Department Of Orthodontics &

Dentofacial Orthopedics
Bapuji Dental COllege &
Hospital Davangere 577004

Seminar on

Growth
Prediction &
VTO
Presented By-
Nandan Kittur
CONTENTS PAGE NO.

-INTRODUCTION 1
-GROWTH PATTERN,
VARIABILITY, AND TIMING 2-6
-METHODS OF GROWTH PREDICTION 7-9
-WHAT ARE WE INTERSTED IN PREDICTING
IN CRANIOFACIAL COMPLEX? 10-11
-INDICATORS OF SKELETAL MATURITY
-HAND WRIST RADIOGRAPHS AND 12-24
SKELETAL MATURITY
-CERVICAL VERTEBRAE AS 25-27
MATURATIONAL INDICATORS
-FRONTAL SINUS DEVELOPMENT AS 28-29
INDICATOR OF PUBERTY
-MANDIBULAR CANINE CALCIFICATION
AND SKELETAL MATURITY 30-31
-MANDIBULAR THIRD MOLAR
DEVELOPMENT AND SKELETAL 32
MATURITY
-PREDICTION OF MANDIBULAR
ROTATION 33-40
-ARCIAL GROWTH OF THE MANDIBLE. 41-48
-VTO( VISUALIZED TREATMENT OBJECTIVE) 49-50
RICKETTS VTO 51-70
HOLDAWAY VTO 71-89
-CONCLUSION 90
-BIBLIOGRAPHY 91-93

2
 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.

1
 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.

2
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.

3
 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.

4
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.

5
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 individual’s growth
status.

6
The effectiveness of a Biologic or Developmental ages in
reducing timing. variability makes this approach useful in
evaluating a child’s growth status.

7
 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:

8
(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 INTERSTED IN
PREDICTING IN CRANIOFACIAL
COMPLEX?

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. Todd’s 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 puberal
statural growth,and menarche in girls occurred after the
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
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.

15
Grave and Brown have recorded 14ossification events
1. PP2= Proximal phalanx of second finger;
epiphysis is as wide as diaphysis
2. MP3= Middle phalanx of third finger;
epiphysis is as wide as diaphysis
3. H-1 Hooking of Hamate –Stage 1
4. Pisi Appearance of Pissiform
5. R= Radius; epiphysis is as wide as
diaphysis
6. S Appearance of Ulnar Sessamoid at
metacrpophalangeal joint of first
Finger
7. H-2 Hooking of Hamate –Stage 2
8. MP3cap Middle phalanx of third finger;
epiphysis caps its diaphysis
9. PP1cap Proximal phalanx of first finger;
epiphysis caps its diaphysis
10. Rcap Radius; epiphysis caps its diaphysis
11. DP3µ Distal phalanx of third finger;
complete epiphyseal union
12. PP3µ Proximal phalanx of third finger;
complete epiphyseal union
13. MP3µ Middle phalanx of third finger;
complete epiphyseal union
14. Rµ Radius; complete epiphyseal union

16
The events fell logically into 3 groups with respect to
ossification times
Events, which occurred before peak growth velocity
1. PP2=
2. MP3=
3. H-1
4. Pisi
5. R=
Events which coincided peak growth velocity
6. S
7. H-2
8. MP3cap
9. PP1cap

17
10. Rcap
Events which followed peak height velocity
11. DP3µ
12. PP3µ
13. MP3µ
14. Rµ
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.

18
Fishman (1974) has given 11 Skeletal Maturity Indicators(SMI)

19
Epiphysis as wide as Diaphysis
1. Third finger – proximal phalanx
2. Third finger –middle phalanx
3. Fifth finger- middle phalanx
Ossification
4. Adductor Sessamoid of thumb
Capping of Epiphysis
5. Third finger- Distal phalanx
6. Third finger- Middle phalanx
7. Fifth finger- Middle phalanx
Fusion of epiphsis and Diaphysis
8. Third finger- Distal phalanx
9. Third finger –Proximal phalanx
10. Third finger- Middle phalanx
11. Radius

Accelerating growth velocity period. SMI 1 - 4

High growth velocity period. SMI 4-7
Decelerating growth velocity period. SMI 7 – 11

Girls generally reach point of peak growth velocity at SMI 5

and boys at SMI 6.

