Growth Prediction

PRESENTED BY : DR.
KISHAN ANTALA
GUIDED BY: DR.HINA DESAI
Introduction
Need of growth prediction
Methods of prediction of craniofacial growth
 HAND WRIST RADIOGRAPHS AND SKELETAL MATURITY
A Cervical vertebrae maturation indicators
Huterian concept
Gnomic growth and logrithmic spiral
Arcial growth
 Mesh analysis
Johnston’s forecast grid
Todd’s methods
 VTO( Visualized Treatment Objective)
 Ricketts VTO
 Holdaway VTO
 clinical implication
 conclusion
Variety is the spice of life. Every child extensively
differs in the rate,amount and direction of growth and
in the expression of the extent of his malocclusion.
Growth pridiction help in predicting to certain extent
the response to treatment and the growth changes.
Growth assessment procedures indicate the growth
status of the patient at a perticular time and provide an
assessment of the percentage of growth left.
As proffit says , growth prediction can never be
accurate especially when the child is growing .
 - Sridhar premkumar, craniofacial growth-194
Growth prediction can be difined as the forecast of
growth related changes with the objactive of prediction
the direction and amount of the growth of the maxilla
and perticularly the mandible as well as the timeing of
the adolescent growth period.
Being able to predict growth well help craniofacial
biologist in two principal way.
 - S premkumar craniofacial growth-194

1:Science of pridiction demands that the knowledge of
the craniofacial biologist be valid and cohesive and that
they understand a great deal about craniofacial growth.
2:predicting the adult features of a patient will help in
the interception and correction of malocclusion.
 - S premkumar , craniofacial growth-194

Growth prediction help the clinician to intercept and correct the
malocclusion.
Used as patient education aids .
VTO is helpful in visualizing, the treatment objectives and
prioritized the objectives, keeping in mind the growth pattern of
patient.
Also help to plan for retention period, thus ensuring stability of
the result.
Growth prediction is usually not done for all the cases but only
for those cases in which prevented,alterd growth pattern is seen.
- Sridher premkumar craniofacial growth-pagno-194

Is also a tool for orthodontic treatment planning but
without forcing any particular treatment procedure.
Response to a particular treatment can be predicted
provide the patient continues in the same growth
direction.
 - Sridhar premkumar craniofacial growth-pag no-195

 William J Hirschfeld AJO Vol 60 no 5 1971
 Several predictive methods that are used can be grouped
as follows-
A) Theoretical B) Regression
C) Experiential D) Time Series
William J Hirschfeld AJO Vol 60 no 5 1971- S premkumar , craniofacial growth-195

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

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
Howeverj 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.

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.
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.

The first recorded Hand-wrist radiograph film was
published by Sydney Rowland of London in 1896. This
was just 4 months after the announcement of the
discovery of the X-Ray by Roentgen.
-B D chaurasia’s,vol 1 ,pag no-26
Stages of Ossification of the
Phalanges
Epiphysis narrower than

Diaphysis.
Epiphysis same width as
Diaphysis.
Capping Stage: Epiphysis
surrounds Diaphysis like a cap.
Union Stage: Bony fusion of
Epiphysis and Diaphysis.
Bjork, Grace and Brown (1967)
They divided skeletal development into 9 stages.
Each of these stages represented a level of skeletal
maturity.
Stage 1: The epiphysis and diaphysis of the proximal

phalanx of index finger were equal. It occurred
approximately three years before the peak of
pubertal growth spurt.
(males 10.6y, females 8.1 y).
Stage 2: The epiphysis and diaphysis of the middle
phalanx of the middle finger were equal.
(males 12.0 y, females 8.1 y).
Brown T skeletal ossification and growth sprurt ajo 1976;Bjork A.pridiction of
age of maximum puberal Growth in body hight.AJO 1969;39-53,Phulari,pag 19
no-210
Stage 3: This stage was characterized by presence of
3 areas of ossification; a) ossification of the hamular
process of the hamate, b) pisiform, c) The epiphysis
and diaphysis of radius were equal.
Stage 4: This stage marked the beginning of the

pubertal growth spurt. It was characterized by; a)
Initial mineralization of the ulnar sesamoid of the
thumb, b) Increased ossification of the hamular
process of the hamate bone.
(males 13.0y, females 10.6 y).
20
Phulari,pag no-210
Stage 5: This stage heralded the peak of the pubertal
growth spurt, capping of the diaphysis by the
epiphysis was seen in; a) Middle phalanx of the third
finger b) Proximal phalanx of the thumb, c) Radius
(males 14.0y, females 11.0y).
Stage 6: This stage signified the end of the pubertal

