Growth analysis and age estimation /fixed orthodontic courses

Growth Prediction & Age
Estimation

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

Contents



Growth spurts
Skeletal Maturity Indicators
1. Hand wrist Radiographs
2. Cervical Vertebrae
3. Mid-palatal suture
4. Densitometry Method
5. Ante-gonial Notch
6. Symphysis Morphology

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
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Dental Indicators
1. Tooth mineralization
2. 3rd molar development
Somatomedian levels
Frontal sinus development


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Important concepts in growth and
development




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Pattern
-Differential growth
-Predictability
Variability
-Concept of normality
-Age equivalence
Timing

Pattern


Pattern represents proportionality-not just
proportional relationships at a point in time but
change in these relationships over time.



Can be defined as-a set of constraints operating
to preserve the integration of parts under
varying conditions or through time.


Cephalocaudal gradient of growth




The accomplishment of normal human proportions is not
merely due to a general slowing down. Different tissues
grow at different rates at different times.



The overall pattern of growth is a reflection of the growth
of the various tissues making up the organism.


Differential growth



Scammon’s curves for growth.
Gave a graph for four major tissues of the body.
-lymphoid
-neural
-general
-genital


Body Composition Changes with Age
STRUCTURE

FETUS

NEW BORN

ADULT

Skin & fat

16 %

26 %

25 %

Viscera

16 %

16 %

11 %

Nervous
system

21 %

15 %

03 %

Muscle

25 %

25 %

43 %

Skeleton

22 %

18 %

18 %


Predictability


Predictability of growth pattern is a specific kind of
proportionality that exists at a particular time and
progresses towards another, at the next time frame with
slight variations.



Any change in growth pattern would indicate some
alterations in the expected changes in body
proportions.


Variability


No two individuals with the exception of monozygotic
twins are alike.



Clinically important to identify if an individual is at the
extreme of normal variation or is outside the range.



What is normal?

Normality


Normality refers to that which is usually expected, is
ordinarily seen or typical – Moyers



Normality may not necessarily be ideal so rather than
categorizing as normal or abnormal one can think of
deviations from the normal pattern.




One way to evaluate normality is using growth charts.



Used to determine if growth is normal in 2 ways- location of the individual relative to the group.
- follow a child’s growth to evaluate any unexpected
changes.


Age equivalence


Because of variability all individual at a given
chronological age are neither of the same size or same
stage of maturation.



It is better to compare biologic development.



“Developmental ages” –skeletal age and dental age are
used.

Timing


One of the factors for variability in growth.



Timing variations arise because biologic clock of
different individuals is set differently.



Timing-largely genetically controlled.
-sex related differences
-physical differences
-environmental




Variation in growth and
development because of
timing are evident in human
adolescence.



Plotting change in weight or
height shows the pattern of
growth.



The distance and velocity
graphs can be plotted and
compared.



Growth effects due
to timing variation
demonstrated using
growth velocity
curves.



Time variability is
reduced if graph
plotted using
developmental age.


Growth spurts




Periods of sudden acceleration of growth.
Due to physiological alteration in hormonal secretion.
Timing-sex linked.
Normal spurts are
 Infantile spurt – at 3 years age
 Juvenile spurt – 7-8 years (females); 8-10 years

(males)
 Pubertal spurt – 10-11 years(females); 15-18 years

(males)



Pubertal growth spurt:



Important period for orthodontic treatment.



Initiated in the brain-secretion of releasing factors,
pituitary gonadotropins.



Sex hormones released-physiological changes occurclassic growth cure pattern.



Timing -2 years earlier in girls.



Affected by genetic and environmental factors.


GIRLS
Total development of adolescent growth- 3½yrs
Stage 1
Beginning of adolescent growth
Stage 2
(12 months later)
Peak velocity in height.
Stage 3
(12-18 months later)
Growth spurt ending.

Appearance of breast buds,
initial pubic hair
Noticeable breast development,
axillary hair, dark/more
abundant pubic hair.

Menses, broadening of hips with
adult fat distribution, breasts
completed


BOYS
Total development of adolescent growth- 5 yrs
Stage 1
Beginning of adolescent growth

Fat spurt, weight gain, feminine fat
distribution

Stage 2
(12 months later)
Height spurt beginning

Redistribution or reduction in fat,
pubic hair, growth of penis

Stage 3
(8-12 months later)
Peak velocity of height.

