©1980 JCO, Inc. May not be distributed without permission. www.jco-online.
com
SURGICAL-ORTHODONTIC
CEPHALOMETRIC
PREDICTION TRACING
LEWARD C. FISH, DDS, MS '
BRUCE N. EPKER, DDS , PHD **
Much of the recent literature has
emphasized the use of combined
surgical-orthodontic treatment of den-
tofacial and craniofacial deformities
with specific emphasis placed upon
the results of such treatment. How-
ever, little has been written about the
mechanics involved in surgical-
orthodontic treatment planning. A
specific discussion of surgical-
orthodontic cephalometric pred iction
tracing as it relates to the correction of
dentofacial deformities does not exist
in the literature. The purpose of this
paper is twofold: 1) to illustrate the
mechanics involved in performing a
prediction tracing for cases involving
both surgery and orthodontics and 2)
to demonstrate the necessity for doing
cephalometric prediction tracings so
that both the orthodontist and the
surgeon can properly plan combined
su rgical-orthodontic treatment.
Because of the extreme diversity
of orthodontic and surgical procedures
em ployed in the su rgical-orthodontic
correction of facial deformities , it is im-
possible to illustrate the method of de-
veloping a prediction tracing for each
' Orthod ontist , Center for the Corre ction of Dentofa-
cial Deformities . John Peter Smith Hospital . Fort
Worth, Texas 76104 .
• * Director , Cent er for the Corre ction of Dentofa -
cial Deform ities , John Peter Sm ith Hospital . Fort
Worth , Texas 76104.
36 © ,geo JPO, Inc.
possible deformity. We will , therefore ,
discuss and illustrate the method em-
ployed for mandibular advancement,
maxillary superior repositioning and
combined maxillary and mandibular
surgery. With the exception of those
methods employed in the treatment
planning for the correction of asym -
metries, al/ surgical-orthodontic cor-
rections are basically the same as, the
reverse of, or a combination of these
proc e dures . Thus , once one is
thoroughly familiar with the techniques
involved for these predictions , the
principles can be easily applied to
other types of deformities.
The techniques discussed herein
were adopted in part from the
mechanics developed by Ricketts for
cephalometric analysis , growth predic-
tion and visual treatment objective
construction as presented by Bench,
Gugino , and Hilgers. ' , 2 A thorough un-
derstanding of these principles will aid
in ones ability to understand and apply
the material presented in this paper.
Whereas, in constructing the VTO , the
skeleton is altered by growth and
treatment, we alter the skeleton surgi-
cally and finish the tracing just as is
done in constructing the VTO.
Finally, it is emphasized that this
paper is not intended to discuss treat-
ment planning in its broad sense. As
we have previously discussed , this in-
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volves a detailed systematic patient
evaluation , decision about the indi-
cated surgery , model surgery, and de-
cision about surgical-orthodontic
sequencing. 3 , 4 , 5, 1 Q, 1 2 Furthermore, this
paper assumes that the cephalomet-
ric x-ray from which the prediction
tracing is to be done was taken with
the patient's lips in repose.
I. Cephalometric Prediction Tracing
for Mandibular Advancements.
Why do prediction tracings for
mandibular .surgery? The basic
reasons for doing predictions for iso-
lated mandibular su rgery (advance-
ment or set-back) are: 1) to accurately
assess the profile esthetic results
which will result from the proposed
surgery, 2) to consider the desirability
Fig . 1 Case 1. Pretreatment records.
VOLUME XIV NUMBER 1
of simultaneous adjunctive proce-
dures such as genioplasty, suprahyoid
myotomy, etc. , 3) to help determine the
sequencing of surgery and orthodon-
tics (i.e., if the surgery is done first will
it be more difficult or easier to do the
indicated orthodontics) , 4) to help de-
cide what type of orthodontics might
