This presentation discusses details about *Clinical VTO *Cephalometric VTO *Dental VTO *Surgical VTO

1. Visualized Treatment Objective(VTO)
Presented by: Dr. Shriya Murarka
Guided by: Dr. Sunita Shrivastav Ma’am

2. Content
• Definition
• Types
1. Clinical VTO
2. Cephalometric VTO
3. Dental VTO
4. Surgical VTO
 Paper Surgery
 Digital VTO
• Summary
• Conclusion
• References
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3. Introduction
• A treatment planning and communication aid that may be used to define the tooth
movements and / or surgical changes required to achieve the desired facial goals.
• Holdaway coined the term visualized treatment objectives.
• A visual treatment objective is like a blue print used in building a house.
• It is a visual plan to forecast the normal growth of the patient and the anticipated
influences of treatment, to establish the individual objectives that are to be achieved
for that patient.( Ricketts)
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4. Jacobson and Sadowsky have outlined the
accomplishments of VTO
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 favorable incisor
repositioning, based on an “ideal”
projected soft tissue facial profile.
5. Assists in determining total arch
length discrepancy when taking into
account “cephalometric correction.”
6. Aids in determining between
extraction and non-extraction treatment.
7. Aids in deciding which teeth to
extract, if extractions are indicated.
8. Assists in planning treatment
mechanics.
9. Assists in deciding which cases are
more suited to surgical and/or surgical-
orthodontic correction.
10. It provides a visual goal or objective
for which to strive during treatment
12/19/2020Jacobson A, Sadowsky PL. A visualized treatment objective. J Clin Orthod 1980;14:554-71. 4

5. Advantages of the VTO
1. Establishment of specific treatment
goals.
2. Formulation of specific treatment
plan to reach treatment goals.
3. Assistance in making midtreatment
correction.
4. Assistance in determining if an ideal
treatment result is attainable
orthodontically/surgically.
5. Enhancing communication between
patients and clinicians..
6. Allowing quantification of proposed
movements to reduce the difficulties in
planning a facial response to different
movements
7. Allowing rapid comparisons of
different treatment options before
arriving at a final treatment plan.
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Visual Treatment Objective: A Review. Indian Journal of Dental Advancements [Internet]. 2018 Sep 30 [cited 2020 Apr
13];10(3). Available from: http://rep.nacd.in/ijda/10/03/10.03.10136.pdf 5

6. 12/19/2020 6
VTO
Clinical Cephalometric
Holdaway
Rickett
Dental
Non surgical
Surgical
Surgical
Paper surgery
Digital VTO

7. Clinical VTO
By Frankel

8. Clinical VTO
• This gives the operator an excellent clue to as
to whether the functional appliance that
postures the mandible forward will improve the
facial appearance and profile.
• Step 1: Habbitual occlusion
• Step 2 : posture the mandible forward into
correct sagittal relationship, reducing the
overjet
Orofacial Orthopedics with the functional Regulator; Frankel F, 7.2,53; 12/19/2020 8

9. If this clinical exercise makes the facial
balance look better, the functional
appliance will probably be beneficial.
The photograph taken can be used to
motivate the patient to an achievable
treatment goal.
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10. • If the profile is not improved by
forward mandibular positioning or is
actually made worse other forms of
treatment may probably be needed.
• Obviously a cursory visualization is
no substitute for cephalometric
analysis to determine the best
possible appliance.
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11. Cephalometric VTO • It is a cephalometric tracing
representing the changes that are
expected during treatment.
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Holdaway’s VTO
•1957
Ricketts’ VTO
•1984