Facial hair appears on upper lip only,
axillary hair, muscular growth with,
harder/more angular body form

Stage 4
(15-24 months later)
Growth spurt ending

Facial hair on chin and lip, adult
distribution/colour of pubic and
axillary hair, adult body form.


Velocity curves in for growth at adolescence shows
difference in timing between boys and girls.




Growth of the jaws correlates with physiologic events
of puberty –same as height.








But correlation is not perfect –juvenile acceleration of
jaw growth occurs.
Sex hormones are produced in adrenals by 6 years‘adrenarche’.
More prominent in girls due to greater adrenal
component.




Important clinically-careful assessment of physiologic
age-plan orthodontic treatment.



Treatment must begin during



mixed dentition-for girls.



Near completion of permanent dentition-for boysProffit.



But according to Graber, boys have a greater tendency
for 3 peaks than girls-very few girls show the mixed
dentition growth spurt.

Introduction






Chronological age is often not sufficient for
assessing the developmental stage and somatic
maturity of the patient.
The biological age is determined from the
skeletal, dental and morphologic age and
the onset of puberty.
Due to individual variations in timing, duration
and velocity of growth, skeletal age assessment is
essential in formulating viable orthodontic
treatment plans.

Clinical Importance





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To determine the amount of significant facial
cranial growth potential left and potential vector
of facial development.
To decide the onset of treatment timing and
type of effective treatment.
To evaluate the treatment prognosis.
To understand the role of genetics and
environment on the skeletal maturation pattern.

Anatomical Region Suitable For Skeletal
Maturational Assessment
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Head and Neck : Skull
Cervical Vertebrae
Upper Limb
:Shoulder Joint-Scapula
Elbow
Hand Wrist and Fingers
Lower Limb
: Femur and Humerus
Hip joint
Knee
Ankle
Foot tarsals and Meta tarsals
Tooth mineralization as an indicator.
Frontal sinus

Hand Wrist Radiographs




Assessment of the skeletal age is often made
with the help of a hand radiograph which can be
considered the Biological clock.
Hand wrist region is made up of numerous small
bones. These bone show a predictable and
scheduled pattern of appearance, ossification
and union from birth to maturity. Hence, this
region is one of the most suited to study growth.

Anatomy of Hand-Wrist
The hand wrist
region is made of
four groups of bones
1.Distal ends of long
bones of forearm.
2.Carpal
3.Metacarpals
4.Phalanges

Anatomy of skeleton of Hand


Indication Of Hand Wrist
Radiographs










In patients who exhibit major discrepancy between
dental and chronologic age.
Determination of skeletal maturity status prior to
treatment of skeletal malocclusion.
To assess the skeletal age in a patient whose growth is
affected by infections, neoplastic or traumatic
conditions.
Help to predict future skeletal maturation rate and
status.
To predict the pubertal growth spurt.

Methods Of Assessing Skeletal Age


Atlas method by Greulich and Pyle



Bjork ,Grave and Brown method



Julian singer’s method

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Fishman’s skeletal maturity indicators

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Hagg and Taranger method

Greulich and Pyle Method
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



Greulich and Pyle (1959) published an atlas containing
ideal skeletal age pictures of the hand-wrist for different
chronological ages and for each sex.
Each photograph in the atlas is representative of a
particular skeletal age.
The patient’s radiograph is matched on an overall basis
with one of the photographs in the atlas.


Bjork , Grave And Brown Method







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They have divided skeletal development into 9 stages.
Each of these stages represents a level of skeletal
maturity.
Appropriate chronological age for each of the stages
was given by Schopf in 1978
This method can differentiate maturation process of
hand bones between 9 to 17 years of age.
The ossification events are localized in the area of the
phalanges, carpal bones, and radius (R)


There are 3 stages of ossification
of the phalanges:
 First stage: Epiphysis shows the
same width as the diaphysis (=)
 Second stage: Capping stage
(=cap); the epiphysis surrounds
the diaphysis like a cap
 Third stage: U-stage (=U); bony
fusion of epiphysis and
diaphysis


First stage: PP2= -stage




The epiphysis of the
proximal phalanx of the
index finger (PP2) has the
same width as the
diaphysis.
This stage occurs
approximately 3 years
before the peak of the
puberal growth spurt.


