Assesment of Growth - OrTHO / Orthodontic Courses by Indian Dental Academy

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Introduction

Histological background of Assessment
Why Orthodontist should be interested
in skeletal growth?

Clinical implication of growth
Requirements of Skeletal growth Assessment
Methods of Assessing using radiograph

Introduction
William K.Roentgen demonstrated his new radiographic discovery in
1895.

Roland & Ranke (German professor and German researcher) 1896
introduced the idea of using the comparative size and shape of the
radiograph shadows of growing bone as indicators of rate of growth and
maturity.

During growth, every bone goes through a series of changes that can
be seen radio graphically.

The timing of the changes varies because each person has his or her
own biological clock.

Sequence of Assessment in growth

In the early 1905, Professor J. W. Pryor, Rotch and
Crampton began tabulating indicators of maturity on sequential
radiographs of the growing hand and wrist. Hellmann published his
observations on the ossifications of epiphysical cartilages of the
hand in 1928.

Todd was one of the first investigator to evaluate skeletal
maturation, he compiled hand wrist data that was further elaborated
by Greulich and Pyle in atlas form .

Flory in 1936, indicated that the beginning of calcification, if the
carpal sesamoid (adductor sesamoid) was a good guide to
determining the period immediately before puberty.

In 1937 Greulich and Pyle has created a radiographic atlas of the
skeletal development of the hand wrist.
Tanner reported about the TW1 &TW2 methods
of scoring born maturity by biological weighted system

Ossification of various bones and hand wrist has been studied in
relation to the puberal growth spurt.

Bjorke and Helm (1967) found a close correlation between the onset
of ossification of the adductor sesamoid bone at the metcarpophalyngeal
joint of the thumb and growth spurt.

Chapman (1972) confirmed that the duration of growth spurt coincides
with the duration of development of the adductor sesamoid and ends with
the fusion of epiphysis of the thumb.

Hand wrist ossification markers of puberal growth has been reported
by Grave And Brown (1976, 1979)

On the other hand Houston et al. (1979) and
Houston (1980) have found that although the
timings of certain ossification events are related to
puberal growth spurt, there is considerable uncertainty in the
predication of timings of growth spurt in individuals, which make the
use of hand wrist radiograph of limited value for the purpose.

Chertkow (1980) has reported not only the commencement of the
growth spurt was closely correlated to the time of certain ossification
events in the hand and wrist but also that there was a high correlation
between these events and the stage of mineralezation of the lower
canine teeth

The prediction of skeletal height has been well documented by Tanner
in (1981)

In 1982 Fishman proposed the system of skeletal materlization
assessment .
Rune et al reported that facial changes were not
related to skeletal pattern, chronological age, growth peak and
treatment duration .

Sarnais also reported that the effect of maxillary protraction has no
relation to the skeletal type, growth peak and treatment period

A different method of determination of the maximum growth period
has been proposed by Sullivan (1983). It is based on consecutive
measurements of standing height to determine changes in growth
velocity, from which a predication of the time of maximum velocity is
made.

Chmura (1984) reported that ossification of the ulna sesemoid was not
found to predict the onset,duration or rate of the puberal growth spurt.

Why should an orthodontist be interested
in skeletal growth?

Many malocclusion are, at lest in part, due to skeletal discrepancies
between the jaws (maxilla and mandible). Such discrepancies are
usually due to difference in the comparative growth of the jaws

. More severe malocclusions may be related to more distant
skeletal discrepancies within the cranial base. Correctly identifying
these growth features may be important in deciding upon a diagnosis
and formulating a treatment plan.

The timing of orthodontic intervention is crucial,and the initiation
of early treatment protocol varies according to malocclusion being
treated, some are dependent on favorable growth for example,
where surgery is being considered, it is important to be able to
identify if the growth has completed.

Greater the growth activity, movement of tooth is more
rapid.

Inopportune or poorly timed extractions performed by the dentist
during growth may have an unfortunate consequence on the developing
occlusion.

More particularly, The dentist should be able to identify abnormal
occlusal development at an early stage in order to undertake suitable
interceptive orthodontics treatment where appropriate.

Most important, precise estimates of a childs maturity status helps to
identify the optimal time for certain type of orthopedic treatment.

It aids the interdisciplinary health teams assessing patients with various
types of short statures,endocrine disorders,and/or metabolic diseases;its
utility is well established for syndrome identification and forensics.

