Growth predictions /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


NAME : NISHEL MUDARTH


MAXILLA


MANDIBLE




Little mandibular
growth



Considerable growth


POSITIONING LOWER INCISORS


REQUIRED MOVEMENT OF
UPPER TEETH


 SHOT

IS….

SCORED

MISSED


Definition
 Rationale of growth prediction
 Approaches for growth prediction
 Growth studies
 Classification of methods
 Johnston's grid
 Template method
 Ricketts methods
 Computerized prediction
 Comparison



Prediction of growth spurt
 Auto correlation analysis
 Growth prediction from
1. Antegonial notch
2.
Parental data
Issues related to growth prediction
Current status
conclusion



DEFINITION
Kendall and Buckland
 “ The process of forecasting the
magnitude of statistical variations, at
some future point of time”
 “Specifying the amount and direction
of future growth in the context of a
base line or reference point”


Growth prediction & VTO
Growth prediction
It is a visual plan to forecast the normal
growth of the patient
 VTO
Anticipated- visualized influences of
treatment .
It is like a blue print used in building
the house.
It enables development of alternative
treatment plans.



Rationale of growth prediction


The principal proponents of
growth prediction Ricketts and
Holdaway have suggested that the
major value of the technique is the
compilation of all the treatment
factors (skeletal tissue ,soft tissue,
growth and mechanics)
together on paper to see how they
inter-relate.

Treatment for growing patient must
be directed to the face that is anticipated
in the future and not to the one which
exists.
The plan should

Take advantage of beneficial aspects of
growth.

Be able to take care of undesirable
effects of continuing growth.





Once the treatment begins there
is a need to continuously monitor
the progress.
It is done against the VTO
forecast. So that if any deviation is
there it becomes apparent and
necessary modification can be
instituted in the mechanics.

To deal with relapse tendencies
Even normal growth during
adolescence favors relapse in the patient
with Class III malocclusion.

Maxillomandibular relationship seen at
the end of treatment in a growing child
may not be the same at maturity.

Therefore treatment completed with
proper facial balance at the age of 12 may
prove unsuccessful at the age of 25.

 The

forecast is valuable for
orthodontist’s self improvement .

 Source

of problemLack or excess growth.
Patient’s lack of cooperation.
Unusual physiologic reaction.

According to Hirschfield and Moyers the
growth prediction aims for
 Future size of a part
 Relationship of parts
 Timing of growth events
 Vectors of growth
 Velocity of growth
 The effects of orthodontic therapy on any
of the above predicted parameters

 Future

size of a part
The prediction of future size, is
primarily a problem of predicting
future increments which are to be
added to the existing size.


 Relationship

of parts
Most important prediction for
the clinician is the future relationship
of parts, i.e. the future facial pattern.
It is the summation of growth of
various component of craniofacial
complex .
Growth prediction is important
because growth alters relationships.

 Timing

of growth events
Growth spurts
involves prediction of its onset
duration and rate of growth.
The thing which makes it
further complicated is its variable
occurrence.

 Vectors

of growth
Most predictive methods thus far
presume a continuation of the
pattern first seen.
Therefore, the presumption is
made that the vectors of growth
present at the time of prediction will
remain.

 Velocity

of growth
It would be of use to know the
future expected rate of growth.
Prediction of velocity is most
important during the growth spurt.


 The

effects of orthodontic therapy on
any of the above predicted
parameters
The clinician must always
wonder what effects his therapy
have on the predicted and actual
growth of one specific face.
R.E.Moyers


Approaches for growth Prediction


HIRSCHFIELD & MOYERS

 BJORK


Hirschfield and Moyers
 Theoretical
 Regression
 Experiential
 Time

series


Science is predictable and reliable.
If the prediction consistently gives
results which match the actual
growth it will become a science

so we take help from statistics
and geometry. Because mathematics
is predictable.



Theoretical method
 Mathematical

construction of a
theoretical model

 Proving

the hypothesis practically


Regression methods


To calculate a value for one
variable, called dependent, on the
basis of its initial state and the
degree of its correlations with one or
more independent variables.


A : B :: A’ : B’
A

= S-N length at 10
 B = upper face Ht. at 10
Regression equation
B= A + 2
 A’ = S-N length at 14
 B’ = ?


Drawbacks
The assumption within the method
that the equation remain constant
over the whole time period.

An individual whose growth is to
be predicted in clinical practice may
not even be a member of the
population upon which the regression
equation is based.



