se of the Moowees mesh di

Jcmeph Ghafari*
Philadelphia, Pa.

A modification of the Moorrees mesh diagram analysis takes advantage of the same basic principles
and provides the same interpretation as the originally described analysis. In addition, linear and
angular measurements may be assessed and compared with the individualized norm drawn through
the analysis inherent to the mesh diagram. This modification is particularly useful for plannin
surgical correction of facial dysmorphoiogy in that an individualized norm for a patient serves as a
graphic guide for assessment of the specific characteristics of the patient’s face and the correction
required to achieve harmonious facial relationship. (AM J ORTHOO DENTOFAC ORTHOP 198?‘;91:475-

Key words: Mesh diagram, cephalometric, grid distortion, modification

he mesh diagram analysis graphically dis-

plays variations among facial components and thereby
provides a description of facial morphology in a single
step.’ The proportional assessment of craniofacial re-
lationship in both bard and soft tissues furnishes a valu-
able guide in orthodontic diagnosis and treatment plan-
n.ing. This article presents a step-by-step review of the
Moorrees mesh diagram analysis and suggests a mod-
ification in its use. Actual examples are presented to
demonstrate the versatility of the analysis.

lPTl0 THE ANALYSIS

New norms for the mesh diagram analysis have been
reported by Moorrees and associates’ along with an
explanation of the m.esh diagram design and its manip-
ulation. The mesh diagram is constructed on the
cephalogram of a patient with the head registered in
natural head position and the teeth in occlusion. Natural
heald position is a term used by anthropologists in the
last century to denote a standardized and reproducible
position of the head that is achieved when the subject
is at ease and focusing his eyes on an object at eye level
in the distance (for example, the setting of the sun
against the shore line). *z3The head radiograph is ob-
tained after instructing the patient to sit upright and Fig. 1. Step 1 in construction of the mesh diagram (see text ior
look straight ahead to a point at eye level on the wall details).
in front of him3 The tracing is oriented on the extra-
cranial vertical corresponding to the natural head po- the vertical axis through (a) nasion and (bj the
sition and the following steps are taken. anterior nasal spine (ANS) (Fig. 2).
Step 1. Draw the vertical axis parallel to the ex- Step 3. Transfer the length of the distance from
tracranial vertica12x3 through point nasion (N) nasion to sella (S) onto the horizontal through N;
(Fig. lj. registered at N, then draw a vertical ~rQ~gh the
Step 2. Draw two horizontal lines perpendicular to transferred point S’ (Fig. 3).
The previous steps already demonstrate three basic
*Assistant Professor of Orthodontics, Department of Orthodontics, School of components underlying the choice of references in the
Dental Medicine, University of Pennsylvania. mesh diagram analysis:
 76 Ghafuri

Fig. 2. Step 2 in construction of the mesh diagram (see text for

Fig. 4. Step 4 in construction of the mesh diagram (see text for
details).
details).

Fig. 3. Step 3 in construction of the mesh diagram (see text for

details). Fig. 5. Step 5 in construction of the mesh diagram (see text for
details).

a. Natural head position a basic vertical unit (V) and a bo~~zo~ta~unit (H)
b. Height of the upper face (N-ANS) (Fig. 4).
c. Depth of the face as related by the distance N-S Step 5. The vertical unit V is transferred once above
The four coordinates thus drawn intersect to form the core grid and three time- under the core grid
a core grid rectangle that characterizes the shape of the (Fig. 5).
upper face of the person studied. Step 6. The horizontal unit H is transferred once in
Step 4. The vertical and horizontal sides of the core front of the core grid and once
rectangle are divided into two parts, representing and horizontal coordinates are drawn; they inter-
 ModiJied use of mesh diagram

