Great smiles have harmony, symmetry, and a

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1 Frontl Cephlometris: Prtil Applitions, Prt 2 Dune Grummons, DDS, MSD 1 /Roert M. Riketts, DDS, MS 2 Aims: To (1) demonstrte the needs nd enefits of three-dimensionl dignosti nd tretment pplitions; (2) illustrte prtil linil pplitions of nteroposterior imges nd frontl nlysis; nd (3) enhne utiliztion of the Riketts nd Grummons frontl nlyses. Methods: Frontl nlysis methods nd pplitions re speified nd integrted into fil, smile, jw, nd olusl therpies. Asymmetry onditions must e differentilly dignosed nd effetively treted. Frontl nd relted imge nlysis nd tring steps re detiled. Results: Asymmetry of fil prts is the rule, rther thn the exeption. Dentl nd fil midlines, olusl plne, hin lotion, nd smile esthetis re primrily emphsized. Beutiful fil proportions nd smile hrmony n e developed despite initil fil dysmorphosis nd disproportions. Conlusions: Ptients view themselves from the frontl perspetive, so this rries priority when ssessing prolems. It is importnt to know the etiology of symmetry to ssist others with geneti ounseling. Fil hrmony nd smile euty re optiml when fil nd mxillry dentl midlines re ligned. The mxillry dentition width should e suffiiently wide to e in hrmony with the individul ptient fil morphology. The olusl plne should e level nd the hin entered s muh s possile. Best fil development nd proportionlity exist when the skeletl nd dentl omponents re optimized trnsversely nd re symmetri. World J Orthod 2004;5: Gret smiles hve hrmony, symmetry, nd rodness onsistent with the individul s fil form, morphology, nd lne. Smiles ommunite, re expressive, nd espeilly eutiful when full. People do not pereive nrrow rh smiles to e ppeling. A proportionl smile fills the lip emrsures nd elimintes lk tringles. We see this s euty in nture, nd suh symmetry is preferred y the puli. Orthodonti pilities hve inresed with improved 3-dimensionl knowledge of dentofil growth nd refined fil orthopedi proedures. The tehnology of tooth movement, fixed funtionl ppline effiienies, spe-gining methods, nd 1 Privte Prtie of Orthodontis, Spokne, Wshington, USA. 2 This WJO 2-prt rtile is the lst pulition involving Dr Riketts efore his deth. CORRESPONDENCE Dune Grummons DDS, MSD, 9425 N Nevd, Suite 100, Spokne, WA , USA. E-mil: dgrummons@ thereple.org or grummons@ol.om nonextrtion pprohes further enhne fil esthetis nd symmetry of the outome. Optiml trnsverse dimension should e developed for estheti nd funtionl dvntges. Fil, skeletl, nd dentl midlines should e entered, with plesing fil nd dentl proportionlity. 1,2 FACIAL ASYMMETRY Definitive tretment philosophy Mxillofil nd plsti surgeons, orthodontists, periodontists, nd/or restortive ollegues n mke signifint nd positive improvements for ptients with symmetri smiles. Benefiil results our struturlly, dentlly, emotionlly, nd esthetilly for those ptients hving dentofil dysplsi with ssoited mlolusion. Progressive liniins tody must ply hndle these symmetri nd dysfuntionl ptients in n interdisiplinry tem pproh. The frontl nlysis pplitions desried in this two-prt rtile 3 provide meningful, prtil, 99

2 Grummons/Riketts nd progressive informtion regrding symmetri nd often omplex tretment situtions. Ordinry ses my e routine, while unusul symmetry prolems hllenge the understnding nd expertise of the therpeuti tem. Tools ville to differentilly hndle suh disproportionl nd dysfuntionl ptients hve dvned signifintly. Better ptient mngement nd preditle tretment responses n our with therpy sed upon fundmentls of si siene, with linil sensiility in omprehensive nd definitive linil pprohes. Answers nd pprohes for these symmetri ptients emphsize fil orthopedi, orthodonti, restortive, orthognthi surgil, nd/or intrpsulr temporomndiulr joint (TMJ) mngement. All this stresses sensile nd progressive tretment, provided in ring mnner. 4 Knowledge is knowing fts; wisdom is knowing wht to do with them. Attrtiveness nd Helth Beuty or ttrtiveness relly is in the eye of the eholder; geneti omponent exists. Men whose photogrphs show fil symmetry re reported more likely to hve psyhologil prolems, diffiulties with onentrtion, nd lower intelligene thn those men judged to e filly symmetri. 5 Mles whose fes re viewed s high in symmetry re rted s more ttrtive, dominnt, sexy, nd helthy. Women whose photogrphs exhiit fil symmetry show poorer helth, emotionl instility, nd re less tive lifestyles, nd were less hppy nd less intelligent thn those whose photogrphs re filly symmetri. We hoose our friends, mtes, employees, nd role models sed in prt on their fil symmetry. Hving symmetri fe does not utomtilly imply superior trits, ut humn fil symmetry hs long een ritil ftor for evlution of ttrtiveness. There is ross-ulturl greement; fes judged s ttrtive in one soiety re judged to e eqully ttrtive in other soieties. 6,7 People with ttrtive fes reeive more positive retions thn those with unttrtive fes 8 nd re given positive ttriutes purely on the sis of fil euty. 9 Fil tions WORLD JOURNAL OF ORTHODONTICS Jw symmetry my e ovious osmetilly, nd often there is funtionl impirment, resulting in diffiulty with fil tions, expressions, hewing, iting, nd swllowing. The fe n pper symmetri during fil expression, with one side ppering more expressive. The soure of this symmetry is in fil motion nd struturl fil symmetry. 10 Struturl symmetry (neutrl expression) ounts for symmetry t pek expression for joy, nger, nd disgust. Expressions re produed more intensely on the left side of the fe, onsistent with the hypothesis tht the right ererl hemisphere is dominnt for the expression of fil emotion. EXAMINATION AND EVALUA ALUATION FOR ASYMMETRIES Exmine ptients from diretly in front while they re seted, nd level the interpupillry plne horizontl with the floor to look for fil symmetries. 11 Look for ny nt of the olusl plne, whih n e mesured from the inner nthus of the eye to the tip of the nine. It is linilly relevnt to oserve midline disrepnies nd importnt to reognize fil symmetries. Mlr hypoplsi is onfirmed y exmining the ptient from ove. Exmine nd note ny symmetry of the middle or lower third of the fe, while exmining the ptient in front. This my e filitted y pling mrks on the ptient s fe nd y nlyzing linil photogrph (Fig 1). Cliniins must do thorough dignosis t the onset nd oserve importnt lues during tretment regrding fil symmetries tht my e sutle or ltent. Photogrphi imges The following imges should e tken nd exmined: Full fe frontl nd ngulr three-qurter views t rest, smiling, nd nimted Right profile; oth profiles if symmetry is oserved Anterior teeth in olusion nd slightly prt Right nd left ul segments In ddition, lk nd white, omputer-reversed emossed imges of the ptient s frontl nd profile views n e useful for tretment plnning. Fmily photogrphs re lso helpful in estlishing the origin of the deformity nd prediting the postopertive norm. For imges to e of gretest vlue, hir should e retrted or removed from the fe. To onstrut photogrphi montge, profile photogrphs re ut nd omputer flipped; the piees re then rerrnged to give n impression of wht is likely to e hieved y fil orthopedis or surgery. 12 This method is empiril nd simplisti, ut it n e helpful (Fig 2). The montge hs limittions, the most ovious eing soft tissue representtion (Fig 3). Sine the montge does 100

