Growth assessment /certified fixed orthodontic courses by Indian dental academy

GROWTH ASSESSMENT

www.indiandentalacademy.com

INDIAN DENTAL ACADEMY
Leader in continuing dental education










Introduction
Requirement of an ideal maturity indicator
Clinical importance
Different methods of growth assessment
Interrelationship among the various
maturity indicators
conclusion


INTRODUCTION






Human growth shows considerable variation in
the chronological ages at which individual
children reach similar developmental events .
Therefore, an understanding of growth events
is of primary importance in the practice of
orthodontics. Biological age, skeletal age,
bone age, and skeletal maturations are nearly
synonymous terms used to describe the
maturation of a person.





In the planning of orthodontic treatment,
anticipation of future growth potential Of the
facial skeleton is essential to ensure the
successful out come of mechanotherapy, and
in the treatment of dentofacial deformities.
It can be important in myofunctionl appliances,
borderline extraction cases, timing of headgear
therapy or in the prognosis of skeletal class two
or three discrepancies.


CHRONOLOGICAL
PHYSIOLOGICAL
DENTAL

MATURATION

SOMATIC

NEURAL
SKELETAL

SEXUAL


Requirement of an ideal
maturity indicator











Should be safe and non invasive
Require minimum radiation
Should be accurate
Stage of maturity should be well defined
Easily identifiable
Cost effective
Require minimum armanterium
Simple to conduct
Valid overtime and across age group

CLINICAL IMPORTANCE


The key to successful treatment in
growing patients is the harnessing of
growth and unless we know the exact
status of growth, both in magnitude as well
as in direction, treatment planning would
not be futile. Hence the knowledge of
maturity indicator is important for;--www.indiandentalacademy.com

To determine the potential vector of
facial development
 To evaluate the rate of growth
 To decide the onset of treatment
planning
 To evaluate the treatment prognosis



Different methods of growth
assessment






Biometrics—is defined as science of
statistical biology ,the collection and
statistical analysis of data regarding a living
organism.
Longitudinal methods —these imply serial
measurements in the same individual or
population over a long period of time. their
advantage lie in the fact that individual
patterns can be defined and the variation
within the group can be analyzed . However
these studies are more expensive and time
consuming and more vulnerable to subject
attrition.







In a longitudinal growth study by Bjork with
means of implant was done to find out the
variation in growth pattern of the human
mandible .
Cross sectional method –groups of varying
ages or at varying stages in development are
examined only once.
Semi longitudinal---monitoring age groups or
subgroups at different level of development
only for that period which separate one group
from another.





Radio isotopes —when injected into the tissues
get incorporated into the developing bone and
act as in vivo markers. Tc 33 is the most
commonly used isotope.
Vital staining —administration of certain dyes to
the experimental animals which incorporated in
the bones. e.g.—Alizarin red 5,tetracyclin.








Natural markers —certain histological features
present in the normal bone such as nutrient canals
,lines of arrested growth and certain prominent
trabeculae can be used as natural markers.
Steriopairs —is a computer analysis in which
positional changes can be studied in a three
dimensional system.
Craniometry —metric study of cranial dimensions
in dry skulls. less suitable for descriptive purpose.


TYPE OF MATURITY INDICATORS
RELEVANT IN ORTHODONTICS
SOMATIC

SEXUAL

DENTAL

SKELETAL

DEMIRJIAN,BUSCHANG et al (AJO 1985)

SOMATIC





An standard growth chart is used to

determine a growth of a child relative to
peer group.
Commonly used for height and weight.
The normal variability is shown by solid
line on the graph.


 INTERPRETATION






—

plotted above the 90%
child was
larger than 90% of the population.
Plotted below the 10% line
child
was smaller than 90% 0f the population
An individual who stood exactly at the midpoint
of the normal distribution would fall along the
50% line of the graph .





Growth can either be plotted either in height and
weight at any age (black) known as distance
curve or the amount of change in any given time
(red line) ,called as velocity curve.
Plotting velocity rather than distance makes it
easier to see when accelerations or
decelerations in the rate of growth occurred.


Growth
velocity
curve for
early,
average and
late
maturating
indicate that
earlier the
adolescent
growth spurt
occurs, the
more intense
it appear to
be.

USES







To predict whether growth is normal or abnormal
To establish a location of individual relative to the
group.
Child who falls beyond the range of 97% of the
population should receive special study before
being accepted as just an extreme of the normal
population.
To predict any unexpected change in growth
pattern.


