Growth Prediction3 / Orthodontic Courses by Indian Dental Academy

GROWTH PREDICTION
Introduction
Definition
Uses
Methods
Limitation

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GROWTH PREDICTION
Introduction
Scammons curve
Cephalocaudal gradient
Data from various studies
Bolton brush study
Iowa growth study
GROWTH PREDICTION
Definition
Assumption of ability to estimate
practically future growth.
Asserting on the basis of theory, data or
experience but in advance of proof.

GROWTH PREDICTION
Why it is necessary ?
Helps in diagnosis
Development of satisfactory treatment
plan

Growth prediction
Methods of predicting facial growth change
According Bjork
Computerized prediction methods
Logarithmic spiral
Arcial growth of the mandible
Visual treatment objective
Jacobson and Sadowsky
Ricketts
Holdways
GROWTH PREDICTION
According Bjork
Longitudinal approach
Metric approach
Structural approach
Growth prediction
Longitudinal approach
- Tweed on growing pt.
- 2 lateral ceph. 12-18 months apart
- 3 categories Type A
Type B
Type C

Growth prediction
type A middle & lower face growth in
unison + equal change in vertical &
horizontal dime.
Type B middle face > lower face
Type C lower face < middle face

Growth prediction
Tweed growth pattern remain constant.
- Moore et al
- No use in predicting changes.
Limitation
Accurate in Retrospective.
Conclusion
Not accurate method.
Growth prediction
Metric approach
- consist of measuring different structure on a single
radiograph & then relating these measurement to
future growth changes .

Correlation coefficient =r
- Association b/w 2 variable
- Direction either positive or negative of the
relationship
- It is used in prediction by -
Squaring the value of r = coefficient of determination
( amount of variation of 2
nd
variable )

Growth prediction

Bjork ,Harvold ,Lande, Solow ,others

- Correlation Coefficient not more 0.4 or 0.5
- 16% to 25% variation

Conclusion
this methods is least clinically siginificant

Growth prediction
Structural approach
- To predict mandible
growth direction
- Superimposition on
metallic implant
- 7 areas
1. Inclination of condyle
2. Curvature of the
mandibular canal
3. Inclination of symphysis

Growth prediction
4. Shape lower border of
the mandible
5. The interincisal angle
6. The interpremolar or
molar angle
7. The anterior lower facial
height
Conclusion
This is also least clinically
siginificant
Growth prediction
Skeiller ,Bjork, and Linde Hansen
(Tried to quantify it)
4 variable
1. MP inclination - Anterior cranial base (MP:SN)
or Ratio of posterior & anterior facial height
2. The intermolar angle
3. Shape of lower border of the mandible
(GO - ME to lower border of the mandible)
4. Symphysis inclination (sym. Anterior surface SN)

Growth prediction
Measurement of these variables were
included
R squar = 0.8612 = 86% variation in direction of
mandibular growth
But 86% was high value

Growth prediction
According Bjork
Logarithmic spiral
Visual treatment object
Growth prediction
Tool of analysis not a method
Advantage
1. Facilitates testing
2. Complex formulas to growth prediction

Growth prediction
Ricketts 1970 potential of computerization
- Cephalogram (diagnosis ,T/P)

Greenberg & Johnston
- Computer forecasts not better than the
assumption of average growth
- No difference bet. this & method based on
simple addition of the average changes.
Growth prediction
According Bjork
Logarithmic spiral
Visual treatment object

Growth prediction
Logarithmic spiral
Golden triangles
Why
how the position of 3 foramina on the
unitary , logarithmic spiral in anterior open
bite and deep bite pt. (Melvin. Moss )

Logarithmic spiral
Evolution of logarithmic spiral
Sectioning of a line
Smaller section is proportional to large section
Larger portion is called golden section
Larger section is Phi /

Small section is 1
Larger = 1.618 times
the smaller
The smaller is 0.618
the length of the
larger
Phi relationship
- Plants, animals, human body , face
Golden progression series of these
proportions
- Symbols -
2
,
3
,
4

Golden triangle
Base of a triangle 1.0
Sides of equilateral
triangle 1.618
Forms a 72 72 -36
degree
Bisection of one base
angle cross the opposite
side

Divide that side into a
golden section

Form new golden
triangle
Bisection of golden triangle can be made in a series

Curve used to connect
the points on a series of
the triangles

Form Logarithmic spiral.
Logarithmic spiral
So human mandible
grows as a logarithmic
spiral on the arc.
Logarithmic spiral
Melvin Moss
Aim - determine the position of 3 foramina on the
unitary , logarithmic spiral in anterior open bite and
deep bite pt.