Fig. 6. Step 6 in construction of the mesh diagram (see text for

details).
Fig. 7. The mesh diagram norm displaying the mean location
of anatomic landmarks within their rectangles (numbering of
vertical and horizontal lines as described by LebreF). Soft-tissue
sect to form a mesh of 24 rectangles over the landmarks: A, glabella; 8, nasion; C, pronasale; D, subnasale;
facial structures (Fig. 6). E, labrale superior; f, stomion; G, labrale inferior; N, supra-
The proportionate location of anatomic landmarks mentale; I, pogonion. Hard-tissue landmarks: 1, glabella; 2, na-
sion; 3, sella turcica; 4, basion; 5, ANS; 6, point A; 7, PNS; 8,
within their respective mesh rectangles on the patient’s
max. inc. edge; 9, max. inc. axis: 70, mand. inc. edge; II, mand.
cephalogram is subsequently compared with the norm inc. axis; 72, point B; 73, symphysis superior; 74, pogonion; 15,
(Fig. 7). Moorrees and associates,’ and Lebret4 distort mentor-r; 76, symphysis inferior; 77, gonion; 78, articulare; 19,
the mesh grid to represent any difference in the pro- ramus (anterior); 20, corpus (superior); 27, anterior part of oc-
portionate location of the landmarks in the patient’s clusal plane; 22, posterior part of occlusal plane; 23, posterior
mesh compared with the norm. By transforming the orbit; 24, key ridge; 25, PTM (deepest point on anterior aspect
of pterygomaxillary fissure).
vertical grid lines, the sagittal components of the soft-
and hard-tissue profile and facial configuration are
shown. Characteristics pertaining to various aspects of angular measurements provides a clear-cut pro-
facial height are displayed through distortion of the portional evaluation in one single display of facial
horizontal grid lines (Fig. 8). form that is readily interpreted. In contrast, con-
Although the mesh diagram analysis as described ventional angular and linear measurements re-
displays deviations of facial form in a simple and ele- quire considerable effort for appraisal of facial
gant way, many clinicians do not use the analysis be- form.
cause of the time and effort required to distort horizontal
MODIFIED MESH ANALYSIS
and vertical grid lines.
The purpose of the present report is to describe a The first six steps are the same as described pre-
method of analysis with the mesh diagram that does viously. Although the next step (7) is inherent in grid
not require grid distortionY but offers nonetheless the distortion, the difference presented here is in fact in the
same two major advantages, namely: final illustration. Interpretation of facial form remains
a. A patient’s profile is not directly compared with the same.
the population norm but with a “patient norm” Step 7. Locate the median proportionate position of
derived from application of the population norm each landmark in its respective grid rectangle of
to a grid scaled on the patient’s facial shape- the patient’s mesh diagram as in the norm grid
upper facial height (N-ANS) and facial depth shown in Fig. 7 (Fig. 9). For example, the mean
(N-S). location of labrale superior (E) is in the fourth
b. Proportionate assessment of landmark location in rectangle (d) from the top of the diagram. Within
a mesh diagram without computation of linear and this rectangle, labrale superior is at 50% from
 Ghafuri Am. .f. Qrthod. Dentqfac. Orthop.
June 1987

Distorted mesh grid displaying deviation of the patient’s

facial components. Fig. 10. individualized norm landmarks connected to achieve
outline of facial components for easy comparison with the actual
position of these landmarks on the patient’s profile (see step 8
in text).

Fig. 9. Individualized norm is obtained by plotting the median

proportionate position of cephalometric landmarks in the pa-
tients mesh diagram (see step 7 in text).

the anterior side (line 1) horizontally and at 30%

from the base (line E) vertically. Gonion is hor-
izontally at 14% from line 4 and vertically at 27% Fig. 11. Case 1, Modified mesh diagram.
from line E of,rectangle (w) according to its me-
dian location. Certain landmarks are positioned
on grid lines. For example, point ANS is on line vide the mean horizontal and vertical locations
D at 13% in front of the comer of rectangle d of landmarks within their respective grid rectan-
and point A on line 2 at 20% from the comer of gles by superposing the latter on the appropriate
the same rectangle. Scales are available that pro- coordinates in the scale4 (Department of Qrtho-