Second stage: MP3= -stage


Epiphysis of the middle
phalanx of the middle
finger (MP3) is of the
same width as the
diaphysis


Stage three: Pisi-, H1-, and R= - stage




This stage of development
can be identified by three
distinct ossification areas;
these show individual
variations but appear at the
same time during the process
of maturation.
Pisi-stage = visible
ossification of the pisiforme




H1-stage = ossification of
the hamular process of
the hamatum



R = -stage, same width of
epiphysis and diaphysis of
the radius


Fourth stage: S- and H2-stage






S-stage=first mineralisation
of the ulnar sesamoid bone
of the metacarpophalangeal
joiant of the thumb.
H2-stage= progressive
ossification of the hamular
process of the hamatum
The fourth stage is reached
shortly before or at the
beginning of the puberal
growth spurt.

Fifth stage: MP3cap-, PP1cap- and Rcap-stage


During this stage, the
diaphysis is covered by the
cap-shaped epiphysis



MP3cap-stage, the process
begins at the middle phalanx
of the third finger








PP1cap-stage, at the
thumb
Rcap-stage, at the radius
This stage of ossification
marks the peak of the
puberal growth spurt.


Sixth stage: DP3u-stage




Visible union of epiphysis
and diaphysis at the distal
finger (DP3).
This stage of
development constitutes
the end of puberal
growth


Seventh stage: PP3u-stage


Visible union of epiphysis
and diaphysis at the
little finger (PP3)


Eighth stage: MP3u-stage


Union of epiphysis and
diaphysis at the middle
finger is clearly visible
(MP3)


Ninth stage: Ru-stage


Complete union of
epiphysis and diaphysis of
the radius.



The ossification of all the
hand bones is complete
and skeletal growth is
finished.

Growth period
Male
Stage1 PP2 =
Stage2 MP3 =
Stage3 Pisi,
H1,R=

Female

10.6yr
12.0

8.1
8.1

12.6

9.6

Stage4 S & H2
13.0
Stage5 MP3,RPP 14.0
P1cap

10.6
11.0

Stage6
Stage7

DP3U
PP3U

15.0
15.9

13.0
13.3

Stage8
Stage9

MP3U
RU

15.9
18.5

13.9
16.0

As a rule, girls reach the various developmental stages 2 years earlier than boys.

Singer’s method of assessment




Julian singer in 1980 proposed a system of hand-wrist
radiograph assessment that would enable the clinician to
rapidly and with some reliability help determine the maturational
status of the patient.
To establish baseline for simple clinical reference, six
stages of hand-wrist development are described. The
stages and characteristics are:


Stage 1 (Early)
1.
2.

3.

Absence of the pisiform,
Absence of the hook of
Hamate and
Epiphysis of proximal
phalanx of second digit
(pp2) narrower than its
shaft.


Stage 2 (Prepuberal)
1.

2.

3.

Proximal phalanx of second
digit and its epiphysis are
equal in width (pp2=),
Initial ossification of hook
of Hamate and
Initial ossification of the
pisiform


Stage 3 (Puberal onset)
1.

2.

3.

Beginning calcification of
ulnar sesamoid,
Increased width of
epiphysis of pp2 and
Increased calcification of
Hamate hook and
pisiform


Stage 4 (Puberal)
1.

2.

Calcified ulnar sesamoid
and
Capping of shaft of the
middle phalanx of third
digit by its epiphysis
(MP3cap)


Stage 5 (Puberal deceleration)
1.
2.

3.
4.

Ulnar sesamoid fully
calcified and
Calcification of epiphysis of
distal phalanx of third digit
with its shaft (DP3u)
All phananges and carpals
fully calcified and
Epiphysis of radius and ulna
not fully calcified with
respective shafts.

Stage 6 (Growth completion)
1.

No remaining growth
sites.


Clinical implication




Stage 2 represents that period prior to the adolescent
growth spurt during which significant amounts of
mandibular growth are possible.
Maxillary orthodontic therapy in conjuction with
mandibular growth might aid correction of a class II
relationship with considerable speed and ease.
Stage 5 represents that period of growth when
orthodontic treatment might be completed and the
patient is in retention therapy.

Fishman’s Skeletal Maturity
Indicators


Proposed by Leonard S
Fishman in 1982.



Make use of anatomical
sites located on thumb,
third finger, fifth finger
and Radius .


The Fishman’s system of interpretation
Uses four
stages of bone maturation


1.Epiphysis equal in width to diaphysis



2.Appearence of adductor sesamoid of thumb



3.Capping of epiphysis.



