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GROWTH SPURTS
significance in orthodontics
Dr Ravikanth Lakkakula
CONTENTS
 Introduction.
 Definition of growth and development.
 Developmental growth periods.
 Methods of studying gro...
 Biological maturity indicators
Morphological age
Chronological age
Dental age
Sexual age
Skeletal age
 Significance of ...
Introduction
• The current Orthodontics worries is about the early
correction of malocclusion, giving importance to the
ha...
 Clinical decisions regarding use of extra oral traction forces,
functional appliances, extraction versus non-extraction
...
Definition of Growth
Author Definition
J s Huxley Self multiplication of living substance
Krogman Increase in size, change...
Development
Author Definition
Todd It is the progress towards maturity.
Proffit Development is in complexity.
Moyers It re...
 Morphogenesis – “A biologic process having an underlying control at the
cellular and tissue levels”.
 Differentiation
...
Correlation between growth and development
According to Proffit
 Growth is basically anatomic phenomenon and quantitative...
 Growth is a dynamic process with a stable pattern of changes
result in increase in physical size and mass during its cou...
A) Prenatal life (about 10 IU months).
1) Period of ovum : conception to 2 weeks.
2) Period of embryo : 2 – 8 weeks.
3) Pe...
b) Middle childhood (grade school) 6 to 9 or 10 years.
c) Late childhood or Prepubertal period (junior high school)
Girls ...
Methods of Studying Growth
 Experimental approach
 Measurement approach
Method of gathering growth data
 Longitudinal s...
A . Measurement approach :
 It is based on the techniques for measuring living animals,
humans.
Advantage:
 Does no harm...
1. Craniometry:
 The first of the measurement approaches of anthropology.
 Based on measurements of skulls found among h...
2.Anthropometry:
 In anthropometry, various landmarks established in studies of
dry skulls are measured in living individ...
3.Cephalometry:
 Is a standardized radiographic technique in craniofacial
region.
 Introduced by Broadbent in 1931.
 Ce...
Advantages:
1. Allows direct measurement of skeletal dimensions, as the bone can be
seen through the soft tissue covering ...
4.Three-dimensional imaging:
 New information now is being obtained with the application of
three-dimensional imaging tec...
b. Experimental approach:
 This approach uses experiments in which growth is
manipulated in some way. This implies that t...
1.Vital staining:
 Uses dyes that stain mineralizing tissues (occasionally
soft tissues) are injected into an animal, the...
 John Hunter observed that the bones of pigs that
occasionally were fed textile waste often stained in an
interesting way...
 Bone remodels rapidly, and areas from which bones being
removed also can be identified by the fact that vital stained
ma...
2.AUTORADIOGRAPHY:
 It is a technique in which a film emulsion is placed over a thin
section of tissue containing radioac...
3.Radioisotopes :
 Radioisotopes of certain elements or compounds are often
used as in vivo markers .
 When injected int...
4. Implant radiology:
 Used extensively by Bjork.
 In this technique, inert metal pins generally made of
titanium are pl...
 These metal pins are well tolerated by the skeleton and
become permanently incorporated into the bone.
 These serve as ...
Longitudinal studies.
These are measurements made of the same person or group at regular
intervals through time.
Advantage...
Cross sectional studies
These are measurements made of different samples or different
individuals and studied at different...
Semi longitudinal studies.
Longitudinal and cross sectional studies can be combined to seek the
advantages of both. In thi...
FACTORS AFFECTING GROWTH AND MATURATION
Heredity
 The basic control of growth, both in magnitude and timing is
located in...
 Genetic factors most likely play a leading role in male and female
growth differences.The marked advancement of girls ov...
 Individuals withTurner’s syndrome having only one X
chromosome, develop with a female pattern of growth
becoming more li...
Hormones
 The anterior lobe of the pituitary gland produces a hormone called
growth hormone or somatotropin. Growth hormo...
 The anterior lobe of pituitary gland also secretes thyrotrophic
hormone, which affects growth by stimulating the thyroid...
Sufficient intake of nutritious foods is essential for normal growth.
Malnutrition may affect all aspects of growth includ...
The effects of malnutrition are reversible to a certain extent as
children have fine recuperative powers. If the adverse e...
Race
Differences in growth among different races can be attributed
to other Nutritional and environmental factors, there s...
Disease :
 The effects of disease are similar to those of malnutrition. After an
illness, a catch up growth period usuall...
Socio- economic factors
Children brought up in affluent and favorable socio-economic
conditions show earlier onset of grow...
Season and circadian Rhythm :
Growth in height is faster in the spring than in autumn on the
contrary, city children tend ...
Secular trend :
Although children are growing at a faster rate they are also stopping
Growth sooner.The adolescent height ...
Concepts of growth
Concept of normality
Rhythm of growth
Differential growth
Timing of growth : Growth spurts
Dr Ravikanth...
Normality
 According to , normal refers to that which is usually expected , is
ordinarily seen , or is typical.
 It had ...
Rhythm of growth
According to Hooton,“ Human growth is not a steady & uniform
process wherein all parts of die body enlarg...
Differential Growth:
The human body does not grow at the same rate throughout life. Different
organs grow at different rat...
Scammon’s curve of growth
The body tissues can be broadly classified into four types. They are lymphoid
tissue, neural tis...
Neural tissue grows very rapidly and almost reaches adult size by 6-7
years of age. Very little growth of neural tissue oc...
Genital tissue consists of the reproductive organs. They show
negligible growth until puberty. However, they grow rapidly ...
Cephalocaudal Gradient of Growth
Cephalocaudal gradient of growth simply means that there is an axis of
increased growth e...
a)The head takes up about 50% of the total body length around the
third month of intra uterine life. At the time of birth,...
b) The lower limbs are rudimentary around the 2nd month of intrauterine
life. They later grow and represent almost 50% of ...
c)There is increased gradient of growth evidence even within
the head and face .
At birth, cranium is proportionally large...
 Hellman pointed out that , of all 3 dimensions grew in different
order i.e.,
 Face : Width > Depth > Height
 Cranium :...
GROWTH SPURTS:
 There are periods of sudden rapid increase, which are termed as
growth spurts.There is a period of rapid ...
Woodside (1968)in his study of Burlington study Group
Torrento , showed
Name of growth spurt Girls Boys
Infantile/childhoo...
Modified by Bjork (1975)
1. Prenatal -- Just before birth.
2. Postnatal
One year after birth.
Mixed dentition growth spurt...
Timing of Puberty
 Velocity curves for growth at adolescence shows difference in
timing between boys and girls.
 Puberta...
 Growth effects because of timing variation can be seen
particularly clearly in girls, in whom the onset of menstruation,...
 At age 11, the early(M1)maturing girl is already past the peak of
her adolescent growth spurt, whereas the late-maturing...
 The timing of puberty makes an important difference in
ultimate body size, in a way that may seem paradoxical at first,
...
First, the sex hormones stimulate the cartilage to grow faster,
and this produces the adolescent growth spurt. But the sex...
 Early cessation of growth after early sexual maturation is
particularly prominent in girls. It is responsible for much o...
 Growth of the jaws usually correlates with the physiologic
events of puberty in about the same way as growth in height.
...
 More growth occurs in the lower extremity than in the upper,
and within the face, more growth takes place in the lower j...
• Growth in width is completed first, then growth in length,
and finally growth in height.
• Growth in width of both jaws,...
Cranium
Maxilla
Mandible
1 to 5 years
85%
45%
40%
5 to 10 years
11%
20%
25%
10 to 20 years
4%
35%
35%
According to Graber ...
