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VVISUALISUAL
TTREATMENTREATMENT
OOBJECTIVEBJECTIVE
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ContentsContents
• Introduction
• Importance of V.T.O in Orthodontics
• Construction of V.T.O ( by Ricketts)
• Dental V.T....
• Three Dimensional planning & visualization
• Current status of Three Dimensional
Imaging
• S.T.O
–Initial S.T.O
–Final S...
Definition :
A treatment planning and communication
aid that may be used to define the tooth
movements and / or surgical c...
IntroductionIntroduction
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• Holdaway coined the term visual
treatment objectives but it more often
associated with Rickets and Rocky
Mountain Data s...
• Treatment for a growing patient must
be planned and directed to the face
and structure that can be anticipated
and not t...
Importance of V.T.O. in Orthodontics:Importance of V.T.O. in Orthodontics:
For a child V.T.O. incorporates the expected
gr...
So for a skeletally normal child, preparing a
V.T.O. using average growth increments can
be quite helpful in understanding...
The visual treatment objective permits
development of alternative treatment
plans.
Then the orthodontist must decide how f...
During treatment it can be used to monitor
measure the treatment progress.
Any deviation from the expected progress will
b...
For an adolescent and adult where the associated
variables with growth are not present (or where
little growth is remainin...
V.T.O by FrankelV.T.O by Frankel
( FR-VTO )( FR-VTO )
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• This gives the operator an excellent clue to as to
whether the functional appliance that postures the
mandible forward w...
• Patient is then asked to posture the mandible
forward into correct sagittal relationship, reducing
the overjet.
• Photog...
• If the profile is not improved by forward mandibular
positioning or is actually made worse other forms of
treatment may ...
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ConstructionConstruction of V.T.Oof V.T.O
(by Ricketts)(by Ricketts)
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The growth prediction is presented in the
following sequence
Cranial base prediction
Mandibular growth prediction
Maxillar...
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Cranial base prediction
Place the tracing paper over the
original tracing. Starting at the
CC point following steps are
us...
ii) Mandibular growth
prediction :
Construction of mandible in its
new position starts with the
rotation of mandible.
Rota...
For facial patterns :
For every standard
deviation on the dolicofacial
pattern side, it opens by 10
.
And for every standa...
Now go to the original
tracing
Superimpose at basion
along the basion-nasion
plane.
Using Dc point rotate up at
nasion to ...
Condylar axis and corpus axis growth
Trace the condylar axis,
coronoid process and
condyle.
On the condylar axis make
mark...
Extend the condylar
axis to the Xi point,
locating a new Xi
point.
With the old and new
Xi points coinciding,
flare corpus...
Symphysis construction
go to original tracing
Slide back along the corpus
axis superimposing the new
and old PM points.
Tr...
iii) Maxillary growth prediction
Return to original
tracing
To locate the new
maxilla within the face,
superimpose at nasi...
To outline the body
of maxilla,
superimpose mark #
1 (superior mark) on
the original menton
along the facial plane
Trace t...
Point A change related to BA-NA :
Point A changes with various mechanics (maximum change)
Mechanics Maximum range
Head gea...
As point A changes as a
result of growth and
mechanics.
Point A and a new APO
plane are drawn by
following steps.
Return t...
IV) V.T.O. – occlusal plane
position :
. Superimpose mark #
2 on original menton
and facial plane, then
parallel mandibula...
V) V.T.O. dentition :
Lower incisor
it is placed in relation to the
Symphysis of mandible
The occlusal plane
APO plane
Ret...
. Superimpose on the corpus axis
at PM.
Place a dot representing the
tip of the lower incisor ideal
position which is 1mm ...
Lower molar :
Without treatment, the lower molars
will erupt directly upwards to the
new occlusal plane.
With treatment 1m...
Upper molar :
Return to original
tracing
Trace the upper
molar in good class I
relationship to the
lower molar by
using ol...
Upper incisors :
place upper incisors in good
overbite
Overbite position (2 ½mm of
overbite and overjet) with an
interinci...
VI) V.T.O. of soft tissues
a) Nose :
Superimpose at nasion along
facial plane
trace bridge of the nose
Superimpose, at ANS...
Superimpose along the facial plane
at occlusal plane.
Divide the horizontal distance
between the original and new
upper in...
c) Lower lip, point B, soft
tissue chin :
In constructing the lower lip
Bisect overjet and overbite of
the original tracin...
Go to original tracing :
Superimpose interincisal points
keeping occlusal planes parallel.
Trace lower lip and soft tissue...
Completed V.T.O. :
When all the steps
are completed we have
our V.T.O
Take the V.T.O
and superimpose in
the five areas to
...
Superimposition (area # 1) basion
nasion at CC.
To evaluate the facial axis change
To evaluate chin growth
Upper molar pos...
Superimposition area # 4
 palate at ANS
To evaluate change within
maxilla – Molars& Incisor
changes
Superimposition area ...
DENTAL V.T.ODENTAL V.T.O
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The dental V.T.O was designed to provide
organized and simplified information to help in
diagnosis, treatment planning and...
It can be used for both orthodontic cases
(using three charts) and surgical cases (using
five charts).
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Using the three charts for
orthodontic case:
Chart 1 : is provided to record midline and molar relationship.
It is essenti...
Arrows are used to record the direction of class II or
class III molar relationship and left or right midline
deviation.
M...
Chart 2 :
It records lower arch discrepancy in two columns.
The 3 to 3 column on the left, for factors occurring from cani...
The following factors are recorded.
1. Crowding or spacing in anterior segment:
This recorded from canine to midline. It i...
2. Crowding or spacing
in premolar region :
this recorded in 7 to 7
column.
3. Crowding or spacing
in the molar area : thi...
4. Curve of spee : recorded by placing a ruler from the distal molar to
the central incisor on each side of the lower arch...
5. Midlines : negative and positive values are recorded in both 3 to
3 column and 7 to 7 column.
If lower skeletal midline...
6. Incisor position :
Anterior and posterior movements of the lower incisors is
recorded as positive and negative values.
...
7. Initial discrepancy :
This represents the total information gathered till this
point in the lower arch analysis.
This i...
8) Interproximal enamel reduction :
If interproximal enamel reduction is indicated the
figures are recorded as positive fi...
9. Expansion :
If intercanine expansion is planned then it is
recorded in 3 to 3 column (source amount recorded) in 7
to 7...
10. Distallization of lower molars :
If an attempt is made to upright or distallize the
lower first molars. The numbers ar...
Chart 3 :
It provides specific information on the planned movements of the
midlines, canines and molars.
Lower midline cor...
Lower premolar / molar space : this is space gained in the premolar,
molar area by procedures like slenderization extracti...
Upper premolar / molar space : first mesial to the upper first molar
mentioned in the figure. This represents the original...
V.T.O in surgical cases
Here the chart 1 and
chart 2 are similar to
how we use in a non-
surgical case.
Chart 3 : planning...
Chart 4 :
Recording of upper arch
discrepancy completed
the same way as chart 2
for a non surgical case
but only for upper...
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Computer Cephalometric
and
Video Imaging Predictions
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cephalometric information into computer memory
is accomplished by digitizing points on the
cephalometric tracing.
First co...
Many orthodontists routinely use cephalometric software for
case diagnosis, treatment planning and also for formulation
co...
Digitization is a process by which analog information in converted
into digital form.
During process of digitization the x...
Modes of digitization
- Point mode
- Stream mode
Point mode digitization
refers to discrete location
of individual landmar...
Stream mode here the
stream of co-ordinated pairs
is recorded as the as the user
traces a radiographic
contour.
This requi...
Application in treatment
visualization
Two visualization approaches are prevalent
Image editing system
Photo cephalometric...
Image editing system :
Here the facial images are modified using a
variety of simple image editing tools to stimulate
the ...