3 VOLUME 5, NUMBER 2, 2004 Grummons/Riketts Fig 1 () Signifint hemimndiulr hyperplsti symmetry. () Fil ssessment is filitted with ette overly upon ptient photo. Fig 2 Interolusl ite registrtion Fig 3 Fil imge ropped t fil midline, then opied nd flipped; this with vertil nd horizontl referenes results in useful symmetri fil projetion imge. to revel dentl nd mxillomndiulr symmetries. Dentl floss is held vertilly s further visul guide. not urtely superimpose on the lterl skull imge or rdiogrph, omputerized simultions n do this. Cst nlysis Anlysis in the mndiulr dentl rh regrding teeth in the frontl dimension onerns mndiulr molr nd premolr width, dentl midlines, nd dentl to skeletl midline. The mxillry molrs reltive to the mndiulr molrs re mesured from the widest points on the ul ontours. Thus, the ondition nd position of the mndiulr rh eomes the sis, sine it is the most limiting ftor nd influenes mxillry rh emplement. Even routine st nlysis revels symmetry, espeilly in unilterl mlolusion (Fig 4). When one side of the mndiulr rh is tipped lingully more thn the opposite side 1 (Figs 5 to 7), the liniin should e prtiulrly oservnt. For unomplited ses, hinge rtiultor my e used. For omplex ses, espeilly those with fil symmetry nd rniofil prolems, feow reording nd/or ntomi rtiultor re essentil. Importnt mrkings on the sts, mde while diretly ompring on the ptient re: Fil midline in reltion to the dentl midline. This n e mrked on the ptient s gingive nd teeth with felt-tipped pen efore tking the impressions. The ink mrk will e trnsferred to the st. Bul segment mrkings to indite the entri reltionship on the sts, or tht of mximl interusption, ie, hitul olusion. Mximl interusption is the finl reltionship to whih the surgil jw movements re usully plnned. However, the preopertive differene etween entri reltion nd hitul olusion my e lrge, nd n give rise to misleding preditions of movement. 101

4 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS Fig 4 () Clss II, sudivision right mlolusion. () Mndiulr midline to right side due to mndiulr symmetri skeletl defiieny. () Left-side reltionship is Clss I dentl. Fig 5 () Mndiulr premolrs nd molrs re in lingully ompressed positions with exessive unilterl rowding. () With nrrow mxille, the mndiulr posterior teeth inline inwrd. Fig 6 (left) The mndiulr olusl rdiogrphi imge is prtiulrly useful to lote symmetri vritions, suh s dentl nd skeletl midlines, hin lotion, rh irregulrity, trnsverse ompenstions, nd lingul ngultions. Fig 7 (right) Dentl rh symmetry nd symmetri rh-length exess required 6 inisors in finl result to rete est olusion nd stle symmetri outome. Rdiogrphs nd digitl imging Understnding the importne of 3-dimensionl ntomy, Riketts introdued the frontl ephlometri rdiogrphi nlysis to id in dignosis A rniostti posteronterior (PA) view of the skull helps to revel fil one symmetry. However, rememer tht the hed my e tilted in the hedholder if the externl uditory meti re symmetri, giving distorted rdiogrphi imge (Fig 8). Cliniins routinely use 2-dimensionl imges, inluding pnorl rdiogrphs (Fig 9), fil nd introrl photogrphs, nd ephlometri trings. These 2- dimensionl views hve limittions; suh geometri, rottionl, nd hed positioning errors men tht the ntomy is not urtely represented. Some elements n e osured, nd lirting the views is prolem (Fig 10). True 3-dimensionl informtion inludes plster sts of the teeth, whih so often re not urtely merged or lirted with the other dignosti informtion. Use of n intertive 3-dimensionl digitl model of ptient s ntomy (Fig 11) would gretly improve the ility to determine different tretment options, monitor hnges over time, predit nd onsistently disply fine tretment results, nd mesure tretment outomes more urtely. 18 The Auspe method (Auspe Interntionl, Glendor, CA, USA) omines stndrd ephlometri rdiogrphs nd routine photogrphs to rete 3-dimensionl mtrix nd 3-dimensionl digitl ptient. 19 Three-dimensionl rdiogrphi imging of dentl strutures is eoming relity due to the dvent of one em omputer tomogrphy (CT) nd 3DX multi-imge miroomputer tomogrphy (NewTom, Aperio, Srsot, FL, USA). Whether viewing one, periodontl ligment spe, enmel, dentin, or pulp, the 3DX imges re etter thn n e generted y the medil CT mhine (Figs 12 to 14). The lulted skin dose for the 3DX sn is out 1/400 the medil CT sn huge redution. Mny ompnies re working on one em units le to imge the whole hed, 102

5 VOLUME 5, NUMBER 2, 2004 Grummons/Riketts d e f Fig 8 () Asymmetri mndiulr orders, whih n e due to true skeletl symmetry, or the hed my e tipped sidewys to fit into the ephlostt due to symmetri uditory metus/porion lotions. () Typil morphology of rml nd ondylr proess. () Morphologi dptive hnges on the symmetri short side. (d) Frontl imge revels mxillomndiulr symmetry. (e) Frontl symmetry tring. (f) Mndiulr orders re different; ompre the two sides. Fig 9 By tring the rml nd ondylr proesses from pnorl imge of mndile (), the two sides n e ompred for relile symmetry ssessment (). Fig 10 (left) Frontl xerordiogrph lerly depits ntomy. Fig 11 (right) Auspe 3-dimensionl frontl imge (Auspe Servies, Glendor, CA, USA). 103

