Rickets Four Step Method To Distinguish Orthodontic Changes From Natural

Growth

RICKETS FOUR STEP METHOD TO

DISTINGUISH ORTHODONTIC CHANGES FROM
NATURAL GROWTH

This is a cephalometric method of predicting changes brought about by

treatment as well as growth, which is measured at 4 points. It is done in 4 steps.

I. To analyse changes in chin.

II.To analyse changes in maxilla.
III. To analyse changes in maxillary teeth
IV. To analyse changes in mandibular teeth.

POSITION ONE:

 This is to study mandibular changes.

 Three points are used:
a) Basion b) Nasion c) Pterygoid point

 The Basion – Nasion line is drawn and a line is drawn from Pt. Point to
Gnathion. This is called the central axis.

 This central axis forms almost an right angle to basion – Nasion line.
Deviation of + 3° can occur.

 This angle is not found to change in the absence of treatment.

 Cervical traction with headgear and use of intermaxillary elastics have both
been found to extrude the teeth leading to bite opening with distal rotation or
opening of the central axis.

 To analyse the changes due to treatment the subsequent radiograph in super

imposed on the Basion-Nasion line and registered at point Pt. This helps
visualize changes in mandible. E.g. Central axis, development of chin etc.

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POSITION TWO

 This is to study the maxillary skeletal changes.

 The land-marks used are a) Basion b) Nasion c) Point A

 The subsequent radiograph in super imposed on the Basion-Nasion line and

registered at Nasion.

 The Basion-Nasion point A angle can be used to study the maxillary changes
occurring due to treatment. The Ba-N-A angle is about 66° and does not
change without treatment. Any changes in the point A position is only due to
orthodontic treatment.

POSITION THREE

This is done to study the changes in the maxillary dentition. The

landmarks used are (a) ANS (b) PNS the subsequent radiographs are
superimposed on the palatal plane (ANS-PNS) and super imposed at ANS.

The position of the incisors and molars are studied.

Without treatment the upper incisor and molar are found to move forward
by only 0.2 – 0.3 mm per year, which is very negligible. Thus any change in
incisor or molar position is entirely due to treatment.

POSITION FOUR

This is done to study the change in mandibular dentition.

The land marks / planes used are –
a) XI point (center of ramus)
b) Protuberance menti (Pm)
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c) Corpus axis 9 x 1 to Pm

The subsequent radiograph are super imposed on the corpus axis and
registered at point Pm.

The changes in lower molar and incisor position are noted in addition to the
changes in occlusal plane.

CEPHALOMETRIC V.T.O

In the case of a Steiner Analysis it can be demonstrated with geometric

principles that the sum of the following four angles always equal to 180 degrees:
ANB, maxillary incisor to the NA plane (1 to NA) mandibular incisor to the NB
plane (1 to NB), and the interincisal angle (1 to 1).

The relationship of maxillary to mandibular incisors was proposed by

downs as the inter incisal angle. He suggested a normal value of 131° + 3° to
represent the ideal relationship, of these two teeth. Riedel, however, suggested
that the relationship between maxillary and mandibular incisors is best determined
by functional and aesthetic considerations.

Considering aesthetics, Riedel suggested that the upper and lower incisor
facial crown angle approach 0° or a straight line.

To apply this cephalometric VTO to a clinical case requires five simple

steps:
_
1. Determine the angulation of 1 and NB.
2. Set upper incisor to lower incisors at a facial crown angle of 0°.
3. Measure the resulting interincisal angle.
4. Estimate the expected ANB angle following treatment.

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5. Calculate the required 1 to NA angulation following treatment. Using the
formula
180° -(1 to NB) – (1 to 1) – (ANB) = (1 to ANA).
Using this simple VTO, it is possible to plan treatment-finishing
requirements and estimate the necessary incisor torque, considering morphologic
pattern, function, stability, and aesthetics.

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RICKETTS 4 STEP METHOD TO DISTINGUISH ORTHODONTIC

CHANGES FROM NATURAL GROWTH

Normal Patient value Inference

STEP I
Changes of chin 90° (+ 3) 870
STEP II
Changes in maxilla 66° 640 -
STEP III
Changes in maxillary Molar protraction =1mm
teeth (position – 6) Incisor retraction=5mm
STEP IV
Changes in mandible Molar protraction =5mm
position (T-6) Incisor retraction=5mm

NOTE : Subsequent super imposed radiographs required to denote the normal

values.

References:
1. Robert Murray Ricketts; A Four-Step Method To Distinguish Orthodontic
Changes From Natural Growth. J Clin Orthod 1975 Apr (208-228

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