Mandibular length changes
 Growth of the mandible continues at a relatively steady rate before
puberty. On the average, r...
 Growth in length and height of both jaws continues through the
period of puberty. In girls, the maxilla grows slowly dow...
 Increases in facial height and concomitant eruption of teeth
continue throughout life, but the decline to the adult leve...
 According to proffit, growth modifications must begin in girls
during mixed dentition period rather than after all succe...
Biological Maturity Indicators
Morphologic Age: Is based on height.
 A child’s height can be compared with those of his s...
 This is determined, using growth charts for the particular
population standards. Growth charts can be used to plot an
in...
INTERPRETATION —
 Plotted above the 90% shows child was larger than 90% of the
population.
 Plotted below the 10% line s...
Chronological age
 The most obvious and easily determined developmental age
parameter.
 Simply calculated from the child...
Dental Age:
 Dental age is determined from three characteristics;
 The first is which teeth have erupted. The second and...
 At dental age 10, approximately one half of the roots of the
mandibular canine and mandibular first premolar have been
c...
Average chronology of permanent tooth development
Tooth
Calcification begins Crown completed Eruption Root completed.
Max ...
Stages of tooth calcification by Nollas(1960)
10.Root apex completed.
9.Root almost completed,open apex.
8.Two thirds of r...
The radiographs are compared with the drawings, and each tooth
is given a developmental scores according to the drawing th...
DENTAL AGE DETERMINATION ACCORDINGTOTHE
STAGE OF MINERALIZATION
o.Tooth germ without signs of calcification.
A. Calcificat...
Dr Ravikanth Lakkakula
Conversion chart for dental age determination, calculated
according to the score-system of dental formation
The overall fi...
 Dental development indicators are also NOT RELAIBLE
predictors of an individual’s stage of skeletal development
because ...
Sexual Age:
 This is based on development of secondary sexual characters
both boys and girls.
 This type of indicator is...
Adolescent Growth Stages versus Secondary Sexual
Characteristics
Total Duration of Adolescent Growth : 3 ½ years period
St...
BoysTotal Duration of Adolescent Growth : 5 years period
Stage 1
Beginning of adolescent
growth
“Fat spurt” weight gain, f...
 Recent research has shown that sexual development really begins
much earlier than previously thought. Sexhormones produc...
Skeletal age assesment
Hand wrist radiographs
The hand – wrist region is made up of numerous small bones.
These bones show...
 We all know end of long bones grow at their end called
epiphysis.
 The newly formed bone starts getting mineralised at ...
A number of methods have been described to assess the skeletal
maturity using hand-wrist radiographs.The following are the...
GREULICH AND PYLE METHOD
 Greulich and Pyle published an atlas containing ideal skeletal
age pictures of the hand-wrist f...
BJORK, GRAVE AND BROWN
They have divided skeletal development into 9 stages. Each of
these stages represents level of skel...
 StageTwo (males 12.0 years,Females 8.1 years):
The epiphysis and diaphysis of the middle phalanx of the middle
finger ar...
StageThree (Males 12.6 years,Females 9.6 years):This stage is
characterized by presence of 3 areas of ossification:
 The ...
Stage Four (Males 13.0 years,Females 10.6 years):This stage
marks the beginning of the pubertal growth spurt. It is
charac...
stage 5 (male 14 years ,female 11 years ): It is a peak of
pubertal growth spurt. Capping of epiphysis and diaphysis seen ...
Stage six (Males 15.0 years,Female 13.0 years):This stage
signifies the end of the pubertal growth spurt. It is characteri...
 Stage Seven (Males 15.9 years, Females 13.3 years): Union
of epiphysis and diaphysis of the proximal phalanx of the litt...
 Stage Eight (Males 15.9 years,Females 13.9 years):This
stage shows fusion between the epiphysis and diaphysis of the
mid...
 Stage Nine (Males 18.5 years,Females 16.0 years): This is
the last stage and it signifies the end of skeletal growth. It...
SINGER’S METHOD OF ASSESSMENT
Julian Singer in 1980 proposed a system of hand wrist radiograph
assessment that would enabl...
Stage one (Early):
 Absence of the pisiform
 Absence of the hook of the hamate and
 Epiphysis of proximal phalanx of se...
StageThree (Puberal onset):
 Beginning calcification of ulnar sesamoid,
 Increased width of epiphysis of PP2 and
 Incre...
Stage Five (Puberal deceleration):
 ulnar sesamoid fully calcified and
 Fusion of epiphysis of distal phalanx of 3rd fin...
FISHMAN’S SKELETAL MATURITY INDICATORS
A system for evaluation of skeletal maturation was proposed by
Leonord S. Fishman i...
 Fishman system uses 4 stages of bone maturation.They are
Dr Ravikanth Lakkakula
11 Adolescent skeletal maturational indicator’s (SMI’s) covering
the entire period o adolescent development.
Skeletal matu...
Ossification
SMI 4.Adductor sesamoid of thumb
Capping of epiphysis
SMI5 - Third finger – Distal phalanx
SMI6 - Third finge...
Fusion of epiphysis and diaphysis
SMI 8.Third finger – Distal phalanx
SMI 9.Third finger – Proximal phalanx
SMI 10.Third f...
Approximate chronological age and percentage of growth completed
corresponding to SMI
Dr Ravikanth Lakkakula
Approximate chronological age and percentage of growth completed
corresponding to SMI
Dr Ravikanth Lakkakula
HAGG ANDTARANGER METHOD(1982)
Skeletal age assessment of
1) The ossification of sesamoid.
2) The middle and distal phalang...
Third finger middle phalanx(MP3)
MP3-F:
The epiphysis is as wide as the metaphysis.
This stage is attained before onset of...
MP3-FG:
The epiphysis is as wide as the metaphysis and there is distinct
medial and / or lateral border of the epiphysis f...
MP3-G: ( the point of maximum pubertal growth spurt)
The sides of the epiphysis have thickened and also cap its metaphysic...
MP3-H: (deceleration part of the curve of pubertal growth
spurt);
Fusion of the epiphysis and metaphysis has begun and is ...
MP3-I:
Is attained before or at en of growth spurt in all subjects except a few
girls.
Dr Ravikanth Lakkakula
Third finger distal phalanx
DP3 - I: Fusion of the epiphysis and metaphysic is completed.This
stage signifies the fusion o...
Radius
R-I:
Fusion of the epiphysis and metaphysis has begun.This stage is attained
1 year before or at the end of growth ...
SKELETAL MATURATION EVALUATION USING CERVICAL
VERTEBRAE
Hassel and Farman (1995) developed a system of skeletal
maturation...
The shapes of the vertebral bodies of C3 and C4 changed from
somewhat wedge shaped, to rectangular, followed by square sha...
Hassel and Farman have put forward the following six stages in
vetribral development.
Stage 1:
This stage called initiatio...
Stage 2:
The second stage is called acceleration. Growth acceleration begins at
this stage, with 65% to 85% of adolescent ...
Stage 3:
The third stage called transition, corresponded to acceleration of
growth towards peak height velocity with 25% t...
Stage 4:
This stage called deceleration corresponds to deceleration of adolescent
growth spurt with 10% to 25% of adolesce...
Stage 5:
The fifth stage is called maturation. Final maturation of the vertebrae
took place during this stage, with 5% to ...
Stage 6:
This stage called completion, corresponds to completion of growth.
Little or no adolescent growth could be expect...
Hand –wrist
SMI
Cervical
vertebral stages
Pubertal growth
remaining
1-2 Initiation 85-100%
3-4 Acceleration 65-85%
5-6 Tra...
