The keystone triad

II. Growth, treatment, and

clinical significance

ROBERT MURRAY RICKETTS, D.D.S., M.S.”

Los Angeles, Calif.

INTRODUCTION

T H E keystone triad was described in an earlier publication1 as consisting of

the chin, point B, and the lower incisor. This unit, located at the “keystone”
of the mandible, includes the symphgsis, the alveolus, and the lower anterior
teeth. Anatomic details, phylogenetic factors, and problems in cephalometric
nomenclature were discussed in the earlier article. The intent of the present
essay is to review growth findings together with treatment changes and at-
tempt to transpose them inbo clinical understanding. This perspective is needed
for a knowledge of the ultimate prognosis of the orthodontic patient.

LABORATORY INVESTIGATIOSS

It had been generally assumed, from the early studies of Brash2 and of
Keith and Campion, that the mandible always grew forward in the face and
that the chin became more prominent. The first work of Humphrey,” the concepts
of John Hunter,5 and other works all contributed to general acceptance of the
belief that the human mandibular body grew in length by means of resorp-
tion of the anterior portion of the ramus and apposition on the posterior sur-
face. The lack of increase in the size of the arc of the mandible led investi-
gators to conclude that little apposition occurred on the chin, and yet the fact
that the chin seemed to become more prominent in many patients confounded
the acceptance of that conclusion.
It was this frame of knowledge that prevailed at the time that &hoar and

The second of two essays to be published in the AMERICAN JOURNAL OF ORTHO-

DONTICS, based on material presented before the Middle Atlantic Society of Ortho-
dontists in Atlantic City, N. J., Oct. 28 and 29, 1963, and before the Jarabak
Foundation in Chicago, Ill., Feb. 1 and 2, 1963.
*Associate Professor of Dentistry, School of Dentistry, University of California.

728
Massle? studied the growth of the monkey mandible by means of alizarin red
S dye. Their findings showed that until the equivalent of human age 6. or
during the mixed dentition, there occurred a general apposition of bone around
thr mandible on all surfaces. This early behavior gave evidence of a g~nc~ral
growth on the external body of the bone in all dimensions. However, at about
the age of the mixed dentition, there was a change in growth characteristics.
Ai eoncentrat.ion of the dye was seen at the alveolar border, the posterior b~rd(~l*
of t,he ramus, the coronoid process, the sigmoid notch, and particularly thcL
caondylar head and process. All these areas were growing by apposition, but
t.hr body of the mandible did not grow. This was confirmed by Jloore’s wor4~
in 19-K).7
The early work of Engel and Brodie8 proved rather conclusively that, tllc,
nlain impetus to growth occurred at the mandibular condple? which propcll~tl
t,he mandible downward and forward, carrying the chin with it or pushing the’
callin ahead. Sarnat and Engel’s study on monkeys that had undergone cotldyl-
octomp also confirmed this observation.
CLINICAL STUDIES

Tn his cephalometric study of prognathism, Bjiirk’” pointed out &at OV~I’

the long growth range the chin tended to become more prognathic in the fan
than the maxilla. Landell also observed this tendency. The average profile t,hus
tended to straighten out, and the ma.ndibular anterior teeth tended to mov11
upward and backward in relation to the profile. This finding has been clrmort-
strated repeatedly, but all patients do not behave in this manner.
The work of Schaefferl’ is of particular interest to our discussion of changes
of the lower incisor. Schaeffer measured the eruption tendencies of the Lowe
incisors in cases taken from Broadbent’s files at the Bolton Foundation. Hc
showed that the lower incisor could erupt upward and forward but that typicall:-
it was carried upward and backward. This could occur in some cases, evt’n
without a change in the tooth’s axial inclination. Schaeffer however, spoke oi
the difficulty of superimposing the symphpsis in some of the C~SCSst,udicd due-
ing the later phases of growth.
C~XDYLE GROWTH AS RELATED TO THE CHIS. The above work representrcl llrc”
status of our knowledge of the changes in tho keystone triad at, the timo thal
I conducted growth studies with laminagraphy.13 The growing condple was
correlated with the change in facial profile, and it was found that the growth
t,endency of the average condyle was straight upward and backward, almos!
up the long axis of the neck of the condyle as typically described. In this typt’
of patient the chin grew downward and forward in the face in the usual manncll..
In some patients, however, the condylar head seemed to incline mor*r$
posteriorly when measured from the mandibular border than had been obscrvcfl
in the beginning (Fig. 1). The mandible became more obtuse in form. This
led to speculation that the growth of the condple was following a more postcrjor
direction and that there was a distal inclination in shape of the condylar ncc*k
and ramus. These patients seemed to show more gro\Tth in anterior height 01
the fact.
730 Rich&s Am. J. Orthodontics
October1964

Fig. 1. A, Tracings of a male patient with predominant vertical growth between the ager
of 12 and 21 years. It will be noted that the facial pattern is long and shallow and that the
Y axis opened even more in spite of efforts to close it with orthodontic treatment and the
extraction of four first permanent molars.
B, Mandibular comparison, superimposed in the manner suggested by BjSrk on the
area of pogonisn and the crypt of the developing third molar, shows an upward and back-
ward growth of the mandibular condyle and apparent resorption of the ante&r border of
the ramus and an upward and backward change in the lower incisor. Notice also the height
increase in the mandibular incisor. Open-bite tends to develop more if the incisors do not
erupt in patients with this type of growth pattern. It will further be noted that develop-
ment of the apparent prominence of the chin from a bony standpoint is due to incisor re-
traction with growth.

