ORTHO BYTES

Video cephalometric diagnosis (VCD): A new concept in

treatment planning ?
David M. Sarver, DMD, MS
Birmingham, AIa.

Let's take a minute and think back, historically, how the and profile images and modify them to project overall
orthodontic treatment planning process has evolved to what esthetic treatment goals. In the case of surgical treatment,
we have today. The original diagnostic records consisted of patients are very motivated to know what they will look like
a set of study models and the patient' s orthodontic problems after surgery. Profile line renderings may represent a
were categorized by dental classification, Angle I, II, and reasonable feedback system for the orthodontist, but has
III. Treatment was then prescribed to reach the norm or little cognitive value to the patient. It is possible to cut
Class I aligned dental relationships. With the arrival of photographs and move the sections in a way that somewhat
cephalometric technology in the 1930s and its increase in simulates the surgical outcome, 1 but does not allow the
popularity, the clarification of the anatomic basis for planner to visualize limiting factors such as the dental
malocclusion became possible. The recognition of the relationships (overjet) or differential soft tissue reaction to
interaction of jaw and tooth positions began a refinement of hard tissue movement. Gaps in the manipulated photographs
orthodontic diagnosis and treatment beyond just dental are unavoidable. The use of video imaging technology
terms. Cephalometric statistical analyses were evolved and allows us to modify facial images to project treatment goals
more quantitative decision making was the result. With the and then discuss them with the patient. The video image is
integration of computers and cephalometric technology in much more realistic than photograph simulation and it is
the 1970s, complex statistical analyses of growth patterns much easier for the patient to comprehend than just the soft
and dentoskeletal relations were established. Computers tissue profile of a cephalometric tracing. Video imaging,
moved into the practice environment, initially in the then, appears to be the next step in the natural progression of
business office, where computer number crunching was the application of technology to orthodontic treatment
very useful in managing the business end of the practice. planning.
Recently, the speed of computerized cephalometrie In recent studies, Kiyak 2 found that 53% of female
programs has helped streamline the laborious manual patients and 41% of male patients listed esthetics as a major
measurement of patient cephalograms and has also sped the factor in their decision to proceed with orthognathic surgery.
creation of the visualization treatment objective (VTO). In Other studies reported patients who rate esthetics as a
the VTO of an orthognathic surgery case, the clinician moderate to major factor in the decision to pursue treatment
classically has used acetate templates of the teeth and jaws range from 76% to 89%. Definition of esthetic parameters
to predict orthodontic and surgical movements to attain would then be quite important in maximizing the chances for
their esthetic and functional goals, and the final profile is patient satisfaction in surgical cases, and it would be
determined by the reaction of the soft tissue to the hard reasonable to make the same assumption in adolescent
tissue movements. In an effort to predict the final esthetic orthodontics.
profile configuration, the orthodontic and surgical In the past several years, there has been an emphasis on
publications are replete with studies of the final soft tissue facial esthetics and its relation to orthodontic treatment. This
reaction to these hard tissue movements. Cephalometric has been particularly true in orthognathic surgery where the
digitizing programs are useful in automating these dramatic changes we have come to expect in our surgery
predictions and, in both cases, single line profile renderings cases have become more predictable. The trend toward more
serve as the profile outline of the final treatment goal. emphasis on the facial outcome of our orthodontic treatment
Where does computerized video image modification fit in plans has been a result of several factors:
this time-proven treatment planning scenario? Video 1. The natural evolution of orthodontics from a tooth oriented
imaging technology allows the orthodontist to gather frontal specialty to a more comprehensively oriented specialty.
(Thus the change in the journal name from Orthodontics to
The cases illustrated in the article in no way are an endorsement of the Orthodontics and Dentofacial Orthopedics.)
software used or imply that this software is any better in quality than other 2. Criticism in the past two decades of occlusal treatment
programs available. The author has absolutely no financial interest in the
product shown. schemes designed without regard to their effect on facial
Am J Orthod Dentofac Orthop 1996;110:117-128-36 outcome.
Reprint requests to: Dr. David M. Sarver, 1705 Vestavia Pkwy., 3. The facial principles learned by orthodontists through the
Birmingham, AL 35216.
Copyright © 1996 by the American Association of Orthodontists.
dramatic increase in surgical treatment in the past two
0889-5406/96/$5.00 + 0 8/8/70555 decades has drawn attention to the desirability of

128 American Journal of Orthodontics and Dentofacial Orthopedics/August 1996

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Fig. 2. Her occlusal relationships were Class I.

