The keystone triad

II. Growth, treatment, and clinical significance

ROBERT Los Angeles, MURRAY Calif. RICKETTS, D.D.S., M.S.

INTRODUCTION

T H E keystone triad was described in an earlier publication1 as consisting of the chin, point B, and the lower incisor. This unit, located at the keystone of the mandible, includes the symphgsis, the alveolus, and the lower anterior teeth. Anatomic details, phylogenetic factors, and problems in cephalometric nomenclature were discussed in the earlier article. The intent of the present essay is to review growth findings together with treatment changes and attempt to transpose them inbo clinical understanding. This perspective is needed for a knowledge of the ultimate prognosis of the orthodontic patient.
LABORATORY INVESTIGATIOSS

It had been generally assumed, from the early studies of Brash2 and of Keith and Campion, that the mandible always grew forward in the face and that the chin became more prominent. The first work of Humphrey, the concepts of John Hunter,5 and other works all contributed to general acceptance of the belief that the human mandibular body grew in length by means of resorption of the anterior portion of the ramus and apposition on the posterior surface. The lack of increase in the size of the arc of the mandible led investigators to conclude that little apposition occurred on the chin, and yet the fact that the chin seemed to become more prominent in many patients confounded the acceptance of that conclusion. It was this frame of knowledge that prevailed at the time that &hoar and
The second of two essays to be published in the AMERICAN JOURNAL OF ORTHODONTICS, based on material presented before the Middle Atlantic Society of Orthodontists in Atlantic City, N. J., Oct. 28 and 29, 1963, and before the Jarabak Foundation in Chicago, Ill., Feb. 1 and 2, 1963. *Associate Professor of Dentistry, School of Dentistry, University of California.

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Massle? studied the growth of the monkey mandible by means of alizarin red S dye. Their findings showed that until the equivalent of human age 6. or during the mixed dentition, there occurred a general apposition of bone around thr mandible on all surfaces. This early behavior gave evidence of a g~nc~ral growth on the external body of the bone in all dimensions. However, at about the age of the mixed dentition, there was a change in growth characteristics. Ai eoncentrat.ion of the dye was seen at the alveolar border, the posterior b~rd(~l* thcL of t,he ramus, the coronoid process, the sigmoid notch, and particularly caondylar head and process. All these areas were growing by apposition, but t.hr body of the mandible did not grow. This was confirmed by Jloores wor4~ in 19-K).7 The early work of Engel and Brodie8 proved rather conclusively that, tllc, nlain impetus to growth occurred at the mandibular condple? which propcll~tl t,he mandible downward and forward, carrying the chin with it or pushing the callin ahead. Sarnat and Engels study on monkeys that had undergone cotldyloctomp also confirmed this observation.
CLINICAL STUDIES

Tn his cephalometric study of prognathism, Bjiirk pointed out &at OV~I the long growth range the chin tended to become more prognathic in the fan than the maxilla. Landell also observed this tendency. The average profile t,hus tended to straighten out, and the ma.ndibular anterior teeth tended to mov11 upward and backward in relation to the profile. This finding has been clrmortstrated repeatedly, but all patients do not behave in this manner. The work of Schaefferl is of particular interest to our discussion of changes of the lower incisor. Schaeffer measured the eruption tendencies of the Lowe incisors in cases taken from Broadbents files at the Bolton Foundation. Hc showed that the lower incisor could erupt upward and forward but that typicall:it was carried upward and backward. This could occur in some cases, evtn without a change in the tooths axial inclination. Schaeffer however, spoke oi the difficulty of superimposing the symphpsis in some of the C~SCS st,udicd dueing the later phases of growth. C~XDYLE GROWTH AS RELATED TO THE CHIS. The above work representrcl llrc status of our knowledge of the changes in tho keystone triad at, the timo thal I conducted growth studies with laminagraphy.13 The growing condple was correlated with the change in facial profile, and it was found that the growth t,endency of the average condyle was straight upward and backward, almos! up the long axis of the neck of the condyle as typically described. In this typt of patient the chin grew downward and forward in the face in the usual manncll.. In some patients, however, the condylar head seemed to incline mor*r$ posteriorly when measured from the mandibular border than had been obscrvcfl in the beginning (Fig. 1). The mandible became more obtuse in form. This led to speculation that the growth of the condple was following a more postcrjor direction and that there was a distal inclination in shape of the condylar ncc*k and ramus. These patients seemed to show more gro\Tth in anterior height 01 the fact.

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Fig. 1. A, Tracings of a male patient with predominant vertical growth between the ager of 12 and 21 years. It will be noted that the facial pattern is long and shallow and that the Y axis opened even more in spite of efforts to close it with orthodontic treatment and the extraction of four first permanent molars. B, Mandibular comparison, superimposed in the manner suggested by BjSrk on the area of pogonisn and the crypt of the developing third molar, shows an upward and backward growth of the mandibular condyle and apparent resorption of the ante&r border of the ramus and an upward and backward change in the lower incisor. Notice also the height increase in the mandibular incisor. Open-bite tends to develop more if the incisors do not erupt in patients with this type of growth pattern. It will further be noted that development of the apparent prominence of the chin from a bony standpoint is due to incisor retraction with growth.

