The Dental VTO : An

Analysis of Orthodontic
Tooth Movements
RICHARD P. McLAUGHLIN , DDS
JOHN [Link], LDS, DOrth
[Link]
II MDS
• Most cephalometric analyses measure Maxillary and Mandibular
skeletal relationships in the vertical and horizontal planes, along with
the position and angulation of the incisors.

• Few Orthodontic analyses, however , provide information about the

direction and amount of dental movements required during
treatment within the maxillary and mandibular arches.
• The dental analysis presented in this article-in effect, a dental
Visualized Treatment Objective – was designed to provide organized
and simplified information to help in diagnosis, treatment planning ,
and the extraction/non extraction decision. It should be used as an
adjunction, but not a substitute for, conventional cephalometric
[Link] takes little time to complete and occupies only a small part
to of treatment card .Progress can be checked by referring to the
dental VTO at the patient’s regular adjustment appointments.
Method
• The dental VTO consists of three charts:
• Chart 1 records the initial midline and first molar positions with the
mandible in centric relation.

• Chart 2 measures the lower arch discrepancy, similarly to the Steiner

analysis. The four primary factors in each case are:
[Link] required for relief of crowding, measured from canine to midline
and from first molar to midline on each side.
2. Space required for the desired correction of protrusion or retrusion of the
mandibular incisors.
3. Space required for leveling the curve of Spee , measured as the deepest
point on a line extending from the distal cusps of the second molars to the
incisal edges of the central incisors on each side; this point is normally
found in the premolar region (Fig. 1).
4. Space required for midline correction.

Four secondary factors that can sometimes provide additional space are
listed, if applicable, below the primary chart:
1. Additional space from interproximal enamel reduction.
2. Additional space from uprighting or distal movement of mandibular first
molars.
• 3. Additional space from buccal uprighting of mandibular canines and
posterior teeth.
• 4. Additional leeway or “E” space.
• According to Moorrees, the leeway space, or the difference in size between
the deciduous canines, first molars, and second molars and the permanent
canines, first premolars, and second premolars, is an average of 1.5mm per
side in the mandibular arch and .9mm per side in the maxillary arch.2 “E”
space, or the difference in size between the primary second molar and the
permanent second premolar, is an average of 2.5mmper side in the
mandibular arch and 2.3mm per side in the maxillary arch (Fig. 2).
Chart 3 records the anticipated treatment change in terms of dental
movements of the first molars, canines, and midline.
• According to the authors There are four possible methods of Class II molar
correction in the growing patient:
a. Mesial movement of the mandibular first molars.
b. Distal movement of the maxillary first molars. This is difficult in the
presence of developing maxillary second and third molars, but it can be
achieved.
c. Limiting forward maxillary skeletal development, or retracting the maxilla.
Because such changes are difficult to isolate, it is debatable how much is
skeletal (above the palatal plane)and how much is dentoalveolar (below
thepalatal plane).
Nasion normally grows forward about 1mm a year relative to sella, while A
point may be maintained or retracted relative to its original position.
d. Forward mandibular rotation. This can occur in two ways:

1) Mandibular growth. The direction of overall facial growth is critical to the

“expression” of mandibular growth.
With more vertical patterns, there is less forward expression of mandibular
growth and hence less interarch dental change.
With less vertical facial growth, mandibular growth is expressed in a more forward
direction, resulting in greater interarch dental change.
2) Limiting vertical maxillary development difficult to significantly
influence the normal vertical development of the facial complex As with forward
maxillary development, vertical development is hard to measure in isolation
and therefore hard to categorize as skeletal or dentoalveolar. Nevertheless,
even a small limitation can greatly enhance a Class IIcorrection.
Case 1:

• 12 year-old male
• Class II Skeletal pattern
• Vertically,Slightly high angle
• Slightly long lower facial height
• No crossbite , the dentition was symmetrical
in the transverse dimension.
• Molar relationships were 4mm Class II on the right side and 3.5mm
Class II on the left. The lower dental midline was deviated 1mm to the
right.
• The mandibular arch showed 3mm of crowding on
the right side, all mesial to the right canine.
• On the left side, there was only 1mm of crowding,
also between the canine and the midline.
The curve of Spee was about 2mm at its deepest
point.
• Steiner suggested that leveling a 2mm curve of
Spee would advance the incisors 1mm, thus
requiring 1mm of space per side for the leveling
process
• The lower midline was deviated1mm to the right,
the midline correction would require 1mm of space
on the left side and provide 1mm of space on the
right
• The mandibular incisors were inclined forward(97° to the mandibular
plane) and were 6mm in front of the APo line.
• Without extractions,the incisors would either remain in this position or,
more likely, be advanced farther.
• With extractions, the incisors could be retracted.
• Therefore, the decision was made to extract the four first premolars and
retract the mandibular incisors 2mm.
• The space-gaining procedures of interproximal reduction, molar
uprighting, and buccal uprighting of posterior teeth were not needed in
this case and were therefore not recorded in
• Chart 2. There was no leeway or “E” space available,since no primary
teeth were present.
• Anticipated treatment changes were recorded in Chart 3 using the
following process:
1. Extraction of the four first premolars produced 7mm of space in each
quadrant, since there was no crowding between the canines and first molars
in either arch. This was indicated by writing “(7)” in each quadrant.
• 2. Because the total lower arch discrepancy from canine to midline was
5mm per side, the mandibular canines needed to be retracted 5mm into
the extraction sites.
• This was recorded on the bottom of the chart, with arrows showing the
direction of movement.
• 3. The mandibular molars could therefore only be moved 2mm to close the remainder
of the 7mm extraction spaces—also indicated with arrows on the bottom of the chart.
• This demonstrated a need for moderate anchorage control in the mandibular arch.
• A mandibular lingual arch,for example, could be considered during the first
3mm of canine retraction. In the present case, the molar relationship on
the right side was 4mm Class II, and since 2mm could be corrected by mesial
movement of the mandibular molar, an additional 2mm of correction
was required.
On the left side, an additional 1.5mm of correction was needed.
These amounts were recorded on the top of Chart 3 with distal arrows.
• A palatal bar and a combination high-pull and cervical-pull headgear were
used to preserve maxillary anchorage in this case.
• If favorable mandibular growth occurred in any of the ways listed above,
maxillary anchorage control could be reduced or eliminated, allowing the
maxillary molars to move more mesially. This could not be predicted before
treatment, however, and so the numbers in Chart 3 represent the worst-
case scenario.
• A functional appliance could also have been considered before fixed
appliance therapy. A good response to the functional appliance might have
reduced the amount of maxillary anchorage support needed later.
Extractions would still have been required after the functionalphase,
assuming incisor retraction was still a treatment objective.
• Taking into account the 2mm distal movement of the maxillary right molar and the 1.5mm
distal movement of the maxillary left molar, the canines would have to be moved 9mm on the
right and 8.5mm on the left to close the 7mm extraction spaces.
• Leveling and alignment were carried out with an .022" edgewise appliance, beginning with
light twisted wires, and proceeding to round wires and finally to .019" × .025" rectangular
wires.
Extraction sites were then closed with the rectangular archwires, using pull-coil springs from
the firstmolars to archwire hooks between the lateral incisors and cuspids.
Class II elastics were used as little as possible, in conjunction with the headgear, to correct the
anteroposterior relationship.
Detailing and finishing were carried out with .019" × .025" rectangular archwires. With only
average cooperation, total treatment time was 35 months .
The patient wore a tooth positioner full-time for six weeks; a maxillary Hawley retainer was
then worn fulltime for six months and at night only thereafter while a fixed mandibular
retainer was bonded.
Case:2
• A female patient age 8
years and 4 months
• Class II skeletal pattern
• A Low angle patient with
a normal lower facial
height
• No crossbites, and
transverse dimension was
symmetrical.
• The patient’s molar relationship was4.5mm Class II on the right side
and 2.5mm Class II on the left (Chart 1).
• The dental midlines were properly aligned.
• The mandibular arch showed 2.5mm of crowding
from the canines to the midline on each side
(Chart 2).
• The leeway space in the mandibular arch, due to
the presence of the primary canines and the first
and second molars, was 1.5mm per side.
• The loss of these teeth would leave a total of only
1mm of crowding per side in the mandibular arch
• The mandibular incisors were 4mm behind the
APo line and at 87° to the mandibular plane,
the decision was made to advance them4mm,
providing 4mm of space per side.
• The curve of Spee was about 1mm deep
bilaterally,requiring 0.5mm of space per side
for leveling.
• No midline correction was needed
• Adding all these factors together, there was
a total lower arch discrepancy of +1mm per side
from canine to midline and +2.5mm per side
from first molar to midline. With this space
available, the mandibular canines could be
advanced 1mm per side, and the molars could
be advanced 2.5mm per side (Chart 3).
• Thus, 2.5mm of the 4.5mm Class II correction on the right side could be
achieved by mesial movement of the mandibular first molar.
• The remaining 2mm would have to be produced by the methods
described under Case 1.
• On the left side, the entire 2.5mm Class II correction could by achieved by
moving the mandibular first molar forward.
• This patient underwent an eight-month first phase of treatment with maxillary
and mandibular2 × 4 appliances, nighttime headgear, and daytime Class II
elastics.
• The second phase,begun at age 12, involved mainly tooth alignment for final
correction, using full fixed appliances in conjunction with headgear and elastics.
• This phase was completed in 20 months.
• Retainers were a maxillary removable wraparound appliance and a mandibular
fixed 4× 4 appliance.
Conclusion:

• This simple analysis to be most helpful as a diagnostic and treatment-

planning aid and as a reference throughout treatment.
• It is also useful in making the extraction/nonextraction decision.
• It has even been applied in some mutilated-dentition cases, and in
patients where second molars were substituted for first molars, or
premolars for canines.