Mesh Diagram and Template Analysis / Orthodontic Courses by Indian Dental Academy

Mesh Diagram and Template analysis
INDIAN DENTAL ACADEMY

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TEMPLATE ANALYSIS:

History of Templates

In 1952, Baum devised a set of four template transparencies-that
were designed to be laid directly on the cephalometric x-ray film
for analysis after the method of Downs.

Higley 1956, developed cephalometric standards for children 4 to
8 years of age, proposed that celluloid transparencies be
constructed for both sexes at each age level. The diagrams
comprised two quadrilaterals formed by joining various
craniofacial points, and outlining the maxillary first molar and the
maxillary and mandibular incisors


In 1975, Johnston introduced a simplified method of generating
long-term forecasts based on the addition of mean increments,
using a printed grid upon which a tracing is superposed. He made
no claims that predictions thus made are without error, but
contended that they are not much worse than would be expected
from an analysis of cephalometric error.
In 1975, Broadbent and Golden, produced a series of frontal and
lateral cephalometric templates of individuals from 1 to 18 years of
age to fulfill the need for a common yardstick or norm.
In 1977,Popovich and Thompson in a later study of 120 boys and
90 girls, developed a series of age, sex, and growth-type specific
lateral templates- Craniofacial Templates. These investigators
found that they were able to obtain a static evaluation, as well as a
dynamic indication of anticipated future growth changes in
individuals.


Ackerman 1979, used the material from the Michigan School
Study1974 and the published material of Riolo and colleagues
(Sexspecific template wth 13% enlargement) to construct a
series of transparent templates for boys and girls in the different
age groups. The templates were adjusted to "zero"
magnification at the midsagittal plane to facilitate standardized
diagnostic use with any cephalometric equipment

The Advantages of Templates to Lateral Head films:

1. They provide a simple system for rapid assessment of
skeletal variables without mathematical calculation or
measurement.

2. They make it easier to judge the outlines of the various
skeletal and soft tissue components than points and planes
do.

3. The degree of balance or imbalance and its location in the
craniofacial complex can be demonstrated.

4. The various areas within the complex that are amenable to
correction by conventional means can be readily identified.

5. Areas of disproportionate growth that may mitigate
against a successful treatment result may be identified and
taken into account in treatment.
6. Templates provide an indicator of general growth
attainment of a child relative to his peers.
7. The effect of visually comparing superposed template and
tracing provides an opportunity for a more complete
understanding of the various craniofacial components.
The Analysis:

Analysis of template is based on a series of
superimpositions of the template over a tracing of the patient
being analyzed.

Classification:
Based on:
I.Age and sexspecific normative data
Templates based on a study in the University of Michigan
Elementary and Secondary School Growth Study

II.Visual comparison ( Rioloetal 1974)
eg: Proportionate template

I.Age and sexspecific Templates:
Each template is, in effect, a compact set of
oriented rulers graduated in years eg-(6 to 16 years),
rather than in millimeters or degrees.
The necessity of deriving 2 templates- one for
male and the other for female is necessary due to
significant differences between growth timings of
the two sexes
There is no list offered of the ways the templates
should be used. It is, however, appropriate to
provide a few general guidelines concerning the
various kinds of superimposition

I .Cranial-Base Superimposition:

The patient's measurement
and the norm are, in effect,
oriented along SN or FH plane

FH plane should be given
first consideration, because it is
closer to the jaws and thus does
not confound an evaluation of the
size and position of the jaws with
clinically irrelevant cranial base
variation.

In some instances, the
template will not even come
close to fitting the face. In
this instance, it may be
necessary to use some other
plane of superimposition
BaN
PMV
ANS-PNS

It is, however, important to emphasize once again that
overall balance is sought, not a strict point-for-point match
with the patient's age.

If the patient is 11 years old, but has a facial skeleton that
generally matches the template points for, say, a child of 9 or
even an adolescent of 14, nothing is amiss;

However, if there is a mismatch (eg, cranial base and
maxilla at 10 years of age and mandible at 6 or 7 years of
age), there may well be a skeletal problem.

