Treatment Planning with Quick Ceph Studio
Since 1986, Quick Ceph has created the orthodontic industry’s leading cephalometric software. We owe our success to a rich feature set, well known ease of use, and commitment to customer care. The program works in a simple step-by-step process: allowing you to utilize all of its powerful features while maintaining an efficient and uninterrupted office workflow. Use the steps below to streamline treatment planning of growing patients in your practice.
1. Media Entry: drag and drop all images, radiographs, model images, 3D models and CBCT-scans into Quick Ceph Studio. Align and crop the photos.
2. Locate the Landmarks: digitize 28 landmarks of the lateral x-ray and trace the outlines of the profile, the maxilla and the mandible with a mouse or stylus. Quick Ceph Studio calculates and displays the Ricketts, Steiner, surgical and many other analyses together with their list of measurements. You may even create your own analyses. Frontal x-rays may also be digitized. Quick Ceph Studio can also calculate the ALD (Arch Length Discrepancy) and the Bolton Discrepancy for you if you digitize a patient’s model teeth. Alternatively, you can measure the ALD and Bolton Discrepancy manually and enter them into the program.
3. Summary Description: go to the "Summary Description" of the Ricketts analysis at the end of the list of its measurements. Here is an example:
FACIAL TYPE: moderate brachyfacial (2.8) SKELETAL: light class II
DENTAL: severe class II division 1 MAXILLA (ant.-post.): normal
MANDIBLE (ant.-post.): normal
UPPER INCISORS: moderate protrusion LOWER INCISORS: normal
LOWER LIP: mild protrusion
OVERJET: 8.1 mm
OVERBITE: 4.8 mm
A "Summary Description" exists for the Ricketts analysis only. According to our knowledge, an equivalent "Summary Description" for the Steiner analysis has never been established. Therefore, many orthodontists use the Ricketts "Summary Description" in combination with the Steiner or user defined analysis in Quick Ceph Studio. While this is certainly possible, we strongly encourage you to learn and understand the details of the Ricketts analysis with its “Facial Axis” to highlight the growth direction of children, who are the majority of your patients.
The "Facial Type" is the most important component of the cephalometric analysis. Malocclusions with mesiofacial or slight brachyfacial facial types are generally much easier to treat than malocclusions with more severe brachyfacial or dolichofacial facial patterns. The reaction to treatment mechanics depends highly on the facial type which is derived from five Ricketts measurements. In the "Summary Description" it is listed first because it is considered even more important than the Angle classification that follows. The Steiner analysis appears to be less comprehensive because it typically uses only one measurement: the GO-GN to SN angle, to establish the facial type.
4. Growth: create a "Growth" tracing in a fraction of a second. Typically choose the default two (2) year growth period (and treatment time) for mesiofacial or slight brachyfacial patients. Choose a three (3) or more year growth period (and treatment time) for dolichofacial patients provided the patient is still growing.
5. Treatment: create a "Treatment" tracing in a fraction of a second. Initially, this is a precise copy of the "Growth" tracing. Everything so far was rather simple and mechanical and should have taken only a few minutes with the majority of the time spent collecting, entering and aligning all images; a task that could easily be delegated to a trained staff member. Now your expertise, the expertise of an orthodontist, is required. The following sections are not intended to teach you orthodontic diagnosis and treatment planning. That takes typically the first six months during an orthodontic postgraduate residency program. Rather, it shows you how to apply your knowledge to visualize various treatment options quickly, better compare the options, demonstrate them to referring dentists and patients, teach them to orthodontic residents and make treatment decisions quicker. Also, please understand that the following examples do not take additional diagnostic findings into consideration such missing, impacted or malformed teeth, caries and many many other issues.
5.1. ALD elimination: go to the pull out window on the right upper side of your "Treatment" tracing. The ALD or amount of crowding in the lower jaw is already present as a negative number provided you have digitized the model images. Otherwise, estimate and type in the space in mm required to eliminate the crowding as a negative number such as -3 or -6 mm. You can move the lower incisors forward and/or the R (right) molar and the L (left) molar backward to gain space by typing a positive number into the related boxes or drag and drop the teeth with the mouse. Watch the box "Net Change." Your goal is to bring this number to 0 mm when you are done. Otherwise you still have crowding or extra space. You can gain significant amount of space by extracting first or second premolars. Type in +7.5 mm or the measured width of the premolar on R and L for a total of 15mm. You typically need to use up the extra extraction space gained by moving the incisors backward and the molars forward. It is your decision to move the incisors or the molars more depending on what you want to achieve and what you can achieve mechanically. Additional space can be generated by stripping the teeth mesially or distally or by holding the E-space. At the end the "Net Change" should read 0 mm.
5.2. Anchorage (holding against growth) of the upper first molar: first familiarize yourself with the pull down menu "Show Reference" at the bottom of the window. Initially it shows "None." Click on "Initial." Your "Initial" tracing will be superimposed over the "Treatment" tracing. With so many lines and teeth this looks confusing first but it will become very clear when you concentrate on selected parts of the tracings. Click on "Growth" and the "Growth" tracing will be superimposed over the "Treatment" tracing. Since the "Treatment" tracing is an exact copy of the "Growth" tracing and we have not moved anything in the "Treatment" tracing yet, we see the same tracing drawn twice on top of each other. Now go back and choose “Initial." Concentrate on the upper molar. See how the upper molar grows down and forward along the facial axis. In an Angle Class II case your goal is to hold the upper molar against growth in order to establish a class I occlusion.