growth spurt. It was characterized by union between
epiphysis and diaphysis of the distal phalanx of the
middle finger.
Phulari,pag no-210 21
Stage 7: Union of epiphysis and diaphysis of the
proximal phalanx of the third finger.
Stage 8: This stage showed fusion between the

epiphysis and diaphysis of the middle phalanx of
the middle finger.
(males 15.9 y females 13.9 y).
Stage 9: This was the last stage and it signified the

end of skeletal growth. It was characterized by
fusion of epiphysis and diaphysis of the radius.
22
Phulari,pag no-210
Cervical vertebrae maturation
indicators
The first seven vertebrae in the spinal column constitute the

cervical spine. The first two, the atlas and the axis are
quite unique, the third through the seventh have great
similarity. Maturational changes can be observed from birth to
full maturity.
In 1972, Lamparski concluded that the cervical vertebrae, as
seen on the routine lateral cephalogram, were as statistically
and clinically reliable in assessing skeletal age as the hand-wrist
technique.
He found that the cervical vertebral indicators were the
same for females and males, but that females developed the
changes earlier .
Graber,pag no- 479 23
In our department we use the cervical vertebrae
assessment which was put forward by Hassel and
Farman (1995)
Hassel, B. and Farman, A.: Skeletal maturation evaluation using

cervical vertebrae, Am. J. Orthod. 107:58-66, 1995.,graber,pag 24
no-480
,
1. Initiation:
-Inferior borders of 2nd 3rd and 4th
cervical vertebrae are flat at this
stage.
• The third and fourth vertebrae
are trapezoid shaped and the
superior vertebral borders are
tapered from posterior to
anterior.
• 100% of pubertal growth
remains.
Hassel, B. and Farman, A.: Skeletal maturation evaluation

using cervical vertebrae, Am. J. Orthod. 107:58-66,
.
1995 Graber,pag no- 480 25
2. Acceleration:
• A notch is present in the inferior
border of the odontoid process(c2).
• Inferior border of fourth vertebrae
remains flat.
• Vertebral bodies of third and fourth
are trapezoid in shape.
• ‘get ready’ stage because peak
interval will begin about 1 year after
this stage is evident.
26
Graber,pag no- 480
3. Transition :
•Distinct notch are shown on the
inferior borders of second and
third vertebrae.
• c4 still flat.
• Vertebral bodies of third and
fourth are still retains trapezoidal
in shape while others are more
rectangular horizontal shape.
•At this stage maximum
craniofacial growth velocity is
anticipated .
27
•Graber,pag no- 480
4. Deceleration stage:
•Distinct notches can be observed on
the inferior borders of second, third
and fourth cervical vertebrae.
begin to be more recangular
horizontal in shape.
• continued craniofacial growth can be
anticipated but lesser rate than is
seen in CS-3.
28
5. Maturation stage:
• notches are observed on the
inferior borders of second, third and
fourth cervical vertebrae.
are almost square in shape.
•In this stage most craniofacial
growth has been achived.
29
•Graber,pag no- 481
6. Completion:
• notching are observed on the
second, third and fourth cervical
vertebrae.
• Vertebral bodies are greater
rectangular vertical in shape.
• Pubertal growth has been
completed.
30
John huter hypothesized a liner model for mandibular
growth where there is resorption in the anterior border of
ramus and deposition in the posterior border, thus
lengthening the mandible. The hunterian concept of
mandibular growth was held as a dictum till bjork proved
that mandible and maxilla underwent rotational growth in
his implant studies.

What is gnomic growth?
 The process where upon the addition to a body leaves the resultant body similar to the original is called gnomic growth.
growth
D’Arcy Thompson classified the sea shells in accordance to their pattern of enlargement and developed an equation.
The Nautilus offers 2 fundamental characterstics-
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.

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

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.
Small lead shots were fixed to foramen ovale. Mandibular foramen.&
foramen mental.
 Moss ML salentijin, herbert p. the logarithmic properties of active and passive mandibular growth.AJO
1974;66:645-64, - S premkumar , craniofacial growth-197
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.
- S premkumar , craniofacial growth-197

Another longitudinal and cross sectional clinical growth data
showed that these foramina moved along the same logarithmic
spiral in geometric fashion, with the gradient of motion directly
increasing with the distance of the foramina from the cranial
base. ie mental foramen moves most and the foramen ovale least.
 In the fetal period the 3 foramina are relatively near the origin of
the spiral and at the same time they are placed nearer to each
other than at later stage. This produces a flatter curvatre hence
gonial angle is relatively flat

With growth due to increase in distance ramus becomes
straight relative to corpus and gonial angle acute.
During all stages of development the corpus stays in
essentially a horizontal position. At the same time
the mandible curves down the logarithmic spiral
course of the inferior alveolar nerve.