In other patients there was greater development in the body of the ramus,
leading to upward and forward growth of the mandibular condyle. The man-
dible and the face tended to develop more squareness or to be more consistent
with the brachyfacial type of facial pattern and the chin tended to move more
forward than downward (Fig. 2).
In attempting to explain these changes, I referred to the muscular sus-
pension apparatus of the mandible. In the final analysis, it was concluded that
the mandible was growing against the function of the muscles which held it
in place. Thus, upward and backward growth of the condyle, with slow devel-
opment of the angle of the ramus, tended to add length to the face or to cause
a downward dropping of the chin.
At the opposite extreme, an upward and forward direction of eondylcf
growth with extensive depression of the angle of the ramus was consistent wi
mandibular squareness and a more prominent chin. In other words, the devte-
opment of a heavy angle seemed to characterize a lower face and chin that wer(*
forward in the face. Bj6rk14 observed the same differences in growth pattern*
but apparently did not quite agree with the consistency of these mandibula:,
patterns with particular facial patterns (Figs. 1 and 2). We have observeli
exceptions, but generally it has held true. Statistics are lacking for these factors.
More recently Bjijrk15 published a follow-up of earlier implant studieh.
Four tantalum pins were placed in the mandible at certain points. At, a later
date, by orienting on these fixed pins, which did not change in their rtlatioll-
ship, he demonstrated the mean and ext.remcs of directional behavior of tht~
growing condyle. The average posterior plane tended to move slightly upwar~l
and forward about 6 degrees from the original mandibular plane. The variut.iotl
toward gonial development was 20 degrees (in an upward and forward dirt.+
tion) . The opposite direction ranged to an distal inclination of 16 degrees (mom
obtuse). Bjiirk did not correlate mandibular behavior with facial chi~~~pe.1)1it

K.C. g-7
14-3

Fig. 2. A type of growth opposite that shown in Fig. 1. a, Tracings of a female patient be-
tween the ages of 9 and 14 years. The X-Y axis changed from 1-7 to +15 degrees as the chin
moved almost directly forward. It will further be noted that the ramus increased markedly
in height and that posterior height developed at a greater rate than anterior height. Kobice
that the c,hin carried the lower incisor forward. In contrast to Fig. 1, which demonstrated
about a 2.5 cm. dropping of the hyoid bone, very little dropping of the hyoid is evidcknt
in this patient.
B shows pattern of growth, superunposed according to BjBrk, and indicates marked vertical
development. However, instead of anterior ramus resorption, as shown in Fig. I, there WBS
apparently resorption of the angle of the ramus and a vertical growth of the ramus. This
produces growth rotation to the chin in an almost forward direction as the mamliblc tends
to “curl” during growth. Notice that the eruption of the first molar is much greater than
that of the incisor in this particular patient. These patients tend to develop closca-l)itcs :IR a
part of their growth pattern. Note that thr symphynis tends t,o incrcnse in width with thl>
addition on the posterior margin.
7 3 2 Ricketts Am. J. Orthodontics
October 3964

since his findings so closely followed my observations or showed even greater

variational behavior, I would assume that the same general observations would
hold for facial change.
LOCAL CHIN MORPHOLOGY. Several observations support the contention that
the lower incisor is suspended from t,he lingual plate of bone and from the
dense compact of t.he planum alveolar on the lingual aspect. Repeated sections
taken by numerous investigators over the past 40 years have substantiated this
fact. It can also be shown very effectively by midsagittal laminagrams of this
bone taken in living subjects.
An over-all thickening of the symphysis menti seems to occur occasionally,
but in these cases one must make observations over a long period in order to
measure the change. An example was seen in a nontreated patient who devel-
oped a beautiful occlusion and a very strong mesognathic pattern, with a marked
increase in the width of the symphysis, in a period of 8 years (Fig. 2).
It has been noted, however, that by the time the lower first molar has
erupted the general width characteristics of the symphysis will have been at-
tained. The average symphysis is almost teardrop in shape. Extreme variations
show either a long, narrow symphysis or one that is short and thick. Patients
with mandibular prognathism or with great alveolar height and retrognathie
patterns often have long, narrow symphyses. The brachyfacial or wide-eyed per-
son often exhibit,s a symphysis with thick, more square outlines. Exceptions
can be found if a search is made, but these cha.racteristics can be identified in
many cases.
It would seem that the presence of these facial types can be taken to in-
dicate that certain functional and morphologic characteristics prevail. The mere
fact that these tendencies can be observed is worth while as a clue for use in
estimating the future. This is a conjecture to be borne out or refuted by re-
search. Clinicians have reflected this suspension in the often-heard expression
“them that’s got-gets” when it comes t,o a chin. Investigations of the cross-
sectional area of the chin should be correlated with mandibular width. As shall
be seen later, this is only one part of a whole complex.
POINT B BEHAVIOR. It is of particular importance to visualize the different
growth patterns of the whole face in order to understand the behavior of the
erupting t.eeth and of point B, which is directly related to the shifting of these
teeth. In 1953 Brodie16 completed the study which he originally started in 1940
on the growth pattern of the face. He noted the tendency for the teeth to shift
on the basal bone of the mandible after the age of 8 years. In his own words:
The late stages of growth have been shown to be accompanied by a continuation of
forward and downward movement of the anterior nasal spine and of pogonion, while the dental
arch and its supporting bone tends to move more slowly and thus drop behind. This de-
creases the prominence of the denture. At the same time, however, such behavior is not
necessarily accompanied by a more upright position of the incisors. These teeth may become
less procumbent, more procumbent, or many remain at their original axial inclination.

