A sivnplijied approach to prediction

Lysle E. Johnston, D.D.S., Ph.D.

Cleveland, Ohio

D espite the fact that cephalometric prediction has been championed

enthusiastically for nearly two decades, most orthodontists have adopted a
“wait and see” attitude. Such caution is not entirely unwarranted: arcane
geometry and “space-age” technology require the expenditure of considerable
time and money for even a modest clinical trial. In view of the fact that
contemporary schemes are essentially mean-change expansions, this complexity
seems curiously inappropriate, both to the simplicity of the problem and to
the utility of the end result.
It will be the purpose of this article to present a simple alternative based
on the addition of mean increments by direct superimposition on a printed
grid and to characterize the accuracy of this approach in a series of &year
forecasts.

Materials and methods

The “forecast grid” developed for this exercise is reproduced in Fig. 1.

Vectors for A, B, and M were inferred from descriptive templates prepared by
Harris and associates,2 and the behavior of N and P was patterned after
reports by Ricketts.4y 5 The various steps required to effect a complete forecast
are depicted in Fig. 2 and are described in the accompanying legend. It may
be noted that the grid produces a moderate flattening of the profile and
occlusal plane, as well as a slight mesial drift of M.
In order to estimate the accuracy with which the landmarks can be re-
positioned, thirty-two 5-year forecasts (nineteen males and thirteen females;
average interval, 7.5 to 12.5 years) were performed on tracings executed a
decade ago as part of another study.3 Each point was advanced one grid-unit
per year. TJsing a standard S-N orientation (registered at S), the forecasts
were superimposed on the outcome, and the prediction errors (horizontal,
vertical, and total) measured to the nearest 0.1 mm. The tip of the nose could
not be included in the validation because its behavior was inferred from a
random subsample (ten males and ten females) of the subjects used in the rest
of the study.
253
 N
. I Ii /l-lII-HIII-I-I-I-Ii-l-l-4
I-I-ti-1.1
l-l-h-l-l
1-1-1-1-1-1
tt-

-Ages 8 to 13,
add 1 unit/year

20 mm

0 1974
1. Johnston

Fig. 1. Forecast grid. 5, Sella; N, nasion; P, posterior nasal spine; NOSE, tip of the nose;
M, any point on the crown of the maxillary first permanent molars; A and B, subspinale
and supramentale. A tracing of the landmarks is superimposed along S-N and registered
at S. The points are then advanced downward and forward one unit per year (but see
Table II).

Forecasting errors seen in the present validation are summarized in Table I.

Discussion

The forecasting technique presented here is essentially a greatly simplified

mean-change expansion and, as might be expected, it performs well when applied
to published examples of other schemes (for example, Ricketts’ “Case T.M.“s)
or to the Bolton Standards of Case Western Reserve University. Unfortunately,
schemes of this type do not fit a random series of patients nearly so well. Nor
 Simplified approach to prediction 255

s
.... ,a,’

PROFILEW ITHOUT
TREATMENT

Fig. 2. Forecasting technique. A, On the initial tracing, draw planes M-A and A-B; place
a mark 0.5 mm. above B for each year of the forecast (for example, 5 years calls for
2.5 mm.)-“pivot.” B, Superimpose a tracing of just the landmarks on the forecast grid
and relocate them one grid-unit per year; draw planes M ’-A’ and A’-B’. C, Center A’-B’
over A-B and trace the incisors; slide the forecast back 0.3 mm. per year and trace the
outline of the lips. D, Superimpose B’ on the pivot point, rotate the forecast until M ’-A’
is parallel to M-A, and trace the symphyseal outline; retract the forecast 0.3 mm. per
year and trace the soft tissue of the chin. E, Add the desired anatomy by regional
superimposition from the original tracing; connect the various parts of the soft-tissue
profile. If desired, a slight protraction of the bridge of the nose can be effected by a
clockwise rotation of the forecast (rotate until P’ is level with P).