Significance of Growth Spurts in Orthodontics
 Pubertal increments offers best time for, determining the
predictability, ...
Functional jaw orthodontic therapy takes advantages of redirection of
remaining growth of craniofacial region. Functional ...
 Orthopaedic appliances like headgears are also advantageous to
correct maxillary prognathism during growing stage of the...
 Maxillary expansion procedures in cases of jaw constriction should
be carried out during early mixed dentition. Growth i...
 Orthopaedic appliances like facemask and chin cup are used for the
treatment of skeletal class III malocclusions early d...
 Active growth cessation is prerequisite for Orthognathic surgery
particularly in cases with mandibular prognathism.
Dr R...
Conclusion
 As we Orthodontists nowadays deal with more and more mixed
dentition cases, many of whom may or may not prese...
 However we should not forget that every individual is unique in
his own aspect and therefore we should not jump to concl...
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Growth spurts - orthodontics

growth spurts

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Growth spurts - orthodontics

  1. 1. GROWTH SPURTS significance in orthodontics Dr Ravikanth Lakkakula
  2. 2. CONTENTS  Introduction.  Definition of growth and development.  Developmental growth periods.  Methods of studying growth and methods of gathering growth data.  Factors affecting growth and maturation.  Concepts of growth. Concept of normality Rhythm of growth Differential growth Timing of growth : Growth spurts Dr Ravikanth Lakkakula
  3. 3.  Biological maturity indicators Morphological age Chronological age Dental age Sexual age Skeletal age  Significance of growth spurts  Conclusion Dr Ravikanth Lakkakula
  4. 4. Introduction • The current Orthodontics worries is about the early correction of malocclusion, giving importance to the harmonization of the bone bases in connection with the discrepancy and positioning of the teeth, that can be corrected in any time of life, for what is of great importance is to know the biggest peak of growth.  An understanding of growth events is of primary importance in the practice of clinical orthodontics. Maturational status can have considerable influence on diagnosis, treatment goals, treatment planning, and the eventual outcome of orthodontic treatment. Dr Ravikanth Lakkakula
  5. 5.  Clinical decisions regarding use of extra oral traction forces, functional appliances, extraction versus non-extraction treatment, or orthognathic surgery are based on growth considerations.  For this reason, prediction of both the times and the amounts of active growth, especially in the craniofacial complex, would be useful to the orthodontist. Dr Ravikanth Lakkakula
  6. 6. Definition of Growth Author Definition J s Huxley Self multiplication of living substance Krogman Increase in size, change in proportion and progressive complexity Todd Growth refers to increase in size Moyers Quantitative aspect of biological development per unit time Proffit Growth usually refers to an increase in size or number Moss Change in any morphological parameter which is measurable Dr Ravikanth Lakkakula
  7. 7. Development Author Definition Todd It is the progress towards maturity. Proffit Development is in complexity. Moyers It refers to all the naturally occurring unidirectional changes in the life of an individual from its existence as a single cell to a multifunctional unit terminating in death. Enlow “Maturational process involving progressive differentiation at the cellular and tissue levels” Salzmann It is the sequences of changes from cell fertilization to maturity. It relates to cell division, growth, differentiation and maturation.Dr Ravikanth Lakkakula
  8. 8.  Morphogenesis – “A biologic process having an underlying control at the cellular and tissue levels”.  Differentiation  The change from generalized cells or tissues to more specialized kinds during development.  The change in quality .  Maturation  Defined as the qualitative changes that occur with age.  Translocation  Change in position . Dr Ravikanth Lakkakula
  9. 9. Correlation between growth and development According to Proffit  Growth is basically anatomic phenomenon and quantitative in nature.  Development is basically physiologic phenomenon and qualitative in nature. Development = growth + differentiation + translocation Dr Ravikanth Lakkakula
  10. 10.  Growth is a dynamic process with a stable pattern of changes result in increase in physical size and mass during its course of development.  Thus , growth is a three fold process “ self multiplication, differentiation, organization” each according to its own kind . A fourth dimension is : TIME. Dr Ravikanth Lakkakula
  11. 11. A) Prenatal life (about 10 IU months). 1) Period of ovum : conception to 2 weeks. 2) Period of embryo : 2 – 8 weeks. 3) Period of fetus : 2 to 10 IU months. B) Birth. C) Postnatal life. I. Infancy: (birth to about 1 year) a) Neonatal period : birth, 1 to 2 weeks. b) Infancy proper : 2 weeks to 1 year. II. Childhood : a) Early childhood (preschool) 1 – 6 years. Developmental growth periods Dr Ravikanth Lakkakula
  12. 12. b) Middle childhood (grade school) 6 to 9 or 10 years. c) Late childhood or Prepubertal period (junior high school) Girls : 9 or 10 to 12 or15 years. Boys : 9 or 10 to 13 or 16 years. III. Puberty : a) Girls mean about 13 years b) Boys mean about 14 years. IV.Adolescence : a) Girls : 13 – 18 years b) Boys : 14 – 20 years. V. Maturity: 18 or 20 to about 60 years VI. Senility: beginning at about 60 years Dr Ravikanth Lakkakula
  13. 13. Methods of Studying Growth  Experimental approach  Measurement approach Method of gathering growth data  Longitudinal study  Cross sectional study  Semi longitudinal study Dr Ravikanth Lakkakula
  14. 14. A . Measurement approach :  It is based on the techniques for measuring living animals, humans. Advantage:  Does no harm the animal /human.  Organism will be available for additional measurements at another time. Methods: 1. Craniometry. 2. Anthropometry. 3. Cephalometry. 4. Three dimensional imaging. Dr Ravikanth Lakkakula
  15. 15. 1. Craniometry:  The first of the measurement approaches of anthropology.  Based on measurements of skulls found among human skeletal remains. Advantage: precise measurements can be made on dry skulls. Disadvantage: study can be only cross sectional. Dr Ravikanth Lakkakula
  16. 16. 2.Anthropometry:  In anthropometry, various landmarks established in studies of dry skulls are measured in living individuals simply by using soft tissue points over lying these bony landmarks.  Measurements obtained would be of different results because the soft tissue thickness overlying both landmarks.  Advantages: longitudinal , growth of an individual can be followed over a period of time with repeated measurements. Dr Ravikanth Lakkakula
  17. 17. 3.Cephalometry:  Is a standardized radiographic technique in craniofacial region.  Introduced by Broadbent in 1931.  Cephalometric radiology, is of considerable importance not only in the study of growth, but also in clinical evaluation of orthodontic patients. Dr Ravikanth Lakkakula
  18. 18. Advantages: 1. Allows direct measurement of skeletal dimensions, as the bone can be seen through the soft tissue covering in a radiograph. Disadvantages: 1.Two-dimensional representation of a three-dimensional structure. 2.The technique depends on precisely orienting the head before making a radiograph, with equally precise control of magnification. 3.Even with precise head positioning, not all measurements are possible. Dr Ravikanth Lakkakula
  19. 19. 4.Three-dimensional imaging:  New information now is being obtained with the application of three-dimensional imaging techniques. Computed axial tomography (CT) allows 3-D reconstructions of the cranium and face.  This method has been applied for several years to plan surgical treatment for patients with facial deformities. Example of a 3D imaging for hemifacial microsomiaDr Ravikanth Lakkakula
