GOOD MORNING

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GROWTH PREDICTION

DR. N V UDAY SAGAR MADDULA

I MDS
DEPARTMENT OF ORTHODONTICS

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 CONTENTS

 Introduction

 Methods of growth prediction

 Gnomic growth and logarithmic spiral

 Arcial growth

 Rickett’s cepahlometric prediction

 Parental data to predict craniofacial growth

 Johnston method

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 Mathematical model for prediction of craniofacial growth

 VTO

 C axis

 G axis

 Other methods to predict growth

 Conclusion

 References

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 INTRODUCTION

 In orthodontic treatment planning, knowledge of facial growth

velocity and percentage of facial growth remaining is very
important for effective growth modification interventions

 Understanding of percentage growth remaining after

completion of orthodontic intervention may be important in
predicting post treatment rebound.

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 Chronologic age may have little or no place in the
assessment of the maturational state of a child, and it is
not a critical factor in the evaluation of over-all growth
potential.

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Methods of prediction of craniofacial growth

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 Prediction methods genrally followed in science are of
four types :
1. Theoritical
2. Regression
3. Experimental
4. Time series

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1.Theoretical methods of prediction-

 A theoretical model is constructed mathematically, and

a test for hypothesis is devised.

 Theoretical models of craniofacial growth have not yet

been defined mathematically in terms precise enough to
permit the application of the method to prediction

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 2. Regression methods- These methods serve to calculate
a value for one variable, called dependent, on the basis
of its initial state and degree of its correlation with one or
more independent variables

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 However Johnston evaluated and revised this method
and concluded-

1.The ultimate accuracy of cephalometric prediction may

be limited by intrinsic error within the cephalometric
method itself.

2. These methods seem inadequate to provide an efficient

estimate of individual change attributable to growth only.

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3. Experiential method-

 These 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
modified for use by others

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 4. Time series methods- 2 types

A) Time series analysis- it extracts in a mathematical form

the fundamental nature of the process as it relates to
time.

B) Smoothing methods –it gives representative or average

values to the parameters of a previously derived time
series equation

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 Gnomic growth and logarithmic spiral

 The process where upon the addition to a body leaves the

resultant body similar to the original is called gnomic
growth.

 D’Arcy Thompson classified the sea shells in accordance to

their pattern of enlargement and developed an equation.

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The Nautilus offers 2 fundamental characteristics-

 1. The shell grows in size but does not change its shape

 2. Its gnomic growth can be described by a particular kind

of curve- the logarithmic or equiangular spiral.

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 The spiral is characterized by the movement of a point
away from the pole along the radius vector with a velocity
increasing as its distance from the pole

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 Logarithmic growth of human mandible

 There are several functional conditions which are not

violated during orofacial growth- one of these is neural
innervations which must never be subjected to external
loading.

 Craniometric studies were performed on American Indian

skull, they are representative of mandible with fetal,
deciduous, mixed and adult dentition.

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 Small lead shots were fixed to foramen ovale,8 Mandibular
foramen & foramen mental

 Lateral x-rays effectively outlined the pathway of the Inf.

Alveolar nerve.

 All the 3 neural foramina at all ages fit precisely upon a

single mathematically defined, logarithmic spiral.

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 Arcial growth

 Ricketts in 1972 developed a method to determine the arc

of growth of the mandible.

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PRINCIPLE:

 A normal human mandible grows by superior anterior

apposition at the ramus on a curve or arc which is a
segment formed from a circle. The radius of this circle is
determined by using the distance from mental
protrubence (Pm) to a point at the forking of the stress
lines at the terminus of the oblique ridge on the medial
side of the ramus( point Eva)

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Landmarks

 Xi point-

 The deepest point on the subcoronoid is selected as R1.

 R2 is selected directly opposite to it on post border of

ramus.

 R3 is selected at the depth of the sigmoid notch.

 R4 is directly on the lower border of ramus.

