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II TransverseDiagnosisOPUS
II TransverseDiagnosisOPUS
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John Hayes
University of Pennsylvania
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Abstract
This article proposes a new a lab method, using dental Educational aims and objectives
The aims and objectives of this article are to: (1) illus-
casts, to determine the “center of the alveolar crest” trate a new measurement method, with easily identifi-
(CAC) at the molars, which is then measured bilaterally able landmarks, to approximate the skeletal transverse
of the maxillary and mandibular arches by measuring
to record a skeletal transverse dimension. A total of 114 from the center of the alveolar crests (CAC); (2) sug-
consecutive untreated patients were then evaluated gest a range of maxillary transverse values that would
be compatible for a given mandibular CAC based on
for their transverse skeletal dimensions using the criteria found from old and prehistoric arches; (3)
CAC measurement. New criteria for determination of more clearly define and diagnose a possible maxil-
lary deficiency; and (4) show the CAC measurements
skeletal transverse deficiency have also been proposed. of 114 consecutive untreated patients to gain some
Using CAC measurement and the new diagnostic sense of maxillary deficiency prevalence in one private
practice.
criteria, 108 of the 114 patients were judged to be
maxillary deficient. The severity of deficiency varied;
some patients were judged to need more maxillary Expected outcomes
Reading the article and correctly answering the questions on page XX,
expansion than others. Thirty-four patients out of the worth 2 hours of verifiable CE, will demonstrate to you that:
114 presented with posterior crossbite. • The skeletal measurement of dental casts using the CAC technique is a
skill that can be learned and mastered.
• The diagnosis of each patient could include a transverse skeletal
I. Proposed CAC measurement technique– assessment of maxillary deficiency or sufficiency based on CAC
measurements and the newly suggested diagnostic criteria.
using dental casts1 • Improved transverse skeletal diagnosis along with other diagnostic
This article proposes a new lab method, using dental techniques can be used to develop an appropriate orthodontic and/or
orthopedic treatment plan.
casts, to estimate the CAC at the molars, which is then • If and when agreed-upon skeletal transverse measurements and criteria
measured bilaterally. The CAC features less variation for maxillary deficiency can become well accepted, patients will tend to
be more consistently diagnosed and treated, and orthodontists should
than measurements at the buccal aspects of the arches. find fewer differences of opinion for second opinions.
This technique avoids the need for posteroanterior (PA) • Orthodontic research needs agreed-upon skeletal measurements and
criteria for improvement in the validity necessary for evidence-based care
films or cone beam computed tomography (CBCT) in (EBC).
an attempt to diagnose a patient’s transverse skeletal
situation. It is hoped that the ease of measurement and
less variation in landmark determination will lead to
more consistent skeletal transverse diagnosis.
Method 1
A caliper is used to capture the buccal and lingual aspects
of the ridges slightly apical to the cemento-enamel
junction (CEJ), which is the alveolar crest area (Figure
8). A caliper set at 14.5 mm is a good start (however,
the caliper may need to be adjusted between 11 mm
and 14.5 mm depending on the buccal-lingual width of Figure 8: Method 1: Measurement of maxillary arch with
caliper. Posterior teeth have been removed to level of CEJ for
the molars). The caliper is then placed over the mesial- demonstration purposes only. CAC shown with the dashed
lingual cusps of the maxillary molars, and a bisecting lines
mark is then made on the teeth representing the mid-
point of the ridge (Figure 9). Bilateral measurements are
recorded. For the mandibular arch, the central fossa of Method 2
each mandibular molar is used, and a bisecting mark is A caliper is not used. Sighting along the maxillary bony
made (Figure 10). Bilateral measurements are recorded. ridge, one draws a curved line to conform to the center
Figure 9: Method 1: Caliper measurement at mesial-lingual Figure 10: Method 1: Caliper measurement at central fossa
cusp of first molar. Location is bisected for CAC of first molar. Location is bisected for CAC
Figure 11: Method 2: Maxillary arch. Sight along ridge while Figure 12: Method 2: Mandibular arch. Sight along ridge
ignoring teeth while ignoring teeth
of the curved alveolar ridge (Figure 11). During this Regarding the accuracy and repeatability of CAC
exercise, the locations of the teeth are ignored because measurements: we will see later that there is, by
teeth are usually inclined and not well-centered on experience, a generous biologically stable range of
the ridge. As with method 1, a second line is drawn acceptable maxillary values for a given mandibular
perpendicular to the center of the ridge line at the CAC transverse dimension. Accordingly, exactness of
mesial lingual cusp tips of teeth Nos. 3 and 14. Bilateral measurement by the CAC technique does not appear
measurements are recorded. For the mandibular arch, to be requisite. However, given some experience, it is
as with method 1, a second line is drawn perpendicular reasonable to expect accuracy and repeatability to be
to the center of the ridge line at the central fossas of teeth within 0.5 mm. Just as we do not need to use a high-
Nos. 19 and 30 (Figure 12). Bilateral measurements are powered microscope to see the writing on this page,
recorded. measuring the CAC of arches to the 0.25 mm would
For either method, the CAC measurement points likely be overkill. For several years, the author has found
and the resulting transverse dimensions should be that orthodontic residents, after a short course in CAC
identical. measurement, easily find confidence in measurement
accuracy and repeatability. The CAC technique has
Discussion also been taught to orthodontic assistants with similar
Molars that are rotated or have drifted due to premature results.
loss of primary teeth or for any other reason will require
an approximation to record the location where the Conclusions
molars should have been located. Additionally, with 1. “Center of alveolar crest” is a measurement that
older patients, one may have some difficulty locating can be used bilaterally for diagnosis of the skeletal
the center of an edentulous ridge due to resorption at transverse dimension by way of either CBCT or the
the buccal aspect. Approximation will also be necessary proposed dental cast technique.
if the first molars have not yet erupted on a very young 2. CAC is determined at or slightly apical to the CEJ
patient. at the 6-year molars. This measurement technique is
References
1. Hayes JL (March, 2003) A clinical approach to identify
transverse discrepancies. Presentation to the Pennsylvania
Association of Orthodontists, Philadelphia.