These rectangular
region of pixels may
also be stretched in a
horizontal or vertical
direction or
proportionately
enlarged...
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Unfortunately the human face is rarely represented
as a collection of rectangles. So it cannot show
complex movements and ...
Photo cephalometric treatment
visualization :
The preferred approach to treatment visualization
involves the software that...
Lateral and frontal photographs are takes with a
35mm camera are mounted on cephalometric x-ray
machine such that it is al...
Positive photographic transparencies are made at a enlargement factor
required to superimpose precisely the visible metall...
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The orthodontist performs the treatment
visualization by manipulating the skeletal and
dental structures on the Cephalomet...
Image standardization for
vediocephalometry
Proper vedio imaging technique has
virtually the same requirements like
radioc...
Vedio imaging has other requirements like
Control of magnification and distortion of image
introduced by hard ware (like c...
Uses of vedio cephalometry :
Patient communication :
Impact of vedio imaging as a communication tool is
tremendous.
In a s...
Treatment in adolescent and adults :
Treatment visualization using computer vidioimaging
is different for growing and non-...
So the use of computer vedio cephalometric
imaging is less predictable in adolescents when
compared with the adults, as th...
Limitations of photocephalometric
analysis :
Facial image acquisition methods are much less well
established
variables suc...
Therefore the cephalometric tracing do not
accurately superimpose over the facial image.
The soft tissue changes cannot be...
Studies done on photocephalometric
analysis :
Hohe et al  first to describe superimposition of clinical
photograph over c...
Thomas J. Cangialosi et al :
Did a study on commercially available computer
prediction programme (quick ceph II) and the
c...
Glenn ,Sameshima et al :
Did a study to evaluate soft tissue changes
prediction in an all 4 extraction case.
Result showed...
THREE-DIMENSIONAL PLANNINGTHREE-DIMENSIONAL PLANNING
&&
VISUALIZATIONVISUALIZATION
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To be more precise in establishing orthodontic
treatment objectives, it is useful to have tracings in
three dimensions, wh...
. These initial tracings also provide a basis for
comparison with progress tracings as well as a
comparison with the postt...
Because orthodontic treatment is three-
dimensional, proper treatment planning requires
three tracings :
the lateral view ...
The three-dimensional
treatment objectives
are shown in three
tracings.
The lateral view, the
Y-Z plane, displays the
orig...
The occlusogram shows
the planned treatment in the
X1-Z1 plane. The original
tooth position is shown in
black.
First, the ...
Then the treatment midline is
established ; this is shown as a
vertical gray line at the incisors
.
The mesiodistal diamet...
. After determining an arch
length inadequacy for each
quadrant, the decision is made
to extract upper first premolars.
Th...
Initial malocclusion
Treatment objectives
achieved
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The frontal view (Y-X
plane) originating from the
posteroanterior head film.
Planning in this view is
helpful for midline
...
Current status
of three
dimensional
imaging
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The craniofacial imaging database currently in
clinical use are designed primarily image
management system for storage, re...
The two dimensional images are composed of
subunits called the picture elements (pixels).
Whereas the three dimensional di...
Tremendous amount of anatomic information is contained
within the voxel volumes and this information can be
retrieved anal...
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SSurgicalurgical
TTreatmentreatment
OObjectivebjective
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The STO is an essential two-dimensional tool in
surgical orthodontic correction of dentofacial
deformities.
The purpose of...
The STO has significant importance in two phases
of treatment planning:
1) The initial STO is prepared before treatment to...
Initial STOInitial STO
In the initial STO, presurgical orthodontic
treatment goals must be established so that the
teeth c...
PRESURGICAL ORTHODONTIC GOALPRESURGICAL ORTHODONTIC GOAL
Presurgical orthodontic treatment goals must be
established by cl...
Ideal presurgical
orthodontic goals are
Position the long axis of
the maxillary incisor at 22
degrees to the nasion-point
...
Removal of dental compensations is
necessary before surgery for maximal
skeletal correction. Correcting the incisors
with ...
Ideal incisor positions and the
corresponding acceptable ANB
angles for orthodontic treatment
as advocated by Root and
Sag...
As the ANB angle is increased, it is
necessary to decrease the upper
incisor angle to the NA line and the
distance from th...
The exact orthodontic treatment plan and
anchorage requirements necessary to
position the teeth to satisfy the presurgical...
The original cephalometric radiograph is traced in black
pencil on matt acetate. Once the initial orthodontic goals
are es...
Cephalometric parameters required to
evaluate the dental compensation due
to underlying skeletal discrepancy are:
Frankfur...
Upper incisor to facial axis – A
line passing through the long
axis of upper incisor
comparable to the parallel of
facial ...
This involves the following steps
Draw the initial tracing with orientation
reference marks including the dentition,
hard ...
The objective is to decompensate to attain a class II
molar relation, a class II incisor relation and to
create sufficient...
This can be carried out by
drawing a vertical reference
line at the extraction space
of first premolar
perpendicular to th...
Construction of vertical
reference line – To simulate the
above planned tooth movement a
vertical reference line
perpendic...
On a third tracing sheet the
occlusal plane is traced along
with the vertical reference line.
Keeping the occlusal plane a...
To simulate the amount of
anterior retraction, slide the
tracing backwards along the
occlusal plane such that the
vertical...
In the lower arch, to
simulate anterior retraction
the tracing is slid along the
occlusal plane such that
the vertical ref...
Make the necessary
remodeling changes in
the hard and soft tissues
following dental
decompensation.
This is traced on a
fo...
Final S.T.O
Accurate determination of skeletal movements is very
essential in treatment planning prior to the surgery. Thi...
Maxillary Segmental Superior Repositioning ;
Mandibular advancement; Vertical Reduction
and APAugmentation Genioplasty
Sel...
A horizontal line parallel to
Frankfort horizontal,
extending from the vertical
line to the pterygoid plates
(The complete...
Mandibular surgical
reference lines
A vertical line in the area
of the vertical buccal
ramus osteotomy
A horizontal line a...
Step 1. Trace all
skeletal and soft tissue
structures that remain
unchanged by the
surgical procedures.
They include the
c...
Select the desired vertical
position of the maxillary
incisor by drawing a
horizontal line parallel to
Frankfort horizonta...
Step 2. The occlusal
plane must now be
determined..
Autorotate the mandible
by placing a pencil or
other instrument in the...
Step3
Trace the proximal mandibular
segment, including the vertical
surgical reference line.
The new occlusal plane can no...
. Step 4.
Position the anterior maxillary
segment.
Move the STO so that the
labial face of the maxillary
incisor is adjace...
Step 5.
Trace the anterior
maxillary segment, teeth,
and surgical reference
lines.
Superimposition of the
STO on the crani...
Step 6. Advance the
mandible by moving
the STO until the
mandibular teeth align
with the established
occlusal plane, with
...
Step 7.
Complete the
advancement by tracing
the mandibular teeth,
mandibular vertical
surgical reference line,
inferior bo...
Step 8.
Position the posterior
maxillary segments.
Move the STO until the
maxillary posterior
teeth interdigitate in
Class...
Step 9.
Trace the posterior
maxillary segment,
teeth, and surgical
reference lines..
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Step 10.
Remove the STO and
construct an NB line on the
STO.
This line is can be used to
determine the desired AP
position...
Determine the desired vertical
position of the chin from the
clinical evaluation and
cephalometric analysis.
A horizontal ...
Step 12. Slide the chin
forward keeping the
surgery lines
superimposed, until the
anterior portion of the
chin approximate...
Step 13.
Trace the osseous
chin segment.
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Step 14.
Superimposition of
the cranial base
structures
demonstrates the
surgical movements.
. Positional alteration
of th...
Step15
As the supporting lip
structures are moving for
ward; the soft tissues of
the lip and nose will
move forward also.
...
Step 16.
To determine soft tissue
change in the chin area,
align the chin of the STO
as well as possible with
the chin of ...
