Visualised treatment objective /certified fixed orthodontic courses by Indian dental academy


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Visualised treatment objective /certified fixed orthodontic courses by Indian dental academy

  1. 1. VISUAL TREATMENT OBJECTIVE INDIAN DENTAL ACADEMY Leader in continuing dental education
  2. 2. The term visual (or visualized) treatment objective (VTO) was coined to communicate the planning of treatment for any orthodontic problem. Procedure based primarily on cephalometrics, the purpose of which is to establish a balanced profile and pleasing facial aesthetics and to evaluate the orthodontic correction necessary to achieve this goal.
  3. 3. V.T.O. is thus a dynamic cephalometric analysis which takes into account both growth and biomechanics, thus achieving its aim of being a Visualized Treatment Objective. It outlines a goal from the inception of treatment and may be usefully employed in monitoring growth and treatment progress.
  4. 4. It is like a blue print used in building the house. It enables development of alternative treatment plans. Term V.T.O. was coined by Holdaway.
  5. 5. V.T.O. accomplishes the following: 1. Predicts growth over an estimated treatment time, based on the individual morphogenetic pattern. 2. Analyzes the soft tissue facial profile. 3. Graphically plans the best soft tissue facial profile for the particular patient. 4. Determines favourable incisor repositioning, based on an "ideal" projected soft tissue facial profile.
  6. 6. 5. Assists in determining total arch length discrepancy when taking into account "cephalometric correction". 6. Aids in determining between extraction and nonextraction treatment. 7. Aids in deciding which teeth to extract, if extractions are indicated. 8. Assists in planning treatment mechanics.
  7. 7. Rickett’s VTO Ricketts stated that all treatment planning constituted some type of prediction. He suggested estimating the amount of change that should occur by predicting the possibilities of tooth movement & facial change. He called his method of prediction a ‘dynamic synthesis’ in which craniofacial growth & tooth movement were predicted. Also allowed for a forecast of the integumental profile.
  8. 8. Basic planes and points
  9. 9.
  10. 10.
  11. 11.
  12. 12. SEQUENCE Cranial base prediction Mandibular growth prediction Maxillary prediction Occlusal plane prediction Dentition Soft tissue
  13. 13. Cranial base prediction Trace the Basion-Nasion plane. Grow Nasion & Basion 1mm (average normal growth) for 2 years.
  14. 14.
  15. 15. Mandibular growth prediction Rotation & lengthening Rotation – From the effects of mechanics used & facial pattern Direction of effective growth is determined The mandibular plane is influenced accordingly Lengtheningcondyle-1 mm/yr body -2 mm/yr
  16. 16.
  17. 17. Superimpose at Ba. Rotate ‘up’ at Nasion to Open the bite. Rotate ‘down’close the bite.
  18. 18. Condylar axis and corpus axis growth
  19. 19.
  20. 20. Symphysis construction
  21. 21. Maxillary prediction 1/3 rd of total facial ht increase is due to upper face Ht increase. Pt A is influenced by tooth movement treatment mechanics is given consideration while relocating it
  22. 22.
  23. 23.
  24. 24. Superimpose point 1 On original menton & Facial plane. Trace palate
  25. 25.
  26. 26. Point A changes
  27. 27.
  28. 28. Occlusal plane position Superimpose mark 2 on original menton, Facial plane. Parallel mandibular planes Rotating at menton
  29. 29.
  30. 30. Lower incisor position Placed in relation to symphysis of mandible. Ideal position – 22° at +1mm to A Po plane, +1mm to occlusal plane. Angle increases 2° with each mm of forward compromise.
  31. 31. superimpose corpus axis at PM. Place incisor at ideal position.
  32. 32.
  33. 33. Mandibular molar Superimpose the lower molar on the new occlusal plane.
  34. 34. Maxillary molar Traced in good class 1 position to lower molar.
  35. 35. Maxillary incisor Place in good overbite overjet position. Interincisal angle-130°.
  36. 36.
  37. 37. Soft tissue -Nose Superimpose at Nasion along facial plane. Trace bridge of nose. Then superimpose at ANS along palatal plane. Moving prediction back 1mm/yr along palatal plane, trace tip of nose fading into bridge.
  38. 38. Soft tissue point A and Upper lip Soft tissue point A remains in same relation to Point A as in the original tracing Superimpose new & old bony point A and make a mark at soft tissue point A.
  39. 39. Divide distance between ‘original’ & ‘new’ incisors into Thirds.
  40. 40. Keeping occlusal planes parallel, superimpose mark 1 on tip of original incisor. Trace upper lip connecting with point A.