Ricketts in 1972 developed a method to determine
the arc of growth of the mandible.
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 protuberance (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) .
Riketts RM a principle arcial growth of mandible.AO 1972;42:368-8, S premkumar , craniofacial
growth-198
-On the basis of this, a primary method of prediction
of development was devised. By plotting a line
through the long axis of the condyle and neck and
extending it to the lower border of the mandible, the
bending of the mandibular form during growth had
been studied.
-The next move was to identify a “central core”
cephalometrically. External mandibular form is subject
to remarkable remodeling and therefore not reliable
as a reference. The attempt to overcome surface
variation and to determine central or internal
structures resulted in the promulgation of new
reference points.
39
S premkumar , craniofacial growth-198
Xi point:
Centre of the ramus and also contacts the
mandibular canal.
Suprapogonion or Protruberance Menti (Pm):

A point on the superior aspect of the
symphysis.
This was taken as it was located at the stress
centre (Ricketts), is the site of reversal lines
(Enlow), and is a stable unchanging point as
seen by implant studies (Bjork).
S premkumar , craniofacial growth-199 40

Dc: Point at the bisection of the condyle neck
as high as visible in the cephalogram below the
fossa.
Now by joining Dc to Xi and Xi to Pm a

repeatable condyle and corpus axis could be
made. And by studying the changes in the
mandible in relation to these axis the growth
could be predicted.
41
Dc R3
R1
R2
Xi
R4
42
Pm
By studying the mandibular growth on these axis
it was found that the bending of the mandible
occurred in an orderly fashion, with greater the
magnitude of growth, greater was the bending.
Now the next task was to make an arc to predict
this growth.
Point Pm, Xi, Dc were used to depict the
mandibular core, and the prediction of the
mandibular size and shape at five years interval
was done.
43
The current arcial prediction of Ricketts was reached in
three steps
1. An arc was made passing through these three points. But
it was found that the increase in size could be produced
but not increase in curvature. The Pm point was taken as
constant.
2. A second arc was made using the tip of the coronoid
process, anterior border of the ramus at the deepest point
(R1) and Pm. Using this it was found that the mandible
would bend too much.
44
3. So it was thought that the actual arc must lie in
between these two.
So a point in between Xi and R1 was selected.
An arc was made with a radius from this point to Pm.
But it was found that it still causes increased bending of

the mandible, also the mandible kept increasing in
size causing a spiral shaped arc.

It was thought that perhaps the stress lines of the
mandible would reveal its hidden secrets. An 850
year old mandible given to Ricketts by the late
William downs revealed the secret.
In the medial aspect a Y
shaped bony prominence was seen at the superior
aspect of the mylohyoid ridge, also above this point a
small nutritive canal was seen.

46
Experimentally 2 new points (Eva and TR) were
located geometrically.
Pt. Eva : This point lies just over the forking
of the stress lines and is made by bisecting Xi
to R3 point and a parallel point (RR or Ramus
Reference) is selected on the anterior border
of the ramus. RR point is connected to point
R3 at the lower border of the sigmoid notch.
This line is crossed by a second line selected
from a point midway of the base of the
coronoid process to the Xi point. The crossing
of these two lines is where the point Eva lies.
47
Point TR (True Radius): This is a point which
is at an equal distance from points Eva and
Pm.
Point Mu: the point of intersection of the arc
with the border of the sigmoid notch.
An arc drawn from the TR point through

the Pm and Eva points shows the direction
of growth of the mandible.

48
Construction of the Growth Arc
R3 Mu
EVA
RR
TR
Xi
Pm
49
Having become satisfied with this arc as a tool for
prediction the next problem lay in the amount of
growth to forecast on the arc.
From point Mu the mandible is grown out on the arc
at the sigmoid notch about 2.5mm/yr.
The coronoid and condylar process grow upward and
outward.

The short and small condyles were found not to
grow and good well-formed condylar heads were
found to grow by 0.4 mm and average condyles 0.2
mm/year.
Growth increment for coronoid came to be 0.8
mm/year.
To determine the drift of the gonial angle on the
arc, no further addition is given in females, in males
0.2mm/year are given on the border of mandible
from the arc.
51
In the series of the steps in forecasting of the
mandible growth. Art work for normal contours is
employed as connections are made from the
coronoid process to point RR on the coronoid crest.
The oblique ridge shows apposition of about
0.4mm/year.