is it easy to evaluate the significance of the forecasting error seen here;

equivalent data are generally unavailable for other methods. Moreover, the
common use of “best-fit” regional superimposition drains much of the meaning
from the few examples which have been published5 :
. . . Fig. 9 [p. 771 shows the results of patient T.M. with the prediction compared
to the actual 8 years later. A general central location shows all points to be within
2 mm. [Italics mine.]
Table I. Prediction error: Total, horizontal, vertical (predicted minus actual, in mm.)
---
Landmark
A B H P
Error N Total X Y T&z i Y Tot02 k j Y Total Y Jr’
Average error
Males -0.4 1.8 -0.8 -1.6 0.5 -0.4 -0.3 1.6 -0.1 -1.6 0.9 0.4 -0.8
Females -0.4 1.7 0.0 -1.7 1.7 1.5 -0.7 2.2 1.0 -2.0 0.4 0.4 -0.2
Average absolute
error
Males 0.8 2.6 1.4 2.1 3.3 2.4 1.6 2.7 1.6 1.7 1.5 0.8 0.9
Females 0.8 2.4 1.4 1.9 3.2 2.8 0.9 2.9 1.8 2.0 1.6 1.1 1.0
Root mean squared
error
Males 1.1 3.1 2.1 2.3 3.7 3.1 2.0 3.1 2.1 2.3 1.6 1.0 1.2
Females 0.9 2.8 1.7 2.2 3.6 3.4 1.2 3.2 2.2 2.3 1.8 1.3 1.3
Root mean squared
technical errora 0.9 * * 1.6 2.2 * * 2.6 2.6 +X XX ** YK Z* X*

*Estimated from Baumrind and Frantzl-includes error for S and N in two tracings. Details
of the calculation will be furnished on request.

In the present study, cranial base superimposition was employed. As a

result, the forecasting error for any given landmark reflects not only the
technical error for that particular point but also a portion of the error for
X and N. Moreover, a validation requires two tracings-initial and final. Thus,
even a perfect method would exhibit, at the very least, nearly two times the
error variance of three landmarks. Viewed in this light, the grid did not
perform too badly. Additional accuracy might obtain if the expansion were
modified to reflect differences in age and sex. To this end, suggestions inferred
from the literature61 7 are presented in Table II.
It is probably safe to assume that any one of a variety of contemporary
schemes will allow the clinician to visua.Zizethe individual impact of the most
likely pattern of growth and thereby permit him to plan treatment accordingly.
Whether or not this would be of long-term benefit remains to be seen.
Although it is an obvious fallacy to assume that a diagnostic aid is useful
merely because it is used, an informed decision should be based, ideally, on
personal experience. For those who are interested, it is hoped that the present
communication will make data collection a bit less painful.
Summary and conclusions

A simplified method of generating long-term forecasts by the use of a

printed “forecast grid” was described and its accuracy characterized for a
series of thirty-two S-year forecasts. Although the predictions were not without
error, they were not much worse than would be expected from an analysis of
cephalometric error, per se. It was concluded that t.he grid may provide a
simple-and perhaps useful-introduction to the subject of growth pre-
diction.
Number
Volume 637 Riwplified npprocrch to predictzon 257

Table II. Grid-units to be added, according to starting age, years of prediction, and sex

Years of predidion
10 9 8 7 6 5 4 3 2
6
7
16 8
15 9 Stnrting
14 10 age
FemnlPs
13 11
Starting
12 12
we
Males 11 13
10 14
9
a
7
6 3 14 15 16 17 18 19 10.5 12 12.5 13
23456789 10 11 12
Years of prediction
Because of technical error, one-year forecasts are not recommended.

The author wishes to express his appreciation to B. Holly Broadbent, Jr., for providing
a prepublieation copy of the Bolton Standards and to Stuart Duchon for his generous technical
assistance.

REFERENCES
1. Baumrind, S., and Frantz, R. C.: The reliability of head film measurements. 1. Landmark
identification, AM. J. ORTHOD.60: 111-127, 1971.
2. Harris, J. E., Johnston, L., and Moyers, R. E.: A cephalometric template: Its construction
and clinical significance, AM. J. ORTHOD.49: 249-263, 1963.
3. Johnston, L. E.: A statistical evaluation of cephalometric prediction, Angle Orthod. 38:
284-304, 1968.
4. Ricketts, R. M.: Planning treatment on the basis of the facial pattern and an estimate
of its growth, Angle Orthod. 27: 14-37, 1957.
5. Ricketts, R. M.: The application of ares, polar centers, gnomons, and k factors in facial
growth prediction, Foundation Orthod. Res. Proc. 4: 53-78, 1971.
6. Riolo, M. L., Moyers, R. E., McNamara, J. A., and Hunter, W. S.: An atlas of craniofacial
growth: Cephalometric standards from the University School Growth Study, the Uni-
versity of Michigan, Ann Arbor, 1974, Center for Human Growth and Development.
7. Woodside, D. G.: Distance curve of mandibular length by age for males, Toronto, 1970,
University of Toronto Department of Orthodontics.

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