Clinical implication of growth assessment
o Prior to rapid maxillary expansion

o When maxillomandibular changes are indicated in the
treatment of class III cases, skeletal class II cases
skeletal opens bites

o In patients with marked discrepancy between dental
and chronological age

o Orthodontic patients requiring orthognathic surgery if
undertaken between the ages of 16 and 20 years

Requirements for assessing skeletal growth

Should be safe
Non-invasive
Requires minimal radiation
Should be accurate
Stage of maturity should be well defined and easily
identifiable
Cost effective
Method should be simple to conduct
Should be valid over a time and across age groups

Methods of assessing maturity using radiograph

Growth spurt
Hand wrist radiograph
MP3
Cervical Vertebral
Assessment by tooth development mandibular canine.
Frontal Sinus
Antigonial notch
Implant samples

Growth Rhythm curve (Bjork)
Description of Hand Wrist X-ray
Description of Hand Wrist X-ray
Ulna
Radius
Capitate Bone
Lunate Bone
Tricuetral Bone
Pisi Form Bone

Hamate Process
Hamate Bone
Trapezium Bone
Trapezoid Bone
Scaphoid Bone
Sesamoid Bone
M
M
M
M
M
P
P
P
P
P
P
P
P
P
P
P
P
P
P
Development of the ring finger, row by row. The image top-left is
from a baby; the image at the lower right is from a nineteen year old.
In the fifth image, the epiphysis appears, which becomes wider and
in the final images fuses with the metaphysis. These images are taken
from the Greulich and Pyle atlas.
Bjork (1972), Grave & Brown (1976)
1.The epiphysis of the proximal
phalanx of the index finger (PP2)has
the same width as the diaphysis
2.Epiphysis of the middle
phalanx of the middle finger
(MP3) is of the same width as
the diaphysis
Pisi stage=Visible ossification of
the pisiforme
H1 stage=Ossification of the
hamular process of the hamatrum
R= stage.same width of epiphysis
and diaphysis of thr radius
4.S-stage=first
mineralisation of the
metacarpophalangeal
joint of the thumb
H2-stage=ossification
of the hamular
process of the
hamatum
5.The diaphysis is
covered by the cap-
shaped epiphysis
In the MP3 cap stage,the
processs begins at the
middle phalanx of the
third finger;
In the PP1 cap stage ,at
the proximal phalanx of
the thumb;and in the
Rcap stage, at the radius
6.Visible union of epiphysis and
diaphysis at the distal phalanx of the
middle finger(DP3)

7.Visible union of epiphysis at the
proximal phalanx of the little
finger(PP3)
8.Union of epiphysis and diaphysis at the
middle phalanx of the middle finger is
clearly visible(MP3)
9.Complete union of epiphysis and
diaphysis of the radius.
The ossification of all the hand bones is
completed and skeletal growth is finished
Fishmans Maturation Index

Hagg &
Tarangers
- MP3

10.6 12.0 12.6 13.0 14.0 15.0 15.9 15.9 18.5
8.1 8.1 9.6 10.6 11.0 13.0 13.3 13.9 16.0

9.
Ru
Growth Period

1.
PP2=

2.
MP3=

3.
Pisi
H1
R=

4.
S
H2

5.
MP3cap
R cap
PP1 cap

6.
DP3

7.
PP3u

8.
MP3u

Skeletal Age assessment by Schopf - 1978
Cervical Vertebrate maturation indicators
1. Initiation (SMI 1&2)

Very significant amount of the adolescent growth expected
C2, C3 and C4 inferior vertebral body borders are flat
Superior vertebral borders are tapered posterior to anterior

2. Acceleration (SMI 3&4)

Significant amount of adolescent growth expected
Concavities developing in lower borders of C2 and C3
Lower borders of C4 vertebral body is flat
C3 and C4 are more rectangular in shape
3. Transition (SMI 5&6)

Moderate amount of adolescent growth is expected
Distinct concavities of the lower borders of C2 and C3
C4 developing concavity in lower border of body
C3 and C4 are rectangular in shape

4. Deceleration (SMI 7&8)

Small amount of adolescent growth is expected
Distinct concavities in lower borders of C2,C3 and C4
C3 and C4 are nearly square in shape

5. Maturation (SMI 9&10)
Insignificant amount of adolescent growth expected
Accentuated concavities in lower borders of C2,C3,C4
C3 and C4 are square in shape

6. Completion (SMI 11)
Adolescent growth is completed
Deep concavities are present for inferior vertebral body
borders of C2,C3 and C4
C3 and C4 heights are greater than widths

C2
C3
C4
C5
C6
Cvs 1 Cvs 2 Cvs 3 Cvs 4 Cvs 5
Cvs 6
Development stage of Cervical Vertebrae
Calcification & Mineralisation of tooth-
Mandibular Canine
(Demirjian & associates)
Eight relevant stages of dental development

Eight relevant stages of dental development

A Calcification if single occlusal points without
fusion of different calcifications

B Fusion of the materialization points the
contour of the occlusal surface is recognizable

C Calcification of the crown is
complete: beginning of dentin deposits.
The pulp chamber is curved, and no
pulp horns are visible.

