The diagnostic facial triangle in the

controZ of treatment objectives

Charles
Tucson,

H. Tweed,
A rig.

D.D.S.

he development of the diagnostic facial triangle as a valuable adjunct

in the analysis and treatment of malocclusion is, I believe, my most important
rontribution
to clinical orthodontics. The attainment of the FMIA requirement
of the diagnostic facial triangle as a result of treatment procedures involves
a working knowledge of the following :
1. The ability to measure and compare available and required arch
lengths.
2. How to make the cephalogram correction to dcterminc total archlength discrepancies.?
3. Preorthodontic
tooth guidance, including serial extraction of teeth.::
4. The growth trend classification, Types A, B, and C.4
5. Anchorage preparation,
first, second, and t,hird degrees.5
6. The necessity for instituting
mechanical therapy in the treatment of
Class I and Class II malocclusions that will maintain the normal
inherent forward and downward growth vector of the middle and
lower face. In other \lTords, maintaining
the integrity of the oc~lusal
plane in such a manner as not to allow it to drop down anteriorly.
Preorthodontic

guidance

Analysis and treatment of malocclusion in the mixed dentition arc more

complicated than in the permanent dentition because, in young children, greater
growth changes occur in the dentofacial complex.
A complete set of records, including photographs, casts, intraoral and lateral
jaw x-ray films, and a lateral cephalogram, must be made. The patient is examined for abnormal sucking, swallowing, or other habits that might be contributing
factors in causing the malocclusion. If such habits are present, the
patient is referred to the speech therapist for treatment.
The first decision that must be made is whether the cast is nonextraction
or extraction in nature. For this, actual available space is measured between
651

Am.

J. Ovthodontics
Juw1969

the mesial surfaces of the first permanent mandibular

molars and recorded on
line marked available
(Fig. 1, C). The mesiodistal widths of the unerupted
mandibular
canine, first premolar, and second premolar teeth (right and left)
are measured on the intraoral x-ray films and the data are transfered to the
upper line of the analysis ca.rd, on which the actual widths of the central and
late mral incisors had previously been recorded as measured directly in the pa-

Required

3-17-61

FM
3P.S

IMPA
8V

lo-2144

340

81.50

1
I

Required
arch
length
Available
arch
length
Arch
length
discrepancy
Cephalogram
correction
Total
discrepancy
Fig.

1.

vol.

1.)

(From

Tweed:

Clinical

orthodontics,

St.

Louis,

1966,

The

C.

V.

HIA
11.50
b4.S

-.._;
ANN
20
So

65.5
65.5

mm.
mm.

65.5
65.5
0
11
11

mm.
mm.
mm.
mm.
mm.

Mosby

Company,

lliagnostic

facial

triaagle

653

tients mouth. In the example shown in Fig. 1, C, required a.rch length is 65.5
mm., as is available arch length. Arch-length discrepancy, therefore, is 0 mm.
The diagnostic facial triangle is then constructed as csplained in detail in my
book entitled Clinicd
Orthodontics.8
Cephalogram

correction

To arrive at the measurement referred to as the cephalogram correction,

we rely primarily on the diagnostic facial triangle.g
The FMA (Fig. 1, B) is 39.5 degrees, the IMPA is 89 degrees, and t,he
FMIA is 51.5 degrees. The FMA is greater than 30 degrees. In such cases, the
FMIA requirement is 65 degrees. However, the FMIA is only 51.5 degrees in
this instance. Therefore, the mandibular
incisors incline labially 13.5 degrees
more than they should. Tipping the mandibular incisors lingually 13.5 degrees
will require shortening bot,h sides of the dental arch. The measurement taken
from the cephalogram, combined with the actual arch-length discrepancy (in
this instance, arch-length discrepancy is 0 degree), and substracted from the
available arch length gives the corrected arch length (Fig. 1, C) . Corrected arch
length gives the amount of the total discrepancy in millimeters.
Serial