Fig. 1. This patient's profile would be considered by orthodontic

standards to be "full" or bidentally protrusive. Facial analysis with
plastic surgery in mind would indicate chin deficiency and lack of
nasal tip projection.

combining functional treatment goals with facial esthetic

goals.
For example, recognition and treatment of mandibular
deficiency in the adult patient results in the two options of
nonsurgical dental compensation or orthodontic decom-
pensation and surgical mandibular advancement. In an Fig. 3. Conventional acetate tracing to outline proposed profile
effort to provide facial improvement while correcting changes expected with orthodontic treatment with four premolar
Class II malocclusions in children, growth modification is extraction and maximum retraction of anterior teeth.
now the treatment of choice rather than dentoalveolar
compensation, which was often the recommended clinician to test various treatment plans before deciding on the
treatment 20 years ago. final plan. This is the essence of the VCD concept because it
allows us, at least in adult or surgical cases, to determine
TREATMENT PLANNING OF ADULT AND beforehand the facial result of proposed treatment.
ORTHOGNATHIC CASES We still have a lot of research and understanding of the
application of this technology that needs to be
Video Cephalometrics accomplished. The experience of the planner is still,
Stressing the importance of soft tissue analysis in without question, the single most important factor in
orthodontic treatment planning, Holdaway 3 thought "we treatment planning success. Clinicians who begin to use
should determine beforehand that the proposed orthodontic this technology should quickly recognize its usefulness,
treatment will not result in adverse facial change." The but they will also realize that it is they who must make
advantage that video cephalometric planning often offers is decisions as to what, in reality, can be accomplished. In
that (1) it allows facial visualization for better comprehension other words, the clinician must design attainable treatment
of the facial response to the dental and/or soft tissue plans and provide "cerebral override" of the computer
manipulation involved in a particular treatment plan; (2) it when needed.
allows quantification of the planned dental and/or osseous It will be most useful to illustrate these concepts of
movements to reduce the guesswork as to the facial response treatment planning by using adult and orthognathic cases for
to our orthodontic treatment plan; and (3) it allows the illustration. As in our treatment plan presentations to
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Fig. 4, Nonorthodontic option that might reach the esthetic goals, Fig. 5. In integrated video cephalometrics, mathematical algorithms
advancement genioplasty and rhinoplasty for tip advancement was plot position of profile outline as result of incisor retraction input. It
outlined on image for patient. is this outline prediction to which computer will "morph" or
"autotreat" video image.

patients, verbal descriptions simply do not communicate the

issues as well as images. We are going to present a
nonsurgical case and a surgical case. A case with an
adolescent patient is not presented because of the
complexity of growth prediction of both hard and soft tissues
in the patient greatly complicates the predictability of VCD
outcome. Video cephalometric planning is certainly not
useless in the case of the adolescent patient because it has
many valuable applications in this type of case, but the
orthodontic/orthognathic case with the adult patient is much
more amenable to any sort of predictable planning because
of the static nature of the dental and soft tissue relationships.
The traditional treatment planning flowchart for orthognathic
patients follows this general outline:
1. Patient and record analysis
a. Facial analysis: frontal, 45 °, and profile examinations
reveal hard and soft tissue relationships, such as
incisor to lip relationships at rest and on smile,
gingival display on smile and on profile,
maxillomandibular and chin relationships. There are a
number of published soft tissue analyses available.
b. Dental analysis: This analysis most often includes
Angle classifications, but is also related to
cephalomeU'ic measurements that quantify protrusion,
proclinations (compensation), and procumbency. Fig. 6. Morphed prediction of orthodontic retreatment.
c. Cephalometric analysis: Hard tissue cephalometric
analysis tend to be presented in "normative values" by advocated as a method of guiding clinicians as to
which the ideal or normal skeletal relationships are where to direct surgery.
compared with each individual patient. Templates 2. Prediction of outcome
based on the Bolton's standards have even been In orthognathic surgery, the primary decision from which
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Fig. 9. Final occlusal outcome.

