Growth prediction and age estimation /certified fixed orthodontic courses by Indian dental academy

Growth Prediction and
Age Estimation

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


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Contents




Introduction
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






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


3

Introduction






As stated by Ricketts, to take the advantage of growth we
must have an idea of –
- its magnitude,
- its direction, and
- its timing .
By using the element of timing of maximum growth in
conjunction with ones knowledge of magnitude and
direction, readily transforms orthodontics to a profession
of “face forming , as well as tooth positioning”.
A number of growth assessment methods like
chronological age, dental age, morphological age, skeletal
age & circumpubertal age are available.

4






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.


5

Clinical Importance of Maturity
Indicators







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To determine the potential vector of facial
development.
To determine the amount of significant facial cranial
growth potential left.
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.

6

Anatomical Region Suitable For Skeletal
Maturational Assessment








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

7

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 : 10-14 years (females); 12-17years (males)

8

Periodic Variations in Growth Rate


The typical growth pattern
of a child is characterized
by a growth rate that
decreases from birth with a
minor midgrowth spurt at
approx. 6-8 years of age, a
prepubertal minimum and a
pubertal or adolescent
growth spurt.


9


10

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.

 Affected by genetic and environmental factors.


11

Adolescence







It can be defined as the period of life when sexual
maturity is attained.
It is a transitional period between the juvenile stage and
adulthood during which adolescent growth spurt takes
place.
This period is particularly important in orthodontic
treatment, because the physical changes at adolescence
significantly affect the face and dentition.
Major events that occur during adolescence include- Exchange from mixed to permanent dentition
- Acceleration in overall rate of facial growth &
- Differential growth of jaws.

12

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

Contemporary Orthodontics – W.R.Proffit, 3rd ed

13

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

Fat spurt, weight gain, feminine fat
distribution (“fat spurt”)

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.


14

Timing of Puberty







Velocity curves for growth at
adolescence shows difference in
timing between boys and girls.
Pubertal growth spurt occurs on
an average nearly 2 years earlier
in girls than boys.
Sex hormones are produced in
adrenals by 6 years-‘adrenarche’.
More prominent in girls due to
greater adrenal component.

15





Growth of the jaws correlates with physiologic events
of puberty in about the same way as growth in height.
Important clinically - careful assessment of physiologic
age - plan orthodontic treatment.


16

Treatment must begin during

 mixed dentition-for girls.
 Near completion of permanent dentition-for boysProffit.


17

Hand Wrist Radiographs






Assessment of the skeletal age is often made with the help
of a hand wrist 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.
For the analysis of skeletal maturity up to the age of 9
years, the stage of mineralization of the carpel bones must
be determined; thereafter the development of metacarpal
bones & phalanx should be evaluated.

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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 (class II & III).
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.
It is a valuable aid in research aimed at studying the role
of heredity, environment, nutrition etc., on the skeletal
maturation pattern.

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Anatomy of Hand-Wrist
The hand wrist region is
made of four groups of
bones
1) Distal ends of long
bones of forearm.
2) Carpals (8)
3) Metacarpals (5)
4) Phalanges (14)

20

Anatomy of skeleton of Hand


21

Methods Of Assessing Skeletal Age


Atlas method by Greulich and Pyle



Bjork ,Grave and Brown method



Julian singer’s method



Fishman’s skeletal maturity indicators



Hagg and Taranger method

22

Greulich and Pyle Method






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.


23

Bjork , Grave And Brown Method









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)
Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. Graber

24

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


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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.


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Second stage: MP3= -stage


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


27

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


28



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



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


29

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.

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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


31







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


32

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


33

Seventh stage: PP3u-stage


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


34

Eighth stage: MP3u-stage


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


35

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.

36

Growth period
Schopf, 1978

Male

Female

Stage1

PP2 =

10.6yr

8.1

Stage2

MP3 =

12.0

8.1

Stage3

Pisi, H1,R= 12.6

9.6

Stage4

S & H2

13.0

10.6

Stage5

MP3,R,PP1 14.0
cap

11.0

Stage6

DP3U

15.0

13.0

Stage7

PP3U

15.9

13.3

Stage8

MP3U

15.9

13.9

Stage9

RU

18.5

16.0

As a rule, girls reach the various developmental stages 2 years earlier than boys.
Orthodontic Diagnosiswww.indiandentalacademy.com and T M. Graber
- Thomas Rakosi, I Jonas

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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:

Julian Singer: Physiologic timing of orthodontic treatment. Angle Orthod 1980,
pg-322-333

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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.


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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


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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


41

Stage 4 (Puberal)
1.

2.

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


42

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.