  20. 20. b. Experimental approach:  This approach uses experiments in which growth is manipulated in some way. This implies that the subject of the experiment is available for study in some detail and the detailed study may be destructive.  Animals may be sacrificed for experimental purpose.  For this reason, such experimental studies arc largely restricted to Non-human species. Dr Ravikanth Lakkakula
  21. 21. 1.Vital staining:  Uses dyes that stain mineralizing tissues (occasionally soft tissues) are injected into an animal, these dyes remain in the bones and teeth and can be detected later after sacrifice of the animal.  This method was originated by the great English anatomist John Hunter in the 18th century. Dr Ravikanth Lakkakula
  22. 22.  John Hunter observed that the bones of pigs that occasionally were fed textile waste often stained in an interesting way, discovered that the active agent was a dye called alizarin.  Alizarin reacts strongly with calcium at sites where bone calcification is occurring (sites of active skeletal growth). Dr Ravikanth Lakkakula
  23. 23.  Bone remodels rapidly, and areas from which bones being removed also can be identified by the fact that vital stained material has been removed from these locations. Dyes used for this purpose: 1.Alizarin red 2.Tetracyline 3.Trypon blue 4. Lead acetate Dr Ravikanth Lakkakula
  24. 24. 2.AUTORADIOGRAPHY:  It is a technique in which a film emulsion is placed over a thin section of tissue containing radioactive isotope, and then is exposed in the dark by radiation.  The location of radiation in the film indicates the site of growth. Commonly used autoradiographic labels are: A. 3 H thymidine. B. 3 H proline. C. Bromodeoxyuridine. Dr Ravikanth Lakkakula
  25. 25. 3.Radioisotopes :  Radioisotopes of certain elements or compounds are often used as in vivo markers .  When injected into the body they get incorporated in the developing bone.  They can be detected by means of Geiger counter. E.g., 1. Technetium 99 2. Calcium 45 Dr Ravikanth Lakkakula
  26. 26. 4. Implant radiology:  Used extensively by Bjork.  In this technique, inert metal pins generally made of titanium are placed in growing bones of the skeleton, including the face and jaws. Dr Ravikanth Lakkakula
  27. 27.  These metal pins are well tolerated by the skeleton and become permanently incorporated into the bone.  These serve as reference points to study the amount, direction and manner of growth. Dr Ravikanth Lakkakula
  28. 28. Longitudinal studies. These are measurements made of the same person or group at regular intervals through time. Advantages: 1.Temporary problems are smoothed with time, 2.Variability in development within a group is put in proper perspective, 3.Serial comparison makes study of specific developmental pattern of individual possible. Disadvantages: Time consuming, Expensive, Sample loss . Dr Ravikanth Lakkakula
  29. 29. Cross sectional studies These are measurements made of different samples or different individuals and studied at different periods. ADVANTAGES 1.Quicker. 2.Less expensive. 3. Statistical treatment of data is easier. 4.Studies can be readily repeated. 5.Method can be used in archeological data. DISADVANTAGES 1.Variation in development among individuals within the sample cannot be studied. Dr Ravikanth Lakkakula
  30. 30. Semi longitudinal studies. Longitudinal and cross sectional studies can be combined to seek the advantages of both. In this way one might compress 15 years of study into 3 years of gathering growth data. Dr Ravikanth Lakkakula
  31. 31. FACTORS AFFECTING GROWTH AND MATURATION Heredity  The basic control of growth, both in magnitude and timing is located in the genes. The potential for growth is genetic. The actual outcome of growth depends on the interaction between the genetic potential and environment influences.  Twin studies shown that body size, body shape, deposition of fat and pattern of growth are under genetic control than environmental. Hereditary controls both ends result and rate of progress toward the end result. Dr Ravikanth Lakkakula
  32. 32.  Genetic factors most likely play a leading role in male and female growth differences.The marked advancement of girls over boys in the rate of maturation is attributed to the delaying action of theY chromosomes in males. By delaying growth, theY chromosome allows grows males to grow longer period than females, therefore marking possible greater overall growth.  Individuals with the chromosome pattern XXY (klinefelter’s syndrome) are long legged and have a growth pattern similar to males even with the presence of two X-chromosomes. Dr Ravikanth Lakkakula
  33. 33.  Individuals withTurner’s syndrome having only one X chromosome, develop with a female pattern of growth becoming more like a female at adulthood. Individual with an XYY chromosome constitution are vary tall (6 feet or more), which lends supports to hypothesis that theY chromosome has a delaying effect on growth. Dr Ravikanth Lakkakula
  34. 34. Hormones  The anterior lobe of the pituitary gland produces a hormone called growth hormone or somatotropin. Growth hormone maintains the normal rate of protein synthesis and appears to inhibit the synthesis of fat and the oxidation of carbohydrate.  It is necessary for proliferation of cartilage cells thus it has a great effect on bone growth and consequently height growth. Its growth functions becomes ineffective when the epiphyses close but it probably maintains its effects on protein synthesis through out life. An excess of growth hormone produces a gigantism and a deficiency of the hormone produces a pituitary dwarf. Dr Ravikanth Lakkakula
  35. 35.  The anterior lobe of pituitary gland also secretes thyrotrophic hormone, which affects growth by stimulating the thyroid gland to secrete the hormones of the thyroid gland, thyroxine and tri- iodothyronine, both stimulate general metabolism and are important in growth of the bones, teeth and brain. Deficiency in childhood of the thyroid hormones produces a mentally retarded dwarf.  The timing sequence of maturation is undoubtedly under hormonal control. Bone and dental growth from birth to the adolescent spurt are under thyroid control. At adolescence bones fall under increasing influence of the gonadal hormones. Dr Ravikanth Lakkakula
  36. 36. Sufficient intake of nutritious foods is essential for normal growth. Malnutrition may affect all aspects of growth including size of parts, body proportions, quality and texture of tissues, and onset of growth events. Malnutrition involves deficiency in calories and required food elements.Undernutrition tends to accentuate the normal differential growth of the body tissues. Growth of teeth takes precedence over bone growth and bone grow better than soft tissues such as muscle and fat. Nutrition Dr Ravikanth Lakkakula
  37. 37. The effects of malnutrition are reversible to a certain extent as children have fine recuperative powers. If the adverse effects are not too severe, the growth process accelerates when proper nutrition is provided.This is called “Catch-up growth”. Dr Ravikanth Lakkakula
  38. 38. Race Differences in growth among different races can be attributed to other Nutritional and environmental factors, there seem to be some evidence that race does play a role in growth process. Eg: InAmerican blacks, calcification and eruption of teeth occurs almost a year earlier than their white counterpart. Dr Ravikanth Lakkakula
  39. 39. Disease :  The effects of disease are similar to those of malnutrition. After an illness, a catch up growth period usually brings the child back to the predetermined growth curve.  Disease that slow growth probably have the effect of reducing growth hormone production as a result of increased production of cortisone during the disease.  Cartilage cell growth is stopped temporarily and the result is seen on x-rays as a line of arrested growth. Similar lines can be found in the teeth. Dr Ravikanth Lakkakula
  40. 40. Socio- economic factors Children brought up in affluent and favorable socio-economic conditions show earlier onset of growth events.They also grow to a larger size that children living in unfavorable socio-economic environment. Family size and birth order First born babies tend to weigh less at birth and have smaller stature but higher I.Q.The smaller the family size, the better would be the nutrition and other favorable conditions. Dr Ravikanth Lakkakula