Experiential method


It is based on the clinical
experience of a single investigator
who attempts to quantify his
observations of practice in such a
way that they can be used by others.
E.g. Ricketts forecast


Drawbacks
 Theoretical

counts:

base is shaky on two

– The assumption must be made that the
individual being predicted will behave as
the mean of a population of which he is
a not a member
– The morphology of the mandible and
other parts is a clue to the future
growth of the face

Time-series methods
 Problem

solving through applied
mathematics
 Time-series is considered to be
composed of four parts :
1. Trend or long-term movement
2. Oscillations about a trend
3. Cyclic or periodic events
4. Random (unsystematic) components

Bjork :
 Longitudinal
 Metric
 Structural.


LONGITUDINAL METHOD
 Individual

is evaluated over a
specified period to determine the
pattern of growth.
 Annual cephalograms
 Serial cephs are used to predict the
growth trend & future growth




This concept was clinically applied
by Tweed on his growing patients.



Facial cephalograms are taken
12 to 18 months apart to evaluate
the skeletal facial changes & then the
pt. is classified into one of the three
categories.

TYPE A

Growth of the middle. and lower face
proceeds in unison.

Changes in the vertical and horizontal
dimensions being approximately equal.
TYPE B

Middle Face grows downward and
forward more ,rapidly than the lower face.
This type of growth is predominantly in a
vertical direction.
TYPE C

Lower face develops at a faster rate
than the middle face.



Tweed's basic assumption was
that the growth pattern would
remain constant.



HOWEVER the pattern and rate of
growth in one period is not similar to
that occurring in a subsequent period
in any given individual.


Metric Approach
It aims at prediction of future
growth on the basis of existing facial
morphology

Measuring different structures on
a single x-ray film. Then relating
these measurements to future
growth.



 Important

aspect - coefficient of
correlation – r
 It signifies the strength of
relationship
 r = 0.8 <
for clinical use
 But coefficient of correlation of facial
dimension when related to future
growth does not exceed 0.4 – 0.5

 Correlation

B/W face at 12 yr and
residual growth - Bjork
Study on Swedish boys following
them over the age of 12-20yr
present with a very low correlation.

Making matter more difficult is
the pubertal spurt.

The ultimate growth in the length
of the mandible cannot be assessed
from its size before puberty

Structural method
 Developed

by Bjork from
Superimpositions on metallic
implants.
 consists of recognizing specific
structural features in the mandible
that indicate future growth trends.
 Predicts extremes of growth patterns
more accurately.

Bjork listed seven areas on
cephalogram
1. The inclination of the condyle
2. The curvature of the mandibular
canal
3. Inclination of the symphysis.
4.
Shape of the lower border of
mandible.
5. The interincisal angle
6. interpremolar or molar angles are
also more acute in forward rotators.
7. The anterior lower face height.

Rossouw, Lombard, Harris 1991
 Postulated that the large frontal
sinus goes hand in hand with the
abnormally large mandible
 Correlation for mandibular lengths
with the large frontal sinus size is
found out to be(0.480)
 Orthodontics or surgery?
 No correlation with pattern.


Growth studies
The numeric standards on which
the present day growth predictions
are based are derived from 3 major
studies reports.
 Bolton-Brush Growth study
 Burlington Growth study
 Michigan Growth study



These studies are carried out
longitudinally over hundreds of
samples and the data is organized to
provide the picture of normal or
average changes.

Present day templates are formed
by treating this information
graphically.



Bolton-Brush growth study




Longitudinal study of over 4000
subjects from birth to adult hood.
Started in 1929 under
B.H.Brodbent at case reserve
university in Ohio.


Records taken include1. Lat. Ceph.
2. P.A. Ceph
3. hand wrist x-ray
4. Dental casts
5. Nutritional medical health status

NO SUBDIVISIONS

All records are currently housed in
Bolton –Brush growth study center.



Burlington Growth study
 Prospective

longitudinal study
started in 1952 in Burlington Canada
under R.E.Moyers of university of
Toronto
 1258 children participated
 Records collected annually from age
3 to 18 year.