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Stage 6 (Growth completion)
1.

No remaining growth
sites.


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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.

45

Fishman’s Skeletal Maturity Indicators
(SMI)


Proposed by Leonard S
Fishman in 1982.



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

Leonard S. Fishman :Radiographic Evaluation of Skeletal Maturation. Angle
orthod vol.52, No.2 april 1982.

46

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


47

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


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49

Significance






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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.


50

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).

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Sesamoid


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


52

Third Finger Middle Phalanx
MP3-F Stage




Start of the curve of pubertal
growth spurt .
Epiphysis is as wide as
metaphysis


53

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.


54

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.


55

MP3-H Stage




Deceleration of the curve of
Fusion of epiphysis and metaphysis
begins.


56

MP3-I Stage



End of pubertal growth spurt
complete.


57

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) .


58

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: Characterized by fusion of the epiphysis and
metaphysis.


These stages were not attained before end of PHV.


59

Cervical Vertebrae Maturity Indicators
(CVMI)




The development of the cervical vertebrae showed
similarities with skeletal maturity indicators found in the
hand wrist area and could as such offer an alternative
method of assessing maturity without the need for a
hand-wrist radiograph.
LAMPARSKI in 1972 was the first person to study
cervical vertebrae and he developed a series of standards
for assessing skeletal age in both males and female based
on cervical vertebrae.


60











Hassel and Farman developed a system of skeletal
maturation determination using cervical vertebrae.
The shapes of the cervical vertebrae were found to be
different at different levels of skeletal development.
The shapes of the cervical bodies of C3 & C4 changed
from somewhat wedge shaped, to rectangular, followed
by square shape.
The inferior vertebral borders were flat when immature,
& they were concave when mature.
Hassel and Farman put forward 6 stages in vertebral
development using C2,C3, & C4 cervical vertebrae.
Hassel, Farman : Skeletal maturation evaluation using cervical vertebrae.
AJODO 1995; 107:58-66.

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62

Kansal and Rajagopal modified MP3
Method




Kansal and Rajagopal modified the MP3 indicators
further and compared it to the cervical vertebrae
maturation indicators (CVMI) as described by Hassel
and Farman.
Periapical radiographs were used for recording MP3
stages.

Rajagopal.R, Kansal.S : A Comparision of modified MP3 stages and the cervical
vertrbrae as growth indicators. JCO/JULY 2002

63

Modified MP3

Cervical Vertebrae

MP3-F Stage

CVMI-1

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

Initiation stage of cervical vertebrae
 C2,C3 and C4 inferior vertebral
body borders are flat.
 Superior vertebral borders are
tapered from posterior to anterior
[wedge shape]
 80-100% of pubertal growth
remains.


64

MP3-FG Stage

Acceleration of the curve of pubertal
growth spurt.
 Epiphysis is as wide as metaphysis.
 Distinct medial and/or 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.

CVMI-2

Acceleration stage of cervical vertebrae.
Concavities are developing in lower
borders of C2 and C3.
 Lower border of C4 vertebral body
is flat.
 C3 and C4 are more rectangular in
shape.
remains.


65

MP3-G Stage

CVMI-3

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

Transition stage of cervical vertebrae

 Distinct concavities are seen in lower
borders of C2 and C3.

 Concavity is developing in lower
border of C4.

 C3 and C4 are rectangular in shape.
 25-65% of pubertal growth remains.


66

MP3-H Stage

CVMI-4

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

Deceleration stage of cervical
vertebrae.
 Distinct concavities are seen in
lower borders of C2, C3 and C4.
 C3 and C4 are nearly square in
shape.
remains.


67

MP3-HI Stage

CVMI-5

Maturation of the curve of pubertal
growth spurt
 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.

Maturation stage of cervical vertebrae.

Accentuated concavities of

C2, C3

and C4 inferior vertebral body
borders are observed.

 C3 and C4 are square in shape.
remains.


68

MP3-I Stage

CVMI-6

End of pubertal growth spurt





Completion stage of cervical vertebrae.

complete.
No radiolucent gap.

 Deep concavities are present in C2,

Dense, radiopaque epiphyseal line
forms integral part of proximal
portion of middle phalanx.

 C3 and C4 are greater in height than

C3 and C4 inferior vertebral body
borders.
in width.

 Pubertal growth is completed.


69

Advantages of modified MP3 method





Significantly low radiation exposure.
High degree of clarity on the radiographs.
Close correlation to the six stages of CVMI.
No need to obtain equipment beyond the standard
periapical x-ray film and dental x-ray machine.


70

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.