In other patients there was greater development in the body of the ramus, leading to upward and forward growth of the mandibular condyle. The mandible and the face tended to develop more squareness or to be more consistent with the brachyfacial type of facial pattern and the chin tended to move more forward than downward (Fig. 2). In attempting to explain these changes, I referred to the muscular suspension apparatus of the mandible. In the final analysis, it was concluded that the mandible was growing against the function of the muscles which held it in place. Thus, upward and backward growth of the condyle, with slow development of the angle of the ramus, tended to add length to the face or to cause a downward dropping of the chin. At the opposite extreme, an upward and forward direction of eondylcf growth with extensive depression of the angle of the ramus was consistent wi

mandibular squareness and a more prominent chin. In other words, the devteopment of a heavy angle seemed to characterize a lower face and chin that wer(* forward in the face. Bj6rk14 observed the same differences in growth pattern* but apparently did not quite agree with the consistency of these mandibula:, patterns with particular facial patterns (Figs. 1 and 2). We have observeli exceptions, but generally it has held true. Statistics are lacking for these factors. More recently Bjijrk15 published a follow-up of earlier implant studieh. Four tantalum pins were placed in the mandible at certain points. At, a later date, by orienting on these fixed pins, which did not change in their rtlatiollship, he demonstrated the mean and ext.remcs of directional behavior of tht~ growing condyle. The average posterior plane tended to move slightly upwar~l and forward about 6 degrees from the original mandibular plane. The variut.iotl toward gonial development was 20 degrees (in an upward and forward dirt.+ tion) . The opposite direction ranged to an distal inclination of 16 degrees (mom obtuse). Bjiirk did not correlate mandibular behavior with facial chi~~~pe.1)1 it

K.C. g-7 14-3

Fig. 2. A type of growth opposite that shown in Fig. 1. a, Tracings of a female patient between the ages of 9 and 14 years. The X-Y axis changed from 1-7 to +15 degrees as the chin moved almost directly forward. It will further be noted that the ramus increased markedly in height and that posterior height developed at a greater rate than anterior height. Kobice that the c,hin carried the lower incisor forward. In contrast to Fig. 1, which demonstrated about a 2.5 cm. dropping of the hyoid bone, very little dropping of the hyoid is evidcknt in this patient. B shows pattern of growth, superunposed according to BjBrk, and indicates marked vertical development. However, instead of anterior ramus resorption, as shown in Fig. I, there WBS apparently resorption of the angle of the ramus and a vertical growth of the ramus. This produces growth rotation to the chin in an almost forward direction as the mamliblc tends to curl during growth. Notice that the eruption of the first molar is much greater than that of the incisor in this particular patient. These patients tend to develop closca-l)itcs :IR a part of their growth pattern. Note that thr symphynis tends t,o incrcnse in width with thl> addition on the posterior margin.

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since his findings so closely followed my observations or showed even greater variational behavior, I would assume that the same general observations would hold for facial change. LOCAL CHIN MORPHOLOGY. Several observations support the contention that the lower incisor is suspended from t,he lingual plate of bone and from the dense compact of t.he planum alveolar on the lingual aspect. Repeated sections taken by numerous investigators over the past 40 years have substantiated this fact. It can also be shown very effectively by midsagittal laminagrams of this bone taken in living subjects. An over-all thickening of the symphysis menti seems to occur occasionally, but in these cases one must make observations over a long period in order to measure the change. An example was seen in a nontreated patient who developed a beautiful occlusion and a very strong mesognathic pattern, with a marked increase in the width of the symphysis, in a period of 8 years (Fig. 2). It has been noted, however, that by the time the lower first molar has erupted the general width characteristics of the symphysis will have been attained. The average symphysis is almost teardrop in shape. Extreme variations show either a long, narrow symphysis or one that is short and thick. Patients with mandibular prognathism or with great alveolar height and retrognathie patterns often have long, narrow symphyses. The brachyfacial or wide-eyed person often exhibit,s a symphysis with thick, more square outlines. Exceptions can be found if a search is made, but these cha.racteristics can be identified in many cases. It would seem that the presence of these facial types can be taken to indicate that certain functional and morphologic characteristics prevail. The mere fact that these tendencies can be observed is worth while as a clue for use in estimating the future. This is a conjecture to be borne out or refuted by research. Clinicians have reflected this suspension in the often-heard expression them thats got-gets when it comes t,o a chin. Investigations of the crosssectional area of the chin should be correlated with mandibular width. As shall be seen later, this is only one part of a whole complex. POINT B BEHAVIOR. It is of particular importance to visualize the different growth patterns of the whole face in order to understand the behavior of the erupting t.eeth and of point B, which is directly related to the shifting of these teeth. In 1953 Brodie16 completed the study which he originally started in 1940 on the growth pattern of the face. He noted the tendency for the teeth to shift on the basal bone of the mandible after the age of 8 years. In his own words:
The late stages of

forward

and downward arch and its supporting creases the prominence necessarily accompanied less procumbent, more

growth have been shown to be accompanied by a continuation of movement of the anterior nasal spine and of pogonion, while the dental bone tends to move more slowly and thus drop behind. This deAt the same time, however, such behavior is not of the denture. by a more upright position of the incisors. These teeth may become procumbent, or many remain at their original axial inclination.

Brodie employed the occlusal plane and dropped perpendicular lines from the occlusal plane in order to reach his conclusions. He referred to t,he previously mentioned work of Xchaeffer in support of those conclusions.