  41. 41. Soft tissue – Lower lip, point B, soft tissue chin
  42. 42. Superimpose interincisal points, keeping occlusal planes parallel. Trace lower lip & soft tissue point B
  43. 43. Completed VTO
  44. 44.
  45. 45. Superimpositions 1st check point : Basion-Nasion at CC point – to evaluate facial axis change, chin growth, upper molar position.
  46. 46. Area 2 – Basion Nasion at Nasion. To evaluate maxillary change.
  47. 47. Area 3 – Corpus axis at PM. To evaluate lower incisors and molars
  48. 48. Area 4 – Palate at ANS. To evaluate upper molars and incisors.
  49. 49. Area 5 – Esthetic plane at the intersection with occlusal plane. To evaluate soft tissue.
  50. 50. Holdaway’s VTO Holdaway VTO emphasizes soft tissue profile balance. Main difference with Ricketts – Holdaway predicted soft tissue profile first, then the position of maxillary incisors. He believed that the mandibular incisor could not be rigidly fixed to any anatomical landmark such as A-Pog line. Instead , the mandibular incisors should be placed relative to maxillary incisors where adequate lip support had been established.
  51. 51. Growth of the cranio-facial skeleton is predicted for the estimated treatment time, and the soft tissue profile between the nose and the chin arranged to create an “ideal” facial profile for the individual patient Maxillary and mandibular incisors are repositioned to eliminate lip strain Allowance is made for probable post treatment “incisor rebound”.
  52. 52. Maxillary teeth are positioned first, and then lower incisors are repositioned to be in harmony with the upper incisors Following the repositioning of the mandibular incisors, the resultant arch length discrepancy may be calculated to determine whether or not teeth should be extracted.
  53. 53. 1 Basion-Nasion line (Ba N). 2. Line Nasion to point A. 3. The Frankfort horizontal plane 4. The Occlusal plane. 5. Downs mandibular plane. 6. The facial axis 7. Holdaway'S line 8. The facial plane
  54. 54. OBJECTIVE : To draw frontonasal area, line Ba-N and line N-A
  55. 55. OBJECTIVE : To express growth in the frontonasal area over a two-year period. Super impose on line BaN and move the VTO until there is 1.5 mm growth in the fronto nasal area Holding the VTO tracing in the position copy the Ricketts facial axis
  56. 56. OBJECTIVE : To express growth in a vertical direction in the mandible, and to draw the anterior portion of the mandible, soft tissue chin and the mandibular plane of Downs
  57. 57. Superimpose the VTO facial axis along the original facial axis. Move the VTO tracing upwards so that the VTO Ba-N line is above the original Ba-N line, the distance between these lines should be three times the amount of growth expressed in the frontonasal area
  58. 58.
  59. 59. OBJECTIVE : To express growth in a horizontal direction in the mandible and draw the posterior border of the mandible. Superimpose on mandibular plane and Move the VTO forward until the original and VTO foramen rotundae are vertically aligned
  60. 60.
  61. 61. OBJECTIVE : To locate and draw the maxilla, and lower half of the nose Super impose the VTO N-A line on the original NA line and move the VTO up until the vertical growth is expressed above the Ba-N line and below the mandibular plane is in the ratio of 40:60
  62. 62. With the V.T.0. tracing in this position copy the maxilla to include posterior 2/3 of hard palate, PNS to ANS to 2mm below the ANS. With the V.T.0. in the same position, draw the new nose up to the middle of the inferior surface of the nose. Estimated growth usually parallels the contour of the old nose in this area. Average nose growth is 1mm per year
  63. 63.
  64. 64. OBJECTIVE : To locate and draw the occlusal plane With the VTO superimposed on line NA, move the VTO tracing so that the vertical growth between the maxilla and the mandible is expressed as being 50% above the maxilla and 50% below the mandible
  65. 65.
  66. 66. Generally occlusal plane is located 3mm below the lip embrasure. This permits the lower lip to envelop lower1/3rd of upper incisor teeth. If cant of occlusal plane in original tracing is correct then this should be maintained.
  67. 67. OBJECTIVE : TO determine the soft tissue lip contour using the Holdaway line 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 soft tissue subnasale 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.
  68. 68.
  69. 69. Also 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 – Superior sulcus depth. 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.
  70. 70.
  71. 71. Superimpose on N-A & VTO maxillary and draw a 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
  72. 72.
  73. 73. Use of the Jacobson-Sadowsky lip-contour template is recommended. Second, with the tracing still superimposed on the maxilla and line N-A and using the occlusal plane as a guide for the lip embrasure, draw the upper lip from the vermilion border to the embrasure. Then from the point on the lower border of the nose where its outline stopped on the VTO, draw in the superior sulcus area. This is a gradual draping to the new vermilion border outline.