Roche (1980)categorized six type of
height growth in children
 Average growers -follows middle range
distance curve and comprise two third
of all the children.
 Early maturing -taller in child hood as
matured faster not particularly tall as
adults.
 Genetically tall —taller than average
children and will be tall as adults .



Late maturing –shorter than average in
childhood and will be adults of average
stature.
 Genetically short —short in childhood and
as adults as well.
 Children who start puberty either very late
or very early subsequently have either
much less or much more growth in height
than expected.



However height and weight tables for
determining developmental status have
proved to be inadequate because of the
factors such as





Heterogenicity of the population
Genetic diversity
Difference in levels of nutrition
Environmental factors





More ever in every population there are
early and late maturing strains and there is
wide variation in age at onset of puberty.
Because of these factors, the developing
status of a child can not be accurately
predicted on the basis of these height and
weight charts .


SEXUAL MATURITY INDICATORS


Characteristic body changes and
secondary sexual characters are seen
during the onset of puberty due to
differential hormonal action.
 Tanner in 1962 outlined the stages of
secondary sexual character with their
relation to pubertal growth spurt
categorizing them into 5 stages. Stage
1 being prepubertal and stage 5 being
mature



Hagg and Taranger (ajo 1982) found that
attainments of menarche and voice
changes in girls and boys respectively are
reliable indicators of the pubertal growth
spurt. In girls menarche usually does not
occur before peak height velocity (PHV) .
In boys pubertal voice is attained closed to
PHV and male voice is attained at PHV or
after.


SKELETAL MATURITY
INDICATORS

HAND WRIST
RADIOGRAPH

CERVICAL
VERTEBRAE
MATURATION


DENTAL
MATURITY
INDICATORS

HAND WRIST RADIOGRAPH




The hand wrist region is made of numerous
small bones which show predictable and
scheduled pattern of appearance
,ossification, and union from birth to
maturity.
Generally left hand radiograph is taken.


ANATOMY OF THE HAND
WRIST


STAGES IN THE
OSSIFICATION OF
PHALANGES







Stage one —the epiphysis and diaphysis
are equal.
Stage two —the epiphysis caps the
diaphysis by surrounding it like a cap.
Stage three ---fusion occurs between the
epiphysis and diaphysis.


THE SESAMOID BONE




The sesamoid bone is a small nodular
bone.
Most often present embedded in the
tendons in the region of the thumb.


METHODS TO ASSESS THE
SKELETAL MATURITY USING
HAND WRIST RADIOGRAPH











ATLAS METHOD BY GREULICH AND
PYLE
BJORK,GRAVE, AND BROWN
MATHOD
SINGER METHOD
FISHMAN SKELETAL MATURITY
INDICATORS
HAGG AND TARANGER METHOD







ATLAS METHOD BY
GREULICH AND PYLE(1950)

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

BJORK,GRAVE AND
BROWN
METHOD
Have divided skeletal development
into 9 stages; Schoph in 1978
associated each of these stages with
a particular chronological age.






Stage 1—(male-10.6y
female-8.1)– the
epiphyis and diaphysis
of the proximal
phalanx of index finger
are equal.Occurs
approx 3 years before
the peak of pubertal
growth spurt
Stage 2-(male-12y
female-8.1) –the
epiphysis and
diaphysis of the middle
phalanx of the middle
phalanx are equal.



Stage 3 (Male-12.6y Female-9.6y)—
1.hamular process of the hamate exhibits
ossification 2.Ossification of pisiform 3.The
epiphysis and diaphysis of radius are equal








Stage 4

(Male-13 y
Female-1o.6y)-initial
mineralization of the
ulnar sesamoid of the
thumb.
Increased ossification
of the hamular process
of the hamate bone.
Marks the beginning of
pubertal growth spurt.






Stage 5----(male14y; female-11y)marks the peak of
the pubertal spurt.
Capping of the
diaphysis by the
epiphysis is seen
in middle phalanx
of the third finger,
Proximal phalanx
of the thumb and
In radius.


Stage 6 (male15y;female-13y)
 Signifies the
end of pubertal
growth spurt
 Union between
diaphysis and
epiphysis of
distal phalanx of
middle finger.

 Stage



7—

(male-15.9
female- 13.9)
Union
between
epiphysis
and
diaphysis
proximal
phalanx of
little finger

 Stage



8–

(male-15.9
female-13.9)
Fusion
between
epiphysis and
diaphysis of
middle
phalanx of the
third finger

 STAGE

9 (Male-



18.5y
Female16y)
Fusion
between
epiphysis
and
diaphysis
of the
radius


SINGER METHOD OF
ASSESSMENT



Six stages of hand wrist development are
described








Stage 1 (early) —absence of pisiform;hook of the
hamate; epiphysis of proximal phalanx of second
finger (PP2) being narrower than its diaphysis
Stage 2- (prepubertal)- initial ossification of the hook
of hamate, pisiform and diaphysis equal to epiphysis
in proximal phalanx of second finger.
Represents the period during which significant
amount of growth of mandible is possible.






