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the mesial surfaces of the first permanent mandibular molars and recorded on
line marked available (Fig. 1, C). The mesiodistal widths of the unerupted
mandibular canine, first premolar, and second premolar teeth (right and left)
are measured on the intraoral x-ray films and the data are transfered to the
upper line of the analysis ca.rd, on which the actual widths of the central and
late mral incisors had previously been recorded as measured directly in the pa-
-.._;
FM IMPA HIA ANN
3-17-61 3P.S 8V 11.50 20
lo-2144 340 81.50 b4.S So
Fig. 1. (From Tweed: Clinical orthodontics, St. Louis, 1966, The C. V. Mosby Company,
vol. 1.)
lliagnostic facial triaagle 653
tients mouth. In the example shown in Fig. 1, C, required a.rch length is 65.5
mm., as is available arch length. Arch-length discrepancy, therefore, is 0 mm.
The diagnostic facial triangle is then constructed as csplained in detail in my
book entitled Clinicd Orthodontics.8
Cephalogram correction
If the diagnosis divulges that there is a discrepancy between teeth and basal
bone structures, or that a cephalogram correction reduces available arch length
appreciably, as in (Fig. 1, C), serial extraction procedures are instituted at the
age of approximately 8 years.lO The sequence is as follows:
1. At approximately 8 years of age, all four deciduous first molars arc
extracted.
2. Some 4 to 10 months later, the first premolar teeth will have erupted
to gum level. At this time, all four erupting first premolars and all
four deciduous canines arc removed. If this is done at least 4 to 6
months prior to eruption of the permanent canines, when they erupt
they usually will migrate posteriorly into good positions.
The irregularities of the mandibular incisors (if not too severe) correct
themselves, and functional denture mechanics tip these teeth lingually to in-
clinations in keeping with the forces to which they are subjected during normal
use (Figs. 1, B and 2, B) . In this instance, the mandibular incisors have tipped
lingually 7.5 degrees during 43 months of guidance ; the irregularities of the
mandibular incisors were self-corrected; the FMA was reduced 5.5 degrees,
the FMIA increased 13 degrees (from 51.5 to 64.5 degrees), and there was a
reduction of I..5 degree in ANB, indicating t.hat the growth trend is Type C.
Obviously, the patient has been greatly benefited by serial extraction procedures,
and mechanical treatment will be of short duration.
Fig. 2. [From Tweed: Clinical orthodontics, St. Louis, 1966, The C. V. Mosby Company,
vol. 1 .I
Diagnostic facial tria&e 655
Anchorage preparation2
TreatmentI
B C
Fig. 3. (From Tweed: Clinical orthodontics, St. Louis, 1966, The C. V. Mosby Company,
vol. 1 .I
656 Tweed
to maintain the integrity of the occlusal plane are working more closely within
the confines of normal growth processes t,han are those who permit great deria-
tions of the occlusal plane to occur as a result of faulty treatment.
Prevention of undesirable changes in the occlusal plane during treat.ment is
important. The solution to the problems appears to concern the control of forces
ut.ilized in treatment. Space will not permit me to discuss this topic in detail
here, but further information will be found in Clinical Orthodontics.7
S-27-61
4-30-65
HA IMFA
38" 88"
33.3" 81 I" 43 3 93 433 13
A B
Fig. 4. (From Tweed: Clinical orthodontics, St. Louis, 1966, The C. V. Mosby Company,
vol. 1 .I
Tracing A
FMA
IMPA
EMTA
ANB
Occlusal and Frankfort, plane angle
Tracing B
FMA
IMPA
FMIA
ANB
Occlusal and Frankfort plane angle
a
658 Tweed
using differential forces without extraoral appliances. A study and comparison of:
the angular changes that have occurred in FMA, IMPA, FMIA, and ArUB in
these two tracings are most enlightening and should convince orthodontists that,
force control is a must in all orthodontic treatment (Table I).
With this brief review of the information required of those who practice
preorthodontic guidance procedures and endeavor to fulfill the requirements
of the diagnostic facial triangle, let us study the records of some children treated
in this manner.
The patient shown in Fig. 5, ~1 rcprescnts a Type A growth t,rend, as indi-
cated by the constancy of the ANB angle, which has remained at 5 degrees
during 32 months of preorthodontic guidance that included serial extraction.
In tracing Fig. 5, A the mandibular incisors have tipped lingually 7.5 degrees
and the FMIA has gone from 58 to 65 degrees which meets the requirements of
the diagnostic facial triangle.
Fig. 5, B illustrates the extent of the distal movement of the ma.xillary in-
cisors which has reduced the ANB angle from 5 to 2 degrees. The FMIA is 65
degrees at the termination of treatment. Treatment. forces have been controlled,
and the integrity of the occlusal plane has been maintained. Anchorage prepara-
tion was second degree. Fig. 5, C, made approximately 3 years later, shows the
FMIA to be 68.5 degrees with the ANB remaining constant at 2 degrees.
The patient shown in Fig. 6 is a sister of the patient shown in Fig. 5. Prr-
orthodontic guidance lasted 4 years and included serial extraction procedures.