extraction

sequence

If the diagnosis divulges that there is a discrepancy between teeth and basal
bone structures, or that a cephalogram correction reduces available arch length
appreciably, as in (Fig. 1, C), serial extraction procedures are instituted at the
age of approximately
8 years.lO The sequence is as follows:
1. At approximately
8 years of age, all four deciduous first molars arc
extracted.
2. Some 4 to 10 months later, the first premolar teeth will have erupted
to gum level. At this time, all four erupting first premolars and all
four deciduous canines arc removed. If this is done at least 4 to 6
months prior to eruption of the permanent canines, when they erupt
they usually will migrate posteriorly into good positions.
The irregularities
of the mandibular
incisors (if not too severe) correct
themselves, and functional
denture mechanics tip these teeth lingually to inclinations in keeping with the forces to which they are subjected during normal
use (Figs. 1, B and 2, B) . In this instance, the mandibular incisors have tipped
lingually 7.5 degrees during 43 months of guidance ; the irregularities
of the
mandibular
incisors were self-corrected;
the FMA was reduced 5.5 degrees,
the FMIA increased 13 degrees (from 51.5 to 64.5 degrees), and there was a
reduction of I..5 degree in ANB, indicating t.hat the growth trend is Type C.
Obviously, the patient has been greatly benefited by serial extraction procedures,
and mechanical treatment will be of short duration.
Growth

trend

classification

(Fig.

3)

Facial growth trends may be classified as Type A, Type B, and Type C.

These types are described in detail in Clinical
OrthodontGxll~ I2 A11 young
patients undergoing preorthodontic
guidance should have lateral cephalograms

654

Tweed

t,aken at the beginning. Some 12 to 18 months later a second cephalogram shonl(1

be taken, and tracings should bc made of both cephalograms. These tracings arc
superimposed on S-N, with S as the reference point. If this is done prior to an)
mechanical treatment procedure, it, is possible to determine the type of facial
growth trend that must be contended with tluring treat~ment. It is important to
ascertain the type of facial growth trcwtl as ear1.v as possible, for it concerns the
prognosis, the time to begin treatment, and the length of treatment timo.

Fig.
vol.

2. [From
1 .I

Tweed:

Clinical

orthodontics,

St.

Louis,

1966,

The

C.

V.

Mosby

Company,

Diagnostic
Anchorage

facial

tria&e

655

preparation2

The degree to which anchorage should be prepared

will vary considerably.

B point downward
and backward for some specific reason, the terminal mandibular
molars must
always be uprighted or kept upright in such positions as will prevent their being
elongated when Class II intermaxillary
force is used. I classify anchorage preparation into three categories : (1) first degree, (2) second degree, and (3) third
clegree. A detailed account is given in Clinical Orthodontics.12

U~WS one is purposely endeavoring to move the teeth and the

TreatmentI

One of the many beneficial developments in ort,hodontic treatment that have

occurred during the past decade has been the effort on the part of a majority
of orthodontists
to control the forces in the orthodontic
appliances they use
in such a manner as not to interfere with t,hc patients normal dentofacial growth
(luring orthodontic treatment.
The
indications are that, in the future, the clinical orthodontist must work
within the confines of the patients growth trend, whether growth is in the vertical direction, the horizontal direction or a combination of the two.
Evidence also indicates that those operators whose treatment permits them

7.20-60
3-2-63

FM1

IMPA MIA

AWB

29.3"
29.50

91.50
w

5*
5'

580
65.5'

7-30.66

MA

IMPA FMIA ANB

29"

89"

62"

Fig.

3.

vol.

1 .I

(From

Tweed:

Clinical

C
orthodontics,

St.

Louis,

1966,

The

C.

V.

Mosby

Company,

656

Tweed

to maintain the integrity of the occlusal plane are working more closely within
the confines of normal growth processes t,han are those who permit great deriations of the occlusal plane to occur as a result of faulty treatment.
Prevention of undesirable changes in the occlusal plane during treat.ment is
important. The solution to the problems appears to concern the control of forces
ut.ilized in treatment. Space will not permit me to discuss this topic in detail
here, but further information
will be found in Clinical
Orthodontics.7
Controlled

orthodontic

forces

versus

differential

forces

To illustrate the importance of forccl control in orthodontic trcatmcnt, the

tracings of two patients with similar Class II, Division 1 malocclusions are compared. The patient whose tracing is shown in Fig. 4 (left) was t,reatcd with the
edgewise arch mechanism utilizing the high-pull headgear in conjunction with
Class II intermaxillary
force and vertical elastic force in the incisor segments t,o
prevent a deviation or lowering of the anterior end of the occlusal plane. The patient shown in Fig. 4, B (right) was trcatetl with the Begg light-wire technique,

S-27-61
4-30-65

HA

IMFA

38"
33.3"

88"
81 I"

43 3

433

93

13

A
Fig.
vol.

