Department Of Orthodontics & Dentofacial Orthopedics Bapuji Dental COllege & Hospital Davangere 577004 Seminar on

Growth Prediction & VTO

Presented ByNandan Kittur

CONTENTS
-INTRODUCTION -GROWTH PATTERN, VARIABILITY, AND TIMING

PAGE NO.
1 2-6 7-9 10-11 12-24 25-27 28-29

-METHODS OF GROWTH PREDICTION -WHAT ARE WE INTERSTED IN PREDICTING IN CRANIOFACIAL COMPLEX? -INDICATORS OF SKELETAL MATURITY -HAND WRIST RADIOGRAPHS AND SKELETAL MATURITY -CERVICAL VERTEBRAE AS MATURATIONAL INDICATORS -FRONTAL SINUS DEVELOPMENT AS INDICATOR OF PUBERTY -MANDIBULAR CANINE CALCIFICATION AND SKELETAL MATURITY -MANDIBULAR THIRD MOLAR DEVELOPMENT AND SKELETAL MATURITY -PREDICTION OF MANDIBULAR ROTATION -ARCIAL GROWTH OF THE MANDIBLE. -VTO( VISUALIZED TREATMENT OBJECTIVE) RICKETTS VTO HOLDAWAY VTO -CONCLUSION

30-31 32

33-40 41-48 49-50 51-70 71-89 90

-BIBLIOGRAPHY

91-93

INTRODUCTION
The growth and development of the human face provides a fascinating interplay of form and function. The mosaic of the morphogenetic pattern, as it is influenced by epigenetic and environmental forces, requires an understanding of many factors if we are to fully appreciate the phenomenon. This has more artistic value as far as orthodontist is concerned. Surveys have shown that two thirds of the cases seen for orthodontic therapy involve types of malocclusion in which growth and development play a significant role in the success or failure of mechanotherapy.

Growth Pattern, Variability, and Timing

In studies of growth, the concept of pattern is an important one. Pattern represents proportionality. The Cephalocaudal gradient of growth strongly affects proportions and leads to changes in proportion with growth.

In fetal life, at about the third month of intrauterine development, the head takes up almost 50% of total body length. At the time of birth, the trunk and limbs have grown faster so that only 30% of body length is the head. At adulthood the head is only 12% the body length. At birth legs are 1/3 the body length, at adulthood they are about half the body length. This reflects the Cephalocaudal gradient of growth. Even within the head and face, the cephalocaudal gradient of growth strongly affects the proportions. In new born, the cranium is larger and face is much smaller, when compared to an adult. Also mandible continues to grow more and later than the growth of maxilla.

Another aspect of normal growth pattern is that, not all tissues of the body grow at the same rate. This is graphically illustrated by the Scammons growth curves.

Growth does not take place at a uniform rate, but there is acceleration and retardation in the rate of growth. The accelerative phases are called growth spurts. There are 3 major growth spurts recorded by Woodside. They seemed to be sex linked. First peak occurred at 3yrs of age. It is called Childhood growth spurt. Second peak at 6 to 7yrs in girls and 7 to 9yrs in boys. It is called Juvenile growth spurt. Third peak was at 11 to 12yrs in girls and 14 to 15yrs in boys. It is the prepubertal growth spurt.

The tendency is generally for boys to have 2 or 3 peaks, while large numbers of girls show only 2 peaks. Very few girls show the mixed dentition growth spurt. But all show the pubertal growth spurt. Another important aspect of growth is Variability. Obviously everyone is not alike in the way that they grow, as in everything else. It can be difficult, but it is important to decide whether the individual is merely an extreme of the normal variation or falls outside the normal range. This is determined, using growth charts for the particular population standards.

The final major concept in Physical growth and development is Timing. Variation in Timing occurs because the same event happens in different individuals at different times. Therefore Chronologic age often is not a good indicator of an individuals growth status.

The effectiveness of a Biologic or Developmental ages in reducing timing. variability makes this approach useful in evaluating a childs growth status.

METHODS OF GROWTH PREDICTION

William Hirschfield and Robert Moyers (1971) Several predictive methods are used in industry and science. We may group these under following headings. 1. Theoretical 2. Regression 3. Experimental 4. Time series THEORETICAL METHODS OF PREDICTION: Astronomers discovered earth size planet several thousand light years away from us by collecting a series of inexplicable apparently random data on the behavior of celestial bodies until a theoretical model could be constructed mathematically which might explain all the unusual activity observed, and a test for the hypothesis was devised. Theoretical models of cranio facial growth have not yet been defined mathematically in terms precise enough to permit the application of the method to prediction. REGRESSION METHODS: These methods serve to calculate a value for one variable called dependent, on the basis of its initial states and the degree of its correlation with one or more independent variables. Johnston has recently evaluated and reviewed regression methods of approach to craniofacial prediction. Among his conclusions is that:

(1) The ultimate accuracy of cephalometric prediction may be limited to some extent by intrinsic errors with the cephalometric method itself. (2) Contemperory methods seem inadequate to provide an efficient estimate of individual changes attributed only to growth. Burstone has reviewed some of the problems of attack and of selection of independent variables with regard to growth prediction. EXPERIMENTAL METHODS: Experimental methods are based on the clinical experience of a single investigator who attempts to quantify his observations of practice in such a way that they can be codified for use by others. The best known example of the experimental method in craniofacial growth prediction is that of Ricketts, whose estimates of growth prediction for the individual utilize means derived from a large sample of treated orthodontic patients. The method is popular and widely used, but its theoretical base is shaky on two counts. First the assumption must be made that the individual being predicted will behave as the mean of a population of which he is not a member. Second, the morphology of the mandible and the other parts is a clue to the future growth of the face, appoint disputed by Horowitz and Hixon, Balbach and Woodside. TIME SERIES METHOD: Because of the great interest in prediction of craniofacial growth and the limitations of the methods thus far tried, it seems pertinent to ask whether there might be some other method of prediction, as yet, untried on growth problems which
9

would provide the desired accuracy, efficiency and individuality for the clinician. Operations research has been concerned with the development of methods which are based on individual not population behaviour. The methods are essentially two types 1. Time series analysis which extracts in a mathematical form the fundamental nature of the process as it relates to time. 2.smoothing methods, either moving averages or exponential, which operate to give representative or average values to the parameters of a previously derived time series equation .For purpose of analysis a time series is considered to be composed of four parts. These are 1. Trend or long term movement 2. Oscillations about a trend 3. Cyclic or periodic events 4. Random compliments The analysis consists of assessment of each of these parts by means of specific statistical tests. Time series method offers more promise for craniofacial growth than any of the methods thus far used.

10

WHAT

ARE

WE IN

INTERSTED

IN

PREDICTING COMPLEX?

CRANIOFACIAL

Future size of part: the prediction of future size, according to Burstone, his primarily a problem of predicting future increments which are to be added to a size that is already known. Most of the size dimension of interest to the orthodontist displays a combination growth curve through time. Relationship of parts: The most important prediction for the clinician is the future relationship of parts, that is, future facial patterns. Pattern, however represented, is a summation of the growth and size in several component regions. Timing of growth events: Because growth does not proceed evenly, certain facial dimensions demonstrate market changes in their velocity curve. These spurts make prediction much more difficult. If one were to predict a spurt, he might want to predict the time of its onset, the duration of the increased rate of growth, and the rate of growth during the spurt. Vectors of growth: Most predictive methods thus far presume a continuation of the pattern first seen therefore; the presumption is made that the vectors of growth presents at the time of prediction will remain. There is much documentation that this presumption is not true. Mandibles, which grow vertically for a period of time inexplicably, start to grow horizontally.

11

Velocity of growth: It would be of use to know the future expected rate of growth. Prediction of velocity is most important during the pubescent spurt. The effect of orthodontic therapy on any of the above predicted parameters: It is not unreasonable for clinician to be interested in predicting what effect the treatment will have on the predicted and actual growth of one specific face.