 The centroid of the rectangle formed is called Xi point.

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 Supra pogonion or Pm- It is a point located at the
superior aspect of symphysis.

 It is labelled Pm

 This is substantiated as a reference point because-

 1. It is the site of a reversal line (Enlow)

 2. Stable unchanging bone in this area of bone (Bjork).

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 Point Dc – It is a point at the bisection of condyle neck

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 Point Eva- it is a biologic point as it is located over the
point of forking of the stress line in the ramus.

 Ramus reference point (RR) is the point halfway between

Xi point and R3 on the anterior border of ramus.

 MU point (murray point)- it is a point on the sigmoid notch

where the curve from Eva touches the notch.

 True radius- it is the centre of the arc. It is intersection of

arcs Eva and Pm

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 DC-Xi lines constitutes the condylar axis

 Xi – Pm line constitutes the corpus axis.

 The condylar and corpus axis together form the core of

the mandible, the path of the mandibular nerve.

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 Ricketts arcial growth of mandible was constructed using
superimposition on lateral cephalograms and they were
interpreted using computer analysis.

 Superimposing on corpus axis, registering at Pm of serial

cephalograms revealed a mandibular growth pattern in
which the ramus was found to curve posteriorly and
anteriorly.

 Using this, Ricketts constructed three arcs.

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 Curve A : passes through DC-Xi and PM.

 If mandibular growth had been along this curve, then it

would open the gonial too wide, which normally does not
happen. The resulting mandible will be too obtuse this
way.

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 Curve B : passes through tip of coronoid process through
anterior border of ramus and through Pm. Mandibular
growth along this curve will too bent.

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 Curve C : final curve was between condylar and coronoid
process through Eva-Pm.

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 Conclusion of Arcial growth

 With the arcial growth, it is evident that the growth of the

mandible in not linear but along an arc.

 Anterior and posterior deposition patterns have been

replaced by superior and anterior deposition of ramus that
takes place along the arc.

 True Arc is the part of the circle formed by the distance

Eva-Pm as the radius.

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 Growth of condylar and coronoid processes are in upward
direction along the arc.

 Annual increase of 2.5 mm was observed in mandible and

this was found to cease at an age of 14.5 yrs for females
and 19 years in males.

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 Occlusal plane and mandibular teeth eruption

 As mandible grows along the arc, space is created for 2nd

and 3rd molars.

 According to Ricketts, the anterior border of ramus does

not undergo resorption to accommodate molars as they
erupt in upward and forward direction.

 Arc growth, upward and forward movement of teeth

together push the chin downwards leading to the
development of chin button.
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 The antero posterior movement of lower incisor is
biologically related to A-pog plane.

 Eruption of posteriors is in upward and forward direction

giving space to 3rd molar, and if the movement is
restrained then it may lead to impaction of 3rd molars.

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 Mesh analysis

 Moorres constructed template in the form of a mesh which

was used to superimpose growth changes in serial lateral
cephalometric radiograph.

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 Construction :

 Moorrees mesh consists of 24 rectangles of equal size.

 It consists of a core rectangle.

 Reference lines are extra cranial, one vertical line is drawn

along nasion, 2 horizontal lines are drawn perpendicular to
this vertical line one through the nasion and another
through the ANS.

 The last vertical line is drawn parallel to vertical nasion line

at a distance of NS from nasion.
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 This core rectangle is divided into 4 parts by drawing a
horizontal line and vertical line.

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 The length and height of mesh rectangle differs among
individuals.

 The size increases from 8-16yrs.

 Boys-4.5mm- ht

 Girls- 3.5mm-ht

 Length- 3.2mm in boys

 Length 2.4mm in girls

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 Johnston method of growth prediction

 This is a simple method based on the addition of mean

increment by direct superimposing on a printed grid

 In this regular angular changes in average direction was

shown i.e each point advanced 1grid/yr using standard SN
orientation registered at S

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Uses of Johnston’s template :

 Relative age of skeleton can be measured i.e patient age

can be 11 years but his skeleton age may be 9 years

 All the components skeletal age may be 11 years but one

component may be of 8 years which depicts malformity.