Step 17.
Draw in the soft
tissues of the chin up
to the level of the
horizontal reference
line of the chin.
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Step 18. Align the labial
surface of the
mandibular
dentoalveolus of the
STO with the
dentolveolus of the CT.
For a vertic...
Step 19.
Trace the remaining soft
tissues of the chin and
lower lip area.
The lower lip will be
elevated relative to the
l...
Step 20.
Superimposition of the
cranial base structures
will demonstrate the
osseous and soft tissue
changes.
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SOFT TISSUE PREDICTION
Soft tissue changes are very important in the
determination of final profile results and should be
...
P (pronasale) : The most prominent or anterior
point of the nose
Sn (subnasale) : The most posterior-superior
point on the...
PROCEDURE SOFT TISSUE
ANATOMIC POINTS
% CHANGE
Advancement LL+
B’
PO’
67-85
100
100
Setback UL
LL
B’
Po’
20
90
90
90
www.i...
PROCEDURE SOFT TISSUE
ANATOMIC POINTS
% CHANGE
Subapical advancement LL 60
Subapical setback LL 75
www.indiandentalacademy...
PROCEDURE SOFT TISSUE
ANATOMIC POINTS
CHANGE
Advancement P
UL
St
30%
50%
Unpredictable
Setback Sn
A
UL
St
30%
30%
50%-65%
...
PROCEDURE SOFT TISSUE
ANATOMIC POINTS
CHANGE
Superior repositioning P
Sn
UL
St
20%
20%
30-40%
20%-40%
Inferior repositioni...
PROCEDURE SOFT TISSUE
ANATOMIC POINT
LITERATURE
REVIEW CHANGE
AP augmentation (osseous) Po’ 75% -80%
AP augmentation
(allo...
PROCEDURE SOFT TISSUE
ANATOMIC POINT
LITERATURE
REVIEW CHANGE
Vertical reduction (inferior
border ostectomy)
Me’
Po’
- 30%...
PROCEDURE SOFT TISSUE
ANATOMIC POINT
LITERATURE
REVIEW CHANGE
AP reduction (anterior
ostectomy)
Po’ 25%
AP reduction (slid...
Conclusion
The dependence of the orthodontists
towards cephalometrics has grown since the
time of its inception in the fie...
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Proffit-Contemporary Orthodontics
Ricketts –Bioprogressive therapy
Arnett ,McLaughlin – Facial And Dental Planning For
Ort...
Graber ,Vanarsdall – Orthodontics Current principles and
techniques -4th
edition
Renkye – Orthognathic surgery
Wolford, Hi...
McLaughlin, Bennett. The Dental VTO: an analysis
of orthodontic tooth movement. JCO 1999,23:394-
403.
Hoss, Sameshima et a...
Philips et al-Photocephalometry errors of projection and hand
mark location. Am J Orth 1984,vol 86,239-245.
Image analysis...
David M. Sarver. Video cephalometric diagnosis- a
new concept in treatment planning. AMJODO
1996,11:128-134.
Bonham Magnes...
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VTO (visualised Treatment objective)

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VTO (visualised Treatment objective)

  1. 1. Good Morning… www.indiandentalacademy.com
  2. 2. VVISUALISUAL TTREATMENTREATMENT OOBJECTIVEBJECTIVE www.indiandentalacademy.com
  3. 3. ContentsContents • Introduction • Importance of V.T.O in Orthodontics • Construction of V.T.O ( by Ricketts) • Dental V.T.O • Computer cephalometric and Video Imaging Prediction • Image editing system • Photo cephalometric treatment visualization www.indiandentalacademy.com
  4. 4. • Three Dimensional planning & visualization • Current status of Three Dimensional Imaging • S.T.O –Initial S.T.O –Final S.T.O • Conclusion • References www.indiandentalacademy.com
  5. 5. Definition : 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. www.indiandentalacademy.com
  6. 6. IntroductionIntroduction www.indiandentalacademy.com
  7. 7. • Holdaway coined the term visual treatment objectives but it more often associated with Rickets and Rocky Mountain Data system (RMDS). • 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 we want to achieve for the patientwww.indiandentalacademy.com
  8. 8. • Treatment for a growing patient must be planned and directed to the face and structure that can be anticipated and not to be skeletal structure patient presents initially. • Essentially V.T.O. consists of patient’s cephalogram modified to demonstrate changes that are anticipated in the course of treatment which is accomplished manually or using a computer programme www.indiandentalacademy.com
  9. 9. Importance of V.T.O. in Orthodontics:Importance of V.T.O. in Orthodontics: For a child V.T.O. incorporates the expected growth or any growth changes induced by treatment i.e., by repositioning of teeth from orthodontic tooth movements. In a child with normal facial proportions, average growth increments are reasonably likely and growth modification is not likely a part of treatment so growth changes can be predicted quite well. www.indiandentalacademy.com
  10. 10. So for a skeletally normal child, preparing a V.T.O. using average growth increments can be quite helpful in understanding the amount of tooth movement needed for correction of malocclusion. But for a child with skeletal problem, given the uncertainity of both growth pattern and response to treatment, a V.T.O. is more often a presentation of what is hoped than what is likely to happen. www.indiandentalacademy.com
  11. 11. The visual treatment objective permits development of alternative treatment plans. Then the orthodontist must decide how far he must go with the mechanics and orthopedics to achieve his goals, whether it is possible to achieve them and what the alternatives are www.indiandentalacademy.com
  12. 12. During treatment it can be used to monitor measure the treatment progress. Any deviation from the expected progress will be recognized and can be instituted early. This type of monitoring is important in accommodating treatment to individual variability. V.T.O also helps in patient education and motivation and helps to achieve a better cooperation. www.indiandentalacademy.com
  13. 13. For an adolescent and adult where the associated variables with growth are not present (or where little growth is remaining) predicting treatment effects becomes easier and more reliable. V.T.O. forecast is valuable for the orthodontists self-improvement in that it permits him to set his goals in advance and compare them with result at the end of treatment. This gives him an objective picture of the areas in which his treatment could be improved.www.indiandentalacademy.com
  14. 14. V.T.O by FrankelV.T.O by Frankel ( FR-VTO )( FR-VTO ) www.indiandentalacademy.com
  15. 15. • 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. • First the patient is asked to swallow and then lick the lips and relax. • Then the patient is instructed to close the teeth in habitual occlusion, again licking the lips first and then to keep the teeth tightly together and lips relaxed. • These two profile relationships are carefully studied and may be photographed to obtain an instant print. www.indiandentalacademy.com
  16. 16. • Patient is then asked to posture the mandible forward into correct sagittal relationship, reducing the overjet. • Photograph of this profile may be compiled with the original snapshot depicting the teeth in occlusion. • 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. www.indiandentalacademy.com
  17. 17. • 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. www.indiandentalacademy.com
  18. 18. www.indiandentalacademy.com
  19. 19. ConstructionConstruction of V.T.Oof V.T.O (by Ricketts)(by Ricketts) www.indiandentalacademy.com
  20. 20. The growth prediction 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 www.indiandentalacademy.com
  21. 21. www.indiandentalacademy.com
  22. 22. 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 www.indiandentalacademy.com
  23. 23. ii) 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 & facial pattern. With mechanics : Convexity reduction – facial axis open 10 for 5mm Molar correction – facial axis open by 10 for 3 mm Overbite correction – facial axis open 10 for 4mm Cross bite correction – facial axis open by 10 to 1 ½0 , recovers half the distance. www.indiandentalacademy.com
  24. 24. For facial patterns : For every standard deviation on the dolicofacial pattern side, it opens by 10 . And for every standard deviation towards the brachyfacial side, it tends to close one degree. Facial axis may close as with the use of high pull headgear or due to extraction. www.indiandentalacademy.com
  25. 25. 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. www.indiandentalacademy.com
  26. 26. 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. www.indiandentalacademy.com
  27. 27. 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). www.indiandentalacademy.com
  28. 28. 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). www.indiandentalacademy.com
  29. 29. iii) 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. www.indiandentalacademy.com
  30. 30. 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). www.indiandentalacademy.com
  31. 31. Point A change related to BA-NA : Point A changes with various mechanics (maximum change) Mechanics Maximum range Head gear - 8mm Class II elastics - 3mm Activator - 2mm Torque - 1-2 mm Class III elastics + 2-3 mm Face mark + 2-4 mm www.indiandentalacademy.com