Fig. 7. Final profile outcome after orthodontic retreatment.

, ~ii~1iiii!ii~i~

Fig. 10. This patient had severe left lateregnathia with resulting
facial asymmetry and, on smile, only 50% of upper incisor was
exposed, as shown in Fig. 13.

be necessary to close an anterior open bite. In the long-face

patient, the esthetic changes with shortening of the face go
hand-in-hand with the correction of the malocclusion.
However, in a short-face patient, impaction of the posterior
maxilla to close an open bite might result in an unduly short
Fig. 8. Miss Alabama 1995. face, and adjunctive genioplasty to increase the facial height
by lengthening the chin may be needed to maintain facial
esthetics. Traditionally, acetate tracings have been used for
all other decisions must flow concerns which operation will prediction of the movements required to correct the existing
produce the most stable correction of the existing malocclusion. Acetate tracings are very useful to determine
malocclusion. Whatever movement is required to correct the placement of hard tissue and the response of soft tissue to
malocclusion obviously has an effect on the facial structure. those movements. However, they are of lesser value for
In some cases this effect may be an improvement and in visualization of the profile outcome and obviously of
some cases actually quite deleterious to the esthetic virtually no value in frontal prediction. Cephalometric
outcome. For example, posterior maxillary impaction may normative values are often used as a guideline for the
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Fig. 12. Severe midline discrepancy reflected skeletal aysmmetry.

Fig. 11. Open bite was present with Class III dental relationship.
Correction of negative overjet would require either maxillary ad-
vancement or mandibular setback. How do we decide which is
best?

placement of the skeletal units. The final esthetic outcome is

heavily dependent on the experience and/or artistic skill of
the treatment planner. Therefore photograph modification
was advocated in the 1980s for improved communication
and planning, and with the evolution of computer
technology, visualization of coordinated facial and dental
plans has been greatly facilitated.
The use of computerized video cephalometrics to serve as
an interactive tool in designing and measuring treatment
plans may be best illustrated through case presentation.
Fig. 13. On smile, only 50% of upper incisor was exposed. This
CASE 1 would indicate that anterior open bite is possibly due to vertical
This patient presented for treatment after previously maxillary anterior dentoalveolardeficiency.
having undergone orthodontic treatment (Figs. 1 and 2). Her
abbreviated problem list was as follows: and lower incisors (Fig. 3). After the tracing is completed,
1. Profile: Characterized by lip fullness, an acute nasolabial several questions still remain:
angle, and mild chin deficiency. 1. While orthodontic retreatment reduces the lip projection,
2. Dental relations: Nicely treated to a Class I occlusion, is a genioplasty desirable to improve the mildly deficient
however, her maxillary and mandibular incisors were chin? Obviously, visualization of those changes and the
proclined and protruded. desirability of a genioplasty depends on the skill of the
3. Cephalometric analysis: The patient measured to be not clinician in being able to visualize from the acetate
only bidentally protrusive, but also had only 1 mm of tracing what the outcome might be, and the patient's
chin projection (NB-Pg). ability to help the clinician decide as to whether a
Cephalometric measurements help as an initial guide, but genioplasty would be desirable. This is a valuable aspect
in dentofacial planning with computerized video of video imaging as far as bioethics and informed consent
cephalometrics, the application of norms as the treatment is concerned, as described by Ackerman and Proffit. 4 Of
goal itself is not advocated. In VCD, the final dental and course, a genioplasty may be considered as a staged
esthetic goals are designed and the proposed movements procedure after the orthodontic retreatment.
quantified with the computer through "retroengineering." In 2. Are there other options available besides orthodontic
other words, the end in mind is planned and the technology retreatment? Other options are indeed available to
helps measure how we get there. balance the profile by recommending advancement
The essence of this patient's problem revolved around her genioplasty and advancement of the nasal tip through
chief complaint. Although orthodontic treatment had rhinoplasty (Fig. 4).
successfully aligned the teeth and adequately spaced them, Our patient was presented a treatment plan through video
the patient was not pleased with her profile. Further advice cephalometric consultation. In this consultation, her
was sought as to what other avenues of treatment might be treatment options were presented as:
provided to attain the desired outcome. 1. Orthodontic retreatment with four premolar extraction
With conventional profile outline tracing, orthodontic and retraction of incisors (Figs. 5 and 6). Retraction on
retreatment shows the lip response to four premolar round wire and chain was advocated because of the
extraction and a 5 mm posterior movement of both upper desirability of uprighting the incisors during retraction.
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Fig. 14. Integrated video cephalogram allows visualization and Fig. 16. Maxillary advancement and cephalometric prediction im-
analysis of hard and soft tissue relationships. Algorithmic predic- proves negative overjet.
tion is used for profile prediction.