Regional superimposition then can be used to answer these
questions by examining the size or position of the individual
elements of the facial skeleton.

II.Regional Superimposition :

The template is placed over the cephalogram
or a tracing of the cephalogram, and the pair of
points that define the measurement is compared with
the template scales at symmetric ages eg, 6 and 6, 8
and 8, 10 and 10, etc) until a match is achieved

1.Cranial base length

Anterior
Posterior
Total

Register on S, read age at N
Register at S, read age at Ba
Ba to N at symmetric ages
Facial height:

Upper anterior
Upper posterior
lower anterior
Anterior
Posterior

ANS to N, or S-N, or FH
PNS to S, or S-N, or FH
ANS to Gn
N to Gn
S toGo

Maxillary size

Length
Effective length

PNS to ANS or point A
Ar to point A

Mandibular size

Ramus height
Body length
Overall
"Effective" length
Ar to Go
Go to Gn, Pog, or point B
Ar to Gn, Pog, or point B
Ar to Gn

Dental position:

Maxillary
dentition

Orient on palatal plane, register
at A, read molar position at
upper contact-point dots (M) and
incisor position at 1 /1
Mandibular
dentition

Orient on mandibular plane (Go-
Gn), register at point B, estimate
molar position by interpolation at
lower terminal planes (M) and
incisor position at 1 /1

Dental
extrusion:

Maxillary

Palatal plane registered
at A to Downs occlusal
plane (DOP ,M or 1/1
Mandibular

Mandibular plane (Go-Gn)
registered at B to DOP or 1/1

II.Proportionate Template Analysis( Visual comparison):

The proportionate template is based on the princi
ple of the visual comparison of lateral cephalometric .
tracings with average normal tracings.

Measurements of body proportions will be used to illustrate
the philosophy of this template.

Average mans height is 5feet 9 inches and so templates are made
In relation to this body height.

It may be argued, however, that a single template cannot be used
for all individuals because of variations in body height
To accommodate variations in skull size, four
templates were designed:

i)The average template that was developed by
averaging "geometrically the dimensions of the
sample.

ii)The large template was intended for largerthan-
average persons

iii)small template for persons with smaller-than-
average craniums and jaws.

iv) In addition, an extra-large template was designed
for considerably larger-than-average individuals

Separate templates for men and women are unnecessary because
the basic skeletal assembly patterns of men and women are so
similar that they can be combined.

The main differences between men and woman are large Frontal sinuses,
supraorbital ridges and noses, as well as the more prominent chin found in
men.

While there is some sexual dimorphism in the craniofacial structures, a
single representative proportionate template may be used for both men and
women.

Application of the Proportionate
template:
The following approaches
to superimposing the template on
the tracing are recommended.

Method 1:

The mid-S-J point of the template
is superimposed on that of the
tracing, and the template is
adjusted to the point where the
Ba-N lines on the template and the
tracing are parallel to each other.
At this time, the anterior and
posterior cranial base lengths are
checked by superimposing S-N
and Ba-S, respectively.
If either cranial base length is grossly deficient or excessive, the
mid-S-J point superpositioning is disregarded .

Method 2:

Here both the Ba-N lines are superimposed and the S-J lines
will be parallel to each other.

The template is then raised or lowered, keeping the Ba-N lines
parallel until both of the midS-J points are equidistant from
either of the Ba-N lines.

In other words, the mid-S-J points should be level with each
other relative to the Ba-N line.

In attempting to identify location and extent of craniofacial
disproportions, methods 1 and 2 will generally suffice.

Method 3:

Some individuals, whom neither of these methods is entirely satisfactory.
In these cases, the template may have to be superimposed using other
reference points or planes.
By moving the tempIate over the tracing, various abnormal bony
craniofaciaI elements can be identified and compared.

The tracing should then be interpreted by systematically observing the
following dental and skeletal relationships and proportions:
1. The relative spatial position of maxilla and mandible.