Stage 3(pubertal onset) —(1):begining of
calcification of ulnar sesamoid.
(2):increased width of epiphysis of PP2
(3):increased calcification of hook of
hamate and pisiform.
Stage 4(pubertal)----calcified ulnar
sesamoid,fusion of epiphysis of DP3 with
its shaft.






Stage 5(pubertal deceleration) —1;fully
calcified ulnar sesamoid. 2; fusion of
epiphysis of distal phalanx of middle finger
with its shaft; 3; epiphysis of radio and
ulna are not fully fused with their
respective shaft .
Stage 6 (growth completion) - no
remaining growth sites are seen.


FISHMAN SKELETAL MATURITY
ASSESSMENT ANGLE ORTHODONTIST 1982


It uses of 4 anatomical site located on
thumb, third finger ,fifth finger and
radius.11 discrete adolescent maturity
indicators covering the entire period of
adolescent growth, are found on these
sites.









This system of interpretation uses 4 stages of bone
maturation
1-epiphysis equal in width to diaphysis
2—appearance of adductor sesamoid of the thumb
3-capping of epiphysis
4-fusion of epiphysis










The 11 skeletal maturity indicators (SMI) are as
follows—
Width of diaphysis equal to epiphysis
SMI:1—proximal phalanx of middle finger
SMI:2—middle phalanx of the middle finger
SMI:3-middle phalanx of the little finger
SMI 4 —OSSIFICATION of sesamoid


Capping of
epiphysis

Distal
phalanx
of middle
finger
SMI-5

Middle
phalanx
of third
finger
SMI-6

Middle
phalanx
of small
finger
SMI-7

FUSION OF EPIPHYSIS AND
DIAPHYSIS
SMI 8

SMI 9

distal phalanx
of middle
finger

SMI 10

proximal
phalanx of
middle finger

SMI 11

Middle
phalanx
of
middle
finger


RADIUS

SYSTEMATIC OBSERVATION SCHEME
4.OSSIFICATION OF ADDUCTOR SESAMOID

NO

WIDTH

YES

8.FUSION OF DP3
YES

1. PP3
2. MP3
3. MP5

NO
CAPPING
5..DP3
6.MP3

7.MP5


FUSION
9.PP3
10.MP3
11.RADIUS

HAGG AND TARANGER METHOD




Skeletal development in the hand and wrist is
analyzed from annual radiograph , taken between the
ages of 6 and 18 years, by the ossification of ulnar
sesamoid of the thumb, and certain specified stages of
three bones MP3 ,DP3, and epiphysis of radius
Sesamoid- is usually attained during the acceleration
period of the pubertal growth spurt











Third finger
middle phalanx—
MP3F—epiphysis
as wide as
metaphysis.
Ends of epiphysis
are tapered and
F stage
rounded
Metaphysis
shows no
undulation
Radiolucent gap
between
epiphysis and
metaphysis is
wide



Attained before onset of PHV by about
40% of individual and at PHV by many
others









MP3—FGepiphysis is as
wide as
metaphysis.
Distinct medial
and/or lateral
border of the
epiphysis forming
a line of
demarcation at
right angle to the
distal border.
This is attained 1
year before or at
p.H.V

Modified by R.Rajgopal and
Sudhansu Kansal (JCO July 2002)




Metaphysis begin to show slight
undulation
Radiolucent gap between metaphysis and
the epiphysis is wide







MP3-G –
Sides of the
epiphysis are
thickened and
also caps its
metaphysis,form
ing a sharp edge
distally at one or
both sides.
Attained at or 1
year after p.H.V.


modification




Marked undulation in the metaphysis gives
it cupid’s bow appearance
Radiolucent gap between epiphysis and
metaphysic is moderate







MP3 H—
Fusion of epiphysis
and metaphysis
has begun.
It is attained after
PHV but before end
of growth spurt by
practically all boys
and about 90% of
all the girls.


MP3 –HI STAGE (new stage added
by these authors)





Superior surface of epiphysis shows
smooth concavity where as metaphysis
shows smooth convex surface almost
fitting into reciprocal concavity of the
epiphysis
No undulation is present in the metaphysis
Radioluscent gap between the epiphysis
and the metaphysis is insignificant.






