GROWTH PREDICTION

Dr. Anand Chowdhary

1st Year PG
Department Of Orthodontics And Dentofacial
Orthopaedics
SHDCH
 CONTENTS
• Introduction
• Growth Spurts
• Methods Of Growth Prediction
• Methods Of Predicting Craniofacial Growth
• Classification Of Growth Predicting Methods
• Hunterian Concept
• Gnomic Growth
• Arcial Growth Of Mandible
• Johnston’s Grid
• Todd’s Equation
• Mooress Mesh
• Ricketts VTO
• Growth : increase in size (Todd)​
“Increase in size, change in proportion, and progressive in
complexity.” (Krogman)​

• Development: “Progress towards maturity.” (Todd)​

“All naturally occurring unidirectional changes in the life of an
individual from its existence as a single cell to its elaboration as
a multi functional unit terminating in death.” (Moyers)​
• Variability : It is important to decide
whether the individual is merely an
extreme of the normal variation or falls
outside the normal range. This is
determined, using growth charts for
the particular population standards. ​
• The final major concept in physical
growth and development is Timing.​
• Variation in timing occurs because the
same event happens in different
individuals at different times.​
• Therefore Chronologic age often is not a
good indicator of an individual’s growth
status​
• Chronological age– It is the age
measured by the time from birth to the
present.​

• Bone/skeletal age – It is the way of

describing the degree of maturation of
a person’s bone. ​

• Growth spurts- there is acceleration and

retardation in the rate of growth.
The accelerative phases are called growth
spurts.​
 GROWTH SPURT

• Just before Birth​

• One year after Birth​
• Mixed Dentition Growth Spurt​
Boys: 8-11 Yrs​
Girls: 7-9 Yrs​
• Pre Pubertal Growth Spurt​
Boys: 14 – 16 Yrs​
Girls: 11 – 13 Yrs​
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
• Helps the clinician to intercept and correct the malocclusion.
• Used as patient education aids.
• Tool for orthodontic treatment planning but without forcing any
particular treatment procedure.
• VTO) is helpful in 'visualizing' the treatment objectives and
prioritizes the objectives, keeping in mind the growth pattern of the
patient.
• Response to a particular treatment can be predicted
• To plan for retention period.
 Why is the growth spurt at puberty
so important in orthodontics? ​

This is the time when most of the development of the

face occurs. Treatment during this time allows the
orthodontist to favorably influence the facial profile in
a growing child. Once growth of the facial bones is
complete, correction of skeletal discrepancies usually
requires surgery.
 Methods Of Prediction
Predictions methods generally followed in science are of four types :
• Theoretical
• Regression
• Experential
• Time Series
 GROWTH PREDICTION IN ORTHODONTICS

• Method of predicting growth are given by various

authors
• Bjork, in 1969, described three methods for predicting
the craniofacial development ​
1. Longitudinal method ​
2. Metric method ​
3. Structural method
Longitudinal method

• This is a commonly used method in

which tracing periodic cephalometric
radiographs follows the course of
development.
• In the period of most rapid growth
this may be established within a year
or two ​
 Metric method​

• This aim at a prediction of the facial development on

the basis of the facial morphology determined
metrically from a single radiographic film.​
​
• This method is not feasible at least from a clinical
point of view no matter which cephalometric analysis
has been used.​
 Structural method

• This is based on the information

concerning the remodelling process of
the mandible during growth, gained
from the implant studies by Bjork.​
 Classification of Growth Prediction Methods
CEPHALOMETRIC METHODS NON CEPHALOMETRIC METHODS

1. Moorrees mesh 1. Moss’s logarithmic spiral

2. Johnston’s transformation grid 2. Hirschfield and Moyers method
3. Jacobson’s grid 3. Mckeown’s allometric method
4. Broadbent’s method 4. Todd’s equation
5. Fishman’s method 5. Finite element method
6. Sneath’s transformation grid
7. Bjork’s implant growth rotation
studies
8. Rickett’s arcial growth of mandible
9. VTOs (Holdaway’s,Rickett’s and
other methods)
• Cephalometric growth prediction methods can further be
classified as: ​

• Template method: The commonly used templates are:​

1. Unisex Bolton template from ages 1 to 18 years;​
2. Burlington template, three configurations; ​
3. Original Burlington or its Michigan modification; ​
4. Johnston’s template analysis​

• Other cephalometric methods include VTOs.​

Hunterian Concept
Gnomonic Growth & The Logarithmic Spiral
 Moss’ method of predicting the mandibular growth along
a logarithmic spiral derives its inspiration from the
concept of “gnomic growth” by D’Arcy Thompson.

