Growth Prediction2 / Orthodontic Courses by Indian Dental Academy

Holdaways soft-tissue VTO
Purpose is to establish a balanced profile and

pleasing facial esthetics and to evaluate the
orthodontic correction necessary to achieve this
goal
Holdaway VTO emphasizes soft tissue profile
balance
INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

Growth of the cranio-facial skeleton is predicted for
the estimated treatment time, and the soft tissue
profile between the nose and the chin arranged to
create an ideal facial profile for the individual
patient
Maxillary and mandibular incisors are repositioned
to eliminate lip strain
Allowance is made for probable post treatment
incisor rebound
Maxillary teeth are positioned first, and then lower
incisors are repositioned to be in harmony with the
upper incisors

Following the repositioning of the mandibular
incisors, the resultant arch length discrepancy
may be calculated to determine whether or not
teeth should be extracted
The VTO is thus a dynamic cephalometric
analysis which takes into account both growth
and biomechanics, thus achieving its aim of
being a Visualized Treatment Objective
It outlines a goal from the inception of
treatment and may be usefully employed in
monitoring growth and treatment progress
In sum, therefore the VTO accomplishes :
Predicts growth over an estimated treatment time,
based on the individual morphogenetic pattern
Analyzes the soft tissue facial profile
Graphically plans the best soft tissue facial profile
for the particular patient
Determines favorable incisor repositioning, based on
an ideal projected soft tissue facial profile
Assists in determining total arch length
discrepancy when taking into account
cephalometric correction
Aids in determining between extraction and
nonextraction treatment
Aids in deciding which teeth to extract
Assists in planning treatment mechanics
Surgery vs. non-surgery
It provides a visual goal or objective for which to
strive during treatment
OJECTIVE : To draw frontonasal area, line
BaN and line NA
OBJECTIVE : To express growth in the frontonasal
area over a two-year period
Super impose on line BaN and move the VTO until
there is 1.5 mm growth in the fronto nasal area
Holding the VTO tracing in the position copy the
Ricketts facial axis
OBJECTIVE : To express growth in a vertical
direction in the mandible, and to draw the anterior
portion of the mandible, soft tissue chin and the
mandibular plane of Downs
Superimpose the VTO facial axis along the original facial axis.
Move the VTO tracing upwards so that the VTO BaN line is
above the original BaN line, the distance between these lines
should be three times the amount of growth expressed in the
frontonasal area

OBJECTIVE : To express growth in a horizontal direction in
the mandible and draw the posterior border of the mandible
Move the VTO forward until the original and VTO foramen
rotundae are vertically aligned
OBJECTIVE : To locate and draw the maxilla, and
lower half of the nose
Super impose the VTO NA line on the original NA
line and move the VTO up until the vertical growth is
expressed above the BaN line and below the
mandibular plane is in the ratio of 40:60
OBJECTIVE : To locate and draw the occlusal plane
With the VTO superimposed on line NA, move the VTO
tracing so that the vertical growth between the maxilla and the
mandible is expressed as being 50% above the maxilla and
50% below the mandible
OBJECTIVE : TO determine the soft tissue lip
contour using the Holdaway line
OBJECTIVE : to reposition lower incisor and calculate
resultant arch length change
judge the position of the lower incisor
To calculate lower arch length change, superimpose tracing
on mandibular plane and register on symphysis. Measure the
distance between old and new incisor position and double this
measurement to determine total arch length discrepancy
OBJECTIVE : To reposition lower first molar, use the plaster
casts to determine arch length discrepancy due to crowding
and/or rotation.
OBJECTIVE : To reposition maxillary first molar
Using the occlusal plane and lower first molar as a guide draw
the maxillary first molar in good Class I occlusion with the
lower first molar
OBJECTIVE : To complete art work
ANS to upper incisor
Anterior portion of hard palate
Lower alveolus lingually and labially
A statistical evaluation of the
Ricketts and Johnston growth-
forecasting methods
Four methods of growth forecasting were compared
Johnston forecast grid
Ave. increments from sella-nasion
Ricketts short-range prediction
Computer forecast
Objective was to predict the final position of the
points A, Pogonion, end of the nose, lower molar
and point Xi with respect to cranial reference lines
The Johnston forecast
grid
Errors were squared, summed, and divided by
the number in the sample to get the mean-
square error. Square root was taken for the rot-
mean-squared error
70% of the predictions will be within 1 rms
error
95 % will be within 2 rms error
Ave. increments from sella-nasion
To study points not included in Johnston
forecast grid, as well as grids applicability to a
10-year growth period
Average increments for each of the points under
consideration were calculated from SN with S as
the origin, and these increments were then used
in a prediction as follows: Using sella-nasion as a
horizontal axis with sella as its center, ave.
increments per year were added
Girls - 15 years
Boys - 19 years
The Ricketts short-
range prediction
Computer forecast
Individual growth curves are used for the mandible,
maxilla, and cranial base rather than using the same
increments for every age group
Abnormal growth with RMDS data bank
Patients who grow abnormally large mandibles with less
growth in the cranial base abnormal Class III patterns
Unusually strong patterns which rotate forward
Abnormally weak facial patterns they rotate distally
Results
Johnston grid
Least accurate
It was accurate as any for predicting the nose
64 percent accurate for Point A
70 percent accurate on Pogonion