best be employed (i.e., extraction ver-
sus non-extraction) and 5) to deter-
mine the anchorage requirements
should extraction treatment be cho-
sen.
The original records of a patient
that was treatment-planned for man-
dibular advancement in concert with
orthodontics are seen in Figure 1. The
patient has a prominent nose , a short
lower face height, a deep labiomental
fold and a recessive chin. The decision
was made to advance the mandible
37
 ©1980 JCO, Inc. May not be distributed without permission. www.jco-online.com
SURGICAL-ORTHODONTIC CEPHALOMETRIC PREDICTION TRACING
primarily on the basis of facial appear-
ance. Thus one basic treatment deci-
sion has been made, but we do not
know how far we wish to advance it,
nor do we know what orthodontic tooth
movement will be necessary to allow
the desired advancement . * These
questions can effectively be answered
by an accurate prediction tracing.
Step 1 - Trace the Stable Structures.
The first step in producing a pre-
diction tracing is to overlay a piece of
acetate paper on the original
cephalometric tracing and trace all
structures which will not be signifi-
cantly altered by the surgery and lor
orthodontics. For mandibular surgery,
these structures will include the deep
cranial features, the maxilla, the maxil-
lary occlusal plane , the mandibular
ramus and the profile to the base of the
nose. Draw in Frankfort Horizontal and
a line from nasion to indicate the op-
timum facial depth, i.e. , 89 0 in females,
90 0 in males (Fig. 2A).
We do not advocate treating pa-
tients "to the numbers", however op-
timum facial depth is a convenient
guide for beginning a prediction for
either mandibular advancement or
set-back surgery. Nasal esthetics and
sex have a direct influence on optimum
chin prominence. Furthermore, mandi-
bular anatomy has an influence on de-
sired chin prominence as the square-
jawed (Mandibular Deficiency Syn-
drome, Type 1)9 individual may appear
' In many cases of mandibular advancement the pa-
tient can protrude the jaw into a Class I occlusion and
these questions can be answered by direct observa-
tion of the patient and a cephalometric x-ray taken
with the lower jaw protruded. However , because at
the dental compensations existing in most cases of
mandibular ret rognathia, merely achieving a Class I
molar and canine oc clusion will not necessarily pro-
duce the optimal facial appearance.
38
too strong with the chin in this position
while those with a tapering lower face
(Mandibular Deficiency Syndrome,
Type 111)9 may still appear too weak.
Step 2 - Add Skeletal Portion
Changed by Surgery
Slide the prediction tracing to the
left and rotate it slightly to position
bony pogonion at the optimum facial
depth, keeping the mandibular oc-
clusal plane in proper relation to the
maxillary occlusal plane. Once a satis-
factory position is achieved, trace the
distal portion of the mandible, the cor-
pus axis , and the soft tissue chin in this
position (Fig. 2B). There is little
change in soft tissue chin thickness, so
the soft tissue chin may be drawn in
just as it was originally.6 .7 However,
this is so only if the original ceph-
alometric radiograph is taken with
the lips in repose. B
Step 3 - New A-Po Line.
Construct a new line from Point A
to pogonion. If a genioplasty is to be
included in the procedure, the anterior
portion of this altered chin, be it bone
or alloplast , is now construed to be
pogonion for purposes of placing the
teeth. The tracing in Figure 2C illus-
trates the skeletal correction. (Note:
Frankfort Horizontal and the Facial
Plane have been omitted for clarity of
illustration .)
Step 4 - Placing the Teeth.
The teeth are placed exactly as
described by Bench, et a1 2 • First the
lower incisor is placed in its optimum
position 1 millimeter ahead of the A-Po
line, 1 millimeter above the occlusal
plane, and at 22 degrees to the A-Po
line.
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FISH AND EPKER

