Jefferson Cephalometric Analysis--Face and Health Focused

Transcription

1 Jefferson Cephalometric Analysis--Face and Health Focused Google: Jefferson Ceph Analysis Video Instruction for video instruction. Note: video instruction teaches how to find Center O. Center O is now replaced with Center T, and this instruction will instruct you to find Center T. Jefferson Cephalometric Analysis is a Face and Health focused analysis. Treating to the face based on this analysis will enhance facial beauty, and alleviate multitude of medical issues, including but not limited to TMD, upper airway obstruction, sleep apnea, etc. First and foremost, credit must be given to Dr. Vikan Sassouni who developed the Sassouni Archial Analysis. Jefferson Cephalometric Analysis is a much simplified, abbreviated and modified version of Sassouni Archial Analysis. The jewel of the Sassouni Archial Analysis are the Anterior Arc and the Vertical Arcs. All the other arcs and measurements in the Sassouni Analysis appear to be extraneous and significantly less important. Jefferson Cephalometric Analysis is based on just the anterior arc and the vertical arcs. Furthermore, replacing Parallel Plane with Jefferson s Cranial Plane, and replacing Center O with Jefferson s Center T significantly simplifies instructions on how to do this analysis. Jefferson Analysis Tracing Technique Armamentarium In order to do the Jefferson Cephalometric Analysis, the following armamentarium will be required: 1. A compass that will draw a minimal radius of 8½ inches (22 centimeters). See Figure One short millimeter ruler and one 12 inch ruler or a C-Thru ruler. See Figure 2. Fig 1 showing two types of compass which can draw a radius 81/2 inches Fig. 2 shows rulers required, a mm (22 centimeters). Either one of these types of compass is necessary to do ruler, and 12 inch or C-Thru ruler. the Jefferson Ceph Analysis.

2 Landmarks Most of the landmarks for this analysis are the same as Steiner analysis. However, there are six additional landmarks. See Figure 3. Fig. 3 shows that the Jefferson Analysis uses most of the same anatomic landmarks as Steiner. However, Jefferson Analysis uses 6 additional landmarks. The six additional landmarks are: 1. Clivus 2. Roof of Orbit 3. Basisphenoid 4. Greater Wing of Sphenoid 5. Ethmoid Cribiform Plate 6. Lateral Wall of Orbit

3 Sassouni Points Once all the anatomic landmarks are drawn, Sassouni points should be plotted. Refer to Figure 4. Fig. 4 illustrates Sassouni points necessary to plot the four major planes of the face. The points shown in Figure 4 are defined as: 1. SOr (supraorbitale): Most anterior point of the intersection of the shadow of roof of orbit and its lateral contour. 2. SI (sella inferior): Lower-most point on the internal contour of the sella tursica. 3. ANS (anterior nasal spine): Anterior tip of premaxilla on midsagittal plane. 4. PNS (posterior nasal spine): Most posterior point on the contour of the maxillary bony plate. 5. C.G. (constructed gonion): The intersection of two lines, of which one line is drawn from articulare and runs tangent to the posterior border of ramus, and the other line is drawn from menton and runs tangent to the lower border of corpus. This point is usually a few millimeters distal and inferior to actual gonion. 6 Oc (5 Occlusal): The mid-occlusal point of the upper and lower second bicuspids or the mid-occlusal point of the upper and lower second deciduous molars. 7. Oc (6 Occlusal): The mid-occlusal point of the upper and lower 6 year molars.

4 8. N (Nasion): The most posterior point on the curve of the juncture of the frontal and nasal bones. 9. P (Pogonion): The anterior most point of the profile of the bony chin. 10. M (Menton): The lowest point on the inferior border of the outline of the symphysis of the mandible. Major Planes of the Face Once the Sassouni points are determined, the four major planes of the face should be established. Each of the four planes is connected by two points. Refer to Figure 5. Fig. 5, showing points where planes are derived. In the Jefferson Cephalometric Analysis, Sassouni s parallel plane will be replaced by the cranial plane. The cranial plane is almost identical to Sassouni s parallel plane but is much

5 easier to extrapolate and trace. As stated earlier, this is one of the modifications in the Jefferson analysis from that of Sassouni analysis. Figure 5 shows how the four major planes are derived. The four planes crucial to this analysis are: 1. Cranial plane: Line drawn from SOr to SI and extended posteriorly. 2. Palatal plane: Line drawn from ANS to PNS and extended posteriorly. 3. Functional Occlusal plane: Line drawn from the mid-occlusal point of the second bicuspids (or the second deciduous molars) to the mid-occlusal point of the six year molar. If these teeth are not fully erupted and are not in occlusal contact, then bisect the distance. Do not bisect upper and lower incisors to determine this plane which is how "occlusal" plane is derived. 4. Mandibular plane: Line drawn from menton running tangent to the lower border of corpus and passing through constructed gonion. Again, this plane goes through constructed gonion and not "actual" gonion. Figure 6 identifies and labels the four major planes of the face in this analysis. Fig. 6 shows the 4 major planes labeled.