Check whether the maxilla and mandible are anteroposteriorly protrusive
or retrusive, and note the relative vertical position of this jaw to the
template.
Note whether the mandibular plane approximates that of the template.
State whether the steepness is mild, moderate, or severe.
Determining the relative spatial position will immediately provide an
indication of which jaw(s) is at fault, its relative position to the
cranium, and the extent of jaw dysplasia.

Measure the distance between the incisal edge of the upper teeth and the
lower border of the upper lip. Judge the distance clinically and
cephalometrically with the lips at rest. On the average, the lip embrasure
is 2 to 3 mm above the incisal edge of the maxillary incisors.
For soft tissues:
Lips-comment on thickness, competence, and strain
Nose-comment on size and shape of root, body, and tip
Chin-comment on thickness, prominence, and deficiency.
2.Maxilla .
Measure length along the palatal plane (ANS-PNS) from Ptm to point A.
State the degree of deficiency that exists: mild, moderate, or severe.
Measure incisor height from the palatal plane to the incisal tip. State
whether the incisor height is excessive or deficient and to what extent.

Determine whether the axial incisor inclination
approximates that of the template. Determine whether
the incisors are too upright or too labially inclined.
Measure molar height from the palatal plane to the
occlusal surface of the maxillary first molar.
Determine whether the molar height is satisfactoy.,
excessive, or deficient.
3.Mandible
Determine whether the body length
Normal, deficient or Excessive
To determine this, superimpose the mandibular planes
of the template and tracing and register on pogonion.
Confirm the observation by moving the template along
the mandibular plane of the tracing and register on
gonion.
Determine whether the ramus height (Ar to Go) is within the
average range and indicate to what extent it is excessive or deficient.
Correlate this measurement with the steepness of the mandibular
plane.
Determine the degree of gonial angle:
average, mildly, moderately, or severely acute or obtuse.
Measure incisor height from menton to the incisor tip:
state normal, excessive, or deficient
For incisor inclination, superimpose on the mandibular plane
registering on menton. Determine the extent (if any) of relative
retrusion or labial inclination of the lower incisors.
Measure molar height from the palatal plane to the occlusal surface
of the mandibular first molar. Check whether the molar height is
satisfactory, deficient, or excessive.
4.Upper/Lower Facial Height:
Determine upper facial height
(N-ANS) as excessive or deficient.
Determine lower facial height (ANS-
menton) as excessive or deficient.
Determine disproportion as none, mild,
moderate, or severe.
5.Vertical Dimensions of Dentition
For maxillary and mandibular incisors
and molars ,
Superimpose the template on the
occlusal plane of the tracing and check
the molar and the incisor heights.
Determine whether the molar and
incisor heights are normal, excessive, or
deficient.

Proportionate templates have been shown to be useful,
particularly in orthognathic surgical procedures,for visually determining
the extent and location of vertical and anteroposterior dysplasias from
lateral headfilm.

Before finalizing a treatment plan involving surgery, final
measurements should always be made on dental casts and not be obtained
from tracings alone.

Templates thus provide a visual appraisal of cephalometric tracing and,
therefore, are simple yet deceptively sophisticated.
Templates exhibit the rare virtue of demanding the active
participation of the clinician.
WhereasConventional numeric analyses permits the clinician (or
perhaps more often an assistant) to go through the motions of recording a
list of uninterpreted numbers
With practice and a modicum of perseverance, use of templates can
become an almost indispensable diagnostic aid.

MESH DIAGRAM ANALYSIS

In 1939,Lucien de Coster, of Belgium, advocated
transformation of a mesh coordinate for analysis of
radiographs in norma lateralis of orthodontic patients.

In 1948 at the Eorsyth Dental Center it was used graphically to convey
the essential aspects of facial development for orthodontic diagnosis

Experience with this method of cephalometric analysis has resulted in
an appreciation of proportions and relationships among facial components,
particularly because sagittal and vertical variations or dysplasias in facial
development, including the soft tissue profile, are registered
simultaneously.