advancement of the chin and the increase in nasal projection

with rhinoplasty. The differences between the orthodontic
(Fig. 6) and nonorthodontic treatment (Fig.4) plans are not
very different. After presentation of these treatment options,
our patient elected for orthodontic retreatment and
requested lingual appliances because of the esthetic
advantages. Because the incisors were flared and much of
the retraction was planned to be accomplished with traction
on round wire, lingual appliances were placed and treatment
performed. Approximately 20 months was needed to
complete the treatment. The final facial and profile outcome
is shown in Figs. 7 and 8, and the occlusal outcome in Fig. 9.

CASE 2
Video cephalometric treatment planning allows quantifi-
cation of a treatment plan to "retroengineer the numbers to a
final plan." In this case, the patient has a Class III open bite
with a severe mandibular left laterognathia (Figs. 10, 11, and
12). The profile is fairly straight, tending more toward
convexity than the concavity that would be expected in a
Class III pattern. On smile, only 50% of her upper incisor is
revealed (Fig. 13). A L e Fort I osteotomy with a downgraft
Fig. 15. Anterior downgraft of maxilla during LeFort I osteotomy is of the anterior portion of the maxilla was considered to
simulated on cephalometric prediction with "click and drag" function. improve the smile line while closing the bite. Transverse
leveling of the maxilla is also required because of the
maxillary compensation for the mandibular asymmetry. The
Therefore rather than closing loop edgewise mechanics Class III discrepancy would have to be treated by either
with en-masse retraction, traction coil on round wire was maxillary advancement or mandibular reduction, which
planned. raises several questions:
2. Advancement genioplasty. 1. Anterior downgraft: How much is required? This is a
3. Rhinoplasty for increased nasal projection. clinical decision based on the percentage of incisor show
Fig. 4 illustrates the esthetic profile changes with on smile and the length of the upper incisor crowns. This
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Fig. 17. Morphing profile to simulate maxillary advancement dem- Fig. 18. Mandibular reduction also increases profile convexity.
onstrates increase in profile convexity.