Records consisted of
 Medical history
 periodontal evaluation
 6 cephalometric radiographs
 Hand wrist x-ray
 dental casts
 I.O. x-rays
Entire material is currently housed in
Burlington growth center university of
Toronto

 Burlington

data has subdivisions on
the bases of sex and growth pattern
 vertical
 horizontal
 average
subjects selected had ideal occlusion


Michigan Growth study
Study was done on the students of
elementary & sec. school under the
university of Michigan.
 Published by Riolo et al. in 1974


Data was obtained from untreated
subjects with normal occlusion an
admixture of cl I & cl II relationship
 So it represent normative rather than ideal
standards.



classification












Based on average values
individualized prediction
short range
long range
manual
Computerized
Templates
Geometric construction

Golden proportions - Prediction of
ideal


Johnston’s forecast grid
 Developed

by L.E. Johnston in 1975

Based on the addition of mean
increments of growth by direct
superimposition on a printed grid

The validity of this grid was
tested in a series of 5 years forecast
on 32 individuals.(7.5 – 12.5 yr)


The land marks used
are :
 S–N plane as a
reference plane
 Point A
 Point B
 Point M
 Posterior Nasal
Spine
 Tip of nose



Vectors for A, B and
M are inbuilt into the
grid and are derived
from the templates
prepared by Harries
and associates and
the behavior of N
and P was patterned
after reports by
Ricketts


Starting age , Years of prediction ,
Sex




Tracing of landmarks is superimposed
along S-N and registered at S



The points are then advanced
downward and forward one unit per
year



Soft tissue is traced by shifting the grid
back 0.3 mm/year


Construction


Shortcomings
a

moderate flattening of the profile
and occlusal plane,
 a slight mesial drift of M.
 Apart from the points A and B other
landmarks have little application


 age

or sex non specific.
 facial pattern - all patients will grow
the same amount and direction.


Template Method
Template is the graphic equivalent
of tables of means and deviations in
various age groups

It provides visual representation
of growth patterns and permits
visual comparison with normals





Baum – 1952
First to develop cephalometric
templates based on down’s analysis he
developed a set of 4 transparencies to be
laid directly on the cephalogram



The serial cephalometric radiographs
obtained during the Burlington, Michigan
and Bolton growth studies have been
treated statistically to allow their use in
growth prediction.

 There

are 2 types of templates :

– Schematic template
– Anatomically complete template


Schematic template
The schematic templates show
the changing position of selected
landmarks with age on a single
template

The "track'' produced by each
landmark was averaged over many
individuals to produce a normative
''picture" of growth in a given
population.



Burlington templates
 Popovich

and Thompson propose
method of growth prediction based
on Burlington templates.
 It uses the tracings at the ages of
4,6,8,10,12,14,17,20
 Registered on S-N LINE
 reference plane used is cranio
-occlusal line drawn 22* to S-N line



Description of movements of points
throughout growth is integrally related to
the particular frame of reference from
which movement is observed.

 Static

aspect – demonstrate degree
of balance or imbalance and its
location
 Dynamic aspect – projects degree of
change anticipated without
treatment


6 sets of templates are available
 Vertical grower male-female
 Avg. grower male female
 Horizontal grower


1.

2.

3.

the lateral templates are used to
determine the growth pattern to which
individual compares most closely.
Appropriate template is selected
considering the age and anterior cranial
base length
Superimposing the template and
individual cephalogram, future
magnitude and direction of growth is
estimated.

Anatomically complete template
 Based

on Bolton growth study data.
 Age-specific
 A reference template is selected so
that the lengths of anterior cranial
base are same
 The growth is predicted by advancing
the template ages from the reference
templates

Anatomic templates


Ricketts Growth Prediction
 Growth

Estimation from facial
pattern- 1957
 Cephalometric Synthesis-1961
 Short-range VTO  Long-range VTO - 1972


Growth Estimation from facial
pattern - 1957




Ricketts suggested that facial
form was to a large degree
determined by the position of the
chin.
Chin position determines the form
of face.


 Chin

position was mainly influenced
by 3 factors
1. Changes in the cranial base
2. Condylar position
3. Condylar growth in amount and
direction
upward + forward - brachycephalic
upward + backward– dolicocephalic

Determinants of chin position


Cranial base flexion

Condylar
positioning
forward/backward


Condylar growthAmount/direction



Summation of total changes


CEPHALOMETRIC ANALYSIS
AND SYNTHESIS
Analysis
 Characterize the condition
 Compare the condition with norms
 Classify
 Communicate


Synthesis
Use in treatment planning
 Static

synthesis- non growing

 Dynamic

synthesis- growing


Static synthesis
Estimation is done about
movement of the teeth and changes
in lips.