Implications of Arcial Growth
Prediction
• It appears that the symphysis rotates essentially during
growth from a horizontal to a more vertical inclination.
• It explains why the mandible plane changes extensively
in some individual and not in others.
• It explains why good dentures may become
progressively more crowded in long tapered faces and
sometimes even in normal faces.
• It suggests a reason why mandible anchorage is risky in
retrognathic faces because less space is available for
molar eruption due to a more vertical eruption in that
type than prognathic types.
53
• S premkumar , craniofacial growth-200
• It explains how the early ankylosis of a lower molar
tooth terminates with the tooth located at the lower
border of mandible, the mandibular arc simply
continues and this tooth becomes trapped with in the
cortical bone.
• It shows why positioning of the roots of the lower first
molar to the buccal, or locking them under cortical
bone, will prevent upward and, therefore, forward
eruption of the whole lower dental arch thereby
enhancing anchorage of the lower arch.
• S premkumar , craniofacial growth-200 54
Drawbacks of Arcial Gowth
Predictions
• It relies heavily on the operator’s skill in tracing the

cephalogram. Minor tracing errors could produce a
wrong prediction.
• Since the growth increments constants are mainly

derived from western population it is to be found out
if these constants are applicable to Indian subjects.
• S premkumar , craniofacial growth-200 55

•Mitchell and Jordan in their study to evaluate
Ricketts prediction method concluded that Ricketts
uses the patients chronologic age rather than the
skeletal age since he requests no hand –wrist film.
Since average growth increments are added to the
age, if the patients has completed growth or if he is
a growth spurt or lag phase, it will alter the results;
particularly if the time interval is short and the
patients is near maturity. (Ricketts presumes that
girls are grown to 14.5 years and boys to 19 years)

Coenrad. F.A moorrees et al
The mesh diagram is composed of a grid of rectangular scaled on

the pt’s upper facial height and devlopment.
 Morrees, CFA,Lebret L.the mash diagram and cephalometrics, S premkumar ,

craniofacial growth-201
The face is inscribed in a coordinate system consisting of 24
rectangles.
 S premkumar , craniofacial growth-201

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
Shape of mesh rectangle is determined by shape of the core
rectangle- represents the ratio between face depth and upper facial
height.

The change in position of each landmark at a perticular
age period(8-16yrs)is calculated as a percentage shift.
There is usually an incrise in overall size of patients
face;every landmarks undergoes growth/ change by a
certain extent with large inter-individual difference but
the facial type remains constant through 8 to 16 years.
Retrognathic mandible have posterior distoration of
rectangles; while high mandibular angles will have
downward displacement of the mash.
Developed by L.E. Johnston in 1975
 Based on the addition of mean increments of growth by
direct superimposition on a printed grid
Johnston designed sex specific templates by utilizing the
numerical standards obtained from the publications of Riolo et
al who used the cephalograms from university of Michigan.
Johnston’s template uses normative standard rather than idiel
standards which can be difficult for comparison while using for
children with altered growth .
 LE johnston.A simplified approch to pridiction; ajo 1975;253-57, S premkumar , craniofacial growth-202
The land marks used are :
S–N plane as a
reference plane
Point A
Point B
Point M
Posterior Nasal Spine
Tip of nose
 S premkumar , craniofacial growth-

202
To discribe template in a very
simpleway,they are age
specific.the use of values like
angles in degrees and
millimeteres linear
measurement is
unwarranted.
Each sex specific template
has oriented set of rulers
which are graded in
years,from 6-16years thus
they are age-specific.
-In first step ,the overall growth of skeleton is assessed
which is followed by the second step where isolated
areas of growth discrepancy are assessed.
-the johnston’s forecast grid shows the average
increments of growth per year for the points
nasion,a,b,nose and posterior nsal spine.it also give a
method of constructing pogonion, given a B point.
There is no individualization in this method , in that ,all
the patients will grow the same amount horizontally
and vertically irrespective of their facial patterns.this
method is accurate to about 70%. S
premkumar , craniofacial growth-203
Uses of template:
The relative age of skeleton is measured
Angles of cranial base ,gonial angle ,mandibular,occlusal
plane angles ,and palatal plane angle can be assessed and
vertical growth of the face is assessed.
Position of upper and lower incisors can be directly
seen ,the differentiation between proclination and
forwardly positioned incisors is easily made out.
Malocclusion is the integration of small deviation of all
parts of face.deviation from normal of every part can be
individually assessed.
Presented by James. T. Todd & Leonard Mark
The model is derived from the basic assumptions about
the long range effects of gravitational pressure on the
remodelling of bone and expressed formally on a single
geometric transformation.
The validity of the model is examined empirically using
data for 20 individuals from the Denver Child research
Council, longitudnal growth study.
 “The overall pattern of craniofacial growth is
primarily controlled by biomechanical influences.” This
is known as Wolf ‘s law.
 todd jt, mark ls. Issues relatedto the pridiction of craniofacial growth.ajo 1981;63-80,- S
The wolf law’s states- The
bone elements place
themselves in the
direction of functional
pressure and increase or
decrease their mass to
reflect the amount of
functional pressure.
 - S premkumar , craniofacial growth-

204
Todd & mark conclude that the mathematical transformation was
shown to make reasonably accurate prediction over a span of 10-15 yrs.
 REVISED CARDIOIDAL STRAIN

 R’ = R +bP
 b =increasing function of time,
 The overall pattern of change can easily be expressed in polar coordinates with a
single pair of equations.