Brodie employed the occlusal plane and dropped perpendicular lines from
the occlusal plane in order to reach his conclusions. He referred to t,he pre-
viously mentioned work of Xchaeffer in support of those conclusions.
 With similar observations, Bjijrk placed implants as far down on the ~J%I-
physis as he could from inside the mouth. In his preliminary studies OVV!
short ranges, Bjiirk demonstrated that metallic implants tended to remain ill
the same position and that actual resorption of bone was occurring in the arc’;1
of point B. In a patient with condylar arrest and alteration of pa,tt,crn, Hjiit‘k
demonstrated that apposition did occur at the angle of the mandible in a CIUI-
centric layer adaptation, possibly as a function for a masseter mu&c 01’ ptcl’: -
goid internus bracing. In that particular case, superimposing on tnrtallic ir+
plants revealed the probability of appositional changes on the bon?: chin. hrlt
in the majorit>- of normal persons resorption of the bonth occurrt~l in the :t~‘c’:t
of point B.
BjSrk’s latest studies of the chin and point B have demonstrated no app+
sition of bone in the region of pogonion. Some apposition was suggested in tijct
area below pogonion, but the area of the m.entnl protubwunce was n’ot dwn,qr (1.
ResorpCon was almost routinely demonstrated in the area of point K 213 t iw
incisors shifted vertically with growth. The increase in thickness of the s:v:~I-
physis seemed to be appositional on the posterior and inferior borders.
By using t,he “central core” thus registered by implants, new light, Nil:>
shed on the directional eruptive possibilities of the teeth. The typical helmviol*
was one of straight upward eruption. Extremes suggested, however, that th(b
teeth could erupt either upwasd and forward or upward and backward 1’r~~m
the body of t,he mandible. The lower incisor was shown to move hncA~~rr-tl
naturally in those eases of obtuse growth. of t,hc mandible. In brachyfacial tylj(lS
the incisor seemingly demonstra.ted for.~~~~l! eruption tendencies. Therc:For~~,
it might be hypothesized that in the brachyfaciat typr the lower anterior tl)cth
will be stable in a more forward position when related to the symphysis.
Further discussion of the behavior of point, K is rc>lati\-c, to trc~atmrnt. J’ctint
K tends to follow the lower incisor. It will bc obstirvcd t~linically that al’trr
forward movement of the lower incisor a ledge of bonct in the planum dvtYJlar
will a,ppear on the lingual side; this will 1~ retained for a time but, will grt~d-
ually disappear. However, no such shelf is seen lahiall,v after lingual nlovrlnSJnt
of the teeth. This would imply that tho hclav>-. slow-rc~sorbing bone is lo~nt ccl
on the lingual side.
BEHAVIOR OF THE LOWER INCISOR. (3ne of the first critical studies with I’(‘-
gard to positioning of the lower incisor during orthodontic treatment, was l)A-
lishcd by IAtowitz17 in 1948. He referred to the earlier work of 8pGdcl ;tntL
Stoner,l” who related the long axis of the incisor to the mandible iu atlll1t.s.
and also to the earlier work in cephalometric analysis conducted in 1936 by
Brodie, Downs, Goldstein, and Myer. IQ Litowitn studied twent;v t.rc~at~t~cl MSCS
and reached the following conclusion:
The tracings of the mandibular symphysis with the incisor tooth gave striking cvidenw
that teeth do not move through bone but rather that the alveolar process is remo&Ic~l as
t,he teeth change their positions. When teeth are moved labially, the alveolar procw+ follows
ant1 when relapse occurs, the bone returns with rhe tooth.

Litowitz further stated tha.t a disturbance of the root apex or (‘rown was
followed by a return to the original position in almost every case, particnlady
if SUCK movemeut had been in the labial direction. In almost every case treated,
however, there was much growth following orthodontic treatment. Litowitz
pointed to the confusion of methods and the various interpretations that could
be made by comparing individual cases in which different techniques had been
used.
I also became concerned about the multiplicity of factors to be known or
understood in the behavior of the lower incisor as a key to treatment planning.20
I studied 150 orthodontically treated pat,ients and compared them with 100
nontreated cases. The behavior of the lower incisor was measured in fifty pa-
tients during treatment with ordinary cervical extraoral anchorage, in fifty
patients treated by intermaxillary anchorage only, and in fifty patients in
whom a combination of intermaxillary elastics and headgear had been employed.
That study was conducted in an effort to provide some data for the plan-
ning of treatment and for the comparison of lower incisor movement during
treatment. The observation period lasted almost 3 years, during the transition
from the mixed to the permanent dentition, or when the patients were at an
age at which children are commonly treated with cervical t,raction and at which
the 2.7 mm. shortening of arch length was supposed to be occurring. The
cephalometric technique employed called for dropping of the perpendicular line
through pogonion to the mandibular plane and measurement of the lower in-
cisor parallel to that line.
In nontreated Class I cases, the lower incisor was located at an average of
about 8 mm. posterior to that perpendicular line and moved about 1 mm. back-
ward during this 219, to 3 year observation period (Fig. 3, A). In the Class II
sample, this movement was only about one half that amount. Stretching this
behavior over a long span would suggest that the lower incisor could possibly
move as much as 3 to 4 mm. backward from the mental protuberance from the
time it erupted until full growth was reached. However, a I to 2 mm. shift
should be expect.ed often.
A contrast in behavior of the lower incisor under the various types of
treatment was noted. Although mandibular growth in the three treated samples
was almost identical to that of the nontreat,ed samples, the behavior of the
lower incisor differed radically. It was shown that the effects of the headgear
contributed to an average lingual movement of almost 1.5 mm. during the time
that the neck strap was worn (Fig. 3, B). The lower incisor tended to move
lingually even more than normal. In Class II patients treated with intermaxil-
lary elastics, the average lower incisor moved 3.0 mm. labially when measured
to the symphysis (Fig. 3, C). On the average, therefore, treatment of Class II
cases by headgear or by intermaxillary elastics alone eventually yielded, at re-
tention of the incisor, an average of 4.5 mm. difference in forward or backward
relation to the anterior border of the symphysis (Fig. 3, D).
A position forward or backward can be related theoretically to arch length
by adding the difference on both sides. Thus, a 1 mm. forffard or backward
position of the lower incisor yields 2 mm. difference in arch length as measured
from the molar. Naturally, with changes in arch form, this is not always true.
Given no change in the arch form, however, a difference of 9 mm. between the
 Keystone trial 7 35