6 Jefferson Center T Jefferson Cephalometric Analysis uses Center T instead of Sassouni s Center O. This is the second modification from the Sassouni Analysis. Locating Center T is easier to explain and extrapolate than Center O. However, Center T and Center O are one and the same. When the four major planes are established, draw and extend these four lines posteriorly. The appearance of these planes should be such that they converge toward an area where the four major planes are most concentrated, and then they begin to diverge. Refer to Figure 7. Fig. 7 showing area where the 4 major planes of the face converge. Locating Center T is much easier than locating Center O. This is the second modification. To find Center T, locate any superior most and inferior most planes where there are two or more planes intersecting. Refer to Figure 8. Note, the superior planes only has one intersecting planes (designated as second intersect line) while the inferior planes have two intersecting planes (designated as first intersect line and third intersect line. These intersecting

7 planes are labeled first, second, and third intersect line. Intersect 1 is closest to the face, and the other intersects are numbered as they move towards the back of the head. Fig. 8 shows superior most and inferior most planes where there are two or more planes intersecting. They are labeled first, second and third intersect line. Now refer to Figure 9. Draw a vertical line perpendicular to floor from the superior intersect line (labeled as second intersect line in Fig. 9) vertically down until it hits the most inferior plane. Next draw a vertical line perpendicular to the floor from the inferior intersect lines (labeled as first and third intersect lines in Fig. 9) until it hits the most superior plane. Fig. 9 shows vertical lines drawn from intersect one, two, and three.

8 Refer to Figure 10. Out of the 3 vertical lines, locate the shortest vertical line. It can be easily seen that the shortest vertical line is the one that was dropped inferiorly from the second intersect line. In Figure 10, the shortest vertical line is labeled. Fig. 10 showing three vertical lines, the arrow pointing to the shortest vertical line. Refer to Figure 11. Now take a millimeter ruler and measure the shortest vertical line and find the mid-point. Fig. 11 shows how to locate the mid-point of the shortest vertical line using a millimeter ruler. The mid- point of the shortest vertical line is Center T.

9 Refer to Figure 12. Once the mid-point of the shortest vertical line is located, a horizontal line is drawn across it. Where the shortest vertical line and the horizontal line intersect is Center T. Center T is a crucial landmark in doing the Jefferson Cephalometric Analysis. Fig. 12 shows horizontal line going through mid-point of the shortest vertical line is the important landmark known as Center T. Anterior Arc The Anterior Arc is a reference arc in front of the facial bones. Its significance is that it helps to determine the esthetic and physiologic anterior-posterior position of the maxilla and the mandible. To establish the anterior arc, place the metal point of the compass on Center T and place the pencil point on boney nasion (N). Refer to Figure 13. Fig. 13 shows the placement of the compass to establish anterior arc.

10 Once the compass points are correctly placed in their location, then draw an arc from just above nasion down past the soft tissue of the chin. Refer to Figure 14. This arc in front of the facial bones is called Anterior Arc. Fig. 14 shows anterior arc going through nasion (N) and being drawn just above nasion and past menton. Sassouni Vertical Arcs There are two short vertical arcs located around the menton area. The upper short vertical arc is the Age 4 vertical arc, and the lower short vertical arc is the age 18 vertical arc. To establish the vertical arcs, take the metal point of the compass and place it on anterior nasal spine (ANS) and place the pencil point on supraorbitale (SOr). Refer to Figure 15. Then rotate the compass down toward the menton area and strike a small arc. This will be the age 4 vertical arc. Fig. 15 shows how to establish age 4 vertical arc based on ANS and SOr.

11 To establish the age 18 vertical arc, place a millimeter ruler from the age 4 vertical arc and measure exactly 10 mm down. Refer to Figure 16. Then strike a short vertical arc that is exactly 10 mm inferior and parallel to the age 4 vertical arc. Fig. 16 shows how to establish Age 18 vertical arc which is 10 mm inferior to the Age 4 vertical arc. Three Reference Arcs The completed tracing is shown in Figure 17. The three arcs thus extrapolated are: 1. Anterior Arc 2. Age 4 Vertical Arc 3. Age 18 and over Vertical Arc Fig. 17 Complete tracing of Jefferson Cephalometric Analysis.