Fig. 12. Case 2, Modified mesh diagram.
dontics, Forsyth Dental Center, Harvard School
of Dental Medicine).
Step 8. Connect the different landmarks represent-
ing the median position as in the norm mesh
diagram, preferably in a color different from the
color used for the patient’s tracing or for the mesh
diagram (Fig. 10).
Step 9. Compare the location of each landmark thus
established with the actual position of this land-
mark on the patient’s profile.
Step 10. Conclusions may be made by direct ob-
servation. In addition, individual distances or an-
gular measurements may be compared with dis-
tances or angular measurements from the “in-
tennediate’ ’ or patient norms instead of the
population’s norms.
Example: IMPA of patient is 100”
IMPA on patient’s norm from the mesh
diagram is 97”
IMPA of general population is 90”
This example demonstrates that the optimal IMPA
for the patient is 97” instead of 90”, rendering the actual
angle (100”) more acceptable.
Another advantage of the analysis is the possibility
of correcting angular measurements to SN line. For
example, the patient’s values for SNA and SNB are 85”
and 74”, respectively. Compared with the norms for
Modified use of mesh diagram
Fig.. 13. Case 3, Modified mesh diagram.
SNA (82”) and SNB (80”), the mandible is retruded
and the maxilla protruded. However, the angular dif-
ference between the patient’s SN line and that on the
mesh norm is 5”. A corrected reading compensating for
the low inclination of the patient’s anterior skull base
increases SNA to 90” (85” + 5”) and SNB to 79”
(74” -I- 5”). The mesh norms are 83” for SNA and 7Y
for SNB. Therefore, the correct diagnosis of the skeletal
configuration is maxillary alveolar prognathism and a
normal rather than retruded mandible.
The following case reports further demons~ate the
value of this analysis in diagnosis and treatment plan-
ning, particularly when surgical correction of a facial
deformity and malocclusion is required. Indeed, the
plotted mean location of landmarks on the patient*s
mesh serves as a guide to determine the optimal ortbo-
dontic and surgical movements in the planning of
treatment.
CASE REPORTS
CASE 1
A direct comparison of the patient’s profile to her nor-
malized profile in the mesh diagram (Fig. I I> shows a large
nose, prognathic maxilla and upper lip, proclined lower in-
cisors, lower lip compatible with upper lip, but a small man-
dible with retruded bony and soft-tissue chin. The nose, max-
illa, and upper lip are positioned forward to the “individu-
 GhQari Am. .I. Orthod. Dento~ac. Orthop.
June 1987

Table I. Selected angular and linear measurements on patient 1 tracing*

Measurement Patient
I Patient’s norm
from mesh I
Population
norm

SNIH 16” 9
SNA 80” + 7” (87”) 81” 82”
SNB 69” + 7” (76”) 18” 79”
ANB 11” 3O 3”
LMPA 104” 88” 90”
l/NB 36”/12 mm 22”14 mm 25’14 mm
&NA 24”16 mm 20”14 mm 22”14 mm
FPIMP 36” 29 27”
MPIH 33” 29 25”

*Measurements made on the tracing for case 1 and compared with the individualized norm derived from the mesh diagram analysis (Fig. 11)
and with population norms from other cephalometric analyses.
H = Horizontal. PP = Palatal plane. MP = Mandibular plane.

Table II. Selected angular and linear measurements on patient 2 tracing”

Patient’s norm Population
Measurement Patient from mesh norm

SNiH 13” 8”
SNA 77” + 5” (82”) 81” 82
SNB 69” + 5” (74”) 7v 79
ANB 8” 3” 3”
IMPA 86 85” 90”
i/NB 32”/8 mm 20’15 mm 25”14 mm
LiNA 31”/8 mm 15”/3 mm 22”/4 mm
PPIMP 43” 29” 27”
MPiH 43” 29” 25

*Measurements made on the tracing for case 2 and compared with the individualized norm derived from the mesh diagram analysis (Pig. 12)
and with population norms from other cephalometric analyses.
H = Horizontal. PP = Palatal plane. MP = Mandibular plane