D - Crown formation is complete up to the cement enamel
junction. Root formation has commenced. The pulp horns
are beginning to differentiate, but the wall of the pulp
remain curved.

E Root length shorter than crown height .The walls of
the pulp chamber are straight, and the pulp horn have
become more differentiated than in the previous stage .In
molars the radicular bifurcation has commenced to
calcify.


F Root length larger than crown
height the walls of the pulp chamber
now form an isosceles triangle. In
molars the bifurcation has developed sufficiently to give
the root a distinct form.

G Root formation finished. Apical foramen still open,
the walls of the root canal are now parallel. In molars only
the distal root is rated.

H Apical foramen is closed the periodontal membrane
surrounding the root and apex is uniform in width
throughout.

Frontal sinus
The frontal sinus bud is present at birth in the ethmoid region but is not
evident radio graphically until the fifth year, when it projects above the
rim. Rapid growth of the sinuses continues until the age of 12 years,
when they reach nearly adult size.

Joffe found frontal sinus enlargement to be associated with prognathic
subjects, but no indication was given as to the correlations with growth-
prediction indicators.

Tanner found that the annual height (stature) growth increments in
children reached at 16 years in boys and 14 years, and it was thought that
these too, are the ages at which frontal sinus enlargement ceased.

Antigonial notch
1. Deep notch subjects had a more retrusive
mandible with a shorter corpus, less ramus height, and a greater gonial
angle than did shallow notch subjects.

2. The mandibular growth direction in deep notch patients, as measured
by the facial axis and the mandibular plane angle, was more vertically
directed than for shallow notch patients.

3. The deep notch subjects had longer total facial height and longer
lower facial height than did the shallow notch subjects. www.indiandentalacademy.com

4. The deep notch subjects had a smaller saddle
angle than did the shallow notch subjects.

5. The deep notch sample experienced less mandibular growth during
the study period examined as evidenced by (1) a smaller increase in total
mandibular length, (2) corpus length, and (3) less displacement of the
chin in a forward direction as compared to the shallow notch sample.

6. Notch depth increased in the deep notch group, while it decreased
slightly in the shallow notch group during the study period.

7. Deep notch patients required a longer duration of orthodontic
treatment than did shallow notch patients.


Implants were used to estimate the possibility of predicting the
direction and the amount of growth rotation of the mandible on the basis
of morphologic criteria observed on a single profile radiograph at
pubertal age.

Morphologic features from the first profile radiograph were
compared with the observed growth changes over a period and their
predicting values calculated.

Cephalometric growth analysis has generally been based on
conventional measurement of the facial morphology, without taking into
account the remodeling processes at the bony surfaces.
Implant Sample

The mandibular growth rotation is composed of a complex system of
movements. In a recent report by Bjrk and Skieller the bony
mandibular corpus and its soft-tissue covering, the matrix, have been
considered as independent tissue systems capable of independent
rotation

Both forward and backward rotation was divided into three
components: total rotation, referring to the rotation of the mandibular
corpus (implant line or reference line) relative to the anterior cranial
base; matrix rotation, referring to the rotation of the soft-tissue matrix
of the mandible (tangential line to lower mandibular border) relative to
the anterior cranial base; and intramatrix rotation, referring to the
rotation of the mandibular corpus within its soft-tissue matrix (or the
difference between reference lines), expressing the amount of
remodeling at the lower border of the mandible.

Though there are different standardization for assessing skeletal growth
and maturation all reach the same goal in the forward advance of events
in treatment plan .

To take full advantage, the specific roles and degree of inter
relationship is required.

Conclusion
Thank You !
Lamons and Gray compared the all the developmental indices to a
company of soldiers who are moving at a constant rate of speed. Now
one pair walk together, then they divide and walk with other. Some run
ahead, others lag behind and even stop to rest; yet all reach the same goal
in the forward advance of events.

To take full advantage of the soldiers potential, information about their
specific roles and degree of inter relationship is required.

Conclusion
Thank You !
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