12 Interpretation of Jefferson Cephalometric Analysis To interpret abnormalities, several ceph tracings of patients at age 4, age 12, and age 21, showing normal or ideal will be presented. Figure 18 shows an ideal cephalometric tracing for all adult patients 18 years old and older. The beauty and simplicity of the Jefferson Cephalometric analysis is that it is universal, regardless of race, age, or sex. Fig. 18, ceph tracing of 21 yo showing ideal. Adults are anyone 18 year old or older. In adults, 18 years old and older, ideal position of the maxilla and the mandible is when: 1. Anterior Nasal Spine (ANS) is within 2 mm of the Anterior Arc. 2. Pogonion (P) is within 2 mm of the Anterior Arc. 3. Menton (M) is within 2 mm of the Age 18 Vertical Arc. It must be emphasized again that the Jefferson Cephalometric Analysis should be used as an adjunct to the treating doctors ultimate and final diagnoses. This analysis provides a road map as to what direction the maxilla and the mandible should be repositioned to achieve ideal facial esthetics, healthy TM joints, more efficient upper airways, and other physiologic health. However, in some adults with facial disharmony, many years of chronic abnormal facial growth and occlusal wear can cause permanent skeletal deformations and wear. In some of these patients, it may not be possible to treat them to the ideal position based on the Jefferson Cephalometric analysis. In such cases, the maxilla and the mandible should only be moved as

13 far as their physiologic tolerance will allow. To move these skeletal structures beyond their physiologic limitation may cause more harm than good. Figure 19 shows an ideal cephalometric tracing of a 4 year old patient. Again, it does not matter if the patient is male or female, and applies to all races. Fig. 19 ceph tracing of a 4 yo patient showing ideal. In all children at age 4 years old, ideal position of the maxilla and the mandible is when: 1. ANS is within 2 mm of the Anterior Arc. 2. P is within 2 mm of the Anterior Arc. 3. M is within 2 mm of the Age 4 Vertical Arc. Figure 20 shows an ideal cephalometric tracing of a 12 year old patient. Again, it does not matter whether the child is male or female, or race.

14 Fig. 20, ceph tracing of a 12 yo patient showing ideal Vertical and A-P position. In all children 12 years old, ideal position of the maxilla and the mandible is when: 1. ANS is within 2 mm of the Anterior Arc. 2. P is within 2 mm of the Anterior Arc. 3. M is within 2 mm of the Age 12 Vertical Arc. The antero-posterior position of the maxilla and the mandible should be within 2 mm of the Anterior Arc, no matter what the age, sex, or race of the patient. However, the lower facial height varies according to age. From age 4 until age 18, the mandible grows vertically down at the rate of ¾ mm (.75 mm) per year. Using this formula, the ideal vertical height of every patients can be derived to the millimeter. Hence, the patient in Figure 20 is 12 years old. From age 4 to 12 is 8 years of growth. Therefore, the mandible grew vertically downward.75 mm for 8 years, or a total of 6 mm. This is how the age 12 vertical height was calculated. To calculate correct vertical for a 12 year old child: 12 4 = 8 x.75 = 6 millimeters

15 It is important to understand that the Vertical Arc Assessment is universal. This assessment applies to all race and sex. Additionally, the Lower Facial Height assessment is diagnosed as Normal, Long, or Short. It is not diagnosed as Normal, Open Bite, or Deep Bite. Open Bite and Deep Bite are dental assessments. Long and Short are skeletal assessments which is what the Sassouni Vertical assessment assesses. How to calculate age appropriate arc was fully explained. However, to make it simple, the following ages and vertical from Age 4 arc to Age 18 are calculated for you. Use the numbers according to age to determine where to strike the small arc inferior to the Age 4 Vertical arc. 4 yo=0mm, 5 yo=.75mm, 6 yo=1.50mm, 7 yo=2.25mm, 8 yo=3.00mm, 9yo=3.75mm, 10yo=4.50mm, 11yo=5.25mm, 12yo=6.00mm, 13yo=6.75mm, 14yo=7.50mm, 15yo=8.25mm, 16yo=9.00mm, 17yo=9.75mm, 18yo=10.50mm. Jefferson Skeletal Classification of Malposition From the Jefferson Cephalomemtric Analysis, the Jefferson Skeletal Classification of Malpositon was developed. This skeletal classification is fast, easy, and accurate. Figure 21 illustrates how the Skeletal Diagram represents the different parts of the Jefferson Cephalometric Analysis. Fig. 21 shows the Skeletal Diagram representing the different parts of the ceph analysis. In Figure 21, the left illustration is the ceph tracing of an adult patient, and the right illustration is the Jefferson Skeletal diagram. In the Skeletal Diagram, A represents maxilla, and B represents Mandible. To remember this, please note that in cephalometric tracings, A- point is located in the maxilla, and B-point is located in the mandible. In the diagram, the tip of the arrow of A is anterior nasal spine (ANS), and the tip of the arrow of B is pogonion (P). Both the cephalometric tracing and the skeletal diagram, ANS and P are touching the Anterior Arc. Therefore, both A (maxilla) and B (mandible) are in proper A-P position. The skeletal classification for the patient in Figure 21 is Skeletal Type I.