MP3 I
Attained
before or at
the end of
growth spurt in
all the subjects
except a few
girls
Fusion of
epiphysis and
metaphysis is
complete.










THIRD FINGER DISTAL PHALANX—DP3 I –Fusion
of epiphysis and metaphysis completed. Attained
during the deceleration period of growth spurt by all
subjects.
CHANGES IN THE DISTAL EPIPHYSIS OF THE
RADIUS
R I- Fusion of epiphysis and metaphysis has begun
and is attained 1 year before or at the end of growth
spurt by about 80% of girls and about 90% of the
boys.
R-IJ- Fusion is almost completed
RJ- Fusion of epiphysis and metaphysis


CERVICAL VERTEBRAE
MATURATION (CVM)




The first seven vertebrae in the spinal
column constitute the cervical spine. The
first two, atlas and axis are quite unique
while the third through the seventh have
great similarity.
Lamparski(1972)-studied changes in size
and shape of cervical vertebrae to create
maturational standards.





Hassel and Farman (ajo 1995) created a method
of evaluating the skeletal maturation of the
orthodontic patient using the cephalometric
radiograph that is routinely taken with
pretreatment records.
11 groups of 10 male and 10 female aged 8-- 18
years, taken from Bolton-brush growth center
and placed in each SMI group numbered 1 to 11
( FISHMAN SMI).








The shape of the cervical vertebrae C2,C3 and
C4 were seen to differ at each level of skeletal
maturity.
Shapes of vertebral bodies of C3 C4 changed
some what from wedge shape to rectangular
followed by square shape. In addition they
become taller as maturity progressed. The
inferior vertebral borders were flat when
immature and concave when mature.
Hassel and Farman have put forward six stages
in the vertebral development.








INITIATION. --This corresponded to a
combination of SMI 1 and 2.
At this stage, adolescent growth was just
beginning and 80% to 100% of adolescent
growth was expected.
Inferior borders of C2, C3, and C4 were flat
at this stage. The vertebrae were wedge
shaped, and the superior vertebral borders
were tapered from posterior to anterior








ACCELERATION.--- This corresponded to a
Growth acceleration was beginning at this stage,
with 65% to 85% of adolescent growth expected.
Concavities were developing in the inferior
borders of C2 and C3. The inferior border of C4
was flat. The bodies of C3 and C4 were nearly
rectangular in shape .








TRANSITION. --This corresponded to a
Adolescent growth was still accelerating at
this stage toward peak height velocity, with
25% to 65% of adolescent growth expected.
Distinct concavities were seen in the inferior
borders of C2 and C3. A concavity was
beginning to develop in the inferior border of
C4. The bodies of C3 and C4 were
rectangular in shape







DECELERATION. --This corresponded to a
Adolescent growth began to decelerate
dramatically at this stage, with 10% to 25%
of adolescent growth expected.
Distinct concavities were seen in the inferior
borders of C2, C3, and C4. The vertebral
bodies of C3 and C4 were becoming more
square in shape .








MATURATION. This corresponded to a
Final maturation of the vertebrae took place
during this stage, with 5% to 10% of
adolescent growth expected.
More accentuated concavities were seen in
the inferior borders of C2, C3, and C4. The
bodies of C3 and C4 were nearly square to
square in shape








COMPLETION. --This corresponded to
SMI 11. Growth was considered to be
complete at this stage.
Little or no adolescent growth was
expected.
Deep concavities were seen in the inferior
borders of C2, C3, and C4. The bodies of
C3 and C4 were square or were greater in
vertical dimension than in horizontal
dimension.








Tiziano Baccetti ,Franchi,McNamara
(Seminars in orthod. 2005) have recently
proposed an improve version of the cervical
vertebrae maturation for the detection of the
peak of the mandible growth based on the
analysis of the second through fourth cervical
vertebrae in single cephalogram.
The new cervical vertebrae maturation
stage(CVMS) presents 6 maturational stages
CS1 and CS2 are prepeak stages ,
The peak in mandibular growth occurs
between CS 3 and CS 4
CS6 is recorded at least 2 year after the
mandibular peak.

CLINICAL APPLICATION






Class II treatment is most effective when it
includes the peak in the mandibular growth
(CS3 ,CS4)
Class III treatment with maxillary expansion and
protraction is effective in the maxilla only when it
is performed before the peak (CS1,CS2) where
as it is effective in the mandible during both
prepubertal and pubertal stages.
Deficiency of mandibular ramus height can be
enhanced significantly when orthopedic treatment
is performed at the peak of the mandibular
growth (CS3).