The lower incisor is positioned
normal to the APo

The upper incisor is then adjusted
to it with normal overbite and overjet

The necessary anchorage can be
envisioned by movement of the
posterior teeth



 The

Dynamic Synthesis

– Growth of the chin - foremost
consideration
– Cranial areas are employed for basal
references





Step 1- cranial behavior –insignificant
step 2 -Chin behavior


 Estimate

based on direction and
magnitude of growth of Y-axis
 Class II case -Y axis open about one
degree during a two year period
 class III case -Y axis closed one
degree
 2.5 – 3.0 mm / Yr – linear growth

Step 3 - Maxilla behavior
Point A and the anterior nasal spine
usually drop vertically about one- third the
total facial height increase during
treatment.
point A is modified by
 extraoral traction
 intermaxillary elastics when accompanied
by torquing action to the upper incisor
teeth.



Teeth setup

22* to mandibular plane
1 mm ahead of A-Pog

LONG RANGE ‘ARCIAL GROWTH’
FORECAST
 ARCIAL

GROWTH PRINCIPLE
A normal human mandible grows by
vertical apposition at the ramus on a
curve or arc, which is a segment of a
circle.
The radius of this circle is determined
by using the distance from mental
protuberance (Pm) to point Eva.

 Ricketts,1972

it has been proved by the studies that
some form of bending of mandible
occurs during growth which is orderly
and in a form of an arc of a circle.
This principle can be used as a
working hypothesis for growth
projection of a mandible .

New planes and points of reference
 Condylar axis
 Corpus axis
 Pt Pm
 Pt Xi
 Pt Eva
 Pt Mu
 Pt TR


Pt Xi

 Pt

Xi represents the center of ramus

Pt PM & Pt Dc



PM is a stress center & located in
dense cortical bone

Condylar axis and Corpus axis



Attempt to overcome surface variation and
to determine central or internal structural

 The

cortical “core” of the mandible,
is recognized using Pm, Xi and Dc
points.
 since all these points and planes are
drawn for particular pt., the
prediction is individualized.


After this experiments were
undertaken to determine a method
by which the form and size of the
mandible, after a five-year growth
interval, could be predicted with use
of only the first x-ray as a reference.

The size increases and form
alterations were available from the
computer



Not enough bending

Excessive bending

 It

was thought that perhaps the
stress lines of the mandible would
reveal its hidden secrets.


A

mandible, alleged to be 850 years
old, which had been given to Ricketts
by the late William B. Down.
 Mandible clearly showed the pattern
of stress lines


convergence of stress
lines at the
 protuberance menti
 Base of coronoid
process on lateral side
 Y-shaped bony
prominence on medial
side – Pt Eva


Pt Eva
Pt Eva almost
exactly coincides
with the forking of
the stress lines on
the internal and
outer table of the
ramus.
 nutritive foramina Growth center ?





When the size increase of the mandible as
determined in the computer study was
incrementally added to the arc at the sigmoid
notch, it was found that the predicted mandible
was almost absolutely correct in size and form
when compared with the final composite.

‘K’ factors


SHORT-RANGE VTO
 To

be used over the period of not
more than 2-3 year.
 Prediction of chin by constructing the
chin acc. To patients own mandibular
line..
 it uses patients existing growth
pattern And provides the
‘safety factor’.

Basic planes and points


SEQUENCE
 Cranial base prediction
 Mandibular growth prediction
 Maxillary prediction
 Occlusal plane prediction
 Dentition
 Soft tissue

Cranial base prediction
 Cranial

base flexion is ignored
 length increments- 1 mm / yr
Take a clue from Spheno-occipetal
synchondrosis


Cranial base prediction

 Nasion

& Basion – 1 mm/yr

Mandibular growth prediction
Rotation & lengthening
 Rotation –
Direction of effective growth is determined
The mandibular plane is influenced
accordingly
 Lengtheningcondyle-1 mm/yr
body -2 mm/yr

Mandibular growth prediction


Rotation

 Rotated

about Ba

Condylar axis and corpus axis

Condylar axis – 1 mm/yr
 Corpus axis – 2 mm/yr



Symphysis construction


Maxillary prediction
1/3 rd of total facial ht increase is
due to upper face Ht increase
 Pt A is influenced by tooth movement
treatment mechanics is given
consideration while relocating it



Maxillary prediction

 Mark

1 with Me

Point A changes
1
3

2


Occlusal plane



Half of lower facial Ht. increase is
attributed to either dentition and new
occlusal plane is constructed

Lower incisor

 22*

to mandibular plane
 +1 mm to A-Pog

Mandibular molar


dentition


Nose


Lips , chin


Completed final prediction


Computer prediction
Computer is essentially a tool of
analysis and not a method of
analysis.