4.

(From

Tweed:

Clinical

B
orthodontics,

St.

Louis,

1966,

The

C.

V.

Mosby

Company,

1 .I

Table

I. Fig.

4 measurements

Heglinning
Angles
Tracing
FMA
IMPA
EMTA
ANB
Occlusal

Tracing

FMA
IMPA
FMIA
ANB
Occlusal

and

and

measured

(degrees)

Frankfort,

plane

angle

Frankfort

plane

angle

value

Posttlmtment
(d~{JU!~S)

value

658

Tweed

using differential forces without extraoral appliances. A study and comparison of:
the angular changes that have occurred in FMA, IMPA, FMIA, and ArUB in
these two tracings are most enlightening and should convince orthodontists that,
force control is a must in all orthodontic treatment (Table I).
With this brief review of the information
required of those who practice
preorthodontic
guidance procedures and endeavor to fulfill the requirements
of the diagnostic facial triangle, let us study the records of some children treated
in this manner.
The patient shown in Fig. 5, ~1 rcprescnts a Type A growth t,rend, as indi-

Fig.

6.

See

text.

L&gnostic

facial

triangle

659

cated by the constancy of the ANB angle, which has remained at 5 degrees
during 32 months of preorthodontic
guidance that included serial extraction.
In tracing Fig. 5, A the mandibular incisors have tipped lingually 7.5 degrees
and the FMIA has gone from 58 to 65 degrees which meets the requirements of
the diagnostic facial triangle.
Fig. 5, B illustrates the extent of the distal movement of the ma.xillary incisors which has reduced the ANB angle from 5 to 2 degrees. The FMIA is 65
degrees at the termination of treatment. Treatment. forces have been controlled,
and the integrity of the occlusal plane has been maintained. Anchorage prepara-

Fig.
cal

7.

(From

Tweed:

orthodontics,

1966,
Company,

The

St.
C.

vol.

V.
2.)

CliniLouis,
Mosby

660

lwcea

,411~. J. Orthodontics
June 1969

tion was second degree. Fig. 5, C, made approximately

3 years later, shows the
FMIA to be 68.5 degrees with the ANB remaining constant at 2 degrees.
The patient shown in Fig. 6 is a sister of the patient shown in Fig. 5. Prrorthodontic
guidance lasted 4 years and included serial extraction procedures.
The growth trend in Fig. 6 is Type (>, as indicated by an ANB reduction
from 4 t,o 2.75 degrees (Fig. 6, 11). The mandibular incisors have tipped lingual-

Diagnostic

facial

triangle

661

ly only 3 degrees, from 92 to 89 degrees. The face is quite protrusive. Fig. 6, B

tracing was made immediately following treatment. The angular changes in the
diagnostic facial triangle are considerable. The mandibular
incisors have been
tipped lingually 1.2 degrees, from an IMPA of 89 degrees to one of 77 degrees.
The FMIA has increased 11 degrees, from 62 to 73 degrees. The maxillary incisors have been moved distally the width of a tooth, resulting in a reduction of
2.75 degrees in the ANB angle, which now reads 0 degrees. Treatment forces
have been well controlled, and the integrity of the occlusal plane was maintained.
Second-degree anchorage preparation was used.
The patient shown in Fig. 7 presents a Type B growth trend. Treatment
time was 35 months. Tremendous efforts were made to cont,rol treatment forces
anal the integrity of the occlusal plane. The hart1 palate was not, allowetl to drop
(lo\vn anteriorly. A high-pull headgear was used. The maxillary incisors have
been intrndetl to touch the hard palate (Fig. 7, 11). Note the extent of the rearward bodily movement of the maxillary incisors, mitll B point dropping down.
Note also the changes in the angular measurements of the diagnostic facial triangle. The FMA has gone from 28 to 22.5 degrees, a reduction of 5.5 degrees.
The IMPA shows that the mandibular incisors have been tipped lingually 18
tlegrees, from 107 to 89 degrees. The FMIA has gone from 45 to 68.5 degrees,
which is 23.5 degrees, and the ANB has been reduced from 10 to 4.25 degrees,
;L distance of 5.75 degrees, Third-degree anchorage preparation was employed.
Fig. 7, B, made 21 months after treatment, rereals several changes in the
diagnostic facial triangle. There has been another reduction in the FXA of 2.5
tlegrees. The total reduction in the FMA now is 8 degrees. JMPA has increased
7 degrees, from 89 to 96 degrees. The FMIA has deteriorated 4.5 degrees, from
68.5 to 64 degrees, a.nd there has been an increase of 0.25 degree in the AKB,
from 4.25 to 4.~5degrees, indicating Ohat the middle face is growing forward at a
slightly greater rate than the lower face and that the growth trend is Type B.
Age and loss of weight improved facial esthetics.
Fig. 8 shows a patient treated almost 20 years ago, when I was unaware of
of the importance of force control and knew nothing about growth-trend classification. I trust that presentation of this case will be helpful to those unfamiliar
with growth trends and the importance of the control of forces used in treatment.
Fig. 8, A reveals that anchorage was not sufficiently prepared, that treatment
forces were not controlled, and that the integrity of the occlusal plane was not
maintained, which permitted the FMA to increase 7.5 degrees, from 33.5 to 41
degrees, resulting in a.n increase of 0.5 degrees in the ANB, from 8.5 to 9 degrees,
with an increase in the occlusal plane to Frankfort
plane angle of 9.5 degrees
or from 15.5 to 25 degrees. The mandibular rotation was not overcome during
his remaining growth, as indicated by photographs and tracings shown in Fig. 8,
c.
These are the records of the growth and treatment
changes that have
occurred in a Type A growth trend case between the ages of 9 and 21
years. Fig. 9, A reveals the angular changes that occurred in the diagnostic
facial triangle over a period of 25$/, months. During this time the patient was
under preorthodontic guidance and serial extraction procedures.

