BIOLOGICAL MECHANISMS OF TOOTH MOVEMENT AND CRANIOFACIAL ADAPTATION Proceedings of the Fourth International Conference Held at New York University College of Dentistry «ih { out Co August 18-21, 2003 Editors Ze’ev Davidovitch, D.M.D. Department of Orthodontics Case Western Reserve University and James Mah, D.D.S., D.M.Se. Department of Orthodontics University of Southern California Sponsored by: y for the Advancement of Orthodontics k University College of Dentistry xt 3M UnitekBiological Mechanisms of Edited by Z. Davidoviteh and J. Mah, pag footh Movement and Craniofacial Adaptation 295-307 © 2004 Harvard Society for the Advancement of Orthodontics, Boston, Massachusetts, USA A stable cephalometric angle for the detection of mandibular rotation Julia Harfin, Graciela Porta and Silvia Kahn de Gruner Department of Orthodontics, Maiménides University, Buenos Aires, Argentina. Key Words: Mandibular Rotation, Measurements, Cephalogram, HP Angle, Stabi Summary ‘The traditional cephalometric measuring methods, for determining mandibular rotation or easy to reproduce, and measuring errors are added to the final result on adult patients. advantageous to minimize th On dry skulls, two mandibular and two maxillary landmarks were chosen and marked with a metallic hot accurate Therefore, it is measurement errors. wire. Initially, Xi point was chosen as the mandibular ramus’ reference landmark. However, it was found that its location on sub: could change. quent lateral cephalograms Therefore, a new landmark, HP, was located on the midpoint of the entrance of the inferior dental nerve. This landmark was found to be locate and reproduce. sy to ‘The second landmark was located on constructed Pm. A vertical line conne: both points was then drawn. A horizontal reference line was located in the base of the nasal cavity, the LI line, formed by the horizontal plates of the palatal bone. All these landmarks landmarks and lines were found to be unchangeable on several subsequent lateral ‘Address Corresponuenee 10: Dr. J juliaharfin@ibertel.com.ar Martin, Av Fe $242, PB-G, CL4258GU Buenos Aines, An 295 cephalometric radiographs of adult patients who had concluded growth, Pre- nd post-treatment lateral cephalograms of orthodontic patients were traced following this method, and the resulting angle, formed by the intersection of the mandibular and maxillary lines was measured. Results The points selected were easy 10 reproduce on the pre- and post-treatment films. No changes were observed in the tracing of these points, and in the superimpositions of both films. The resulting angle was easy to trace and measure, helping to determ accurately whether mandibular rotation had occurred during orthodontic treatn Conclusion this new angle (HP, Harfin-Porta angle) is an accurate, easy to reproduce method for evaluating mandibular rotation, Introduce! Cephato; n ams al very useful aids for the diagnosis of malocelusions, and the evaluation of the progress and outcome of orthodontic treatment These radiographs mai: jharfin@attgtobal.net,Haren, FH PLANE Fig. 1 Construction of the Xi point. can facilitate a determination of the extent of treatment. related alterations in the facial skeleton. Of particular interest in this regard is the issue of mandibular rotation, its direction and extent. For this purpose, Ricketts? ANS-Xi-Pm (anterior nasal spine, m and the prom: ndibular centroid, ntonian point) ceph lometric angle is usually being used.'* However, it is frequently dif ficult to accurately reproduce this angle in consecutive films. The identification of a cephalometric landmark is influenced by numerous factors, includir the structure that lodges it, the effect of X-rays on its, its locatior form, its location on the film, and the geometry of its radiographic image. Moreover, it must be remembered that a lateral cephalogram is a two dimensional image of a three dimensional object.’ These considera~ tions compelled us to search for a replacement for Ricketts” ANS-) the Xi point, which was defined as a point located in the geometric center of the mandibular ramus, obtained by construction (Fig. i-Pm angle. This angle hinges around 1). However, in daily practice the precise localization of this point is not free of errors. Difficulties in the det xact location of the Xi point result from the fact that this landmark ermination of th is not an independent anatomical structure, but is rather dependent upon a plane external to the mandible, the Frankfort Horizontal (FH) plane, whose precise location Iso a subject of uncertainties and errors. This plane, which is formed by a line drawn between Porion and JULIA; PORTA, GRACIELA; KAHN DE GRUNER, 296 Fig. 2 Porion's location on a lateral cephalogram Fig. 3 Orbitale's location on a lateral cephalogram Orbitale, is being used frequently for orientation, superposition, and reference purposes, despite the inherent difficulties in the accurate localization of these landmarks on a lateral cephalogram. The locationA STABLE CEPHALOMETRIC ANGLE FOR DETECTING MANDIBULAR ROTATION Fig. 4 Discrepancies in the location of Or and Po on cephlograms of Porion can be masked by the density of the petrous, part of the temporal bone in the area of the middle and internal ear, as well as by the form and direction of the central X-ray (Fig.2). For that reason, Vion’ transformed Porion into an arbitrarily defined point, and Ricketts incorporated it as such into his cephalometric analysis. ‘The opposite end of the FH plane consists of the Orbitale (Or) points, located in the inferior part of the orbital rims. These landmarks may be masked by the lack of density of these bony rims, by being curved structures detected by the most divergent rays, and by the black image product of the pneumatic cavity of the maxillary sinus (Fig.3). Due to these limitations, achieving a perfect su~ perposition of bilateral craniofacial skeletal structu best. In this task, diserepa may occur in both’ the vertical and antero-posterior planes (Fig.4). Therefore, when wishing to utilize Po and Or as reproducible landmarks, it must be decided whether each point should be located most posteriorly, occurs infrequently, a anteriorly, superiorly, inferiorly, the average of all points or, in the case of accentuated asymmetries, trace each side of the face separately. Additional reasons for discrepancies in superpositions of cephalometric tracings are due to the use of radiographs obtained by different radiological operators, different X-ray machines, or at different clinical facilities. Moreover, inaccuracies may result from the lack of strict adherence 297 PL FA Fig. 5 Construction of R1 and R3, to standard rules of determination of the location of cach landmark, or difficulties in the visualization of these points on the radiographs. Similar difficulties are frequently encountered in efforts to define the location of the mandibular centroid. These efforts are based on the determination of 4 lines that repesenting the borders of the mandibular ramus (R1-R4, Fig.5)."* The R1 points, located in the deepest part of the contour of the mandibular ramus, perpendicular to the FH plane, may be obscured by the image of the posterior teeth, and/or by the density and thickness of the palatal veil. The R2 points (mirror imi of R1) are masked in some cases by the arch ofHARFIN, JULIA; PoRTA, GRACIELA; KAHN DE GRUNER, SILVIA w™, Fig. 6 Eight different Xi points due to bilateral asymmetties in the shape of the mandibular rami and tha location of the left and right Poand Or Fig. 7 Image of two hemispines Fig. 8 Image of nasal cartlague on ANS the Atlas (C1), depending on the patient’s cervical curvature and the postural position. The R3 points. located in the most concave part of the sigmoideus recess, parallel to FH, may be hidden by the image of enlarged adenoids, or by the outline of the airway in that region. The R4 points (mirror image of R3) do not present any problems in their visuali tion. In all the cases, it depends on the local physical 298 Fig. 9 Developed nasal crest i characteristics of the bony tissue (i.e. direction, sym- metry, and density). Fi the left 6 demonstrates that an asymmetry between nd right mandibular rami, and differences between the locations of the two Po and the two Or result landmarks, ma the loc; different > ization of up to 8 i points on the same film. Such a situation is confusing, at best, and unacceptable for diagnosticA STABLE CEPHALOMETRIC ANGLE FOR DETEC Fig. 10 Underdeveloped ANS TING MANDIBULAR ROTATION Fig. 11 ANS camouflaged by soft tissues Fig. 12 PNSimage with two hemispines purposes. ‘This obvious deficiency, resulting from the use of bilateral structures, may be obviated by the use of line stretched between two points located in the midfix cial plane. Such a line could be drawn between the anterior nasal spine (ANS (PNS). However, the e: landmarks is also prone to diffic and the posterior nasal spine act localization of these ties and errors. Factors that may reduce the precision in locating the radiographic image of ANS may be a diffuse image due to the existence of two hemispines (Fig. 7); image blurred by the nasal cartilage (Fig. 8); a very larg nasal crest (Fig. 9); a poorly developed ANS (Fig. 10); and camouflage by soft tissues (Fig. 11) Difficulties encountered in the exact localization of 299 Fig, 13 Camouflage of PNS by the palatal Vel (8) PNS on a lateral cephalogram can be due to a diffuse (Fig. 12); a dense palatal veil (Fig ges of retained dental (Fig. 14), Thus, the ANS~PNS lin entity for the purpose of superpositions of cephalo- created by the existence of two hemispines 13); and by ima- tly an unreliable metric tracings. This reality compelled us to search for another line, free of interferences, that can be located repeatedly and with precision on subsequent radio: graphs. For this purpose we chose the radiographic outline of the maxillary palatal plates lamina of the palatal bones, the L-J line* (Fi nd the horizontal - 15). \¢ on the base of the nose, we called it (an horizontal I L-J line. It is no capable to change with growth and it is easy to visualize and trace on the X-ray )HARHN.JULIAS PORTA, GRACIELA KAHN DE GRUNER, SILVIA Fig. 14 Retained dental units that may abscure the image of PNS in a lateral ce Hhlogram: rools (left) and crown (right) Fig, 15 The LJ Line It is thus evident that traditional cephalometric analysis methods that rely upon superpositions on the Po-Or and the ANS-PNS lines for determining the extent of orthodontic treatment outcomes in terms of e and not easy to mandibular rotation, are not ace reproduce, so measuring errors are added to the final result in adult patients. Therefore, the objective of this study was to construct an angle on lateral cephalo~ grams of adult patients that would facilitate accurate, reproducible, and reliable superpositions of pre- and post-treatment tracings. Materials and Methods In this study, 100 dry mandibles of adult subjects, 300 from the Department of Anatomy, Faculty of Me~ dicne, University of Buenos Aires, were examined. Millimetric measurements of the location of the en: trance of the inferior dental nerve into the mandibular ramus were performed. In addition, lateral and panora~ ied of each half jaw, as ton. This mic radiog aphs were obtai well as of the the entire craniofacial skel te the Xi and HP points material was used to lox anatomically and radiographically, and to determine the distance between these landmarks (Figs. 16-18). Results The HP point was used to to construct on the lateral n), which cephalogram the line HP-Pm (Promentota STABLE CEPHALOMETRIC ANGLE FOR DETECHING MANDIBULAR ROFATION Fig, 16 Entrance of the inferior dental nerve into the mandibular ramus (HP point), shown radiographically (left) and anatomically right) Fig. 17 Occlusal view of owing the 301HARFIN, JULIA; PoRTA, GRACIELA; KAHN DE GRUNER, SILVIA i) THROUGH coNsTPeUSTION FH PLANE Fig. 18 A comparison between Xi point (ell) and HP point (right) Fig. 19 The LH istration ofthe jaws Pm angle, drawn schematically on a partial created an acute angle with the LJ line (Figs, 19 and 20). The photographs shown below present the pre- and posttreatn ent photographic and radiographic records of a 22 year old female, who received orthodontic 302 Fig, 20 The L.-HP-Pm angle, drawn on a lateral cephalogram of an adult patient treatment for the correction of a Class IIT malocelu~ sion, The treatment lasted 2. years and 5 months. Superposition of the pre- and post-treatment tr acings revealed that the LJ-HP-Pm angle had increased from 7 to 8.5 degrees during the treatment periodHAR FIN, JULIAS PoRTA, GRACIELA; KANN DE GRUNER, SILVIA The post-treatment pictures:‘A STABLE CEPHALOMETRIC ANGLE FOR DETECTING MANDIBULAR ROTATION, ‘Superpositions of pre- and post-treatment cephalometric tracings Initial Criteria for sample selection and size Adult skulls were chosen for this study due to the fact that there was no longer any growth. ‘The HP point was measured on 100 dry adult skulls, on their X.rays and on cephalograms of the dry skulls Millimetric measurements of the location of the entrance of the inferior dental nerve into the mandibular ramus were performed . Then lateral and panorami cere obtained of each half jaw. radiographs 