A B

c D

Fig.2 Cephalometric prediction tracing for

mandibular advancement.
A. Tracing of structures which will not be
altered with surgery or orthodontics.
B. Placement of distal mandible Into op-
timum relation with remainder of skeleton.
C. Addition of new A-Po line and corpus
axis.
D. Ideal placement of upper and lower In-
cisors, calculated position of molars, and
lips traced.
E. Superimposed original and prediction
tracing to evaluate overall treatment objec-
tives and results.

VOLUME XIV NUMBER 1 39

 ©1980 JCO, Inc. May not be distributed without permission. www.jco-online.com
Fig. 3 Case 2. Pretreatment records.
thodontics will be necessary. Further-
more, we need to know if autorotation
alone will produce an adequate chin or
if we will wish to add a genioplasty or
consider simultaneous mandibular
advancement. These questions can be
answered from a prediction tracing.
Step 1 - Trace the Stable Structures.
As is the case with all prediction
tracings, we again begin by tracing the
structures which will not be modified
either surgically or orthodontically
(Fig. 4A) . This should include point A
as will be discussed later.
Step 2 - Determination of Ideal Verti-
cal Position for the Upper Incisor.
Regardless of how accurate your
VOLUME XIV NUMBER 1
FISH AND EPKER
cephalometric technique, we recom-
mend that the measurement of the
amount of upper central incisor ex-
posed , i.e., that from stomion of the
upper lip to incisal edge , be made clini-
cally with the patient standing in a re-
laxed posture . This is the single most
important measurement in preparation
for supe rior repositioning of the maxilla
and can be confirmed cephalometri-
cally. Once the amount of incisor ex-
posed beneath the upper lip is deter-
mined, the " ideal" amount of superior
repositioning of the upper incisor can
be determined by the formula :
Y-2
X = -- - -
0.8
where X is the amount of superior re-
positioning necessary and Y is the
amount of upper incisor showing . This
41
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SURGICAL-ORTHODONTIC CEPHALOMETRIC PREDICTION TRACING

o o
v v

A B

o
v

c D

Fig. 4 Cephalometric prediction tracing for

maxillary superior reposit ioning.
A. Tracing of structures which will not be
altered with surgery or orthodontics.
B. Line parallel to the Frankfort horizontal at
o desired vertical level of maxillary central in-
cisors.
C. Autorotation of mandible around condyle
as it will occur with the proposed amount of
superior repositioning of the maxilla.
D. Having added the proposed amount of
genioplasty, a new A-Po line Is drawn to the
new Po as determined by the genioplasty.
E. Placement of teeth as described.

42 JCO/JANUARY 1980
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FISH AND EPKER

o o
v
ov

F G

o
v

Fig. 4 (Continued)
F. Tracing of new nasal profile.
G. Tracing of new upper lip position.
H. Tracing of new lower lip position.
I. Tracing of new soft-tissue chin.
J. Superimposed original cephalometric
tracing and prediction tracing.
o
v

VOLUME XIV NUMBER 1 43

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SURGICAL-ORTHODONTIC CEPHALOMETRIC PREDICTION TRACING

formula is used because the upper lip noted is the change in Point A. If this
tends to shorten approximately 20% of point moves posteriorly as it often will
the amount of superior surgical reposi- in order to correct an existing Class II
tioning; thus, a 1:1 relationship be- occlusion , we then use old Point A in
tween the amount of tooth showing determining the A-Po relationship for
and the amount of repositioning the lower incisor. This point is fre-
necessary does not exist. 12 Further- quently obliterated by the surgery and
more, if the superior movement is to be furthermore the soft tissues of the mid-
accompanied by posterior movement face, relatively unaffected by the
of the incisors and an acute nasolabial surgery, still retain the same basic re-
angle is present, the lip will not shorten lationship with old Point A making the
quite as much as predicted . Con- physiologic basis for the A-Po line
versely, with an obtuse nasolabial valid while using the old Point A. Con-
angle and anterior movement of the versely, if point A moves anteriorly the
incisor, the lip will tend to shorten soft tissue will be moved forward and
slightly more. These slight variations the new Point A is used to construct the
may be disregarded, unless the an- A-Po line.
terior-posterior change is more than 6
millimeters.
Step 4 - Genioplasty Determination.
Once the desired amount of verti-
cal incisor repositioning is determined, The second feature which must be
draw a line parallel to Frankfort hori- noted is the new soft tissue chin posi-
zontal on the prediction tracing to rep- tion. (This is where the chin autoro-
resent the desired vertical position tates to.) Several methods are availa-
(Fig. 48) . ble to assess chin position , but the au-
thors find those illustrated in Figure 5
to be the most helpful. If the chin is
Step 3 - Autorotation of the Mandi-
ble.
Superimpose the original and
prediction tracings and , keeping the
mandibular condyle in the same posi-
tion, rotate the predictiQn tracing
clockwise until the occlusal plane is
1mm above the line indicating the de-
sired position of the upper incisor.
Trace the mandible in this position .
The corpus axis and the occlusal plane
are also traced in at this time (Fig. 4C).
The change in point A and the soft
tissue chin contour must be carefully
studied at this time. To allow easier
observation of these features, one
may wish to trace, with dotted lines, the
soft tissue chin, the lower incisor, and
Flg.5 Cephalometric criteria which may be
Point A. used to help determine optimum anteropos-
The first feature that must be terior soft·tissue chin position.