These conditions can be anticipated at young age
even before orthodontic diagnosis
Foramen
1. Foramen ovale
2. Mandibular foramen inferior alveolar nerve
3. Mental foramen
Logarithmic spiral
Introduction
Studied the position of the inferior
alveolar nerve

Conclusion
These foramina , at all ages fit precisely
upon a single mathematically defined
logarithmic spiral

Logarithmic spiral

Foramen moved down
along this same
logarithmic spiral in
geometric fashion

The gradient of motion
directly increasing with the
distance of the foramina
from cranial base.
Logarithmic spiral
Method and materials
2 group of pt.
Columbia university University of utah
16 pt - 3 m & 4 f 4 groups
(Ant Open bite) 10 pt Normal swallowers
- 4 m & 5 f 10 pt Tongue thrust
(Deep bite) 5 pt Angle II div 1
5 pt Ant open bite
Logarithmic spiral
Tracing of cranial base & mandibular outline
from films

Superimposed the logarithmic spiral

Position of 3 foramen marked on it.
Logarithmic spiral
Result
Singular position of
foramen ovale in
anterior open bite.
Foramen ovale located
farther down the
spiral.
Help in diagnosis
No sexual dimorphism
Logarithmic spiral
Mandibular & mental
foramen also further
down the logarithmic
spiral in AOB
Not as diagnostically
unique
Distance between
these not decreased.

Logarithmic spiral

Foramen oval cluster
relatively high up on
the spiral in deep bite.
Logarithmic spiral
Discussion
Mandibular shape - inferior alveolar nerve
- 2 factors foramina position on the spiral
distance between them.

Fetal & circumnatal periods
- All foramina placed near the origin of spiral and
nearer to each other
- Flatter curvature
- Mandible gonial angle relatively obtuse or flat.

Logarithmic spiral

With growth , all foramina moved down along
the spiral and distance

Ramus becomes more erect relatively to
corpus

Gonial angle becomes acute
Logarithmic spiral
Anterior open bite
Foramen ovale down
along the spiral

Distance mand. &mental
foramen not decrease

Course of inferior alveolar
nerve flatter

Ramus & corpus more
obutse
Logarithmic spiral
Deep bite
Higher up on the spiral

3 neural foramina
distance not decreased

Inferior alveolar nerve
curvilinear course

Ramus & corpus more
acute
Logarithmic spiral
Anterior cranial base Richardson
Sella - NA
Deep bite
Anterior
open bite
Logarithmic spiral
Anterior open bite Deep bite
Gonial angle
Ar Go-Me Obtuse Acute

Mandibular size
Ramus Shorter No significant
Corpus Normal length linear difference

Anterior cranial base
(S-Na) No difference

Logarithmic spiral
Anterior open bite Deep bite
Periosteal functional matrix
(Massater) No difference in attachment site

Capsular functional matrix
Oral functioning space
Abnormal Normal
Growth prediction
According Bjork
Logarithmic spiral

Principal of Arcial growth of the
mandible
Robert M. Ricketts
Purpose explain a method for finding the arcial
growth of the mandible and to enumerate some uses of
the principal

Based on computer study

Predict long range growth forecast


Principal mandible grows by superior-
anterior apposition at the ramus on a
curve or arc which is a segment formed
from a circle.

Radius Pm to point Eva.

Growth of the mandible
1. Roentgenographic cephalometric
2. Bjork
3. Enlow
Bjork
- variation in the mandibular bending.
- Resorption of lower angular border
- 3
rd
molar crypt stable longitudinal reference
Enlow
3D growth pattern Remodeling area
Reversal areas of stability


Prediction of mandibular growth
Primary methods
- Long axis of condyle & neck
- Lower border of mandible
Central core cephalomertrically
Search for reference point
External mandible (mandibular plane,ramus plane,
condyle symphysis )

Xi point center of
ramus
Occlusal plane
Entrance of neurotrophic
bundles
Bisect the height of ramus from the
sigmoid notch

Dc point
Condyle axis
Corpus axis
Change in angle - change
in mandibular form
Second method
Magnitude & angular
relation.
More successful as a
method of forecasting


Suprapogonion / Pm
Reference point
Ricketts stress center
Enlow site of reversal
line
Bjork - cosistent

The objective of research was still towards
finding a method to critically predict future
form and size of the mandible over the
long range.

computer study
5 yrs growth study of mandible & lower
dental arch
In lateral & frontal head films -362
measurement

Material
40 pt lateral & frontal cephalometric film
One group 8 yrs another group -13 yrs
No orth. t/t
20M & 20F
20 class I with normal occlusion
20 - class II malocclusion


Findings
Mandible bend
degree per year.
Bending in an orderly
manner.
Growth arc was
operative.