Computers are programmed to
use equations based on manual
methods

computer technology facilitates
testing and applying more complex
formulas to growth prediction.



In 1970s Ricketts introduced his
method of computer analysis based
on his vast clinical experience.

Initially the computer forecast was
based on the pattern extension
method proposed by Ricketts.



Rocky Mountain Data System
Rocky mountain Data systems (RMDS)

In conjunction with the early
investigations of Ricketts, Rocky
mountain co. designed a computerized
cephalometric analysis, to quantify
craniofacial characteristics in more detail.

The computer growth forecast method
is essentially similar to the Ricketts
method with some modifications.

Modifications
Individual growth curves are
used for the mandible, maxilla, and
soft tissue rather than using the
same increments for every age group
 Abnormal growth predicted with
RMDS data bank



Growth curves
Individual growth curves are based on
national/ethnic groups
(e.g.: Growth curves for German
children, Japanese Children).

They show relative amounts of normal
cranial growth at various ages for
particular race.
3 types
 Upper face
 Lower face
 Soft tissue



Growth curves




The RMDS computer performs
growth predictions by combining
these growth curves with average
linier and directional change for
approximately 200 cephalometric
landmarks


Computerized ceph. analysis


Modules.

A module is defined as the average
amount of growth observed for the
average American Caucasian patient in a
unit time

For each cephalometric landmark the
amount of change in position per module
of growth, and the direction of change per
module are known.

Modules




The computer will determine the
amount of modules which elapsed during
the period being forecasted.



The change for each point
- direction
- amount per module is known.
it is multiplied by the number of modules.
The result is a computer growth
forecast without treatment.

Abnormal class III patterns



Consistent type emerged which grew
excessively in mandible and less in cranial
base than predicted.

Study reveled that patients differs
from normals in –
 Abnormally forward location of
porion.
 Forward position of ramus.
 Downward deflection of cranial
base.
 Class III molars.
.

Predictor measurements

 Proportionately

increased growth in
mandible than the cranial base.

These predictor measurements are
used to get insight as to which PT. would
require early ortho treatment ,
conventional one ,or surgical correction
after the growth is complete.

Subjects with mandibular prognathism
who can be properly treated by
orthodontic tooth movement alone can be
distinguished from subjects with
mandibular prognathism that requires
orthognathic surgery.





Four methods of growth forecasting
were compared by Schulof & Bagha
1975
– Johnston forecast grid
– Ave. increments from sella-nasion
– Ricketts short-range prediction
– Computer forecast (coupling of
Ricketts short –long range prediction)


Results
JOHNSTON GRID
 Least accurate
 64 % accurate for Point A
 70 % accurate on Pogonion
 It was accurate as any for predicting
the nose
The basic objection to this method is
that it applies growth rates of one
age group to another

AVERAGE INCREMENTS
 Improvement over the Johnston grid
at both Pogonion and point A


RICKETTS SHORT-RANGE
PREDICTION METHOD
 Less error than Johnston grid or average
increments
 Some of the smaller over-all error was due
to the fact that point CC, the origin of this
growth prediction, is closer to Pogonion
than to Sella
 10 to 20 percent improvement over
average increments

RMDS COMPUTER PROGRAM
 Most accurate of the four methods
 21% more accurate than
Ricketts
 56% more accurate than
Johnston grid


Its main strength lies in
recognizing and predicting the
growth of unusual face patterns .
Which are the main problem areas of
treatment.
 In this area the computer prediction
accuracy improved to 90 %



Growth is not only Statistics ,it’s a
biological process. Growth prediction
should not over look important biological
phenomena occurring during growth
because we are treating a child not a
cephalometric tracing.

One such much talked about, biological
phenomenon is growth spurt.



How Often Does It Occur?
 Bjork's 1963 study
Out of the 45 boys evaluated
only 11 individuals (less than 25%)
had what Can be described as a
discernible pubertal growth
accentuation.


What is the Magnitude' of the Spurt?


Bjork's findings
1.

2.

3.

There was a significant acceleration in
condylar growth in less than 25% of the
samples.
The magnitude, duration and timing of
the spurt varied widely even in this
selected sub-sample of 11 subjects.
There was no relationship between the
intensity of the growth and its direction.


