Growth prediction (2) /certified fixed orthodontic courses by Indian dental academy

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Growth prediction (2) /certified fixed orthodontic courses by Indian dental academy

  1. 1. GROWTH ASSESSMENTGROWTH ASSESSMENT www.indiandentalacademy.comwww.indiandentalacademy.com INDIAN DENTAL ACADEMYINDIAN DENTAL ACADEMY  Leader in continuing dental educationLeader in continuing dental education  www.indiandentalacademy.comwww.indiandentalacademy.com
  2. 2. IntroductionIntroduction • An understanding of growth events is of primaryAn understanding of growth events is of primary importance in the practice of clinicalimportance in the practice of clinical orthodonticsorthodontics • Biological , skeletal age or bone age andBiological , skeletal age or bone age and skeletal maturation are nearly synonymousskeletal maturation are nearly synonymous terms used to described the maturational stageterms used to described the maturational stage of a personof a person • Due to individual variation in growth timing ,Due to individual variation in growth timing , duration and velocity of growth, skeletal ageduration and velocity of growth, skeletal age assessment is essential in formulatingassessment is essential in formulating orthodontic treatment plans.orthodontic treatment plans. www.indiandentalacademy.comwww.indiandentalacademy.com
  3. 3. • Maturational status can have considerable influence onMaturational status can have considerable influence on diagnosis, treatment goals, treatment planning anddiagnosis, treatment goals, treatment planning and eventual outcome of orthodontic treatment.eventual outcome of orthodontic treatment. • Clinical decisions regarding use of extra oral tractionClinical decisions regarding use of extra oral traction forces, functional appliances, extraction versus nonforces, functional appliances, extraction versus non extraction treatment or Orthognethic surgery all are atextraction treatment or Orthognethic surgery all are at least partially based on growth considerations.least partially based on growth considerations. • Prediction of both the time and amount of active growthPrediction of both the time and amount of active growth especially in the craniofacial complex would be useful toespecially in the craniofacial complex would be useful to the orthodontist.the orthodontist. www.indiandentalacademy.comwww.indiandentalacademy.com
  4. 4. Prediction/Assessment/MaturityPrediction/Assessment/Maturity IndicatorIndicator Predict – to say in advance.Predict – to say in advance. AssessmentAssessment • Analysis of the nature and amount ofAnalysis of the nature and amount of growth that has taken place.growth that has taken place. PredictionPrediction • To make a statement about the furtherTo make a statement about the further development of anatomical entitydevelopment of anatomical entity www.indiandentalacademy.comwww.indiandentalacademy.com
  5. 5. Clinical ImportanceClinical Importance • To determine potential vector of facial developmentTo determine potential vector of facial development • To determine the amount of significant cranial growthTo determine the amount of significant cranial growth potential leftpotential left • To evaluate the rate of growthTo evaluate the rate of growth • To decide the onset of treatment timingTo decide the onset of treatment timing • To decide the type of effective treatment:To decide the type of effective treatment: • a) Orthopedic (removable or fixed )a) Orthopedic (removable or fixed ) • b) Orthodonticb) Orthodontic • c) Orthognethic surgical procedurec) Orthognethic surgical procedure • d) Combination of aboved) Combination of above • To evaluate the treatment prognosisTo evaluate the treatment prognosis • To understood the role of genetics and environment onTo understood the role of genetics and environment on the skeletal maturation pattern.the skeletal maturation pattern. www.indiandentalacademy.comwww.indiandentalacademy.com
  6. 6. Ideal requirement of maturityIdeal requirement of maturity indicatorindicator • Should be safeShould be safe • Non invasiveNon invasive • Require minimum radiationRequire minimum radiation • Should be accurateShould be accurate • Stages of maturity should be well defined and easilyStages of maturity should be well defined and easily identifiableidentifiable • Cost effectiveCost effective • Minimum armamentarium and personal requirementMinimum armamentarium and personal requirement • Method should be simple to conductMethod should be simple to conduct • Should be valid over time and across age groups.Should be valid over time and across age groups. www.indiandentalacademy.comwww.indiandentalacademy.com