4.Fusion of epiphysis


Fishman method –Eleven SMIs
Width of Epiphysis equal to Diaphysis
SMI-1 Third finger-Proximal Phalanx
SMI-2 Third finger-Middle Phalanx
SMI-3 Fifth finger-Middle Phalanx
SMI-4 Appearance of adductor sesamoid of the
thumb
Capping of Epiphysis
SMI-5 Third finger –Distal Phalanx
SMI-7 Fifth finger-Middle Phalanx
Fusion of Epiphysis and Diaphysis
SMI-8 Third finger-Distal Phalanx
SMI-9 Third finger-Proximal Phalanx
SMI-11 Seen in Radius


Significance








SMI 1,2,3 :- Occur approximately 3 years before the
pubertal growth spurt.
SMI 4 :- This stage occurs shortly before or at the
beginning of pubertal growth spurt.
SMI 5,6,7 :- This stage occurs at the peak of the
SMI 8,9,10,11 :- The ossification of all hand bones is
completed and skeletal growth is finished.


Maturation Assessment by Hagg and
Taranger




Hagg and Taranger in 1980 described 5 stages of MP3
growth , based primarily on epiphyseal changes.
Skeletal development in the hand-wrist is analyzed from
annual radiographs, taken between the ages of 6 and 18
years, by assessment of the ossification of the ulnar
sesamoid of the metacarpophalangeal joint of first
finger (S) and Certain specified stages of 3 epiphyseal
bones:
- Middle and distal phalanges of third finger (MP3 and DP3)
- distal epiphysis of Radius (R).

Sesamoid


Sesamoid is usually attained during the
acceleration period of the pubertal growth
spurt (onset of peak height velocity)


Third Finger Middle Phalanx
MP3-F Stage








Start of the curve of pubertal
growth spurt .
Epiphysis is as wide as
metaphysis
End of epiphysis are tapered
and rounded.
Radiolucent gap [cartilageous
epiphyseal growth plate] between
epiphysis and metaphysis is wide.

MP3-FG Stage







Acceleration of the curve of
Epiphysis is as wide as
metaphysis.
Distinct medial and lateral border
of epiphysis forms line of
demarcation at right angle to
distal border.
Metaphysis begins to show slight
undulation.
Radiolucent gap between
metaphysis and epiphysis is wide.

MP3-G Stage







Maximum point of pubertal
growth spurt.
Sides of epiphysis have
thickened and cap its
metaphysis, forming sharp distal
edge on one or both the sides.
Marked undulations in
metaphysis give it “Cupid’s
bow’’ appearance.
Radiolucent gap is moderate.

MP3-H Stage








Deceleration of the curve of
Fusion of epiphysis and metaphysis
begins.
Side of epiphysis form obtuse
angle to distal border.
Epiphysis is beginning to narrow.
Slight convexity in metaphysis.
Typical Cupid’s bow appearance is
absent .
Radiolucent gap is narrow.

MP3-HI Stage







Maturation of the curve of
Superior surface of epiphysis
shows smooth concavity.
Metaphysis shows smooth, convex
surface, almost fitting into
reciprocal concavity of epiphysis.
No undulation present in
metaphysis.
Radiolucent gap is insignificant.

MP3-I Stage






End of pubertal growth spurt
Fusion of epiphysis and metaphysis
complete.
No radiolucent gap.
Dense, radiopaque epiphyseal line
forms integral part of proximal
portion of middle phalanx.


Third finger distal phalanx


DP3-1:Fusion of Epiphysis and Metaphysis is
completed.

-This is attained during the deceleration period
of pubertal growth spurt ( end of PHV) .


Radius
R-I:Fusion of the epiphysis and Metaphysis has
began.
-This stage is attained 1 year before or at the end of
growth spurt.
 R-IJ:Fusion is almost completed but there is still a
small cap at one or both margin.
 R-J:Characterised by fusion of the epiphysis and
metaphysis.


These stages were not attained before end of PHV.


Dental age








Chronological and dental age are synchronous in the
normal patient.
A child is labeled as an early or late developer if there
is a difference of +/- 2 years from the average value.
If the chronologic age of the patient is younger than
the dental age, one can rely on increased growth to a
greater degree than when dental age is retarded in
relation to the chronologic age ( and possibly biologic
age).
Dental age can be determined two methods:
- Stage of eruption
- stage of tooth mineralization on radiograph

Stage of Eruption






Determination of dental age from observation of
eruption has been the only method available for a
long time
In certain cases however, the accuracy of the
method is limited.
During the quiescent period in eruption, this
appoach is inadequate.