PREDICTION OF FACIAL CHANGES
FROM SKELETAL BODY CHANGES

Standing height
Autocorrelation analysis (Bishara)

Analysis compares growth profile of
various facial parameters to that of
standing height b/w 8 – 15 yrs of age
 Correlation is below 0.5
 Mandibular length in girls had a clinically
significant correlation with the timing of
changes in standing height (r = 0.83 )

The findings
Growth profile of height was
significantly different from that of
mandibular length and relationship

Autocorrelation analysis have
little predictive value in determining
the growth profile of any of the
mandibular parameters - except for
Ar-Pog for females.



Clinical implications
Timings and magnitude of facial changes
and mandibular length in particular cannot
be predicted from standing Ht. or skeletal
maturation.
 However significant mandibular changes in
size and relationship take place during
adolescence.
 Starting treatment of A-P discrepancies
without waiting for pubertal spurt



Antegonial notch - an indication of
mandibular growth potential:
Prominent mandibular antegonial
notch is a commonly reported finding in
subjects with arrested growth of the
mandibular condyles.
 Singer and Hunter 1987,
The craniofacial characteristics of
individuals with deep mandibular
antegonial notch, compared with those of
shallow notch by the use of longitudinal
lateral cephalometric radiographs.



They concluded that,
 Deep notch subjects had a more
retrusive mandible with
 Shorter corpus,
 Less ramus height
 Greater gonial angle
than did shallow notch subjects.

The results suggests that
 deep mandibular antegonial notch is
indicative of a diminished mandibular
growth potential and a vertically
directed mandibular growth pattern.


The growth of the mandibular condyle
fails to contribute to the lowering of the
mandible,

masseter and medial pterygoid,
continue to grow and cause the bone in
the region of the angle to grow downward

A relative tension is generated between
the angle and the muscle sling such that
bone deposition occurs in the area under
the angle posterior to the notch.



PARENTAL DATA TO PREDICT THE
GROWTH
SUZUKI ET AL 1991

There is a similarity between the facial
form and features of an offspring and that
of his parents.

If the face of a young offspring
resembles the face of either parent, it
usually continues to resemble that parent.

The phenotype of facial appearance
does not change with growth.




Coefficients of correlation of craniofacial
forms ranged b/w 0.5-0.9 and they
increased from childhood to adulthood.



Suzuki et al. by studying 1700
cephalogram deduced, correlation
coefficients to develop prediction models
(in the form of a mathematical equation)
to predict the individual growth of
children, based on data relating to their
parents.

Current status of growth prediction
Current data on which norms used in
growth prediction are based is sample
specific.
More the individual resembles this
sample group, more accurate is the
prediction.
Ideally separate growth standards should be
established for sexes, racial groups, facial
patterns ect. But available data sets are
too small to allow this kind of division.



All 3 major studies BOLTON,
BURLINGTON, MICHIGAN are carried out
on whites of north European descent.
growth prediction is based on avg. changes,
but pt. may not have avg. amount or
direction of growth.
so our ability to predict facial growth is
poorest for the very patients who need it
most.

In country like India. With various
ethnic origins, multi racial, multicultural
population growth prediction simply does
not work. Because that much ‘Purity’ of
the population does not exist.

Growth prediction based on mean
values projects mean forecast which will
be applicable for most in a population but
it may not be the case with your own
patient.



Clinical decision making
In severe skeletal discrepancies
prediction is not much of a challenge. One
can assume that the existing growth
pattern prevails. And orthopedic correction
should be included in the treatment plan.
Average skeletal discrepancy
For the majority of cases, future growth is
less predictable.
“ worst case scenario “

CONCLUSION
The overall changes in the size and
relationship of the human face in 20 year
period From childhood to adulthood are, In
general difficult to accurately predict for
an individual. This is because the changes
are under the influence of the combined
and complex effects of the hard to predict,
genomic, and environmental factors.

The situation is rendered even more
complex because we are using a two
dimensional image to predict a three
dimensional multifunctional object.



CONCLUSION




Because of the uncertainties involved in
predicting growth ,orthodontic treatment
becomes a game of strategy against nature.
However The Goal of growth prediction is to
reduce the clinicians ignorance of the future.
The best can be done ,is to base the
treatment planning in the existing facial pattern
allowing for average growth changes for the
group to which patient belongs. With the
knowledge and better understanding of growth
prediction, we can be skilled and better equipped
to intervene during growth process.


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