Mc Namara,Franchi et al (AJO 2000) Used the
CVM method to define the optimum timing for
treatment of class two malocclusion with twin
block.
The subject in the early treated group started twin
block therapy in stage 1 or 2 and were compared
with subjects treated during or slightly after stage
3
The more favorable mandibular skeleton
modifications were induced in the group that
started therapy in stage three group which is
concurrent with the onset of the peak in mand
growth.



DENTAL MATURITY INDICATORS

TOOTH
ERUPTION

TOOTH
FORMATION

however tooth eruption is much more variable in its timing than
other skeletal maturity indicators (Nolla1960,Vanderliden1979)
tooth formation is also reported to be more variable than
calcification sequence- Nolla 1960.
Demirjian,Goldstein,Tanner(1973) —proposed a method for
estimating dental maturity by radiographic appearance of
seven teeth on the left side of the mandible.










STAGE A -cusp tips are calcified but not yet fused.
STAGE B –cusp tips are united so an occlusal out line
can be determined.
STAGE C —enamel formation is complete at occlusal
surface. Dentin deposition has commenced. Outline of
pulp chamber is curved.
STAGE D —crown complete till CEJ. Pulp chamber
curved being concave toward cervical region in single
rooted tooth. In molars pulp chamber-trapezoid form.
Pulp horns are beginning to differentiate. Root
formation is seen
STAGE E –pulp chambers are more straight. Horns
more differentiated .Root length is less than crown.







STAGE F —wall of pulp chamber form an triangle;
root length equal or> than crown. Root bifurcation has
developed suffice to give root a distinct outline and
funnel shape endings.
STAGE G - Root canal walls are parallel, apical end is
partially opened.
STAGE H- Apical end is completely closed. The pdl
has uniform width around the root and the apex.








CHERTKOW(AJO 1979) Studied the relationship
between tooth mineralization and early radiographic
evidence of the ulnar sesamoid in children of
Caucasoid origin. Calcification of adductor sesamoid
was closely related to stage g of mandibular canine .
No significant sex difference in the state of maturation
of this tooth in relation to this particular stage of
skeletal development.
So this stage may be used as maturity indicator for the
commencement of circumpubertal growth spurt.










Coutinho, Buschang, Miranda (ajo 1993) also studied
the relationship between mandibular canine and
skeletal maturity indicators; according to authorsCANINE STAGE F

Initiation of puberty

CANINE STAGE G
concides with MP3 CAP; PP5
Cap . Presence of adductor sesamoid. it is indicative
of PHV.
Stage G which indicates eruption of canine occurs
approx 1 year before PHV in boys and 5 month before
in girls;





kralassiri et al (AO 2002)
studied Thai
individuals and found mand 2nd premolar to show
highest correlation.
Vysal et al (AO 2004)
studied on Turkish
individuals, found mand molar to show highest
correlation .


INTER-RELATIONSHIP AMONG
SOMATIC ,SKELETAL ,DENTAL,AND
SEXUAL MATURITY




HAGG AND TARANGER(AJO 1982)-Investigated
the pubertal growth spurt and the dental skeletal
and pubertal development in a longitudinal study of
212 Swedish children. They found 2 year sex
difference in age in the beginning of peak and end
of growth spurt . Dental development was not
found as an useful indicator .The peak and end but
not the beginning of the pubertal growth spurt
could be determined from the skeletal development
of hand wrist and pubertal development.

Inter-relationship among somatic ,skeletal ,dental, and
sexual maturity (Demirjian, Buschang et al ajo 1985)








The interrelationship among all these measures
for 50 French Canadian girls were evaluated.
There was significant correlation among ages of
PHV, menarche and 75% skeletal maturity.
Age of menarche was most closely related to
PHV.
90% of the dental development in the subjects
did not show significant relationship with other
maturity indicators;
The results imply that dental developments are
independent of other maturity indicators.



Lewis, Roche ,Wagner (AO,1985)—found that
timing of pubertal growth spurt in cranial base
and mandible occurred after the onset of
ossification of ulnar sesamoid but before PHV
and menarche.


Association between Growth
Stunting with Dental
Development and Skeletal
Maturation Stage (AO 2005)








A study was done by Carlos Flores-Mira; et al to
determine the skeletal maturity. stage of the middle
phalanx of the third finger (MP3) and the dental
development of the left mandibular canine in 280 high
school children (140 stunted and 140 normal controls)
between 9.5 and 16.5 years of age, from a
representative Peruvian school.
A high correlation was found between maturity
indicators regardless of the nutritional status
Growth stunting was not associated with dental
development and skeletal maturity stages in Peruvian
school children. ( Angle Orthod 2005;.)