20
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 of Pisiform
2. Absence of Hook of Hamate
3. Epiphysis of proximal phalanx of second digit (PP2) narrower
than its shaft

Stage 2 (Prepuberal):
1. Proximal phalanx of second digit and its epiphysis are equal in
width (PP2).
2. Initial ossification of hook of hamate .
3. Initial ossification of pisiform.

Stage 3 (Puberal onset):

1. Beginning calcification of Ulnar sessamoid.
2. Increased width of epiphysis of PP2
3. Increased calcification of hamate hook and pisiform.

Stage 4 (Puberal):
1. Calcified ulnar sessamoid
2. Capping of shaft of middle phalanx of third digit by its
epiphysis(MP3cap)

Stage 5 (Puberal Deceleration):

21
1. Ulnar sessamoid fully calcified
2. Calcification of the shaft of middle phalanx of third digit by
its epiphysis (DP3u).
3. All phalanges and carpals fully calcified.
4. Epiphysis of radius and ulna not fully calcified with
respective shafts.
Stage 6 (Growth completion):
No remaining growth sites.

22
Hagg and Taranger (1982) investigated a prospective
longitudinal study in 212
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
23
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.

24
Results:
The pubertal growth spurt: ONSET was at 10.0yrs in
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.

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).

25
 At PHV 90% of the subjects were in either stage MP3-
FG 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.

26
27
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) the cervical vertebrae are wedge

shaped, with the superior vertebral borders tapering from
posterior to anterior.
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 25-
65% of adolescent growth anticipated.

28
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.

29
30
31
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
subject’s 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.

32
33
 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.

34
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: distal phalanx of third finger, complete
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.

36
 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
37
are present, the more reliable the prediction will be. However, it
is evident that these signs are not so clearly developed before
puberty.

38
The seven signs are related to the following features
1) Inclination of the condylar head.
2) Curvature of the mandibular canal.

39
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.

40
 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

41
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.
42
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.

43
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
44
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.

45
 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.

46
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.

47
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 ½ 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.

48
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
49
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

50
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.) This phenomenon explains why reversal lines are
observed at the area of pogonion and suprapogonion.
3.) It explains why the mandible plane changes extensively
in some individual and not in others.

51
4.) It shows why ankylosed teeth are observed to affect
occlusal plane development.
5.) It explains how the early ankylosis of a lower molar
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.

52
DRAW BACK OF ARCIAL GROWTH PREDICTIONS:

1.) It relies heavily on the operator’s 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.

53
 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

54
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 self-
improvement 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.

55
 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

56
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.

57
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.

58
2. Molar Correction — Facial Axis opens 1°/3mm.
3. Overbite Correction — Facial Axis opens 1°/4mm.
4. Crossbite Correction— Facial Axis opens 1°-1½°. 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 1½° 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.

59
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.

60
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).

61
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.

62
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).

63
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 ½mm.

64
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).

65
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.

66
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)

67
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.

68
Example of using the upper molar as a template.

VTO — Dentition — Upper Incisor

Place upper incisor in good overbite-overjet position (2½mm
overbite, 2½mm 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.

69
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.

70
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.

71
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

72
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.

73
If you have completed the steps, you now have your Visual
Treatment Objective. Take your VTO and superimpose it in the

74
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.

75
 Holdaway VTO
In using the Ricketts facial axis to find the mandibular and soft-
tissue 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

76
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°

77
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 hard-
and 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.

78
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.

79
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.

80
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

84
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

88
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

89
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.

90
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).

92
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°.

93
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.

94
 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.

95
 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 hand-
wrist 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.

96
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) Hägg, 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. 35:1-
11, 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) O’Reilly, M. and Yanniello, G.: Mandibular growth
changes and maturation of cervical vertebrae, Angle
Orthod. 58:179-184, 1988.

97
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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