  32. 32. 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. www.indiandentalacademy.com
  33. 33. IV) V.T.O. – occlusal plane position : . 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) www.indiandentalacademy.com
  34. 34. V) V.T.O. dentition : Lower incisor it is placed in relation to the Symphysis of mandible The occlusal plane APO plane Return to original tracing www.indiandentalacademy.com
  35. 35. . 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 220 at 1mm to the APO plane and +1mm to the occlusal plane, but the angle increases 20 with each mm of compromise www.indiandentalacademy.com
  36. 36. 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. For example If the incisors are moved by 2mm we gain 4mm of space. There is leeway space So there was a net gain of 8mm space so lower molars can be moved by 4mm on each side. . Superimpose lower molar on the new occlusal plane at the new molar position www.indiandentalacademy.com
  37. 37. 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. www.indiandentalacademy.com
  38. 38. Upper incisors : place upper incisors in good overbite Overbite position (2 ½mm of overbite and overjet) with an interincisal angle of 1300 ± 100 . 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. www.indiandentalacademy.com
  39. 39. VI) V.T.O. of soft tissues a) Nose : Superimpose at nasion along facial plane trace bridge of the nose Superimpose, at ANS along palatal plane . Move prediction back 1mm per year along the palatal plane, trace the tip of nose fading into bridge. www.indiandentalacademy.com
  40. 40. 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’. www.indiandentalacademy.com
  41. 41. c) 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. www.indiandentalacademy.com
  42. 42. Go to original tracing : Superimpose interincisal points keeping occlusal planes parallel. Trace lower lip and soft tissue B point. The soft tissue below the lower lip remains in the same relationship to point B as in original tracing. Soft tissue point B drops down as the lower lip recontours. Superimpose on the symphysis and arrange the soft tissue of the chin. It ‘drops down’ and should be evenly distributed over the symphysis. (take into consideration reduction of strain and bite opening)www.indiandentalacademy.com
  43. 43. Completed V.T.O. : When all the steps are completed we have our V.T.O Take the V.T.O and superimpose in the five areas to establish individual objectives for case. www.indiandentalacademy.com
  44. 44. Superimposition (area # 1) basion nasion at CC. To evaluate the facial axis change To evaluate chin growth Upper molar position Superimposition area # 2  basion – nasion at nasion for evaluating Maxillary change To evaluate point A change Superimposition area # 3  corpus axis at PM To evaluate dentition To evaluate anchor requirements www.indiandentalacademy.com
  45. 45. Superimposition area # 4  palate at ANS To evaluate change within maxilla – Molars& Incisor changes Superimposition area # 5  Aesthetic plane at the intersection with occlusal plane. This is to evaluate the soft tissues www.indiandentalacademy.com
  46. 46. DENTAL V.T.ODENTAL V.T.O www.indiandentalacademy.com
  47. 47. 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. www.indiandentalacademy.com
  48. 48. It can be used for both orthodontic cases (using three charts) and surgical cases (using five charts). www.indiandentalacademy.com
  49. 49. Using the three charts for orthodontic case: Chart 1 : is provided to record midline and molar relationship. It is essential that these factors be recorded with the mandible in centric relation. www.indiandentalacademy.com
  50. 50. 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) www.indiandentalacademy.com
  51. 51. 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. www.indiandentalacademy.com
  52. 52. The following factors are recorded. 1. Crowding or spacing in anterior segment: This recorded from canine to midline. It is recorded as positive number for spacing and negative for crowding. It is recorded in the 3 to 3 column. The same figures are automatically recorded to 7 to 7 column. www.indiandentalacademy.com
  53. 53. 2. Crowding or spacing in premolar region : this recorded in 7 to 7 column. 3. Crowding or spacing in the molar area : this is also recorded only in 7 to 7 column. www.indiandentalacademy.com
  54. 54. 4. Curve of spee : recorded by placing a ruler from the distal molar to the central incisor on each side of the lower arch. The deepest point in the curve of spee can be measured in millimeters. These are divided in half and placed on the left and right side in 3 to 3 column (curve of spee may be different on the left and right side). Similar amounts are recorded in 7 to 7 column. www.indiandentalacademy.com
  55. 55. 5. Midlines : negative and positive values are recorded in both 3 to 3 column and 7 to 7 column. If lower skeletal midline deviation exists, and a decision is made to correct these deviations with dental compensations, the correction must be added to the lower dental midline area of chart 1 and then to chart 2. If the skeletal deviation is to be corrected surgically, then no correction is added to chart 2. www.indiandentalacademy.com
  56. 56. 6. Incisor position : Anterior and posterior movements of the lower incisors is recorded as positive and negative values. For eg : 1mm of anterior movement of incisor provides 1mm of space per side. This should be recorded on both sides of 3 to 3 column same thing is recorded in 7 to 7 column. Similarly if 2mm of posterior incisor movement is required then it is recorded as minus 2mm on both 3 to 3 column and 7 to 7 column www.indiandentalacademy.com
  57. 57. 7. Initial discrepancy : This represents the total information gathered till this point in the lower arch analysis. This is an appropriate time to decide the case will be treated on a non-extraction basis (whether it is possible to treat the ease by proximal slenderization, expansion or distallizing of first molars) or if extraction treatment is indicated. www.indiandentalacademy.com
  58. 58. 8) Interproximal enamel reduction : If interproximal enamel reduction is indicated the figures are recorded as positive figures in 3 to 3 column, same amount is recorded in 7 to 7 column. If enamel reduction is needed in premolar or molar region then it is recorded in 7 to 7 column. www.indiandentalacademy.com
  59. 59. 9. Expansion : If intercanine expansion is planned then it is recorded in 3 to 3 column (source amount recorded) in 7 to 7 column. If expansion is carried in premolar and molar region it must be added to 7 to 7 column. www.indiandentalacademy.com
  60. 60. 10. Distallization of lower molars : If an attempt is made to upright or distallize the lower first molars. The numbers are recorded in 7 to 7 column. 12. Remaining discrepancy : This records a total initial discrepancy which is gained. www.indiandentalacademy.com
  61. 61. Chart 3 : It 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. www.indiandentalacademy.com
  62. 62. Lower premolar / molar space : this is space gained in the premolar, molar area by procedures like slenderization extraction, expansion and distallization 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) www.indiandentalacademy.com
  63. 63. Upper premolar / molar space : first mesial to the upper first molar mentioned in the figure. This represents the original crowding and spacing in the premolar region and the space gained in this region by extraction, slenderiation arch expansion etc. Upper canine movement : this movement is recorded based on the movement of upper molars and space available in the premolar region. Upper midline correction : this is based on the original upper dental midline position recorded in chart 1. www.indiandentalacademy.com
  64. 64. V.T.O in surgical cases Here the chart 1 and chart 2 are similar to how we use in a non- surgical case. Chart 3 : planning of lower arch tooth movements. It is completed in the same way as the lower half of chart 3 in a non-surgical case. www.indiandentalacademy.com
  65. 65. Chart 4 : Recording of upper arch discrepancy completed the same way as chart 2 for a non surgical case but only for upper arch. Chart 5 : Planning the upper arch tooth movements. This is completed in the same way as the upper half of chart 3 of a non- surgical case. www.indiandentalacademy.com
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  67. 67. Computer Cephalometric and Video Imaging Predictions www.indiandentalacademy.com