44 JCO/JANUARY 1980
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adequate , then geniop lasty is not
necessary . However, if the chin is still
weak, as in our example either man-
dibular advancement or some type of
genioplasty must be added to the
treatment plan for optimum esthetics .
Conversely, if the chin is too strong,
then some procedure to reduce it may
be required.
Ideally, we would like to determine
the " normal " position for the soft tissue
chin and then plan our genioplasty to
produce this desired result. For bony
genioplasties, the ratio of anterior-
posterior soft tissue change to bony
change is about 0.6:1, thus, if 5 mil-
limeters more chin is desired , a bony
advancement of 8 millimeters will be
required . If alloplastic material is to be
added, this ratio approaches 1:1 thus
5 millimeters of alloplast will produce
5 millimeters more soft tissue chin.s
For patients who are not to un-
dergo orthodontic treatment or where
the lower incisors cannot be retracted
sufficiently, best chin-lip-nose balance
is usually attained by placing an allo-
plastic genioplasty thick enough to
bring the material to a line from Point A
and passing 1 to 3 millimeters lingual
to the lower incisor tip , thus producing
a " normal" A-Po relationship for the
lower incisor.
Figure 4D shows our patient with
the projected genioplasty necessary to
produce the optimum chin projection.
Once the amount of genioplasty has
been determined , the new A-Po line
can be constructed using the genio-
plasty as a new pognonion and either
the old Point A or new Point A as dis-
cussed previously.
Step 5 - Placement of Teeth in Ideal
Positions.
This step is carried out exactly as
described by Bench, et al! After plac-
VOLUME XIV NUMBER 1
FISH AND EPKER
ing the teeth in their ideal position (Fig.
4E), we are now ready to trace the new
profile. (The excessive overjet in this
patient is produced by a missing lower
incisor.)
Step 6 - Nasal Outline.
With superior repositioning of the
maxilla, the nasal tip is generally ele-
vated slightly . This is more pro-
nounced if the maxilla is moved up-
ward and forward , less pronounced if
upward and backward . The lower bor-
der of the nose is relatively unchanged
though it too may be elevated a small
amount. Accordingly , the prediction
tracing should be placed on the origi-
nal with the fixed landmarks superim-
posed and the nasal outline traced with
the aforementioned alterations (Fig.
4F) .
Step 7 - Upper Lip.
The upper lip reacts to superior
repositioning in the following ways: 1)
the length from subnasale to upper lip
stomion shortens 1/5 of the amount of
superior repositioning , 2) the thick-
ness increases by 1/3 of the amount of
incisor retraction , and 3) the lip thins
out slightly if the upper incisor is
moved forward, but in all but the most
extreme instances this is unnotice-
able . To trace the new uppe r lip one
should superimpose on the fixed cra-
nial structures and study the change in
incisor position . If the upper incisor is
retracted such that it lies posterior to
an imaginary line from the labial sur-
face to Point A on the original tracing,
then lip support has been reduced and
one should trace the new lip in the fol-
lowing manner :
Divide the vertical distance from
old incisor tip to new incisor tip into
fifths and the anterior-posterior
45
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SURGICAL-ORTHODONTIC CEPHALOMETRIC PREDICTION TRACING
distance into thirds. Move the pre-
diction tracing down 1/5 and
forward 2/3 and draw in the new lip
vermillion . Connect the new lip
vermillion to the previously traced
subnasale in an artistic manner.
Subnasale is affected so little by
superior repositioning that for pre-
diction it can be considered a fixed
point.
If the upper incisor has moved di-
rectly up the line from the labial surface
to Point A of the original tracing, then
lip support is unchanged and one
should trace the new lip in the following
manner:
Divide the vertical distance from