With similar observations, Bjijrk placed implants as far down on the ~J%Iphysis as he could from inside the mouth. In his preliminary studies OVV! short ranges, Bjiirk demonstrated that metallic implants tended to remain ill the same position and that actual resorption of bone was occurring in the arc;1 of point B. In a patient with condylar arrest and alteration of pa,tt,crn, Hjiitk demonstrated that apposition did occur at the angle of the mandible in a CIUIcentric layer adaptation, possibly as a function for a masseter mu&c 01 ptcl: goid internus bracing. In that particular case, superimposing on tnrtallic ir+ plants revealed the probability of appositional changes on the bon?: chin. hrlt in the majorit>- of normal persons resorption of the bonth occurrt~l in the :t~c:t of point B. BjSrks latest studies of the chin and point B have demonstrated no app+ sition of bone in the region of pogonion. Some apposition was suggested in tijct area below pogonion, but the area of the m.entnl protubwunce was not dwn,qr (1. ResorpCon was almost routinely demonstrated in the area of point K 213 t iw incisors shifted vertically with growth. The increase in thickness of the s:v:~Iphysis seemed to be appositional on the posterior and inferior borders. By using t,he central core thus registered by implants, new light, Nil:> shed on the directional eruptive possibilities of the teeth. The typical helmviol* was one of straight upward eruption. Extremes suggested, however, that th(b teeth could erupt either upwasd and forward or upward and backward 1r~~m the body of t,he mandible. The lower incisor was shown to move hncA~~rr-tl naturally in those eases of obtuse growth. of t,hc mandible. In brachyfacial tylj(lS the incisor seemingly demonstra.ted for.~~~~l! eruption tendencies. Therc:For~~, it might be hypothesized that in the brachyfaciat typr the lower anterior tl)cth will be stable in a more forward position when related to the symphysis. Further discussion of the behavior of point, K is rc>lati\-c, to trc~atmrnt. Jctint K tends to follow the lower incisor. It will bc obstirvcd t~linically that altrr forward movement of the lower incisor a ledge of bonct in the planum dvtYJlar will a,ppear on the lingual side; this will 1~ retained for a time but, will grt~dually disappear. However, no such shelf is seen lahiall,v after lingual nlovrlnSJnt of the teeth. This would imply that tho hclav>-. slow-rc~sorbing bone is lo~nt ccl on the lingual side. BEHAVIOR OF THE LOWER INCISOR. (3ne of the first critical studies with I(gard to positioning of the lower incisor during orthodontic treatment, was l)Alishcd by IAtowitz17 in 1948. He referred to the earlier work of 8pGdcl ;tntL Stoner,l who related the long axis of the incisor to the mandible iu atlll1t.s. and also to the earlier work in cephalometric analysis conducted in 1936 by MSCS Brodie, Downs, Goldstein, and Myer. IQ Litowitn studied twent;v t.rc~at~t~cl and reached the following conclusion:
The tracings of the mandibular symphysis with the incisor tooth gave that teeth do not move through bone but rather that the alveolar process t,he teeth change their positions. When teeth are moved labially, the alveolar ant1 when relapse occurs, the bone returns with rhe tooth. striking cvidenw is remo&Ic~l as procw+ follows

Litowitz further stated tha.t a disturbance of the root apex or (rown was followed by a return to the original position in almost every case, particnlady

if SUCK movemeut had been in the labial direction. In almost every case treated, however, there was much growth following orthodontic treatment. Litowitz pointed to the confusion of methods and the various interpretations that could be made by comparing individual cases in which different techniques had been used. I also became concerned about the multiplicity of factors to be known or understood in the behavior of the lower incisor as a key to treatment planning.20 I studied 150 orthodontically treated pat,ients and compared them with 100 nontreated cases. The behavior of the lower incisor was measured in fifty patients during treatment with ordinary cervical extraoral anchorage, in fifty patients treated by intermaxillary anchorage only, and in fifty patients in whom a combination of intermaxillary elastics and headgear had been employed. That study was conducted in an effort to provide some data for the planning of treatment and for the comparison of lower incisor movement during treatment. The observation period lasted almost 3 years, during the transition from the mixed to the permanent dentition, or when the patients were at an age at which children are commonly treated with cervical t,raction and at which the 2.7 mm. shortening of arch length was supposed to be occurring. The cephalometric technique employed called for dropping of the perpendicular line through pogonion to the mandibular plane and measurement of the lower incisor parallel to that line. In nontreated Class I cases, the lower incisor was located at an average of about 8 mm. posterior to that perpendicular line and moved about 1 mm. backward during this 219, to 3 year observation period (Fig. 3, A). In the Class II sample, this movement was only about one half that amount. Stretching this behavior over a long span would suggest that the lower incisor could possibly move as much as 3 to 4 mm. backward from the mental protuberance from the time it erupted until full growth was reached. However, a I to 2 mm. shift should be expect.ed often. A contrast in behavior of the lower incisor under the various types of treatment was noted. Although mandibular growth in the three treated samples was almost identical to that of the nontreat,ed samples, the behavior of the lower incisor differed radically. It was shown that the effects of the headgear contributed to an average lingual movement of almost 1.5 mm. during the time that the neck strap was worn (Fig. 3, B). The lower incisor tended to move lingually even more than normal. In Class II patients treated with intermaxillary elastics, the average lower incisor moved 3.0 mm. labially when measured to the symphysis (Fig. 3, C). On the average, therefore, treatment of Class II cases by headgear or by intermaxillary elastics alone eventually yielded, at retention of the incisor, an average of 4.5 mm. difference in forward or backward relation to the anterior border of the symphysis (Fig. 3, D). A position forward or backward can be related theoretically to arch length by adding the difference on both sides. Thus, a 1 mm. forffard or backward position of the lower incisor yields 2 mm. difference in arch length as measured from the molar. Naturally, with changes in arch form, this is not always true. Given no change in the arch form, however, a difference of 9 mm. between the

Keystone

trial

7 35

two groups is more than the width of an incisor. When a combination of headgear and elastics was worn, the average patient behaved almost exactly as one in the nnt.reated Class I sample, although about. 35 per cent of these cases wcrc extraction cases during treatment as were those in the intermaxillary tllastics sample. The technique employed involved measurement from a vertical line through pogonion perpendicular to the mandibular plane. Over short spans this method was considered reliable. From deductive reasoning, I came to treat many cases of mandibular alveo-

C.-r. -1.5

C EL. 3-3.0
Fig. 3. A, The normal tendency for movement of the lower (registered on the symphysis and the mandibular plane) during the transition in dentition. Notice a 0.7 mm. posterior 13, The on the incisor average behavior upper arch hut was double that of the incisor in 100 Class II not treated on the lower arch. usually experienced, now being