two groups is more than the width of an incisor. When a combination of head-
gear and elastics was worn, the average patient behaved almost exactly as one
in the nnt.reated Class I sample, although about. 35 per cent of these cases wcrc
extraction cases during treatment as were those in the intermaxillary tllastics
sample. The technique employed involved measurement from a vertical line
through pogonion perpendicular to the mandibular plane. Over short spans
this method was considered reliable.
From deductive reasoning, I came to treat many cases of mandibular alveo-

C.-r. -1.5

C D
EL. 3-3.0 DIFF 4.5
Fig. 3. A, The normal tendency for movement of the lower incisor relative to the symphysix
(registered on the symphysis and the mandibular plane) in 100 normal persons followed
during the transition in dentition. Notice a 0.7 mm. posterior movement of the lower incisor.
13, The average behavior of the incisor in 100 Class II cases treated with cervical tractiou
on the upper arch hut not treated on the lower arch. The distal movement of the Iow~r
incisor was double that usually experienced, now being 1.5 mm.
C, The average behavior in Class II nonextraction patients treated solely with intermaxil-
lary elastics. It will be noted that the lower incisor moved forward 3 mm. during inter-
maxillary traction.
D, The difference seen between the Class II cases treated with intermaxillary elastics and
those treated with cervical traction. Dotted area indicates that position of the lower incisor
typically observed in patients treated with extraoral anchorage. Darkened area indicates
position following intermaxillary elastic treatment. The mean difference, therefore, results
in a 4.5 mm. difference in the position of the lower incisor relative to the symphysis and
yields a 9 mm. arch length (4.5 x 2 = 9).
lar retrusion with iIlt,~~~ltlasilIiI~y dastics i~lom!, all I10ugl~ in sucli cas(ls t.li~~r~~
was a calcdatrd risk of forward movement of the incisors.” The IOW~I incaisors
were observed to bc moved forward c\rasticaIIy in thcst: patic>nts, thr nlor~mwnt
of some cvcn approaching 1 full ccntimetcr. After a time, the alveolar ?KNK!
seemed to re-form on the labial aspect of the tooth. Most cases treated !n this
manner appeared to be holding well several years after orthodontic treatment,
which would be contrary to the findings of Litowitz. Even though these teeth
were upright or moved lingually during retention, it should be pointed out that
a slight lingual drift M-as consistent with normal development and was there-
fore to be expected.
Clinicians often fear a loss of bone or a clefting of tissue labial to the in-
cisor, called “stripping.” Often stripping of the lower incisor has occurred
even before the start of treatment. I have claimed that this is due to extreme
tightness of the mentalis muscle and to a pressure ischemia. In other subjects
it was consistent with a history of traumatic conditions.
I should state immediately that the lower incisor should never be moved
promiscuously, as it has been with many techniques. In many cases, however,
particularly those in which patients have short brachyfacial patterns, the lower
incisor is actually intruded as it is brought forward into a wider portion of
the symphysis and therefore results in greater covering on the labial surface
instead being “shoved” out of the bone.
In the treatment of some patients with stripping, various clinicians recom-
mended extraction to prevent forward movement of the lower incisors for fear
of further bone loss. Other clinicians, however, have indicated that a forward
movement is desirable in spite of stripping and prescribe long retention periods.
In still other patients, it has been recommended that the lower incisors be re-
tracted lest they move backward under tension of lip muscles if the arch were
expanded.
These arguments show t,hat a factor entirely independent from esthetic
considerations has prevailed. In discussing behavior of the incisor clinically,
two other observations should be mentioned. It will be noted that, without ex-
ception, a change in point B is directly related to the behavior of the lower
incisor-so much so that a measure of the lower incisor is a measure of the
change in point B. Furthermore, the thickness of the soft tissue labial to point
B remains the same to a remarkable degree. A comparison shows that the thick-
ness of tissue of the lower lip labial to point B is almost identical in all but a
very few cases. A change in position of the lower incisor with its accompanying
alveolus very definitely affects the soft-tissue contour of the sublabial area in
either direction (forward or backward). 23 In this manner, an esthetically cf-
fective chin can be either produced or reduced.
FACTORS IN U)NG-RANGE PROGNOSIS. In a longitudinal study in which age
groups were used in order to dovetail for the full age span, Bencll”3 correlated
changes of the hyoid bone relationship with the growth of the cervical vertebrae
and the behavior of the denture profile. He showed that the hyoid bone con-
tinued to drop downward from the chin at ages later than those at which active
stages of change are usually thought to be taking place. In addition, Bench
measured the position of the lower incisor and showed that these changes Jver’t’
consistent with the alterations of the hyoid posture. He further showed a strong
correlation with changes in the hyoid bone and growth of the cervical vert(‘bra(‘.
In patients in whom growth of the cervical vertebrae was not occurring and in
whom bra&ycephalic tendencies were seen, he was able t,o demo’nstrate marked
forward growth of the chin. In other patients with severe dropping ol tl,c’
chin a,nd vertical cervical growth, there was an upward and backward alt(‘r;l-
tion in the outline of the symphysis as the lower incisor drifted posteriorl?
According to all the foregoing basic and clinical studies, t.he natural form
of the chin and the natural position of the teeth seem to be correlat.ed wit 11
deep underlying nebulous factors and tend to behave in a biologic spiral. Thx
height of the individual, growth of the cervical vertebrae, the form of TII~~
mandible, the width of the face, the changes in the tongue and hyoid I)oII(~.
and the individual characteristics of the lip and mouth were seen to play :t
role in determining the relationship of t,he chin to point, B and the lower in-
cisors. It was hypothesized that most crowdin, v of lower incisors was due I*)
growth changes rather than to the force of third-molar eruption, as commnnlh
claimed. In other words, the forces producin g the rollapse were coming froiil
the anterior area to crowd the anterior teeth backward. The third molars l),‘-
came a buttress in this sense.
In describing various characteristics of t,he mandible as a background t’(11
the estimation of growth during orthodontic treatment, I included a consid-
eration of all these factors. ” It will be recalled that I further described t(.rr
different characteristics of the mandible to be considered in an estimation (‘s-
ercise, O~C of which was t,he width of the symphysis. The natural f()rc(bs Irl
growth and change have been shown to he of vital (aoncern to a full ~oml,~-
hension of orthodontic planning and secure? ultimate results. The secret ,it’
stability of point B or the lower alveolar bone is, t.hcrefort, a prime consider;i-
tion. Thr key to this understanding is a knoxledge of the function of the JI,IIS-
culat ure of the tongue and lips and the natural growth of the (ahin wit11 its
alveolar boric. My clinical criterion for proper managt~mc~nt, of the lolv~r jr,-
&or thus follows.