12. Rickett’s VTO
It is presented in the following sequence
• Cranial base prediction
• Mandibular growth prediction
• Maxillary growth prediction
• Occlusal plane position
• Location of dentition
• Soft tissue of the face
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13. 1) Cranial base prediction
• Place the tracing paper over the
original tracing.
• Starting at the CC point following
steps are used to construct the cranial
base.
• Trace the basion nasion line. Grow the
nasion 1mm / year (grow for the
estimated amount of time). Grow
basion 1mm / year. Slide tracing back
so nasion coincide and trace nasion
back. Slide tracing forward so the
basion coincides and trace basion area
.
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14. 2) Mandibular growth prediction :
• Construction of mandible in its new
position starts with the rotation of
mandible.
• Rotation : Mandible either opens or closes
from the effects of mechanics used & with
facial pattern.
With mechanics :
• Convexity reduction – facial axis open 1 ̊̊
for 5mm
• Molar correction – facial axis open by 1 ̊
for 3 mm
• Overbite correction – facial axis open 1 ̊ for
4mm
• Cross bite correction – facial axis open by
1 ̊ to 1 ½ ̊
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15. • Now go to the original tracing
• Superimpose at basion along the
basion-nasion plane.
• Using Dc point rotate up at nasion to
open the bite and rotate down at
nasion to close the bite.
• This rotation depends on anticipated
treatment effects.
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16. Condylar axis and corpus axis growth
Trace the condylar axis, coronoid process
and condyle.
• On the condylar axis make mark 1mm
per year down from point DC.
• Slide the mark up to the basion nasion
line
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17. • Extend the condylar axis to the Xi
point, locating a new Xi point.
• With the old and new Xi points
coinciding, flare corpus axis, extend it
2mm per year forward of the old PM
point (PM point moves forward 2mm /
year in normal growth).
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18. Symphysis construction
• go to original tracing
• Slide back along the corpus axis
superimposing the new and old PM
points.
• Trace the symphysis and draw in
mandibular plane.
• Construct the facial plane from NA to
PO.
• Construct a facial axis from CC to Gn.
(where facial plane and mandibular
plane cross)
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19. 3) Maxillary growth prediction
• Return to original tracing
• To locate the new maxilla within the
face, superimpose at nasion along the
facial plane and divide the distance
between the original and new mentons
into third by drawing two marks.
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20. • To outline the body of maxilla,
superimpose mark # 1 (superior mark)
on the original menton along the facial
plane
• Trace the palate (with exception of
point A).
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21. Point A change related to BA-NA
• Point A changes with various
mechanics (maximum change)
• Head gear - 8mm
• Class II elastics - 3mm
• Activator - 2mm
• Torque - 1-2 mm
• Class III elastics + 2to 3 mm
• Face mask + 2 to 4 mm
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22. As point A changes as a result of growth
and mechanics, Point A and a new APO
plane are drawn by following steps.
• Return to original tracing
• Point A altered distally with
treatment – for each mm of distal
movement. Point ‘A’ will drop ½ mm
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23. 4)Occlusal Plane
• Superimpose mark # 2
on original menton and
facial plane, then
parallel mandibular
planes rotating at
menton.
• Construct a occlusal
plane (may tip 3 degrees
either way depending on
class II or class III
treatment)
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24. 5) Dentition
Lower incisor :
• it is placed in relation to the Symphysis of
mandible, the occlusal plane and APO plane
• Return to original tracing
• Superimpose on the corpus axis at PM.
Place a dot representing the tip of the lower
incisor ideal position which is 1mm above
the occlusal plane and 1mm in front of the
APO plane.
• Aligning over the original incisor outline
draw the lower incisor in final position. The
angle is at 22 ̊ at 1mm to the APO plane
and +1mm to the occlusal plane
• but the angle increases 2 ̊ with each mm of
compromise
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25. Lower molar :
• Without treatment, the lower molars
will erupt directly upwards to the new
occlusal plane.
• With treatment 1mm of molar
movement equals 2mm of arch length.
• Superimpose lower molar on the new
occlusal plane at the new molar
position
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26. Upper molar
• Return to original tracing
• Trace the upper molar in good class
I relationship to the lower molar by
using old molar as template.
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27. Upper incisors : place upper incisors in
good overbite
• Overbite position (2 ½mm of overbite
and overjet) with an interincisal angle
of 130 ̊̊ ± 10 .
• In open bite pattern, keep a greater
angle
• In deep bite pattern, keep at a lesser
angle.
• Do this by using the original incisor as
template.
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28. a) Nose
• Superimposed at nasion along facial
plane and palatal plane, the prediction
is moved back 1 mm/year along the
palatal plane, and the tip of the nose is
traced fading into bridge.
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6) Soft tissue tracing