  68. 68. cephalometric information into computer memory is accomplished by digitizing points on the cephalometric tracing. First computer cephalometric programs were used primarily for planning surgical treatment for adults. Now the commercially available programmes allow superimposition of profile images. Either the direct images or conventional images digitized by scanning are used onto the tracing, so that the doctor and patient can readily visualize the treatment effects. www.indiandentalacademy.com
  69. 69. Many orthodontists routinely use cephalometric software for case diagnosis, treatment planning and also for formulation complete generated visual treatment objectives. Different steps involved are: Digitization Display Analysis Treatment planning Hard copywww.indiandentalacademy.com
  70. 70. Digitization is a process by which analog information in converted into digital form. During process of digitization the x-y coordinates of the cephalometric landmarks are recorded and stored in a data base from which various cephalometric measurements are made. Digitizers may be opaque translucent or transparent. Translucent and transparent digitizers can be backlit. www.indiandentalacademy.com
  71. 71. Modes of digitization - Point mode - Stream mode Point mode digitization refers to discrete location of individual landmarks. This is time consuming but landmarks can be located more accurately. www.indiandentalacademy.com
  72. 72. Stream mode here the stream of co-ordinated pairs is recorded as the as the user traces a radiographic contour. This requires the user to use the mouse or the cursor to trace the contour so it is more technique sensitive. www.indiandentalacademy.com
  73. 73. Application in treatment visualization Two visualization approaches are prevalent Image editing system Photo cephalometric treatment visualization www.indiandentalacademy.com
  74. 74. Image editing system : Here the facial images are modified using a variety of simple image editing tools to stimulate the effects of treatment on facial form. The artistic skill of the operator controls the quality of the final image. Simple image editing applications lets the use copy a rectangular region of pixels from one region to another, in an cut and paste process www.indiandentalacademy.com
  75. 75. These rectangular region of pixels may also be stretched in a horizontal or vertical direction or proportionately enlarged or reduced. These basic image transformation capabilities, when performed in various combinations, can be used crudely to stimulate treatment induced facial changes.www.indiandentalacademy.com
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  78. 78. Unfortunately the human face is rarely represented as a collection of rectangles. So it cannot show complex movements and changes occurring due to this. A more sophisticated image editing approach is to sue a process known as “tessellation”. Digital image wrapping methods are used to transform the pixels within the tessellated surface to smoothly blend with the edges of the image in the stimulated post treatment image. www.indiandentalacademy.com
  79. 79. Photo cephalometric treatment visualization : The preferred approach to treatment visualization involves the software that extends the algorithms used in cephalometric treatment planning software to embrace lateral facial images. www.indiandentalacademy.com
  80. 80. Lateral and frontal photographs are takes with a 35mm camera are mounted on cephalometric x-ray machine such that it is aligned with the central ray. www.indiandentalacademy.com
  81. 81. Positive photographic transparencies are made at a enlargement factor required to superimpose precisely the visible metallic markers over their radiographic equivalents. To use cephalometric prediction as a guide for image manipulation, the pre treatment cephalogram must be linked in a meaningful way to the facial image. The cephalometric profile tracing is superimposed over the image profile and scaled, translated and rotated by the operator so that it matches the underlying contour of the facial bit map as closely as possible www.indiandentalacademy.com
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  86. 86. The orthodontist performs the treatment visualization by manipulating the skeletal and dental structures on the Cephalometric portion of the pair. The predicted cephalometric profile changes are automatically applied to the facial image regions. The differences between the pretreatment and predicted cephalometric profiles, when superimposed on the image, guide the manipulation of the regions of the bitmap during automatic generation of image www.indiandentalacademy.com
  87. 87. Image standardization for vediocephalometry Proper vedio imaging technique has virtually the same requirements like radiocephalometry. Standardization of rotational head position Desirability of natural head position Minimization and standardization of image magnification Reproducibility www.indiandentalacademy.com
  88. 88. Vedio imaging has other requirements like Control of magnification and distortion of image introduced by hard ware (like camera, monitor, software and cephalogram) Facial lighting requirements Should minimize shadowing, which makes visualization of facial contours difficult. Relaxed facial muscles is an requirement for appropriate evaluation, accurate prediction and reproducibility of images. www.indiandentalacademy.com
  89. 89. Uses of vedio cephalometry : Patient communication : Impact of vedio imaging as a communication tool is tremendous. In a study by Kiyak and associates. In non imaged patients 45% of patients should satisfaction with esthetic outcomes. Whereas in vedioimaging 85% of patients reported satisfaction with their esthetic outcome. This may be because the patients expectations of the outcome are successfully modeled www.indiandentalacademy.com
  90. 90. Treatment in adolescent and adults : Treatment visualization using computer vidioimaging is different for growing and non-growing patients. In a growing patient there are variables like Dynamics of facial growth In growing patients it not only involves the hard tissues (like maxilla, mandible and teeth) but also involves the soft tissues. This soft tissue profile in the final, adult profile is important. Treatment timing : treatment response is more dramatic when it is coordinated with the growth spurt. Local environmental factors and habits www.indiandentalacademy.com
  91. 91. So the use of computer vedio cephalometric imaging is less predictable in adolescents when compared with the adults, as the adults more static and their treatment outcomes are more predictable. www.indiandentalacademy.com
  92. 92. Limitations of photocephalometric analysis : Facial image acquisition methods are much less well established variables such as - Camera resolution. Focal length Distance from the camera to patient Lighting conditions Patients head positioning Lip position Mandibular postural position can and do vary greatly www.indiandentalacademy.com
  93. 93. Therefore the cephalometric tracing do not accurately superimpose over the facial image. The soft tissue changes cannot be mapped accurately Hence the orthodontist should exercise caution and restraint when providing image hard copy of treatment simulation to patients and should counsel patients as to limitations of imaging systems www.indiandentalacademy.com
  94. 94. Studies done on photocephalometric analysis : Hohe et al  first to describe superimposition of clinical photograph over cephalograms. Phillips et al have measured the errors inherent in photocephalometric superimposition i.e. whether lateral and frontal photographs can be accurately superimposed over lateral and frontal cephalograms. They reported that photographic images and radiographic images cannot be superimposed accurately at any depth. So photocephalometric technique cannot be implemented accurately www.indiandentalacademy.com
  95. 95. Thomas J. Cangialosi et al : Did a study on commercially available computer prediction programme (quick ceph II) and the computer prediction programme was compared with the manual method of prediction was sufficient to give a good graphic changes However the computer offers a added advantage. Quicker access of information and greater accuracy in producing the tracing www.indiandentalacademy.com
  96. 96. Glenn ,Sameshima et al : Did a study to evaluate soft tissue changes prediction in an all 4 extraction case. Result showed both V.T.O.& vedioimages were accurate. The predicted images resembled the treatment outcome. But one should be careful, particularly of the lower lip area where variable soft tissue response to treatment were noted. They also did study on vedioimaging for mixed and adolescent treatment and found that computer generated V.T.O. was more accurate in mixed dentition but unacceptable for adolescent group www.indiandentalacademy.com
  97. 97. THREE-DIMENSIONAL PLANNINGTHREE-DIMENSIONAL PLANNING && VISUALIZATIONVISUALIZATION www.indiandentalacademy.com