D DIFF 4.5
incisor relative in 100 normal movement of to the symphysix persons followed the lower incisor. the tractiou Iow~r

cases treated with cervical The distal movement of 1.5 mm. treated forward

C, The average behavior lary elastics. It will be maxillary traction.

in Class II nonextraction patients noted that the lower incisor moved

solely with intermaxil3 mm. during inter-

D, The difference seen between the Class II cases treated with intermaxillary elastics and those treated with cervical traction. Dotted area indicates that position of the lower incisor typically observed in patients treated with extraoral anchorage. Darkened area indicates position following intermaxillary elastic treatment. The mean difference, therefore, results in a 4.5 mm. difference in the position of the lower incisor relative to the symphysis and yields a 9 mm. arch length (4.5 x 2 = 9).

lar retrusion with iIlt,~~~ltlasilIiI~y dastics i~lom!, all I10ugl~ in sucli cas(ls t.li~~r~~ was a calcdatrd risk of forward movement of the incisors. The IOW~I incaisors were observed to bc moved forward c\rasticaIIy in thcst: patic>nts, thr nlor~mwnt of some cvcn approaching 1 full ccntimetcr. After a time, the alveolar ?KNK! seemed to re-form on the labial aspect of the tooth. Most cases treated !n this manner appeared to be holding well several years after orthodontic treatment, which would be contrary to the findings of Litowitz. Even though these teeth were upright or moved lingually during retention, it should be pointed out that a slight lingual drift M-as consistent with normal development and was therefore to be expected. Clinicians often fear a loss of bone or a clefting of tissue labial to the incisor, called stripping. Often stripping of the lower incisor has occurred even before the start of treatment. I have claimed that this is due to extreme tightness of the mentalis muscle and to a pressure ischemia. In other subjects it was consistent with a history of traumatic conditions. I should state immediately that the lower incisor should never be moved promiscuously, as it has been with many techniques. In many cases, however, particularly those in which patients have short brachyfacial patterns, the lower incisor is actually intruded as it is brought forward into a wider portion of the symphysis and therefore results in greater covering on the labial surface instead being shoved out of the bone. In the treatment of some patients with stripping, various clinicians recommended extraction to prevent forward movement of the lower incisors for fear of further bone loss. Other clinicians, however, have indicated that a forward movement is desirable in spite of stripping and prescribe long retention periods. In still other patients, it has been recommended that the lower incisors be retracted lest they move backward under tension of lip muscles if the arch were expanded. These arguments show t,hat a factor entirely independent from esthetic considerations has prevailed. In discussing behavior of the incisor clinically, two other observations should be mentioned. It will be noted that, without exception, a change in point B is directly related to the behavior of the lower incisor-so much so that a measure of the lower incisor is a measure of the change in point B. Furthermore, the thickness of the soft tissue labial to point B remains the same to a remarkable degree. A comparison shows that the thickness of tissue of the lower lip labial to point B is almost identical in all but a very few cases. A change in position of the lower incisor with its accompanying alveolus very definitely affects the soft-tissue contour of the sublabial area in either direction (forward or backward). 23 In this manner, an esthetically cffective chin can be either produced or reduced. FACTORS IN U)NG-RANGE PROGNOSIS. In a longitudinal study in which age groups were used in order to dovetail for the full age span, Bencll3 correlated changes of the hyoid bone relationship with the growth of the cervical vertebrae and the behavior of the denture profile. He showed that the hyoid bone continued to drop downward from the chin at ages later than those at which active stages of change are usually thought to be taking place. In addition, Bench

measured the position of the lower incisor and showed that these changes Jvert consistent with the alterations of the hyoid posture. He further showed a strong correlation with changes in the hyoid bone and growth of the cervical vert(bra(. In patients in whom growth of the cervical vertebrae was not occurring and in whom bra&ycephalic tendencies were seen, he was able t,o demonstrate marked forward growth of the chin. In other patients with severe dropping ol tl,c chin a,nd vertical cervical growth, there was an upward and backward alt(r;ltion in the outline of the symphysis as the lower incisor drifted posteriorl? According to all the foregoing basic and clinical studies, t.he natural form of the chin and the natural position of the teeth seem to be correlat.ed wit 11 deep underlying nebulous factors and tend to behave in a biologic spiral. Thx height of the individual, growth of the cervical vertebrae, the form of TII~~ mandible, the width of the face, the changes in the tongue and hyoid I)oII(~. and the individual characteristics of the lip and mouth were seen to play :t role in determining the relationship of t,he chin to point, B and the lower incisors. It was hypothesized that most crowdin, v of lower incisors was due I*) growth changes rather than to the force of third-molar eruption, as commnnlh claimed. In other words, the forces producin g the rollapse were coming froiil the anterior area to crowd the anterior teeth backward. The third molars l),came a buttress in this sense. In describing various characteristics of t,he mandible as a background t(11 the estimation of growth during orthodontic treatment, I included a consideration of all these factors. It will be recalled that I further described t(.rr different characteristics of the mandible to be considered in an estimation (sercise, O~C of which was t,he width of the symphysis. The natural f()rc(bs Irl growth and change have been shown to he of vital (aoncern to a full ~oml,~hension of orthodontic planning and secure? ultimate results. The secret ,it stability of point B or the lower alveolar bone is, t.hcrefort, a prime consider;ition. Thr key to this understanding is a knoxledge of the function of the JI,IISculat ure of the tongue and lips and the natural growth of the (ahin wit11 its alveolar boric. My clinical criterion for proper managt~mc~nt, of the lolv~r jr,&or thus follows.
CLISIChT, TOOTH ISTERPRETATION AXGIJLATION VERSUS SPATIAL RELATIOR. ~?%tiCCd~y ail i?W.?stigat(~r,&