29. • Superimpose along the facial plane at
occlusal plane.
• Divide the horizontal distance between
the original and new upper incisor tips
into thirds by using two marks.
• Soft tissue point ‘A’ remains at the same
relationship to point A as in the original
tracing
• superimpose new and old point A, and
make a mark at soft tissue point A.
• Keeping the occlusal planes parallel,
superimpose mark # 1 (posterior mark)
on the tip of original incisor slide
forwards by 2/3 rd. Trace the upper lip
connecting with point ‘A’.
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30. Lower lip, point B, soft tissue chin :
• In constructing the lower lip
• Bisect overjet and overbite of the
original tracing and mark a point.
• Then bisect the overjet and overbite of
the V.T.O. and mark the point.
• Superimpose interincisal points
keeping occlusal planes parallel and
trace lower lip and soft tissue B point.
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31. Completed tracing with superimposition
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32. 12 sequential steps
Plane of reference is Sn plane
Step 1: Copying original tracing
a) The frontonasal area
b) The sella nasion line
c) The nasion point A line
• Step 2:
A) Superimpose SN line.
B) Move the tracing to show expected
growth. Copy the sella outline.
C) copy or change facial axis.
Holdaway, R. A. (1984). A soft-tissue cephalometric analysis and its use in orthodontic treatment planning. Part II. American
Journal of Orthodontics, 85(4), 279–293. doi:10.1016/0002-9416(84)90185-4
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Holdaway’s VTO

33. Step 3: Vertical growth of mandible
determining anterior facial height
a) Superimpose VTO tracing on SN
line.Move VTO SN line above
original SN
b) copy the anterior portion of the
mandible, including the symphysis
and anterior half of the lower border.
Also draw the soft-tissue chin
c) Copy the Downs mandibular plane
Step 4 : Anteroposterior growth of
mandible, determining the posterior
border
a) superimpose on the mandibular
plane and move the VT0 forward
until the original sella and the VT0
sella are in a vertical relation.
b) with the tracing in this position, copy
the gonial angle, the posterior
border, and the ramus.
c) superimpose on sella to complete the
condyle.
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34. • Step 5: Maxilla and Lower nose
a) Superimpose the VTO NA line on the
original NA line and move the VTO up
until 40% of the total growth is
expressed above the SN line and 60%
below the mandible.
b) With the tracing in this position, copy
the maxilla to include the posterior
two thirds of the hard palate, PNS to
ANS to 3 mm below ANS.
c) with the tracing in this same position,
complete the nose outline around the
tip to the middle of the inferior surface.
• Step 6: Occlusal Plane
a) with the VT0 still superimposed on the
line NA, move the VT0 so that vertical
growth between the maxilla and the
mandible is expressed 50% above the
maxilla and 50% below the mandible.
b) with the tracing in this position, copy
the occlusal plan.
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35. Step 7: Lip contour
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.
b) with the tracing still superimposed on
the maxilla and line NA 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.
Textbook of craniofacial growth; Shreedhar premkumar;Growth prediction;206 12/19/2020 35

36. Step 8: Upper incisor position
a) Lip strain
b) Upper lip change
c) Maxillary incisor rebound
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37. Step 9: Lower incisor position
• superimpose the VTO on the
mandibular plane and symphysis.
Using the template, reposition
the lower incisor to be in ideal
retention occlusion with the
maxillary incisor, using the
occlusal plane as a guide and by
tipping the tooth about the apex
unless bodily movement is needed
to improve the form of the inferior
sulcus area.
• Amount of lower incisor
movement
Total discrepancy= (2*lower incisor
movement)+Crowding(calculated by
model analysis)
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38. Step 10: Lower molar position
With the tracing superimposed on the
mandibular plane and symphysis and
using the occlusal plane as a vertical
guide, draw the lower molar where it
must be to eliminate remaining space if
extractions must be part of the
treatment plan.
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39. Step 11: Upper molar position
• First, using the occlusal plane and the
lower first molar as a guide, with a
tooth template, position the upper first
molar in ideal Class I occlusion with
the lower first molar.
• Second, superimposing tracings on the
original NA line and the outline of the
maxilla, evaluate the extent of upper
molar movement.
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40. Step 12: Point A
• The position of Point A is assessed by
the best fit of the maxilla.
• Drastic change when bodily movement
of upper incisors or orthopedic
appliance
• Change is analysed and drawn
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41. Completed tracing
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42. Disadvantages of cephalometric VTO
• Only 2 Dimensions
• Growth behavior can be observed only relative to an arbitrarily chosen
point location and reference line
• 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 fixed reference point
• Incapable of correctly depicting time related changes of biologic shape or
of changes in location of shapes ; only anecdotal observations are
possible
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43. Dental VTO
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44. Dental VTO
• The dental V.T.O was designed to provide organized and simplified information
to help in diagnosis, treatment planning and extraction / non- extraction
decision.
• It should be used as a adjunct and not substitute for conventional
Cephalometric analysis.
• It takes little time to complete and occupies only a small part of the treatment
card. Dental V.T.O. provides specific information concerning the movements of
the midlines, canines and molars after desired incisor position has been
established.
• It can be used for both orthodontic cases (using three charts) and surgical
cases (using five charts).
The Dental VTO: An Analysis of Orthodontic Tooth Movement
RICHARD P. McLAUGHLIN; JOHN C. BENNETT; JCO, July 1999
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45. 3 charts for
orthodontic case
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46. 12/19/2020 46