662

Tweed

Am.

.I. 0j~thodolztic.s

tlune1969

L)iagnostic
facial hiangle

663

Fig. 9, A shows that there has been no change in the ANB, which has rcmained at 4 degrees. The middle and lower face arc growing forward and downward in unison. Tracing B reveals the angular changes that have occurred in
the diagnostic facial triangle as a result of treatment and growth.
FMA
(degrees)

Nor. 29, 1956

Frl1. 7, 1961

Fig.

10.

See

INPA
(degrees)

26
22

102.5
93

text.

6.1563
6-23.67

30

21

91.5
96

17.5 I.50

59

3 75

6-1561
P-5-68

30
25

91s
W

515
65

IS
I I

664

lweecl

Treatment mechanics have been well controlled, as indiwted by the maintenance of integrity of the occlusal plane and the normal growth vector of the lowcl
face. Observe the 4 degree reduction in the FMA. A series of tracings made of
this case revealed a contjinuous flattening of the FMA. The ANB remained constant at 0 until the sercnteenth year. Fig. 9, C shows tracings made from cephalograms taken before preorthodontic
guidanw at aq 9 and later at age 21.

Nov.
;\ug.

Fig.

11.

See

29, 1956
16, 1967

text.

1m A
(tlegrccs)

IJIPA
(tle,qms)

FJf Id
(tlr,l/ro s)

26
Il.5

IO.5
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!I;

*x1.5
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(tlc,q,x
k
1.23

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Volume
~Nuvnber

55
6

Diagnostic

facial

triangle

665

Note the dramatic ramus growth and the 14.5 degree flattening of the FMA.
Fig. 10 shows the records of a patient with a Type C growth trend (Fig.
10). At the end of preorthodontic
guidance, which included serial extraction
procedures, the changes in the angular measurements of the diagnostic facial
triangle were as follows (Fig. 10, d) :
FMA
(degrees)
June
June

15, 1963
20, 1967

30
25

IUPA
(degrees)
92.5
96

FKZA
(degrees)

ANB
(degrees)

57.5
59

5.5
3.75

The face is protrusive. Anchorage preparation

was second-degree. The following changes have occurred in the diagnostic facial triangle from t,he heginning of guidance to the termination of treatment :
FUA
(degrees)
June
Sept.

15, 1963
5, 1968

30
25

ZiuPA
(degrees)
92.5
90

FMIA
(degrees)
57.5
65

ANB
(degrees)
5.5
1.5

Controlled mechanics of treatment have maintained the integrity

of both
the occlusal plane and the normal growth vector. Note the 5 degree reduction
in the FMA and the 4 degree reduction in the ANB, as well as the improvement
in facial esthetics when the requirements of the diagnostic facial triangle are
fulfilled.
The records of the sister of the foregoing patient (Fig. 10) are shown in
Fig. 11. This girl also has a Type C growth trend and has gone through a serial
extraction procedure during preorthodontic
guidance. This child is unusual in
that, as a result of serial extraction, her occlusion is so beautiful that I did not
treat her. The changes that have occurred in the diagnostic facial triangle arc as
follows :
FMA
(degrees)
Nov.
Nov.