old incisor tip to new incisor tip into
fifths. Move the prediction tracing
down 1/5 and trace the new lip,
connecting it to subnasale as
above .
If, as in our illustration , the upper
incisor is forward of the line from labial
surface to Point A of the original trac-
ing, then lip support has been in-
creased and the new lip is traced as
follows:
Divide the vertical distance from
old incisortipto new incisor tip into
fifths . Move the prediction tracing
down 1/5. Then, while maintaining
this vertical position, rotate and
slide the prediction tracing such
that the long axis of the upper in-
cisor in the prediction tracing is
parallel to, and the labial surface is
flush with , the line from the labial
surface to Point A of the original
tracing. Trace the ' new lip in this
position (Fig. 4G). This effectively
maintains the original lip thick-
ness.
Step 8 - Lower Lip.
In most instances the lower lip
46
vermillion is traced in the same relation
to the lower incisors as existed prior to
treatment. Superimpose the lower in-
cisor on the prediction tracing over that
on the original and trace the lower lip.
Where the lower incisors are re-
tracted 5 millimeters or more , we find
that the lip tends to thicken slightly.
Thus the lower incisors are not exactly
superimposed , but the prediction trac-
ing is moved slightly to the Iingual of an
exact superimposition (i.e., the lip
thickens slightly) and the lip traced in
this position (Fig. 4H). Some artistic
freedom must be employed when deal-
ing with a hypotonic lip. In our experi-
ence, the hypotonic lip may increase
mildly in tonicity following production
of lip competence and added support
for the lip via augmentation genio-
plasty. If one feels that such a result is
likely , then the lip would be traced
slightly thinner for purposes of predic-
tion.
Step 9 - Chin.
If no genioplasty is projected, the
soft tissue chin will be relatively unaf-
fected by treatment and should be
traced by simply superimposing on the
mandibular symphysis. If a sliding
genioplasty is done , the chin is traced
by first superimposing on the original
symphysis and then sliding the predic-
tion tracing back 6/ 10 of the amount of
the genioplasty and tracing the new
chin contour. If an alioplastic implant is
added, the new chin contour can be
determined by simply superimposing
the alloplastic implant on the original
symphysis and tracing the chin (Fig.
41).
Once the tracing is completed, we
again must study it to determine if in-
deed we have achieved a satisfactory
result. To once again gain optimum
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Fig.6 Case 3. Pretreatment records.
appreciation for the proposed changes
superimposition of the original and
prediction tracing is done (Fig . 4J),
again superimposing on the structures
not significantly altered by the surgery
and /or orthodontics.
Frequently, it is necessary to do
several prediction tracings, trying dif-
ferent surgical approaches to a prob-
lem (i.e., superior repositioning vs.
superior repositioning with genioplasty
vs. su perior repositioning with man-
dibular advancement) before one can
determine which result is best.
Certainly it is better to retreat a patient
on paper than to wish that a different
surgical approach had been em-
ployed after the fact.
VOLUME XIV NUMBER 1
FISH AND EPKER
III. Cephalometric prediction trac-
ing for combined maxillary and
mandibular cases.
Once the techniques for predic-
tion tracing involving the mandible
alone or the maxilla alone are mas-
tered, it is a simple step to combine the
two when surgery in both jaws is indi-
cated. The basic technique involved is
to trace the stable structu res, place the
maxilla in the desired position both ver-
tically and anterior-posteriorly and
then place the mandible in its desired
position.
The records of a patient are seen
in Figure 6. The patient exhibits narrow
alar bases, an excessive interlabial
47
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o o