47. 1. Midline-molar position
• Chart 1 : provided to record midline
and molar relationship. It is essential
that these factors be recorded with the
mandible in centric relation.
• Arrows are used to record the direction
of class II or class III molar
relationship and left or right midline
deviation. Midline deviations due to
functional side shifts are not recorded,
since they represent deviation from
centric relation. (CR)
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48. 2. Lower arch discrepancy
Chart 2 :
• It records lower arch discrepancy in
two columns. The 3 to 3 column on the
left, for factors occurring from canine
to canine and the 7 to 7 column on
right ; for factors related to the entire
lower arch.
• Each column is further divided into
right and left sides.
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49. • Completed chart
• The decision was made for all 4 1st
premolar extraction.
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50. Chart 3 : Planning the
proposed dental movements
• provides specific information on the planned
movements of the midlines, canines and
molars.
• Lower midline correction : this is based on
the original lower dental midline position
recorded in chart 1.
• Lower canine movements : this is based on
the remaining discrepancy in chart 2. If
there is a negative value then the canine
should move to an equivalent amount. A
positive value requires a mesial movement of
the canine.
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51. • Lower premolar / molar space : this is
space gained in the premolar, molar area
by procedures like stripping, extraction,
expansion and distalization of molars.
• Lower first molar movements : this
movement is based on the required
movement of canine and available space
in premolar region.
• Upper first molar movement : the
planned movement in the upper arch is
based on the initial molar relationship
recorded in chart 1 and the movement
recorded for the lower molars. (This
calculation does not take into account
the growth changes)
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52. 12/19/2020 52
Pre post

53. 12/19/2020 53

54. Dental VTO for surgical case
• Midline molar position
• Lower arch discrepancy
• Proposed Lower arch dental
movements
• Upper arch discrepancy
• Proposed Upper arch dental
movements
Proposed Upper Arch Movement

55. 12/19/2020 55
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56. Chart 1: Recording the initial position of molars and
canine
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57. Chart 2: Recording
lower arch
discrepancy
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58. Chart 3: Planning the lower arch tooth movement
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59. Chart 4: Recording
upper arch
discrepancy
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60. Chart 5: Planning the upper arch tooth movement
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61. 12/19/2020 62
PRE POST