CLISIChT, ISTERPRETATION

TOOTH AXGIJLATION VERSUS SPATIAL RELATIOR. ~?%tiCCd~y ail i?W.?stigat(~r,&

front 19.i.5 to 1955, were measuring the angulation
of the lower incisor rrrthrl
than its spatial relationship to the symphysis or profile. For the most part,
the orth,odontist was trying to avoid the wovenlent of the ape3: of the incisor
for fPar of root resorption or destruction of the alvcbolar bone or gingival I is-
SW. TtJ appeared to mc, however, that the angulation of the tooth was less iln-
portant, than its t,rur anterior post,erior position. Tll~ question was : "To w11;1i
sho~ltl it 1~ rc~latrd?” We accepted, ant1 still clt~frnd, pogonion and l)oint ,\
as 111~. atilc~rior limits 01’ bnsal lwttt: in 111~ tn;~tldilml;~r ant1 niasillary IWIIC~.
rctspwt ivthlv. Thcrcforc>, I started measuring tliv I)ositiou of 111~ tip of tlrc. St,-
cisor to the lint A-pogonion for various B(‘ilSOIlS (Fir. 1, -1 2nd Ii 1. l+'or* tit,-
scriptive purposrs I called this thcl fl(~nllltY~ 1,lilTli’.
738 Ricketts Am. J. Orthodontics
October 1964

A B
Fig. 4. The different inclinations of the A-pogonion plane as revealed in concave faces (A)
and convex faces (B). This is the line thought to be most useful and critical in the clinical
evaluation of the lower incisor.

We learned from the study of comparative anatomy that certain animals

with diminished development of the maxilla have a lower incisor that is lingually
inclined in such a position that it functions as a reciproca’l member for both
jaws. The tooth serves both jaws, not just the mandible or the maxilla alone.
With this functional consideration in mind, the A-pogonion plane was later
referred to as the reciprocal denture plane. In order to describe the labio-
lingual location of the lower incisor, I have employed the APO plane as the
most useful clinical reference; today, after 15 years, I stand more firmly on
that conviction than ever (Fig. 5). Why have I become more insistent con-
cerning the value of the A-pogonion plane as a sensible reference for the lower
incisor? What is the controversy?
The chief argument advanced by the opponents of this approach is that
pogonion is unstable because of secondary growth characteristics or the devel-
opment of a button on the chin, which makes it unusable because of the addition
of bone on the chin. Furthermore, many are concerned over the acceptance of
narrow standards or a single ideal incisor relationship for the population as a
whole. I also have sensed that clinicians fear any method which would ever
suggest that the lower incisor should be moved forward. There are also those
who believe that planning should be initiated not with the lower incisor but,
with the molars. Finally, and hardest to comprehend, there is the need for
realizing changes in point A or the chin with growth and treatment-a con-
sideration of dynamics rather than statics in interpretation of the lower incisol

from the APO plane.

For t,he purpose of constructive argument, I would pose three questions 511
defense of the use of the reciprocal denture plane reference for the lowN* in-
cisor : (3 ) If point A changes with orthodontic treatment, why is it maintained
as a basal point? (2) What true basal point at the anterior border of the marl-
dible is most usable? (3) When a so-called “button” develops, what is it. lion
does it form, and how frequently?
In answer to the first question, point A, selected at the deepest point OR
the contour of the bone between the anterior nasal spine and the alveolus, does
change when the upper anterior teeth are moved. However, the nasal spine is
definitely a process and the alveolar process is a process, and between thtJst&
two lies the most basic part of the denture base at the anterior limit. It shoul(\
be mentioned that all bone in the anterior pnrt of the maxilla is thin and, zmni-
nated. NO true heavy compact areas are available for reference in the same:
sense as the symphysis. Since point A was originally defined, various clinicia,ns
and investigators have sought a better reference point., but clinicians somehow
have continued to go back to the basic point first described. Point A must 1~:
selected carefully, but it has proved to be a vastly useful point to most of tll()sca
who have understood its problems and variations.