  7. 7. LATE AND EARLYLATE AND EARLY DEVELOPMENTDEVELOPMENT • Six type of skeletal developmentSix type of skeletal development 11stst groupgroup Average childrenAverage children 22ndnd groupgroup children who are tall in childhood only b/cchildren who are tall in childhood only b/c matured faster than average, not particularlymatured faster than average, not particularly tall adultstall adults 33rdrd groupgroup not only early matures but are genetically tallnot only early matures but are genetically tall also and will be tall adults.also and will be tall adults. 4rh group4rh group who are small b/c they mature late but willwho are small b/c they mature late but will eventually be of average stature.eventually be of average stature. 55thth groupgroup children who are both late developing andchildren who are both late developing and genetically short in stature.genetically short in stature. 66thth groupgroup indefinite group who start puberty muchindefinite group who start puberty much earlier or much late than usual.earlier or much late than usual.www.indiandentalacademy.comwww.indiandentalacademy.com
  8. 8. Indices of maturityIndices of maturity • Neural ageNeural age • Mental ageMental age • Physiological and biochemical agePhysiological and biochemical age • Chronological ageChronological age • Sexual/pubertal ageSexual/pubertal age • Dental ageDental age • Age determination using growth chartsAge determination using growth charts • Skeletal/anatomic/radiological ageSkeletal/anatomic/radiological age www.indiandentalacademy.comwww.indiandentalacademy.com
  9. 9. Neural ageNeural age • Gesell and his colleaguesGesell and his colleagues in Americain America have done great deal of work on thehave done great deal of work on the neural development in humans.neural development in humans. • Certain landmarks of development wereCertain landmarks of development were accounted.accounted. • Help us to understand that the patient isHelp us to understand that the patient is mentally developed to understand thementally developed to understand the need for treatment .need for treatment . www.indiandentalacademy.comwww.indiandentalacademy.com
  10. 10. Neural AgeNeural Age • Developmental landmarksDevelopmental landmarks • Years Age (months)Years Age (months) • 22 follows moving object with eyesfollows moving object with eyes 44 can sit propped up for a short time, movescan sit propped up for a short time, moves head to inspect surroundingshead to inspect surroundings 6 grasps objects, begin to bang and shake them6 grasps objects, begin to bang and shake them 88 may sit unaidedmay sit unaided 10 creeps, picks up small objects between10 creeps, picks up small objects between fingersfingers and thumb, one/two words,and thumb, one/two words, tries to help withtries to help with feedingfeeding 11 cruises holding on to rail of cot, walks withcruises holding on to rail of cot, walks with oneone hand held, throws objects on floor, cooperateshand held, throws objects on floor, cooperates in dressing, waves good-byein dressing, waves good-bye 1.51.5 walks, runs awkwardly and stiffy, can trunwalks, runs awkwardly and stiffy, can trun pagespages of book, abt 30 words, builds towersof book, abt 30 words, builds towers of 3-4 blockof 3-4 block www.indiandentalacademy.comwww.indiandentalacademy.com
  11. 11. yrsyrs 22 Runs without falling, uses three word sentences ,Runs without falling, uses three word sentences , can turn doorknob, obeys simple instructions, buildscan turn doorknob, obeys simple instructions, builds towers of 6-7 blocks, bowel and bladder controltowers of 6-7 blocks, bowel and bladder control some times good.some times good. 33 walks erect. Stand on foot, climbs, can put on shoeswalks erect. Stand on foot, climbs, can put on shoes and unbutton some buttons, bowel and bladderand unbutton some buttons, bowel and bladder control is established.control is established. 44 Cleans teeth , washes and dried face and hands.Cleans teeth , washes and dried face and hands. 55 can tie shoe lasses and is beginning to use tools,can tie shoe lasses and is beginning to use tools, some are reading quite well, questions abt meaningsome are reading quite well, questions abt meaning of wardsof wards 66 reads, balls are bounced and sometimes caught.reads, balls are bounced and sometimes caught. www.indiandentalacademy.comwww.indiandentalacademy.com