62. PRE POST
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63. 12/19/2020 64
PRE POST

64. Surgical VTO
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65. • It was Wolford (1985) who used the VTO for surgical-orthodontic treatment
planning and coined the term Surgical Treatment Objective (STO).
Uses of an STO: (Taylor 1998)
Plan dental movements.
 Assess need for extractions
Plan mechanics.
Plan type of surgery and nature of osteotomies.
A basis for communication, informed consenting, splint construction.
Provides a reasonable prediction of soft tissue changes, that can provide a basis
for computer imaging.
Wolford, L.et al STO prediction tracing. 1985 Mosby, St.Louis
Taylor, P. In ‘orthodontics and dentofacial orthopaedics’ Ch.
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66. The objective of treatment simulation is to allow the clinician to visualize and
manipulate the skeletal and dental structures, so to compare different treatment
alternatives.
• Paper surgery method has been in use for the past 20 years.
• Acetate tracings of skeletal structures are manually repositioned over the
original cephalometric tracing to simulate the proposed surgical movements.
• The post-treatment soft tissue outcome is established by using acceptable
guidelines for the ratio of soft to hard tissue changes.
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67. Class II case
Class II Division 1 malocclusion with
normognathic maxilla and retrognathic
mandible and horizontal growth pattern
with convex profile
Mandibular length short by 5mm.
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68. Tracing of maxilla
and mandible
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69. Correction by mandibular
advancement
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70. Class III case
• Angles’s class III malocclusion with
retrognathic maxilla and prognathic
mandible with horizontal growth
pattern and concave profile
• Mandibular length excess by 10 mm
with anteriorly positioned with saddle
angle of 116
• with normally positioned maxilla and
decreased length by 10 mm.
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71. Tracing of maxilla
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72. Tracing of mandible
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73. Maxillary advancement
and mandibular setback
planning
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74. The major weaknesses of this technique is that:
• Variables in soft tissue thickness, tonicity, individual responses
• Differences in the surgeon’s manipulation will introduce
uncertainties that make soft tissue prediction more of an ‘art’ form.
• The ‘line drawing’ produced by this approach is an inadequate
means by which to portray the proposed result to the patient.
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75. Digital VTO
• Computerised diagnostic and planning software that produced a soft tissue profile ‘line
drawing’ as a result of manipulation of digitised structures of lateral cephalometric
radiographs.
• Using any of the commercially available programmes, the clinician can simulate
surgical movements on the screen and rapidly compare different treatment options.
• Hard copies can then be used as visual aids in treatment planning. This method of
prediction is no more accurate than manual predictions as the computer predictions are
based on the same guidelines and the resultant line drawing is still lacking in providing
a lifelike aesthetic representation.
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76. • Computerised diagnostic and planning
software that integrates video images
with the patient’s lateral cephalograph to
aid in planning and predicting surgical
orthodontic procedures
(Videocephalometrics).
• Visualisation of facial changes is
enhanced as is patient/clinician
communication; alternative treatment
plans can be evaluated with ease, and
realistic patient expectations may be
achieved
Orthognathic Prediction Software
There are numerous programmes available
for the analyses and prediction of
orthognathic treatment:
• OPAL image version 2.2
• Dolphin imaging 10
• Dentofacial Planner 8.05
• Quick Ceph Image
• Computer assisted simulation system for
Orthognathic surgery (CASSOS)
• NEMOCEPH
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77. Advantages of digital imaging over other prediction
techniques
• The image facilitates communication between clinician and patient by
establishing visual treatment goals for orthodontics and surgery. By
involving the patient in the decision of treatment options, acceptance of
the treatment outcome should be improved.
• Valuable aid in treatment planing decisions by providing a maniputable
image for the orthodontist and surgeons to decide on the best soft tissue
outcome. This technique is also helpful on deciding the necessity of
adjunctive soft tissue procedures
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78. • In order to use a computer programme
to plan orthognathic treatment, the
radiograph needs to be digitised prior
to analysis. Two methods are described
1. Direct computer digitisation of the
radiograph:
The radiograph is placed onto a
digitising light box. Anatomical points
are entered into computer using a cursor
or electronic pen
2. Indirect computer digitisation of the
radiograph:
• Image is captured (scanned image or
true digital image) and stored on the
computer. Image displayed in
orthognathic programme and digitised
using a cursor.
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79. Case example for surgical
planning
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80. Extraoral Photos

81. Intraoral Photos
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82. Radiographs
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83. Cephalometric surgery

84. Manual method

85. Nemoceph Tracings

86. Pre Surgical VTO

87. References
• Jacobson A, Sadowsky PL. A visualized treatment objective. J Clin Orthod
1980;14:554-71.
• Visual Treatment Objective: A Review. Indian Journal of Dental Advancements
[Internet]. 2018 Sep 30 [cited 2020 Apr 13];10(3). Available from:
http://rep.nacd.in/ijda/10/03/10.03.10136.pdf
• William Arnet; Facial and dental planning for Orthodontists and Oral surgeons
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88. Thankyou
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