6 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS Fig 12 () Frontl 3-dimensionl imge generted with NewTom 9000 (Aperio Servies, Srsot, FL, USA). () NewTom frontl imge, oronl setion. Fig 13 Rml proess nd zygomti rh symmetries re evident when right/left sides re ompred. Fig 14 () Hemimxillry nd hemimndiulr skeletl nd dentl symmetries ptured y NewTom dimensionl imging tehnologies. () Asymmetri mndiulr morphologi vritions. whih will ultimtely reple tody's ephlometri nd pnorl imges with one 3-dimensionl sn. Three-dimensionl, orreted TMJ tomogrphy revels TMJ degenertive joint disese (DJD) whih ommonly ours susequent to fil mro- or mirotrum, fil jw symmetry, omplex Clss II or Clss III skeletl/dentl mlreltionships, mjor dentl rehilittion, dentl rossite, deep-ite onditions, open ite (nterior) onditions, multiple missing posterior teeth, nd/or prfuntion tht is exessive or long-term. 4 MAXILLOMANDIBULAR ASYMMETRY Y FEATURES Mny fil symmetries re mild or so slowly progressive tht they re not linilly signifint. Other fil symmetries neessitte reevlution nd eome reognizle during dolesent growth. There re dentl, skeletl, nd funtionl symmetries; most re omintion. The simplest symmetry to tret is the dentl symmetry, if reognized nd treted in the mixed dentition stge. These symmetries n e due to premture loss of teeth, s when one primry nine is exfolited signifintly erlier thn its ontrlterl. Ankylosed teeth n lso led to dentl symmetry. A dentl symmetry reognized erly is routine to orret nd mnge; witing until the permnent dentition stge retes prolem more omplited nd ostly to overome. A dentl symmetry demonstrtes symmetri skeleton nd growth pttern. A funtionl symmetry involves symmetri jw nd dentition, while the ptient funtions in n symmetri wy. Untreted funtionl shifts usully result in skeletl symmetry. 20 A 104

7 VOLUME 5, NUMBER 2, 2004 skeletl symmetry is hrterized y symmetri dentition without funtionl shift. It n e present t irth, with growth susequently eing symmetri (nonprogressive symmetry), or my e progressive skeletl symmetry tht worsens with ontinued symmetri growth. Most individuls with symmetri fil growth hve ompenstions in the dentition. A prolem list should e generted to differentilly dignose nd tret fil symmetries. Asymmetry ssessment nd tretment strtegies When developing symmetry is reognized, the liniin should promptly tke the pproprite progress reords, reevlute the se, nd estlish speifi, differentil tretment strtegy with lterntives. Remove the orthodonti pplines t the right stge, if the ptient is younger, nd wit for growth to e ompleted. Tret with definitive jw surgery lter. Wth for ltent growth, espeilly if mndiulr hyperplsi is suspeted. Surgeons redily dignose symmetries when they evlute ptients fter growth is ompleted, ut suh dignosis is more diffiult in younger ptients euse the symmetry my not e s developed nor s reognizle. After ptients omplete their dolesent growth, prolems eome evident. Fil symmetry susequent to rml or mndiulr ody hemihypertrophy, ondylr proess elongtion, or plsi my lso our. Funtionl oservtions: Olusl nd trnsverse plne symmetry; pnorl nd ephlometri views Lower order superimpositions; on ephlogrm nd pnorl imges Distne etween first molrs nd the vertil rmus; pnorl view TMJ dysfuntion; mnul jw posturing or positioning splint Dentl sts; midlines oinident or not Struturl symmetry: Signs of developing symmetries Asymmetri nine ul overjet Asymmetri mndiulr nine positions within rh Unilterl posterior open ite Crossites tht develop Seond molr unerupted on symmetri side Tipping of the olusl plne Midlines no longer oinident Grummons/Riketts Body length nd rml height not symmetri, nor is the distne from the seond molr to the nterior order of the rmus Vertil symmetries oserved on lterl ephlometri imges, with lk of superimposition of the olusl plne nd lower orders of the mndile Frontl ephlometri imges revel hnging dentl nd skeletl midlines, hnging hin lotion, olusl plne nd gonil ngle hnges Asymmetry development: Rule out orl pthosis, suh s infrtemporl foss or ondylr tumor Chek for displed or degenertive dis with hnge in jw position or morphology Consider trum s etiology of symmetry Identify likely ptients for eventul orthognthi surgery Mintin mxillry midline oinident with the fe, nd the mndiulr midline resonly oinident with underlying mndiulr skeletl support Coordinte rhes to ompenste for the symmetry, or set up the rhes for eventul jw surgery Consider dentl ompenstions, ut not eyond the iologi limits; or deompenste the dentition for lter surgery Limit mxillry olusl plne tipping y using olusl splints nd/or trnspltl rh or qudhelix ppline for nhorge support By 8 yers of ge, 80% of dult hed size hs developed. Thus, the fil orthopedist nd orthodontist hve only 20% of remining growth to influene nd utilize to ugment the result othopedilly nd oluslly. At 13 yers of ge, 90% of hed size hs developed nd thus only 10% remins. The differene of this 20% t 8 yers nd 10% t 13 represents twie the pility for the orthodontist to utilize. The liniin lerly wnts to e treting these fil orthopedi prolems y 7, 8, or 9 yers of ge. 12,21 22 FRONTAL ANALYSIS SIMPLIFIED Tretment plnning often requires t lest two ptient evlutions with linil interviews, photogrphi nd video imging, dynmi nd nimted ssessments, ephlometry, nd dentl sts. At lest two prmeters should e used to onfirm ny prt of the symmetry nlysis. For instne, ompre the externl fil proportions with the mesurements of the hrd tissue ephlometry, or the rdiogrphi inisors ngultion mesurements, 105

8 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS d e f Fig 15 () Fil neuromotor defiit retes soft tissue symmetry. () Mndiulr developmentl symmetry. () Dentofil ompenstions with symmetry. (d) Trnsverse onstrition irregulrities. (e) Mndiulr symmetry with mxillry ompenstions. (f) Tring of sme imge. ompred with the study sts nd the ptient. Both liner nd ngulr mesurements re useful nd diretive, ut must e used rtionlly. Some ptients hve vlues t the extremes of the norml rnge (Fig 15). In suh ses, de-emphsize the mesurements in fvor of other methods of predition, suh s templte or sensile linil judgments. 3,23 Frontl (PA) rdiogrphs or digitl imges re reommended when the liniin is nlyzing nd providing funtionl jw orthopedis, orthognthi surgery, symmetry mehnis, TMJ disese mngement, nd/or treting jw growth disorders. As prt 1 of this rtile explined, two versions of the Riketts nd Grummons frontl nlyses re used worldwide. 3,24 The simplified version is the most prtil nd useful nlysis (Fig 16). It permits the liniin to redily oserve the midsgittl referene (MSR) line to ompre right nd left sides for disproportionl reltionships nd speifi lotion nd extent of fil symmetry. 25 The omplex frontl nlysis version is volumetri nd intended for omputerized proessing nd nlysis. 26,27 The MSR is the skeletl midline referene line tht ompres the right nd left sides of ptient s fe to detet skeletl nd dentl symmetry. It is onstruted from the ntomi hrist glli (Cg), vertilly through the nterior nsl spine (ANS), nd extended inferiorly eneth the hin (Me). From speifi skeletl nd dentl lndmrks (Figs 17 nd 18), perpendiulr lines n e drwn lterlly (trnsversely) to ssess reltionships etween skeletl nd dentl referenes. Oserving down the MSR line, the intersetion of the right nd left referenes n e esily ompred where they interset the MSR to see nd mesure symmetries. 2,3,24 For exmple, if the line from the right side ntegonion (Ag) is 3 mm ove the intersetion of the left Ag line, then the liniin knows tht these points re symmetri y 3 mm vertilly. There re severl speifi fil growth onepts tht the liniin should keep in mind when using the frontl nlyses: 1. Frontl growth. Using the ehvior of the norml in width s referene nd inditor. 2. Nsl width. The inside order of the nsl vity (N) inreses only 0.5 mm per yer until mturity. 3. Mxillry width. The inrese etween J points is 1 mm per yer. When the mesurement inreses y 6 mm in 24 months, the liniin n hope tht essentilly 4 mm of tht is orthopedi. 4. Mndiulr width. Width inreses 1.35 mm yer t Ag points until mturity. 106