  41. 41. Season and circadian Rhythm : Growth in height is faster in the spring than in autumn on the contrary, city children tend to mature faster than rural ones, especially in less developed countries. Weight and growth proceeds faster in the autumn than in the spring. There is evidence that growth in height and eruption of teeth is greater at night than in the daytime. The reason for these differences is probably related to fluctuations in hormone release. Dr Ravikanth Lakkakula
  42. 42. Secular trend : Although children are growing at a faster rate they are also stopping Growth sooner.The adolescent height spurt is earlier now, but not more accentuated today than in past. An interesting feature of secular trend is the progressive advancement in the timing of menarche.This change may be related to better nutrition. Dr Ravikanth Lakkakula
  43. 43. Concepts of growth Concept of normality Rhythm of growth Differential growth Timing of growth : Growth spurts Dr Ravikanth Lakkakula
  44. 44. Normality  According to , normal refers to that which is usually expected , is ordinarily seen , or is typical.  It had Range & Ideal values, these are fixed value.  On comparison with normal, a variable can be measured.  Normality may not necessarily be ideal. Deviation from usual pattern can be used to express quantitative variability. This can be done by using “growth charts”. Dr Ravikanth Lakkakula
  45. 45. Rhythm of growth According to Hooton,“ Human growth is not a steady & uniform process wherein all parts of die body enlarge at the same rate & the increments of one year arc equal to that of the proceeding or succeeding year”.  This growth rhythm is most clearly seen in stature or body height. Dr Ravikanth Lakkakula
  46. 46. Differential Growth: The human body does not grow at the same rate throughout life. Different organs grow at different rates to a different amount and at different times. This is termed differential growth. Here it would be best to mention two important aspects of growth, both of which help us understand the concepts of differential growth more clearly. These are: 1. Scammon’s curve of growth 2. Cephalo caudal gradient of growth. Dr Ravikanth Lakkakula
  47. 47. Scammon’s curve of growth The body tissues can be broadly classified into four types. They are lymphoid tissue, neural tissue, general tissue and genital tissue. Each of these tissues grows at different times and rate . Lymphoid tissue proliferates rapidly in late childhood and reaches almost 200% of adult size. This is an adaptation to protect children from infection, as they are more prone to them. By about 18 years of age, lymphoid tissue undergoes involution to reach adult size. Dr Ravikanth Lakkakula
  48. 48. Neural tissue grows very rapidly and almost reaches adult size by 6-7 years of age. Very little growth of neural tissue occurs after 6-7 years. This facilitates intake of further knowledge. General tissue or visceral tissue consists of the muscles, bones and other organs. These tissues exhibit an “S” shaped curve with rapid growth upto 2-3 years of age followed by a slow phase of growth between 3- 10years. After the tenth year, a rapid phase of growth occurs terminating by the 18-20th year. Dr Ravikanth Lakkakula
  49. 49. Genital tissue consists of the reproductive organs. They show negligible growth until puberty. However, they grow rapidly at puberty reaching adult size after which growth ceases. Dr Ravikanth Lakkakula
  50. 50. Cephalocaudal Gradient of Growth Cephalocaudal gradient of growth simply means that there is an axis of increased growth extending from head towards the feet. Dr Ravikanth Lakkakula
  51. 51. a)The head takes up about 50% of the total body length around the third month of intra uterine life. At the time of birth, the trunk and the limbs have grown more than the head, thereby reducing the head to about 30% of body length. The overall pattern of growth continues with a progressive reduction in the relative size of the head to about 12% in the adult. 3rd month of IU Birth Adult Head 50% 39% 12% Limbs (Lower) rudimentary 30% 50% Dr Ravikanth Lakkakula
  52. 52. b) The lower limbs are rudimentary around the 2nd month of intrauterine life. They later grow and represent almost 50% of the body length at adulthood. Dr Ravikanth Lakkakula
  53. 53. c)There is increased gradient of growth evidence even within the head and face . At birth, cranium is proportionally larger than face , Post natally the face grows more than cranium.  Mandible shows more growth than maxilla post natally. Dr Ravikanth Lakkakula
  54. 54.  Hellman pointed out that , of all 3 dimensions grew in different order i.e.,  Face : Width > Depth > Height  Cranium : Height >Width >Depth Dr Ravikanth Lakkakula
  55. 55. GROWTH SPURTS:  There are periods of sudden rapid increase, which are termed as growth spurts.There is a period of rapid increase of growth just before birth and another just before, and at beginning of puberty.  The rate of growth is more rapid at the beginning of cellular differentiation, increases until birth and decrease there after. This uneven activity is responsible for the interpretation of growth as appearing in “spurts”.  Believed to be due to physiological changes in hormonal secretion.Dr Ravikanth Lakkakula
  56. 56. Woodside (1968)in his study of Burlington study Group Torrento , showed Name of growth spurt Girls Boys Infantile/childhood growth spurt 3 yrs 3 yrs Juvenile/mixed dentition growth Spurt 6-7yrs 7-9yrs Pre Pubertal/adolescent growth spurt 11-12yrs 14-15yrs Dr Ravikanth Lakkakula
  57. 57. Modified by Bjork (1975) 1. Prenatal -- Just before birth. 2. Postnatal One year after birth. Mixed dentition growth spurt Females : 7- 9 years. Males : 8-11 years. Pre Pubertal growth spurt Females: 11-13 years. Males: 14-16 years. Dr Ravikanth Lakkakula
  58. 58. 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. Dr Ravikanth Lakkakula
  59. 59.  Growth effects because of timing variation can be seen particularly clearly in girls, in whom the onset of menstruation, often referred to as menarche, gives an excellent indicator of the arrival of sexual maturity.  Sexual maturation is accompanied by a spurt in growth. When the growth velocity curves for early (M1), average (M2), and late(M3) maturing girls are compared, the marked differences in size between these girls during growth are apparent. Dr Ravikanth Lakkakula
  60. 60.  At age 11, the early(M1)maturing girl is already past the peak of her adolescent growth spurt, whereas the late-maturing girl (M3) has not even begun to grow rapidly.This sort of timing variation, which occurs in many ways other than that shown here, can be an important contributor to variability. Dr Ravikanth Lakkakula
  61. 61.  The timing of puberty makes an important difference in ultimate body size, in a way that may seem paradoxical at first, the earlier the onset of puberty, the smaller the adult size, and vice versa. Growth in height depends on endochondral bone growth at the epiphyseal plates of the long bones, and the impact of the sex hormones on endochondral bonegrowth is twofold. Dr Ravikanth Lakkakula
  62. 62. First, the sex hormones stimulate the cartilage to grow faster, and this produces the adolescent growth spurt. But the sex hormones also cause an increase in the rate of skeletal maturation, which for the long Bones is the rate at which cartilage is transformed into bone. The acceleration in maturation is even greater than the acceleration in growth.Thus during the rapid growth at adolescence, the cartilage is used up faster than it is replaced. Toward the end of adolescence, the last of the cartilage is transformed into bone, and the epiphyseal plates close.At this point growth potential is lost and growth stops. Dr Ravikanth Lakkakula