  74. 74.
  75. 75. Third, superimpose on line NA and the occlusal plane. Form the lower lip, remembering that from 1 mm behind the H line to 2 mm anterior can be excellent, depending on variations of thickness of the two lips. Again, most cases will fall on the H line or within 0.5 mm of it.
  76. 76.
  77. 77. Objective – To relocate Maxillary central incisor Lip Strain - in well-balanced soft tissue profiles the distance along a horizontal line extending between a point 3mm below the original point A to the point where the line crosses the upper lip is within 1mm of the distance between the labial surface of the maxillary incisor to the tip of the upper lip. Should the lower measurement be less than within 1mm of the upper measurement, then lip strain is said to exist.
  78. 78.
  79. 79.
  80. 80. To eliminate lip strain where it exists the upper incisor is moved back to allow the aforementioned readings to be within 1mm of each other. Where no lip strain exists retraction of the maxillary incisors allows the upper lip to move backwards an equal amount, i.e. lip and incisors maintain a 1:1 ratio.
  81. 81. Maxillary Incisor Rebound— Generally, during posttreatment maxillary incisors tend to move labially 0.5mm in Class I cases and 1.5mm in Class 11 cases. This is referred to as "Incisor Rebound".
  82. 82. Superimpose the V.T.0. tracing on the N-A line and the maxilla and trace in the maxillary incisor, taking cognisance of the amount it is to be repositioned. The axial inclination of this tooth is judged and the occlusal plane is used to locate it vertically. The tip of the maxillary incisor touches the occlusal plane.
  83. 83.
  84. 84. OBJECTIVE : to reposition lower incisor and calculate resultant arch length change judge the position of the lower incisor To calculate lower arch length change, superimpose tracing on mandibular plane and register on symphysis. Measure the distance between old and new incisor position and double this measurement to determine total arch length discrepancy
  85. 85.
  86. 86. OBJECTIVE : To reposition lower first molar, use the plaster casts to determine arch length discrepancy due to crowding and/or rotation.
  87. 87. OBJECTIVE : To reposition maxillary first molar Using the occlusal plane and lower first molar as a guide draw the maxillary first molar in good Class I occlusion with the lower first molar
  88. 88. OBJECTIVE : To complete art work ANS to upper incisor Anterior portion of hard palate Lower alveolus lingually and labially
  89. 89. DENTAL V.T.O. Proposed by Richard P. McLaughlin & John C. Bennett. (JCO 1999). Designed to provide organized and simplified information to help in diagnosis, treatment planning, and the extraction/nonextraction decision. It should be used as an adjunct to, but not a substitute for, conventional cephalometric analyses.
  90. 90. It takes little time to complete and occupies only a small part of the treatment card. Progress can be checked by referring to the dental VTO at the patient’s regular adjustment appointments.
  91. 91. Consists of 3 charts : Chart 1 records the initial midline and first molar positions with the mandible in centric relation.
  92. 92. Chart 2 measures the lower arch discrepancy, similarly to the Steiner analysis. The four primary factors in each case are: 1. Space required for relief of crowding, measured from canine to midline and from first molar to midline on each side. 2. Space required for the desired correction of protrusion or retrusion of the mandibular incisors.
  93. 93. 3. Space required for leveling the curve of Spee.
  94. 94. 4 .Space required for midline correction. Four secondary factors that can sometimes provide additional space are listed, if applicable, below the primary chart: 1. Additional space from interproximal enamel reduction. 2. Additional space from uprighting or distal movement of mandibular first molars.
  95. 95. 3. Additional space from buccal uprighting of mandibular canines and posterior teeth. 4. Additional leeway or “E” space.
  96. 96.
  97. 97. The primary & secondary factors are added together at the bottom of the chart to determine the total lower arch discrepancy from canine to midline and from first molar to midline on each side.
  98. 98. Chart 3 records the anticipated treatment change in terms of dental movements of the first molars, canines, and midline.
  99. 99. Case Report 12 year old male presented with a Class II skeletal pattern. Molar relation were 4mm Class II on right side, 3.5mm Class II on left. Lower dental midline was deviated 1mm to right.
  100. 100. The mandibular arch showed 3mm of crowding on the right side, all mesial to the right canine. Therefore, the amount of crowding from first molar to midline was the same as the amount from canine to midline.
  101. 101. The curve of Spee was about 2mm at its deepest point. Steiner suggested that leveling a 2mm curve of Spee would advance the incisors 1mm, thus requiring 1mm of space per side for the leveling process. Because the lower midline was deviated 1mm to the right, the midline correction would require 1mm of space on the left side and provide 1mm of space on the right.