 Thompson explained the two fundamental features of

chambered nautilus :
(i) The shell grows in size and there is no change in shape.
(ii) The gnomonic growth can be described by a curve. This
curve is called as logarithmic or equiangular spiral
 Gnomic Growth Of Human Face

Nasal (left) and Oral (right) functioning spaces of human fetuses demonstrating
gnomonic growth
(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
• After Moss' postulate of logarithmic spiral, 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 :
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.
 Drawbacks of arcial growth prediction​
1. It relies heavily on the operators skill in tracing the
cephalogram.​
2. Mitchell & Jordan (1975) concluded Ricketts uses
chronological age rather than the skeletal age. If the
patient is in a growth spurt or lag phase it will alter the
result.​
3. The growth increments constants are for a
fixed population.​
 MOORREES MESH
• Coenraad F. A. Moorrees
• Constructed a template in the form of a mesh which was used to
superimpose growth changes in serial lateral cephalometric
radiograph.
• The size increases from 8-16yrs.​
Boys-4.5mm- height
Girls- 3.5mm-height​
• 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.​
• Retrognathic mandibles have posterior distortion of
the rectangles; while high mandibular angles will
have downward displacement of the mesh.
 JOHNSTON’S GRID
• Sex and Age specific.
• Method : The Johnston's forecast grid shows the average increments of growth
per year for the nasion, point A and B, nose and posterior nasal spine. It also
gives a method of constructing pogonion, given a B point. This method is
accurate to about 70 percent.

Forecast grid : S, sella; N,

nasion; P, posterior nasal spine; Nose, tip
of nose; M, any point on the crown of
maxillary first molars; A and B, subspinale
and supramentale. The tracing of the
landmarks is superimposed along S-N and
registered at S. The points are then
advanced downwards one unit per year
Cranial Base Superimposition :
 Maxillary and mandibular growth are always related by holding a
third plane of reference, either cranial base or FH plane.
 Cranial base generally used is SN plane; other planes Ba-N, PMV.
 SN plane, registered at S is the easiest plane to use, because the
landmarks are easily located by a common practitioner
Regional Superimposition :
Regional template is placed over the cephalogram and measurement
is made between two points [e.g. PNS-ANS for maxilla, GO-Pg for
mandible] and age noted in years

Prediction :
To predict facial growth, every point is advanced one grid unit per
year superimposed on SN registered at S.
Uses Of Template :

1. The relative age of the skeleton is measured

2. Angles of cranial base, gonial angle, mandibular, occlusal
plane angle ,and palatal plane angle can be assessed and vertical
growth of the face is assessed.
3. Position of upper and lower incisors can be directly seen, the
differentiation between proclination and forwardly positioned
incisors is easily made out.
4. Vertical facial proportions are judged in years; AFH 10 years but
PFH only 8 years
5. Malocclusion is the integration of small deviations of all parts of
the face. ie dental and skeletal cause differentiated
 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.

P = a R (1–cos θ)
Todd explained that ,if all bone elements
were placed or displaced in the direction
of gravitational pressure, (as supported
by Wolff's law,) then they would all
move outward along radial lines
emanating from the center of the sphere
and the displacement along these radial
lines of growth would increase
monotonically over time as a function of
pressure.
Predicting Craniofacial Growth :

To test the equation, lateral cephalogram of subjects taken at younger

(T1) and older (T2) groups were taken.

The initial T1 cephalogram was traced and ANS and Gn were

located and traced.
Superimposition was done on polar graph paper so that ANS and Gn
were at 125º and 160º radial coordinate.

The second cephalogram T2 was placed over young cephalogram

and centered so that:
• Tips of the heads [vertex] were superimposed
• ANS and Gn in older profile were as near to polar co-ordinates as
in the younger cephalograms.
The profile of the patient is marked as series of points 3 to 5 mm
apart by using the equations, a continuum of skull outlines were
drawn. The predicted skull outline is compared with profile at older
age and is shown to make reasonably accurate growth predictions
over a span of about 10 to 15 years.​

The predictions that were made with this growth model were not
totally accurate because of the mechanical sources of error and,
perhaps, oral habits, such as thumbsucking,
nailbiting,mouthbreathing, teeth clenching, or unusual facial
expressions or facial postures.
 VISUALIZED TREATMENT OBJECTIVE (VTO)

• It was coined by Holdaway.