305 What was measured? measured, ‘The new ngle HP was What were the results of these mesurements? HP angle is a stable angle to measure mandibular rota-tion . HP point as the LJ line does not change during treatment, so the angle is ac-urate to reproduce and for measuring mandibular rotation When superpositions in adults patients are made, the position of the Xi point is more anterior inferiorHARFIN, JULIA; PORTA, GRACIELA; KAHN DE GRUNER, SILVIA than the HP ppoint Statistical analysis of the data For the statistical analysis of the data, the measurements ( HP1, HP2, HP3 y HP4 ) were put in correspondence with the series of the natural numbers, that will be used as a subscript of the used variables (x and y). Thus each ‘measurement is represented as xi, and the total of them like x1, x2, xn-1, xn, where n is the amount of conducted measurements. The mean of the sample is given by: n-l n-1 The standard deviation (s) is the positive square root of the sample’s variance. Within the interval (x-s x+s) are 90% of the measured values. ‘The sample’s mean values Anteroposterior X : (26.9 + 4.9) mm. Vertical Y : (47 + 6.2) mm The detailed results are presented below in the form of histograms. For the preparation of the histograms, the interval between the minimum measurement (X,qi,)) and maximum ( X,,,.) was divided into 10 bands of equal length. The height of the bar for each band is proportional to the relative frequency of this band. The width of each band is then: Gay Fin) 10 What is HP1, 2, 3, and 4? HPI represents R1, the deepest part of the contour of the mandibular ramus , not taking into account the FH plane. HP2 is the mirror image of HP1, vimilar to R2. HP3 (similar to R3) is located in the deepest part of the sigmoid notch. HP4 is ¢ mirror image of R4, not taking into account the FH plane. 306 HP1+HP2 | 21,9 238 25,7 27,6 295 31.4 93,3 95,2 37,1 mm ‘ HP3+HP4 29 | | 314 34,8 382 41,6 45 48,4 51,8 55,2 586 62 mm | What does the vertical axis represent? In HP! + HP” the vertical axis represents the distance between these lines (HP1 and HP2), measured in the 100 mandibles. What is the meaning of the mm on the horizontal axis? In HP3 + HP4 the horizontal axis represents the distance between these lines, measured in the 100 mandibles. Discussion : In most finally cases we, orthodontists desire to see if some mandibular rotation happened as a result, ex- pected or not of treatment, its direction and extent. For this purpose , Ricketts’ lower facial height is usually being used.’ However, it is frecuently difficult to accurately reproduce this angle in consecutive films, ion of a cephalometric land- mark is influenced by numerous factors. Accuracy is needed, for example in the pre and post treatmentA STABLE CEPHALOMETRIC ANGLE FOR DETECTING MANDIBULAR ROTATION X-rays , if superimpositions are wanted to be made. ‘Traditional cephalometric analysis methods that rely upon superpositions on the Po-Or and the ANS~ PNS lines for determing the extent of orthodontic treatment outcomes in terms of mandibular rotation, are not accurate and not easy to reproduce, so measuring errors are added to the final result in adult patients. Conclusion ‘This study demonstrated that the LJ-HP-Pm angle is reliable for measuring mandibular rotation reulting from orthodontic treatment. References 1. Ricketts, R.: Provocations and perceptions in craniofacial orthopedics. Dental Science and ial Art. Nine Books in Three Volumes. R.M.O. Inc., First Edition, 1989, U.S.A., Vol 1 Book 1, Part 1 and 2 2. Brand, R., Isselhard, D. : Anatom a de las estructuras orofaciales. Tit. Orig.: Anatomy of 307 orofacial structures” Spanish Ed. Hartcourt Brace- Mosby, 6.Ed., 1999, Madrid, Spa Cuenod, C.A.; Doyon, D.; Halimi, P: Cuademos de IRM, Anatomia de cabeza Nro. 2, Masson S.A., 1991, Barcelona, Spain Goaz, P., White, S.: Radiologfa oral. Principios € interpretacion. Tit. Orig..Oral Radiology. Mosby-Doyma, 1995, Barcelona, Spain. estul Lj Latarjet, A. Anatom?a Humana. Salvat Editores, 9. Ed. 1987, Barcelona, Spain. Ricketts, R., GUGINO , bench R : : Bioprogre- ssive Therapy. Ed. Panamericana ~ R.M.O. Ine., 1992, Buenos Aires, Argentina, Vion, P.E.; Anatomia cefalométrica. Tit. Orig.t Anatomie Cephalometrique. Livraria Editora Santos, Sao Paulo, Brasil, 1994. Velayos, J-L., Diaz Santana, H.: Anatomia de la cabeza con enfoque odontoestomatoldgico. Editorial Médica Panamericana, 3°, Ed., 2001, Madrid, Spai