16 Figure 22 shows the Jefferson Skeletal Classification system. Using the skeletal diagram, it illustrates diagrammatically the various types of skeletal abnormalities. Fig. 22 shows various types of skeletal malpositions found in Jefferson Analysis. Interpretation of the Jefferson Skeletal Classification is as follows: Skeletal Type I: Both maxilla and mandible in normal A-P position. Skeletal Type IIA: Maxilla prognathic and mandible in normal A-P position. Skeletal Type IIB: Maxilla in normal A-P position and mandible in retrognathic. Skeletal Type IIC: Maxilla prognathic and mandible retrognathic. Skeletal Type IIIA: Maxilla retrognathic and mandible in normal A-P position. Skeletal Type IIIB: Maxilla in normal A-P position and mandible prognathic. Skeletal Type IIIC: Maxilla retrognathic and mandible prognathic. Skeletal Type BR: Bi-skeletal retrognathic. Skeletal Type BP: Bi-skeletal prognathic. To clearly demarcate skeletal assessment from dental assessment, the term Type will be used for skeletal assessments, and Class will be used for dental assessments. For example, a patient may have the following skeletal and dental assessment of Skeletal Type IIB, Short; Dental Class II div 1. Jefferson Cephalometric analysis treats to the ideal facial profile. If patients are treated to Skeletal I, Normal vertical, facial profile will conform to the divine proportion and will be beautiful and healthy.

17 Application of the Jefferson Cephalometric Analysis Fig. 23 shows the various types of facial profiles seen in the general population. Only one is beautiful. Figure 23 shows the various facial profiles found in the human population in all races. Facial profile F is universally deemed the most esthetically pleasing. Concurrently, this facial profile is physiologically the healthiest. Individuals with facial profile F has the least incidence of TMD, sleep apnea, and other major medical problems. Any patients with facial profiles A to E, will very often have medical issues. Based on the Jefferson Cephalometric Analysis, treating all patients to Skeletal Type I, Normal Vertical will treat patients to facial profile F and alleviate medical problems.

18 Actual Patient Case Showing Application of Jefferson Cephalometric Analysis For the sake of brevity, only Skeletal Type III case will be illustrated. Figures 24a and 24b show a child with a skeletal Type III profile. Is the problem due to normal maxillary A-P and a prognathic mandible, or retrognathic maxilla and a normal mandibular A-P, or a retrognathic maxilla and a progrnathic mandible? The Jefferson Cephalometric analysis shows that it is due to a retrognathic maxilla and a prognathic mandible. The vertical is normal. The skeletal and dental assessment is Skeletal Type IIIC, Normal; Dental Class III. Fig. 24a, skeletal III profile. Fig. 24b, analysis shows Skeletal IIIC, Normal. Figures 25a and 25b show post treatment facial profile and post treatment ceph tracing showing the maxilla and mandible is repositioned to ideal position, Skeletal I, Normal. Fig. 25a, ideal profile. Fig. 25b, analysis shows Skeletal I, Normal

19 As previously emphasized, treating patients to Skeletal Type I, Normal Vertical will alleviate multitude of medical issues. The pretreatment and post treatment cephalometric radiograph clearly show that the nasal and pharyngeal airways have significantly enlarged, allowing this child to have a more normal and more efficient respiration. Which in turn will alleviate multitude of medical issues such as sleep apnea, ADD and Hyperactivity, etc. See Figure 26 Fig. 26, comparison of nasal and pharyngeal airways between pre (left) and post (right) treatment cephs. Treating patients to Skeletal Type I, Normal Vertical, will enhance facial esthetics and will help alleviate multitude of medical problems. This will always occur even if patients are Skeletal Type II, Skeletal Type BR, and Skeletal Type BP.