Revelo.B, Fishman.L.S : Maturational evaluation of ossification of the midpalatal
suture. AJODO 1994; 105;288-92

71





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.


72





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.

73







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
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.

74

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)

75





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.

76

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 (FH to S-Gn)
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)

77







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


78





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.


79



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
80
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.

81





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.

Todd Aki, RS Nanda, Frans Currier : Assessment of Symphysis morphology as a
predictor of the direction of mandibular growth. AJODO 1994; 106; 60-9.

82

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.

83





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.
CP Singer, AH Mamandras, WS Hunter : The Depth of the mandibular
antegonial notch as an indicator of mandibular growth potential. AJODO
1987; 91; 117-24.

84





> 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.


85

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)

86



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.


87

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.


88

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

89

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.


90

Orthodontic Diagnosis www.indiandentalacademy.com
- Thomas Rakosi, I Jonas and T M. Graber

91

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





When determining dental age radiographically
according to the stages of germination, 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.

92







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.


93







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.


94

Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M.
Graber

95


96


97

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





Most of the studies correlating dental maturation to
skeletal maturation have not included the lower 3rd
molars.
Engstrom in 1983 conducted a study to analyze
development of the lower 3rd molar and whether it
could be correlated to skeletal maturity.
A probable reason for the great variability seen in
previous studies regarding 3rd molar development might
be because its development was related to chronological
age rather than skeletal age.

Engstrom.C Engstrom.H, Sagne.s : Lower third molar development in relation to
skeletal maturity and chronological age. Angle orthodontist; vol.53, no.2, april 1983.

98

Developmental stages of the lower 3rd molar



The stages of development of the lower 3rd molar were
determined from OPGs.
The developmental stages were categorized into-


99

Hand wrist x-rays were taken and their skeletal
development classified as 

PP2=

: proximal phalanx of second
finger, the epiphysis as wide



as diaphysis.
MP3cap : Middle phalanx of third
finger, the epiphysis cap its



DP3u



Ru

diaphysis.
: Distal phalanx of third
finger, complete epiphyseal
union.
: Distal epiphysis of radius,

100

Conclusions










Development of lower third molar appeared slightly
earlier in boys than in girls.
Strong correlation was found between chronological
age and third molar development.
A strong correlation was also found between third
molar development and skeletal maturity.
At stage PP2- The 3rd molar showed signs of completed
crown molar mineralization in most subjects. (B)
At stage MP3cap- Lower third molar crown formation
was complete in most subjects and root development
has begun in some. (C)

101







At stage DP3u- Lower third molar crown was still
incomplete in some subjects but full root length was
attained in others. (E)
At stage Ru- Only the crown was completed in 1/3rd of
subjects. Half the root had developed in 1/3rd and full
length was seen in another 1/3rd. (E)
The results seem to show that lower third molar
development on the whole seems to be correlated with
skeletal maturation.


102

Frontal Sinus Development as an
Indicator for Somatic Maturity at Puberty






The possibility of predicting the stage of somatic
maturity by analyzing frontal sinus growth was evaluated.
The development of the frontal sinus as seen in lateral
cephalograms was assessed at various ages.
The material composed of 53 boys. Lateral head films
existed for each individual over a 2 year period along with
body height data for 7 years including the pubertal period.
The head films were taken at yearly intervals and body
height readings were taken every 3-6 months.
Sabin Ruf, Hans Pancherz : Frontal sinus development as an indicator for somatic
maturity at puberty? AJO-DO 1996;110;476-82 .

103



Two lateral head films of each subject were analysed at
1year and 2 year intervals. Two prediction intervals T1
and T2 (1yr & 2yr) were formed.

 The peripheral borders of the
frontal sinus were traced. The
highest point Sh &the lowest
point Sl were marked. A line was
drawn connecting Sh & Sl. A
perpendicular to this line was
drawn at the widest pt and the
max. width of the sinus was
assessd.

104





The average yearly growth velocity (mm/yr) of frontal
sinus was calculated seperatedly for each of prediction
intervals T1 or T2.
The average yearly body height increase in mm was
calculated. The max body growth velocity at puberty was
assigned a term body height peak or Bp.

 Frontal sinus growth velocity is
closely related to body height
growth velocity during puberty.
 Frontal sinus growth shows a
well defined pubertal peak (Sp).
This occurs approx. 1.4 yrs after
Bp or body height peak.