Stage of tooth mineralization on
radiograph (Demirjian et al 1973)






When determining dental age radiographically
according to the stages of germinations, the degree of
the development of individual teeth is compared to a
fixed scale.
For age determination one does not rely on the last
stage of tooth formation but on the entire process of
dental mineralization.
The procedure can be used for the entire deciduous
and mixed dentition period, and is not influnced by
early loss of deciduous teeth.







The calculation is made using a point evaluation
system.
Each tooth is given a point value according to its
state of development.
The sum of individual points gives the development
value, which can be transferred into the dental age
with the aid of standard tables.








The smaller the sum of points, the younger the
dental age; the higher the sum, the older the dental
age.
Experience shows that the method is sufficiently
accurate if the stage of mineralization of teeth 1-7 in
the left lower quadrant is examined.
The procedure is not valid for patients with several
congenitally absent teeth.


Lower third molar development in
relation to Skeletal Maturity and
Chronological Age


Mid Palatal Suture as an Indicator of
Maturity




In 1982, Fishman developed the system of skeletal
maturation assessment (SMA) which involves the
identification of 11 skeletal maturity indicators on H/W
radiographs that occur serially from the onset to
termination of adolescence.
All measurements associated with the growth of the
mandible correlate in intensity and timing with growth in
stature. The maxilla demonstrates less conformity.






Therefore knowing more about the development of the
maxilla can help a clinician to better time procedures
like maxillary expansion.
Fishman in 1994 conducted a study to evaluate the
ossification pattern of the mid-palatal suture and
whether this could be used as a maturity indicator.


Development of human mid palatal
suture






Three palatal processes develop that separate the nasal
cavity and the mouth.
1) The median palatal process.
2) Two lateral palatine processes.
Median palatine process – Primary palate
2 Lateral palatine processes – Secondary palate
Embryologically both form b/w 5-12 week of IUL.


The mid palatal suture is formed by 3 parts:
1)Interpremaxillary part
2)Maxillry part
3)Interpalatine part.
 A Well established Interpremaxillary suture was formed
in 47 day old embryo (primary palate)
 The first indication of sutural formation of secondary
palate (maxillary and inter palatine part) is at approx.
10 ½ weeks of age.
 A definite suture is formed by the 12th week of life.







Stages of ossification of midpalatal suture were compared
with Fishman’s SMI stages.
Certain landmarks were
identified on the occlusal films
which formed the basis of
comparision.

 Point A - Most anterior point on premaxilla
 Point B – Most posterior point on the posterior wall of
the incisive foramen.
 Point P – point tangent to a line connecting the posterior
walls of greater palatine foramen.







All measurements were made for –
a. Length
b. Percentage of development.
These were recorded for the following dimensions :
A-P - total dimension of the suture of the suture
A-B - anterior dimension of the suture
B-P - posterior dimension of the suture
The results reveled that there is significant correlation
b/n maturational development and the beginning of
ossification of the mid-palatal suture.


SMI
SMI 3

MPS

CORRELATION

Only about 8% fused

Before SMI 4 Very little or no midpalatal
approximation exists

Before beginning
of puberty

b/w SMI 4 - 7 An osseous interdigitation is
very evident with approximation
in some areas

Occurs during
pubertal growth
spurt

SMI 9

Increase in rate of
approximation (25%)

Deceleration of
pubertal growth
spurt

SMI 11

Only 50% approximated
End of adolescence
(higher %age occurs posteriorly)





No differences were seen in the pattern of
approximation b/w males and females.
This study has also verified the fact that midpalatal
approximation occurs more posteriorly during the
entire adolescent period.

Clinical implication :
 An ideal time to initiate orthopedic expansion is during
the early maturational stage, SMI 1 to 4.
 Theoretically less orthopedic force values would be
required if treatment is initiated early.

Symphysis morphology as a predictor of
the direction of mandibular growth




Nanda et al determined in their study that Symphysis
morphology could be used as a predictor of the direction
of mandibular growth.
The direction of mandibular growth was evaluated with
seven cephalometric measurements that included –
1. y – axis
2. SN to mandibular plane
3. Palatal plane to mandibular plane
4. Gonial angle
5. Sum of saddle, articular and gonial angle (Bjork sum)
6. Percentage lower facial height
7. Posterior/Anterior face height (Jaraback ratio)







The mandibular symphyseal dimensions studied were
height, depth, ratio (height/depth), and angle.
The Symphysis height was defined as the distance
from the superior to the inferior limit on the grid.
The Symphysis depth was defined as the distance from
the anterior to the posterior limit on the grid






Symphysis ratio was calculated by dividing Symphysis
height by depth.
The Symphysis angle was determined by the posteriorsuperior angle formed by the line through menton and
point B and the mandibular plane.