  98. 98. To be more precise in establishing orthodontic treatment objectives, it is useful to have tracings in three dimensions, where the original teeth, the bones, and the facial soft tissues are shown in the pretreatment and posttreatment positions. This visual representation of treatment helps the orthodontist avoid surprises during treatment since the actual treatment can be visualized on the treatment-plan tracings www.indiandentalacademy.com
  99. 99. . These initial tracings also provide a basis for comparison with progress tracings as well as a comparison with the posttreatment tracings. This final evaluation is of utmost importance in establishing a retention plan. www.indiandentalacademy.com
  100. 100. Because orthodontic treatment is three- dimensional, proper treatment planning requires three tracings : the lateral view (the Y-Z plane) made from the lateral cephalometric headfilm, the frontal view (the Y-X plane) made from the posteroanterior cephalometric headfilm, The occlusal view (the X1-Z1 plane) made from the occlusogram, a 1:1 photo of the occlusal aspect of the dental casts. www.indiandentalacademy.com
  101. 101. The three-dimensional treatment objectives are shown in three tracings. The lateral view, the Y-Z plane, displays the original tooth and bone relationships (black), the growth prediction (blue), and the final tooth position (red). www.indiandentalacademy.com
  102. 102. The occlusogram shows the planned treatment in the X1-Z1 plane. The original tooth position is shown in black. First, the final arch form is determined; this is shown as a red line through the incisal edges and the tips of the buccal cusp The inner gray arch connects the future contact areas of the teeth. www.indiandentalacademy.com
  103. 103. Then the treatment midline is established ; this is shown as a vertical gray line at the incisors . The mesiodistal diameters of the teeth are marked off on the inner gray arch so that the arch length inadequacy can be determined. The distance between the original mesial of the first molar and the horizontal gray line is a direct measurement of the arch length inadequacy. www.indiandentalacademy.com
  104. 104. . After determining an arch length inadequacy for each quadrant, the decision is made to extract upper first premolars. The new mesial – distal contact areas are marked. The distance between the horizontal red line and the original first molar position (black) shows the amount of mesial movement that is required of the molar. www.indiandentalacademy.com
  105. 105. Initial malocclusion Treatment objectives achieved www.indiandentalacademy.com
  106. 106. The frontal view (Y-X plane) originating from the posteroanterior head film. Planning in this view is helpful for midline determination and the establishment of a desirable transverse plane of occlusion . This view is particularly important in the treatment planning of orthodontic asymmetries requiring orthognathic surgery.www.indiandentalacademy.com
  107. 107. Current status of three dimensional imaging www.indiandentalacademy.com
  108. 108. The craniofacial imaging database currently in clinical use are designed primarily image management system for storage, retrieval and viewing of two dimensional patient images Dolphin imaging and quick ceph systems. These systems allow for two dimensional measurements on a uncaliberated and uncorrelated cephalometric images for the purpose of orthodontic assessment. www.indiandentalacademy.com
  109. 109. The two dimensional images are composed of subunits called the picture elements (pixels). Whereas the three dimensional digital images are composed of volumetric elements the (voxels). The newer generation of multiscrew detector (cone beam computed tomography) CT scanner and CBCT allow for the acquisition of isotrophic voxels. Here the X, Y, Z are equal in dimension. www.indiandentalacademy.com
  110. 110. Tremendous amount of anatomic information is contained within the voxel volumes and this information can be retrieved analyzed and viewed at a computer workstation using visualization and analytical software. From this data a three dimensional model can be created that can be rotated as an object to be viewed from any angle. These allow the orthodontic practitioner to manipulate the digital patient model to stimulate treatment and dynamically test feasibility of various treatment approaches. www.indiandentalacademy.com
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  125. 125. SSurgicalurgical TTreatmentreatment OObjectivebjective www.indiandentalacademy.com
  126. 126. The STO is an essential two-dimensional tool in surgical orthodontic correction of dentofacial deformities. The purpose of the STO is threefold: To establish the presurgical orthodontic goals To develop an accurate surgical objective that will achieve the best functional and esthetic result To create the facial profile objective, which can be used as a visual aid in consultation. www.indiandentalacademy.com
  127. 127. The STO has significant importance in two phases of treatment planning: 1) The initial STO is prepared before treatment to determine the orthodontic and surgical goal; 2) The final STO is prepared before surgery to determine exact vertical, anteroposterior (AP) skeletal, and soft tissue changes to be achieved. The STO is invaluable to the orthodontist and surgeon in establishing treatment objectives and projected results. It is both a diagnostic aid and a treatment planning aid. www.indiandentalacademy.com
  128. 128. Initial STOInitial STO In the initial STO, presurgical orthodontic treatment goals must be established so that the teeth can be relocated on the original cephalometric tracing. An initial STO may then be completed to relocate the hard tissues. www.indiandentalacademy.com
  129. 129. PRESURGICAL ORTHODONTIC GOALPRESURGICAL ORTHODONTIC GOAL Presurgical orthodontic treatment goals must be established by clinical examination, dental model evaluation, and cephalometric analysis. Orthodontic goals should be to upright the teeth over their respective basal bone, while also satisfying spatial requirements. www.indiandentalacademy.com
  130. 130. Ideal presurgical orthodontic goals are Position the long axis of the maxillary incisor at 22 degrees to the nasion-point A(NA) line with the labial face of the incisor 4 mm anterior to that line. Position the long axis of the mandibular incisor at 20 degrees to the nasion- point B(NB) line with the labial face of the incisor 4 mm anterior to that line.www.indiandentalacademy.com
  131. 131. Removal of dental compensations is necessary before surgery for maximal skeletal correction. Correcting the incisors with respect to their basal bone (NA and NB lines) will remove the dental compensations www.indiandentalacademy.com
  132. 132. Ideal incisor positions and the corresponding acceptable ANB angles for orthodontic treatment as advocated by Root and Sagehorn. Surgical skeletal correction to an ideal 2-degree ANB angle will produce an ideal interincisal angle of 136 degrees when the proper incisor goals are achieved presurgically. An increase or decrease in the ANB angle will require changes in incisor angulation to maintain the ideal interincisal angle of 136 degrees. www.indiandentalacademy.com
  133. 133. As the ANB angle is increased, it is necessary to decrease the upper incisor angle to the NA line and the distance from the labial face to that line. Thus, as the ANB angle is increased, the upper incisors must become less protrusive and the lower incisors more protrusive to achieve an acceptable interincisal angle. Conversely, as the ANB angle is decreased (below 2 degrees), the upper incisors must become more protrusive and the lower incisors less protrusive. www.indiandentalacademy.com
  134. 134. The exact orthodontic treatment plan and anchorage requirements necessary to position the teeth to satisfy the presurgical orthodontic treatment must be designed by the orthodontist to achieve that goal. Relocation of the molar teeth will depend on the arch length requirements (space) and the mechanics used by the orthodontist to achieve the ideal incisor positions. www.indiandentalacademy.com
  135. 135. The original cephalometric radiograph is traced in black pencil on matt acetate. Once the initial orthodontic goals are established, the teeth must be redrawn on the original CT. With colored pencil. After the teeth have been relocated on the CT tracing, initial STO is constructed. The initial STO is helpful to : Establish the final presurgical orthodontic goals Establish the surgical dentoskeletal objective Establish the genioplastic procedures with chin evaluation Establish the soft tissue facial profile objective. www.indiandentalacademy.com