5.3. Mesiofacial or slight brachyfacial, maximum anchorage: if your patient has a mesiofacial or slight brachyfacial growth pattern, the anchorage of the upper molars is usually no problem. Mesiofacial or slight brachyfacial patients are typically the easiest cases to treat. Simple class II elastics or similar appliances and good patient cooperation will hold the upper molars in place against growth without the danger to extrude them and to open the bite. You simulate this by moving the upper molar back and up exactly into the “Initial" position before “Growth." Click on the menu "Show Reference" and choose “None." If the upper and lower molars are still not in a complete class I relationship you might consider moving the whole lower dentition forward slightly by dragging the lower molar and the lower incisor forward an equal amount. Make sure that the "Net Change" of the ALD calculation remains 0 (zero). Finally move the upper incisor into a class I relationship to the lower incisor and adjust its torque. Adjust the torque of the lower incisor and the tip of all molars if necessary. Click on the menu "Show Reference" again and choose “Growth”. This allows you see the amount of movements by comparing the red teeth with the green teeth. Again the green teeth show just growth, the red teeth show growth + treatment. Make sure no movement is unrealistically large.
-- Notice how important it is to be able to alternatively superimpose the “Initial" and the “Growth” tracing for precise treatment planning. Don’t forget to compare the initial profile with the profile after treatment simulation and evaluate the facial esthetics.
At the end, click on the lateral “Photo” together with the lateral tracing icon and then click on Morph to evaluate the esthetics of the projected lateral photo after treatment.
5.4. Severe brachyfacial, minimum anchorage: the process is similar as shown before in 5.3. However, it is generally not required and actually not advisable to extract premolars to eliminate the ALD in most severe brachyfacial cases because the retraction of incisors can result in open spaces that are very difficult to close. Such undesirable effects can immediately be seen by simulating premolar extraction in severe brachyfacial cases. Again, it is very important to compare the initial profile with the profile after treatment simulation and evaluate the facial esthetics. Make sure your treatment improves the profile or at least keeps it the same.
5.5. Dolichofacial, moderate anchorage tried with class II elastics (bad option): the situation is completely different if your patient has a dolichofacial growth pattern. Now the anchorage of the upper molar becomes a big problem. Treating a patient with a dolichofacial growth pattern is much more difficult than treating a patient with either a mesiofacial or a brachyfacial growth pattern. Even with the same occlusion, the same overjet, the same overbite and the same skeletal age, you are faced with a much more difficult and time consuming treatment scenario. As a teaching example, let us simulate what would happen if class II elastics were applied in dolichofacial patients. Click again on the menu "Show Reference" and choose “Initial". Move the upper molar back to its original position before growth but extrude it 2 or 3 mms, the effect of class II elastics in dolichofacial patients. Switch off the “Initial” tracing in the "Show Reference" menu and open rotate the mandible around the hinge axis by dragging the little square box at Gnathion (box number 7 on page 108 in the manual) until the upper molar does not overlap the lower molar anymore. Pay close attention to the movement of the lower molar. Due to this open rotation of the mandible, the lower molar actually moves backward preventing your class II situation to be improved. Even worse, opening the mandible has created an open bite and severe lip strain that often can hardly be controlled. This is definitely not a desirable outcome and a viable treatment plan. So, how do you solve that? The following sections will demonstration this.
5.6. Dolichofacial, maximum anchorage with high pull headgear: a high pull headgear with good patient cooperation can hold the upper molar in place against growth in dolichofacial patients without extruding molars and without open rotating the mandible. Provided the class II malocclusion was not too severe, a class I occlusion can be achieved. As demonstrated before in 5.3 superimpose the “Initial" and the “Growth” tracing alternatively for precise treatment planning while making sure the "Net Change" of the ALD calculation remains zero.
5.7 Dolichofacial, minimum anchorage with extraction of 4 premolars: if a high pull headgear is not an option and/or the ALD is too large, the extraction of all four first or second premolars should be considered to eliminate the class II malocclusion and the crowding while preventing opening the Facial Axis (the line form Pterygoid to Gnathion) of the mandible. Simulate this by leaving the upper molar in the forward and downward “Growth” position instead of moving it back into its “Initial" position. In other words, allow the molar to grow forward and downward. Close the resulting extraction space by retracting the incisors and/or by forward movement of the molars depending on the desirable anterior-posterior position of the incisors. Ricketts suggests placing the lower lip 2 mm behind the esthetic line (Tip of the Nose to Soft Menton).
5.8 Dolichofacial, minimum anchorage with extraction of upper premolars only: as a compromise, the upper first premolars can be extracted leaving the molars in a class II position but achieving a class I relationship of the frontal dentition. This treatment minimizes the extrusion of the upper molars and the danger of opening of the bite (and the facial axis) during treatment. However, it results in a compromised occlusion. Keep in mind that if the ALD is large, the facial profile change will be minimal. In borderline cases you can create multiple “Treatment” sessions. This allows you to compare non-extraction, 4 premolar extraction, upper premolar extraction and surgical treatments. This allows you to choose the best treatment compromise together with the patient and the parents during the patient consultation. It is also a very powerful tool to communicate your decision to third parties involved such as: the referring dentist, the surgeon and the insurance company.