of the lower incisor rrrthrl than its spatial relationship to the symphysis or profile. For the most part, the orth,odontist was trying to avoid the wovenlent of the ape3: of the incisor for fPar of root resorption or destruction of the alvcbolar bone or gingival I isSW. TtJ appeared to mc, however, that the angulation of the tooth was less ilnportant, than its t,rur anterior post,erior position. Tll~ question was : "To w11;1i sho~ltl it 1~ rc~latrd? We accepted, ant1 still clt~frnd, pogonion and l)oint ,\ as 111~. atilc~rior limits 01 bnsal lwttt: in 111~ tn;~tldilml;~r ant1 niasillary IWIIC~. rctspwt ivthlv. Thcrcforc>, I started measuring tliv I)ositiou of 111~ tip of tlrc. St,cisor to the lint A-pogonion for various B(ilSOIlS (Fir. 1, -1 2nd Ii 1. l+'or* tit,scriptive purposrs I called this thcl fl(~nllltY~ 1,lilTli.
were measuring

front 19.i.5 to 1955,

the angulation

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Fig. 4. The different inclinations of the A-pogonion plane as revealed in concave faces (A) and convex faces (B). This is the line thought to be most useful and critical in the clinical evaluation of the lower incisor.

We learned from the study of comparative anatomy that certain animals with diminished development of the maxilla have a lower incisor that is lingually inclined in such a position that it functions as a reciprocal member for both jaws. The tooth serves both jaws, not just the mandible or the maxilla alone. With this functional consideration in mind, the A-pogonion plane was later referred to as the reciprocal denture plane. In order to describe the labiolingual location of the lower incisor, I have employed the APO plane as the most useful clinical reference; today, after 15 years, I stand more firmly on that conviction than ever (Fig. 5). Why have I become more insistent concerning the value of the A-pogonion plane as a sensible reference for the lower incisor? What is the controversy? The chief argument advanced by the opponents of this approach is that pogonion is unstable because of secondary growth characteristics or the development of a button on the chin, which makes it unusable because of the addition of bone on the chin. Furthermore, many are concerned over the acceptance of narrow standards or a single ideal incisor relationship for the population as a whole. I also have sensed that clinicians fear any method which would ever suggest that the lower incisor should be moved forward. There are also those who believe that planning should be initiated not with the lower incisor but, with the molars. Finally, and hardest to comprehend, there is the need for realizing changes in point A or the chin with growth and treatment-a con-

sideration of dynamics rather than statics in interpretation of the lower incisol from the APO plane. For t,he purpose of constructive argument, I would pose three questions 511 defense of the use of the reciprocal denture plane reference for the lowN* incisor : (3 ) If point A changes with orthodontic treatment, why is it maintained as a basal point? (2) What true basal point at the anterior border of the marldible is most usable? (3) When a so-called button develops, what is it. lion does it form, and how frequently? In answer to the first question, point A, selected at the deepest point OR the contour of the bone between the anterior nasal spine and the alveolus, does change when the upper anterior teeth are moved. However, the nasal spine is definitely a process and the alveolar process is a process, and between thtJst& two lies the most basic part of the denture base at the anterior limit. It shoul(\ be mentioned that all bone in the anterior pnrt of the maxilla is thin and, zmninated. NO true heavy compact areas are available for reference in the same: sense as the symphysis. Since point A was originally defined, various clinicia,ns and investigators have sought a better reference point., but clinicians somehow have continued to go back to the basic point first described. Point A must 1~: selected carefully, but it has proved to be a vastly useful point to most of tll()sca who have understood its problems and variations.

Fig. 5. Range of rlontic eases. The t.o the A-pogonion plane. The striped tooth is +8 mm. to tion, or -3 to +3.

variation in the two standard deviations from the mean in l,OOU ortlrodarkened area in the center shows average or typical position relative plane, that is, 0.5 mm. forward and at 31.5 degrees to the A-pogonion tooth to the lingual, for practical interpretation, is -6 mm., and the dottetl the A-pogonion plane. Phnnin g is usually conlirrtrd to one standrtrd tlwin-

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D
Fig. 6. Patient S. L. Tracings of a girl from age 9 to age 15 depict a patient with severe brachyfacial type of growth similar to that seen in Fig, 2. Note the retraction of the lower incisor, which explains tbc severe button increase. Very little increase in facial height was seen in this brachyfacial patient, as the facial angle increased from 92 to 95 degrees and the Y axis closed 3 degrees during this treatment period. This behavior occurred despite intermaxillary elastics and every attempt the fact that the patient was treated only with was made to bring the lower arch forward.

I think that the answer to the second question has been covcrcd in my first article on the keystone triad. According to implant studies, there does not al)pear to be a better anterior basal landmark on the chin than pogonion, eith(Lr for serial work or for morphologic reference. The answer to the question about the frequency of a so-called button drb* veloping is still to be found. We do, however, have some information on how prominent chins develop and at what age. I have selected from my practice the serial records of three patients to illustrate the most extreme cases of developing promimlnt chins that, I havcl tv~~r witnessed. The first case (Figs. 6 and 7) demonstrates the retrusion of the denttlr(a that. occurred as a result of forward growth of the mandible and shift,ing of tl~c teeth in closing spaces. Extremely small teeth were present. I have seen this phenomrnon on numerous occasions when spaces were closed orthodontic4 iy because of congenitally absent teeth. A depression developed at, the chin in tllca area above the mental protuberance. This change has been observed frequently bp clinicians disciplined to extract in a very high percent,agr of cases. whttn a~ chorage was overly conserved. The second patient showed no suggestion of a bony prominence in the arca of the chin a,t the age of 7 or 8 years (Figs. 8 and 9). By the age of 17 :1r1 apparent button of several millimeters was seen in the lateral head film. On closc~ inspection, however, a double outline was not.ed. It was observed in the oblique film that the chin was characterized by an extremely large bony prornincncti at the Znteral aspect of the symphysis, namely, t,he mental tubercle. I would conjecture that this might account for the difficulty encountered by many clinicians in superimposing on the symphysis in some cases. The third patient underwent cleft, palate correction in three or four different stages over a period of almost IO years (Figs. 10 and 11). The lower arch m-as employed for anchorage, and vigorous traction led to its backward movemerri to bury first the lower first molar at one stage and then the lowttr secontl molars