 Vertical facial proportions can be judged in years, i.e AFH

of age 8 years and PFH of 10 years.

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 Todd’s equation of growth

 Todd considered the human head as a fluid filled sphere

and applied mathematic equation to estimate
gravitational pressure at any point in the sphere to assess
bone growth.

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P = a R (1-cosø)

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 Prediction of craniofacial growth using Todd’s equation

 Lateral cephalograms taken at younger age are placed on

a polar graph paper and ANS & Gn points were located.

 Cephalogram taken at older age are superimposed with

the reference point as the vertex and the same
anatomical structures are located on the polar graph
paper.

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 Disadvantages :

 Human skulls are not perfectly spherical in shape.

 Constant gravitational force alone does not act open the

skill, many other forces act.

 Predicted growth may vary due to presence of different

habits like thumbsucking ,nail biting, mouth breathing etc.

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 Visualized treatment objective

 Given by Holdaway

 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.

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1.Predicts growth over an estimated treatment time, based
on the individual morphogenetic pattern.

2. Analyzes the soft tissue facial profile.

3. Graphically plans the best soft tissue facial profile for the
particular patient.

4. Determines favorable incisor repositioning, based on an

“ideal” projected soft tissue facial profile.

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 5. Assists in determining total arch length discrepancy
when taking into account “cephalometric correction.”

 6. Aids in determining between extraction and non-

extraction treatment.

 7. Aids in deciding which teeth to extract, if extractions

are indicated.

 8. Assists in planning treatment mechanics.

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 9. Assists in deciding which cases are more suited to
surgical and/or surgical- orthodontic correction.

 10. It provides a visual goal or objective for which to

strive during treatment

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 Limitations of VTO

 1. Use of average growth increments in growth prediction.

 2. Use of existing morphological traits to predict future

growth events.

 3. Failure of presenting VTO analyses as an exact

representation of treatment outcome

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 Holdaway method of VTO

 Step I

 (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.

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 Step II

 First, superimpose on the SN line and move the tracing to

show expected growth (0.66 to 0.75 mm per year).Second,
copy the outline of sella.

 Third, copy the facial axis (Ricketts' foramen rotundum to

gnathion)

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 Step III – vertical growth of mandible

 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.

 Second, copy the anterior portion of the mandible,

including symphysis and anterior half of the lower border
then draw the soft-tissue chin.

 Third, copy the Downs mandibular plane.

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 Step IV – anteroposterior growth of mandible

 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,the
ramus and the condyle.

 At this point total vertical height has been forecast.

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 Step V – maxilla and lower nose

 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 mandibular plane.

 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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 Step VI – occlusal plane

 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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 Step VII – lip contour

 First, line up a straight tangent to the chin and angle it

back to a point at which it forms a 3 to 3.5 mm
measurement to the superior sulcus outline of the original
tracing and draw the H line to this. And when we draw the
superior sulcus area to the new upper lip tip point, a 5
mm superior sulcus depth develops almost automatically.

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 Second, with the tracing still superimposed in same
position, 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, draw in
the superior sulcus area. This will give us the new
vermilion border outline.

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 Step VIII – upper incisor position

 First, lip strain that shows up as excessive upper lip taper

should be the first consideration. the basic lip thickness
measurement and the thickness of lip at the vermilion
border should be considered.

 Next in case of lip strain, we should consider , 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.
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 Finally, with the tracing still superimposed on line NA and
the maxilla, place the maxillary incisor template, taking
account of the amount, that it is to be repositioned , its
axial inclination, and the relationship of the incisal edge
to the occlusal plane, draw the tooth.

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 Step IX – lower incisor position

 First, superimpose the VTO on the mandibular plane and

symphysis. Using the template, draw the lower incisor to
be in proper occlusion with the maxillary incisor, using the
occlusal plane as a guide.