Originally,Total facial height was used as the vertical reference(scaling
factor) for construction of the mesh diagram and face depth.
length of anterior skull base -- Horizontal scaling factor

But since lower face height is more affected than upper face
height in individuals with malocclusion, the latter distance
adopted subsequently as the vertical scaling factor for tbe
mesh diagram.

Landmarks:
I. Soft tissue landmarks:
glabella, nasion, pronasale (tip of the nose),
subnasale ( attachment of upper lip to the nasal septum )
labrale superius (most prominent point of the upper lip),
stomion (contact point of upper and lower lips),
labrale inferius (most prominent point of lower lip),
supramentale (sulcus labiomentalis),
pogonion (the most prominent point on the chin).

Mesh diagram Landmarks:
II.Hard tissue Landmarks:

Symphysis mentalis : point B, pogonion, menton, the most
dorsal point on the symphysis mentalis to depict its greatest
thickness, and a point on the lingual surface where the symphysis
converges around the mandibular incisors

Breadth of the Ramus:a point on the concave anterior contour just
above the 0cclusal plane of the teeth and a point along the
posterior contour of the ramus

Thickness of the neck of the condyle:obtained hy marking the
intersection between the anterior and posterior contours of the
condylar neck and the caudad (inferior) surface of the clivus
(posterior skull base
The maxillary area,
Reveals a triangular area.
A)Its posterior (dorsal) limit represents the deepest point on the anterior aspect
of the pterygomaxillary fissure that separates the dorsal (posterior) aspect of
the maxilla from the left and right pterygoid processes.
B)The highest point of the triangle represents the dorsal limit of the orbital
wall in the infratemporal fossa
C)Third point of the triangle represents the lower (caudad) limit of the
zygomatic process.

The functional occlusal plane was drawn to best estimate as a line
through the cusps of maxillary and mandibular posterior tooth crowns.

Inclination of maxillary and mandibular central incisors :incisal
margins of the maxillary and mandibular central incisors to somewhere along
the root or the pulp canal
Construction of the Mesh Diagram:
The mesh diagram is constructed
by first drawing a core rectangle, by drawing
a vertical through nasion, parallel to the
extracranial reference line and two
horizontal lines perpendicular to this
vertical, one at nasion and the second
through the anterior nasal spine (ANS). The
fourth line is drawn parallel to the vertical at
a distance from nasion equal to (NS)]
By dividing the sides of the core grid
rectangle into two equal parts, the
distances are obtained for drawing
additional horizontal and vertical grid lines
to complete the mesh diagram.
The face is thereby inscribed in a
rectilinear coordinate system composed of
24 small rectangles
The X coordinate were scaled to anterior
cranial base length
y coordinate---to the upper face height.

Individual variation in the position of facial landmarks
and teeth implied that the facial configurations of the subjects
studied differed markedly in the degree of prognathism and in
facial shape.

So contour ellipses were used to illustrate variations.
The amount and direction of this variation in the location of a
given landmark were reflected in the lengths of the major and
minor axes of the corresponding ellipses.

No variance was found at Nasion (horizontal) and ANS
(vertical) as they served to scale the coordinates of the grid

The major and minor axes of the ellipses were longest
for landmarks at greatest distance from the origin of the
coordinate system (nasion). As variances of the landmarks were
expressed in proportion to upper face height and face depth
To determine the need for
separate age norms of children
at various ages, a mesh diagram
analysis was undertaken on the
purely longitudinal sample of
male and female twin pairs
Moorreess 1991

Although the size of the mesh
rectangles at 8 and 16 years
varied, anatomic landmarks in
the mesh coordinate system at 8
years of age, when plotted in the
mesh coordinate system of the
same individuals at 16 years,
showed that the location of
landmarks at both ages was
remarkably close
Procedure for Mesh Distortion:

The mesh coordinates are subsequently
distorted to display differences in the
proportionate location of each landmark in the
individual`s mesh.