105

In males the average age at frontal sinus peak is 15.1 yrs.
 In a 1 yr period, growth of 1.3 mm/yr is seen in frontal
sinus in 84% of subjects. (T1)
 In a 2 yr period, growth of 1.2 mm/yr is seen in 70% of
subjects in frontal sinus region. (T2)
Prediction procedure:
 The frontal sinus growth velocity Sv was compared with
T1 & T2 values.
 If Sv value was as high as or higher than T values, it can
be assumed that the frontal sinus peak was reached during
the prediction interval. Therefore Bp has been reached
approx. 1.4 yes before the midpoint of the observation
interval.



106







If Sv value was lower than T values, it cannot be said
whether the subject is prepeak or post peak in frontal
sinus growth. The age of the subject is also needed.
As the frontal sinus peak is reached at 15.1 yrs, a low
subject age means that the frontal sinus peak has not
yet been reached. Therefore Bp (body ht peak) has not
been reached.
If subjects age is more than 15.1 yrs with a Sv value
lower than T value, it can be assumed that the frontal
sinus growth peak has passed and also that the Bp has
passed more than 1.4 yrs before the beginning of the
observation interval. (T1 or T2).

107

Results:






If the only prediction was whether the pubertal growth
peak in height has been passed, the precision of the
method was rather high.(90%)
However, if the age of body height peak was to be
predicted, the method accuracy was lower.(55%)
The study suggests that the somatic maturity stage may be
predicted rather accurately by analyzing frontal sinus
developmental on pre-existing lateral head films.


108

Assessment of Physical Maturation by
Somatomedin Levels During Puberty




This study was undertaken by leonard Rothenburg in
1977. it was performed on 27 caucasian subjects, all
females.
Growth hormone has long been known to play an
important role in linear growth. However, growth
hormone determination is not of any value because
growth hormone does not act directly on linear growth
but acts through an intermediary called Somatomedin.
Somatomedin is stimulated by growth hormone and has
a direct effect on cartilage.

109







This study determines whether Somatomedin levels
could serve as markers for assessing maturation levels.
3 developmental categories were established based on a
physical examination by a pediatrician –
Category A Prepubertal
stage 1
Category B Circumpubertal
stage 2,3
Category C Postpubertal
stage 4,5
Blood samples were taken and the somatomedin levels
assessed.


110

Results:




There was a significant difference between the
somatomedin levels in plasma of circumpubertal and
post-pubertal females.
No significant difference was seen in the levels of
prepubertal and circumpubertal females.


111

Evaluation of skeletal maturation by using a
computed X-ray Densitometry method







This study was conducted in japan in the year 1995.
The aim of this study was to obtain data about bone
density in normal children.
It examined relationships between bone density,
chronological age, bone age and cephalometric
measurements. The subjects consisted of 462 girls and
298 boys from 6-20 years.
Hand wrist pictures were taken of all the subjects and
the densitometric pattern of the 2nd metacarpal bone was
measured by computed x-ray densitometry method

112

Results:




Bone density increased significantly until the age of 14
years in girls and 16 years in boys.
There were differences between the sexes at each age.
Bone density showed a strong co-relation with bone age
rather than chronological age. Therefore Bone Density
may be an efficient indicator for estimating bone
maturation in a person.


113

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.


114





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.

115

Bibliography












Hand book of orthodontics – R.E.Moyers, 4th ed
Facial Growth – D.H.Enlow, 3rd ed
Orthodontics – current principles and techniques – T.M.Graber,
R.L.Vanarsdall 3rd ed
Leonard S. Fishman :Radiographic Evaluation of Skeletal
Maturation. Angle orthod vol.52, No.2 april 1982.
Julian Singer: Physiologic timing of orthodontic treatment. Angle
Orthod 1980, pg-322-333
Hassel, Farman : Skeletal maturation evaluation using cervical
vertebrae. AJODO 1995; 107:58-66.

116













Rajagopal.R, Kansal.S : A Comparision of modified MP3 stages and
the cervical vertrbrae as growth indicators. JCO/JULY 2002
Revelo.B, Fishman.L.S : Maturational evaluation of ossification of
the midpalatal suture. AJODO 1994; 105;288-92
CP Singer, AH Mamandras, WS Hunter : The Depth of the
mandibular antegonial notch as an indicator of mandibular growth
potential. AJODO 1987; 91; 117-24.
Todd Aki, RS Nanda, Frans Currier : Assessment of Symphysis
morphology as a predictor of the direction of mandibular growth.
AJODO 1994; 106; 60-9.
Engstrom.C Engstrom.H, Sagne.s : Lower third molar development
in relation to skeletal maturity and chronological age. Angle
orthodontist; vol.53, no.2, april 1983.
Sabin Ruf, Hans Pancherz : Frontal sinus development as an
indicator for somatic maturity at puberty? AJO-DO 1996;110;47682.
117

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