alized norm” according to location of landmarks by almost
equal amounts (5 to 6 mm), which reflects proportional har-
mony of these structures. However, the chin is retruded rel-
ative to its normalized position (4 mm) and even more relative
to the prognathic upper face. Thus, bony pogonion is 9 mm
retruded , relative to the nose and lips, which are 5 mm anterior
to the mean location on the individualized mesh for this
patient.
The values of selected angles and distances measured on
the patient’s tracing have been compared with corresponding
measurements on the patient’s mesh norm and with means of
the general population from other cephalometric analyses
(Table I). Although the patient’s SNA and SNB angles suggest
a rather normal position of the maxilla and a retruded man-
dible, a corrected reading is obtained by adding 7” to SNA
and SNB, which is the difference between the inclination of
the patient’s SN line and its inclination on the mesh norm.
Therefore, both angles are undervalued and a 7” correction
factor for the low inclination of the anterior skull base (SN)
must be made. The correct skeletal diagnosis is maxillary
prognatbism (87”) and mandibular retrognathism (76”).
This example underlines the value of the complete mesh
analysis for comprehensive interpretation of the facial con-
figuration because the soft-tissue profile is evaluated at the
same time as, and in relation to, the skeletal profile. Not only
does the direct observation provide a faster reading of the
facial disharmony than multiple angular and linear measure-
ments, it also allows a proportionate assessment of facial
shape not readily obtained through such measurements.
CASE 2
The profile of this patient shows a normal position of
point A, but it is slightly retropostioned to pronasale, which
is forward to its median location on the mesh diagram (Fig.
12). The severe overjet and open bite are evident, both the
product of alveolar and skeletal discrepancies. The major
skeletal disharmony is in the retrognathic and hyperdivergent
mandible, owing to a short ramus and corpus, and a large
gonial angle. The lower lip and soft-tissue chin are retropo-
sitioned. Selected angular and linear measurements on the
patient’s tracing, his mesh norm, and population norms are
presented in Table II.
CASE 3
The malocclusion of a 19-year-old white male patient was
characterized by mesioclusion of posterior teeth and negative
Volume 91
Number 6
Fig. 14. Case 3, Pretreatment and posttreatment cephalometric
tracings superimposed on the cranial base.
overjet. The maxillary first premolars had been extracted at
an earlier age to correct crowding of anterior teeth, which
now show spacing among the canines and incisors. (Because
of these extractions, the optimal occlusal relationship after
treatment would show distoclusion of molars and normoclu-
sion of canines.)
The skeletal nature of the mesioclusion (Fig. 13) could
be optimally corrected with a combined orthodontic-surgical
treatment. Although the maxilla was in normal position rel-
ative to the cranial structures, it was considered “relatively
retrognathic” when evaluated to pronasale. Indeed, pronasale
was 5 mm anterior to its median location. Since a surgical
reduction of the nose was discarded, an “optimal” position
of the maxilla could be achieved by its advancement. On the
other hand, although the mandible was prognathic (8 mm),
the marked degree of prognathism relative to the prominent
nose was less apparent (3 mm). The patient had a gummy
smile, incompetent lips, and anterior maxillary hyperplasia
(4 mm). Correction of these deviations could be achieved
surgically with intrusion of the maxilla. Because such an
intrusion would induce forward rotation of the mandible, a 5
mm surgical set back and vertical rotation were necessary to
reduce the mandibu1a.r prognathism.
Pretreatment and posttreatment cephalometric tracings
were superimposed on the cranial base (Fig. 14). To evaluate
the treatment plan, the individualized mesh norm displayed
in Fig. 13 was superimposed on the posttreatment tracing and
registered on pronasale; the vertical references were kept par-
ModiJied use of mesh diagram
Fig. 15. Case 3, Individualized mesh norm shown in Fig. 13
superimposed on the posttreatment tracing and registered on
pronasale with the vertical references kept parallel.
allel (Fig. 15). The closeness of the treatment outcome to the
individualized mesh norm, used as a guide for the treatment
planning, is clearly demonstrated.
DISCUSSION
Traditional linear and angular measurements of the
facial configuration furnish fragmented information that
must be integrated to obtain the necessary clues for
treatment planning. The mesh diagram, as presented,
produces a graphic and therefore readily identifiable
framework to determine treatment approaches to facial
dysmorphology and malocclusion.
The mesh diagram analysis provides a pro~o~io~ate
assessment of landmark location in an individuahzed
grid scaled to the patient’s facial shape. Hard and soft
tissues are displayed simultaneously and can be eval-
uated separately and relative to each other. The ex-
panded horizons introduced in patient care by means
of combining orthodontic treatment and max.illofacial
surgery require analytic approaches to cephalometrics .
The orientation of the mesh coordinate system ac-
cording to the natural head position of the patient en-
sures comparability between findings from the clinical
examination and cephalometric analysis. The ’ “natu-
ral” head posture can be readily registered in the ceph-
alostat by using common sense judgment to prevent an
 Am. J. Orthod. Denrofk. Orflzop.
June 1987