This objective is accomplished by two steps:
1. By locating the median proportionate position
of each landmark in its respective grid rectangle
of the patient's mesh diagram
Eg:the mean location of gonion within its small
grid rectangle is horizontaly at 14% from the
anterior vertical line and vertically at 27% from
the upper horizontal line.

Deviation of the patient's gonion from its median
location is represented by an arrow that depicts
the displacement factor.

2. Distorting the grid lines of the specific small mesh
rectangle to reflect the deviation of each landmark from
its normal proportional location.

Due to variations in landmarks, the sides of some
rectangles will be elongated while others will be
shortened, indicating the sites of facial disproportion or
disharmony .

~ After the location of all landmarks has been
evaluated, distortions are drawn through the points
marked on the tracing for various landmarks.

These distortions are smoothed and thereby constitute
trend lines revealing the differences in the individual's
facial pattern with respect to the norm.
When the mesh is drawn on the tracing of the lateral cephalogram
of an individual patient, it is important to compare first the size of the
individual's small individual rectangles with the size of the small
rectangles of the norm

If the height is smaller (the length being the same as that on the norm),
the face is short in comparison to its depth

If the hcight is greater, the face is longer.

The same reasoning pertains to the length of the small rectangles.

If the length is greater (the height being the same as that on the norm)
the face is deep,

If the length is shorter, the face is shallow

Distortion of the vertical grid lines:

This first vertical line is distorted only for soft-tissue
landmarks: glabella, soft-tissue nasion, the tip of the nose,
subnasale, labrale superior, stomion (if the lips are closed),
labrale inferior, supramentale, and soft-tissue pogonion.

Soft-tissue nasion may be unreliable because it is often
compressed by the headrest of the cephalostat during
careless positioning of the patient in the cephalostat

The Second vertical line is distorted for the bony landmarks
of the anterior part of the face: glabella, ANS, point A,
incisal edges of the maxillary and mandibular central
incisors, pointB, pogonion, and gnathion.

Distortion Qf vertical 4 is determined
by: articulare, basion, and gonion, but
not sella turcica, in asmuch as the
distance nasion-sella turcica
determines the location of line 4.

Distortion of vertical 5 follows the
distortions of vertical 4, since the
distortion of vertical 5 is based on the
position of the same landmarks.

Vertical grid line 3 is distorted last
because it is influenced by the
distortions of vertical 2 and vertical 4
1 2 3 4 5
A
B
C
D
E
F
G
The horizontal grid lines distortions
They are represented by lines A to G.

The first and second horizontal lines (A and B) are distorted only for the
vertical location of sella turcica.

The third line (C) is distorted for the tip of the nose, articulare, and basion.

Line D is distorted for the tip of the nose, the posterior nasal spine, articulare,
and basion.
It will always pass through the anterior nasal spine, because this
landmark is used for .scaling the mesh diagram

Line E is distorted for stomion (if the lips are closed), the incisal edge of the
maxillary central incisors, and the incisal edge of the mandibular central
incisors

Line F is distorted for gnathion and gonion

Line G will parallel the distortion of line F.

Utilization Of the Mesh
Diagram Method:

1.Mesh diagram analysis of a patient
with a mesognathic face, everted but
potentially competent lips, and overjet
of maxillary incisors.
Transformations of horizontal grid
lines indicate a slightly long anterior
face height and short posterior face
height as well as a short ramus due to
caudad position of the condyle and
cephalad position of gonion.

2.A retrusive mandible,
cephalad position of gonion
and steep mandibular plane,
shown by the grid
transformations of a patient
with Class II, division 1
malocclusion. The soft-tissue
profile likewise indicates a
retrusive mandible, pouting
lips, and a stub nose.
3.Mesh diagram analysis of
a patient with a Class III type
of malocclusion resulting
from marked mandibular
prognathism.