Large Symphysis ratio – receding chin,
high mandibular plane,
high angle SN-MP,
large saddle, articulare & gonial angles,



large anterior facial height,
large percentage lower facial height
Small Symphysis ratio – large chin
low mandibular plane
low angle SN-MP
low saddle, articular & gonial angles
Small anterior facial height
Small percentage lower facial height









The axiom about the chin is that those children who
have, will get more with growth, whereas those who do
not will not get much growth at the chin.
Symphysis ratio was strongly related to the direction of
mandibular growth in men.
Symphysis with an anterior growth direction of the
mandible had a short height, large depth, small ratio,
and large angle.
In contrast, a Symphysis with a large height, small
depth, large ratio, and small angle demonstrated a
posterior growth direction.





Growth changes in Symphysis continued up to
adulthood in both female and male subjects, with the
female subjects having a smaller and earlier occurring
change compared with the male subjects.
Symphysis height, depth, and ratio increased while
Symphysis angle decreased with age.


Ante gonial Notch – As an indicator of
mandibular growth potential





The presence of a prominent mandibular ante gonial
notch is a commonly reported finding in subjects with
disturbed or arrested growth of the mandibular
condyles.
In unilateral condylar hypoplasia, marked mandibular
notching develops only on the affected side.
Bjork’s implant studies have showed that in forward
rotating mandibles apposition occurs below the
Symphysis and resorption takes place under the angle.
Conversely, in backward mandibular rotation
apposition beneath the angle is common and resorption
underneath the Symphysis is possible.



The direction of mandibular growth rotation is reflected
in the location and degree of remodeling on the inferior
surface of the mandible and most pronounced area of
remodeling is below the angular region.



Singer and Hunter did a study to compare the
craniofacial characteristics and growth potential of
orthodontically treated patients with deep mandibular
ante gonial notch; with those of a similar group of
shallow notch subjects by use of lateral cephalometric
radiographs.





> 3 mm - Very deep mandibular ante gonial notch
< 3 mm - Very shallow mandibular ante gonial notch
These extremes were examined by them with the hope
that any biologic relationship might be more readily
apparent in extremes of population.


Concluding remarks were:
Deep notch subjects –
 more retrusive mandible with short corpus, less ramus
height, and a greater gonial angle than did shallow
notch subjects.
 Mandibular growth direction was more vertically
directed
 Longer total facial height and longer lower facial height
 Smaller saddle angle
 Required a longer duration of orthodontic treatment
(extractions 3 times the frequency, high-pull and
straight-pull head gear, shallow notch subjects – wore
low pull head gear exclusively)



During the average 4-year period examined, the deep
notch subjects experienced less mandibular growth as
evidenced by1. a smaller increase in total mandibular length.
2. corpus length, and
3. less displacement of the chin in a horizontal direction
than did the shallow notch subjects.


Clinical implication


The results of this study suggest that the clinical
presence of a deep mandibular ante gonial notch is
indicative of a diminished mandibular growth potential
and a vertically directed mandibular growth pattern.



An explanation for this could be when the growth of
the mandibular condyle fails to contribute to the
lowering of the mandible, the masseter and medial pterygoid
by their continued growth, cause the bone in the region
of the angle to grow downward, producing notching


Frontal Sinus Development as an
Indicator for Somatic Maturity at Puberty


Conclusion






Maturational development embodies the biologic
progression through life. In the growing years,
indicators of the level of maturational development of
the individual provide the best means for evaluating
biologic age.
Maturational development can be assed with the help
of all the indicators previously described.
However, it must be kept in mind that every child
demonstrates a unique sequential pattern of events.
No child is the same as the other.






Skeletal indicators of maturation have been proved to
be the most reliable. A combination of skeletal and
dental indicators tend to give a very accurate picture
of each child’s developmental status.
Finally it must be kept in mind that in orthodontic
practice it may be more relevant to evaluate the
development of the patient in relation to his own
growth potential in order to assess whether peak
velocity growth is imminent, present or completed.
The choice of indicators to be used finally depends
upon an orthodontist’s preference.

Bibliography







Hand book of orthodontics – R.E.Moyers, 4th ed
Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T
M. Graber
Contemporary Orthodontics – W.R.Proffit, 3rd ed
Facial Growth – D.H.Enlow, 3rd ed
Orthodontics – current principles and techniques –
T.M.Graber, R.L.Vanarsdall 3rd ed


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