Relationship between growth pattern
and the maturation stage of permanent
teeth (AO,Nov,2005)




A study by Neves et al was done on 256 individuals
using lateral cephalograms to assess the growth
pattern and OPGs were used to asses the dental
maturation age at the age of 8 years. A significant
correlation was found between the dental ages of
the vertical and horizontal group, with the vertical
group having a more advanced dental age.
It was concluded that subjects with vertical growth
patterns should be expected to mature dentally
earlier than horizontal growers.

Midpalatal region as an indicator of
maturity








This study was done by Bernel Revelo et al to
determine whether a positive correlation exist
between adolescent maturation development
and the approximation of the mid palatal suture.
Hand wrist radiograph were taken and individual
were classified as accelerated, average ,delayed
based on Fishman skeletal maturity indicators
and occlusal radiograph were taken to assess
the sutural approximation.
Sample consisted of 39 male and 45 female(age8-18 year)




The results of this study revealed that
there is significant correlation between
maturational development and the
beginning of ossification of the midpalatal
suture; however, a great amount of
variation exists in the way this suture
closes.


Frontal sinus development as an
indicator for somatic maturity at
puberty.








A study was done by Sabine Ruf Hans et al to
evaluate the possibility of the frontal sinus
development as an indicator for somatic maturity
at puberty.
The subject consisted of 53 samples with angle
class II div I malocclusion who treated
orthodontically during growth period .
Lateral head film covering at least two year
interval and longitudinal body height growth data
existed for all the subjects.



Frontal
sinus
growth was
compared
with
longitudinal
body height
growth.






Frontal sinus growth velocity at puberty is
closely related to body height growth
velocity .
Frontal sinus growth shows a well-defined
pubertal peak (Sp), which on the average,
occurs 1.4 years after the pubertal body
height peak (Bp).



It was concluded that if only prediction
was whether the pubertal growth peak in
height has been passed the precision of
the method was rather high
(approximately 90%). However, if the age
of body height peak was to be predicted,
the method accuracy was lower
(approximately 55%).


Lower third molar development in
relation to skeletal maturity and
chronological age—Christer
Engstrom et al –AO,1983.






None of the earlier studies included the
development of third molar in relation to the
skeletal maturity.
However some of the great variability found
in previous studies on third molar
development might be due to the fact that the
development was related to chronological
age rather than the skeletal age.






221 (123 girls,88 boys) were selected at
random. the developmental stages of third
molar were categorized into one of the
following classes:-A—tooth germ visible as a rounded
radioluscency. B—cusp mineralization
complete. C—crown formation complete. D
—root half formed. E—root formation
complete but apex not closed.




A hand wrist was also taken and skeletal
development was classified as

PP2

Epiphysis
as wide as
diaphysis

MP3
cap

DP3 u

Epiphysi Epiphyseal
union
s caps
diaphysis


Ru

Epiphyseal
union









A strong correlation was found between
the skeletal maturation ,chronological age,
and the developmental stages of the third
molar.
PP2—complete crown mineralization in
majority of the subjects.
MP3—complete crown formation in most
of the individuals and beginning of the root
development.
DP3u– crown was still incomplete in some,
but it had already attained full root length
in others.





Ru—crown completed in one third, half of
the root development in one third, and had
reached full length in another one third.
Absence of one or both lower third molar
was observed in 11% of the subjects.






A large no of dental stages makes it very
difficult to discriminate the tooth
development and may adversely affect the
possibility of identifying the relationship
between tooth development and
maturation.
In this study different tooth development
stages of the third molar were chosen long
enough to span the various skeletal
stages and so provide a meaningful
comparison.

Ossification of the distal phalanx
of the first digit as a maturity
indicator for the initiation of the
treatment of class III
malocclusion ( AJO-DO 1996)








Orthodonic treatment of mild(0 to -2ANB) to
moderate(-3 to-5 ANB) skeletal class III
malocclusions should begin in the early mixed
dentition so that disharmony can be corrected
with growth modifications.
So a reliable indicator of the stage of skeletal
maturation and the potential for further
craniofacial growth especially residual
mandibular growth in these group of individuals
would be useful.
In a study done by Shigemi Goto , Takehumi ,
Negoro et al in japanes female( AJO-DO 1996) it
was concluded that ossification of the distal
phalanx of the first digit occurs after the pubertal
growth peak







This event is closely related with declining
growth rate of the mandibular condyles
especially in the girls.
They also found that the stage
immediately before fusion of the distal
epiphysis was associated with a minimal
amount of craniofacial growth.
The results of these studies showed that
the maturation stage characterized by
complete fusion of the epiphysis and
diaphysis of the first digit always occurred
after the pubertal growth spurt.