Gravity influences the
biomechanics of growth
which is exerted on every
point with in the
craniofacial complex and
it also provides a counter
force for the action of
muscles.
 - S premkumar , craniofacial growth-

204
Heads are not perfectly spherical
There are other sources of stress operating on craniofacial
complex besides the force gravity
The orientation of the head with respect to the gravity does
not remain fixed.
The predictions that were made were not accurate
because of-mechanical errorsOral habits Nevertheless
they very closely predict the actual outcome of growth……

The term VTO which stands for Visualized Treatment
Objective was first coined by Holdaway but used
extensively by Dr. Ricketts.
The term visual (or visualized ) treatment objective (VTO)
was coined to communicate the planning of treatment for
any orthodontic problem.
A Visual Treatment Objective (VTO) is like a blueprint
used in building a house. 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.
. The treatment plan should take advantage of the beneficial
aspects of growth and minimize any undesirable effects of growth,
if possible.
The Visual Treatment Objective permits the development of
alternative treatment plans. After setting up the teeth ideally
within the anticipated or "grown" facial pattern, the orthodontist
must decide how far he must go with mechanics and orthopedics
to achieve his goals, whether it is possible to achieve them, and
what the alternatives are.
Once treatment has begun, there is a continuing need for a visual
goal against which treatment progress can be measured and
monitored. By superimposing a progress tracing between the
original tracing and the forecast goal, the orthodontist may
evaluate progress along a definitely prescribed route. - S premkumar , craniofacial
growth-205
The VTO forecast is valuable for the orthodontist's self-
improvement in that it permits him to set his goals in
advance and compare them with the results at the end of
treatment. Identification of the discrepancies between
goals and results provide him with an objective picture of
the areas in which his treatment could be improved.

A step-by-step procedure to construct a VTO for a in the
following sequence (putting in average growth for an
estimated two-year period of active treatment and the
objectives that we wish to achieve with our mechanics):
1. the cranial base prediction
2. the mandibular growth prediction
3. the maxillary growth prediction
4. the occlusal plane position
5. the location of the dentition
6. the soft tissue of the face
VTO — Cranial Base Prediction
Place the tracing paper over the original tracing and starting at
CC point, follow these steps to construct the cranial base:
1. Trace the Basion-Nasion Plane. Put a mark at point CC.
2. Grow Nasion 1mm/year (average normal growth) for 2 years
(estimated treatment time).
3. Grow Basion 1mm/year (average normal growth) for 2 years
(estimated treatment time).
4. Slide tracing back so Nasions coincide and trace Nasion area.
5. Slide tracing forward so Basions coincide and trace Basion
area.
VTO — Mandibular Growth Prediction — Rotation
The construction of the mandible and its new position
start with the rotation of the mandible. The mandible
rotates open or closed from the effects of the mechanics
used and the facial pattern present. The average such
effect on mandibular rotation is as follows:-


Mechanics
1. Convexity Reduction— Facial Axis opens 1°/5mm.
2. Molar Correction — Facial Axis opens 1°/3mm.
3. Overbite Correction — Facial Axis opens 1°/4mm.
4. Crossbite Correction— Facial Axis opens 1°-1½°. Recovers half the
distance
5. Facial Pattern— Facial Axis opens 1°/1 S.D. dolichofacial; 1°
closing effect against mechanics if brachyfacial.
In constructing the VTO, these factors must be taken into
consideration in deciding what can be expected to happen to the
facial axis.

6. Superimpose at Basion along the Basion-Nasion plane. Rotate
"up" at Nasion to open the bite and "down" at Nasion to close
the bite using point DC as the fulcrum. This rotation depends
on anticipated treatment effects (whether treatment can be
expected to open or close the facial axis).
7. Trace Condylar Axis, Coronoid Process, and Condyle.
8. On condylar axis, make mark 1mm per year down from point
DC.
9. Slide mark up to the Basion-Nasion plane along the condylar
axis. Extend the condylar axis to XI point, locating a new XI
point.