12

Indicators of Skeletal Maturity

HAND WRIST RADIOGRAPHS AND SKELETAL MATURITY

The first recorded Hand-wrist radiograph film was published by Sydney Rowland of London in 1896. This was just 4 months after the announcement of the discovery of the X-Ray by Roentgen. In 1926 Carter reported on a radiographic study of carpal bones in children. Howard (1928) using hand X-rays, reported on the physiologic changes of bone centers in a large group of male and female children from ages 5to16. In 1929 two comprehensive growth studies were begun, one at the Brush foundation of Western Reserve University, Cleveland, Ohio under the direction of T. Wingate. Todd, and the other at the Harvard School of Public Health, Boston, Massachusetts under Harold Stuart. Todds work was continued
13

after his death by William Greulich. S. Idell Pyle was also involved in the Cleveland project, and it was she who was instrumental in preparing the standards of growth in popular use today utilizing the hand-wrist film. The concept that facial growth was in some way related to general body growth was reported by Nanda(1955) . He stated that facial growth tended to lag slightly behind general body growth in height during the pubertal growth spurt period. Rose (1960) cited a cross sectional study of 125 individuals and determined that carpal ranking was an ineffective guide to facial development. Stature and body weight were thought to be the best indicators. Bhamba(1961) stated that the face showed the characteristic skeletal growth pattern with the time of maximal spurt occurring a little after the spurt in body height. Johnston(1965)demonstrated a relationship between skeletal and facial growth and emphasized that there were, in addition to normal growth patterns, retarded as well as accelerated types which required special attention. Hunter (1966) reported that the carpal bones as well as adjacent skeletal structures had proven to be the most satisfactory sites for determining skeletal maturation. Bjork and Helm(1967) stated that the appearance of the ulnar sessamoid on the Hand-wrist radiograph was significantly related to the onset of maximum puberal statural growth in height. The sessamoid appeared before maximal maximum puberal growth. Helm et al (1971) they found that one stage (PP2=) invariably occurred one to five years before maximum growth. The stage
14

puberal

statural growth,and menarche in girls occurred after the

MP3 cap occurred close to the tome of the along with the ulnar sessamoid. The DP3 stage occurred from one to three years after the maximum. Brown, Barrett &Grave (1971) found that two other events occurred significantly at least one year prior to peak growth velocity. They were initial ossification of hook of hamate as well as of pissiform. Pileski et al (1973) reported that 20% females and 25% males did not exhibit appearance of sessamoid, until after maximum growth velocity was reached. Grave and Brown (1976) suggested that the epiphyseal union of radius could be used to assess the duration of retentive phase of treatment. Bowden (1976) cautioned that strict reliance on Hand wrist indicators to determine the state of facial growth could not be guaranteed and that the relationship, although valid, was probably not absolute. Grave and Brown (1979) described the use of hand wrist film in orthodontic treatment to take advantage of the puberal growth spurt.

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Grave and Brown have recorded 14ossification events 1. 2. 3. 4. 5. 6. PP2= MP3= H-1 Pisi R= S Finger 7. 8. 9. 10.
11.

Proximal phalanx of second finger; Middle phalanx of third finger; Hooking of Hamate Stage 1 Appearance of Pissiform Radius; epiphysis is as wide as Appearance of Ulnar Sessamoid at

epiphysis is as wide as diaphysis epiphysis is as wide as diaphysis

diaphysis metacrpophalangeal joint of first H-2 MP3cap PP1cap Rcap DP3 PP3 MP3 R Hooking of Hamate Stage 2 Middle phalanx of third finger; Proximal phalanx of first finger; Radius; epiphysis caps its diaphysis Distal phalanx of third finger; Proximal phalanx of third finger; Middle phalanx of third finger; Radius; complete epiphyseal union

epiphysis caps its diaphysis epiphysis caps its diaphysis

complete epiphyseal union

12.

complete epiphyseal union

13.

complete epiphyseal union

14.

16

The events fell logically into 3 groups with respect to ossification times Events, which occurred before peak growth velocity 1. 2. 3. 4. 5. 6. 7. 8. 9. PP2= MP3= H-1 Pisi R= S H-2 MP3cap PP1cap
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Events which coincided peak growth velocity

10.

Rcap DP3 PP3 MP3 R

Events which followed peak height velocity

11. 12. 13. 14.

Fusion of distal phalanges occurs about the time of menarche and it is suggested that epiphyseal union of radius can be used to assess the duration of retention phase of treatment.

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Fishman (1974) has given 11 Skeletal Maturity Indicators(SMI)

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Epiphysis as wide as Diaphysis 1. 2. Third finger proximal phalanx Third finger middle phalanx

3. Fifth finger- middle phalanx Ossification 4. 5. 6. 7. 8. 9. 10. 11. Adductor Sessamoid of thumb Third finger- Distal phalanx Third finger- Middle phalanx Fifth finger- Middle phalanx Third finger- Distal phalanx Third finger Proximal phalanx Third finger- Middle phalanx Radius SMI 1 - 4 SMI 4-7 SMI 7 11 Capping of Epiphysis

Fusion of epiphsis and Diaphysis

Accelerating growth velocity period. High growth velocity period. Decelerating growth velocity period.

Girls generally reach point of peak growth velocity at SMI 5 and boys at SMI 6.

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Boys do not take a longer time to mature. They simply do it at a later chronologic age. The period of male adolescence generally lasts no longer than female adolescence. Julian Singer (1980) has described 6 stages of development on the hand wrist radiograph. Stage 1 (Early):
1. Absence 2. Absence

of Pisiform of Hook of Hamate of proximal phalanx of second digit (PP2) narrower

3. Epiphysis

than its shaft Stage 2 (Prepuberal):

1. Proximal

phalanx of second digit and its epiphysis are equal in

width (PP2).
2. Initial 3. Initial

ossification of hook of hamate . ossification of pisiform.

Stage 3 (Puberal onset):

1. Beginning 2. Increased 3. Increased

calcification of Ulnar sessamoid.

width of epiphysis of PP2 calcification of hamate hook and pisiform.

Stage 4 (Puberal): 1. Calcified ulnar sessamoid of shaft of middle phalanx of third digit by its
2. Capping

epiphysis(MP3cap) Stage 5 (Puberal Deceleration):

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1.

Ulnar sessamoid fully calcified of the shaft of middle phalanx of third digit by

2. Calcification

its epiphysis (DP3u). 3. 4. All phalanges and carpals fully calcified. Epiphysis of radius and ulna not fully calcified with

respective shafts. Stage 6 (Growth completion): No remaining growth sites.

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Hagg and Taranger (1982) longitudinal study in 212

investigated a prospective

Swedish children. Data comprised of Standing height, Tooth emergence, pubertal development and Handwrist radiographs.

Adolescent growth was studied by graphical analysis of the unsmoothed incremental curves of standing height. The curves
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were based on the annual increments from 3 to 20 years. First, the peak height velocity (PHV) was located on incremental curves for each subject. The growth curves were observed for reliable estimates of the beginning and end of the pubertal growth spurt. A marked, continuous increase in growth rate up to PHV was found from one growth event, ONSET. In all subjects the increase in growth rate during puberty was more than 10mm; that is, ONSET and PHV did not coincide. A marked, continuous deceleration in growth occurred down to the first annual increment below 20mm. (END).

Dental development was assessed by dental emergence stages. Skeletal development was analyzed using hand wrist radiographs taken annually from 6 to 18 yrs. Pubertal development was analyzed from 10 to 18 yrs of age by determining menarche in girls and change in voice in boys.
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Results: The pubertal growth spurt: girls and 12.1 yrs in boys. PHV was at 12.0 yrs in girls and 14.1 yrs in boys. END was at 14.8 yrs in girls and 17.1 yrs in boys. ONSET was at 10.0yrs in

Dental development and pubertal growth spurt: The dental emergence stages were not useful as indicators of pubertal growth spurt. Skeletal development and the pubertal growth spurt : At ONSET 40% girls and 25% boys had ossified ulnar sessamoid. (S).
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At PHV 90% of the subjects were in either stage MP3FG or stage MP3-G. At END 95% boys and 80% girls were in one of the three radius stages. (R-I, R-IJ, R-J)

Pubertal development and the pubertal growth spurt: Menarche was reached 1.1 yrs after PHV. Pubertal voice was attained 0.2 yrs before PHV. Male voice was attained 0.9 years after PHV.