First arc Pm ,Xi ,Dc
Straightening of the
mandible
To determine the true arc of growth of the
mandible

Second arc - tip of
coronoid , R1 , Pm
Segment of circle small in
radius.
Excessive bending of
mandible


True arc Condylar &
Coronoid process ,
Ramus center & its ant.
Border
Radius increase or
changing with the size of
the mandible
Changing arc or ultimate
spiral would result.
Growth could not be
represented as simple
segment of circle


Stress lines
850 yrs. Old mandible
William B. Downs
Disintegration of
interprismatic subs.
Stress lines in the outer
& inner plates

Examination of
stress lines / lateral
surface
Convergence at
protuberance menti
Upward ,backward &
outward from EO
Gnarled area at the
coronoid base.


Stress line /medial side
Mylohyoid ridge
YM /Y-shaped bony
prominence
- Center of quadrant of
ramus
- Inner & outer cortical tables
showed confluence
TP/ Triangular plane
Nutritive foramina


2 new point - Eva &TR
Eva- forking of stress lines
in ramus

TR /true radius center
of circle from Pog through
Eva

Mu point

Mandible size increased,
increment added to the
arc at the sigmoid notch.

Predicted mandible was
almost absolutely correct
in size and form when
compared with the final
composite

Mandible growth occurs
on a arc
This method proved
extremely accurate in
50 treated cases
which were predicted
and compared for
periods of as long as
14 yrs later.

Amount of growth to
forecast on the arc
- 2.5 yearly increase
14.5 F & 19M

Symphysis lower
border 1mm each 8
yrs / M

Coronoid & condylar
process different

Coronoid 0.8mm/yr

Condylar - variable
1. Short & weak 0.0mm
2. Long condyles
0.4mm/yr
3. Average 0.2mm /yr

Gonion angle growth
50% of the total
increase in mandibular
growth

Females - no further
addition

Males above +0.2mm

External oblique ridge
0.4mm/yr.

RR point stable bone
Ramal width

Impaction of third molar and Arcial
growth prognosis 25 adult skull
normal occlusion

1. Lower third molar 50 % ahead the EOR
50% favorable prognosis
2. Mesial to the EOR 100 % favorable prognosis
3. Distal to the EOR poorer
45 % of the nonextracted cases required third molar
extraction.

Bisect the height of ramus from the
sigmoid notch down to the lower border in
a perpendicular plane from FH ,then
bisected the width of the mandible called
XI point

Xi point center of
ramus
Occlusal plane
Entrance of neurotrophic
bundles

2 new point - Eva &TR
Eva- forking of stress lines in
ramus
A center of upward & forward
quadrant of ramus
By bisecting R2 & R3 point

TR /true radius center of
circle from Pog through Eva

Mu point

Class III
The amount of mandibular
growth in the forecast is
one sixth more in the
classIII

May be occur in
closed bite faces
Growth prediction
According Bjork
Logarithmic spiral
Visualized treatment objective

Definition
Uses
Ricketts
Holdways

Definition
It is a visual plan to forecast the normal
growth of the pt and the anticipated
influences of treatment , to establish the
individual objectives we want to achieve for
that pt

Uses
1. Predict growth over an estimated T/t time
2. Analyzes the soft tissue facial profile
3. Determines favourable incisor repositioning
based on an ideal projected soft tissue
profile
4. Determines total arch length discrepancy

5. Aids in determining b/w extraction &
nonextraction treatment
6. Surgical orthodontic correction

Ricketts
Holdways

ALEX JACOBSON &
P.LIONEL SADOWSKY
All cephalometric headfilms to be taken in the lips
closed position even if they are strained to close

Construct a VTO by considering average growth for
an estimated 2 yr period of active t/t & the objective
we want to achieve with our mechanics

Cephalometric tracing for VTO
Anterior & posterior cranial base
Pterygomaxillary fissure
Orbit
Anterior outlines of frontal bone
Nasal bone & Nasion
ANS &PNS ,hard palate
Upper central incisor & its alveolar process
Mandible
External auditory meatus
Soft tissue profiles
Upper & lower molar
Cephalometric tracing for VTO
BAN (Basion-nasion line)
Line Na - POINT A
F H PLANE
Occlusal plane
Downs mandibular plane
Facial axis
Holdways line
Facial plane
Step of VTO
Step 1 obj. To draw frontonasal area , BAN & NA
line.