  63. 63.  Early cessation of growth after early sexual maturation is particularly prominent in girls. It is responsible for much of the difference in adult size between men and women.  Girls mature earlier on the average, and finish their growth much sooner. Boys are not bigger than girls until they grow for a longer time at adolescence.The difference arises because there is slow but steady growth before the growth spurt, and so when the growth spurt occurs, for those who mature late, it takes off from a higher plateau.  The epiphyseal plates close more slowly in males than in females, and therefore the cutoff in growth that accompanies the attainment of sexual maturity is also more complete in girls. Dr Ravikanth Lakkakula
  64. 64.  Growth of the jaws usually correlates with the physiologic events of puberty in about the same way as growth in height. There is an adolescent growth spurt in the length of the mandible, though not nearly as dramatic a spurt as that in body height, and a modest though discernible increase in growth at the sutures of the maxilla.  The cephalocaudal gradient of growth, which is part of the normal pattern, is dramatically evident at puberty. Dr Ravikanth Lakkakula
  65. 65.  More growth occurs in the lower extremity than in the upper, and within the face, more growth takes place in the lower jaw than in the upper.This produces an acceleration in mandibular growth relative to the maxilla and results in the differential jaw growth referred to previously.  The maturing face becomes less convex as the mandible and chin become more prominent as a result of the differential jaw growth. Dr Ravikanth Lakkakula
  66. 66. • Growth in width is completed first, then growth in length, and finally growth in height. • Growth in width of both jaws, including the width of the dental arches, tends to be completed before adolescent growth spurt. • Growth in width at the palatal suture occurs during the first 5 years of age, mostly at the intermaxillary and interpalatine suture. • Intercanine width more likely to decrease than increase after age 12. Dr Ravikanth Lakkakula
  67. 67. Cranium Maxilla Mandible 1 to 5 years 85% 45% 40% 5 to 10 years 11% 20% 25% 10 to 20 years 4% 35% 35% According to Graber Percentage of craniofacial growth completed at different stages. Dr Ravikanth Lakkakula
  68. 68. Mandibular length changes  Growth of the mandible continues at a relatively steady rate before puberty. On the average, ramus height increases 1 to 2 mm per year and body length increases 2 to 3 mm per year. Dr Ravikanth Lakkakula
  69. 69.  Growth in length and height of both jaws continues through the period of puberty. In girls, the maxilla grows slowly downward and forward to age 14 to 15 on the average (more accurately, by 2 to 3 years after first menstruation), then tends to grow slightly more almost straight forward .  In both sexes, growth in vertical height of the face continues longer than growth in length, with the late vertical growth primarily in the mandible. Dr Ravikanth Lakkakula
  70. 70.  Increases in facial height and concomitant eruption of teeth continue throughout life, but the decline to the adult level which for vertical growth is surprisingly large often does not occur until the early 20’s in boys, somewhat earlier in girls.  Growth of the jaws correlates with physiologic events of puberty in about the same way as growth in height. It is important clinically to careful assessment of physiologic age to plan orthodontic treatment. Dr Ravikanth Lakkakula
  71. 71.  According to proffit, growth modifications must begin in girls during mixed dentition period rather than after all succedaneous teeth have erupted, due to the adolescent growth spurt often preceds the final transition of dentition, so by the time second premolars and molars erupt growth get completed.  In slow maturing boys on the other hand the dentition can be relatively complete while a considerable amount of physical growth remains. Dr Ravikanth Lakkakula
  72. 72. Biological Maturity Indicators Morphologic Age: Is based on height.  A child’s height can be compared with those of his same age group and other age groups to determine where he stands in relation to others. Height, or morphologic age, is useful as a maturity indicator from late infancy to early adulthood.  Everyone is not alike in the way that they grow. It can be difficult, but is important to decide whether the individual is merely an extreme of the normal variation or falls outside the normal range. Dr Ravikanth Lakkakula
  73. 73.  This is determined, using growth charts for the particular population standards. Growth charts can be used to plot an individuals growth. These charts provide information regarding the position of the individual with relation to the group, and it can also be used to follow a child overtime to evaluate whether there is an unexpected change in growth pattern. Dr Ravikanth Lakkakula
  74. 74. INTERPRETATION —  Plotted above the 90% shows child was larger than 90% of the population.  Plotted below the 10% line shows 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. Dr Ravikanth Lakkakula
  75. 75. Chronological age  The most obvious and easily determined developmental age parameter.  Simply calculated from the child date of birth to till examination of the patient date.  Because of the wide variation among individuals in the timing of the pubertal growth spurt, chronologic age cannot be used in the evaluation of growth potential(Fiani,1998). Dr Ravikanth Lakkakula
  76. 76. Dental Age:  Dental age is determined from three characteristics;  The first is which teeth have erupted. The second and third, which are closely related, are the amount of resorption of the roots of primary teeth and the amount of development of the permanent teeth. For e.g. At dental age 10 there is a greater amount of both resorption of the primary canines and molars, and root development of their permanent successors. Dr Ravikanth Lakkakula
  77. 77.  At dental age 10, approximately one half of the roots of the mandibular canine and mandibular first premolar have been completed, nearly half the root of the upper first premolar is complete, and there is significant root development of the mandibular second premolar, maxillary canine, and maxillary second premolar. Dr Ravikanth Lakkakula
  78. 78. Average chronology of permanent tooth development Tooth Calcification begins Crown completed Eruption Root completed. Max Mand Max Mand Max Mand Max Mand Central incisor 3 M 3 M 4 ½ Y 3 ½ Y 7 ¼ Y 6 ¼ Y 10 ½ Y 9 ½ Y Lateral incisor 11 M 3 M 5 ½ Y 4 Y 8 ¼ Y 7 ½ Y 11 Y 10 Y Canine 4 M 4 M 6 Y 5 ¾ Y 11 ½ Y 10 ½ Y 13 ½ Y 12 ¾ Y 1st premolar 20 M 22 M 7 Y 6 ¾ y 10 ½ Y 10 ½ Y 13 ½ Y 13 ½ Y 2nd premolar 27 M 28 M 7 ¾ Y 7 ½ y 11 Y 11 ¼ Y 14 ½ Y 15 Y 1st molar 32 W 32 W 4 ¼ Y 3 ¾ y 6 ¼ Y 6 Y 10 ½ Y 10 ¾ Y 2nd molar 27 M 27 M 7 ¾ Y 7 ½ y 12 ½ Y 12 Y 15 ¾ Y 16 Y 3rd molar 8 Y 9 Y 14 Y 14 Y 20 Y 20 Y 22 Y 22 Y Dr Ravikanth Lakkakula
  79. 79. Stages of tooth calcification by Nollas(1960) 10.Root apex completed. 9.Root almost completed,open apex. 8.Two thirds of root completed. 7.One third of root completed. 6.Crown completed. 5.Crown almost completed. 4.Two thirds of crown completed. 3.One third of crown completed. 2.Initial calcification. 1.Crypt present. 0.Crypt absent. Dr Ravikanth Lakkakula
  80. 80. The radiographs are compared with the drawings, and each tooth is given a developmental scores according to the drawing that it most closely approximates. If the development of the tooth should lie between two stages, half values or plus scores are used. Dr Ravikanth Lakkakula
  81. 81. DENTAL AGE DETERMINATION ACCORDINGTOTHE STAGE OF MINERALIZATION o.Tooth germ without signs of calcification. A. Calcification of single occlusal points without fusion of different calcification. B. Fusion of mineralization points.The contour of the occlusal surface is recognizable. C. Calcification of the crown is complete; beginning of dentin deposits. D. Crown formation is complete up to the Cemento-enamel junction. E. Root length shorter than crown height. F. Root length larger than crown height. G. Root formation finished.Apical foramen still open. H.Apical foramen is closed. Dr Ravikanth Lakkakula
  82. 82. Dr Ravikanth Lakkakula
  83. 83. Conversion chart for dental age determination, calculated according to the score-system of dental formation The overall figure for assessment of dental age is obtained by adding together the separate values for 7 teeth for each quadrant.Dr Ravikanth Lakkakula