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Cervical Vertebrae as Maturational Indicators Lamparski (1972) used cervial vertebrae morphology to assess pubertal growth spurt. Hassel and Farman (1995) modified his criteria and gave 6 stages of cervical vertebrae development. Garcia Fernandez (1998) related these stages with the SMI given by Fishman. The six stages are as follows

Initiation (SMI 1 and 2) posterior to anterior.

the cervical vertebrae are wedge

shaped, with the superior vertebral borders tapering from 80to 100% growth can be anticipated at this stage. Acceleration (SMI 3 and 4) concavities develop along the inferior borders of C2and C3. The bodies of C3 and C4 are nearly rectangular, and the inferior border of C4 is flat. Growth acceleration begins at this stage, when 65-85% of adolescent growth can be anticipated. Transition (SMI 5 and 6) distinct concavities develop on the inferior borders of C2 and C3. A concavity begins to develop at inferior border of C4, and the bodies of C3 and C4 are rectangular. Adolescent growth accelerates towards peak velocity, with 2565% of adolescent growth anticipated.

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Deceleration (SMI 7 and 8) Clear concavities are seen on the inferior borders of C2, C3, and C4 with the bodies of C3 and C4 nearly square. Only 10-25% of adolescent growth remains. Maturation (SMI 9 and 10) Accentuated cavities are seen on the inferior borders of C2, C3, and C4, and the bodies of C3 and C4 are nearly square. Final maturation takes place at this stage when 5-10% adolescent growth can be anticipated. Completion (SMI 11) Deep concavities are seen on the inferior borders of C2, C3, and C4, and the vertebral bodies are more vertical than horizontal. Little to no adolescent growth is expected at this stage.

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30

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Frontal Sinus Development as indicator of puberty Sabine Ruf and Hans Pancherz (1996) evaluated the development of the frontal sinus to the longitudinal data of the subjects growth charts. Results showed that Frontal sinus growth velocity at puberty is closely related to body height growth velocity. Frontal sinus shows a well defined pubertal peak (Sp), which on an average, occurs 1.4 years after the pubertal body height peak. (Bp). If the only prediction was that whether pubertal growth maximum has passed the precision of this method was high (90 %). But if incidence of body peak was to be predicted the accuracy is only 55%. Moreover, it is only possible if 2 cephalograms approximately 1-2 yrs spaced, of the same individual are available.

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Mandibular Canine calcification and skeletal Maturity Sandra Coutinho et al in 1993 related canine calcification stages to skeletal maturity indicators as shown in the figures. They concluded that the initiation of pubertal growth spurt relates with stage F of canine calcification. Stage G occurs approximately around 1 yrs before PHV in boys but only 5 months before PHV in girls. The intermediate stage between stage F and stage G should be used to identify the early stages of pubertal growth spurt.

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35

Mandibular third Molar development and Skeletal maturity Engstorm (1983) compared lower third molar development stages with skeletal maturity indicators. Third molar stages were A: Tooth germ visible as rounded radiolucency B: cusp mineralization complete. C: Cown formation complete. D: Root half formed. E: Root formation complete but apex not closed. Skeletal indicators used were PP2: proximal phalanx of second finger, epiphysis as wide as diaphysis MP3 cap: middle phalanx third finger, epiphysis caps the diaphysis DP3 u: epiphyseal union. Ru: Distal epiphysis of radius, complete epiphyseal union. At stage PP2 third molar crown completion took place in majority of subjects. At stage MP3 cap crown completion in all and root development had begun in few subjects. At DP3 u Root length was completed in some subjects. At R u one third subjects crown was complete, half the root was complete in other one third, and in the remaining third root had reached full length. distal phalanx of third finger, complete

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PREDICTION OF MANDIBULAR ROTATION

In 1969 Bjork discussed three methods of growth prediction 1) A longitudinal method, which consists of following the course of development by annual cepholograms, is shown to be of limited use for this purpose, as the remodeling process at the lower border of the mandible to a large extent masks the actual rotation. 2) A metric method, which aims at prediction based on a metric description of the facial morphology at a single stage of development, has for not proved of value. 3) A structural method is described by which it may be possible to predict, from a single cephalogram, the course of rotation, where this feature is marked. This method is based on the information gained from implant studies of the remodeling process of the mandible during growth. The principle is to recognize specific structural features that develop as a result of the remodeling in a particular type of mandibular rotation. A prediction of the subsequent course is then made on the assumption that the trend will continue. Such structural signs are detailed as follows. Structural signs of growth rotation: From the clinical stand point, it is important to detect extreme types of mandibular rotation occurring during growth. Seven structural signs of extreme growth rotation are considered in relation to the condylar growth direction. Not all of them will be found in a particular individual, but the greater the number that
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are present, the more reliable the prediction will be. However, it is evident that these signs are not so clearly developed before puberty.

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The seven signs are related to the following features 1) Inclination of the condylar head. 2) Curvature of the mandibular canal.
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3) Shape of the lower border of the mandible. 4) Inclination of symphisis, ) Interincisal angle 6) Inter premolar or inter molar angles 7) Anterior lower face height. In horizontal growing individuals: 1) The condyles are inclined forward. 2) The mandibular canal curvature tends to be greater than that of the mandibular contour. 3) The lower border presents with pronounced apposition below the symphysis and the anterior part of the mandible produces an anterior rounding, with a thick cortical layer, while the resorption at the angle produces a typical concavity. 4) The symphysis swings forwards in the face, and the chin is prominent. 5) The difference in the inter incisal angle is evident; in spite of the compensatory tipping of the lower incisors is more when compared to vertical growing individuals. 6) The difference in the interpremolar and inter molar angles in the two growth types is also clear is more in horizontal growth than vertical type growth pattern. 7) A compression or reduced lower anterior face height. In vertical growing individuals: 1) the condyle is backwardly inclined. 2) The mandibular canal is straight or in pathologic cases, it may even curve in the opposite direction. 3) The lower border of the mandible anteriorly rounding is absent and the cortical layer is thin and lower contour at the jaw angle is convex.
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4) The inclination of the symphysis is swung back, with receding chin. The evaluation is complicated by the simultaneous remodelling of the alveolar process in the opposite direction, as is exemplified by the cranium with openbite. 5) The inter incisal angle is reduced in this case due to more proclination. 6) The inter premolar and molar angles in this growth pattern is reduced. 7) The over development of L.A.F.H is seen in backward rotating mandibles. Taking the consideration of these structural signs the growth trend is predicted. The mechanism underlying the mandibular rotation and the centers of rotation will be considered. From the start point of growth, the mandible may be regarded as a more or less unconstrained bone it may change its inclination in several ways. A critical factor in this respect is the site of the center of rotation, which may be located at the posterior or anterior ends of the bone or somewhere in between, in which case the ends of the mandible swing in different directions, thus the center may not necessarily lie at the temporomandibular joints, as it usually imagined, although this is not readily evident from examination by conventional techniques. There follows schematic account of the various types of rotation of the mandible that may be recognized with the implant method are as follows. Bjork based on the location of C/R classified forward rotation 3 types: Type I: There is a forward rotation about the centers in the condyles which gives rise to a deep bite, in which the lower
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dental

arch

is

pressed

into

the

upper,

resulting

in

underdevelopment of the anterior face height. The cause may be occlusal imbalance due to loss of teeth or powerful muscular pressure. This deep bite of the bite may occur at nay age during active growth process.