9 VOLUME 5, NUMBER 2, 2004 Grummons/Riketts Mxillry width Olusl plne Fil midline upper dentl to fil Dentl midlines upper to lower Chin lotion Fig 16 () Grummons frontl nlysis. () Riketts frontl nlysis. () Frontl symmetry inditors. 1. Sgittl suture or longitudinl suture 2. Mxillry sinus 3. Oritl surfe (frontl one) 4. Superior oritl fissure 5. Superior order of petrosl prt 6. Formen rotundum 7. Zygomti rh 8. Mstoid proess 9. Oipitl ondyle 10. Nsl vity 11. Bsion 12. Mentl formen 13. Mentl spine 14. Angle of mndile 15. Anterior nsl spine 16. Nsl septum 17. Coronoid proess 18. Condylr hed or ondyle 19. Oritl plte or lmin ppyre (ethmoid one) 20. Suproritl mrgin 21. Artiulr tuerle 22. Styloid proess 23. Perpendiulr plte (ethmoid one) 24. Coronl suture 25. Crist glli 26. Frontl sinus 27. Frontozygomti suture 28. Odontoid proess Fig 17 Antomi renderings y Kunihiko Miyshit, DDS, in Contemporry Cephlometri Rdiogrphy (Tokyo: Quintessene, 1986). Reprinted with permission. 1. J point 2. Mlr (M) 3. Mxillre (Mx) 4. Mxillry first molr 5. Zygomti rh 6. Inferior order of the skull se 7. Seond molr 8. Lterl wll of the mxillry sinus 9. Olique line 10. Outer surfe of the upper prt of the mxillry sinus 11. Inferior order of the zygomti one 12. Mxillry sinus 13. Outer surfe of the mxillry tuerosity Fig 18 Antomi reltionships t lterl fil region. Line drwing nd legend y Kunihiko Miyshit, DDS, in Contemporry Cephlometri Rdiogrphy (Tokyo: Quintessene, 1986). Reprinted with permission. 107

10 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS Fig 19 () Mndiulr ody symmetry disguised y genioplsty proedure. () Chin entered despite rml nd ody regionl symmetry. () Chin reloted to symmetri position to disguise underlying mndiulr symmetry. 5. Mndiulr molr width. Mndiulr first permnent molrs hnge little in width one erupted. Any mesurle inreses or dereses in intermolr width is proly n indued hnge. Mxillry molrs tend to e stle ut re ltered y tongue onditions nd rething hnges. Usully width hnges re ssoited with tretment effets. 6. Mndiulr first premolr width. One the first premolrs reh the plne of olusion, little width hnge n e expeted. 7. Frontl growth nd ngulr prmeters. This follows tringulr form from the Ag points nd meets t the nsion region. The vertex of tringle for mxillry growth t J hs n pex level with the top of the orits. In the lterl perspetive, the mndiulr inisor position reeives priority; in the frontl, the mxillry inisor domintes tretment deisions. Mxillomndiulr nlysis strts with the nsl width, then proeeds to the mxille, prtiulrly the mxillry inisors to fil midline, then to the mxillry molrs, nd finlly to the mndiulr rh. 1,15,17,28,29 ASSESSMENT OF THE CHIN The hin is worthy of speil onsidertion. The need for hin surgery my e diffiult to predit euse mny proedures influene its position. The vertil hin height nd its prominene n e independently modified surgilly y redution, lterl movements, nd/or ugmenttion. If in dout, hin profile hnges should e exmined preopertively with lterl ephlometri nd frontl predition tring. If still in dout, edute the ptient tht postopertive orretion my e indited. Agin, it is importnt to ompre the dentl midlines to eh other nd with the midlines of the fe, nose, philtrum, nd the hin. Vrious mndiulr disrepnies n e resolved with rottion genioplsty fter the dentl reltionships hve een orreted (Fig 19). Derottion of n symmetri hin is esthetilly importnt. If the symmetry lso inludes tilt in the trnsverse olusl plne, this n e simultneously leveled with osteotomies of oth jws (imxillry proedure) or symmetri mndiulr dvnement with greter olusl gp on one side ompred to the other, so the lower jw orders n eome symmetri on oth sides. ESTHETIC CONCERNS OF MAXILLARY Y ASYMMETRY The mxillry midline is one of the most sensitive estheti onerns of ptients. Tretment deisions for symmetries often revolve round the position of the mxillry inisors reltive to the fil midline. Cliniins must determine wht level of symmetry tht orthodonti tretment lone n orret, nd ssess when nd if surgery is needed to orret the 108

