Ricketts cephalometric superimposition

Presented by: Dr. Hasan Md. Rizvi BDS, FCPS-ll Trainee, Dept. of Orthodontics, DDCH

Supervisor: Prof. Dr. Md. Zakir Hossain BDS, PhD(Japan) Prof. & Head, Dept. of Orthodontics, DDCH.

Important Cephalometric Land Marks in Ricketts cephalometric analysis:

PT Point. Intersection of the inferior border of the formen rotundum with the posterior wall of the pterygomaxillary fissure Basion(BA): Most inferior posterior point of the occip-ital bone at the anterior margin of the occipital foramen. CC Point (Center of Cranium) :Cephalometric landmark formed by the intersection of the two lines BANA and PT-GN. Gnathion(GN): Cephalometric landmark formed by the intersection of the tangent to the most inferior point on the inferior border of the symphysis and the most inferior point of the gonial region, and the line connecting NA and PO.

XI point : a point located at the geographic center of the ramus .

Protuberaance menti or supra pogonion (PM) : A point selected where the curvature of the anterior border of the symphysis changes from concave to convex.

DC point : Cephalometric landmark representing the center of the neck of the condyle on the Basion Nasion line.

The method of Ricketts was developed in order to provide a simple basis, orderly and credible way, to view and verify the changes that occur during an orthodontic treatment. This analysis is to superimpose the initial x ray on the final layout of the same patient in five locations, to identify changes that are expected to occur due to growth, or due to orthodontic mechanics. This helps to plan our treatment and select our mechanics and to describe the alterations that occur. The five Superimposition areas are used to evaluate the face in the following order: The chin. The maxilla. The teeth in the mandible. The teeth in the maxilla. The facial profile.

Superimposition Area 1 (Evaluation Area 1) '

The first superimposition (Basion-Nasion at CC Point) establishes Evaluation Area 1, within which we evaluate the amount of growth of the chin in millimeters; any change in chin in an opening or closing direction that may result from our mechanics; and any change in upper molar. In normal growth, the chin grows down the facial axis and the six year molars also grow down the facial axis.

Normal Growth of mandible

Patient under observation

During the facial growth of "normal" patients, ie those lacking functional problems such as mouth breathing, swallowing, altered, disturbed habits (poor posture and habits of sucking), among others, the growth direction of Facial axis changes very little, closing on average 0.2 degrees per year.

The mandible increased on average 2.5 mm / year from 8 to 18 years along the axis

Patient after three years of treatment

The patient age at baseline (9 years and 3 months) with probably a growth spurt during this period. In the first area we can observe an increase in the growth of the mandible of 12 or 3.5 mm / year. Facial Axis closed 3 (counterclockwise spin of the jaw), from 86 to 89 even with all extrusive mechanics used during treatment (cervical traction with headgear, and elastic Quad Class II).

Superimpostion Area 2 (Evaluation Area 2)

The second superimposition area (Basion-Nasion at Nasion) establishes Evaluation Area 2 to show any change in the maxilla (Point A). The Basion-Nasion-Point A Angle does not change in normal growth. Therefore, any change in this angle would be due to the effect of our mechanics. We evaluate the effect of headgear (force and type), Class II elastics, Class III elastics, torque, activator, etc. on the convexity of the maxilla.

Normal Growth of maxilla

Patient after three years of treatment

we can observe a restriction in maxillary anterior displacement and the angle basion-nasion with the center at nasion decreased from 63 to 60 degrees.

Superimposition Area 3 (Evaluation Areas 3 and 4) The third superimposition area (Corpus Axis at PM) establishes Evaluation Area 3 and Evaluation Area 4, which together evaluate any changes that take place in the mandibular denture. The technique consists of superimposing the initial and final strokes on the plane Xi-Pm with the center of the two paths in Pm. Thus we observe the changes in the lower incisors and first molars, respectively, assessment areas three and four. In Evaluation Area 3, we evaluate whether we are going to intrude, extrude, advance or retract the lower incisors, which helps us determine what type of utility arch we will use. In Evaluation Area 4, we evaluate the lower molars to determine what type of anchorage we need and whether we wish to advance, upright or hold the lower molars.

Normal development of incisors and first molars in untreated patients : During normal growth the first molars are moving upward (0.5 mm / year) and forward (0.3 mm / year) and up the incisors (0.5 mm / year) and back slightly (0.2 mm / year).

Patient after three years of treatment

1. The first molars erupted 1.5 mm and 2mm moved mesially during treatment and helped close the extraction space and the correction of Class II molar relationship.
2. The lower incisors were extruded 3mm, and were retracted 5 mm, more than would occur with normal development of teeth that helped close extraction space.

Superimposition Area 4 (Evaluation Areas 5 and 6) The fourth Superimposition area (Palate at ANS) establishes Evaluation Area 5 and Evaluation Area 6, which together evaluate any changes that take place in the maxillary denture. The technique consists of superimposing the initial palatal plane (ANS-PNS) and the final palatal plane (ANS-PNS) at the center of the two planes coincide in ANS

In Evaluation Area 5, we evaluate what we are going to do with the upper molars hold, intrude, extrude, distallize or bring them forward.
In Evaluation Area 6, we evaluate what we are going to do with the upper incisors intrude, extrude, retract, advance, torque or tip them.

Normal development of maxillary incisors and first molars in untreated patients : When the palatal plane is superimposed, it becomes possible to observe the vertical development of the upper teeth down and forward. The upper incisors erupt following his own long axis 0.4 mm / year and the first molars erupted 0.7 mm / year down to 0.3 mm / year ahead, following the path of Facial axis

Patient after three years of treatment

1. The first molars were distalized 2.5 mm, as a result of orthodontic mechanics in
Class II (headgear and Class II elastics). This distal movement of maxillary first molars occurred in a direction opposite the normal development of the dental arch. The first molars were also extruded 3mm.

2. The upper incisors also had a slight extrusion of 2 mm, ie 0.6 mm

more than the expected value and were retracted 8mm bodily. This move occurred because of the mechanics used in the treatment .

Superimposition Area 5 (Evaluation Area 7) The fifth Superimposition area (Esthetic Plane at the crossing of the Occlusal Plane) establishes Evaluation Area 7 with which we evaluate the soft tissue profile. uses the aesthetic plane formed by the union of the most anterior point of the nose to the most anterior point of the chin and the functional occlusal plane, passing between the cusps of the molars and premolars. This technique consists of superimposing the initial and final aesthetic level with the center at the intersection of these with the functional occlusal plane, We use Superimposition Area 5 and Evaluation Area 7 to evaluate the effect of our mechanics on the soft tissue of the face.

In normal growth, the face becomes less protrusive with reference to the esthetic plane due to the growth of the nose and chin .

Patient after three years of treatment

The patient's facial aesthetics changed considerably after orthodontic treatment, facial orthopedic as shown by the overlay ,providing a more harmonious face, since the lips are behind the aesthetic line, as recommended by Ricketts. The retraction of the upper and lower incisors, the growth of the nose and chin positioning resulted in more and less prominent of the distal upper and lower lips.