritcal line
Perpendicular to FHP
extending inferiorly
from nasion
HARD TISSUE EVALUATION:
NASION PERPENDICULAR
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Cephalometric values from Ann Arbor sample
Composite Norms
Ajo-Do 1984
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Maxillary skeletal protrusion Maxillary skeletal retrusion
Examples
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Soft Tissue Analysis
The nasiolabial angle is formed
By drawing a line tangent to the
base of the nose and a line
tangent to the upper lip



The ideal value is 102 8
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Maxillary protrution Maxillary retrusion Retrusion with normal
Nasolabial angle
Examples
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The cant of the upper lip Should be
slightly forward to form an angle of
14 8 in females and 8 8 in
adult males with the
Nasion perpendicular
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Relating Mandible To Maxilla
1. Anteroposterior Relationship
2. Vertical Relationship
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Anteroposterior Relationship
Of Mandible With Maxilla
A geometric relationship exists between
the effective length of the midface and that
of the mandible.
Any given effective midfacial length
corresponds to a given effective
mandibular length.
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The effective midfacial length
is determined by measuring a
line from condylion to point A
Condylon is the most
posterosuperior point
on the outline of the
mandibular condyle
The effective mandibular
length is derived by
constructing a line from
condylion to anatomic
gnathion
Gnathion is the most
anteroinferior aspect of
the mandibular
symphysis
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Composite Norms
Ajo-Do 1984
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Bolton Standards
Ajo-Do 1984
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Burligton Values
Ajo-Do 1984
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The effective lengths of midface and
mandible described in the analysis is not
age or sex dependent but related to size of
the component parts. So the term "small
"medium," and "large" are used rather than
"mixed dentition," "adult female" and "adult
male."

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Retrusive mandible
Examples
Protrusive mandible
Retrusive maxilla
Protrusive mandible
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Vertical Relationship
lower anterior facial height is
measured from anterior nasal
spine to menton.


This linear measurement
increases with age and is
correlated to the effective length
of the midface
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Composite Norms
Adult Male
Adult Female
Mixed dentition
Ajo-Do 1984
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Examples
Increase in vertical height
Decrease in vertical height
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26 4.5 at 9 years and decreases by 1
every 3 years
The Mandibular Plane Angle
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The Facial Axis
Average value is 90 3.5 .


Excessive vertical development is
indicated by negative values (values
less than 90), and deficient vertical
facial development is indicated by
positive values (values greater than
90).

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Examples
Retrusive Mandible
Protrusive mandible
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Relating the mandible to the
cranial base
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The relationship of the mandible to the
cranial base is determined by measuring
the distance from Pogonion to the Nasion
perpendicular.
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Cephalometric values from Ann Arbor sample
Composite Norms
Ajo-Do 1984
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EXAMPLES
Retrusive
Protrusive
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Relating the upper incisor to
the maxilla
1. Anteroposterior position
2. Vertical position

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Anteroposterior position
The position of the upper incisor can be located
by using measurements that relate the dental
portion of the maxilla to the skeletal portion of
the maxilla.
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The measurement from
point A to the facial surface
of the upper incisor horizontally
is 4 to 6 mm
This is accomplished by drawing a
vertical line through point A,
parallel to the nasion perpendicular.
The distance from this constructed
point A perpendicular to the facial
surface of the upper incisor is
measured.
Ajo-Do 1984
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Cephalometric values from Ann Arbor sample
Composite Norms
Ajo-Do 1984
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Vertical
The vertical position of the upper
incisor is best determined at the time of
the clinical examination.
Typically, the incisal edge of the upper
incisor lies 2 to 3 mm below the upper
lip at rest.
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It is in the range of 2 to 3 mm.
Women show more within this
range
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Relating the lower incisor to
the mandible
1. Anteroposterior position
2. Vertical position

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Anteroposterior position
The anteroposterior position of the lower
incisor can be determined by using a
measurement of the facial surface of the
lower incisor to the A-pogonion line
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Composite Value is 1 to 3 mm
Ajo-Do 1984
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Airway analysis
1. Upper pharynx
2. Lower pharynx

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Upper pharynx.

The upper pharyngeal width is measured from a
point on the posterior outline of the soft palate to
the closest point on the posterior pharyngeal
wall.
This measurement is taken on the anterior half
of the soft palate outline because the area
immediately adjacent to the posterior opening of
the nose is critical in determining upper
respiratory patency.


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Average Value is approximately
15 to 20 mm in width
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Lower pharynx.
Lower pharyngeal width is measured
from the intersection of the posterior
border of the tongue and the inferior
border of the mandible to the closest point
on the posterior pharyngeal wall.

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Average Value is 11 to 14 mm.