occasional strained position when the patient turns his CONCLUSION

head upward or downward. Although this head position The mesh diagram analysis ( oorrees and asso-
is standardized, it lacks mathematic precision and the ciates’) displays facial form by distortion of grid lines.
resultant small variations in its reproducibility are far The modification described in this article uses the same
smalier than the often marked differences encountered principles and provides the same interpretations as the
in the inclination of the anterior skull base (NS) or the distorted diagram by means of an individualized norm
Frankfort horizontal. Few orthodontists realize that the for each patient. ln addition to ce~~alometric assess-
Frankfort horizontal was designed to approximate nat- ment through direct observation, linear and angular
ural head position of skeletal material. The vertical measurements may be used and compared with the in-
location of orbitale and porion is variable and, conse- dividualized patient norms. Particularly, the patients
quently, this Frankfort horizontal does not necessarily with severe facial dysmorphology are suited for the
represent a true horizontal reference line.3 proportional analysis provided by the mesh diagram,
The norm that is drawn on the patient’s mesh is which is also used as a guide for treatment planning
individualized according to the patient’s upper facial when surgical correction of facial deformities and mal-
space-that is, facial depth (N-S) and facial height (N- occlusions is required.
ANS). The resultant “average” profile and hard-tissue
The author gratefully acknowledges Dr. Coenraad F. A.
configurations are a useful abstraction at best because Moorrees, Professor and Chairman of Orthodontics at the
of the existing range of individual variations among Harvard School of Dental Medicine-Forsyth Dental Center,
subjects with harmonious facial development and, like- whose advice, guidance, and critical review were essential in
wise, satisfactory occlusion. Nonetheless, the method producing this article.
provides a practical and valuable guide to normalize a
face without violating the characteristic facial type of
REFERENCES
the patient. Diagnosis in orthodontics is obviously not
1. Moorrees CFA, van Vemooij ME, Lebret LML, Glatky CB, Kent
limited to anatomic characteristics, and treatment plan- RL Jr, Reed RB. New norms for the mesh diagram analysis. AM
ning is influenced by considerations that are nonana- J ORTHOD 1976;69:57-71.
tomic in nature and different for each patient.5 These 2. Moorrees CFA, Kean MR: Natural head position, a basic consid-
considerations, together with the morphologic aspects eration in the interpretation of cephalometric radiographs. Am J
Phys Anthrop 1958;16:213-34.
of the patient’s face, determine the treatment objectives
3. Moorrees CFA. Natural head position. In: Jacobson A, Caufieid
for optimal, but individualized, correction of facial dys- PW, eds. Introduction to radiographic cephalometry. Philadelphia:
morphology and malocclusion. Lea & Febiger, 1985:84-9.
The analysis presented can be readily produced by 4. Lebret LML: The mesh diagram-A guide to its use in clinical
the use of a personal computer with plotting capability, orthodontics. In: Jacobson A, Caufield PW, eds. Introduction to
after entering facial depth (SN distance) and upper fa- radiographic cephalometry. Philadelphia: Lea & Febiger, 1985:90-
106.
cial height (N-ANS) of a patient. The program for this
5. Moorrees CFA. Normal variation and its bearing on the use of
graphic display uses the average proportionate location cephalometric radiographs in orthodontic diagnosis. AM J ORTHOD
of landmarks from the normative study’ (Fig. 7) to 1953;39:942-950.
produce an individualized mesh diagram for the patient 6. Moorrees CFA, Lebret LML, Reed RB, gent RL Jr, Glatky CB.
that includes the normal outlines of the profile and hard- The computerized mesh diagram analysis. Transactions of the
Third International Orthodontic Congress. 1975: 185-95.
tissue configurations. The patient’s tracing on clear ac-
etate can be superposed on the plot and then modified
as necessary. The entire analysis can be computerized Reprint requests to:
after entering the x and y coordinates of all selected Dr. Joseph Ghafari
Department of Orthodontics
facial landmarks with a digitizer. In fact, mesh distor-
School of Dental Medicine
tion can be computerized and drawn as shown by Moor- University of Pennsylvania
rees and associates? and the maxillary and mandibular 4001 Spruce Street Al
incisor and chin configurations normalized to the upper Philadelphia, PA 19104
face of the patient.