  84. 84.  Dental development indicators are also NOT RELAIBLE predictors of an individual’s stage of skeletal development because of difference in timing of their eruption and development , congenital absence of teeth.  But one study (Krailassir et al, Angle Orthod 2002) shows that the canine stage F for both sexes coincided with the MP3 stage and indicated the onset of a period of accelerating growth. The findings of this study indicate that tooth calcification stages might be clinically used as a maturity indicator of the pubertal growth period. Dr Ravikanth Lakkakula
  85. 85. Sexual Age:  This is based on development of secondary sexual characters both boys and girls.  This type of indicator is useful only for assessment of adolescent growth. Dr Ravikanth Lakkakula
  86. 86. Adolescent Growth Stages versus Secondary Sexual Characteristics Total Duration of Adolescent Growth : 3 ½ years period Stage 1 Beginning of adolescent Growth Appearance of breast buds, initial pubic hair. Stage 2 (About 12 Months Later) Peak velocity physical growth (in height) Noticeable breast development, axillary hair, darker/more abundant pubic hair. Stage 3 (12-18 Months Later) Growth spurt ending Menses, broadening of hips with adult fat distribution, breasts completed. Girls Dr Ravikanth Lakkakula
  87. 87. BoysTotal Duration of Adolescent Growth : 5 years period Stage 1 Beginning of adolescent growth “Fat spurt” weight gain, feminine fat distribution. Stage 2 (About 12 Months Later) Height spurt beginning Redistribution/reduction in fat, pubic hair, growth of penis. Stage 3 (8-12 Months Later) Peak velocity in 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/color of pubic and axillary hair, adult body form. Boys Dr Ravikanth Lakkakula
  88. 88.  Recent research has shown that sexual development really begins much earlier than previously thought. Sexhormones produced by the adrenal glands first appear at age 6 in both sexes, primarily in the form of a weak androgen (dehydroepiandrosterone , [DHEA]).This activation of the adrenal component of the system is referred to as adrenarche.  DHEA reaches a critical level at about age 10 that correlates with the initiation of sexual attraction.It is likely that a juvenile acceleration in growth is related to the intensity of adrenarche and not surprising that a juvenile acceleration is more prominent in girls because of the greater adrenal component of their early sexual development. Dr Ravikanth Lakkakula
  89. 89. Skeletal age assesment Hand wrist radiographs The hand – wrist region is made up of numerous small bones. These bones show a predictable and scheduled pattern of appearance, ossification and union from birth to maturity.There by merely comparing a patient’s hand-wrist radiograph with standard radiographs that represent different skeletal ages, we will be able to determine the skeletal maturation status of that individual. Dr Ravikanth Lakkakula
  90. 90.  We all know end of long bones grow at their end called epiphysis.  The newly formed bone starts getting mineralised at the metaphysis and the most matured bone seen at the diaphysis. The epiphysis initially forms a cartilage tissue which later ossifies and fuses with the metaphysis as it matures. Dr Ravikanth Lakkakula
  91. 91. A number of methods have been described to assess the skeletal maturity using hand-wrist radiographs.The following are the most commonly used methods:  Atlas methods by Greulich and Pyle  Bjork, Grave and Brown Method  Fishman’s Skeletal Maturity Indicators  Hagg andTaranger Methods Dr Ravikanth Lakkakula
  92. 92. GREULICH AND PYLE METHOD  Greulich and Pyle 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. Dr Ravikanth Lakkakula
  93. 93. BJORK, GRAVE AND BROWN They have divided skeletal development into 9 stages. Each of these stages represents level of skeletal maturity.Appropriate chronological age for each of the stages was given by Schopf in 1978. Stage One (males 10.6 years,Females 8.1 years):The epiphysis and diaphysis of the proximal phalanx of index finger are equal. It occurs approximately three years before the peak of pubertal growth spurt. Dr Ravikanth Lakkakula
  94. 94.  StageTwo (males 12.0 years,Females 8.1 years): The epiphysis and diaphysis of the middle phalanx of the middle finger are equal. Dr Ravikanth Lakkakula
  95. 95. StageThree (Males 12.6 years,Females 9.6 years):This stage is characterized by presence of 3 areas of ossification:  The hamular process of the hamate exhibits ossification.  Ossification of pisiform.  The epiphysis and diaphysis of radius are equal. Dr Ravikanth Lakkakula
  96. 96. Stage Four (Males 13.0 years,Females 10.6 years):This stage marks the beginning of the pubertal growth spurt. It is characterized by:  Initial mineralization of the ulnar sesamoid of the thumb.  Increased ossification of the hamular process of the hamate bone. Dr Ravikanth Lakkakula
  97. 97. stage 5 (male 14 years ,female 11 years ): It is a peak of pubertal growth spurt. Capping of epiphysis and diaphysis seen in a. Middle phalanx of 3rd finger. b. Proximal phalanx of thumb. c. Radius. Dr Ravikanth Lakkakula
  98. 98. Stage six (Males 15.0 years,Female 13.0 years):This stage signifies the end of the pubertal growth spurt. It is characterized by union between epiphysis and diaphysis of the distal phalanx of the middle finger. Dr Ravikanth Lakkakula
  99. 99.  Stage Seven (Males 15.9 years, Females 13.3 years): Union of epiphysis and diaphysis of the proximal phalanx of the little finger occurs. Dr Ravikanth Lakkakula
  100. 100.  Stage Eight (Males 15.9 years,Females 13.9 years):This stage shows fusion between the epiphysis and diaphysis of the middle phalanx of the middle finger. Dr Ravikanth Lakkakula
  101. 101.  Stage Nine (Males 18.5 years,Females 16.0 years): This is the last stage and it signifies the end of skeletal growth. It is characterized by fusion of epiphysis and diaphysis of the radius. Dr Ravikanth Lakkakula
  102. 102. 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 degree of reliability help determine the maturational status of the patient. Six stages of hand wrist development are described. The stages and their characteristics are: Dr Ravikanth Lakkakula
  103. 103. Stage one (Early):  Absence of the pisiform  Absence of the hook of the hamate and  Epiphysis of proximal phalanx of second digit (PP2) narrower than its shaft. StageTwo (Prepuberal):  Proximal phalanx of second digit and its epiphysis are equal in width ,  Initial ossification of hook of the hamate and  Initial ossification of the pisiform. Dr Ravikanth Lakkakula
  104. 104. StageThree (Puberal onset):  Beginning calcification of ulnar sesamoid,  Increased width of epiphysis of PP2 and  Increased calcification of hamate hook and pisiform . Stage Four (Puberal):  Calcified ulnar sesamoid and  Capping of shaft of the middle phalanx of third digit by its epiphysis (MP3cap). Dr Ravikanth Lakkakula
  105. 105. Stage Five (Puberal deceleration):  ulnar sesamoid fully calcified and  Fusion of epiphysis of distal phalanx of 3rd finger with its shaft and epiphysis of radius and ulnar no fully calcified fused with respective shaft. Stage Six (Growth completion):  No remaining growth sites. Dr Ravikanth Lakkakula
  106. 106. FISHMAN’S SKELETAL MATURITY INDICATORS A system for evaluation of skeletal maturation was proposed by Leonord S. Fishman in 1982. System Fishman uses only four stages of bone maturation, all found at six anatomical sites located on the thumb, third finger, fifth finger and radius. Dr Ravikanth Lakkakula
  107. 107.  Fishman system uses 4 stages of bone maturation.They are Dr Ravikanth Lakkakula
  108. 108. 11 Adolescent skeletal maturational indicator’s (SMI’s) covering the entire period o adolescent development. Skeletal maturity indicators (SMI) Width of epiphysis as wide as diaphysis SMI 1.Third finger – Proximal phalanx. SMI2.Third finger – Middle phalanx SMI 3. Fifth finger – Middle phalanx Dr Ravikanth Lakkakula
  109. 109. Ossification SMI 4.Adductor sesamoid of thumb Capping of epiphysis SMI5 - Third finger – Distal phalanx SMI6 - Third finger – Middle phalanx SMI 7 - Fifth finger – Middle phalanx Dr Ravikanth Lakkakula
