Good Morning Ricketts Visual Treatment Objective & SuperimpositionIntroduction: A Visual Treatment Objective (VTO) is like a blueprint 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 that patient. Treatment for a growing patient must be planned and directed to the face and structure that can be anticipated in the future, not to the skeletal structure that the patient presents initially. The treatment plan should take advantage of the beneficial aspects of growth and minimize any undesirable effects of growth, if possible.The Visual Treatment Objective permits the development of alternative treatment plans. After setting up the teeth ideally within the anticipated or grown facial pattern, the orthodontist must decide how far he must go with mechanics and orthopedics to achieve his goals, whether it is possible to achieve them, and what the alternatives are.A step-by-step procedure to construct a VTO for Case X in the following sequence (putting in average growth for an estimated two-year period of active treatment and the objectives :1.the cranial base prediction2.the mandibular growth prediction3.the maxillary growth prediction4.the occlusal plane position5.the location of the dentition6.the soft tissue of the face

Point A Changes With Various Mechanism:

Mechanics Maximum Range Headgear - 8 mmClass II Elastics - 3 mm Activator - 2 mmTorque - 1 2 mmClass III Elastics + 2 3 mm Facial Mask + 2 4 mm Dentition Lower Incisors:

For this exercise, superimpose on the corpus axis at PM. Place dot representing the tip of the lower incisor in the ideal position to the new occlusion plane, which is 1mm above the occlusion plane and 1mm ahead of APO line Dentition Upper Incisors:

place upper incisors in good overbite Overjet position (2.5 mm overbite, 2.5mm Overjet) with an interincisal angle of 130+ 100. Openbite patterns at a greater angle, deepbite patterns at a lesser angle Superimposition:

After completion of the steps, Take VTO and superimpose it in the five superimposition areas to establish individual objectives for the case.The use of superimposition areas and evaluation areas to establish treatment design include changes due to normal growth and changes due to various treatment mechanics are different for each individual because of his individual morphology and facial type. In order to forecast effectively and decide upon the correct treatment design, it is necessary for us to first understand the individual patient and describe his basic facial, skeletal and dental structures. secondly we should be able to anticipate normal growth in amount and direction in the various areas of the face and the jaws. thirdly we should understand the response of his individual skeletal and facial structures to various treatment mechanics.The cephalometric x-ray and tracing are used as the basic tools of treatment design and the following four objectives are A basic description of the cranial structures.An analysis of normal growth changeA treatment designAn evaluation of growth and treatment results.The five superimposition areas are used to evaluate the face in the following order:1.The chin.2.The maxilla.3.The teeth in the mandible. 4.The teeth in the maxilla.5.The facial profile.Superimposition Area 1 (Evaluation Area 1)

The first superimposition (Basion-Nasion at CC Point) establishes Evaluation Area 1, within which we evaluate the amount of growth of the chin in millimeters; any change in chin in an opening or closing direction that may result from our mechanics; and any change in upper molar.In normal growth, the chin grows down the facial axis and the upper six year molars also grow down the facial axis.

Superimposition Area 2 (Evaluation Area 2)

The second superimposition area (Basion-Nasion at Nasion) establishes Evaluation Area 2 to show any change in the maxilla (Point A). The Basion-Nasion-Point A Angle does not change in normal growth. Therefore, any change in this angle would be due to the effect of our mechanics. With Evaluation Area 2, we determine whether we wish to use an orthodontic or an orthopedic force on the maxilla with a headgear.

Superimposition Area 3 (Evaluation Areas 3 and 4)

The third superimposition area (Corpus Axis at PM) establishes Evaluation Area 3 and Evaluation Area 4, which together evaluate any changes that take place in the mandibular denture. In normal growth, the lower denture remains constant with the APO Plane (the denture plane).In Evaluation Area 3, we evaluate whether we are going to intrude, extrude, advance or retract the lower incisors, which helps us determine what type of utility arch we will use.In Evaluation Area 4, we evaluate the lower molars to determine what type of anchorage we need and whether we wish to advance, upright or hold the lower molars.

Superimposition Area 4 (Evaluation Areas 5 and 6)

The fourth superimposition area (Palate at ANS) establishes Evaluation Area 5 and Evaluation Area 6, which together evaluate any changes that take place in the maxillary denture. In normal growth, upper molars and upper incisors grow on their polar axis.In Evaluation Area 5, we evaluate what we are going to do with the upper molars hold, intrude, extrude, distallize or bring them forward.In Evaluation Area 6, we evaluate what we are going to do with the upper incisors intrude, extrude, retract, advance, torque or tip them.

Superimposition Area 5 (Evaluation Area 7)

5th Superimposition Area (esthetic plane at the crossing of the occlusal plane)The fifth superimposition area (Esthetic Plane at the crossing of the Occlusal Plane) establishes Evaluation Area 7 with which we evaluate the soft tissue profile. In normal growth, the face becomes less protrusive with reference to the esthetic plane. We use Superimposition Area 5 and Evaluation Area 7 to evaluate the effect of our mechanics on the soft tissue of the face.

Bibliography Robert M Ricketts, Ruel W. Bench, Carl F.Gugino, James J. HIlgers, Robert J. Schulhof. Bioprogressive therapy. 1st Book. Rocky Mountain Orthodontics: Page, 35-70

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