Fig. 5. Range of variation in the two standard deviations from the mean in l,OOU ortlro-
rlontic eases. The darkened area in the center shows average or typical position relative
t.o the A-pogonion plane, that is, 0.5 mm. forward and at 31.5 degrees to the A-pogonion
plane. The striped tooth to the lingual, for practical interpretation, is -6 mm., and the dottetl
tooth is +8 mm. to the A-pogonion plane. Phnnin g is usually conlirrtrd to one standrtrd tlwin-
tion, or -3 to +3.
740 Ricketts Am. J. Orthodontics
octotw 1964

D
Fig. 6. Patient S. L. Tracings of a girl from age 9 to age 15 depict a patient with severe
brachyfacial type of growth similar to that seen in Fig, 2. Note the retraction of the lower
incisor, which explains tbc severe button increase. Very little increase in facial height was
seen in this brachyfacial patient, as the facial angle increased from 92 to 95 degrees and
the ‘Y axis closed 3 degrees during this treatment period. This behavior occurred despite
the fact that the patient was treated only with intermaxillary elastics and every attempt
was made to bring the lower arch forward.
 I think that the answer to the second question has been covcrcd in my first
article on the keystone triad. According to implant studies, there does not al)-
pear to be a better anterior basal landmark on the chin than pogonion, eith(Lr
for serial work or for morphologic reference.
The answer to the question about the frequency of a so-called button drb*
veloping is still to be found. We do, however, have some information on how
prominent chins develop and at what age.
I have selected from my practice the serial records of three patients to il-
lustrate the most extreme cases of developing promimlnt chins that, I havcl tv~~r
witnessed.
The first case (Figs. 6 and 7) demonstrates the retrusion of the denttlr(a
that. occurred as a result of forward growth of the mandible and shift,ing of tl~c
teeth in closing spaces. Extremely small teeth were present. I have seen this
phenomrnon on numerous occasions when spaces were closed orthodontic4 iy
because of congenitally absent teeth. A depression developed at, the chin in tllca
area above the mental protuberance. This change has been observed frequently
bp clinicians disciplined to extract in a very high percent,agr of cases. whttn a~
chorage was overly conserved.
The second patient showed no suggestion of a bony prominence in the arca
of the chin a,t the age of 7 or 8 years (Figs. 8 and 9). By the age of 1’7 :1r1
apparent button of several millimeters was seen in the lateral head film. On closc~
inspection, however, a double outline was not.ed. It was observed in the oblique
film that the chin was characterized by an extremely large bony prornincncti
at the Znteral aspect of the symphysis, namely, t,he mental tubercle. I would
conjecture that this might account for the difficulty encountered by many clini-
cians in superimposing on the symphysis in some cases.
The third patient underwent cleft, palate correction in three or four different
stages over a period of almost IO years (Figs. 10 and 11). The lower arch m-as
employed for anchorage, and vigorous traction led to its backward movemerri
to bury first the lower first molar at one stage and then the lowttr secontl molars
 L.R.. 9-l 18-3 \

/-v-f// A * f7/-?/

I
I
\
I
I
I
I
I

I
I
\

‘. ‘.
Y-. .* I\
C D
Fig. 8. 8, Tracings of boy between the ages of 9 and 18 with marked vertical development
during growth and treatment, similar to the type shown in Fig. 1. Very little change was
seen in the facial angle, which usually increases in a normally growing face. Note that tb
Y axis changed from 0 to -5 degrees during this interval.
B, Comparison with B reveals that the great amount of growth appeared in the area of
the outline of the chin; however, careful vieTYing suggested that this was lateral to the mid-
line in the area of the mental tubercles. A severe clefting of the bony chin was found by
palpation. Notice, finally, that both the lower incisor and the lower molar erupted extensivt>ly
in this type of growth pattern (C and D).
Fig. 0. Before- and after-treatment roentgenograms of patient shown in Fig. 8.

at a later time, even after premolars had been extracted. It would be hard to
imagine anything other than a shift of the denture on the base of the mandible,
since the width of the symphysis did not thicken at all. An esthetically ‘Lstrong
chin” was developed, with no bone increase in the symphysis.
CLINICAL USE OF THE APO PLANE. Many clinicians have had trouble in using
the APO plane for reference because of the dynamics of growth change. Before
planning treatment, the clinician should have a knowledge of the variations
in lower-incisor position that exist in nature. It was for this information that
I measured the first 1,000 clinical orthodontic cases seen in my private prap-
tice (Fig. 5). The findings revealed that the average lower incisor was 0.4 mm.
ahead of this plane, or about 0.5 mm. for practical purposes. Its variation was
t2.7 mm. in standard deviation, but again for practical use I have called it
t2.5 mm. In general, convex faces displayed lower incisors that were forwalad
on the chin, and in concave faces teeth were more retrusive from the symphysis
because of the seeming adaptation of the incisor to the contour o-f the fact>.
I related the lower incisor to different age groups in that same cross-sectional
st,udy. It was seen that the convexity of the face diminished in the age groul.is,
but the lower incisor remained within 1 nlnz. of the same relationship to the
A-pogonion plane in all groups. I concluded t,hat the uprighting o-f t,he tooth
nnit the rctlmaction of t,hc lower incisor were commensurate with a change in
caonvexity and were part of the normal development, partic*nlarly when Itr~-
opinion was reinforced b.y other longitudinal studies.
Therefore, a critical interpretation was gained by relating only the lowc~r
incisor and forgetting about point B. The lower incisor studied in rehtion tn
the, A-pogonion plcrne automatically consitlers the fncial pnttern of th.e ikldi-
 16-I