  136. 136. Cephalometric parameters required to evaluate the dental compensation due to underlying skeletal discrepancy are: Frankfurt horizontal plane-a line constructed from the porion to the orbitale Facing axis angle -a line constructed from basion to nasion with the intersection at CC point. This determines the growth pattern of an individual. N perpendicdular to point A- Linear distance measured from nasion perpendicular to point A. Evaluates the relationship of the maxilla to the cranial base. N perpendicular to Pogonion – Linear distance measured from nasion perpendicular to pogonion. This evaluates the relationship of the mandible to the cranial base. www.indiandentalacademy.com
  137. 137. Upper incisor to facial axis – A line passing through the long axis of upper incisor comparable to the parallel of facial axis. It determines the final torque requirements Upper incisor to Point A vertical – The linear distance measured to assess the position of the incisor in relation to its skeletal base.. Lower incisor to MPA – This is the angle measured from the long axis of the lower incisor to the MPA. It helps in determining the relation of the incisor to its skeletal base. Lower incisor to A pogonion – A line drawn from point A to the pogonion and the position of lower incisor is evaluated www.indiandentalacademy.com
  138. 138. This involves the following steps Draw the initial tracing with orientation reference marks including the dentition, hard tissues and soft tissues in black. Measure the mesio-distal width of the first pre-molar. Assess the existing molar and incisal relationship to determine the anchorage requirements and plan for the amount of molar mesialization and anterior retraction. E.g. template of a patient, the molars are in end-on relation, with the incisors in class II div. I. On evaluation of the parameters the dentition appears to have compensated, indicating a requirement for dental decompensation. www.indiandentalacademy.com
  139. 139. The objective is to decompensate to attain a class II molar relation, a class II incisor relation and to create sufficient overjet for surgical correction. If the upper molar has to be brought into a class II relationship it must be mesialized by approximately 3 mm and the upper incisors are retracted minimally by 4 mm to get them into their ideal inclinations in the skeletal base. www.indiandentalacademy.com
  140. 140. This can be carried out by drawing a vertical reference line at the extraction space of first premolar perpendicular to the occlusal plane at a point approximately 3 mm from the second pre-molar in the upper arch. Similarly considering the anchorage requirements, the total extraction space in the lower arch can be utilized for maximum retraction of the lower incisors. www.indiandentalacademy.com
  141. 141. Construction of vertical reference line – To simulate the above planned tooth movement a vertical reference line perpendicular to the occlusal plane is constructed at the extraction space. For example if the extraction space is of 7 mm. The vertical reference line is constructed 3mm mesial to second premolar dividing the 7 mm space into 3 mm (for molar mesialization) and 4 mm for anterior retraction www.indiandentalacademy.com
  142. 142. On a third tracing sheet the occlusal plane is traced along with the vertical reference line. Keeping the occlusal plane and the vertical reference line as your guide shift the tracing forwards in such a manner that the vertical reference line coincides with the mesial aspect of the second pre- molar. At this point the molar and pre- molar teeth are traced and the tracing is re-oriented. This shows the amount of molar mesialization to be achieved. www.indiandentalacademy.com
  143. 143. To simulate the amount of anterior retraction, slide the tracing backwards along the occlusal plane such that the vertical reference line coincides with the anterior limit of the extraction space. www.indiandentalacademy.com
  144. 144. In the lower arch, to simulate anterior retraction the tracing is slid along the occlusal plane such that the vertical reference line coincides with the anterior limit of the extraction space. Trace the incisors changing its axial inclination as desired depicting a controlled tipping movement. www.indiandentalacademy.com
  145. 145. Make the necessary remodeling changes in the hard and soft tissues following dental decompensation. This is traced on a fourth tracing paper with a colored pencil. This completes the initial STO. www.indiandentalacademy.com
  146. 146. Final S.T.O Accurate determination of skeletal movements is very essential in treatment planning prior to the surgery. This section is divided into three sections 1) single jaw S.T.O 2) Double jaw S.T.O 3) Chin S.T.O The final STO is performed on the CT after the presurgical orthodontic treatment has been completed. Immediately before surgery a cephalometric radiograph is taken and accurately traced with pencil on matt acetate. It is advisable to trace all teeth to accurately determine dental structures. www.indiandentalacademy.com
  147. 147. Maxillary Segmental Superior Repositioning ; Mandibular advancement; Vertical Reduction and APAugmentation Genioplasty Select surgical sites and draw appropriate surgical reference lines. For multiple maxillary osteotomies, extraction of maxillary first bicuspids, bilateral mandibular ramus osteotomies, and osseous genioplasty, draw the following lines: Maxillary surgical reference lines A horizontal line parallel to Frankfort horizontal from the piriform rim to the zygomatic buttress area a minimum of 5 mm above the cuspid apex. A vertical line in the zygomatic buttress area, extending inferiorly approximately 5 mm from the anterior horizontal reference line. www.indiandentalacademy.com
  148. 148. A horizontal line parallel to Frankfort horizontal, extending from the vertical line to the pterygoid plates (The completed surgical reference lines represent the inferior cut of the maxillary step ostectomy.) short vertical lines in the area of the cuspid and the second molar through the horizontal surgical reference lines. A vertical line bisecting the first bicuspid, extending from the occlusal surface to the horizontal surgical reference line of the maxilla www.indiandentalacademy.com
  149. 149. Mandibular surgical reference lines A vertical line in the area of the vertical buccal ramus osteotomy A horizontal line above the inferior border of the mandible at the level of the inferior cut of the chin ostectomy www.indiandentalacademy.com
  150. 150. Step 1. Trace all skeletal and soft tissue structures that remain unchanged by the surgical procedures. They include the cranial structures and soft tissues of the forehead and upper nose. www.indiandentalacademy.com
  151. 151. Select the desired vertical position of the maxillary incisor by drawing a horizontal line parallel to Frankfort horizontal at the predetermined vertical level Then draw a vertical reference line crossing the horizontal line to represent the desired anterior position of the maxillary www.indiandentalacademy.com
  152. 152. Step 2. The occlusal plane must now be determined.. Autorotate the mandible by placing a pencil or other instrument in the condylar head area. Rotate the STO clockwise until the horizontal reference line for the maxillary incisor is approximately 2 mm below the mandibular incisal edge. The amount of lower incisor above the horizontal reference line indicates the desired overbite www.indiandentalacademy.com
  153. 153. Step3 Trace the proximal mandibular segment, including the vertical surgical reference line. The new occlusal plane can now be established. Occlusal plane as dictated by the mandibular autorotation. A line is constructed through the cusp tips of the mandibular molars and bicuspids and connecting with the vertical and horizontal reference lines previously drawn. www.indiandentalacademy.com
  154. 154. . Step 4. Position the anterior maxillary segment. Move the STO so that the labial face of the maxillary incisor is adjacent to the vertical line and the incisal edge is on the horizontal line. . The more the STO is rotated counterclockwise, the more the incisors are uprighted. The more the incisor teeth are uprighted, the higher the cuspid becomes in relation to the newly established occlusal plane. www.indiandentalacademy.com
  155. 155. Step 5. Trace the anterior maxillary segment, teeth, and surgical reference lines. Superimposition of the STO on the cranial base structures will demonstrate the movement of the anterior maxillary segment. www.indiandentalacademy.com
  156. 156. Step 6. Advance the mandible by moving the STO until the mandibular teeth align with the established occlusal plane, with appropriate overjet and overbite relative to the maxillary anterior teeth www.indiandentalacademy.com
  157. 157. Step 7. Complete the advancement by tracing the mandibular teeth, mandibular vertical surgical reference line, inferior border of the mandible, and the anterior portion of the mandible above the genioplasty reference line www.indiandentalacademy.com
