Dental Virtual Treatment Objective (VTO)

Sercan Akyalcin, D.D.S., M.S., Ph.D.

Associate Professor and Graduate Program Director, Tufts University School of Dental
Medicine, Department of Orthodontics, Boston/MA, sercan.akyalcin@tufts.edu
The dental VTO should be regarded as a static figure that is used to calculate the amount
of tooth movement in each arch quadrant necessary to reach the treatment goals. It does
not incorporate any changes resulting from growth. Differential growth of the jaws may
contribute to the occlusal correction, and may affect the prediction of the dental
movement. One should consider how much growth is expected during the expected
treatment period and monitor the proposed tooth movement at each appointment in
growing patients.

Step I

The first part of the dental VTO requires defining the maxillary and mandibular dental
midlines and molar relationships when the patient is biting in centric occlusion (Table
1A). Class I molar relationship should be recorded as ‘0’. Angle Class II relationship will
be shown with an arrow pointing forward, whereas Angle Class III relationship will be
demonstrated with a backward facing arrow for both the right and left sides, including the
millimetric discrepancy on the upper portion of the chart. Maxillary and mandibular
dental midline deviations should be recorded according to the facial midline, indicating
the direction that the midline is shifted.

Step II

The second part involves a number of calculations of the amount of discrepancy that
exists in the mandibular arch (Table 1B). The space needs in the mandibular arch and
tooth movement necessary to address these needs are established first. Maxillary tooth
movement is calculated accordingly. Please note that the discrepancy is divided into ‘3-3’
and ‘7-7’ columns. The rationale behind this approach is to identify the required
movements of the canines to resolve the anterior discrepancy before any other decisions
are made.

Several steps are involved in the calculation of mandibular arch discrepancy. Crowding
should be recorded as (-) and extra space should be recorded as (+) numbers.

Anterior Crowding/Spacing: The orthodontist should measure the discrepancy from

canine to midline (3-3) on each side. This value should also be transferred to the 7-7
column because anterior crowding contributes to the total arch discrepancy.

Crowding/Spacing Bicuspids/E: Next the discrepancy in the premolar/E space should

be determined. If the D and Es are present, the orthodontist should be mindful of the size
differences between the primary and permanent teeth. The size difference should be
added to the ‘space gained’ for each arch quadrant in Step III. This value should only be
recorded for the 7-7 column since there are no premolars/primary molars in the 3-3 area.

Crowding/Spacing Molars: The next step is to evaluate the crowding/spacing in the first
and second molars. In most circumstances, this is best evaluated using a panoramic
radiograph to determine if the second molars are tipped and/or blocked out. The anterior
aspect of the ramus resorbs with growth and makes more room for the erupting second
molars. However, in nongrowing patients, uprighting the second molars can be very
difficult to achieve without adequate space. This value should also be recorded only in
the 7-7 column.

Curve of Spee: The space needed for leveling a deep curve of Spee is calculated in a way
where 1 mm of space is needed to level every 2 mm of depth in the curve of Spee on each
side of the dental arch. This will add to the space discrepancy as a (-) value. In some
Class III and open bite cases, the clinician may choose to finish the case with a slightly
deeper curve of Spee. For instance, if the clinician is planning to accentuate the curve of
Spee at 1 mm, (+) 0.5 mm space will be gained on each side of the dental arch.

Midline: Space required for midline correction should be recorded as a positive number
on one side and a negative number on the other side. If the mandibular dental midline is
deviated 2 mm to the right, it needs to be moved 2 mm to the left. This will bring about 2
mm of space discrepancy for the left (-), and 2 mm of space gain for the right side (+).

Incisor Position: After careful analysis, a decision should be made to maintain, advance
or retract the mandibular incisors as required by the facial objectives. While advancing
the incisors are recorded as (+) values, retraction should be recorded as (-) numbers.
According to Steiner,6 2.5 degrees of change in incisor inclination would be the
equivalent of 1 mm space on both the left and right sides. For instance, if an orthodontist
is uprighting the mandibular incisors by 5 degrees, 2 mm of space would be needed on
each side.

Initial Discrepancy: The initial arch length discrepancy is diagnosed for both the 3-3
and 7-7 columns separately.

Possible 3-3 treatment solutions include stripping, expansion/uprighting of the canines if

they are tipped lingually and extraction of an incisor. Uprighting/distalizing the first
molars is a difficult movement that will not help in solving the anterior discrepancy at all.
Therefore, this box is disabled for the 3-3 column. Once a final number is reached for the
remaining discrepancy in the 3-3 column, the amount of discrepancy will indicate how
far the mandibular canines must move to fulfill the treatment objectives. Establishing the
right and left side canine movement is critical because these numbers will determine
whether extractions are needed.

The solutions for a 7-7 discrepancy should be considered next. If there is a negative
number remaining from the 3-3 discrepancy, decisions should be made about how to
develop the space necessary for distal movement of the canines. In moderate to severe
cases, the answer is usually premolar extractions. In order to satisfy the treatment goals,
the target for the remaining discrepancy in the 7-7 column after calculation should either
be zero or a plus number. A negative number means that the space discrepancy has not
yet been resolved.
Step III

The last step of the VTO is the establishment of required tooth movement in the dental
arch quadrants (Table 1C). It will be determined at this time where the midlines, canines
and molars should go. The mandibular dental midline and remaining discrepancy for the
canines should be filled first since the mandibular arch serves as the diagnostic template
for the maxillary arch. If premolars are extracted to resolve an anterior discrepancy in the
mandibular arch, the remaining (3-3) discrepancy should be subtracted from the size of
the premolar which was removed from the respective mandibular arch quadrant. The size
of the premolar is technically the space gained in that dental arch quadrant, and should be
noted in the parentheses. The difference between the space gained and the remaining
discrepancy should provide the amount of molar protraction needed to close the
extraction space in the same quadrant. If there is crowding in the premolar area, the
amount of crowding should be subtracted from the space gained by extracting a premolar.
Conversely, E space and any interproximal reduction (IPR) planned from the mesial of
the first molar to the distal of the canine should be added to the space gained. The mesial
movement of the molars should always be the difference between the amount of distal
movement of the canines and the amount of space available as indicated in the
parentheses. Establishing the canine versus the molar movement in the mandibular arch is
an excellent opportunity to plan the anchorage requirements such as placing miniscrews.

Next, the movement of the maxillary teeth should be determined. At this point, we
already know how much the mandibular molars will be moved. The maxillary molars
should be moved according to targeted molar relationship. The maxillary canine
movement should be calculated by subtracting the molar movement from the space
available in that quadrant. If the case starts with a Class I molar relationship, and the
molar objective is to finish in Class I position, then the maxillary molar will have to
move the same amount of the mandibular molar. If the molar relationship is a 2 mm Class
II, and the objective is to finish in Class I molar relationship and 3 mm mandibular molar
protraction is planned, then the maxillary molar should be held with maximum anchorage
since it can only move forward 1 mm. Accordingly, if a 7 mm tooth is extracted in the
maxillary arch, the maxillary canine has to be retracted 6 mm to close the extraction
space.