A B

c o

o o

E F

Fig. 7 Cephalometric prediction tracing for combined maxillary and mandibular cases.
A. Tracing of structures which will not be altered with surgery or orthodontics.
B. Vertical referent parallel to Frankfort horizontal to determine new upper Incisor position.
C. Determination of anteroposterior position of maxilla and upper teeth.
D. Placement of mandible Into optimum position with maxilla.
E. Finished prediction tracing .
F. Superimposed original cephalometric tracing and prediction tracing.

48 JCO/JANUARY 1980
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gap and a long appearance to the
lower third of the face. In profile the
severity of the problem is better ap-
preciated, as the nasolabial angle is
obtuse and the chin extremely reces-
sive. Because of the obtuse nasolabial
angle, the maxilla would optimally be
moved superiorly and anteriorly. Since
a severe Class II malocclusion exists
and the chin is so recessive, auto rota-
tion alone will not correct these prob-
lems, even if the maxilla is moved
straight superiorly. Therefore, a simul-
taneous mandibular advancement
must be considered. With this in mind,
the prediction tracing is done as fol-
lows:
Step 1 - Trace the Stable Structures
(Fig. 7A).
Step 2 - Determine the Ideal Vertical
Position for the Upper Incisor.
Some care must be taken here, as
the use of the aforementioned formula
may not be entirely accurate. In the
patient with an obtuse nasolabial
angle, where the maxilla will come for-
ward to increase lip support, slightly
more shortening of the lip will be pro-
duced than might otherwise be ex-
pected. Thus, slightly more superior
movement of the incisor will be desira-
ble. Superimpose the original and the
prediction tracings and draw a line
parallel with Frankfort horizontal to in-
dicate the desired vertical position of
the upper incisor. Trace a line from
original point A tangent to the labial of
the upper incisor as a reference for the
original upper lip support (Fig. 7B).
Step 3 - Autorotation of the Occlusal
Plane.
Keeping the condyle in the same
VOLUME XIV NUMBER 1
FISH AND EPKER
position, rotate the prediction tracing
clockwise until the occlusal plane is
1 mm above the line indicating the de-
sired position of the upper incisor.
Trace the occlusal plane and the man-
dibular ramus in this position.
Without moving the drawings, one
should now assess the anterior-
posterior change of the maxilla by such
rotation. This is done by comparing the
new Point A-incisor line to the one
made to show the position prior to rota-
tion . Frequently, enough anterior
movement has been effected by the
rotation alone and the anterior maxilla
can be traced at this point. If, however,
more anterior movement is desired,
then the maxilla is moved anteriorly
along the occlusal plane by sliding the
tracing posteriorly until the desired
amount of forward movement (i.e., in-
crease in lip support) is attained.
With the desired anterior-posterior
maxillary position attained, point A
should be drawn in. The upper incisor
and molar position are marked for fu-
ture reference. By adding Frankfort
Horizontal and the optimum facial
depth line we now have a tracing which
should look like that made of the fixed
skeletal landmarks drawn in the first
step of the mandibular advancement
procedure, except that the nose has
not yet been traced (Fig. 7C).
Step 4 - Mandibular Movement.
This is done exactly as was done
in Step 2 under mandibular advance-
ment (Fig . 70) .
Steps 5-10· Completing the Tracing.
Once the new position of the man-