S-N average increments
Improvement over the Johnston grid at both
Pogonion and point A
Ricketts short-range prediction method
Less rms error than Johnston grid or SN average increments

Some of the smaller over-all error was due to the fact that
point CC, the origin of this growth prediction, is closer to
Pogonion than to Sella

10 to 20 percent improvement of this method over average
increments
RMDS computer program
Based on theories of Ricketts
Individualized further by using growth rates variable for the
patients age and by recognising unusual facial patterns
Most accurate of the four methods
21% more accurate than Ricketts
56% more accurate than Johnston grid

If the actual growth was far different from the
predicted growth, the records were often returned to
the laboratory so that a file of abnormal growth
could be compiled
A consistent type emerged one which grew more in
the mandible and less in the cranial base than predicted
Prediction of abnormal growth in
Class III malocclusions
The three most consistent measurements which
deviated from the normal in these patients were
ramus position, porion location and cranial
deflection
Predictor measurements
Hokkaido University Orthodontic Department
For cranial deflection, porion location and
ramus position the greater the value, the more
likely the patient is hypothesized to have a Class
III growth pattern
With molar relation, the lesser the value, the
more likely the patient is to have a Class III
malocclusion
Clinical norm
(CN)
Standard
Deviation
Cranial deflection 28 3.0
Ramus position 75.5 2.8
Porion location 37 2.5
Molar relation -3.0 2.6
Amount of abnormality, or deviation is calculated
by :

V-CN
SD
Cephalometric analysis was conducted at baseline and 7
years for 40 children (20 girls, 20 boys) who received no
orthodontic treatment. Ricketts long-range prediction
was performed from baseline cephalograms and
compared with actual growth 7 years later. Twenty-one
cephalometric (12 angular and 9 linear) parameters were
measured on actual and predicted tracings. The Pearson
correlation coefficient was used to evaluate
relationships between the predicted and actual
measurements.
There was a higher level of correlation for growth
prediction in girls
Evaluation of Ricketts long-range growth
prediction in Turkish children

The baseline average age was 9.2 0.82 years for girls
and 9.3 0.92 years for boys
Linear measurements: 1, Convexity; 2, Condylion-Point
A; 3, Condylion-Gnathion; 4, Lower lip to E plane; 5,
Upper lip length; 6, Cranial length (anterior) (CC-Na);
7, Ramus height (CF-Go); 8, Porion to PTV; 9, Corpus
length (Xi-Pm).
Angular measurements: 1, Lower face height; 2,
Nasolabial angle; 3, Facial depth; 4, Facial axis; 5,
Maxillary depth; 6, Maxillary height; 7, Palatal plane-FH
plane; 8, Mandibular plane-FH plane; 9, BNA angle; 10,
Cranial deflection; 11, Ramus-Xi position; 12,
Mandibular arc angle.
Ricketts long-range growth prediction applied to
Turkish children showed statistically significantly higher
correlations between predicted and actual
measurements in:
Convexity, lower face height, condylion, point A, upper
lip length, facial depth, facial axis, palatal plane-FH
plane angle, mandibular plane-FH plane angle, ramus
height, and mandibular arc angle in girls
Lower face height, nasolabial angle, porion to PTV,
ramus-Xi position, cranial deflection, condylion-point
A, lower lip-E plane, facial axis, BNA angle, and
mandibular arc angle in boys.


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Holdaways soft-tissue VTO

Purpose is to establish a balanced profile and

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