11 VOLUME 5, NUMBER 2, 2004 deformity. Soft tissues n ompenste or mouflge the underlying skeletl symmetry nd mke the deision more hllenging. Aording to Kokih, 30 mxillry midline devition of 4 mm from the fil midline is needed for the generl dentist or lyperson to reognize the defet, while Grummons found tht ptients ould pereive mxillry dentl to fil midline vritions one they rehed only 2 mm. 2,12 The ptient n ultimtely deide whether to pursue surgery to orret the midline devition. Cnting or tilting of the mxillry nterior teeth n our when ttempting to move the mxillry midline. Therefore, odily movement nd teeth uprightness re importnt in midline orretion. TRANSVERSE AND OCCLUSAL PLANE Clinil exmintion nd study sts will indite whether orthodonti tretment or segmentl surgil orretion is required to oordinte the dentl rhes. Avoid tipping of molrs to ul exess when orthodontilly expnding the mxillry rh, sine molrs will relpse k to physiologi xil inlintion. Nongrowing ptients should undergo expndsion with surgil ssistne. Whenever there is surgil ltertion in the mxillry olusl plne, mndiulr osteotomy is typilly required to mth it, or t lest other movements with differentil posterior teeth eruption to the new postopertive olusl plne. Identify the positive ttriutes of ptient s smile nd protet those plesing hrteristis. The responsiility of the orthodontist inludes understnding growth nd development in dentoskeletl terms, nd lso soft tissue growth, mturtion, nd ging euse of individulized dynmis. The trnsverse nt of the mxillry olusl plne n e due to differentil dentl eruption (Fig 20). Disply of the nterior teeth n e modified orthodontilly, surgilly, or with osmeti periodontis. Skeletl symmetry of the mndile will result in ompenstory nt to the mxill, often requiring orthognthi orretion. The olique view of the smile revels hrteristis of the smile not otinle on the frontl view nd ertinly not otinle through ny ephlometri nlysis. The pltl plne my e nted nteriorly or posteriorly. In the most desirle orienttion, the olusl plne is onsonnt with the urvture of the lower lip on smile. Modifition of the olusl plne in predolesents n e omplished with growth modifition pplines suh s vertil ontrol funtionl pplines, the differentil Herst ppline, nd high-pull hedger. In lte dolesent nd dult ptients, surgil modifition of the mxillry olusl plne is often indited. Clokwise olusl plne rottion y mxillry or doule-jw surgery my hrmonize the positions of the mxillry inisl edges with the lips. 23 TURBOS Turos or onded resin dhesives to the olusl surfes help to estlish new nd improved mndiulr referene position. While these turos re in ple on primry molrs, the permnent first molrs n erupt severl millimeters more. Thus, more optiml vertil dimension with leveled nd symmetri funtionl olusl plne n e estlished. With this, the TMJs eome postured optimlly (deompressed), irwy nd hed posture re helped, nd the inisors n ler during funtion. Unilterl onding n e t different height thn the ontrlterl side, so tht symmetri posterior eruption n e enourged nd guided. This improves olusl plne symmetry. ASYMMETRIC PROTRACTION FACEMASK THERAPY The Grummons protrtion femsk (Gret Lkes Orthodontis, Tonwnd, NY, USA) is effetive in influening midfil hypoplsi nd mxillry Clss III defiieny without ompression on the hin nd unfvorle TMJ overloding. It filittes nterior movement of the mxillry skeletl omplex nd/or mxillry nd mndiulr teeth (funtionl jw orthopedis). One side n e protrted more thn the opposite side; hene symmetri forwrd nd inferior movements. The erlier the tretment, the more the fe dpts to the onept nd responds to the therpy. The lter the tretment, the more the tretment pln must dpt to the fe. 21 Movements n e greter on one side thn the other, whih lters the mxillry midline nd olusl plne towrd the tretment ojetives, with etter fil nd dentl symmetry. MAXILLARY Y TRANSVERSE APPLIANCE THERAPY Grummons/Riketts A ommon linil sitution is hild with n pprent unilterl rossite, ut when the mndile is positioned in entri reltion, the rossite is tully ilterl. Long-term, those individuls with unilterl posterior rossite with CR-CO shift hve een shown to hve higher inidene of temporomndiulr disorders. 4,31 Assessment of dentl rh 109

12 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS d g i e h j f Fig 20 Mxillry vertil symmetry. () Unilterl nonreduing TMJ menisus nd dvned osteorthrosis used mndiulr symmetry on the short side. () Olusl plne tipped s ompenstion to mndiulr symmetry. () Olusl plne nd smile mde level with symmetri fil omponents fter mxillry surgil, orthodonti, nd periodontl therpies. Frontl imging t (d) pretretment nd (e) posttretment, nd (f) frontl summry nlysis. The ptient hd Clss II mlolusion. (g) Asymmetri smile plne. (h) Short-side Clss II prolems. (i) Optimized olusl orretion. (j) Differentil posterior tooth eruptions to level the olusl plne. symmetry in the mixed dentition my e useful in exploring dysmorphogenesis. 32 Trnsverse intr-rh symmetries exeed AP symmetries in mgnitude nd prevlene. In ddition, individuls with ostrutive irwy onditions hve normlly high symmetry vlues. Dentl rh symmetry in hildren with lrge overjets is evident 30% of the time, with trnsverse symmetries of 2 mm or more t the mxillry first permnent molrs. A mxillry trnsverse hypoplsi results in nrrow posterior segment, with onstrited nd lingully ompensted lower urve of Wilson nd onstrited rh form. When one side of the mxillry omponent is more nrrow thn the other, symmetri lower ompenstion exists, refleting opposing rh irregulrities. The side of greter onstrition is the side of greter symmetry, with the mxillry rh serving s the templte for the mndiulr rh. 12,21 Often symmetri rowding in the mndiulr rh mirrors the symmetri skeletl prolem in the mxillry rh. As the mxillry rh differentilly expnds, the mndiulr rh n unlok nd eome trnsversely uprighted nd symmetrilly ligned. 33,34 As mndiulr dentl ompenstions re reversed, the mndiulr posterior ompressed rh is ully uprighted to normlize the urve of Wilson. Cre is 110