As much as 90% of the total growth in length of
the cranial base and maxillary and mandibular
length had already been achieved at this stage
that minimal craniofacial growth was left after
this stage, particularly in females.
However these findings seem to contradict the
results recently reported by Battage (Eur J
Orthod 1993;). who showed some continued
mandibular growth in British females with Class
III malocclusion after puberty.






She reported that when comparing groups
of female patients with Class I and Class
III malocclusions, those with Class III
malocclusions continued to grow longer in
the mandible.
This difference may be associated with
differences in ethnicity and needs further
investigation.






Results of this study suggest that determination
of the stage of skeletal maturation of the first
digit of the distal phalanx may provide a quick
and useful clinical method for assessing the
residual growth potential in female patients with
mild to moderate Class III malocclusions.
This method is potentially helpful in patients
where continued mandibular growth could be
detrimental to the stability of the treatment
result .






However, caution should be exercised, as
mandibular growth may still continue after
closure of the distal phalanx of the first digit,
especially in more severe Class III
malocclusions that are due to mandibular
prognathism.
In those patients with more severe skeletal
discrepancies, other methods should be applied
to determine remaining growth, such as analysis
of serial head films or nuclear bone scanning, to
more accurately determine the condylar bone
activity.


Physiological and biological age








Many physiological and biological changes
during growth show sex difference in timing
and are more closely related to other
indices of maturation than the chronological
age.
Girls show a spurt in systolic blood
pressure which occurs earlier than the
corresponding spurt in the male.
The resting mouth temp. which falls by 0.5
to 1% from infancy to maturity, reaches its
adult value earlier in boys than in girls.









In the plasma inorganic phosphate shows a
steady fall from the high levels of childhood to
reach adult figures by the age of 15 in girls and
17 in boys.
The alkaline phosphatase rises significantly in
parallel with growth velocity between the ages of
8-12 in girls and 10-14 in boys and thereafter it
falls rapidly to adult level.
Ratio of creatine to creatinine in the urine is
thought to fall progressively with age after about
the age of 14 ½ years.
Girls maturing early have a lower ratio than
those of the same chronological age maturing
late.

Assessment of physical maturation
and somatomedin level during
puberty








Since the pubertal period is initiated by gonadal
secretions controlled by FSH AND LH. So
appearance of these hormones may serve as
indicator to the onset of the adolescence. (Odell
W.D et al 1967)
The role of growth hormone has been described
as an indirect because of its action through
SULFATION factor.
Sulfation factor acts directly on the cartilege and
has got long half life in the plasma which makes
it rational to look for changes in plasma level
during puberty.





A pilot study was done on 27 Caucasian
girls and there developmental status was
classified as prepubertal,circumpubertal
and post pubertal by an qualified
pediatrician.
An orthodontic assessment was made
including clinical dental examination
,lat.ceph,wrist radiograph of left hand and
height and weight determination.blood
samples were taken to determine the
plasma somatomedin levels.





The results showed that there was significant
difference between the somatomedin levels in
the plasma of circumpubertal and postpubertal
females. however no significant difeerence was
found the between the prepubertal and the
circumpubertal group.
In addition the skeletal age appeared to be
better indicator of the physical maturity than the
chronological age.


CONCLUSION







Maturational development embodies the overall
biologic progression through life. In the growing years
indicators of level of maturational development of the
individual provide the best means for evaluating the
biologic age.
Maturational development can be accurately assessed
with the help of all the indicators previously described.
However it must be kept in the mind that every child
demonstrates a unique sequential pattern of events.
No child is same as the other.
The growth factor is a critical variable in orthodontic
treatment .The purpose of assessment of pubertal
growth spurt is that there is growth of facial
dimensions during this period.









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 the 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.

References:-








WILLIAM R.PROFFIT,HENERY W.FIELDS, JR.—
CONTEMPORARY ORTHODONTICS,3rd EDITION
Carlos Flores-Mira;et al--- Association between Growth
Stunting with Dental Development and Skeletal
Maturation Stage.-- The Angle Orthodontist Nov 2005 ,
Vol 75, No 6, page, 935 --942
Madhu S, Hedge AM, Munshi AK.-- The development
stages of the middle phalanx of the third finger (MP3): a
sole indicator in assessing the skeletal maturity?--- J Clin
Ped Dent 2003; 27:.page- 149–156
Julian Singer—Physiological Timing of Orthodontic
Treatment—Am J Orthod. Oct 1980.vol-50,no.4,page322-333
Calvin J Hunter –The correlation of facial growth with
body height and skeletal maturation at adolescence. Am j
Orhod .,January,1966,vol.36,no.1,page.44-54