Type II: Forward growth rotation of the mandible about a center located at the incisal edge of the lower anterior teeth is due to the combination of marked development of the posterior face height and normal increase in the anterior height. The posterior part of the mandible then rotates away from maxilla. The increase in the posterior face height has two components. The first is the lowering of the middle cranial fossa in relation to anterior one as the cranial base bends, the condylar fossa then being lowered. The second component is the increase in the height of the ramus, which is pronounced in the case of vertical growth at the mandibular condyles. Because of the vertical direction of the condylar growth, the mandible is lowered more than it is carried forward. Because of the muscular and ligamentous attachments, the lowering takes place as a forward rotation in relation to the maxilla, with the center at the incisal edges of the lower incisors. The eruption of the molars keeps pace with the rotation. Because of the simultaneous marked resorption below the gonial angle, the height in this region may not increase to a great extent and the lower border undergoes a characteristic remodelling.
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Type III: In anomalous occlusion of the anterior teeth the forward rotation of the mandible with growth changes its character in the case of large maxillary overjet or mandibular overjet, the center of rotation no longer lies at the incisors but is displaced backward in the dental arch, to the level of the premolars. In this type of rotation the anterior face height becomes underdeveloped when the posterior face height increases. The dental arches are pressed into each other and basal deep bite develops.

Backward rotation is less frequent than forward rotation and has been examined by the implant method in considerably fewer subjects two types have been recognized.
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Type I: Here the center of the backward rotation lies in the temporomandibular joints. This is the case when the bite is raised by orthodontic means, by a change in the intercuspation or by a bite raising appliance and results in an increase in the anterior face height. Backward rotation of the mandible about a center in the joints also occurs in connection with growth of the cranial base. In the case of flattening of the cranial base, the middle cranial fossa is raised in relation to the anterior one, and then the mandible is also raised. There may be other causes also, such as an incomplete development in height of the middle cranial fossa. This underdevelopment in the posterior face height leads to a backward rotation of the mandible, with overdevelopment of the anterior face height and possibly openbite as a consequence.

Type II: Backward rotation here occurs about a center situated at the most distal occluding molars. This occurs in connection with the growth in the sagittal direction at the mandibular condyles. As the mandible grows in the direction of its length it is carried forward more than it is lowered in the
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face, and because of its attachment to muscles and ligaments it is rotated backward. In this type of rotation the symphysis is swung backward and the chin is drawn back below the face. The soft tissue of the chin may not follow this movement, and a characteristic double chin can form. Basal openbite may develop, and there is difficulty in closing the lips with out tension. Since the position of the lower incisors, are related functionally to the upper incisors, they become retroclined in the mandible and the alveolar prognathism is reduced.

In regarding to the degree of rotation of the mandible, investigators like Bjork, Lavergne and Gasson found an annual rotation of 1.070 which ranges from 00 to 2.100 when compared to sells nasion line and found 70 during a period of six years around the pubertal growth spurt in the forward rotation growth pattern individuals. In posterior rotation growth pattern the mean degree of rotation was 0.300 with range from 0.060 to 0.850 when related to S.N. line.

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ARCIAL GROWTH of the Mandible:

R.M.Ricketts using trial and error procedure with longitudinal cephalomatric records and computers has developed a method to determine the arc of growth of the mandible. The principle is a normal human mandible grows by superior anterior (vertical) apposition at the ramus or the curve or arc which is a segment formed from a circle. The radius of this circle is determined by using the distance from mental protuberance to a point at the forking of the stress lines at the terminus of the oblique ridge on the medial side of the ramus (pt. Eva) On the basis of this, a primary method of prediction of development was devised. By plotting a line through the long axis of the condyle and neck and extending it to the form during growth had been studied. Consequently, findings from this method suggested that the technique could serve as a working hypothesis for growth prediction for the clinical problem of prognosis of growth. The next move was to identify a central core cephalometrically. External mandibular form is subject to remarkable remodeling and therefore not reliable as a reference. The attempt to surface variation and to determine central or internal structure resulted in the center of the ramus.

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Method for determination of xi point: R1= deepest point on the subcoronoid incisure R2=point selected opposite R1 on the posterior border of ramus. R3=depth of the sigmoid notch R4=point selected directly inferiorly on the lower border of ramus A point at the superior aspect of the symphysis was selected as supra pogonion. It was labelled p.m. (Protuberance menti) This is substantiated as reference because (i) it is located at approximately a stress center-Ricketts. (ii) Its site of a reversal line Enlow and (iii) it is consistent with the findings from implant studies Bjork; which indicated stable unchanging bone in this area of the chin. There fore, a bone crest located at the superior aspect of the compact bone on the anterior contour of the symphysis was accepted as the most stable and useful reference for out most basal bone in the mandible. By bisecting the height and width of the ramus at its narrowest dimension a geometric center was determined and labelled xi point. Investigation of normal mandible from 25 dried skulls showed in every instance that this point fell in contract with the mandibular canal. Rickets used a point described previously with laminagraphs at the bisection of the condyle neck as high as visible in the cephalogram film below the fossa. This was labelled Dc Accordingly by connecting Dc point with xi a repeated condyle axis was established. Further by connecting xi to p.m. a corpus axis was erected.

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It is an angle formed by the intersection of the condylar axis (DC-xi) and a backward extension (xi-p.m.) from the center of ramus to suprapognion. The mean is 26 + 4. This angle has a tendency to increase with age (0.5/yrs). The first mandible is a reterognathic one with a steep mandible plane and grows vertically. The middle one is normal and the 3rd mandible with an high angle is indicative of a forward growing mandible. Consequently by studying linear growth on these planes and the form change as a change in a angulation between the two an interpretation could be gained regarding the characteristics of mandible growth in a given patients. Samples that were superimposed on the corpus axis and registered at xi point were found to bend about degree each year. It was recognized that a bending was occuring in an orderly manner and therefore the greater the magnitude of growth, greater the bending. It was apparent that a growth arc was operative. It was of interest to see if this arc could be reduced to a segment of a circle an ellipse or a spiral curve. The mandible became more obtuse than was the actual behavior of the sample. This shows the method used to determine the true arc of mandible po,xi, and c2 (center of condyle head) were connected and increments added. After using pm, xi and dc points as a method of depicting the cortical core of the mandible, experiments were undertaken to determine a method by which the form and size of the mandible; often at 5 years interval could be predicted with the use of only the first x-ray as reference.

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Results showed that the arc size increase was seen, but not enough bending occurred. Pm was then retained as a stable and reliable reference for further study. A second arc was explored by using the tip of the coronoid process, the anterior border of the ramus at its deepest curve (R1) and the same pm point. The extension of this curve exhibited the segment of a circle too small in radius and resulted in excessive bending of the mandible when the same gradient of growth was employed for a project. These 2 unsuccessful arcs obviously bracketed the true arc, which must be somewhere in the mandible between the condyloid and coronoid process and between xi and the anterior border of the ramus. Hence Ricketts decided to construct an experimental arc bisecting the 2 previous arcs. By establishing a halfway point between xi and Ri points (the center and anterior border of ramus) and using the distance from this points to pm as radius of a circle an arc could be producer. The use of this arc still bent the mandible a fraction too much. In addition a radius selected from this point would increase or a changing arc or ultimate spiral shape would result. Growth therefore could not be represented as a simple segment of a circle if these dimensions were employed. It was though that perhaps the stress lines of the mandible would reveal its hidden secrets. An 850 years old mandible given to Ricketts by the late William downs revealed the secret. On close investigation of the mandible the true arc was determined. This mandible had been weathered to a state of disintegration of the interprismatic substance of the external cortical bone and clearly showed stress lines in the outer and inner plates. The lines thus exhibited the design of the mandible
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for bracing externally. (Y1 forking of the stress lines at the base of the coronoid process). Experimentally 2 new points (Eva and TR) were located geometrically; point Eva is also a biologic line in the ramus. When the size increase of the mandible as determined in the computer study was incrementally added to the arc at the sigmoid notch it was found that the predicted mandible was almost absolutely correct in size and form when compared with the final composite. The growth increase for the condylar and coronoid processes were different when measured from a point at the point crossing of the arc of the sigmoid notch. The point of crossing was labelled as Mu (Murray point which is named after Ricketts father). RR (Ramus reference) point is the point halfway between xi point and R3 the bisections of which locates point Eva. Eva in turn is used to find a TR (true radius) measured from pm point. Now using TR. as the center of a circle, an arc is drawn. Mu Murray point is the crossing of this arc on the sigmoid notch. By constructing the growth arc, growing the mandible on this arc, and extending the processing and drifting angular process a new forecasting technique is developed. Having become satisfied with this arc as a tool for prediction the next problem lay in the amount of growth on forecast on the arc. The coronoid and condylar process grow upward and outward in a direction essentially as a function of the curve of an original arc. Some condyles did not grow at all from the original point Mu while others grew significantly. The short and small condyles were found not to grow and good well-formed condylar heads were found to grow by 0.4 mm and average
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condyles 0.2 mm/year. Growth increment for coronoid 0.8 mm/year. Symphysis-1mm/year. Apposition of the lower border of the symphasis for males occurs at about 1mm each 8yrs. From point Mu the mandible is grown out on the arc at the sigmoid notch about 2.5mm/yr. The method to determine the drift of the gonial angle on the arc in females no further addition are given on the border of mandible from the arc, in males 0.2mm/year are given. The drift of the mandible occurs almost at a pace of 50% of the total mandible growth. In the series of the steps in forecasting of the mandible growth. Art work for normal contours is employed as connections are made from the coronoid process to point RR on the coronoid crest. The oblique ridge shows opposition of about 0.4mm/year. Implication of article growth prediction 1.) It appears that the symphysis rotates essentially during growth from a horizontal to a more vertical inclination and the suggestion is presented that the genial tubercles and the lingual plate drop downward in the process. This explains the major part of the form characteristics of the symphysis, in the cephalogram film (chin button development). Implant studies have shown that greatest apposition takes place at the inferior margin of symphysis (and perhaps the posterior side) in the preschool years. The growth by apposition may appear lateral to the midline on the symphysis as bulk is needed for bracing. 2.) 3.) This phenomenon explains why reversal lines are It explains why the mandible plane changes extensively observed at the area of pogonion and suprapogonion. in some individual and not in others.