13 VOLUME 5, NUMBER 2, 2004 neessry to void expnsion eyond the trnsverse guidelines, s desried y Riketts 1 nd Grummons 2 for eh fil pttern (wider in rhyfil ptients, less wide in mesofil, nd tpered for dolihofil ptients). 3 The envelope of stility determines the trnsverse prmeter of orretion. Mndiulr lveolr widening nd fvorle lveolr orthopedi remodeling our when n expnsion ppline is used in the mndiulr rh while primry molrs/nines re present. Asymmetri mndiulr rh widening n e hieved y pling the expnsion srew t the orner of the rh, rther thn t the midline. 4 MANDIBULAR ARCH AS THE TARGET T ARCH The urrent logi is mndiulr rh mngement s the trget rh, with orthopedi emphsis (skeletl) to improve jw proportions, onditions, nd reltionships. Tretment plnning nd limittions lie with the restritions of the mndiulr rh. Angle s lssifition ws sed on the mxillry molrs. However, siene hs proven tht the gretest linil restritions lie in the mndiulr lveolus nd the mndiulr dentl rh, prtiulrly in the mndiulr trnsverse dimension nd its tretment. While the mxillry rh n e signifintly widened to orret trnsverse hypoplsi, the finl width determinnt is the mndiulr rh, with whih the mxillry rh must oordinte muh like fitting the lid on ox. The trnsverse dimension n e ltered (orthopedilly if erly; lter y distrtion osteogenesis nd orthognthi surgery) with stle results. Nrrow or trnsverse restritions of the mxille re ompensted y nrrower mndiulr posterior rhes or rossites. Often, one side is more nrrow thn the other, so mxillry nd mndiulr symmetri rh width nd lingul tooth ngultions re oserved. Differentil widening nd trnsverse uprighting during tretment must lso e dministered. Therefore, in plnning mndiulr molr positions, the hnges to e mde in the mxillry width re influened y the mndiulr posterior width guidelines. A lingully inlined mndiulr posterior rh form n e symmetri from one side to the other (see Figs 5 nd 6). MODE OF ACTION BONE PHYSIOLOGY Mndiulr dentolveolr expnsion is usully desired in response to mxillry orthopedi expnsion. Arh development while posterior primry molrs re still in ple produes signifint lveolr development, with growth nd fvorle remodeling. During the mixed dentition stges, development of the intermolr nd interpremolr widths (rther thn rh redution y extrtion therpy) is fvored to unlok mndiulr posture for optiml AP growth nd development. Tretment to develop the mxillry width permits the mndiulr rh to undergo trnsverse uprighting (lterl deompenstion) while uprighting the mndiulr posterior teeth trnsversely nd ligning roots underneth the rowns within the periodontl support. As the mxillry rh width inreses, more nterior mndiulr posturing nd plement n our. 2,4,35,36 As the mndiulr rh is widened nd reshped, the inisors n tully eome uprighted (rther thn flred) nd optimlly uprighted within the lveolr support. Signifint hnges in 3 dimensions n e mde in the midfe, prtiulrly if strted erly. If delyed, they must e surgilly ssisted or orreted lter, or the ptient is left with impirments nd ompromises. Otining skeletl ongruity is first priority; otherwise, ompenstions ound. On prtil sis, the gretest trnsverse skeletl tretment potentil lies in the mxillry rh. There exists the ility to: (1) ffet the pltl suture; (2) ffet other midfil sutures; (3) hnge funtion; nd (4) modify the mxillry lveolr proess. Untreted Clss II ses hve pil se defiienies tht n worsen over time. These n vry from right to left sides, whih results in lower fil third regionl symmetry. Nie orthopedi nd orthodonti hnges n preditly our with pplines tht require little ompline from ptients. With fil nd dentolveolr symmetry, estheti nd funtionl olusl enefits eome pprent in the results. The trnsverse perspetive deserves gret ppreition nd ttention with tody s 3- dimensionl tretments nd estheti emphsis. MANDIBULAR ASYMMETRY Grummons/Riketts The symmetri mndiulr short side hrteristilly hs Clss II skeletl nd dentl reltionships. The midline is typilly off-enter nd towrd the defiient side. The olusion is usully Clss II on the short side, with end-to-end ul segments s tretment limittion in the finl result. The skilled liniin might equilirte or provide oronoplsty, s needed, for n improved finl funtionl result. Mndiulr nines re often symmetri in the rh, nd the olusl plne is usully higher on the short side. There re fewer mstitory musle fiers with less ross-setionl re on the defiient side. 111

14 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS d e f Fig 21 () Clss II mndiulr skeletl defiieny. () Symmetri mxillry olusl plne. () Clss II, sudivision 1 mlolusion. (d) Asymmetri mndiulr sts onfirm symmetri Clss II reltionships. (e) Mndiulr posture optimized nd overorreted. (f) Mndiulr growth modifition (symmetri Herst therpy) yields symmetri nd optimized Clss I outome. Asymmetri mndiulr morphology in Clss III ses, unilterl ondylr remodeling, or TMJ degenertive hnges resulting in Clss II hnges on the ffeted side, nd trumti ses with Clss II mlolusion on the ffeted side with nterior open ite, n lso our. Asymmetri extrtions re often neessry to mouflge the underlying skeletl Clss II or III prolems. Surgil intervention for mxillomndiulr dysplsi is often indited nd enefiil. This results in more optiml mndiulr nd dentl proportions, stility, nd symmetry for est ptient enefits. Funtionl jw orthopedis or growth modifition should e pplied erly nd differentilly, with the short side dvning more thn the ontrlterl side. This results in optiml midline plement nd 3-dimensionl orretion. In funtionl jw orthopedi therpy, the stute nd pereptive liniin will differentilly distrt nd elongte the short side, so the mndiulr order, olusl plne, nd midlines eome more symmetri. Spe within the rhes (rh length) n e gined y midsgittl jw development orthopedis with lterl width inreses nd from differentil Herst therpy growth modifition enefits (Fig 21). 2,35 Mndiulr elongtion nd hyperplsi It is importnt to distinguish etween mndiulr symmetry due to unilterl elongtion nd hyperplsi, sine the esstion of growth is different. Elongtion involves ongoing growth of the mndile, with exessive length of the ody nd/or ondyle long norml growth lines resulting in more otuse gonil ngle. Horizontl elongtion results in superimposition of the olusl plnes nd the lower orders of the mndile, nd it n ffet the opposite side. With vertil elongtion, there need e no hnge in the lower midline nor devition to the opposite side. A unilterl open ite n our in ptients with elongtion in the ondylr proess. This my lso our in ptients treted exessively with Nne or fixed trnspltl rh with unilterl open ite euse ompenstory vertil eruption of the molrs nnot our due to prolonged molr nhorge. Elongtion tends to stop when growth stops. Horizontl nd vertil omponents n e omined. With hyperplsi, there is inresed ulk of one tht results in more ute gonil ngle. There is lso inresed distne etween the pies of the teeth nd the lower order of the mndile on one side. These ffet superimposition of the lower orders of the mndile on ephlogrms. 1,20 TMJ AND MASTICATOR TORY DYSFUNCTIONAL ISSUES It is ler tht mny ptients with dentofil deformities hve oexisting TMJ disorders. 1 Age, gender, dentl wer, unilterl posterior tooth ontt in the retruded position, nd posterior rossite orrelted with TMJ liking. Jw movement defletion nd 112

