Growth Prediction in

Orthodontics
Dr. Ramy Ishaq
BDS, MSc, PhD Orthodontics Cairo University
Morth RCSED UK
Chapter Outline
• Introduction
• Need for Growth Prediction
• Methods of Prediction
• Hunterian concept
• Gnomonic growth
• Arcial growth by Ricketts
• Moorrees mesh
• Johnson’s template
• Todd’s equation
• Visualized treatment objective (Holdaway)
• Visualized treatment objective (Ricketts)
• Morphometrics methods
Introduction
• Every child extensively differs in the rate, amount and direction of
growth and in the expression of the extent of his malocclusion
• Every child has a unique pattern of development.
• To achieve a successful orthodontic or surgical result, the
orthodontist must have some understanding of the patient’s future
facial growth potential.
• For this reason, there has been a long-standing interest in maxillary
and mandibular growth prediction.
• In 1938, Brodie at al. found that there was a definite correlation
between success in treatment and good facial growth
Before and after treatment
• Before beginning treatment, it would be advantageous if the
orthodontist could reliably estimate how future changes in the
vertical or the horizontal relationships of the jaws are related to the
incremental skeletal increases and the timing of growth. It is also
important to evaluate whether posttreatment growth will affect
factors related to retention care.
 • Many authors agree that it is
important to be able to accurately
growth can predict the direction, timing,
work magnitude of the facial changes that
occur with growth in an individual
with (Bishara, 2000; Ricketts, 1957;
or Turchetta et al., 2007), therefore
reducing the difficulty in treatment
against planning, especially since growth can
work with or against the orthodontist.
the
orthodontist.
• Dentofacial orthopedics is concerned with attempts to alter the size
or direction or location of growth of some components of the
craniofacial complex.
• Growth prediction helps in predicting to a certain extent the response
to treatment and the growth changes.
Definition of Growth prediction
• Growth prediction can be defined as the forecast of growth related
changes with the objective of predicting the direction and amount of
the growth of the maxilla and particularly the mandible as well as the
timing of the adolescent growth period.
Need for Growth Prediction
• Growth prediction helps the clinician to intercept and correct the
malocclusion.
• Growth prediction can be used as patient education aids.
• Growth prediction (VTO) is helpful in 'visualizing' the treatment
objectives and prioritizes the objectives, keeping in mind the growth
pattern of the patient.
Need for Growth Prediction
• Growth prediction is a tool for orthodontic treatment planning but
without forcing any particular treatment procedure.
• Response to a particular treatment can be predicted, provided the
patient continues in the same growth direction.
• If the patient continues to be in the growth phase even after
treatment, growth following the conclusion of treatment can be
predicted to plan for retention period, thus ensuring stability of the
results.
Methods of Prediction

Prediction methods generally

followed in science are of 4 types.

Theoretical Regression Experiential Time series

Methods of Prediction It would be
surprising
to find out that
Its easier now to classify growth
most of the
prediction methods into:
prediction methods,
except
a few, concentrate
Cephalometric methods.
on the prediction of
the growth of
Non-cephalometric mandible more than
methods. on any other part of
the face.
Cephalometric growth prediction methods
can further be classified as:

Template method

Other cephalometric
methods like VTOs
Template method

The • Unisex Bolton template from ages 1 to 18

commonly years
• Burlington template, three configurations
used • Original Burlington or its Michigan
templates modification
• Johnston’s template analysis.
are:
Non-cephalometric methods
• Growth prediction methods can be used as a short-term forecast to
plan strategy and anchorage and long-term forecast to give evaluation
of final results and to analyse aesthetics and facial balance
Hunterian Concept
• John Hunter hypothesized a
linear model for mandibular
growth where there is
resorption in the anterior border
of ramus and deposition in the
posterior border, thus
lengthening the mandible.
• This meant no rotation with
growth
Gnomonic Growth and the Logarithmic Spiral
• The growth of the shell of a sea
mollusk is along a logarithmic
spiral, which is in perfect
geometrical proportion.
• Thompson called the growth
along the spiral as "gnomonic
growth".
Logarithmic or equiangular spiral
• The important feature of this
spiral is
• the movement of a point away
from the pole along the radius
vector
• the velocity increasing with the
distance from the pole. The
angles formed with the pole will
be equal.
Stages of development with a common path
along the inferior alveolar nerve
Mandibles at 4 different stages of
development were included in the study
• Fetal
• Deciduous
• mixed dentition
• adult mandible.

The X-rays were superimposed and it was

found that
• the path of inferior alveolar nerve was along a
logarithmic curve and that the four curves of all
the mandibles were superimposed
 (A) Location of
foramen ovale,
mandibular
foramen, and
mental foramen in
the fetal,
deciduous, mixed
and adult skulls;
 (B) The
foramina are
aligned
perfectly on
a logarithmic
spiral—a
single curve
Arcial Growth of Mandible
• Ricketts described a pattern of arcial growth of mandible.
• The advantage of Ricketts arcial growth pattern was that an arc of
growth can be constructed for every individual depending on the
length of the core of the mandible.
Principle of Arcial Growth
• The normal human mandible grows by supero-anterior
• (vertical) apposition at the ramus on a curve or arch 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).
Landmarks
• Ricketts, in order to locate a central core which is immune
• to surface deposition and resorption, introduced the two
• important landmarks, his greatest achievement on the
• mandibular ramus, the Xi point and Eva.
Xi point: It
represents
the
geometric
center of
ramus
Other points and lines
Eva
DC point
PM point or Suprapogonion

MU point (Murray)

Tr/True radius

DC-Xi line

Xi-PM line
Curve A
• Curve A was through DC-Xi and
PM .
• If mandibular growth had been
along this curve, then it would
open the gonial angle too wide,
which normally does not
happen.
• The resulting mandible will be
too obtuse this way.
Curve B
• This curve was constructed
passing from the tip of coronoid
process through the anterior
border of ramus, and through
Pm
• The mandibular growth along
this curve would be bent too
much.
Curve C Arc of Mandible:
• The final curve was between
coronoid and condylar processes
through Eva-PM.
• When annual increments of
mandibular growth [about 2.5
mm] added and mandibular
growth predicted along this
curve, it was found to correlate
very well with the final
composite of the computer
analysis
Moorrees Mesh
• Moorrees constructed a template in the form of a mesh which was
used to superimpose growth changes in serial LCR
Construction
• 24 equal sized rectangles
• core rectangle, the size of which
varies for every patient and this
determines the size of all the
other rectangles.
 extracranial vertical lines

Reference vertical parallel to extracranial vertical is drawn

through nasion
lines that
forms the 2 horizontal lines are drawn perpendicular to
the extracranial vertical, one through nasion
core rectangle and the other through ANS.

The last vertical is drawn parallel to vertical

through nasion at a distance of NS from nasion.
 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
Grid Johnston's grid though appearing very complex,
is actually extremely simple when used.
Johnston's template uses normative standard
[by including children with malocclusion] rather
than ideal standards which can be difficult for
comparison while using for children with altered
growth.
 Forecast grid
developed by
Johnston
The tracing of the
landmarks is
superimposed along S-
N and registered at S.
The points are then
advanced downwards
1 unit per year
Todd’s Equation
• The disadvantages of ordinary prediction methods are:
• They are all in the form one of linear coordinate system, either
rectangle or grid system, it cannot predict radial growth, the angular
coordinate of each landmark remains a constant.
• There are many frames of reference used to describe growth. Every
frame of reference can give a description of growth changes, for
example, SN superimposition is markedly different from FH plane
superimposition.
Todd’s Equation
• Todd considered that biomechanical influences on growth and the
foremost influence is that of the force of gravity.
Visualized Treatment Objective (VTO)
• Visualized Treatment Objective was coined by Holdaway.
• According to Proffit, A VTO is a cephalometric tracing representing
the changes that are expected during treatment ().
• Ricketts defines VTO as a visual plan to forecast the normal growth of
the patient and anticipated influences of treatment