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4.) 5.)

It shows why ankylosed teeth are observed to affect It explains how the early ankylosis of a lower molar

occlusal plane development. tooth terminates with the tooth located at the lower border of mandible,the mandibular arc simply continues and this tooth becomes trapped with in the cortical bone and the lower border resorbs point up to it 6.) It suggests a reason why mandible anchorage is risky in retrognathic faces because less space is available for molar eruption due to a more vertical eruption in that type than prognathic types. 7.) It explains why good dentures may become progressively more crowded in long tapered faces and sometimes even in normal faces. 8.) It suggests that abnormal growth or margins of the mandible can be understood as a friction of relative contribution of the coronoid and process.

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DRAW BACK OF ARCIAL GROWTH PREDICTIONS: 1.) It relies heavily on the operators skill in tracing the

cephalogram. Minor tracing errors could produce a wrong prediction. 2.) Mitchell and Jordan (1975) in their study to evaluate Ricketts prediction method concluded that Ricketts uses the patients chronologic age rather than the skeletal age since he requests no hand wrist film. Since average growth increments are added to the age, if the patients has completed growth or if he is a growth spurt or lag phase, it will alter the results; particularly if the time interval is short and the patients is near maturity. (Ricketts presumes that girls are grown to 14.5 years and boys to 19 years) 3.) Since the growth increments constants are mainly derived from western population it is to be found out if these constants are applicable to Indian subjects.

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VTO( Visualized Treatment Objective)

The term VTO which stands for Visualized Treatment Objective was first coined by Holdaway but used extensively by Dr. Ricketts. The term visual (or visualized ) treatment objective (VTO) was coined to communicate the planning of treatment for any orthodontic problem. A Visual Treatment Objective (VTO) is like a blueprint used in building a house. It is a visual plan to forecast the normal growth of the patient and the anticipated influences of treatment, to establish the individual objectives we want to achieve for that patient. Treatment for a growing patient must be planned and directed to the face and structure that can be anticipated in the future, not to the skeletal structure that the patient presents initially. The treatment plan should take advantage of the beneficial aspects of growth and minimize any undesirable effects of growth, if possible. The Visual Treatment Objective permits the development of alternative treatment plans. After setting up the teeth ideally within the anticipated or "grown" facial pattern, the orthodontist must decide how far he must go with mechanics and orthopedics to achieve his goals, whether it is possible to achieve them, and what the alternatives are. Once treatment has begun, there is a continuing need for a visual goal against which treatment progress can be measured and monitored. By superimposing a progress tracing between
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the original tracing and the forecast goal, the orthodontist may evaluate progress along a definitely prescribed route. Any deviation from expected progress will become apparent immediately and the need for midcourse corrections will be recognized and can be instituted early. Although the majority of individuals react predictably to treatment, particular individuals may deviate from the usual pattern and require alterations in strategy. Differences in response to treatment may result from lack of patient cooperation, variations in growth patterns, or from ineffective orthodontic mechanics. The necessity for this type of monitoring is important in accommodating treatment to individual variability. The VTO forecast is valuable for the orthodontist's selfimprovement in that it permits him to set his goals in advance and compare them with the results at the end of treatment. Identification of the discrepancies between goals and results provide him with an objective picture of the areas in which his treatment could be improved.

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Ricketts VTO

A step-by-step procedure to construct a VTO for a in the following sequence (putting in average growth for an estimated two-year period of active treatment and the objectives that we wish to achieve with our mechanics): 1. the cranial base prediction 2. the mandibular growth prediction 3. the maxillary growth prediction 4. the occlusal plane position 5. the location of the dentition 6. the soft tissue of the face

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VTO Cranial Base Prediction Place the tracing paper over the original tracing and starting at CC point, follow these steps to construct the cranial base: 1. Trace the Basion-Nasion Plane. Put a mark at point CC. 2. Grow Nasion 1mm/year (average normal growth) for 2 years (estimated treatment time). 3. Grow Basion 1mm/year (average normal growth) for 2 years (estimated treatment time). 4. Slide tracing back so Nasions coincide and trace Nasion area. 5. Slide tracing forward so Basions coincide and trace Basion area.

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VTO Mandibular Growth Prediction Rotation The construction of the mandible and its new position start with the rotation of the mandible. The mandible rotates open or closed from the effects of the mechanics used and the facial pattern present. The average such effect on mandibular rotation is as follows:

Mechanics 1. Convexity Reduction Facial Axis opens 1/5mm.

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2. Molar Correction Facial Axis opens 1/3mm. 3. Overbite Correction Facial Axis opens 1/4mm. 4. Crossbite Correction Facial Axis opens 1-1. Recovers half the distance 5. Facial Pattern Facial Axis opens 1/1 S.D. dolichofacial; 1 closing effect against mechanics if brachyfacial. In constructing the VTO, these factors must be taken into consideration in deciding what can be expected to happen to the facial axis. Treatment may open the facial axis as with Class II mechanics, or it may close the facial axis as with the use of high pull headgear or due to extraction. Facial axis opens 1 for 5mm of convexity reduction, for 3mm of molar correction, and for 4mm of overbite correction. It opens 1 to 1 in crossbite correction and recovers half that amount. For every standard deviation on the dolichofacial pattern side, it opens 1 and for every standard deviation toward the brachyfacial side, it tends to close one degree. 6. Superimpose at Basion along the Basion-Nasion plane. Rotate "up" at Nasion to open the bite and "down" at Nasion to close the bite using point DC as the fulcrum. This rotation depends on anticipated treatment effects (whether treatment can be expected to open or close the facial axis). 7. Trace Condylar Axis, Coronoid Process, and Condyle.

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VTO Mandibular Growth Prediction Condylar Axis Growth & Corpus Axis Growth Return to tracing on page 745. 8. On condylar axis, make mark 1mm per year down from point DC. 9. Slide mark up to the Basion-Nasion plane along the condylar axis. Extend the condylar axis to XI point, locating a new XI point. 10. With old and new XI points coinciding, trace corpus axis, extending it 2mm per year forward of old PM point. (PM moves forward 2mm/year in normal growth.) 11. Draw posterior border of the ramus and lower border of the mandible.