15 VOLUME 5, NUMBER 2, 2004 Grummons/Riketts symmetri olusl slide relte to temporomndiulr dysfuntion (TMD), mndiulr symmetry, nd trnsverse disrepny. In hildren, there n e reltionship etween TMD nd ertin olusl ftors, s well s etween TMD nd poor posture. In primry dentition group, the TMD signs of highest inidene were devition during opening (12.5%), liking (50%), nd posterior ondylr displement (75.5%). These three signs signifintly orrelte with olusl ftors suh s frontl open ite, devition of soft tissue, midline symmetry, deep overite, lrge overjet, rossite, nd ruxism. TMJ rtiulr surfe degenertive nd/or remodeling hnges our with resultnt mndiulr symmetry to vrying degrees, depending upon the pthosis. Funtionl shifts in older ptients should e treted with deprogrmming splints to hieve more reproduile mndiulr referene position, nd then e reevluted nd treted, using rtiulted sts to evlute the dentl nd skeletl positions. Imges should e retken in entri reltion or posturl position, so relile tretment deisions n e mde. An individul my pper symmetri in hitul olusion nd symmetri fter deprogrmming nd stiliztion orthoti therpy. Loss of vertil height of the mndiulr rmus my use hyperontts of posterior teeth on the ffeted side. Progressive loss of vertil rml height usully ours. A posterior open ite reltionship susequent to n inrese of mndiulr rmus length my indue loss of posterior teeth ontts on the ffeted side. If progressive, this my disple the mndile ontrlterlly with rossite or symmetri reltionship. The mehnism of TMJ rtiulr rtilge degenertion is primrily mirotrum (ie, prfuntion) with hroni joint overloding ommon in distress-relted repetitive ruxism. Mrotrum, used y diret low, n lso preipitte progressive hondromli or softening of rtiulr rtilge. Without fvorle remodeling, rekdown ours, with eventul symmetri ntomi prts (Figs 22 nd 23). When mndiulr growth is distured on the frtured ondylr side, mndiulr devition nd mxillry nting to the ffeted side results (Figs 23 to 25). Following the ompletion of growth, the symmetries n e orreted y omined orthodonti-surgil tretment. Fil symmetry is ommon susequent to erly ondylr frtures. 4,37 Mndiulr symmetry seondry to TMJ nd/or mndiulr dysfuntion When relpses re enountered, n understnding of the iology of the olusion is employed to explin AP Lterl Fig 22 Suondylr frture (AP nd lterl views) on growing ptient nd susequent progressive remodeling nd repir to essentilly norml onformtion. the resons for suh filures. The underlying uses need investigtion from iologi viewpoint. Homeostsis is the funtion of vrious prts nd orgns to mintin the whole system in equilirium. When this is distured, disese ensues. Beuse the TMJ is normlly suspended nd not prt of the ntigrvity system, it usully is not sujeted to hevy or prolonged mehnil loding. When norml loding pressure is present, it is of gliding nture nd is reltively intermittent. When lenhing of the jws or ontinuous fores due to musulr imlnes ompress this joint over long durtion, it eomes overloded nd distured. Displements of the ondyle nd dis our nd new symmetri equilirium must e ttined over time. A pthologi ompression in the joint ours; destrutive or unfvorle dptive hnges ensue. When the onditions eome hroni, joint spe is lost. The tissues, in n effort to reh homeostsis, redue nd modify nd new musulr sttus evolves. Advned resorption of the ondyle n e prt of the dptive proess. Soft tissue hnges preede hrd tissue remodeling; thus the dis remodels first (see Fig 20). 4,38 Adpttion is djustment to environmentl onditions due to lolized exessive remodeling; it results in lol irregulrities of the rtiulr joint tissues. Remodeling is fundmentl reuilding of dult soft nd hrd tissues; this mintins proportions nd reltionships etween form nd funtion within strutures throughout dult life. When growth is ompleted, remodeling generlly tkes over. Fvorle remodeling is physiology t work nd is termed dpttion. Arthrosis (degenertive joint disese, 113

16 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS d e f Fig 23 () Condylr proess frtured into the infrtemporl fosse. () Unfvorle medil ondylr proess displement. () Grdul formtion of ondylr proess 1 yer lter on dolesent ptient. (d) After 18 months of mndiulr unilterl TMJ distrtion ppline therpy. (e) The ondylr proess developed in 4 yers, nd fil symmetry ws restored. (f) Full rnge of TMJ motion estlished. Fig 24 () Suondylr frture resulting in posttrumti mndiulr symmetry; typil frontl tring (Riketts). () Asymmetri frontl tring (Grummons) of sme skull. osteorthrosis) is primrily noninflmmtory joint disese, hrterized y rek in the ontinuity of the rtiulr tissue with negtive dpttion or seondry hnges in the underlying tissues. Degenertive joint disese is disese of overloding, leding to rtiulr surfe hnges nd struturl symmetry. At the minimum, tody s orthodontist must e informed regrding ommon TMD with thorough understnding of pin mehnisms nd symmetri struturl onsequenes. In most ses of fil symmetries, the mndile is primrily ffeted nd ompenstory hnges our in the mxill. 39 The gol when treting mndiulr symmetries is to hieve oinident skeletl symmetry. Interept the prolem erly when there is funtionl symmetry in the mixed dentition y doing mxillry expnsion nd permit symmetri neutrl mndiulr positioning. In young people, funtionl shifts n led to dis derngements nd symmetri dpttions in the ondylr foss tht my e progressive. A longstnding funtionl shift retes n environment in the TMJ for future symmetri growth, even if it is not genetilly progrmmed. Condylr displement ours on the non-rossite side, where the mndile my e positioned nteriorly nd inferiorly. 30 Evidene of joint remodeling in ses with funtionl 114

17 VOLUME 5, NUMBER 2, 2004 Grummons/Riketts d e f Fig 25 Mndiulr order symmetry. () Pretretment mndiulr symmetry. () PA ephlogrm. () Frontl tring. (d) Posttretment. (e) Posttretment PA imge. (f) Frontl symmetry nd tringles. shifts exists in hildren with rossites, while more ondylr symmetry exists thn in dults with untreted rossites where the ondyles were symmetri. 31 A steeper ondylr eminene develops on the rossite side nd shllower eminene on the non-rossite side, inditing foss remodeling. 40 The shpe of the foss ffets the growth of the mndile. An ltertion in shpe of the ondylr pth indues hnges in growth of the mndile. This symmetri growth my ontinue even fter orretion of rossite, if the mount of remodeling ws signifint. SURGICAL CORRECTION OF FACIAL ASYMMETRIES Mndiulr elongtion involving exessive vertil growth often requires surgery euse of the unilterl open ite nd neessry hnges in the olusl plne. A mild mndiulr ody elongtion is esier to interept, with ompenstory expnsion of the mxill. Hyperplsis nd vertil elongtions usully require surgery, wheres ody elongtion hs the possiility of orthodonti orretion. Definitive evlution of fil morphology (dolihoephli fil type, divergent jws pttern; rhyephli fil type, onvergent jws pttern) nd hrd/soft tissue ssessment inludes ephlometris (lterl nd frontl), rtiulted sts, 3-dimensionl dt nd tretments, fil photogrphs (frontl, three-qurter, nd lterl views), smile dynmis, nd nimtion studies. Funtionl mtrix nd neuromusulr findings further influene deisions nd tretments. The 4-D funtionl sptil model inludes ssessment of the trnsverse, AP, vertil proportions, rnge of motion, nd time (mturtion). Frontl nd lterl ephlometri nlyses should interrelte to fil photogrphs; frontl nd lterl nimted smile oservtions eome interrelted to informtion out the funtionl mtrix (rething, swllowing, musles, rnge of motion, posture, nd hits). At the finish of therpy, liniins must lote the dentition in the mxillomndiulr stti neutrl zone in ll dimensions (Fig 26). MANDIBULAR DISTRACTION OSTEOGENESIS For nongrowing ptients, mndiulr midline expnsion for greter skeletl nd dentl rh width improvements is eing omplished suessfully with mndiulr surgillyssisted distrtion osteogenesis (DO).The distne from the molrs to referene line of J-Ag t the level of the frontl olusl plne n e modified in this wy. 41,42 115