  102. 102. The mandibular incisors were inclined forward (97° to the mandibular plane) and were 6mm in front of the APo line. Without extractions,the incisors would either remain in this position or, more likely, be advanced farther. With extractions, the incisors could be retracted. Therefore, the decision was made to extract the four first premolars and retract the mandibular incisors 2mm.
  103. 103.
  104. 104. Extraction of four first premolars – produces 7mm space.
  105. 105. As total discrepancy in lower arch 5mm/side, mandibular canines needed to be retracted 5mm into the extraction sites.
  106. 106. Mandibular molars could be moved only 2mm. This demonstrated a need for moderate anchorage control in mandibular arch. A mandibular lingual arch could be considered during 3mm of canine extraction.
  107. 107. Mandibular midline needed to be moved 1mm to right.
  108. 108. 4 possible methods of Class II molar correction in growing patient : a. Mesial movement of the mandibular first molars (in this case, 2mm per side). b. Distal movement of the maxillary first molars. This is difficult in the presence of developing maxillary second and third molars, but it can be achieved.
  109. 109. c. Limiting forward maxillary skeletal development, or retracting the maxilla. Because such changes are difficult to isolate, it is debatable how much is skeletal (above the palatal plane) and how much is dentoalveolar (below the 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.
  110. 110. d. Forward mandibular rotation. This can occur in two ways: 1) Mandibular growth. The direction of overall facial growth is critical to the “expression” of mandibular growth. With more vertical patterns, there is less forward expression of mandibular growth and hence less interarch dental change.
  111. 111. 2) Limiting vertical maxillary development. Although sizable claims have been made for this method, it is difficult to significantly influence the normal vertical development of the facial complex. Even a small limitation can greatly enhance a Class II correction.
  112. 112. In the present case, the molar relationship on the right side was 4mm Class II, and since 2mm could be corrected by mesial movement of the mandibular molar, an additional 2mm of correction was required. On the left side, an additional 1.5mm of correction was needed.
  113. 113. A palatal bar & a combination high-pull & cervical pull headgear were used to preserve maxillary anchorage.
  114. 114. Taking into account the 2mm distal movement of the maxillary right molar and the 1.5mm 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.
  115. 115.
  116. 116. A functional appliance could also have been considered before fixed appliance therapy. A good response to the functional appliance might have reduced the amount of maxillary anchorage support needed later. Extractions would still have been required after the functional phase, assuming incisor retraction was still a treatment objective.
  117. 117. TOMAC: An Orthognathic treatment planning system. Proposed by Tony G. McCollum in 2001. It is a surgical-orthodontic treatment planning & prediction system designed to identify the best possible soft tissue profile by testing the effects of various orthodontic & surgical options.
  118. 118. In the TOMAC VTO, the soft tissue goals are traced in first, and the hard tissues are then adapted based on known soft to hard tissue responses. The TOMAC VTO is constructed in three stages: test, presurgical-orthodontic, and surgical. The essential underlying principle is that the soft-tissue profile is changed first, setting a goal toward which hard-tissue changes are adapted.
  119. 119. Test VTO – This is where the various orthodontic and surgical options are tested and the optimum combination is visualized. – In the anteroposterior plane, the facial contour angle (FCA) is changed to the chosen ideal.
  120. 120. Facial Contour Angle The facial contour angle (FCA) is highly relevant to the analysis because it measures the convexity or concavity of the face .
  121. 121. This angle is formed by tangents to glabella and soft-tissue pogonion, intersecting at subnasale.
  122. 122. Line from glabella to subnasale – Upper facial contour plane. Line from subnasale to pogonion – Lower facial contour plane.
  123. 123. The acute angle between these planes is the facial contour angle, which describes the degree of anteroposterior discrepancy of the total face. Normal value – according to Burstone is -11º ± 3º.
  124. 124. Varies according to facial type, with leptoproscopic (long face) individuals tending to be more convex, around -16°, euryproscopic (short face) patients tending to have more acute angles : -7°.
  125. 125. – The upper and lower jaws, or both, are traced in their new positions according to the softtissue reactions to surgical movements, and the teeth are then decompensated accordingly. – The incisor movements are measured and reconciled with arch-length discrepancies and with the physiological positions of the teeth in the alveolar bone.
  126. 126. – In the vertical plane, the key is the position of the maxillary incisor in relation to the relaxed upper lip. – The maxillary incisors are moved vertically on the tracing, if necessary, into their ideal positions relative to the upper lip, and the mandible is autorotated so that the correct vertical relationship of the maxillary and mandibular incisors is obtained.