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VTO Mandibular Growth Prediction Symphysis Construction 12. Slide back along the corpus axis superimposing at new and old PM. Trace the symphysis and draw in mandibular plane. 13. Construct the facial plane from NA to PO. 14. Construct facial axis from CC to GN (where facial plane and mandibular plane cross).

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VTO Maxillary Growth Prediction 15. To locate the "new" maxilla within the face, superimpose at Nasion along the facial plane and divide the distance between "original" and "new" Mentons into thirds by drawing two marks.

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15.

To outline the body of the maxilla, superimpose mark

#1 (superior mark) on the original Menton along the facial plane. Trace the palate (with the exception of point A).

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VTO Maxillary Growth Prediction Point A Change Related to BA-NA These are the maximum ranges of Point A change with various mechanics:

Point A is altered as a result of growth and mechanics. Point A and a new APO plane are drawn by the following steps: 17. Point A can be altered distally with treatment. Place according to orthopedic problem and treatment objectives. For each mm of distal movement, Point A will drop mm.

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18. Construct new APo plane. VTO Occlusal Plane Position 19. Superimpose mark #2 on original Menton and facial plane, then parallel mandibular planes rotating at Menton. Construct occlusal plane (may tip 3 degrees either way depending on Class II or Class III treatment).

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VTO Dentition Lower Incisor The lower incisor is placed in relationship to the symphysis of the mandible, the occlusal plane and the APO plane. The arch length requirements and realistic results dictate its location. 20. For this exercise, superimpose on the corpus axis at PM. Place a dot representing the tip of the lower incisor in the ideal position to the new occlusal plane, which is 1 mm above the occlusal plane and 1 mm ahead of the APO plane. 21. Aligning over the original incisor outline or using a template, draw in the lower incisor in the final position as required by arch length. The angle is 22 at +1mm to the APo plane and + 1 mm to occlusal plane, but the angle increases 2 with each mm of forward compromise.

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VTO Dentition Lower Molar Without treatment, the lower molar will erupt directly upward to the new occlusal plane. With treatment, 1mm of molar movement equals 2mm of arch length. We moved the lower incisor forward 2mm in this case. There was also 4mm of leeway space. Therefore, the following calculation allows us to move the lower molar forward 4mm on each side: lower incisor forward 2mm = +4mm arch length leeway space = +4mm arch length +8mm arch length (lower molar forward 4mm on each side)

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22. Superimpose the lower molar on the new occlusal plane at the molar (*), slide forward 4mm, upright molar and draw it in.

VTO Dentition Upper Molar 23. Trace the upper molar in good Class I position to the lower molar. Use the old molar as a template.

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Example of using the upper molar as a template. VTO Dentition Upper Incisor Place upper incisor in good overbite-overjet position (2mm overbite, 2mm overjet) with an interincisal angle of 130 10. Open bite patterns at a greater angle, deep bite patterns at a lesser angle. 24. Trace the upper incisor in its proper relationship, aligning over the original incisor or by use of a template.

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Example of using the upper incisor as a template VTO Soft Tissue Nose 25. Superimpose at Nasion along the , facial plane. Trace bridge of nose.

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26. Superimpose at anterior nasal spine (ANS) along the palatal plane. 27. Move prediction "back" 1mm per year (therefore, 2mm in this case) along the palatal plane. Trace tip of nose fading into bridge. VTO Soft Tissue Point A and Upper Lip . 28. Superimpose along the facial plane at the occlusal plane. Using the same technique as for marking the symphysis, divide the horizontal distance between the "original" and "new" upper incisor tips into thirds by using two marks.

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29. Soft tissue Point A remains in the same relation to Point A as in the original tracing. Superimpose new and old bony Point A, and make a mark at soft tissue Point A. 30. Keeping the occlusal planes parallel, superimpose mark # 1 (posterior mark) on the tip of the original incisor (slide forward 2/3rds). Trace upper lip connecting with soft tissue Point A. VTO Soft Tissue Lower Lip, Point B, and Soft Tissue Chin In constructing the lower lip, we bisect the overjet and overbite of the original tracing and mark the point. We then bisect the overjet and overbite of the VTO and mark the point. OVERBITE, ORIGINAL , VTO , OVERJET

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Return to tracing on page 745. 31.Superimpose interincisal points, keeping occlusal planes parallel.Trace lower lip and soft tissue B point. The soft tissue below the lower lip remains in the same relation to point B as in the original tracing. Soft tissue point B drops down as the lower lip recontours. VTO Completed Visual Treatment Objective 32. Superimpose on the symphyses,and arrange the soft tissue of the chin. It "drops down" and should I be evenly distributed over the symphysis taking into consideration reduction of strain and bite opening.

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If you have completed the steps, you now have your Visual Treatment Objective. Take your VTO and superimpose it in the
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five superimposition areas to establish your individual objectives for this case. In Superimposition Area 1 (Basion-Nasion at CC), Evaluation 1 is chin change. In this case, our objective is to allow 2 of opening of the facial axis, to expect the amount of chin growth shown, and to expect that the upper molar will grow down the facial axis. In Superimposition Area 2 (Basion-Nasion at Nasion), Evaluation 2 is maxillary change. One of our objectives is to reduce point A only 2mm in this case. In Superimposition Area 3 (Corpus Axis at PM), Evaluation 3 is the lower incisors. In this case, we are just tipping the lower incisors slightly. In Superimposition Area 3 we also have Evaluation 4, the lower molars. In this case, we are advancing the lower molars approximately 4mm. In Superimposition Area 4 (Palate at ANS), we have Evaluation 5, the upper molars. In this case, all we have to do is hold the upper molars, even though this is a Class II division 1 malocclusion. Superimposition Area 4 also includes Evaluation 6, the upper incisors, and we see that we are going to have to distalize the upper incisors. In Superimposition Area 5 (Esthetic Plane at the intersection with Occlusal Plane), we have Evaluation 7, the soft tissue, and we see that we are going to have a great amount of soft tissue reduction in this case.

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Holdaway VTO
In using the Ricketts facial axis to find the mandibular and softtissue chin position, Jacobsen and Sadowsky report three times the growth of that at nasion, which is nearly always less than 1 mm per year. If my observations are correct, usually only 0.66 to 0.75 mm per year occurs, whereas growth on the facial axis is reasonably consistent at 3 mm per year except during growth spurts, especially the pubertal growth spurt, when it may approach twice that amount in some boys. Another variation from the article by Jacobsen and Sadowsky involves those cases which at the time of retention will not fall into the best range in the convexity H angle chart, on both the convex and the concave sides. The use of the line to the vermilion border of the upper lip perpendicular to the Frankfort plane plus the variable H angle as skeletal convexity varies should be substituted whenever upper lip curl or overall lip support appears questionable by the usual method. The overall effects of growth and treatment appear more accurate with this simplified technique for growth forecasting when used along with our own understanding of the treatment responses of my own patients. Jacobsen and Sadowsky are correct in their statement: "Growth responses are generally predictable within certain limits and can be measured. The VTO as described here is based on this philosophy. Newer studies, however, have indicated quite clearly that one cannot rely completely on the constancy of the growth pattern, since increments of facial growth are not necessarily uniform in either direction or rate. It is recognized that precise prediction of skeletal or soft-tissue growth in amount or direction is beyond our present knowledge. However, until the stage is reached
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whereby orthodontists and/or scientific investigators are able to accurately predict or determine direction and rates of growth, we have no alternative but to avail ourselves of our present knowledge of growth based on average increments." Orthodontic treatment is monitored with progress head films, usually at 6-month intervals. Whenever a case is encountered in which growth is occurring in a different direction than expected, a new midtreatment VTO is then constructed so that changes in treatment procedures can be made and any disfiguring lip responses can be avoided. Whenever possible, it is a good plan to take head films for a year or two prior to beginning treatment and thus develop a growth profile for the case, assuming that there is an opportunity to examine the patient that early. Developing pretreatment growth profiles of our patients helps to overcome our inadequacies in growth forecasting. In addition to the six reference lines for the actual VTO construction, three more shown in Fig. 1, A (dotted lines) are added to the tracing to facilitate rapid copying of portions of the pretreatment lateral cephalometric tracing.