L.R.. 9-l

18-3
A

/-v-f//

f7/-?/

I I \ I I I I I I I \

. . -. Y .* I \

Fig. 8. 8, Tracings of boy between the ages of 9 and 18 with marked vertical development in Fig. 1. Very little change was during growth and treatment, similar to the type shown seen in the facial angle, which usually increases in a normally growing face. Note that tb Y axis changed from 0 to -5 degrees during this interval. B, Comparison with B reveals that the great amount of growth appeared in the area of the outline of the chin; however, careful vieTYing suggested that this was lateral to the midline in the area of the mental tubercles. A severe clefting of the bony chin was found by palpation. Notice, finally, that both the lower incisor and the lower molar erupted extensivt>ly in this type of growth pattern (C and D).

Fig. 0. Before-

and after-treatment

roentgenograms

of patient

shown in Fig. 8.

at a later time, even after premolars had been extracted. It would be hard to imagine anything other than a shift of the denture on the base of the mandible, since the width of the symphysis did not thicken at all. An esthetically Lstrong chin was developed, with no bone increase in the symphysis. CLINICAL USE OF THE APO PLANE. Many clinicians have had trouble in using the APO plane for reference because of the dynamics of growth change. Before planning treatment, the clinician should have a knowledge of the variations in lower-incisor position that exist in nature. It was for this information that I measured the first 1,000 clinical orthodontic cases seen in my private praptice (Fig. 5). The findings revealed that the average lower incisor was 0.4 mm. ahead of this plane, or about 0.5 mm. for practical purposes. Its variation was t2.7 mm. in standard deviation, but again for practical use I have called it t2.5 mm. In general, convex faces displayed lower incisors that were forwalad on the chin, and in concave faces teeth were more retrusive from the symphysis because of the seeming adaptation of the incisor to the contour o-f the fact>. I related the lower incisor to different age groups in that same cross-sectional st,udy. It was seen that the convexity of the face diminished in the age groul.is, but the lower incisor remained within 1 nlnz. of the same relationship to the A-pogonion plane in all groups. I concluded t,hat the uprighting o-f t,he tooth nnit the rctlmaction of t,hc lower incisor were commensurate with a change in caonvexity and were part of the normal development, partic*nlarly when Itr~opinion was reinforced b.y other longitudinal studies. Therefore, a critical interpretation was gained by relating only the lowc~r tn incisor and forgetting about point B. The lower incisor studied in rehtion the, A-pogonion plcrne automatically consitlers the fncial pnttern of th.e ikldi-

16-I

Fig. 10. Tracings of patient P. I?., a girl, from age 5 to age 16. Clinically, this patient had a complete bilateral cleft lip and palate, and the facial angle changed from 85 to 91 degrees during the course of treatment and growth. An attempt was made to bring the maxillary segments forward during treatment and the mandibular teeth were employed for anchorage, shows the opening of the Y axis, but the teeth moved posteriorly (H). f:, A comparison TrI intermaxillary elastics. D, Tracings possibly produced by the prolonged use of Class suggest a movement of the lower incisor lingually to the planum alveolar of the symphysis. Note tho upward and backward movement of the lower first molar in spite of premolar extraction in the lower arch. It is difficult to imagine anything but alveolar and tooth rcsince no anteroposterior increase whatsoever traction producing the prominence of this chin, was present in the thickness of the symphysis.

vidual and also is useful at his state of growth ctnd de~~elopmen~t. Downs has referred to the arc of the face in a quite similar manner of measuring rclatiotlship to the lower incisor.

The final question for this essay is : HOW do we consider the needed changes incisor, alteration of point B, and the contour of the c~hin in orthoin the lower dontic treatment planning? Lets fare it. In spite of recognized biologic pitfalls, most of us are treating toward but not necessarily to some sort of average or standard. We all sock :I ccrta.in amount of security in plannin g because, as clinicians, we must obscrvc, study, and make decisions and cannot continually procrastinate or take uncaiculated chances. Therefore, we are concerned with some conceived goal, whcthcr we admit, it or not. We can ill afford to take chances repeatedly when we -Facc~ the responsibilities of finished stable results. As one student said to mc: I km)\\ I can move teeth but what I need is a target. The correct use of the Downs-Ricketts APO plane, Steiners NA lint, the> Steiner-Holdaway NB line, or the Tweed triangle rests upon the predicte!tl or estimated alteration of facial relationship result)ing from growth and trcatment changes. We have concentrated first on the behavior of the chin, the alveolus, and the lower incisor as a keystone unit, but in addition we have mentioned the reciprocit,y of this tooth to both jaws. Therefore, we must consitl(~r also t,he behavior of the maxilla, or point A, in order to plan effectively. I have stated that., in my opinion, the orthodontist should strive to play the lower incisor within one standard deviation of the APO plane as point A cxntl later. In other* pogonion will be located at the end of treatment and possibly words, the lower incisor should be related to the jaws that will exist at thtl ~1 of treatment.

0 I/

Fig. 12. 8, Tracing of patient with severe Class II, Division 1 malocclusion, slight retrognathic pattern, severe convexity of the face, and a lower incisor located lingually in relation to the A-pogonion plane. Correction of relationship of the lower incisor to the A-pogonion plane can be accomplished as shown in B, C, and D.