Step 2 obj. Growth in frontonasal area over 2 yr.
- Frontonasal area 1.5 mm growth
- 1/4mm per year ( Dr. Holdways studies )

Step 3 object Mandible growth in vertical direc.
- Ant. Portion of mandible
- Soft tissue chin
- Downs mandibular plane

Superimpose on the facial axis
The distance b/w VTO & ceph Ban line should be 3
times the amount of growth expressed previously in
FN area
Step 4 obj. Mandible growth in horizontal
direction.
- Draw the Post border of mandible
Forward growth at chin point = Nasion
Total vertical facial height as well as forward
location of chin established
Step 5 obj. To locate maxilla & lower half of nose
Superimpose on NA line & move up
There is 40% of total vertical growth above BaN
line & 60% below mandible
Nose growth 1mm/year.

Step 6 obj. To locate and draw the occlusal plane
Superimpose on NA plane
Vertical growth is 50% above maxilla & 50% below
mandible

Step 7 obj. To determine soft tissue lip contour
using the new H-line

The distance b/w upper lip contour & H-line is
3 - 7mm (Dr. Holdways studies )
Step 8 obj. To relocate the maxillary central incisor
Upper lip thickness = Basic upper lip thickness
( within 1 mm )
Lip strain is difference b/w above measurement
Maxillary incisor rebound - 0.5mm in class I
- 1.5 mm in class II
In this case
Lip strain = 4 mm
Lip movement = 4 mm
Maxillary incisor rebound = 1.5 mm
Total 9.5 mm
Step 9 obj. To reposition lower incisor
- Calculate resultant arch length change

Arch length change - measure the distance b/w
old and new incisor position (2mm)
Double the above distance

Arch length change is in this case is 4 mm

Step 10 obj. To reposition mandibular first molar

Total arch length discrepancy = arch length loss
+arch length discrepancy / model discrepancy
8 mm = 4 mm + 4mm

Extraction of 2
nd
PM on both side - 15 mm space
Step 11 obj. To reposition the maxillary first

Holdways
Ricketts

A Soft - tissue cephalometric analysis
Reed A. Holdway
Based on soft - tissue measurement

Variations
Sella nasion line is used express forward growth
at nasion
Growth on facial axis is 3mm/yr except during
growth spurts

Head films should be taken with the pts
lip touching position

Original tracing 9 reference line
SN plane
FH plane
Occlusal plane
Nasion to Pog line (hard & soft tissue)
H- line
Nasion to point A line / facial plane
Facial axis
Downs Mandibular plane


Steps of VTO tracing

Step 1 Draw Frontonasal area
Sella nasion line
Nasion- point A line


Step 2 - Express horizontal growth in the FN
area for the estimated T/t
Growth at nasion is 0.66 to 0.75 mm/yr
Prediction of growth at nasion is an overall
prediction for all midfacial structure


Step 3 Mandible growth in vertical dire.
Growth on facial axis is 3 mm/yr except in growth
spurt period

Step 4 Mandible growth in horizontal dire.
At this point total vertical height has been forecast


Step 5 To locate maxilla, the new point A &
lower half of nose

Vertical growth above the SN line & below the
mandible is in ratio of 40 :60
The vertical growth of the nose over 2 yr period
keeps pace with the growth from the maxilla
vertically to the anterior cranial base


Step 6 - locate and draw the occlusal
plane
Vertical growth is 50% above maxilla & 50%
below mandible
The occlusal plane is located 3 mm below the lip
embrasure


Step 7 To determine soft tissue lip contour
using the new H-line

The distance b/w upper lip contour & H-line is
3 - 7mm
Short & thin lip 3 mm
Long & thick lip 5 mm