dible has been traced, the balance of
the tracing is done as outlined in Steps
4-9 under Maxillary Superior Reposi-
49
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SURGICAL-ORTHODONTIC CEPHALOMETRIC PREDICTION TRACING
tioning . The finished prediction tracing
is seen in Figure 7E.
In Figure 7F the superimposed
tracings are illustrated .
Utilizing the Prediction Tracing -
The Surgeon 's View
The primary concern of any pro-
posed surgical-orthodontic procedure is
that facial esthetics is improved and
never worsened. In this respect, it is
important to appreciate that the dis-
cussion on cephalometric prediction
tracings included herein related en-
tirely to planning for optimum profile
results. Nonetheless, the full face
changes must be kept in mind , and if
optimization of full face esthetics re-
sults in mild compromises in profile re-
sults, this is acceptable . Such an in-
stance would occur where superior
maxillary repositioning is planned and
the prediction tracing reveals that with
the proposed amount of superior max-
illary repositioning the maxilla will
need to be simultaneously re-
positioned posteriorly 4 millimeters.
The patient, however , has a 110° naso-
labial angle and " ideal " prediction trac-
ing placement of the maxilla tells us it
must therefore not be posteriorly re-
positioned . The decision must then be
either 1) to obtain ideal profile results,
which will necessitate a simultaneous
mandibular advancement of 2 to 3 mil-
limeters, or 2) to " compromise " and
move the maxilla back 4 millimeters
and thereby avoid the additional
surgery. What does one do? Optimize
full face results and compromise .
However, in the same situation, when
the maxilla has to be excessively
reposit ioned posteriorly (Smm), it is
warranted to do surgery in both jaws.
The point-use clinical judgment and
do not always treat to numbers .
50
Finally, prediction tracings permit
the surgeon to accurately plan for
augmentation genioplasty, reduc-
tion genioplasty, suprahyoid myot-
omy , etc. , as discussed herein and
elsewhere , which he is unable to do
otherwise except by " Kentucky wind-
age".7,B.,Q ,,3
Utilizing the Prediction Tracing -
The Orthodontist's View
An accurate cephalometriC pre -
diction tracing is a necessary tool for
the orthodontist because it allows him
to discern the anterior-posterior dental
compensations present in a given
malocclusion , and plan orthodontic
treatment which will effectively elimi-
nate these compensations, thus allow-
ing the surgeon to effect the desired
esthetic result.
In studying the desired orthodon-
tic changes for the mandibular ad-
vancement patient presented (Figs . 1
and 2) , we use two superimpositions
suggested by Bench . ' 4 The first
superimposition , corpus axis at PM ,
shows the orthodontic change neces-
sary in the mandible (Fig. SA). Here we
can see that the lower arch will require
extraction of the lower first premolars
and maximum anchorage in order to
retract the lower canine and incisors to
the desired position. The second
superimposition, ANS-PNS at ANS ,
shows the necessary changes in the
maxilla (Fig. SB). Here we see quite a
different situation with the upper in-
cisors staying relatively where they
are, but the upper molar being brought
forward nearly a full premolar width .
Thus, in the upper arch we would elect to
remove the second premolars and at-
tempt to bring the upper molars for-
ward . Carried one step further , if we
superimpose the treated arches on the
JCO/JANUARY 1980
 ©1980 JCO, Inc. May not be distributed without permission. www.jco-online.com