B, Correction
maxillary retracted,

by forward elastics or the with very little

movement monobloc. movement

of the lower incisor typically Notice that the upper incisor of point A.

seen with the is uprighted

use of interand slightly

C, Orthopedic retraction of the maxilla and point gear and vigorous intermaxillary elastic traction. over the lower incisor, with no movement of the to promote a more ideal relationship of the lower

A very frequently seen with forceful headIn this situation point A is brought back lower incisor relative to the chin, in order incisor to the A-pogonion plane.

D, The

change in position of the lower incisor by forward movement of the chin by growth. chin in the brachyfacial patient moves forward 2 and 7.

relative to A-pogonion plane as manifested The upper incisor is held in place while the in a manner similar to that seen in Figs.

Keystone

triad

i-47

Let us, therefore, enumerate the possibilities of corrcct,ion OC the lowcr :illcisor in relation to the A-pogonion plane. Let us suppose that, we have a patient, whose lower incisor is slightly lingual to the APO planca, which is more or less typical of many Class II malocclusion cases (Fig. I?, d ). We know that the lower incisor normally lies slightly ahead of this reference plane and that wc must treat the patient. We must realize that we can either move the tooth ot effect the end points of the reference line, that is, point A or pogonion. Again, what are the possibilities? First, we can move the lower incisor forward (Fig. 12, B). Sometimes this is a correct choice; at other times it is dangerous to stability. Therefore, we must be careful in recommending forward movement of the lower teeth. However, in profiles that are already straight we may have no choice but to do so. Second, we can effect an alteration of point A in two ways. We can, 1)~ toryuc control, retract the upper incisor and move point 9 backward by local alveolar alteration (Fig. 9, B). In addition, research has suggested that extraoral force reduces the entire hard palate or nasal floor by downward and backward tipping. Therefore, it is suggested that, the maxillary growth bchavic~r is altered (Fig. 8, C). Another means by which the APO plane may bc uprightcd is through forward growth of the chin at a faster rate than that at which point A moves forward (Fig. 8, D) . As has been shown in many cases of natural normal growth, such processes do occur, but they occur slowly. Forward growth of t,he chin, carrying with it the lower teeth, thereby corrects thtso teeth to the jaw rclationship. The final possibility, and probably the most common, is the combination of any two, three, or four of the foregoing. Given a case in u-hich the lowcl incisor is in a retroposed or retruded position, one could move it forward rapidly in the denture profile by a combination of backward movement of point, -4- local forward movement of the lower incisor, and forward growth of the chin, carrying with it the lower incisor. Such cases show marked improvompnl in a matter of a few weeks! However, in given cases of severe convexity and mandibu1a.r retrognathisnl. in which lower incisors need to be moved posteriorly, the problem is more (astreme a.nd it, takes longer to achieve the desired results. In such cases point A, or the maxilla, must be retracted over greater distances, which takes longer to achieve. Also, forward mandibular growth is needed. Longer periods are advoretcd t,o take advantage of growth in thpsc patients.
CLINICAL PROBLEMS

In the final analysis, the orthodontist is dealing mainly with occlusion (dontal or orthodontic) and profile relationships (orthopedic, skeletal, or structural). He works with the profile of the face but, perhaps more important, also with the profile of the denture. The profile of the face can be measured from the facial plane (N-PO), and the profile of the denture can be measured to the denture plane (A-PO). These lines or planes serve as references. Findings and standards serve as guides for the orthodontists discretion in correction. He

has his choice. .If he wants to correct convexity or concavity, hc attempts to line UP the anterior part of the maxilla toward the facial plant. Tf 11~ lv;ltits to correct the dental convexity, hc attempts to lint 111)the teeth to t,hc dcnturc plane. All faces arc not alike, however, and in many casts the wisdom of correcting skeletal convexity can be questioned. Likewise, the need for full dental correction to flat relationships is doubted when the lips are loose and flaccid, when the tongue is large and forward, when the nose is long, or when a fullness of the denture will be stable, where the mouth can be closed with no strain and is esthetically acceptable, and where the teeth are long-lasting in service to the patient. It is within these parameters that wc differ in value judgments. In actual practice, and in the prognosis of a trca,tment, I try t,o hold to the principle of accepting a range of variation within the confines of one standard deviation from the mean of the antcroposterior position of the lower incisor to the APO plane. This usually yields a range of approximately 5 mm. (-2 mm. to +3 mm.). In individual cases with aberrant muscle problems, these limits are extended sometimes to beyond one standard deviation (-2 to +5 mm.) without harmful effects when the teeth are stable, the lips are smooth in contour, and the mouth can be closed with relaxation.
SUMMARY

This is the second of two articles discussing the chin, point B, and the lower incisor. I have called this unit the keystone triad. Basic science and laboratory investigation have suggested t,hat deep biologic phenomena are responsible for chin form and denture behavior. Clinical studies of growth have been numerous and point to an average tendency toward natural retraction of the lower incisor with growth and maturation. The development of the chin may be considered in two aspects: (1) the forward thrust of the chin as it is carried forward by growth of the condyle and ramus of the mandible and (2) the local alteration in shape and contour of the symphysis by remodeling resorption in the area of point B and apposition on the lingual and inferior borders of the symphysis. Little or no apposition has been noted in the mental protuberance or pogonion area. The symphysis seems to be unaffected by orthodontic treatment, except for the adaptation of the planum alveolar and alveolar bone as the teeth are moved forward or backward and point B follows. The prevailing concept is t,hat masses of enveloping muscles move the denprognosis depends upon the clinicians ture as growth proceeds. Long-range sophistication in understanding these biologic forces. The difference in behavior of the incisor with various treatment procedures was reviewed. A 4.5 mm. mean difference in position of the lower incisors in relation to the symphysis was noted between extraoral anchorage and intermaxillary anchorage Class II correction in nonextraction cases. The position of the lower incisor in the jaws seems to bc more adequately defined by an anteroposterior measurement than by its axial inclination. Our criterion for clinical analysis is the incisors relationship to the A-pogonion