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 Step X – lower molar position

 Than With the tracing superimposed on the mandibular

plane and symphysis and using the occlusal plane as a
vertical guide, draw the lower molar.

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 Step XI – upper molar position

 First, using the occlusal plane and the lower first molar as
a guide, with a tooth template, position the upper first
molar with the lower first molar.

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 Step XII – point A

 the position of point A is assessed only the best fit of

maxilla.

 Change in position will be drastic for bodily movement of

upper incisor and orthopaedic appliances.

 According to this point A is analyzed and drawn.

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 RICKETT’S VTO

 Growth changes of the craniofacial complex should be

studied by keeping the center of least growth as a
registration point.

 Ricketts found that the center of least growth is near the

pterygomaxillary fissure because growth changes occur in
a radial manner from this area while the area itself
remains constant.

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 A point called the “cc point” at intersection of Ba-Na line
to facial axis was constructed, and then, superimpositions
were done on the Ba-N plane registered at cc point.

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 Six areas of prediction were described:

 1. Cranial base prediction

 2. Mandibular growth prediction

 3. Maxillary growth prediction

 4. Occlusal plane position

 5. Location of the dentition

 6. Soft tissue of the face

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 C- AXIS: growth vector for maxilla

 M point- by Nanda & Meritt (AJO 1994)

 It is a constructed point representing the center of the

largest circle that is tangent to the superior, anterior &
palatal surfaces of maxilla as seen in the sagital plane

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 C-Axis: The line from the sella (S) to M- point is defined as
C- axis.

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 It permits the quantification of a complex maxillary
growth process

 Upto age 14, both male and females show- growth

increment of 1.41mm &1.31mm/yr.

The mean growth axis angle (C-axis- SN)

 Increased for both males and females.

 Males = 3.98

 Females = 2.25
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Palatal plane is geometrically related to C-axis.

 Females= increases from 35.4 – 37.4

 Males =increases from 39.3- 41.6

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 G –Axis : A growth vector for mandible

 Stanley Braun et al , Angle orthodontist, Vol 74 No3 ,2004

 G point : it is a point representing the centre of largest

circle that is tangent to the internal inf, anterior, and
post surfaces of the mandibular symphyseal region as seen
on lateral cephalograms.

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 Length of this axis is determined by Sella & G- point.

 Direction is determined by alpha angle

-Mean growth axis vector angle

 Theta angle- Mandibular plane & G-axis.

- Mean mandibular plane angle

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 G-axis length

Females – 1.6mm/yr

Males – 2.3mm/yr

 Mean Growth vector angle

Females – decreases 0.02/yr

Males – increases 0.14/yr

 Mean mandibular plane angle

Females –increases by 0.4/yr

Males – increases by 0.3/yr 91

Other methods for growth prediction :

 FEM studies

 Growth tensors

 Growth strains

 Parental data to predict growth of craniofacial form

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 Conclusion

 Burstone has pointed out “ the knowledge of prediction might

best proceed by learning to predict untreated growing faces.”
 The clinician must always wonder what effect his therapy
is having on the patient and actual growth of one specific
face.

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 References

 Textbook of craniofacial growth by Dr. Sridhar premkumar

 Visual Treatment Objective: A Review by Mounika Deva,

Vasu Murthy Sesham , Indian J Dent Adv 2018

 Stanley Braun et al , Angle orthodontist, Vol 74 No3 ,2004

 Nanda & Meritt (AJO 1994)

 Grave, K. and Brown, T.: Skeletal ossification and the

adolescent growth spurt, Am. J. Orthod. 69:611-619, 1976

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 Proffit W.R. Contemperory Orthodontics 3rd Ed. Mosby
2000.

 Fundamentals of craniofacial growth – A.D. Dixon.

 Essentials of facial growth – D.H. Enlow.

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Thank you

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