Neves et al—Comparative study of the
maturation of permanent teeth in subjects with
horizontal and vertical growth patterns.-Am J
Orthod. Nov 2005,page-619—623.
Urban Hagg and John Taranger--Maturation
indicators and the pubertal growth spurt —Am J
Orthod, Oct 1982—vol.82,no-4,page-299—308.
Leonard S.Fishman—Radiographic Evaluation
of Skeletal Maturation-The Angle Orthodontist –
April 1982,vol-52,no-2,page-88-112
K.C.Grave and T.Brown—Skeletal ossification
and the adolescent growth spurt.--- Am J
Orthod, June 1976-vol-69,no-6,page-611—619.







Seymour Chertkow—Tooth mineralization
as an indicator of the pubertal growth
spurt-Am J Orthod, January 1980 ,vol77,no.-1,page-79—92.
PATRICIA GARCIA-FERNANDEZ et al--The cervical Vertebrae as Maturational
Indicator, JCO April 1998-vol-XXXII,no4,page-221-225.
Brent Hassel et al-Skeletal maturation
evaluation using cervical vertebrae-Am J
Orthod, January 1995,vol-107,no-1,page58-66.









Sandra Coutinho et al –Relationship between
mandibular canine calcification stages and
skeletal maturity-Am.J.Orthod, Sep 1993,vol104,n0-3,page.263-268.
Tiziano Baccetti et al-The cervical vertebral
maturation method for the assessment of
optimal treatment timing in dentofacial
orthopedics. Seminar in
ORTHODONTICS,2005,11:Page,119-129 .
Tiziano Baccetti , McNamara et al—An improved
version of the cervical vertebral maturation
method for the assessment of mandibular
growth-Feb 2002,VOL-72,NO.4,page,316-323
Tiziano Baccetti et al-Treatment timing for twin –
block therapy.
Am.J.Orthod,Aug.2000.vol.118,no.2,page.159170.









A.Demirjian et al-Interrelationship among measures
of somatic, skeletal, dental, and sexual maturity.- Am
J Orthod ,Nov,1985,vol-88,no-5,page- 433-438.
Nanda RS-The rate of growth several facial
components measured from serial cephalometric
roentgenograms.-1955-Am J orthod. VOL- 41
Page- 658-673.
Leonard H.Rothenberg et al-Physical maturation and
somatomedin levels during puberty-Am J
Orthod.June,1977.vol-71,n0.4,page ,666-676.
Hussam M. Abdel-Kader –The reliability of dental xray film in assessment of MP3 stages of the pubertal
growth spurt-Am.J .Orthod.Oct1998,vol-114,no4,page,427-429.









Christer Engstrom et al-Lower third molar
development in relation to skeletal maturity and
chronological age.-The Angle Orthodontist .April
1983,vol.53,no.2,page,97-106.
K.S.Negi, Vijay P .Sharma et al-Assessment of
growth impetus using MP3 maturation and its
correlation with CVMI and dental age. J Ind
Orthod.Soc,2003. 36,page,204-213.
Heloiso R.Leite et al-skeletal age assessment
using the first,second and third fingers of the
hand.Am J Orthod, December,1987.vol-92,n06,page,492-498.
R.RAJAGOPAL,SUDHANSU KANSAL—A
comparison of of modified MP3 stages and the
cervical vertebrae as growth indicators.JCO,July
2002,vol.XXXVI.No.7.page,398-406







Sabine Ruf et al-- Frontal sinus development as
an indicator for somatic maturity at puberty --.Am
J Orthod. Nov 1996 (476 - 482):
Bernal Revelo et al- Maturational evaluation of
ossification of the midpalatal suture-- Am J
Orthod March,1994 (288 - 292):
Shigemi Goto et al --Ossification of the distal
phalanx of the first digit as a maturity indicator
for initiation of orthodontic treatment of Class III
malocclusion in Japanese women-Am j
Orthod ,Nov 1996, Volume (490 - 501):


Thank you
Leader in continuing dental education


Growth assessment /certified fixed orthodontic courses by Indian dental academy

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (20)

Similaire à Growth assessment /certified fixed orthodontic courses by Indian dental academy

Similaire à Growth assessment /certified fixed orthodontic courses by Indian dental academy (20)

Plus de Indian dental academy

Plus de Indian dental academy (20)

Dernier

Dernier (20)

Growth assessment /certified fixed orthodontic courses by Indian dental academy