GOOD MORNING
Dr. Robert Murray
Ricketts is
considered as one
of the legends in
orthodontics.
Dr.ROBERT REED A. HOLDAWAY
MURRAY RICKETTS
GROWTH
PREDICTION
P. SAI RAMYA
SREE
I MDS
CONTENTS:-
Introduction
Methods of predicting facial growth change
Hunterian concept
Gnomonic growth
Arcial growth of mandible
Visual treatment objective(VTO)
Conclusion
References
INTRODUCTION:-
Growth prediction helps in predicting the response to treatment and
associated growth changes.
Predicting the adult features of patient will help in the interception and
correction of malocclusion.
Growth prediction is a tool for orthodontic treatment planning and is
helpful in visualizing the treatment objectives.
METHODS OF PREDICTING FACIAL GROWTH CHANGE:-
Cephalometric method
• Metric
• Longitudinal
• structural
Cartesian coordinate system[mesh diagram]
Computerised method.
The longitudinal, structural and metric methods of prediction are of a
limited clinical value.
Recent computer technology has provided more sophisticated approaches
to this ongoing problem.
Longitudinal approach:-
• By Tweed by studying on growing individuals.
• Advised taking two lateral cephalograms with 12-18 months apart and
then evaluated the skeletal facial changes in them .
Metric method:-
• Predicts the interrelationship of changes within facial structure ,
between various facial structures and other body dimensions .
Structural method:-
• Developed by Bjork from super imposition of metallic implants.
• Implant radiography.
Cartesian coordinate system:-
A mesh diagram is used to assess the facial morphology.
Core grid: 4 rectangles
Rest of the face : 20 rectangles
Rectilinear coordinate system composed of 24 small
rectangles.
Concluded that size increases from 8 to 16 years of age.
Height increments are 4.5mm in boys and 3.5mm in
girls.
Length increments – 3.2mm in boys and 2.4mm in girls.
Computerized prediction methods:-
Programmed to use equations based on longitudinal , metric and
structural methods.
Computerisation is a tool of analysis rather than method of
analysis.
Biggest advantage is that it facilitates applying more complex
formulae to growth prediction.
HUNTERIAN CONCEPT:-
Given by John Hunter.
He noticed linear growth of mandible(lengthening).
Resorption in anterior border and deposition in posterior border.
GNOMONIC GROWTH or LOGARITHMIC SPIRAL:-
The portion of increment which when added does not alter shape but
only produces an increase in size is called gnomon in Greek by Aristotle.
D’Arcy Thompson classified the sea shells in accordance to their pattern
of enlargement and developed an equation.
The Nautilus offers 2 fundamental characteristics :-
1. Original shape remains constant.
2. Its gnomic growth can be described by an 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.
GNOMONIC GROWTH or LOGARITHMIC SPIRAL:-
Moss and Salentejin:
They predicted that mandible grows in spiral path.
Moss predicted that mandibular growth is along a logarithmic spiral.
He actually inspired from gnomonic growth concept of D'Arcy
Thompson.
GNOMONIC GROWTH OF MANDIBLE:-
Lead shots are implanted at three foramina along the path of the nerve
namely foramen ovale, mandibular foramen, mental foramen.
As the mandibular bone increases in size , base appears to rotate along
the spiral.
As the bone lengthens in growth the distance between the foramina
increases
Gnomonic growth of the human head:-
Moss indicates that orofacial capsular matrices particularly the
oronasopharyngeal functioning spaces also manifest gnomonic
growth .
In a study, he sectioned the heads of human fetuses with a crown
rump length ranging from 26-163 mm mid sagitally for direct
measurements of the oral, nasal and pharyngeal cavities.
On analysis, the oral and nasal functioning spaces enlarge but they do
ARCIAL GROWTH OF MANDIBLE:-
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 the 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}.
Proposed by Dr. Robert Murray Rickets.
Xi point: It represents the geometric center of ramus.
R1: Most concave point on the anterior border of
ramus.
R3: Deepest point on the sigmoid notch.
R2: Point opposite R1 on the posterior border of ramus.
R4: Point opposite to R3 inferior border.
Eva point is the confluence or the point of the forking of the
stress lines at the terminus of the oblique ridge on the medial
surface of the ramus
DC point: It is the midpoint or the bisecting point of the condylar
neck.
PM point or Suprapogonion: It is the point where the anterior border of
symphysis of mandible turns from convex to concave. It was found to be
the most stable point in mandible and is hence, used as reference.
MU point (Murray): This point was named after Ricketts’ father. It is a
point on the sigmoid notch where the curve from Eva touches the notch
Tr/True radius: It is the center of the arc. It is the intersection of arcs from
Eva and PM drawn with Eva PM as the radius.
DC-Xi line constitutes the Condylar axis.
Xi-PM line constitutes the Corpus axis.
According to Ricketts, each individual generates his own unique arc. 3
curves were ultimately drawn:
CURVE A – Passes through DC -Xi and Pm. (gonial angle would be too
obtuse)
CURVE B - Passes through tip of the coronoid process and Pm.( mandible
is bent too much)
CURVE C – Passes through point Eva and Pm.( absolutely correct size)
DRAWBACKS OF ARCIAL GROWTH PREDICTION:-
It relies heavily on the operators skill in tracing the cephalogram.
If the patient is in a growth spurt it will alter the result.
VTO:-
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.
This treatment forecast was developed by Ricketts and Rocky mountain
data system(RMDS) and VTO was coined by Holdaway.
RICKETTS’ VTO:-
Growth changes of the craniofacial complex studied by keeping the
center of least growth as registration point i.e. near pterygomaxillary
fissure.
The intersection of basion-nasion line to the facial axis is named as cc
point and decided superimposition will be on BA-N plane registered at
cc point. divided areas to be predicted into six:
1. cranial base
2. Mandibular growth prediction
3. Maxillary growth prediction
4. Occlusal plane position
5. Dentition
CRANIAL BASE:-
The cranial base is designated by a line joining the most anterior point of
the Foramen Magnum (Basion) with the Nasion.
Prediction:
In normal patient, the cranial base will grow 2mm per year during the
active growth period.
This is expressed as 1mm of forward growth of Nasion and 1mm of
backward growth of Basion, both along the original cranial base length.
MANDIBULAR GROWTH PREDICTION:-
Condylar axis: is defined as a line from a point on the Ba-N Line midway
between the anterior and posterior borders at the condylar neck {DC
POINT} to the geometric centre of the mandibular ramus.
Corpus axis: The length of the body of the mandible is defined by a line
from Xi point to the anterior point on the mandibular symphysis
PREDICTION:-
Condylar axis grows 1mm per year.
Corpus axis grows 2mm per year.
MANDIBULAR ARC:-
The angle formed by the condylar and corpus axis describes the configuration of the
mandible.
Prediction:
A small angle is indicative of steep mandibular plane associated with a vertically growing
mandible.
A larger than normal angle is correlated with a square mandible associated with more
favorable forward mandibular growth.
MANDIBULAR CHANGES:-
The facial axis is the line between the Pt-point and the cephalometric Gnathion. This angle
remains stable during growth and any changes would be due to clinicians mechanotherapy.
During treatment, the changes that can occur are:
MAXILLARY GROWTH PREDICTION:-
Changes in maxilla can evaluated by superimposing on B- Na and at
nasion-point A.
Nasion and point A grow forward same amount each year. The angle
formed by intersection of N-A and basion-nasion thus remains same during
normal growth.
The clinician must realize the effects of orthopedic appliances on the
maxilla and more specifically on the point A .
Skeletal convexity is determined by relation between point A and facial
plane. If A is in front of plane, skeleton is said to be convex
MAXILLARY CHANGES:-
A list of mechanics and their effect on the antero-posterior position of
point A of the maxilla as it relates to the vertical facial plane{N-pog}.
Clinically, the palatal plane {ans –pns} rotates in a clockwise direction
as the forces produced by the appliance affect the midface region. Point
A will not only move distally but also drop inferiorly half the distance.
Maximum range of point A changes with various mechanisms
DENTITION:-
Once the position of the mandible and maxilla is determined, a line is drawn between point
A and Po The incisor teeth are then related to the A-Po line.
The mandibular incisor usually stays in a constant relationship to the A-Po line throughout
the growth. In ideal situation, the incisal edge is 1mm ahead of the A-Po line,1mm above
occlusal plane,
Significance: Any anterior or posterior movement of the lower incisor has a two-fold effect
on the arch length of the dentition. If the lower incisor is moved back 1mm, the arch length
is decreased by 2mm.
Upper incisor: The maxillary incisor also remains constant to the A-Po
line. The incisal edge of the upper incisor is 3.5 mm to the A-Po line,1mm
below occlusal plane.
Interincisal relationship: This remains the same during growth. The
normal angle is 130º.The upper incisor should be 28 degrees and the lower
incisor 22 degrees to the A-Po line. 2 degree change in angle for 1mm.
Molar relationship: Position of molars is determined by ideal incisor
position and consequent arch length discrepancy. The upper molar is 3mm
distal to it’s lower counterpart.
CONCLUSION :-
If the patient continues to be in growth phase even after
treatment, growth following the termination of treatment can be
predicted to plan for retention period, thus ensuring the stability
of results.
Growth prediction would be reasonable only in average growers
but not in abnormal growers.
REFERENCES:-
Bishara- Text book of orthodontics
Sridhar Premkumar - Textbook of craniofacial growth.
Bhalajhi S.I.- Text book of Orthodontics.
THANKYOU
