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Ricketts cephalometric superimposition

Important Cephalometric Land Marks in Ricketts cephalometric analysis:

PT Point. Intersection of the inferior border of the formen rotundum with the posterior wall of the pterygomaxillary fissure Basion(BA): Most inferior posterior point of the occip-ital bone at the anterior margin of the occipital foramen. CC Point (Center of Cranium) :Cephalometric landmark formed by the intersection of the two lines BA-NA and !-"N. nathion# !): Cephalometric landmark formed by the intersection of the tangent to the most inferior point on the inferior border of the symphysis and the most inferior point of the gonial region$ and the line connecting NA and %. "I point : a point located at the geographic center of the ramus . Protu#eraance menti or supra po$onion (PM) : A point selected where the cur&ature of the anterior border of the symphysis changes from conca&e to con&ex. %C point : Cephalometric landmark representing the center of the neck of the condyle on the Basion Nasion line.


!he method of (icketts was de&eloped in order to pro&ide a simple basis$ orderly and credible way$ to &iew and &erify the changes that occur during an orthodontic treatment. !his analysis is to superimpose the initial x ray on the final layout of the same patient in fi&e locations$ to identify changes that are expected to occur due to growth$ or due to orthodontic mechanics. !his helps to plan our treatment and select our mechanics and to describe the alterations that occur. !he fi&e )uperimposition areas are used to e&aluate the face in the following order* !he chin. !he maxilla. !he teeth in the mandible. !he teeth in the maxilla. !he facial profile. &uperimposition Area ' (()aluation Area ') * !he first superimposition #Basion-Nasion at CC oint+ establishes ,&aluation Area '$ within which we e&aluate the amount of growth of the chin in millimeters- any change in chin in an opening or closing direction that may result from our mechanics- and any change in upper molar. In normal growth$ the chin grows down the facial axis and the six year molars also grow down the facial axis.


ro+th of mandi#le

Patient under o#ser)ation

/uring the facial growth of 0normal0 patients$ ie those lacking functional problems such as mouth breathing$ swallowing$ altered$ disturbed habits #poor posture and habits of sucking+$ among others$ the growth direction of 1acial axis changes &ery little$ closing on a&erage 2.. degrees per year. !he mandible increased on a&erage ..3 mm 4 year from 5 to '5 years along the axis

Patient after three years of treatment

!he patient age at baseline #7 years and 6 months+ with probably a growth spurt during this period. In the first area we can obser&e an increase in the growth of the mandible of '. or 6.3 mm 4 year. 1acial Axis closed 6 #counterclockwise spin of the 8aw+$ from 59 : to 57 : e&en with all extrusi&e mechanics used during treatment (cer)ical traction +ith head$ear, and elastic -uad Class II). &uperimpostion Area / (()aluation Area /) !he second superimposition area #Basion-Nasion at Nasion+ establishes ,&aluation Area . to show any change in the maxilla # oint A+. !he Basion-Nasion- oint A Angle does not change in normal growth. !herefore$ any change in this angle would be due to the effect of our mechanics. ;e e&aluate the effect of headgear #force and type+$ Class II elastics$ Class III elastics$ tor<ue$ acti&ator$ etc. on the con&exity of the maxilla.


ro+th of ma0illa

Patient after three years of treatment

we can obser&e a restriction in maxillary anterior displacement and the angle basion-nasion with the center at nasion decreased from 96 to 92 degrees.

&uperimposition Area 1 (()aluation Areas 1 and 2)

!he third superimposition area #Corpus Axis at M+ establishes ,&aluation Area 6 and ,&aluation Area =$ which together e&aluate any changes that take place in the mandibular denture. !he techni<ue consists of superimposing the initial and final strokes on the plane >i- m with the center of the two paths in m. !hus we obser&e the changes in the lower incisors and first molars$ respecti&ely$ assessment areas three and four. In ,&aluation Area 6$ we e&aluate whether we are going to intrude$ extrude$ ad&ance or retract the lower incisors$ which helps us determine what type of utility arch we will use. In ,&aluation Area =$ we e&aluate the lower molars to determine what type of anchorage we need and whether we wish to ad&ance$ upright or hold the lower molars.

!ormal de)elopment of incisors and first molars in untreated patients * /uring normal growth the first molars are mo&ing upward #2.3 mm 4 year+ and forward #2.6 mm 4 year+ and up the incisors #2.3 mm 4 year+ and back slightly #2.. mm 4 year+. Patient after three years of treatment

'. !he first molars erupted '.3 mm and .mm mo&ed mesially during treatment and helped close the extraction space and the correction of Class II molar relationship. .. !he lower incisors were extruded 6mm$ and were retracted 3 mm$ more than would occur with normal de&elopment of teeth that helped close extraction space.

&uperimposition Area 2 (()aluation Areas 3 and 4)

!he fourth )uperimposition area # alate at AN)+ establishes ,&aluation Area 3 and ,&aluation Area 9$ which together e&aluate any changes that take place in the maxillary denture. !he techni<ue consists of superimposing the initial palatal plane #AN)- N)+ and the final palatal plane #AN)- N)+ at the center of the two planes coincide in AN) In ,&aluation Area 3$ we e&aluate what we are going to do with the upper molars ? hold$ intrude$ extrude$ distalli@e or bring them forward. In ,&aluation Area 9$ we e&aluate what we are going to do with the upper incisors ? intrude$ extrude$ retract$ ad&ance$ tor<ue or tip them.

Normal de&elopment of maxillary incisors and first molars in untreated patients * ;hen the palatal plane is superimposed$ it becomes possible to obser&e the &ertical de&elopment of the upper teeth down and forward. !he upper incisors erupt following his own long axis 2.= mm 4 year and the first molars erupted 2.A mm 4 year down to 2.6 mm 4 year ahead$ following the path of 1acial axis

Patient after three years of treatment

'. !he first molars were distali@ed ..3 mm$ as a result of orthodontic mechanics in Class II #headgear and Class II elastics+. !his distal mo&ement of maxillary first molars occurred in a direction opposite the normal de&elopment of the dental arch. !he first molars were also extruded 6mm. .. !he upper incisors also had a slight extrusion of . mm$ ie 2.9 mm more than the expected &alue and were retracted 5mm bodily. !his mo&e occurred because of the mechanics used in the treatment . &uperimposition Area 3 (()aluation Area 5) !he fifth )uperimposition area #,sthetic lane at the crossing of the %cclusal lane+ establishes ,&aluation Area A with which we e&aluate the soft tissue profile. uses the aesthetic plane formed by the union of the most anterior point of the nose to the most anterior point of the chin and the functional occlusal plane$ passing between the cusps of the molars and premolars. !his techni<ue consists of superimposing the initial and final aesthetic le&el with the center at the intersection of these with the functional occlusal plane$;e use )uperimposition Area 3 and ,&aluation Area A to e&aluate the effect of our mechanics on the soft tissue of the face.

In normal growth$ the face

becomes less protrusi&e with reference to the esthetic plane due to the growth of the nose and chin .

Patient after three years of treatment

!he patientBs facial aesthetics changed considerably after orthodontic treatment$ facial orthopedic as shown by the o&erlay $pro&iding a more harmonious face$ since the lips are behind the aesthetic line$ as recommended by (icketts. !he retraction of the upper and lower incisors$ the growth of the nose and chin positioning resulted in more and less prominent of the distal upper and lower lips.