10. With old and new XI points coinciding, trace corpus axis,
extending it 2mm per year forward of old PM point. (PM
moves forward 2mm/year in normal growth.)
11. Draw posterior border of the ramus and lower border of the
mandible.
12. Slide back along the corpus axis superimposing at new and
old PM. Trace the symphysis and draw in mandibular plane.
13. Construct the facial plane from NA to PO.
14. Construct facial axis from CC to GN (where facial plane and
mandibular plane cross).

To locate the "new" maxilla within the face, superimpose at
Nasion along the facial plane and divide the distance between
"original" and "new" Mentons into thirds by drawing two marks.
These are the maximum ranges of Point A change with various
mechanics:

Point A is altered as a result of growth and mechanics.
 Point A can be altered distally with treatment. Place
according to orthopedic problem and treatment objectives.
For each mm of distal movement, Point A will drop ½mm.

Superimpose mark 2 on original Menton and facial
plane, then parallel mandibular planes rotating at
Menton. Construct occlusal plane .

The lower incisor is placed in relationship to the symphysis of
the mandible, the occlusal plane and the APO plane. The arch
length requirements and realistic results dictate its location.
 For this exercise, superimpose on the corpus axis at PM. Place
a dot representing the tip of the lower incisor in the ideal
position to the new occlusal plane, which is 1 mm above the
occlusal plane and 1 mm ahead of the APO plane.
 Aligning over the original incisor outline or using a template,
draw in the lower incisor in the final position as required by
arch length. The angle is 22° at +1mm to the APo plane and + 1
mm to occlusal plane, but the angle increases 2° with each mm
of forward compromise. - S premkumar , craniofacial growth-
211
Without treatment, the lower molar will erupt directly upward to the
new occlusal plane. With treatment, 1mm of molar movement equals
2mm of arch length. We moved the lower incisor forward 2mm in this
case. There was also 4mm of leeway space. Therefore, the following
calculation allows us to move the lower molar forward 4mm on each
side:
lower incisor
forward 2mm = +4mm arch length
leeway space = +4mm arch length
 +8mm arch length
(lower molar forward 4mm on each side)
 Superimpose the lower molar on the new occlusal plane at the
molar , slide forward 4mm, upright molar and draw it in. -S
 Trace the upper molar in good Class I position to the
lower molar. Use the old molar as a template.
- S premkumar , craniofacial growth-211

 Keeping the occlusal planes parallel, superimpose mark 1
(posterior mark) on the tip of the original incisor (slide forward
2/3rds).
Trace upper lip connecting with soft tissue Point A.

Upper incisor is drawn on good overjet and overbite
(2.5mm)relation to lower incisor. Interincisal angle of 130 degree
is maintained.
Soft tissue:
Bridge of the nose: superimpose nasion along facial plane and
palatal plane.the pridiction is moved back 1mm/year along
the palatal plane.
Upper lip:the difference in position between the old and new
upper incisors is the correction.the distance is divided into
three parts and mark 1,2,3.soft tissue thickness of the upper
lip dose not change,so by superimposing old and new point
A,soft tissue point A is traced.- S premkumar , craniofacial growth-212
In constructing the lower lip, we bisect the overjet and
overbite of the original tracing and mark the point. We
then bisect the overjet and overbite of the VTO and mark
the point.

Superimpose interincisal
points, keeping occlusal
planes parallel.Trace lower
lip and soft tissue B point.
The soft tissue below the
lower lip remains in the
same relation to point B as
in the original tracing. Soft
tissue point B drops down
as the lower lip
recontours.
Holdaway’s vto has12 sequential step.the plane of reference in
SN plane.
Step I (Fig. 1, B and C)
The first step is to place a clean sheet of tracing material over
the original tracing, copying (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.
Holdaway RA. A soft tissue cephalometric analysis and its u e in orthodontic treatment planning. Am
J Orthod 1983;84:1-28
Holdaway RA. A soft tissue cephalometric analysis and its u e in orthodontic treatment planning. Am
J Orthod 1984; - S premkumar , craniofacial growth-206
Step II (Fig. 2)
First, superimpose on the SN line and move the tracing to show
expected growth (0.66 to 0.75 mm per year unless a pubertal
growth spurt is expected from wrist plate studies). Second, copy
the outline of sella. Third, either copy or change the facial axis
(Ricketts' foramen rotundum to gnathion) as you expect it to
behave according to the facial type of the patient and the
treatment mechanics that you customarily use in such cases.
(The facial axis line is usually opened about 1°, but it may even
be closed if one is confident that mandibular growth of the
forward rotational type will occur during treatment.)

Step III (Fig. 3, A and B)
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, except in accelerated growth-
spurt periods. (Note: since the facial axis may be opened
or closed as judged from the facial pattern, the SN lines
will not be parallel if we have changed the facial axis.)