  127. 127. – The new Facial Contour Angle is measured and compared with the chosen ideal Facial Contour Angle . – Appropriate anteroposterior jaw movements are then effected to obtain the ideal total profile.
  128. 128. – The teeth are decompensated into positions most favorable to the desired surgical changes, keeping in mind arch-length discrepancies and physiological positions in the alveolar bone. – The incisor movements required to accomplish the skeletal changes are measured for use in the presurgical VTO.
  129. 129. Presurgical-Orthodontic VTO – This is constructed from the information in the test VTO. – Any necessary incisor decompensations, molar adjustments, and soft-tissue changes become the orthodontic objectives prior to the surgical procedure.
  130. 130. Surgical VTO – The surgical VTO is constructed over the presurgical VTO, with the surgical cuts diagramed on the tracings of the jaws. The simulated surgical movements are governed by the decompensated positions of the incisors. – The soft-tissue profile is then drawn according to the expected soft-tissue/hard-tissue ratios of movement
  131. 131.
  132. 132. Test VTO _- Hard & Soft tissues that will not change after surgery
  133. 133. Mandibular structures after advancement
  134. 134. Incisor decompensation needed to achieve best profile.
  135. 135. Presurgical-Orthodontic VTO – Construct a new VTO to reflect the orthodontic movements that will be needed to allow surgery to create the ideal (or nearest to ideal) profile. – Bite opening or closing is measured by the change in angulation of the line from condylion to gnathion.
  136. 136. It is important to draw in the softtissue changes that will occur as a result of any orthodontic decompensation
  137. 137. Surgical VTO
  138. 138. Lew et al (1998) took a sample of 34 growing Class II patients to assess the reliability of manual & computer generated VTOs when compared with actual treatment results. Skeletal, dental & soft tissue measurements were performed on the VTO & the posttreatment changes. Both methods were accurate when predicting skeletal changes that occurred during treatment.
  139. 139. For soft tissue prediction, only slight difference was seen with the computer being slightly more accurate. Both methods were moderately successful in forecasting dental alterations during treatment. Overall the prediction tracings were accurate to only a moderate degree, with marked individual variation evident throughout the sample.
  140. 140. Inadequacies of VTO 1) Use of average growth increments in growth prediction. 2) The use of existing morphological traits to predict future growth events. 3) The fallibility of presenting VTO analysis as an exact representation of the treatment outcome.
  141. 141. Conclusion VTO can be helpful as a diagnostic & treatment planning aid and as a reference throughout treatment. It is also useful in making extraction non extraction decision.
  142. 142. With soft tissue responses to hard tissue movements better understood than in past, these & other influential factors could be incorporated into computerized technology, using multiple regression equations to provide extremely accurate treatment planning information.
  143. 143. References 1) Ricketts R.M. : Planning treatment on the basis of the facial pattern and an estimate of its growth. Angle Orthod 1957;27;14-37. 2) Ricketts R.M. : Cephalometric synthesis : An exercise instating objectives & planning treatment with tracings of head roentgenogram. AJO 1960;46;647-673. 3) Holdaway RA : A soft tissue cephalometric analysis and its use in orthodontic treatment planning. Part 1. AJO 1983;84;1-28.
  144. 144. 4) Holdaway RA : A soft tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. AJO , 1984;85;279-293. 5) Jacobson A, Sadowsky PL : A visualized treatment objective. JCO 1980;14;554-571. 6) Tony G. McCollum : TOMAC : An orthognathic treatment planning system. Part 1 – Soft tissue analysis. JCO 2001;35(6) ; 356-364.
  145. 145. 7) Tony G. McCollum : TOMAC : An orthognathic treatment planning system. Part 2 VTO construction in the horizontal dimension. JCO 2001, 35 (7); 434-443. 8) Tony G. McCollum : TOMAC : An orthognathic treatment planning system. Part 3 VTO construction in the vertical dimension. JCO 2001, 35 (8); 479-490. 9)Richard P McLaughlin, John C. Bennett : The Dental VTO : An analysis of orthodontic tooth movement. JCO 1999,33(7) ; 394-403.
  146. 146. 10) Lew B. Sample,Lionel Sadowsky, Edwin Bradley : An evaluation of 2 VTO methods. Angle Orthod 1998;68(5);401-408. 11) Roberts M Ricketts, Ruel W Bench, Carl F Gugino, james J Hilgers, Robert J Schullof : Bioprogressive Therapy. Rocky Montain/Orthodontics. 1980. page- 35-54.
  147. 147. Thank you Leader in continuing dental education