Fig. 10. Tracings of patient P. I?., a girl, from age 5 to age 16. Clinically, this patient had a
complete bilateral cleft lip and palate, and the facial angle changed from 85 to 91 degrees
during the course of treatment and growth. An attempt was made to bring the maxillary
segments forward during treatment and the mandibular teeth were employed for anchorage,
but the teeth moved posteriorly (H). f:, A comparison shows the opening of the Y axis,
possibly produced by the prolonged use of Class TrI intermaxillary elastics. D, Tracings
suggest a movement of the lower incisor lingually to the planum alveolar of the symphysis.
Note tho upward and backward movement of the lower first molar in spite of premolar ex-
traction in the lower arch. It is difficult to imagine anything but alveolar and tooth rc-
traction producing the prominence of this chin, since no anteroposterior increase whatsoever
was present in the thickness of the symphysis.
vidual and also is useful at his state of growth ctnd de~~elopmen~t. Downs has
referred to the arc of the face in a quite similar manner of measuring rclatiotl-
ship to the lower incisor.

The final question for this essay is : “HOW do we consider the needed changes
in the lower incisor, alteration of point B, and the contour of the c~hin in ortho-
dontic treatment planning?”
Let’s fare it. In spite of recognized biologic pitfalls, most of us are treating
toward but not necessarily to some sort of average or standard. We all sock :I
ccrta.in amount of security in plannin g because, as clinicians, we must obscrvc”,
study, and make decisions and cannot continually procrastinate or take uncai-
culated chances. Therefore, we are concerned with some conceived goal, whcthcr
we admit, it or not. We can ill afford to take chances repeatedly when we -Facc~
the responsibilities of finished stable results. As one student said to mc: “I km)\\
I can move teeth but what I need is a target.”
The correct use of the Downs-Ricketts APO plane, Steiner’s NA lint, the>
Steiner-Holdaway NB line, or the Tweed triangle rests upon the predicte!tl or
estimated alteration of facial relationship result)ing from growth and trcat-
ment changes. We have concentrated first on the behavior of the chin, the
alveolus, and the lower incisor as a keystone unit, but in addition we have men-
tioned the reciprocit,y of this tooth to both jaws. Therefore, we must consitl(~r
also t,he behavior of the maxilla, or point A, in order to plan effectively.
I have stated that., in my opinion, the orthodontist should strive to play
the lower incisor within one standard deviation of the APO plane as point A cxntl
pogonion will be located at the end of treatment and possibly later. In other*
words, the lower incisor should be related to the jaws that will exist at thtl ~1
of treatment.
 0
I/

C D
Fig. 12. 8, Tracing of patient with severe Class II, Division 1 malocclusion, slight retrognathic
pattern, severe convexity of the face, and a lower incisor located lingually in relation to
the A-pogonion plane. Correction of relationship of the lower incisor to the A-pogonion plane
can be accomplished as shown in B, C, and D.
B, Correction by forward movement of the lower incisor typically seen with the use of inter-
maxillary elastics or the monobloc. Notice that the upper incisor is uprighted and slightly
retracted, with very little movement of point A.
C, Orthopedic retraction of the maxilla and point A very frequently seen with forceful head-
gear and vigorous intermaxillary elastic traction. In this situation point A is brought back
over the lower incisor, with no movement of the lower incisor relative to the chin, in order
to promote a more ideal relationship of the lower incisor to the A-pogonion plane.
D, The change in position of the lower incisor relative to A-pogonion plane as manifested
by forward movement of the chin by growth. The upper incisor is held in place while the
chin in the brachyfacial patient moves forward in a manner similar to that seen in Figs.
2 and 7.
 Keystone triad i-47

Let us, therefore, enumerate the possibilities of corrcct,ion OC the lowcr :ill-
cisor in relation to the A-pogonion plane. Let us suppose that, we have a patient,
whose lower incisor is slightly lingual to the APO planca, which is more or less
typical of many Class II malocclusion cases (Fig. I?, d ). We know that the
lower incisor normally lies slightly ahead of this reference plane and that wc
must treat the patient. We must realize that we can either move the tooth ot
effect the end points of the reference line, that is, point A or pogonion.
Again, what are the possibilities? First, we can move the lower incisor
forward (Fig. 12, B). Sometimes this is a correct choice; at other times it is
dangerous to stability. Therefore, we must be careful in recommending forward
movement of the lower teeth. However, in profiles that are already straight
we may have no choice but to do so.
Second, we can effect an alteration of point A in two ways. We can, 1)~
toryuc control, retract the upper incisor and move point 9 backward by local
alveolar alteration (Fig. 9, B). In addition, research has suggested that extra-
oral force reduces the entire hard palate or nasal floor by downward and back-
ward tipping. Therefore, it is suggested that, the maxillary growth bchavic~r
is altered (Fig. 8, C).
Another means by which the APO plane may bc uprightcd is through for-
ward growth of the chin at a faster rate than that at which point A moves
forward (Fig. 8, D) . As has been shown in many cases of natural normal growth,
such processes do occur, but they occur slowly. Forward growth of t,he chin,
carrying with it the lower teeth, thereby corrects thtso teeth to the jaw rcla-
tionship.
The final possibility, and probably the most common, is the combination
of any two, three, or four of the foregoing. Given a case in u-hich the lowcl
incisor is in a retroposed or retruded position, one could move it forward
rapidly in the denture profile by a combination of backward movement of point,
-4- local forward movement of the lower incisor, and forward growth of the
chin, carrying with it the lower incisor. Such cases show marked improvompnl
in a matter of a few weeks!
However, in given cases of severe convexity and mandibu1a.r retrognathisnl.
in which lower incisors need to be moved posteriorly, the problem is more (as-
treme a.nd it, takes longer to achieve the desired results. In such cases point A,
or the maxilla, must be retracted over greater distances, which takes longer to
achieve. Also, forward mandibular growth is needed. Longer periods are ad-
voretcd t,o take advantage of growth in thpsc patients.