Step 8 To relocate the maxillary central
incisor

Upper lip thickness = Basic upper lip thickness
( within 1 mm )
Lip strain is difference b/w above measurement
Maxillary incisor rebound - 0.5mm in class I
- 1.5 mm in class II


Step 9 To reposition lower incisor
- Calculate resultant arch length change

Arch length change - distance b/w old and new
incisor position
Double the above distance

Arch length change is in this case is 8 mm


Step 10 To reposition mandibular first molar

Total arch length discrepancy = arch length change
+arch length discrepancy / model discrepancy
10 mm = 8mm + 2mm
Extraction of 2
nd
PM on both side - 15 mm space

Step 11 To reposition the maxillary first

Holdways
Ricketts

RICKETTS
Original tracing
Nasion
ANS
Point A
PM
POG
CC
Basion
DC
XI


Construction of VTO
Cranial base prediction
Mandibular growth prediction
Maxillary growth prediction
Occlusal plane prediction
The location of the dentition
The soft tissue of the face

VTO Cranial base prediction
Mark at CC point
Trace BaN Plane
Nasion -1mm /yr
Basion 1 mm/yr


VTO Mandibular growth prediction
Condylar axis growth
Corpus axis growth
Symphysis growth
VTO Mandibular growth prediction Rotation

Mandible rotates open or closed from the effects of
mechanics used & the facial pattern present

Mechanics
5 mm convexity reduction Facial axis open 1 degree
4 mm overbite correction

Facial pattern


VTO Mandibular growth prediction Rotation

Superimpose at Basion
Rotate VTO tracing up to open the bite at nasion or
down to open the bite
This rotation depends on treatment effect
Trace condylar axis, coronoid & condylar process

VTO Mandibular growth prediction
Condylar axis , Corpus axis growth

Condylar axis moves 1mm /yr down from DC point
PM moves forward 2mm /yr in normal growth

VTO Mandibular growth prediction -Symphysis
growth
Coincide old & new PM
Copy the symphysis , mandibular plane
Construct facial plane & facial axis


VTO Maxillary growth prediction
Superimpose at nasion along the facial plane
Divide the original & new menton into 3 part by
using 2 mark
Superimpose mark 1 on original menton , copy the
maxilla


VTO Maxillary growth prediction
Point A change related to BA NA

Position of Point A change with growth & different mechanics
Mechanics Maximum range
1. HG - 8 mm
2.Class II elastics - 3 mm
3.Torque - 1 to 2 mm
4.Class III elastics + 2-3mm
5.Facial mask + 2- 4mm
Point A and APO plane

VTO Occlusal plane prediction
Superimpose mark 2 on original menton along facial
plane
Copy the occlusal plane

VTO - Dentition - Lower central incisor
Superimpose on the corpus axis at PM
Place a point 1mm above to occ. Plane &
1mm ahead to APO line


VTO - Dentition - Lower first molar
Arch length change is 4mm
Leeway space is 4mm

VTO - Dentition - Upper first molar
Upper central incisor
VTO Soft tissue area

Growth prediction
Overall changes in size and relationship of
human face from childhood to adulthood
are difficult to accurately predict due to
influence of the combined and complex
effects of genetic and environment factor.
Growth prediction

Facial and dental changes in Adolescent and their clinical
implication
Samir E Bishara ,AO 2000,Vol.60,No.6
Difference between functional matrices in anterior open
bite and in deep bite
Melvin L. Moss, AJO 1970, Vol. 42,No.3
A principal of Arcial growth of the mandible
Robert M . Ricketts AJO 1972,Vol .42 ,No.4
Provocations & perception in craniofacial orthopedics
Robert M . Ricketts
Issues related to the prediction of craniofacial growth
James Todd , AJO 1981,Vol .79 ,No. 2
A soft tissue cephalometric analysis and its use in
orthodontic treatment planning
Holdway , AJO 1984 ,Vol. 84 ,No. 4

Growth prediction

A Visulized treatment objective
Alen Jacobson , P Lionel Sadowsky
Prediction of the mandibular growth rotation
Bjork , AJO 1969 , Vol. 39
Bioprogessive Therapy VTO
Ruel W Bench , James J. Higler , JCO 1977, November
Contemporary orthodontics - William R. Proffit
Orthodontic current principles & techniques
T.M Graber , Robert Vanarsdall
Orthodontic principles & practice
T.M Graber
Ricketts interview ,JCO 1975 ,may, jun ,july


Thank you

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