The transformations of
horizontal grid lines indicate
the cephalad position of
sella turcica, articulare, and
basion, as well as to a lesser
degree, gonion. The
displacement vector for
gonion also has a ventral
component.

Mesh diagram analysis
of a patient with open
bite in a Class III type of
malocclusion.

The transformations of
vertical grid lines indicate
marked mandibular pro-
gnathism and proclined
mandibular incisors as
well as the dorsal position
of basion.

The distorted horizontal
grid lines reveal the
caudad dysplasia of the
anterior aspect of the
mandible resulting in long
lower face height.

Mesh diagram used in the Norma Frontalis:

Kaplin 1985, pursued the use of the Cartesian
coordinate system oriented on a facial midline through
the crista galli, for studying radiographs in norma
frontalis as in norma sagittalis.

The basic grid of this coordinate system is composed
of the midline and parallel to it another vertical line
through the right or left zygoma, as well as two
horizontal lines also perpendicular to the midline (one
through the crista galli at its intersection with the
sphenoid and the other through ANS).

This core grid serves to construct a coordinate system of 24 rectangles
based on half the length of the horizontal and vertical dimensions of the
core grid

The distortions of differences in the proportionate location of
landmarks are entered unilaterally, the other side serving for reference

Shortness of right ramus
compared to left
midline deviation of mandibular
incisors, chin; condyle, and ramus
in both horizontal and vertical
direction
Computerized Mesh
Diagram Analysis

The remarkable advances in the
state-of-the-art personal computers,
digitizing and plotting equipment, as well
as their relatively low cost make
computerized grid distortion an attractive
alternative to hand distortions.

Itconsiders the upper and lower face
separately
Treatment changes in the facial profile and
underlying hard tissue structures are
demonstrated by superimposing the initial
and posttreatment cephalograms on the
anterior cranial base.
.. Pretreatment

_____ postreatment
To assess the effectiveness of this
treatment, the posttreatment cephalometric
tracing was superimposed with the
indiyidualized norm and registered on
pronasale while the vertical references
were kept parallel .
Results showed that the treatment outcome
was remarkably close to the patient's
computer-generated individual norm.

The computerized mesh diagram is a departure from all other computerized
cephalometric analyses in that it is less time-consuming because facial land-
marks are not digitized. Moreover, the use of the individualized norm is
flexible because the patient's tracing can be manipulated over the norm in as
many ways as necessary to formulate treatment alternatives before deciding
on the final treatment plan
The mesh method should gain recognition because a computerized
program is now available that generates an individualized norm for
a patient by simply entering the values of facial depth and height.

Patients with severe facial dysmorphologic features are particularly
suited for a proportional analysis with the mesh diagram when
surgical correction of facial deformities and malocclusions is
required.

The mesh diagram, contributes to treatment planning and thus the
treatment outcome by recognizing and respecting the individuality
of each patient
References:

1.. Jacobson A. The proportionate template as a diagnostic aid.
AmJ Orthod 1979;75:156-172.

2. Jacobson A. Orthognathic diagnosis using the proportional
template. Oral Surg 1980;38:820. .

3.Jacobson A, Kirkpatrick M. Proportionate templates for
orthodontic diagnosis in children. J Clin Orthod 1983;17:180.

4.HarrisJE,Johnston L, Moyers RE. A cephalometric template: Its
construction and clinical significance. Amj Orthod 1963; 49:249.

5.Johnston LE Jr. Template Analysis. J Clin Orthod
1987;21:585-90.
6. Moorrees CFA. Normal variation and its bearing on the use
of cephalometric radiographs in orthodontic diagnosis AmJ
Orthod 1953;39:942-950.
7. Moorrees CFA, van Venrooij ME, Lebret LML, GlatkyCB,
Kent RLJr, Reed RB. New norms for the meshdiagram analysis.
AmJ Orthod 1976;69:57-71
8.Alexandre Jacobson: Radiographic Cephalometry,1995
9.William Proffit: Contemporary Orthodontics:3
rd
edition,
2000


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