3, 1961
5, 1966

29
25

IMPA
(degrees)
99
94

FMIA
(degrees)
52
61

ANB
(degrees)
4.5
3

The FMA has flattened 4 degrees ; the mandibular

incisors have tipped
lingually 5 degrees, to an IMPA of 94 degrees. As a result of these angular
changes the FMIA now reads 61 degrees, an increase of 9 degrees in that angle.
Comparing these two sisters, I regret that I did not treat this one, for if I
had fulfilled the requirements of the diagnostic facial triangle and reduced the
ANB angle, the face would not be so protrusive and facial esthetics wo~&l have
been greatly improved. What poor decisions we all make at times!
In Fig. 12 tracings A and A show the results of treatment of two Class I
discrepancy malocclusions. The patient in tracing A was treated in the mixed
dentition, and the patient represented by A was treated in the permanent dentition. Both present Type A growth trends, and anchorage preparation
was
second-degree. Note that the integrity of the occlusal plane has not been violated
in either case. The anterior hard palate and the nasal spine have not been
lowered in spite of the great distances that the maxillary incisors were moved

9-11 52
6-i-54

fMA IMPA HAlA ANR

34 5 94
II I 4.75
341 78
67 I
--.I

MA
28
241

IMPA

107
90

76

101

13

AN8
10

FA1
IA-2

MA

Z-26.51
4-12.61

31
91
32.5 88

14
I.5
59.5 3.5

II 20.51 335s
11-23.53 II

16,

12

D
Fig.

12.

See

text.

IMPA
107
BB

distally by force-controlled
treatment mechanics. In Fig. 12, A the mandibular
incisors were tipped lingually 16 degrees, and there has been a decrease of 5.25
degrees in the ANB. The occlusal to Frankfort
plane angle has decreased 2
degrees, from 13.5 to 11.5 degrees. In Fig. 12, d the mandibular incisors have
been tipped lingually 24 dcgrccs. There has been a 2.5 degree reduction in the
angle formed by occlusal and Frankfort
planes; observe also that treatment
mechanics have been coordinated with the normal inherent downward
and
forward growth vector of the middle and lower face as indicated by not even the
slightest semblance of B point dropping down or backward. Compare these
beautiful results of force-controlled
treatment mechanics with B, C, and D.
These three cases demonstrate the results of lack of control of treatment
mechanics which have permitted a serious deviation of the occlusal plane, with
the result that B point has dropped downward and backward. Observe that the
anterior nasal spine and the anterior hard palate have dropped down. Note the
increases in the occlusal to Frankfort
angles (6 degrees, 9.5 degrees, and 3.5
tlegrees). Compare the angular changes that hare occurred in the diagnositic
facial triangle as a result of control of treatment forces in A and d, B, C, and D
with the angular changes in the diagnostic facial triangle that have occurred in
tracings B, C, and D when treatment forces within the orthodontic mechanisms
are not controlled.
Rarely is it possible to achieve the requirement
of the diagnostic facial
triangle unless controlled treatment mechanics are utilized. On the other hand,
it is possible to achierc its requirements in approximately
80 per cent of the
cases by instituting
force-control mechanics in ones practice. It is my fervent
hope that every orthodontist
will take the time to find out how easy it is to
practice force-control mechanics and how rich are the rewards when the requirements of the diagnostic facial triangle have been the results of his efforts.
REFERENCES

1. Tm-eed,
Charles
H.:
vol. 1, pp. 33, 252.
2. Ibid.,
pp. 259-260.
3. Ibid.,
pp. 248-268.
4. Ibid.,
pp. 13-30.
5. Ibid.,
pp. 7-12.
6. Ibid.,
pp. 232-247.
7. Ibid.,
~01s. 1 and 2.
8. Ibid.,
vol. 1, pp. 252
9. Ibid.,
pp. 31-82.
10. Ibid.,
p. 261.
11. Ibid.,
pp. 13-30.
12. Ibid.,
pp. 7-12.
13. Ibid.,
pp. 232-248.

Clinical

et seq.

orthodont,ics,

St.

Louis,

1966,

The

C. V.

Mosly

Company,