Second, copy the anterior
portion of the mandible,
including the symphysis
and anterior half of the
lower border. Also draw the
soft-tissue chin, eliminating
any hypertonicity evident in
the mentalis area. (Slightly
round out this area.)
Third, copy the Downs
mandibular plane.
Step IV (Fig. 4, A and B)
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,
and the ramus.
Finally, superimpose on sella
to complete the condyle-
Step V (Fig. 5, A and B)
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 mandible. (Note: This
may be varied as you
perceive the facial type to be
short or long.)
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.
Step VI (Fig. 6, A and B)
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.
Step VII
Note: When there is a uniform distribution of the soft tissues
in the profile and the upper lip is of average length, and where
the cant of the H line is not adversely affected by excessive
facial convexity or concavity, the depth of the superior sulcus
measured to the H line is most ideal at 5 mm. A range of 3 to 7
mm allows one to maintain type with short and/or thin lips
and long and/or thick lips. Additional refinement of the
technique, which covers all of the above, is gained by use of
the vertical line from Frankfort plane to the vermilion border
of the upper lip, which is ideal at 3 mm with a range from 1 to 4
mm.
To find the point along the lower border of the nose outline
at which the new H line will intersect it, both perspectives
are used in the exceptional cases just mentioned.
First, line up a straight-edge tangent to the chin and angle it
back to a point where there is a 3 to 3.5 mm measurement to
the superior sulcus outline of the original tracing and draw
the H line to this. As one redrapes the superior sulcus area
to the new tip of the upper lip point, a 5 mm superior sulcus
depth develops almost automatically. If you have trouble
with this, the use of the Jacobson-Sadowsky lip-contour
template is recommended.
Step VIII
First, with the exceptions noted earlier, lip strain that shows up
as excessive upper lip taper is our first consideration. In the
case shown in Fig. 9, the basic lip thickness measurement was
15 mm and the thickness at the vermilion border was 10 mm.
One millimeter of taper is normal, leaving a lip strain factor of 4
mm.
Next we are concerned with 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. In the
present case this also amounts to 4 mm.

The third consideration is maxillary incisor "rebound." When
the maxillary incisors have been retracted 5 mm or more and
the case has been slightly overtreated to a near edge-to-edge
incisor overbite and overjet relationship, we can expect about
1.5 mm relapse tendency. Obviously, there will be no tendency
to move labially in those cases in which the upper incisor is not
retracted or in those cases, such as anterior crossbites and/or
Class III cases, in which the maxillary incisors have been
expanded labially. Here the incisor retraction is significant, and
we will use 1.5 mm for incisor rebound. In this particular
patient, then, the calculations would be as follows: (1)
Elimination of lip strain, 4 mm. (2) Upper lip change, 4 mm. (3)
Maxillary incisor rebound, 1.5 mm.
Finally, with the tracing
still superimposed on line
NA and the maxilla, place
the maxillary incisor
template, taking
cognizance of the amount
that it is to be repositioned
(9.5 mm in this case), its
axial inclination, and the
relationship of the incisal
edge to the occlusal plane,
and draw the tooth.
Step IX: First, superimpose
the VTO on the
mandibular plane and
symphysis. Using the
template, reposition the
lower incisor to be in ideal
retention occlusion with
the maxillary incisor, using
the occlusal plane as a
guide and by tipping the
tooth about the infirior
sulcus area.
Second, with the tracing in this same position, measure
the amount of lingual movement of the lower incisors.
Twice this amount is the arch length loss due to lower
incisor (uprighting) lingual tipping or gain from labial
tipping when indicated. This loss of arch length is now
combined with the arch length discrepancy determined
from the model to obtain the total arch length
discrepancy. In this case, the calculations would be (1)
arch length loss from reposition, 2 ´ 4 = 8 mm; (2)
model discrepancy, 2 mm; (3) total discrepancy, 10 mm.
Step X (Fig. 11, A and B)
With the tracing superimposed on the mandibular plane and
symphysis and using the occlusal plane as a vertical guide,
draw the lower molar where it must be to eliminate
remaining space if extractions must be part of the treatment
plan. In the case shown in Fig. 11, each lower molar must be
moved forward 2.5 mm.