  110. 110. Fusion of epiphysis and diaphysis SMI 8.Third finger – Distal phalanx SMI 9.Third finger – Proximal phalanx SMI 10.Third finger – Middle phalanx SMI 11. Radius Dr Ravikanth Lakkakula
  111. 111. Approximate chronological age and percentage of growth completed corresponding to SMI Dr Ravikanth Lakkakula
  112. 112. Approximate chronological age and percentage of growth completed corresponding to SMI Dr Ravikanth Lakkakula
  113. 113. HAGG ANDTARANGER METHOD(1982) Skeletal age assessment of 1) The ossification of sesamoid. 2) The middle and distal phalanges of the third finger. 3) The distal epiphysis of the radius. Sesamoid  Sesamoid is usually attained during the acceleration period of the pubertal growth spurt (onset of P.H.V.). Dr Ravikanth Lakkakula
  114. 114. Third finger middle phalanx(MP3) MP3-F: The epiphysis is as wide as the metaphysis. This stage is attained before onset of P.H.V. by about 40 percent of the subjects and P.H.V. by many others. Dr Ravikanth Lakkakula
  115. 115. MP3-FG: The epiphysis is as wide as the metaphysis and there is distinct medial and / or lateral border of the epiphysis forming a line of demarcation at right angles to the distal border.This stage is attained 1 year before or at P.H.V. Dr Ravikanth Lakkakula
  116. 116. MP3-G: ( the point of maximum pubertal growth spurt) The sides of the epiphysis have thickened and also cap its metaphysic, forming a sharp edge distally at one or both sides.This stage is attained at or 1 year after P.H.V. Dr Ravikanth Lakkakula
  117. 117. MP3-H: (deceleration part of the curve of pubertal growth spurt); Fusion of the epiphysis and metaphysis has begun and is attained after PHV but before end of growth spurt by practically all boys and about 90 percent of the girls. Dr Ravikanth Lakkakula
  118. 118. MP3-I: Is attained before or at en of growth spurt in all subjects except a few girls. Dr Ravikanth Lakkakula
  119. 119. Third finger distal phalanx DP3 - I: Fusion of the epiphysis and metaphysic is completed.This stage signifies the fusion of the epiphysis and metaphysic and is attained during the acceleration period of the pubertal growth spurt (i.e. end of P.H.V.) by all subjects. Dr Ravikanth Lakkakula
  120. 120. Radius R-I: Fusion of the epiphysis and metaphysis has begun.This stage is attained 1 year before or at the end of growth spurt by about 80% of the girls and about 90% of the boys. R-IJ: Fusion is almost completed but there is still a small gap at one or both margins. R-J: Is characterized by fusion of the epiphysis and metaphysic.These stages were not attained before end PHV by any subject. Dr Ravikanth Lakkakula
  121. 121. SKELETAL MATURATION EVALUATION USING CERVICAL VERTEBRAE Hassel and Farman (1995) developed a system of skeletal maturation determination using the cervical vertebrae. The shapes of the cervical vertebrae were seen to differ at each level of skeletal development.This provided a means to determine the skeletal maturity of a person and thereby determine whether the possibility of potential growth existed. Dr Ravikanth Lakkakula
  122. 122. The shapes of the vertebral bodies of C3 and C4 changed from somewhat wedge shaped, to rectangular, followed by square shape. They became taller as skeletal maturity progressed. The inferior vertebral borders were flat when immature, and they were concave when mature.The curvatures of the inferior vertebral borders were seen to appear sequentially from C2 to C3 to C4 as the skeleton matured.The concavities became more distinct as the person matured. Dr Ravikanth Lakkakula
  123. 123. Hassel and Farman have put forward the following six stages in vetribral development. Stage 1: This stage called initiation, corresponds to beginning of adolescent growth with 80% to 100% of adolescent growth 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. Dr Ravikanth Lakkakula
  124. 124. Stage 2: The second stage is called acceleration. Growth acceleration begins 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. Dr Ravikanth Lakkakula
  125. 125. Stage 3: The third stage called transition, corresponded to acceleration of growth towards 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. Dr Ravikanth Lakkakula
  126. 126. Stage 4: This stage called deceleration corresponds to deceleration of adolescent growth spurt 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. Dr Ravikanth Lakkakula
  127. 127. Stage 5: The fifth stage is called maturation. 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. Dr Ravikanth Lakkakula
  128. 128. Stage 6: This stage called completion, corresponds to completion of growth. Little or no adolescent growth could be 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. Dr Ravikanth Lakkakula
  129. 129. Hand –wrist SMI Cervical vertebral stages Pubertal growth remaining 1-2 Initiation 85-100% 3-4 Acceleration 65-85% 5-6 Transition 25-65% 7-8 Deceleration 10-25% 9-10 Maturation 5-10% 11 completion 0% Correlation of hand-wrist and cervical vertebral maturation stages Dr Ravikanth Lakkakula
  130. 130. Significance of Growth Spurts in Orthodontics  Pubertal increments offers best time for, determining the predictability, growth direction, patient management and total treatment time.  Understanding the growth, predictability of future growth of maxilla, mandible and alveolar process helps in diagnosing and achieving excellent results of the malocclusion. Dr Ravikanth Lakkakula
  131. 131. Functional jaw orthodontic therapy takes advantages of redirection of remaining growth of craniofacial region. Functional appliances like Twin block, Bionator, Frankel appliances are given for class II skeletal correction. Effectiveness of these appliances to modify skeletal growth is minimal after pubertal growth spurt. Dr Ravikanth Lakkakula
  132. 132.  Orthopaedic appliances like headgears are also advantageous to correct maxillary prognathism during growing stage of the patient. Maxillary horizontal growth is completed much earlier than mandible and so the use of headgear to restrict or redirect its growth should be started much before pubertal growth spurt in mixed dentition period. Dr Ravikanth Lakkakula
  133. 133.  Maxillary expansion procedures in cases of jaw constriction should be carried out during early mixed dentition. Growth in width of maxilla occurs by sutural growth in interpalatine and intermaxillary sutures. Maximum growth occurs in first 5 years.The skeletal expansion procedures should be carried out before the fusion of palatal sutures, i.e. by 10 years. Dr Ravikanth Lakkakula
  134. 134.  Orthopaedic appliances like facemask and chin cup are used for the treatment of skeletal class III malocclusions early during the mixed dentition period. However, the continuing growth of mandible and its pubertal growth spurt can lead to development of malocclusion after early interventions. Dr Ravikanth Lakkakula
  135. 135.  Active growth cessation is prerequisite for Orthognathic surgery particularly in cases with mandibular prognathism. Dr Ravikanth Lakkakula
  136. 136. Conclusion  As we Orthodontists nowadays deal with more and more mixed dentition cases, many of whom may or may not present with a skeletal malocclusion. It is very important for us to determine the magnitude and direction of growth if we are to treat these cases with a fair amount of success.  It is a great challenge therefore to diagnose and to plan an ideal treatment for these cases keeping in mind their growth potential. Dr Ravikanth Lakkakula
  137. 137.  However we should not forget that every individual is unique in his own aspect and therefore we should not jump to conclusions but study our patients over time and treat them to their individual requirements.  The pubertal growth spurt of is an advantageous period in the orthodontic treatment and it should be kept in mind in connection with the planning of the treatment. One of the objectives of the orthodontic treatment during the adolescence, in the cases with skeletal discrepancies is to take advantage of the changes of growth of the patient. Dr Ravikanth Lakkakula

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