The growth trend in Fig. 6 is Type (>, as indicated by an ANB reduction
from 4 t,o 2.75 degrees (Fig. 6, 11). The mandibular incisors have tipped lingual-
Diagnostic facial triangle 661
Fig. 9, A shows that there has been no change in the ANB, which has rc-
mained at 4 degrees. The middle and lower face arc growing forward and down-
ward in unison. Tracing B reveals the angular changes that have occurred in
the diagnostic facial triangle as a result of treatment and growth.
FMA INPA
(degrees) (degrees)
Nor. 29, 1956 26 102.5
Frl1. 7, 1961 22 93
Note the dramatic ramus growth and the 14.5 degree flattening of the FMA.
Fig. 10 shows the records of a patient with a Type C growth trend (Fig.
10). At the end of preorthodontic guidance, which included serial extraction
procedures, the changes in the angular measurements of the diagnostic facial
triangle were as follows (Fig. 10, d) :
FMA IUPA FKZA ANB
(degrees) (degrees) (degrees) (degrees)
June 15, 1963 30 92.5 57.5 5.5
June 20, 1967 25 96 59 3.75
The FMA has flattened 4 degrees ; the mandibular incisors have tipped
lingually 5 degrees, to an IMPA of 94 degrees. As a result of these angular
changes the FMIA now reads 61 degrees, an increase of 9 degrees in that angle.
Comparing these two sisters, I regret that I did not treat this one, for if I
had fulfilled the requirements of the diagnostic facial triangle and reduced the
ANB angle, the face would not be so protrusive and facial esthetics wo~&l have
been greatly improved. What poor decisions we all make at times!
In Fig. 12 tracings A and A show the results of treatment of two Class I
discrepancy malocclusions. The patient in tracing A was treated in the mixed
dentition, and the patient represented by A was treated in the permanent den-
tition. Both present Type A growth trends, and anchorage preparation was
second-degree. Note that the integrity of the occlusal plane has not been violated
in either case. The anterior hard palate and the nasal spine have not been
lowered in spite of the great distances that the maxillary incisors were moved
fMA IMPA HAlA ANR
9-11 52 34 5 94 II I 4.75 76 101 13 0
6-i-54 341 78 67 I --.I
MA IMPA AN8
28 107 10
241 90 6
FA1
IA-2
MA IMPA
Z-26.51 31 91 14 I.5 16, II 20.51 335s 107
4-12.61 32.5 88 59.5 3.5 12 11-23.53 II BB
D D
Fig. 12. See text.
distally by force-controlled treatment mechanics. In Fig. 12, A the mandibular
incisors were tipped lingually 16 degrees, and there has been a decrease of 5.25
degrees in the ANB. The occlusal to Frankfort plane angle has decreased 2
degrees, from 13.5 to 11.5 degrees. In Fig. 12, d the mandibular incisors have
been tipped lingually 24 dcgrccs. There has been a 2.5 degree reduction in the
angle formed by occlusal and Frankfort planes; observe also that treatment
mechanics have been coordinated with the normal inherent downward and
forward growth vector of the middle and lower face as indicated by not even the
slightest semblance of B point dropping down or backward. Compare these
beautiful results of force-controlled treatment mechanics with B, C, and D.
These three cases demonstrate the results of lack of control of treatment
mechanics which have permitted a serious deviation of the occlusal plane, with
the result that B point has dropped downward and backward. Observe that the
anterior nasal spine and the anterior hard palate have dropped down. Note the
increases in the occlusal to Frankfort angles (6 degrees, 9.5 degrees, and 3.5
tlegrees). Compare the angular changes that hare occurred in the diagnositic
facial triangle as a result of control of treatment forces in A and d, B, C, and D
with the angular changes in the diagnostic facial triangle that have occurred in
tracings B, C, and D when treatment forces within the orthodontic mechanisms
are not controlled.
Rarely is it possible to achieve the requirement of the diagnostic facial
triangle unless controlled treatment mechanics are utilized. On the other hand,
it is possible to achierc its requirements in approximately 80 per cent of the
cases by instituting force-control mechanics in ones practice. It is my fervent
hope that every orthodontist will take the time to find out how easy it is to
practice force-control mechanics and how rich are the rewards when the require-
ments of the diagnostic facial triangle have been the results of his efforts.
REFERENCES
1. Tm-eed, Charles H.: Clinical orthodont,ics, St. Louis, 1966, The C. V. Mosly Company,
vol. 1, pp. 33, 252.
2. Ibid., pp. 259-260.
3. Ibid., pp. 248-268.
4. Ibid., pp. 13-30.
5. Ibid., pp. 7-12.
6. Ibid., pp. 232-247.
7. Ibid., ~01s. 1 and 2.
8. Ibid., vol. 1, pp. 252 et seq.
9. Ibid., pp. 31-82.
10. Ibid., p. 261.
11. Ibid., pp. 13-30.
12. Ibid., pp. 7-12.
13. Ibid., pp. 232-248.