must be a clinical judgement rather than a cephalometric

assessment because the anterior esthetic relationship will
be determined entirely by the patients clinical presentation
and not by any cephalometric criteria.
2. Does the maxilla need to come forward or the mandible
go back to correct the Class III relationship? Would these
movements make the profile unfavorably convex?
3. If the profile does become convex (as would be
expected), will genioplasty be required to balance the
profile? If a genioplasty is desired, how much is needed
to attain the desired end result?
Cephalometric analysis simply cannot answer these
questions. In addition, improvisation in the operating room
is not very safe either. Mock surgical treatment through
video cephalometric planning is an excellent method of
testing all these options for facial outcome, virtually
arriving at the diagnosis through the testing of the treatment
plans. Correction of the malocclusion with facial balance is
designed, movement on the computer screen is quantified
through the software package, and rather than arriving at a
treatment plan that is based on normative values and
directing treatment toward that norm, we are outlining the
desired profile result on our computer screen. This allows
the planners to retroengineer the numbers, which enables the Fig. 19. With maxillary and mandibular osteotomies, 4 mm chin
surgeon to enter the operating room with a quantitative plan, advancement results in restoration of profile esthetics. Rhinoplasty
which in turn maximizes the chances of the planning team to is also simulated to refine nasal dorsum and tip.
achieve the outcome designed on the computer screen. This
article will not go into the issues of predictability because ram, which results in a negative overjet of 3 mm (Fig. 15). The
data have already been published on this topic, and many options that follow are (1) to move the maxilla forward 5 rnm,
studies will be forthcoming dealing with these issues. resulting in an increase in profile convexity (Figs. 16 and 17),
Fig. 14 illustrates the integrated video cephalometric and (2) to move the mandible posteriorly 5 mm with sagittal
planning template. The anterior maxilla is moved inferiorly 4 rotation to correct the mandibular asymmetry (Fig. 18).
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Fig. 20. Simuation of simultaneous rhinoplasty is important because maxillary surgery would tend to ac-
centuate alar base width.

Fig. 21. After Maxillomandibularsurgery, anterior open bite was

corrected and midlines coincident.

In this case, a 3 mm anterior m o v e m e n t of the maxilla

was planned because of the anterior downgraft and a 2
mm mandibular reduction was planned with the rotation.
A 4 mm chin advancement restores the profile (Fig. 19).
In the frontal image, a rhinoplasty is shown to reduce the
width of the bridge of the nose and the Mar bases of the
nose (Fig. 20). This procedure is performed simulta-
neously with the orthognathic surgery because the Fig. 22. Inferior movement of anterior maxilla greatly improved
smile line, with all upper incisor displayed with smile animation.
maxillary advancement would be expected to worsen the
already wide nose.
The final occlusal relations (Fig. 21), smile (Fig. 22), and
profile (Fig. 23) were excellent. 3. This communication is more effective and less time-
consuming.
CONCLUSION Because imaging is more realistic and lifelike, the
In summary, the integration of video imaging into the treatment planning process is facilitated for the orthodontist
counseling of patients on esthetic considerations of by the following:
treatment offers several advantages: 1. Improved visualization of the individual treatment plans.
1. A higher level of communication. This results in greater precision in planning a desired
2. More precision in this communication. outcome.
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In a study of our patients whose surgeries were planned

interactively with video imaging technology, 90% of
patients reported they thought the final result was as good as
or better than the projected image? This means one of three
things:
1. We are very accurate and honest with our projected
treatment goals as far as their attainability.
2. In surgical cases, our surgeons are very good at placing
the osteotomies where they are planned.
3. The use of imaging more clearly describes to the patient
what to expect from their procedures, and therefore their
expectations may be more reasonable.
Patient unhappiness would tend to occur then, when (1)
the planners outline treatment that is clinically unattainable,
and (2) the orthodontist or surgeon is clinically unable to
"deliver the goods" as outlined.
Video cephalometric treatment planning (1) quantitates
movements in adult surgical cases; (2) allows interaction of
the patient with the clinicians to help direct the treatment
plan to the desired end result; and (3) allows facial planning
and provides quantitative feedback as to what is required to
attain a particular treatment plan.
I would like to thank Dr. Sherri Weissman for her help in the
preparation of this manuscript.

REFERENCES
Fig.23. Profile balance was excellant. CoordinatedVDC planning
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2. Kiyak HA, Hohl T, West RA, McNeill RW. Psychological changes in orthognathic
surgery patients: a 24 month followup. J Oral Maxillofac Surg 1984;42:506-12.
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