A greater than average value
suggests anterior positioning
of the tongue
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Ricketts Analysis
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Relation of the Mandible
1. Facial axis
2. Facial(depth)angle
3. Mandibular plane
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1. Facial Axis
The angle formed between the basion-
nasion plane and the plane from foramen
rotundum (PT) to gnathion.

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Pt point
The junction of the
pterygomaxillary
fissure and the
foramen rotundum
The outline of the
foramen rotundum can
be approximated at the
10.30 (face of a clock)
position on the circular
outline of the superior
border of the
pterygomaxillary fissure
Facial axis is a line
extending from the
foramen rotundum (Pt) to
gnathion
The angle formed
between the basion-
nasion plane and the
plane from foramen
rotundum (PT) to
gnathion is 90 3.5
A lesser angle suggests a
retropositioned chin, whereas
an angle greater than a right
angle suggests a protrusive or
forward growing chin

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2.Facial(depth)angle
The angle between the facial plane (N-
Pog) and the Frankfort horizontal.
This angle provides some indication of the
horizontal position of the chin.
It also suggests whether a skteletal Class
II or III pattern is due to the position of the
mandible
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Facial plane
Extends from Nasion to
Pogonion
Facial angle is formed between
facial plane (N-Pog) and the
Frankfurt horizontal line
This angle is 87 3 at 9 years
of age and it has to be
increased by 1 every 3 years
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3.Mandibular Plane

A high or steep mandibular plane angle
implies that an open bite may be due to
the skeletal morphologic characteristics of
the mandible. A low mandibular plane
suggests the opposite (ie, a deep bite).
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Mandibular plane
Extends from gnathion to gonion
26. 60 4.5 at 9 years and decreases by 1
every 3 years
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Convexity
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The convexity of the middle
face is measured from Point
A to the facial plane (N-Pog).
The clinical norm at 9 years
of age is 2.0 mm and
decreases 1 degree every 5
years
Convexity At Point A
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II.Convexity At Point A
High Convexity implies a Class II skeletal
pattern. Negative Convexity suggests a
Class III skeletal pattern.
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Dentition
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Lower incisor to A-Pog
The A-Pog plane is referred to as the
denture plane and is a useful reference
line from which to measure the position of
the anterior teeth.

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A-Pog Line
Extends from point A to Pogonion
Ideally, the lower incisor should be
located 1.0 2 mm ahead of the A-
Pog line . This measurement is used to
define the protrusion of the lower arch.
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A-Pog Line
If the measured value of lower incisor to
A-Pog line is more than the average value
then extraction is indicated.
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Upper Molar To PtV
This measurement assists in determining
whether the malocclusion is due to the
position of the upper or lower molar. It is
also useful in deciding whether extractions
are necessary.
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Pterygoid Vertical(PtV)
A vertical line drawn throgh distal
radiographic outline of the
pterygomaxillary fissure and
perpendicular to FHP

The distance from the pterygoid
vertical (back of the maxilla) to
the distal of the upper molar.
On average is measured,
This measurement should equal
the age of the patient +3.0 mm
(eg, a patient 11 years of age has
a norm of 11 + 3 = 14 mm).
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Lower incisor to A-Pog
This measurement provides some idea of
lower incisor procumbency
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The angle between the long axis of the
lower incisor and the A-PO plane (1 to A-
PO) is measured.
On the ayerage, this angle should be 28
4.
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Profile
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Lower lip to E-plane
The distance between the lower lip and
the esthetic (nose-chin) plane is an
indication of the soft tissue balance
between the lips and the profile
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Esthetic line (E-line)
Extends from soft tissue tip of
nose(En) to soft tissue Chin
point(DT)
The average norm for this
measurement is -2.0 mm at 9
years of age. The positive
values are those ahead of the E-
line.
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Condylar Axis and
Corpus Axis
These are used to describe the morphology
of the mandible
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Xi Point
Locate FHP and Draw PtV Plane
perpendicular to the FHP and
locate four R1, R2, R3, & R4
R1 is the deepest point on the anterior
border of the ramus
R2 is located on the posterior border
of the ramus ,opposite R1

R3 is the deepest point of the
sigmoid notch
R4 is opposite R3 on the
inferior border of the mandible
Construct four Planes tangent to thes
points and it forms a rectangle enclosing
the ramus
Xi point can be located at the center
of the rectangle at the intersection
of the diagonals
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Condyle (Dc) point
The point In the center of the
the condyle neck along the
Ba-N plane
Suprapogonion (PM) point
The point at which the shape
of the symphysis mentalis
changes from convex to concave
Condylar Axis extends
from Xi to Dc
Corpus axis extends from
Xi to PM point
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