Results1
Age demographics graph (Figure 13)
Ages ranged from 5 to 17 years. The predominant age
group was in the 7-9-year segments.
Mandibular arch graph (Figure 14), Table 1 Figure 15: Maxillary CAC measurement of 114 consecutive patients
Average transverse width (male and female combined),
some class II patients will be aided in their growth in width to the mandible as determined by CAC
toward class I by improving the maxillary width to at measurement for “acceptable harmony.”
least within 4 mm of the solid black line representing 4. Some of the 114 subjects needed CAC expansion
“optimal harmony.” in excess of 10 mm; others needed CAC expansion
It is interesting to note that the widest maxilla as little as 5 mm to reach “optimal” harmony. Most
is not from a patient with the widest mandible, and patients were between these recommended expansion
the narrowest maxilla is not from a patient with the goals.
narrowest mandible. As one moves to the right along the 5. Considering the 114 consecutive pretreatment
x-axis, towards mandibular values of 47 mm or more, patients in the study, no arches of those patients
the likelihood of a class III growth pattern increases. approached the interarch “ideal harmony” found from
Accordingly, for young patients, a wider-than-average a previous study of old and prehistoric skulls.
mandible may be a predictor of future class III growth. 6. Using the CAC measurement technique and the new
As revealed, there was variability among patients diagnostic criteria for the skeletal transverse, 108 of
in transverse CAC dimension. Using the new the 114 patients were judged to be maxillary deficient.
diagnostic criteria for the skeletal transverse, 108 of Thirty-four patients out of the 114 presented with
the 114 patients were judged to be maxillary deficient. posterior crossbite.
Maxillary skeletal transverse deficiency may be more 7. Maxillary skeletal transverse deficiency may be more
prevalent than previously thought, based on CAC prevalent than previously thought.
measurement and the new criteria.
The severity of deficiency varied; some patients
were judged to need more maxillary expansion than
others. For example, considering males, with “optimal John L. Hayes, DMD, MBA, received
harmony” as the criterion, the CAC expansion his dental degree from the Boston
recommendation varied from 5 mm to 17 mm in the University H.M. Goldman School of
sample of 58 subjects. For females, with the same Graduate Dentistry and his orthodontic
criterion, the CAC expansion recommendation varied certificate from the University of
Pennsylvania School of Dental
from 5 mm to 14 mm in the sample of 56 patients. Medicine Orthodontic Department
It was found that CAC measurements, post-RPE where he is a Clinical Associate. Dr.
did not change over time from measurements taken Hayes is on the Editorial Review Board
immediately after RPE removal. Thus, the skeletal of the American Journal of Orthodontics and Dentofacial
changes remained stable. Orthopedics, as well as Orthodontic Practice US. He
continues to research and lecture on the advantages
On the other hand, the dental measurements did of early interceptive treatment and on the etiology of
change, as suspected, once the RPE was removed and malocclusions. He is board certified by the ABO. He has
when the arches were not held in retention. Dental been the secretary of his local dental society since 1986.
relapse post-RPE could easily be determined when Dr. Hayes is in private practice in Williamsport, PA, with
the skeletal transverse dimension was measured by his wife, Sharon, who is also an orthodontist. He can be
reached at jhayesortho@comcast.net
CAC. The dental relapse phenomenon is not new
information.1,5,6 In some cases, the relapse was 30% of
that measured by turnbuckle (a modified Haas design);
in other cases, it was more than 50%. A study by the References
author was accomplished by measurement of models 1. Hayes JL (March, 2003) A clinical approach to identify
transverse discrepancies. Presentation to the Pennsylvania
from unretained patients that were taken at least 6 Association of Orthodontists, Philadelphia.
weeks post-RPE removal compared to measurement of
2. Hayes JL (November, 2007) Kennewick Man helps to Prove
the patient’s RPE turnbuckle expansion.1 a Premise. Unpublished Manuscript, Physical Anthropology,
National Museum of Natural History, Smithsonian Institution.
Conclusions 3. Hayes JL (October 9, 2009) On the Origin of Malocclusions
1. There was variability in transverse dimensions for by Means of Skeletal Transverse Disharmony: “The Williamsport
Orthodontic Study” Presentation to the University of
patients that approaches a bell-shaped curve; there were Pennsylvania Department of Orthodontics, Annual Alumnae
numerous interarch skeletal transverse combinations of Meeting, Philadelphia.
maxilla to mandible. Not all combinations appeared to 4. Lundstrom AF (1923) Malocclusion of the Teeth Regarded
support class I occlusions, in the long term, especially as a Problem in the Connection with the Apical Base. Svensk
Tandlakare Tidskrift.
those far below the dashed line (Figures 17 and 18).
2. The author’s previous study of old and prehistoric 5. Haas AJ (1980) Long-term posttreatment evaluation of rapid
palatal expansion. Angle Ortho 50:189-217.
skulls suggested a criterion for the upper limit of
maxillary transverse skeletal width: a maxilla up to 6. Vanarsdall RL Jr (1999) Transverse dimension and long-term
stability. Seminars in Orthodontics 5:171-180.
5-mm wider than the mandible as determined by CAC
measurement for “optimal harmony.”
3. Another study by the author suggested a working
criterion for the lower limit of maxillary transverse
skeletal width: a maxilla should at least be equal