plane, measured in millimeters from the in&al tip and the angle of its long axis to the APO plane. Even when so-called buttons are present., the point A-pogonion relationship for the lower incisor still seems to be useful. For cont,emporary orthodontics, a knowledge of this unit (the keystoncl triad) is a key to treatment planning. Proper execution of this method depends upon conceived a.lteration of point A, because the lower incisor is referred tcr point A through this plane in a reciprocal relationship to both jaws that it must serve. The growth of the chin looms as a matter of equal concern. In or&t, to use point A and PO references, their behavior must be estimated during treatment. I have attempted to treat toward the mean (to.5 mm.), or to within on( standard deviation of the mean of the anteroposterior position of the lowet* incisor to the APO plane. In the broad sense of variation, this is -2 to -6 mm. If I have not achieved stability with this arrangement, then I am willing to accept the risks of relapse, because this range seems to be a sensible guide it, the light of contemporary esthetic and functional objectives. Mouth esthetics will almost always be complimentary to the face when t,hr* teeth are arranged in the manner suggested in this article. I believe that when esthetic harmony is achieved, the chances of functional equilibrium are vastl!, improved. The goals described here have been developed from studies of the normal and from more than 1,000 successfully treated malocclusion cases. This is the manner in which normal faces are arranged, and I simply try to ximulati> normal conditions by using the criterion proposed here.
REFERENCES

The Keystone Triad, AM. J. ORTHODONTICS 50: 244-264, 1964. 1. Ricketts, R. M.: 2. Brash, J. C.: The Growth of the Jaws and Palate, London, 1924, Dental Board of i&r United Kingdom. 3. Keith, Sir Arthur, and Campion, George G.: A Contribution to the Mechanism of Gromiil of the Human Face, D. Record 42: 61-88, 1926. 4. Humphrey, G. M.: On the Growth of the Jaws, Tr. Cambridge Phil. Sot. 11: 1866. 5. Hunter, John: The Natural History of Human Teeth, ed. 3, 1803. Post-natal Cranio-facial and Skeletal Development in the 6. Schour, I., and Massler, M.: illbino Rat and the Macacus Rhesus Monkey as Demonstrated hy Vital Injections of Alizarine Red S, Anat. Rec. 76: 94, 1940. 7. Moore, A. W.: Head Growth of the Macaque Monkey as Revealed by Vital Staining Embedding and Undecalcified Sectioning, Asl-. J. ORTHODONTICS 35: 654-671, 1949. Growth and Mandibular Deformities, SurgStlr> 8. Engel, M. B., and Brodie, A. G.: Condylar
22: 976-992, 1947.

9. Rarnat, B. G., and Engel, M. B.: A Serial Study of Xandibular Growth After of the Condylc in the Macaca Rhesus Monkey, Plaat. & Reconstruct. Surg. 7: 1951. 10. BjSrk, Arne: The Significance of Growth Changes in Facial Pattern ant1 Their ship to Changes in Occlusion, D. Record 71: 197, 1951. 11. I,ande, M. J.: Growth Behavior of the Human Bony Profile as Revealed by Serial metric Roentgenography, Angle Orthodontist 22: 78, 1952. Iwtl~ I Wing Gro\\ 17. Schaeffer, Aaron: Behavior of the Isis of IIurnan TIl&~r Orthodontist 19: 241-254, 1959. 13. Ricketts, R. M. : A Study of Changes in Tcrr~l~oroma~ldihular Relations Associated the lrc~atmrnt of Class II Malocclusion, JIM. .J. OIY~~~~D~~ST~CS 38: 91X-933,

Removal 364-380, lbrlatiorr(~phaloI II, ,111~l~~ \i-i I II

1952.

750

Ricketts

Am.

J. Orthodmtice October 1964

14. Bjijrk, Ame: Cranial Base Development, AX. J. ORTIU.ILIONTICS 41: 198.225, 1955. 15. BjSrk, Ame: Variations in the Growth Pattern of the Human Mandible: Longitudinal Radiographic Study by Implant Method, J. D. Res. 42: 400-411, 1963. 16. Brodie, A. G.: Late Growth in the Human Face, Angle Orthodontist 23: 146, 1953. 17. Litowitz, Robert: A Study of the Movements of Certain Teeth During and Following Orthodontic Treatment, Angle Orthodontist 28: 3-4, 1948. 18. Speidel, T. D., and Stoner, M. M.: Variation of Mandibular Incisor Axis in Adult Normal Occlusion, AM. J. ORTHODONTICS 6; ORAL SURG. 30: 536, 1944. 19. Brodie, A. G., Downs, W. B., Goldstein, A., and Myer, E.: A Cephalometric Appraisal of Orthodontic Results: a Preliminary Report, Angle Orthodontist 8: 261, 1938. 20. Ricketts, R. M.: The Influence of Orthodontic Treatment on Facial Growth and Dcvelopment, Angle Orthodontist 30: 103, 1960. 21. Ricketts, R. M.: Cephalometric Synthesis, AK J. ORTHODONTICS 46: 647-673, 1960. 22. Ricketts, R. M.: Cephalometric Analysis and Synthesis, Angle Orthodontist 31: 141-156, 1960. 23. Bench, Rue1 W.: Growth of the Cervical Vertebrae as Related to Tongue, Face, and Den ture Behavior, AM. J. ORTHODONTICS 49: 183-214, 1963.