CLINICAL PROBLEMS

In the final analysis, the orthodontist is dealing mainly with occlusion (don-
tal or orthodontic) and profile relationships (orthopedic, skeletal, or structural).
He works with the profile of the face but, perhaps more important, also with
the profile of the denture. The profile of the face can be measured from the
facial plane (N-PO), and the profile of the denture can be measured to the
denture plane (A-PO). These lines or planes serve as references. Findings and
standards serve as guides for the orthodontist’s discretion in correction. He
 has his choice. .If he wants to correct convexity or concavity, hc attempts to
line UP the anterior part of the maxilla toward the facial plant. Tf 11~ lv;ltits
to correct the dental convexity, hc attempts to lint 111)the teeth to t,hc dcnturc
plane.
All faces arc not alike, however, and in many casts the wisdom of correct-
ing skeletal convexity can be questioned. Likewise, the need for full dental
correction to flat relationships is doubted when the lips are loose and flaccid,
when the tongue is large and forward, when the nose is long, or when a fullness
of the denture will be stable, where the mouth can be closed with no strain and
is esthetically acceptable, and where the teeth are long-lasting in service to
the patient. It is within these parameters that wc differ in value judgments.
In actual practice, and in the prognosis of a trca,tment, I try t,o hold to
the principle of accepting a range of variation within the confines of one stan-
dard deviation from the mean of the antcroposterior position of the lower in-
cisor to the APO plane. This usually yields a range of approximately 5 mm.
(-2 mm. to +3 mm.). In individual cases with aberrant muscle problems, these
limits are extended sometimes to beyond one standard deviation (-2 to +5 mm.)
without harmful effects when the teeth are stable, the lips are smooth in con-
tour, and the mouth can be closed with relaxation.

SUMMARY

This is the second of two articles discussing the chin, point B, and the
lower incisor. I have called this unit the keystone triad. Basic science and
laboratory investigation have suggested t,hat deep biologic phenomena are
responsible for chin form and denture behavior. Clinical studies of growth
have been numerous and point to an average tendency toward natural retraction
of the lower incisor with growth and maturation.
The development of the chin may be considered in two aspects: (1) the
forward thrust of the chin as it is carried forward by growth of the condyle
and ramus of the mandible and (2) the local alteration in shape and contour
of the symphysis by remodeling resorption in the area of point B and ap-
position on the lingual and inferior borders of the symphysis. Little or no
apposition has been noted in the mental protuberance or pogonion area. The
symphysis seems to be unaffected by orthodontic treatment, except for the
adaptation of the planum alveolar and alveolar bone as the teeth are moved
forward or backward and point B follows.
The prevailing concept is t,hat masses of enveloping muscles move the den-
ture as growth proceeds. Long-range prognosis depends upon the clinician’s
sophistication in understanding these biologic forces. The difference in be-
havior of the incisor with various treatment procedures was reviewed. A 4.5
mm. mean difference in position of the lower incisors in relation to the symphy-
sis was noted between extraoral anchorage and intermaxillary anchorage Class
II correction in nonextraction cases.
The position of the lower incisor in the jaws seems to bc more adequately
defined by an anteroposterior measurement than by its axial inclination. Our
criterion for clinical analysis is the incisor’s relationship to the A-pogonion
plane, measured in millimeters from the in&al tip and the angle of its long
axis to the APO plane. Even when so-called “buttons” are present., the point
A-pogonion relationship for the lower incisor still seems to be useful.
For cont,emporary orthodontics, a knowledge of this unit (the keystoncl
triad) is a key to treatment planning. Proper execution of this method depends
upon conceived a.lteration of point A, because the lower incisor is referred tcr
point A through this plane in a reciprocal relationship to both jaws that it
must serve. The growth of the chin looms as a matter of equal concern. In or&t,
to use point A and PO references, their behavior must be estimated during
treatment.
I have attempted to treat toward the mean (to.5 mm.), or to within on(’
standard deviation of the mean of the anteroposterior position of the lowet*
incisor to the APO plane. In the broad sense of variation, this is -2 to -6 mm.
If I have not achieved stability with this arrangement, then I am willing to
accept the risks of relapse, because this range seems to be a sensible guide it,
the light of contemporary esthetic and functional objectives.
Mouth esthetics will almost always be complimentary to the face when t,hr*
teeth are arranged in the manner suggested in this article. I believe that when
esthetic harmony is achieved, the chances of functional equilibrium are vastl!,
improved. The goals described here have been developed from studies of the
normal and from more than 1,000 successfully treated malocclusion cases. This
is the manner in which normal faces are arranged, and I simply try to ximulati>
normal conditions by using the criterion proposed here.

REFERENCES

1. Ricketts, R. M.: The Keystone Triad, AM. J. ORTHODONTICS 50: 244-264, 1964.
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3. Keith, Sir Arthur, and Campion, George G.: A Contribution to the Mechanism of Gromiil
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11. I,ande, M. J.: Growth Behavior of the Human Bony Profile as Revealed by Serial (‘~phalo-
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the ‘l’rc~atmrnt of Class II Malocclusion, JIM. .J. OIY~~~~D~~ST~CS 38: 91X-933, 1952.
750 Ricketts Am. J. Orthodmtice
October 1964

14. Bjijrk, Ame: Cranial Base Development, AX. J. ORTIU.ILIONTICS 41: 198.225, 1955.
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