First is the nasion to point A line. In longitudinal growth studies of patients not undergoing orthodontic treatment, the constancy of the angle SNA is extremely good only about 1
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change in 5 years on the average. For 1- or 2-year forecasts, we can disregard such a small amount. Reference lines or angles that are very near to constants offer our best chance of constructing visual treatment objectives that we can confidently use as treatment goals and guides during orthodontic treatment. Second is Ricketts' facial axis (foramen rotundum to gnathion). This is used as a guide to direction of mandibular growth. Third is the mandibular plane (Downs). Some may prefer to use the Go-Gn line as a lower border of the mandibular reference line. Either is acceptable, but the Downs mandibular plane line is preferred because of its nearness to the actual lower border. The headfilm should be taken with the patient's lips lightly touching.

VTO steps
Step I (Fig. 1, B and C) The first step is to place a clean sheet of tracing material over the original tracing, copying (1) the frontonasal area, both hardand soft-tissue, with the soft-tissue nose carried down to near the point where the outline of the nose starts to change directions; (2) the sella-nasion line; and (3) the nasion-point A line.

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Step II (Fig. 2) First, superimpose on the SN line and move the tracing to show expected growth (0.66 to 0.75 mm per year unless a pubertal growth spurt is expected from wrist plate studies).

Second, copy the outline of sella. Third, either copy or change the facial axis (Ricketts' foramen rotundum to gnathion) as you expect it to behave according to the facial type of the patient and the treatment mechanics that you customarily use in such cases. (The facial axis line is usually opened about 1, but it may even be closed if one is confident that mandibular growth of the forward rotational type will occur during treatment.) Note: It is important to understand that the prediction of growth at nasion, along the SN line, is actually an overall prediction for all midfacial structures, including the nasal bone, the maxilla, and the soft tissues.

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Step III (Fig. 3, A and B) First, superimpose the VTO facial axis on the original and move the VTO up so that the VTO SN line is above the original SN. The amount of movement will usually be 3 mm per year of growth, except in accelerated growth-spurt periods. (Note: since the facial axis may be opened or closed as judged from the facial pattern, the SN lines will not be parallel if we have changed the facial axis.)

Second, copy the anterior portion of the mandible, including the symphysis and anterior half of the lower border. Also draw the soft-tissue chin, eliminating any hypertonicity evident in the mentalis area. (Slightly round out this area.) Third, copy the Downs mandibular plane.
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Step IV (Fig. 4, A and B) First, superimpose on the mandibular plane and move the VTO forward until the original sella and the VTO sella are in a vertical relation.

Next, with the tracing in this position, copy the gonial angle, the posterior border, and the ramus.

Finally, superimpose on sella to complete the condyle.

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Note: At this point total vertical height has been forecast, as has the forward location of the chin structures, both hard and soft, and consideration will have been given to effects of treatment mechanics on vertical dimension. One should not open the facial axis more than 1 to 2 because greater opening than this is usually inconsistent with good treatment mechanics. Step V (Fig. 5, A and B) First, superimpose the VTO NA line on the original NA line and move the VTO up until 40% of the total growth is expressed above the SN line and 60% below the mandible. (Note: This may be varied as you perceive the facial type to be short or long.)

Second, with the tracing in this position, copy the maxilla to include the posterior two thirds of the hard palate, PNS to ANS to 3 mm below ANS. Third, also with the tracing in this same position, complete the nose outline around the tip to the middle of the inferior surface.

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Note: The vertical growth of the nose over the usual 18 to 24 months of estimated treatment time keeps pace with the growth from the maxilla vertically to the anterior cranial base. Thus, its relationship to ANS is relatively constant. In some cases there may be an elevation of the nasal bone and greater development of the nasal bulk, but this is difficult to predict and thus some noses will have changed form more than this VTO procedure suggests. Step VI (Fig. 6, A and B) First, with the VTO still superimposed on the line NA, move the VTO so that vertical growth between the maxilla and the mandible is expressed 50% above the maxilla and 50% below the mandible.

Second, with the tracing in this position, copy the occlusal plan.
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Note: Ideally, the occlusal plane is located about 3 mm below the lip embrasure. This permits the lower lip to envelop the lower third of the crowns of the upper incisor teeth. If the cant of the occlusal plane is correct, it should be maintained. If not, then it can be altered accordingly at this stage. In cases involving short upper lips, it may not be practical to intrude the upper incisors to this extent, but the vertical relationship of the teeth and gingival tissue will be more esthetically pleasing if we can reach this goal. Step VII (Fig. 7, A and B) Note: When there is a uniform distribution of the soft tissues in the profile and the upper lip is of average length, and where the cant of the H line is not adversely affected by excessive facial convexity or concavity, the depth of the superior sulcus measured to the H line is most ideal at 5 mm. A range of 3 to 7 mm allows one to maintain type with short and/or thin lips and long and/or thick lips. Additional refinement of the technique, which covers all of the above, is gained by use of the vertical line from Frankfort plane to the vermilion border of the upper lip, which is ideal at 3 mm with a range from 1 to 4 mm. To find the point along the lower border of the nose outline at

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which the new H line will intersect it, both perspectives are used in the exceptional cases just mentioned. First, line up a straight-edge tangent to the chin and angle it back to a point where there is a 3 to 3.5 mm measurement to the superior sulcus outline of the original tracing and draw the H line to this. As one redrapes the superior sulcus area to the new tip of the upper lip point, a 5 mm superior sulcus depth develops almost automatically. If you have trouble with this, the use of the Jacobson-Sadowsky lip-contour template is recommended.

Second, with the tracing still superimposed on the maxilla and line NA and using the occlusal plane (Fig. 8, A and B) as a guide for the lip embrasure, draw the upper lip from the vermilion border to the embrasure. Then from the point on the lower border of the nose where its outline stopped on the VTO,
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draw in the superior sulcus area. This is a gradual draping to the new vermilion border outline.

Third, superimpose on line NA and the occlusal plane. Form the lower lip, remembering that from 1 mm behind the H line to 2 mm anterior can be excellent, depending on variations of thickness of the two lips. Again, most cases will fall on the H line or within 0.5 mm of it. Finally, complete the inferior sulcus drape from the lower lip to the chin in a form harmonious with the superior sulcus. (Note: The lips are not expected to have fully adapted to this position in more than about one half of the cases at the time of retention.) Step VIII (Fig. 9, A and B)

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First, with the exceptions noted earlier, lip strain that shows up as excessive upper lip taper is our first consideration. In the case shown in Fig. 9, the basic lip thickness measurement was 15 mm and the thickness at the vermilion border was 10 mm. One millimeter of taper is normal, leaving a lip strain factor of 4 mm. Next we are concerned with how many millimeters the upper lip is back from its original position. This is measured with the tracings superimposed on line NA and the maxilla. In the present case this also amounts to 4 mm.