18 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS d e f g h i j k l 116

19 VOLUME 5, NUMBER 2, 2004 Grummons/Riketts m n o p q r s t Fig 26 ( to l fing pge) Steps in nlyzing nd tretment plnning mxillomndiulr symmetry from the frontl perspetive. () Mxillomndiulr skeletl symmetry with dentl ompenstions; seline frontl symmetry nlysis to estlish frontl visulized tretment ojetives (FVTO) steps. () Upper fil third lndmrks. () Asymmetri mxillry omponent dded to frontl tring. (d) The mxillry omponent is moved to symmetri midline nd olusl plne plement. (e) Overly of symmetri nd symmetri mxillry omponents. (f) Mndiulr symmetri omponent. (g) Mndiulr omponent reloted to symmetri midline plement. (h) Overly of mndiulr symmetri nd symmetri omponents. (i) Mxillry jw leveled, mndiulr jw moved symmetrilly forwrd nd to midline, followed y mndiulr posterior teeth erupted to leveled olusl plne. (j) Mxillry nd mndiulr omponents in symmetri plement s prt of frontl visulized tretment gols (FVTG). (k) Asymmetri hin lotion nd mxillry jw still misligned. (l) Symmetri hin plement s mouflge nd mxillry omponent remins symmetri. (m) Mxillry omponent nd hin mde symmetri. (n) Both jws remin symmetri; hin reloted to pper symmetri t hin midline. (o) Both jws moved to level olusl plne nd to orret midlines nd hin. (p) FVTG revels mxillomndiulr symmetry with hin lotion undeided (my e eptle or my need mentoplsty). (q) Mxillry jw leveled while mndiulr jw nd hin remin symmetri. (r) Mndiulr jw ody remins symmetri though hin is moved to symmetri midline position, whih disguises the underlying mxillomndiulr issues. (s) Both jws nd hin optimlly symmetri. (t) Superimpositions of mxillomndiulr nd hin tretment hnges. 117

20 Grummons/Riketts WORLD JOURNAL OF ORTHODONTICS Fig 27 (,) Crnioervil normlities t tls-xis (C-1, C-2) level evident on PA ephlogrms tken with the mouth wide open. () Odontoid proess well visulized (NewTom). CRANIOCERVICAL ISSUES The reltionships of the ervil vertere n lert the liniin to possile normlities regrding hed rottion or side-end in the PA rdiogrph with the mouth wide open. 4,36 Cervil (C2) nd odontoid proess regions re visile nd le to e evluted in this view (Fig 27). SUMMARY The orthodontist must pply the optiml tretment pproh for the speifi needs nd unique symmetri irumstnes of eh individul ptient, rther thn expeting nd/or requiring tht eh ptient fit liniin-preferred tretment pproh. Applying suh philosophy nd elief system insures tht liniins will e more exting, nd the ptient will enefit immesurly from symmetri results with speifi 3-dimensionl lifelong dvntges. Orthodontists re well-trined regrding sgittl, AP, nd vertil disrepnies, ut urrently less emphsis is pled on the trnsverse nd frontl dimensions. Ptients view themselves nd shpe self-pereptions from the frontl perspetive, so this view must hve greter signifine. Erly orthopedi intervention nd nonextrtion pprohes provide for est funtionl olusion, symmetri nd proportionl struturl stility, with finl symmetri, estheti smile nd optimized lip support. Mn s mind, one strethed y new ides, n never remin the sme. ACKNOWLEDGMENTS The fmilies of these uthors remin onsistently supportive. The editoril guidne from Dr Thoms Grer is exeptionl. Teri Anyn nd Cri Whrton of my ple stff lso deserve signifint knowledgment nd grtitude. REFERENCES 1. Riketts RM. Provotions nd Pereptions in Crnio-Fil Orthopedis (ed 1). Denver: Roky Mountin Orthodontis, Grummons D. Nonextrtion emphsis: Spe-gining effiienies, prts 1 nd 2. World J Orthod 2001;3:21 32, Riketts RM. Grummons, D. Frontl ephlometris: Prtil pplitions, prt 1. World J Orthod 2003;4: Grummons DC. Orthodontis for the TMJ/TMD Ptient. Sottsdle: Wright nd Co, Thornhill R, Gngestd SW. Humn fil euty. Humn Nture 1993;4: Cunninghm MR. Mesuring the physil in physil ttrtiveness: Qusi-experiments on the soioiology of femle fil euty. J Personlity So Psyh 1986;50: Perrett DI, My KA, Yoshikw S. Fil shpe nd judgments of femle ttrtiveness. Nture 1994;368: Sigll H, Lndy D. Rditing euty: The effets of hving physilly ttrtive prtner on person pereption. J Personlity So Psyh 1973;28: Dion K, Bersheid E, Wlster E. Wht is eutiful is good. J Personlity So Psyh 1972;24: Liu Y, Wever RL, Shmidt K, Sern N, Cohn J. Teh Report CMU-RI-TR-01-23, Rootis Institute, Crnegie Mellon University, August Zhrisson B. Integrting estheti dentistry nd spe losure in ptients with missing mxillry lterl inisors. J Clin Orthod 2001;35: Grummons DC. Trnsverse dimension nonextrtion emphsis. In: Bolender CJ, Bounour GH, Brt Y (eds). Extrtion versus Nonextrtion. Pris: SID, 1995: Riketts RM. A foundtion for ephlometri ommunition. Am J Orthod 1960;41: Riketts RM. Cephlometri nlysis nd synthesis. Angle Orthod 1961;31: Riketts RM. The Keystone trid I: Antomy, phylogenetis, nd linil referenes. Am J Orthod 1964;50: Riketts RM. Stepping stones of progress. Pro Found Orthod Res 1975; Riketts RM. Understnding the VTO: Its Constrution nd Mehnis for Exeution (vol I nd II) Sottsdle, Arizon: Amerin Institute of Bioprogressive Edution, Hther D. Mxillofil imging. In: NNeill C (ed). Siene nd Prtie of Olusion. Chigo: Quintessene, 1997: