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Orthodontic Tooth Movement: The Dental VTO: An Analysis of
Orthodontic Tooth Movement: The Dental VTO: An Analysis of
Method
The dental VTO consists of three charts:
Chart 1 records the initial midline and first
molar positions with the mandible in centric rela-
tion.
Chart 2 measures the lower arch discrepan-
cy, similarly to the Steiner analysis.1 The four
primary factors in each case are:
Fig. 1 Curve of Spee measured as deepest point
1. Space required for relief of crowding, mea- along line extending from distal cusps of second
sured from canine to midline and from first molars to incisal edges of central incisors on each
molar to midline on each side. side.
Midline
Molars
Curve of Spee
C of S -1 -1
Midline M +1 -1
3x3
Total 3x3 -5 -5
6x6
T
6x6 -5 -5
Lower Arch Discrepancy
Midline
Cuspids
1st Molars
R MIDLINE-MOLAR POSITION L
4 3.5
Chart 1
3x3 -3 -1
per side in the mandibular arch and 2.3mm per C
side in the maxillary arch (Fig. 2). 6x6 -3 -1
The primary and secondary factors are
added together at the bottom of the chart to deter- P -2 -2
Case 1
A 12-year-old male presented with a Class left side, there was only 1mm of crowding, also
II skeletal pattern (Fig. 3). Vertically, he had a between the canine and the midline.
slightly high angle and a slightly long lower The curve of Spee was about 2mm at its
facial height. There were no crossbites, and the deepest point. Steiner suggested that leveling a
dentition was symmetrical in the transverse 2mm curve of Spee would advance the incisors
dimension. 1mm, thus requiring 1mm of space per side for
The patient’s dental relationships were the leveling process. We have found this rule of
recorded in centric relation (Chart 1). His molar thumb to be clinically accurate.
Fig. 3 Case 1. 12-year-old male with Class II skeletal pattern before treatment.
Because the lower midline was deviated be moved 2mm to close the remainder of the
1mm to the right, the midline correction would 7mm extraction spaces—also indicated with
require 1mm of space on the left side and provide arrows on the bottom of the chart. This demon-
1mm of space on the right. strated a need for moderate anchorage control in
The mandibular incisors were inclined for- the mandibular arch. A mandibular lingual arch,
ward (97° to the mandibular plane) and were for example, could be considered during the first
6mm in front of the APo line. Without extrac- 3mm of canine retraction.
tions, the incisors would either remain in this 4. The mandibular midline needed to be moved
position or, more likely, be advanced farther. 1mm to the right, as shown by the arrow on the
With extractions, the incisors could be retracted. bottom of the chart.
Therefore, the decision was made to extract the 5. There are four possible methods of Class II
four first premolars and retract the mandibular molar correction in the growing patient:
incisors 2mm. a. Mesial movement of the mandibular first
The space-gaining procedures of interprox- molars (in this case, 2mm per side).
imal reduction, molar uprighting, and buccal b. Distal movement of the maxillary first
uprighting of posterior teeth were not needed in molars. This is difficult in the presence of devel-
this case and were therefore not recorded in oping maxillary second and third molars, but it
Chart 2. There was no leeway or “E” space avail- can be achieved. Superimposition of beginning
able, since no primary teeth were present. headfilms with progress or final headfilms will
Anticipated treatment changes were record- inevitably show downward and forward move-
ed in Chart 3 using the following process: ment of the maxillary first molars, due to the
growth of the entire facial complex. Although
this rotation may lead some clinicians to contend
ANTICIPATED TREATMENT CHANGE that no distalization has occurred, it does not
R L mean there has been no dentoalveolar or skeletal
2 9 0 8.5 1.5
(7) (7)
change in the maxillary molar positions.
c. Limiting forward maxillary skeletal devel-
opment, or retracting the maxilla. Because such
(7) (7) changes are difficult to isolate, it is debatable
2 5 1 5 2
how much is skeletal (above the palatal plane)
and how much is dentoalveolar (below the
Chart 3 palatal plane). Nasion normally grows forward
about 1mm a year relative to sella, while A point
may be maintained or retracted relative to its
original position.
1. Extraction of the four first premolars pro- d. Forward mandibular rotation. This can
duced 7mm of space in each quadrant, since occur in two ways:
there was no crowding between the canines and 1) Mandibular growth. The direction of
first molars in either arch. This was indicated by overall facial growth is critical to the “expres-
writing “(7)” in each quadrant. sion” of mandibular growth. With more vertical
2. Because the total lower arch discrepancy patterns, there is less forward expression of
from canine to midline was 5mm per side, the mandibular growth and hence less interarch den-
mandibular canines needed to be retracted 5mm tal change. With less vertical facial growth,
into the extraction sites. This was recorded on the mandibular growth is expressed in a more for-
bottom of the chart, with arrows showing the ward direction, resulting in greater interarch den-
direction of movement. tal change.
3. The mandibular molars could therefore only 2) Limiting vertical maxillary develop-
ment. Although sizable claims have been made wires. Extraction sites were then closed with the
for this method, it is difficult to significantly rectangular archwires, using pull-coil springs
influence the normal vertical development of the from the first molars to archwire hooks between
facial complex. As with forward maxillary devel- the lateral incisors and cuspids. Class II elastics
opment, vertical development is hard to measure were used as little as possible, in conjunction
in isolation and therefore hard to categorize as with the headgear, to correct the anteroposterior
skeletal or dentoalveolar. Nevertheless, even a relationship. Detailing and finishing were carried
small limitation can greatly enhance a Class II out with .019" × .025" rectangular archwires.
correction. With only average cooperation, total treat-
6. In the present case, the molar relationship on ment time was 35 months (Fig. 4). The patient
the right side was 4mm Class II, and since 2mm wore a tooth positioner full-time for six weeks; a
could be corrected by mesial movement of the maxillary Hawley retainer was then worn full-
mandibular molar, an additional 2mm of correc- time for six months and at night only thereafter,
tion was required. On the left side, an additional while a fixed mandibular retainer was bonded.
1.5mm of correction was needed. These amounts Despite greater-than-average vertical
were recorded on the top of Chart 3 with distal development during treatment, the results were
arrows. within normal limits. The occlusion was correct-
A palatal bar and a combination high-pull ed from a Class II, division 1 to a Class I. The
and cervical-pull headgear were used to preserve maxillary incisors were retracted from 13mm in
maxillary anchorage in this case. If favorable front of NA to 4mm in front of NA, and their
mandibular growth occurred in any of the ways angulation to NA was reduced from 38° to 22°.
listed above, maxillary anchorage control could
be reduced or eliminated, allowing the maxillary
Case 2
molars to move more mesially. This could not
be predicted before treatment, however, and so A female patient age 8 years and 4 months
the numbers in Chart 3 represent the worst-case presented with a Class II skeletal pattern (Fig. 5).
scenario. Vertically, she was a low-angle patient with a
A functional appliance could also have normal lower facial height. There were no cross-
been considered before fixed appliance therapy. bites, and the transverse dimension was symmet-
A good response to the functional appliance rical.
might have reduced the amount of maxillary The patient’s molar relationship was
anchorage support needed later. Extractions 4.5mm Class II on the right side and 2.5mm
would still have been required after the function- Class II on the left (Chart 1). The dental midlines
al phase, assuming incisor retraction was still a
treatment objective.
7. Taking into account the 2mm distal move- R MIDLINE-MOLAR POSITION L
ment of the maxillary right molar and the 1.5mm 4.5 2.5
distal movement of the maxillary left molar, the
canines would have to be moved 9mm on the
right and 8.5mm on the left to close the 7mm
extraction spaces. This emphasizes the potential
benefits of favorable growth and a favorable
functional appliance response. Chart 1
Leveling and alignment were carried out
with an .022" edgewise appliance, beginning
with light twisted wires, and proceeding to round were properly aligned.
wires and finally to .019" × .025" rectangular The mandibular arch showed 2.5mm of
B C D
Fig. 4 Case 1. A. After four bicuspid extractions and 35 months of treatment. B. Superimposition on SN at S.
C. Superimposition on palatal plane and palatal curvature. D. Superimposition on mandibular symphysis and
mandibular plane.
Fig. 5 Case 2. 8-year-old female with Class II skeletal pattern before treatment.
B C D
Fig. 6 Case 2. A. After two phases of nonextraction treatment. B. Superimposition on SN at S.
C. Superimposition on palatal plane and palatal curvature. D. Superimposition on mandibular symphysis and
mandibular plane.
C of S
side, the entire 2.5mm Class II correction could
-.5 -.5
by achieved by moving the mandibular first
M 0 0 molar forward.
This patient underwent an eight-month first
3x3 +1 +1 phase of treatment with maxillary and mandibu-
T lar 2 × 4 appliances, nighttime headgear, and
6x6 +2.5 +2.5 daytime Class II elastics. The second phase,
begun at age 12, involved mainly tooth align-
Leeway Space +1.5 +1.5 ment for final correction, using full fixed appli-
Chart 2 ances in conjunction with headgear and elastics.
This phase was completed in 20 months (Fig. 6).
Retainers were a maxillary removable
lar arch, due to the presence of the primary wraparound appliance and a mandibular fixed 4
canines and the first and second molars, was × 4 appliance.
1.5mm per side. The loss of these teeth would
leave a total of only 1mm of crowding per side in
the mandibular arch. Conclusion
Because the mandibular incisors were 4mm We have used the dental VTO in clinical
behind the APo line and at 87° to the mandibular practice for several years, and we have found this
plane, the decision was made to advance them simple analysis to be most helpful as a diagnos-
4mm, providing 4mm of space per side. The tic and treatment-planning aid and as a reference
curve of Spee was about 1mm deep bilaterally, throughout treatment. It is also useful in making
requiring .5mm of space per side for leveling. No the extraction/nonextraction decision.
midline correction was needed. There have been few cases in which the
Adding all these factors together, there was analysis did not work. It has even been applied in
a total lower arch discrepancy of +1mm per side some mutilated-dentition cases, and in patients
from canine to midline and +2.5mm per side where second molars were substituted for first
from first molar to midline. With this space molars, or premolars for canines.
available, the mandibular canines could be
advanced 1mm per side, and the molars could be
REFERENCES
advanced 2.5mm per side (Chart 3).
Thus, 2.5mm of the 4.5mm Class II correc-
tion on the right side could be achieved by mesial 1. Steiner, C.C.: Cephalometrics for you and me, Am. J. Orthod.
movement of the mandibular first molar. The 39:729-755, 1953.
2. Moorrees, C.F.A.: The Dentition of the Growing Child: A
remaining 2mm would have to be produced by Longitudinal Study of Dental Development Between 3 and 18
the methods described under Case 1. On the left Years of Age, Harvard University Press, Boston, 1959.