Step XI
First, using the occlusal plane and the lower first molar as a
guide, with a tooth template, position the upper first molar
in ideal Class I occlusion with the lower first molar.
Second, superimposing tracings on the original NA line and
the outline of the maxilla, evaluate the extent of upper molar
movement. In cases that worked out as lower arch
nonextraction cases, one may still need to think about other
extraction alternatives in the upper arch, such as upper
second through stripping and polishing than to extract at all.
molars when good third molar buds are developing or upper
first premolars. - S premkumar , craniofacial growth-208
Step XII
The position of point a is assessed by the best fit of maxilla.
Change in position will be drastic for bodily movement of
upper incisor and orthopedic appliances.the change in
position of point A is analyzed and drawn.

 help to plan for retention period,thus ensuring stability of the
result
VTO is helpful in visualizing, treatment objectives and prioritized
the objectives, keeping in mind the growth pattern of patient.
Also help the clinician to intercept and correct the malocclusion.
Response to a particular treatment can be predicted provide the
patient continues in the same growth direction.
Is also a tool for orthodontic treatment planning but without
forcing any particular treatment procedure.
 The overall changes in the size and
relationship of the human face in 20 year period
From childhood to adulthood , In general difficult
to accurately predict for an individual. This is
because the changes are under the influence of
the combined and complex effects of the hard to
predict, genomic, and environmental factors.
 The situation is rendered even more complex
because we are using a two dimensional image to
predict a three dimensional multifunctional
object.

 Because of the uncertainties involved in
predicting growth ,orthodontic treatment
becomes a game of strategy against nature.
 However The Goal of growth prediction is to
reduce the clinicians ignorance of the future.
The best can be done ,is to base the
treatment planning in the existing facial pattern
allowing for average growth changes for the group
to which patient belongs. With the knowledge
and better understanding of growth prediction,
we can be skilled and better equipped to
intervene during growth process.

Growth Prediction

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Growth Prediction

Uploaded by

Copyright:

Available Formats

PRESENTED BY : DR.

 - S premkumar craniofacial growth-194

 - S premkumar , craniofacial growth-194

- Sridher premkumar craniofacial growth-pagno-194

 - Sridhar premkumar craniofacial growth-pag no-195

William J Hirschfeld AJO Vol 60 no 5 1971- S premkumar , craniofacial growth-195

 A theoretical model is constructed mathematically, and a test for

William J Hirschfeld AJO Vol 60 no 5 1971- S premkumar , craniofacial growth-195

William J Hirschfeld AJO Vol 60 no 5 1971- S premkumar , craniofacial growth-195

4. Time series methods- 2 types

William J Hirschfeld AJO Vol 60 no 5 1971- S premkumar , craniofacial growth-195

Epiphysis narrower than

Stage 1: The epiphysis and diaphysis of the proximal

Stage 4: This stage marked the beginning of the

Stage 6: This stage signified the end of the pubertal

Stage 8: This stage showed fusion between the

Stage 9: This was the last stage and it signified the

The first seven vertebrae in the spinal column constitute the

Hassel, B. and Farman, A.: Skeletal maturation evaluation using

Hassel, B. and Farman, A.: Skeletal maturation evaluation

 - S premkumar , craniofacial growth-196

 - S premkumar , craniofacial growth-196

 - S premkumar , craniofacial growth-196

 - S premkumar , craniofacial growth-196

- S premkumar , craniofacial growth-197

- S premkumar , craniofacial growth-197

- S premkumar , craniofacial growth-197

Suprapogonion or Protruberance Menti (Pm):

S premkumar , craniofacial growth-199 40

Now by joining Dc to Xi and Xi to Pm a

But it was found that it still causes increased bending of

S premkumar , craniofacial growth-200 45

S premkumar , craniofacial growth-200

An arc drawn from the TR point through

S premkumar , craniofacial growth-200

S premkumar , craniofacial growth-200 50

S premkumar , craniofacial growth-200

S premkumar , craniofacial growth-200 52

• It relies heavily on the operator’s skill in tracing the

• Since the growth increments constants are mainly

• S premkumar , craniofacial growth-200 55

S premkumar , craniofacial growth-200 56

The mesh diagram is composed of a grid of rectangular scaled on

 Morrees, CFA,Lebret L.the mash diagram and cephalometrics, S premkumar ,

 S premkumar , craniofacial growth-201

 S premkumar , craniofacial growth-201

 S premkumar , craniofacial growth-

 - S premkumar , craniofacial growth-

 REVISED CARDIOIDAL STRAIN

- S premkumar , craniofacial growth-204

 - S premkumar , craniofacial growth-

 - S premkumar , craniofacial growth-204

 - S premkumar , craniofacial growth-205

 S premkumar , craniofacial growth-210

 - S premkumar , craniofacial growth-210

 - S premkumar , craniofacial growth-210

 - S premkumar , craniofacial growth-211

 - S premkumar , craniofacial growth-211

- S premkumar , craniofacial growth-211

 - S premkumar , craniofacial growth-211

- S premkumar , craniofacial growth-211

- S premkumar , craniofacial growth-212

- S premkumar , craniofacial growth-212