• A VTO is a cephalometric tracing representing the changes that are
expected during the treatment. (PROFFIT)
• Ricketts defines VTO as a visual plan to forecast the normal growth
of the patient and anticipated influences of treatment, to establish
individual objectives that are to be achieved for that patient.
• Jacobson and Sadowsky (1980), have outlined the
accomplishments of VTO as follows:

 It predicts growth over an estimated treatment time, based on

individual morphogenetic pattern.
 Analyses the soft tissue profile.
 Graphically plans the best soft tissue profile for every patient.
 Determines favorable incisor repositioning, based on an ideal
projected soft tissue facial profile.
 Assists in determining the total arch length discrepancy when
taking into account 'cephalometric correction'.
 Aids in determining whether the case is extraction or non-
extraction
 Aids in deciding which tooth to extract in an extraction case.
 Aids in planning treatment mechanics.
 Aids in deciding which cases are more suited to surgical and/or
surgical orthodontic correction.
 It provides a visual goal or objective to be achieved at the end of
treatment
Advantages Of VTO :
 Establishment of specific treatment goals.
 Formulation of specific treatment plan to attain the treatment goals.
 Allowing rapid comparison of different treatment options before arriving
at a final treatment plan.
 Assists in measuring and monitoring treatment progress, for making
mid-treatment correction.
 Enhancing communication between patients, parents and clinicians.
 Etiology for variation in treatment response can be recognized like lack
of patient cooperation, variation in growth pattern, etc.

Limitations of VTO :
 Use of average growth increments in prediction.
 Use of existing morphological traits to predict future events.
 VTO is presented as an exact representation of treatment outcome which
cannot be so in all the cases
 RICKETTS VTO
• According to Ricketts, growth changes of the craniofacial complex
should be studied by keeping the center of least growth as the
registration point.
• He divided areas to be predicted into :
1. Cranial base prediction.
2. Mandibular growth prediction.
3. Maxillary growth prediction.
4. Occlusal plane position.
5. Location of dentition.
6. Soft tissue of the face.
CRANIAL BASE :

• Nasion grows forward

1 mm/year .
• Similarly, Basion is
grown backward 1
mm/year.
MANDIBULAR GROWTH PREDICTION :

• The mandibular angle changes for every treatment procedure.

It is calculated as degree of opening or closing of facial axis.
The facial axis opens 1º with growth.
• The following changes occurs in the facial axis :
1. Convexity reduction—facial axis opens 1º/5 mm.
2. Molar correction—facial axis opens 1º/3 mm.
3. Overbite reduction—facial axis opens 1º/4 mm.
4. Cross bite correction—facial axis opens 1º-1½º, recovers
half the distance.
5. Facial pattern—with dolichofacial pattern the angle opens
1º and vice versa
MAXILLARY GROWTH PREDICTION :

• Now the height of the anterior and posterior face has

been determined.
• Maxilla's new position has to be predicted within this
vertical dimension. The distance between old and new
menton is divided into three portions (thirds) by distinct
marks and named 1, 2 and 3. Superimposing mark 1 on
the original menton along the facial plane, trace the
palate.
• Point A is not traced at this juncture because it undergoes extensive
changes with growth and treatment. With normal growth, point A
should move forward but it undergoes the changes
 OCCLUSAL PLANE :

• For each distal movement of point

A, it will drop down by ½ mm.
• Superimpose mark 2 on the old
menton and facial plane, parallel the
mandibular planes by rotating at
menton, now construct the occlusal
plane.
 LOWER INCISORS
• Lower incisor position is determined by arch length.
• The following are considered requirements when lower incisors are
drawn:
• Occlusal plane relation.
• A Pg line relation.
• Symphyseal relation
 LOWER MOLAR
• Without treatment,the lower molar
will erupt directly towards the
occlusal plane.
• With treatment,the lower molar
might move forward.
• Every 1 mm forward of the lower
molar arch length will decrease by 2
mm.
• Movement of lower molar is decided
depending on the lower incisor
position.
 UPPER MOLAR :
Upper molar is drawn to class I relation with the lower molar.

UPPER INCISOR :
Upper incisor is drawn on good overjet and overbite (2.5 mm)
relation to lower incisor. Interincisal angle of 130º is maintained.
 SOFT TISSUE
• A. Bridge of the nose

Superimpose nasion along facial plane and palatal plane. The

prediction is moved back 1 mm/year along the palatal plane. Tip of
the nose is now traced and merged with the superior aspect of the
nose drawn
• B. Upper Lip
• C. Lower Lip
Disadvantages of Roentgenographic cephalometric
methods (Moss, Salentijn and Skalak)
• Using radiographic cephalometry growth can be observed in two
dimensions only.
• Growth behavior can be observed only relative to an arbitrarily
chosen point location and reference line direction.
• Growth behavior of an individual differs greatly when studied by
different radiographic methods.
• Cephalic regions with little or no growth may appear to rotate or
translate with respect to some arbitrarily fixed reference points.
• It is impossible to construct a model of growth using a
cephalogram that is independent of the choices of fixed point and
fixed line.