  158. 158. Step 8. Position the posterior maxillary segments. Move the STO until the maxillary posterior teeth interdigitate in Class II molar occlusion with the mandibular teeth of the STO. Align the mesial surface of the second bicuspid crown with the distal surface of the cuspid crown www.indiandentalacademy.com
  159. 159. Step 9. Trace the posterior maxillary segment, teeth, and surgical reference lines.. www.indiandentalacademy.com
  160. 160. Step 10. Remove the STO and construct an NB line on the STO. This line is can be used to determine the desired AP position of the chin. Measure from the labial surface of the lower incisor to the NB line on the STO. This measurement is approximately 5 mm. For proper facial balance, the chin should be an equal distance in front of the NB line. Superimpose the mandibles of the STO and the CT. www.indiandentalacademy.com
  161. 161. Determine the desired vertical position of the chin from the clinical evaluation and cephalometric analysis. A horizontal line is drawn from this mark posteriorly to the inferior border of the mandible. This represents the desired superior osteotomy. The space between the two surgical reference lines indicates the amount of bone to be removed with the procedure Step 11. Superimpose the superior surgical reference line of the chin and the inferior surgical reference line of the chin. www.indiandentalacademy.com
  162. 162. Step 12. Slide the chin forward keeping the surgery lines superimposed, until the anterior portion of the chin approximates the vertical reference line. www.indiandentalacademy.com
  163. 163. Step 13. Trace the osseous chin segment. www.indiandentalacademy.com
  164. 164. Step 14. Superimposition of the cranial base structures demonstrates the surgical movements. . Positional alteration of the dentoalveolus will influence soft tissue change of the lip and nose . www.indiandentalacademy.com
  165. 165. Step15 As the supporting lip structures are moving for ward; the soft tissues of the lip and nose will move forward also. The amount of soft tissue change of the upper lip and nose will depend on the method of soft tissue management. Trace the soft tissues in the new position. www.indiandentalacademy.com
  166. 166. Step 16. To determine soft tissue change in the chin area, align the chin of the STO as well as possible with the chin of the CT, keeping the Frankfort horizontal planes relatively parallel to each other. www.indiandentalacademy.com
  167. 167. Step 17. Draw in the soft tissues of the chin up to the level of the horizontal reference line of the chin. www.indiandentalacademy.com
  168. 168. Step 18. Align the labial surface of the mandibular dentoalveolus of the STO with the dentolveolus of the CT. For a vertical reduction genioplasty, vertically align the horizontal genioplasty surgical reference lines, and align the labial aspect of the dentoalveolus and incisors as well as possible. www.indiandentalacademy.com
  169. 169. Step 19. Trace the remaining soft tissues of the chin and lower lip area. The lower lip will be elevated relative to the lower incisors because of the vertical reduction and increased AP chin position. Note that some artistic interpretation is necessary in the positioning of the lower lip on the STO. www.indiandentalacademy.com
  170. 170. Step 20. Superimposition of the cranial base structures will demonstrate the osseous and soft tissue changes. www.indiandentalacademy.com
  171. 171. SOFT TISSUE PREDICTION Soft tissue changes are very important in the determination of final profile results and should be projected as accurately as possible. However, determining soft tissue changes in orthognathic surgery is less exacting than predicting dental-osseous alterations. The soft tissue may move significantly different than the osseous structures, creating difficulties in determining accurate soft tissue changes on the STO. www.indiandentalacademy.com
  172. 172. P (pronasale) : The most prominent or anterior point of the nose Sn (subnasale) : The most posterior-superior point on the nasolabial curvature A (soft tissue A point) : The point of greatest concavity of the upper lip between subnasale and labrale superius. UL (labrale superius) : The most anterior point on the upper lip. St (stomion upper lip) : The most inferior point on the upper lip. LL (labrale inferius) : The most anterior point on the lower lip B’ (soft tissue B point) : The point of greatest concavity of the lower lip between labrale inferius and soft tissue pogonion. Po’ (soft tissue pogonion) : The most anterior point on the soft tissue chin. Me’ (soft tissue menton) : The most inferior point on the soft tissue chin. www.indiandentalacademy.com
  173. 173. PROCEDURE SOFT TISSUE ANATOMIC POINTS % CHANGE Advancement LL+ B’ PO’ 67-85 100 100 Setback UL LL B’ Po’ 20 90 90 90 www.indiandentalacademy.com
  174. 174. PROCEDURE SOFT TISSUE ANATOMIC POINTS % CHANGE Subapical advancement LL 60 Subapical setback LL 75 www.indiandentalacademy.com
  175. 175. PROCEDURE SOFT TISSUE ANATOMIC POINTS CHANGE Advancement P UL St 30% 50% Unpredictable Setback Sn A UL St 30% 30% 50%-65% Unpredictable www.indiandentalacademy.com
  176. 176. PROCEDURE SOFT TISSUE ANATOMIC POINTS CHANGE Superior repositioning P Sn UL St 20% 20% 30-40% 20%-40% Inferior repositioning St 15% www.indiandentalacademy.com
  177. 177. PROCEDURE SOFT TISSUE ANATOMIC POINT LITERATURE REVIEW CHANGE AP augmentation (osseous) Po’ 75% -80% AP augmentation (alloplastic) Po’ 80%-85% Vertical augmentation (osseous) Me’ 100% www.indiandentalacademy.com
  178. 178. PROCEDURE SOFT TISSUE ANATOMIC POINT LITERATURE REVIEW CHANGE Vertical reduction (inferior border ostectomy) Me’ Po’ - 30% -25% Vertical reduction (wedge - Kole) Me’ 90% www.indiandentalacademy.com
  179. 179. PROCEDURE SOFT TISSUE ANATOMIC POINT LITERATURE REVIEW CHANGE AP reduction (anterior ostectomy) Po’ 25% AP reduction (sliding osteotomy) Po’ 90% www.indiandentalacademy.com
  180. 180. Conclusion The dependence of the orthodontists towards cephalometrics has grown since the time of its inception in the field of orthodontics. It would be wiser however to look on the cephalometric readings with a clinical eye to make the ideal use of this tool. www.indiandentalacademy.com
  181. 181. www.indiandentalacademy.com
  182. 182. Proffit-Contemporary Orthodontics Ricketts –Bioprogressive therapy Arnett ,McLaughlin – Facial And Dental Planning For Orthodontists And Oral surgeons Vizas – Atlas Of Advanced Orthodontics Burstone , Marcott – Problem Solving In Orthodontics Graber,Vanarsdall – Orthodontics Current Principles and Techniques -3rd Edition ReferencesReferences www.indiandentalacademy.com
  183. 183. Graber ,Vanarsdall – Orthodontics Current principles and techniques -4th edition Renkye – Orthognathic surgery Wolford, Hillard,Dugan- Surgical treatment objective. Athanasios – Orthodontic Cephalometry. Jacobson - Radiographic cephalometry Graber ,Rakosi, Petrovic -Dentofacial orthopaedics with functional appliances Frankel & Frankel- Orofacial Orthopaedics with functional regulator References…References… www.indiandentalacademy.com
  184. 184. McLaughlin, Bennett. The Dental VTO: an analysis of orthodontic tooth movement. JCO 1999,23:394- 403. Hoss, Sameshima et al. The accuracy of video imaging for mixed dentition and adolescent treatment. The Angle orthodontist, 1997, 67:355- 364. Thuan ,Sameshima et al. The role of computerized video imaging in predicting adult extraction treatment outcomes. The Angle orthodontist, 1998, 68:391-400. John Eastman. Computer assisted orthognathic surgical treatment planning. The Angle orthodontist, 1992, 62:227-234. References…References… www.indiandentalacademy.com
  185. 185. Philips et al-Photocephalometry errors of projection and hand mark location. Am J Orth 1984,vol 86,239-245. Image analysis and superimposition of 3D cone beam computed tomography model-AMJODO 2006;129 611-618 B.Mollenhauer,Vto course notes ribbon arch brackets news letter Aug 1993 1-6 Ricketts. The value of cephalometrics & computerized technology. The Angle orthodontist, 1972, 42:179-199. Thomas Cangialosi –Relaibility of computer generated prediction tracing -The Angle orthodontist, 1995, 65:277-284. References…References… www.indiandentalacademy.com
  186. 186. David M. Sarver. Video cephalometric diagnosis- a new concept in treatment planning. AMJODO 1996,11:128-134. Bonham Magness ,Mini visual treatment objective A.J.O.DO May 1987,361-374 Reed Holdaway ,Soft tissue cephalometric analysis and its use in orthodontic treatment planning –part-I AJO 1983 vol84 ;1-28 Reed Holdaway ,Soft tissue cephalometric analysis and its use in orthodontic treatment planning –part-II AJO 1984; 85:271-293. References…References… www.indiandentalacademy.com
  187. 187. www.indiandentalacademy.com
  188. 188. Thank youwww.indiandentalacademy.com

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