The third consideration is maxillary incisor "rebound." When the maxillary incisors have been retracted 5 mm or more and the case has been slightly overtreated to a near edge-to-edge incisor overbite and overjet relationship, we can expect about 1.5 mm relapse tendency. Obviously, there will be no tendency
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to move labially in those cases in which the upper incisor is not retracted or in those cases, such as anterior crossbites and/or Class III cases, in which the maxillary incisors have been expanded labially. Here the incisor retraction is significant, and we will use 1.5 mm for incisor rebound. In this particular patient, then, the calculations would be as follows: (1) Elimination of lip strain, 4 mm. (2) Upper lip change, 4 mm. (3) Maxillary incisor rebound, 1.5 mm. Finally, with the tracing still superimposed on line NA and the maxilla, place the maxillary incisor template, taking cognizance of the amount that it is to be repositioned (9.5 mm in this case), its axial inclination, and the relationship of the incisal edge to the occlusal plane, and draw the tooth. Step IX (Fig. 10, A and B) First, superimpose the VTO on the mandibular plane and symphysis. Using the template, reposition the lower incisor to be in ideal retention occlusion with the maxillary incisor, using the occlusal plane as a guide and by tipping the tooth about the

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apex unless bodily movement is needed to improve the form of

the inferior sulcus area. Second, with the tracing in this same position, measure the amount of lingual movement of the lower incisors. Twice this amount is the arch length loss due to lower incisor (uprighting) lingual tipping or gain from labial tipping when indicated. This loss of arch length is now combined with the arch length
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discrepancy determined from the model to obtain the total arch length discrepancy. In this case, the calculations would be (1) arch length loss from reposition, 2 4 = 8 mm; (2) model discrepancy, 2 mm; (3) total discrepancy, 10 mm. Step X (Fig. 11, A and B) With the tracing superimposed on the mandibular plane and symphysis and using the occlusal plane as a vertical guide, draw the lower molar where it must be to eliminate remaining space if extractions must be part of the treatment plan. In the case shown in Fig. 11, each lower molar must be moved forward 2.5 mm. Note: By using the VTO approach, you will come upon many cases where mesially tipped lower molars can be uprighted to gain all of the model arch length discrepancy when the incisor position is adequate. Distal tipping of lower molars 2.5 mm can allow nonextraction treatment in cases of a model discrepancy of 5 mm. In other cases, especially those having a history of thumb- or lip-sucking or in which serial extraction is contraindicated, the VTO will show that the lower incisors need to be moved forward, thus also increasing arch length and reducing the need to extract. On occasion both approaches can be used. In my opinion, lower incisors should not be moved forward to a point more than 1 mm anterior to the A-pogonion line, as posttreatment stability and long-term periodontal health are usually endangered by so doing.

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The use of the VTO at this point to study and evaluate anchorage and arch length is one of its great advantages. If the lower molar must be moved anteriorly as much as 3.5 mm, the lower second premolars will be removed. There are cases in which there is an extremely thin alveolar process, particularly those cases that have deficient lower face height where the lower molars seem to get locked up in cortical bone if the second premolars are extracted. Extraction of the second premolars instead of the first premolars actually increases the lower molar anchorage. When these two factors combine as contraindications to forward lower molar movement, it is sometimes better to look at judicious narrowing of the teeth through stripping and polishing than to extract at all. Step XI (Fig. 12, A)
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First, using the occlusal plane and the lower first molar as a guide, with a tooth template, position the upper first molar in ideal Class I occlusion with the lower first molar. Second, superimposing tracings on the original NA line and the outline of the maxilla, evaluate the extent of upper molar movement. In cases that worked out as lower arch nonextraction cases, one may still need to think about other extraction alternatives in the upper arch, such as upper second molars when good third molar buds are developing or upper first premolars.

Step XII (Fig. 12, B) Note: As to how point A changes with incisor retraction, it is imperative that the clinician study the before and after tracings of many cases superimposed on the original NA line and best fit of the maxilla to get the "feel" for this step. Obviously the change in point A is greater when the upper incisor root apices are moved a considerable distance than when the upper incisors are tipped lingually. More change in A point is also evident when the tracing is superimposed in this manner if we are going to use heavier orthopedic forces, especially in younger patients (in the mixed dentition).

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When completed, the VTO can be used not only in case analysis and treatment planning, but as we consider movement of the various groups of teeth to correct a malocclusion the mechanical procedures that will be most direct and efficient practially suggest themselves. Mention must also be made of the usefulness of VTOs to monitor treatment from periodic head films. Using all that we think we know about growth and facial types, on occasion we discover that nature has something else in mind and we may need to change the course of our treatment because of an unexpected growth response. As we look at the retention tracing in Fig. 13, A, it is evident that the tooth movement objectives of the VTO were accomplished. The soft-tissue analysis measurements, while greatly improved, still fail to meet the VTO goals, even though the soft-tissue chin position has improved 1. This is because the lips still have not completely adapted to the tooth movement. There is an increased measurement of the upper lip thickness at the vermilion border from 10 to 16 mm. The H angle has improved from 23 to 14. However, with a 2 mm convexity, ideally it should be 12.

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In the 7-year follow-up shown in Fig. 13, B, the soft-tissue facial angle is an ideal 90. The superior sulcus form is excellent to both reference lines. The upper lip has 1 mm of normal taper, with a slight decrease in basic thickness. Skeletal convexity is down to 0, and the H angle is ideal at 10. The upper lip has completed its adaptive changes and has a 1 mm taper.

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Conclusion
As we Orthodontists nowadays deal with more and more of mixed dentition cases , many of whom may or may not present with a skeletal malocclusion. It is very important for us to determine the magnitude and direction of growth if we are to treat these cases with a fair amount of success. It is a great challenge therefore to diagnose and to plan an ideal treatment for these cases keeping in mind their growth potential. The above mentioned studies were attempts made by various people in order to ascertain the type of growth in their patients and set forth guidelines for us to follow. However we should not forget that every individual is unique in his own aspect and therefore we should not jump to conclusions but study our patients over time and treat them to their individual requirements.

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Bibliography
1) Bergersen, E.: The male adolescent growth spurt: Its prediction and relation to skeletal maturation, Angle Orthod. 42:319-338, 1972. 2) Bjork, A. and Helm, S.: Prediction of the age of maximum pubertal growth in body height, Angle Orthod. 37:134-143, 1967. 3) Chapman, S.: Ossification of the adductor sesamoid and the adolescent growth spurt, Angle Orthod. 42:236-244, 1972. 4) Chertkow, S. and Fatti, P.: The relationship between tooth mineralization and early radiographic evidence of the ulnar sesamoid, Angle Orthod. 49:282-288, 1979. 5) Demirjian, A.; Buschang, R.; Tanguay, R.; and Patterson, K.: Interrelationships among measures of somatic, skeletal, dental and sexual maturity, Am. J. Orthod. 88:433-438, 1985. 6) Fishman, L.: Radiographic evaluation of skeletal maturation, a clinically oriented study based on handwrist films, Angle Orthod. 52:88-112, 1982. 7) Grave, K. and Brown, T.: Skeletal ossification and the adolescent growth spurt, Am. J. Orthod. 69:611-619, 1976. 8) Hassel, B. and Farman, A.: Skeletal maturation evaluation using cervical vertebrae, Am. J. Orthod. 107:58-66, 1995.

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9) Moore, R.; Moyer, B.; and Dubois, L.: Skeletal maturation and craniofacial growth, Am. J. Orthod. 98:33-40, 1990. 10) Graber T.M. Orthodontics PPrinciples and Practice. Saunders WB 1995. 11) Greulich, W. and Pyle, S.: Radiographic ossification and the adolescent growth spurt, Am. J. Orthod. 69:611-619, 1959. 12) Hgg, U. and Taranger, J.: Maturation indicators and the pubertal growth spurt, Am. J. Orthod. 82:299-308, 1982. 13) Holdaway RA. A soft tissue cephalometric analysis and its u e in orthodontic treatment planning. Am J Orthod 1983;84:1-28
14)

Holdaway RA. A soft tissue cephalometric analysis and its u e in orthodontic treatment planning. Am J Orthod 1984;87:279-293

15) Jacobson A. Radiographic Cephalometery. Quintessence 1995. 16) Johnston, F. and Hufham, H.: Skeletal maturation and cephalofacial development, Angle Orthod. 35:111, 1965. 17) Nanda, R.: The rates of growth of several facial components measured from serial cephalometric roentgenograms, Am. J. Orthod. 41:658-673, 1955. 18) OReilly, M. and Yanniello, G.: Mandibular growth changes and maturation of cervical vertebrae, Angle Orthod. 58:179-184, 1988.

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19) Pileski, R.: Relationship of the ulnar sesamoid and maximum mandibular growth velocity, Angle Orthod. 43:162-170, 1973.
20)

Proffit W.R. Contemperory Orthodontics 3rd Ed. Mosby 2000.

21) Sierra, A.: Assessment of dental and skeletal maturity: A new approach, Angle Orthod. 57:194-208, 1987.

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