FISH AND EPKER

A B

c o
Fig. 8 Utilizing the prediction tracing.
A. Desired orthodontic change in the mandible.
B. Desired orthodontic change in the maxilla.
C. Desired position of the teeth prior to surgery to allow desired anteroposterior change at
surgery.
D. Superimposition showing desired orthodontic change following surgery.

original tracing, we can see the mag-
nitude of the Class II malocclusion
which we wish to achieve prior to
surgery to allow the patient's lower jaw
to be advanced into the optimum posi-
tion (Fig . SC).
In the second patient presented
(Figs . 3 and 4) , this type of prediction
was of less advantage to the orthodon-
tist, as the occlusion was basically
Class I and the surgery was done first.
It does , however , alert us to the fact
that following surgery we will be treat-
ing a maximum anchorage case and
thus our mechanics can be planned
accordingly (Fig. SO). Because the

VOLUME XIV NUMBER 1 51

 ©1980 JCO, Inc. May not be distributed without permission. www.jco-online.com

SURGICAL-ORTHODONTIC CEPHALOMETRIC PREDICTION TRACING

prediction tracing in this particular II-Surgical Considerations for Mandibular Ad-

case was of no value presurgically ,
one must not feel that this is always the
case. In many Class II cases which are
planned for maxillary surgery , the
lower arch needs to be " set up" or-
thodontically to allow an accurate as-
sessment of the orthodontic mechan-
ics necessary to produce the de-
sired lower arch upon which the
maxilla can be set at surgery. The max-
illary superimposition in such a case
will not be meaningful, as the surgeon
can effect the anterior-posterior
changes desired and these are more
effectively studied via model surgery
done immediately prior to the surgery
itself.
One last benefit can be derived
from these detailed prediction tracings
and this is in the area of consultation.
With an accurate tracing, one can , in
effect, show patients and their parents
the proposed treatment results, at
least in profile, which should allow
them to better understand and more
readily accept the proposed treatment.
vancement, Oral Surg ., [45 :349 , 1978 .]
7. Schendel , S.A.; Wolford, L.M. ; and Epker ,
B .N .: Mandibular Deficiency Syndrome, Part
III-Surgical Advancem ent of the Defic ient
Mandible in Growing Children: Treatment Re-
sults in Twelve Patients, Oral Surg ., [45 :364 ,
1978.]
8 . Dann , J .A. and Epker, B .N . : Proplast
Genioplasty: A Retrospective Study of Treat-
me nt Results , Angle Orth odontist, [47 :173 ,
1977.]
9 . Wolford , L.M. ; Walker , G.; Schendel , S.A.;
Fish , L.C.; and Epker, B.N.: Mandibular Defi -
ciency Syndrome, Part I-Clinical Deliniation
and Therapeutic Significance , Oral Surg .,
[45:329 , 1978.]
10. Fish , L.C. and Epker, B.N. : Superior Reposi-
tioning the Maxilla : What to do with the Mandi-
ble , J . Oral Surg. , [ In press , 1979.]
11 . Schendrel , S.A. ; Eisenfeld , J.; Bell , W.H.;
Epker, B.N.; and Mishelevech, D.J. : The Long
Face Syndrome : Vertical Maxillary Excess,Am .
J . Ortho. , [70 :398 , 1976.]
12 . Fish , L.C .; Wolford , L.M .; and Epker, B.N. :
Surgical-Orthodontic Correction of Vertical
Maxillary Excess,Am. J . Ortho ., [73 :241 , 1978.]
13 . Hohl, T . and Epker , B.N.: Mac rogenia : A
Study of Tissu e Changes with Surgical Recom-
mendations, Oral Surg. , [41 :545 , 1976.]
14 . Bench , R.W.: Seven Position Ser i al
Cephalometric Appraisal , Proceedings-Foun-
dation for Orthodontic Research , 1972.

REFERENCES

1. Bench, RW.; Gugino , C.F. and Hilgers, J.J. :

Bioprogressive Therapy: Part 2 - Principles of
the Bioprogressive Therapy , J . Glin . Orth o.,
[11 :661 , 1977.]
2. Bench , RW .; Gugino , C.F .; and Hilgers,
J .J .: Bioprogressive Therapy : Part 3 -Visual
Treatment Objective, J . Glin . Ortho. , [1 1:744 ,
1977.]
3. Epker, B.N . and Wolford , L.M .: Middle Third
Face Ostectomies: Their Use in the Correction
of Acquired and Developmental Dentofacial and
Craniofacial Deformities ,J . Oral Surg ., [33 :491,
1975.]
4. Epker, B.N. and Fish , L.C.: Surgical Or-
thodontic Correction of Open Bite Deformity ,
Am . J . Ortho ., [71 :278 , 1977.]
5. Epker, B.N.; Fish, L.C .; and Paulus , P.J .:
Surgical Orthodontic Correction of Maxillary De-
ficiency , Oral Surg ., [46 :171 , 1978.]
6. Epker , B.N. ; Fish , L.C.; and Wolford , L.M. :
Mandibular Deficiency Syndrome , Part

52 JeO/JANUARY 1980