  12. 12. MENTAL AGEMENTAL AGE • Attempt to device performance tests, measuresAttempt to device performance tests, measures intelligence by stanford binet test /or Wechslerintelligence by stanford binet test /or Wechsler scalescale • Help in determining the outlook of the patientHelp in determining the outlook of the patient towards treatment.towards treatment. • Also help In determining the expected level ofAlso help In determining the expected level of cooperation that can be expected from patient.cooperation that can be expected from patient. • Mental age:Mental age: ““index of maturation of mind”index of maturation of mind” increase at a rate that depends on manyincrease at a rate that depends on many intrinsicintrinsic and environmental factors.”and environmental factors.” www.indiandentalacademy.comwww.indiandentalacademy.com
  13. 13. A) IQ which is the mental age expressed as a percentage of theA) IQ which is the mental age expressed as a percentage of the chronological age.chronological age. thus a child with a mental age of 12 yrs and a chronologicalthus a child with a mental age of 12 yrs and a chronological age of 10 would have an IQ of 120.age of 10 would have an IQ of 120. B) Ability to draw a human figure is often used to assessB) Ability to draw a human figure is often used to assess development and the items the child includes can be scoreddevelopment and the items the child includes can be scored and rated in terms of mental age. This is good correlationand rated in terms of mental age. This is good correlation between assessments made between 5 and 11 years of age.between assessments made between 5 and 11 years of age. C) Use as the standard capacity of the child to read.C) Use as the standard capacity of the child to read. www.indiandentalacademy.comwww.indiandentalacademy.com
  14. 14. PHYSIOLOGICAL AND BIOCHEMICALPHYSIOLOGICAL AND BIOCHEMICAL AGEAGE A)A) Girls show a spurt in systolic blood pressure which occursGirls show a spurt in systolic blood pressure which occurs earlier than the corresponding spurt in the maleearlier than the corresponding spurt in the male Resting mouth temperature which falls by 0.5 to 1 *c fromResting mouth temperature which falls by 0.5 to 1 *c from infancy to maturity and reaches its adult value earlier ininfancy to maturity and reaches its adult value earlier in girls.girls. B)B) In the plasma, inorganic phosphate shows a steady fallIn the plasma, inorganic phosphate shows a steady fall from the high levels of childhood to reach adult by the agefrom the high levels of childhood to reach adult by the age 15 in girls and 17 in boys.15 in girls and 17 in boys. c)c) Alkaline phosphate rises significantly in parallel withAlkaline phosphate rises significantly in parallel with growth between the ages of 8-12 yrs in girls and 10-14yrsgrowth between the ages of 8-12 yrs in girls and 10-14yrs in boys.in boys. D)D) Ratio of creatinine in the urineRatio of creatinine in the urine fall progressively with age after abt 14.5 yrs probablyfall progressively with age after abt 14.5 yrs probably under hormonal influences.under hormonal influences. www.indiandentalacademy.comwww.indiandentalacademy.com
  15. 15. CHRONOLOGICAL AGECHRONOLOGICAL AGE • Poor indicator of maturityPoor indicator of maturity • Little identifying stages of development fromLittle identifying stages of development from adolescence to adulthood.adolescence to adulthood. • Help to categorize individual asHelp to categorize individual as • ““ early , average, late maturer.”early , average, late maturer.” • Enable an orthodontist toEnable an orthodontist to determine and predict thedetermine and predict the rate and magnitude of facial growthrate and magnitude of facial growth • Help to decide time, duration and method ofHelp to decide time, duration and method of treatment.treatment. www.indiandentalacademy.comwww.indiandentalacademy.com
  16. 16. Age Determination Using Growth chartsAge Determination Using Growth charts • Involves height, weight and chronological age of childInvolves height, weight and chronological age of child.. • Variation seen in boys and girlsVariation seen in boys and girls • Uses :Uses : Use to understand growth patterns in terms of deviationsUse to understand growth patterns in terms of deviations from the usual pattern to express variability quantitatively.from the usual pattern to express variability quantitatively.  can be done by compare the child with standardcan be done by compare the child with standard growth charts. And determine growth isgrowth charts. And determine growth is normal/abnormal and child is early/late maturer.normal/abnormal and child is early/late maturer.  growth charts can be followed from birth togrowth charts can be followed from birth to adulthood to determineadulthood to determine pattern, variability andpattern, variability and timing and predictability of growth.timing and predictability of growth. www.indiandentalacademy.comwww.indiandentalacademy.com
  17. 17. 3.3. Determine peak height velocity which is circum pubertalDetermine peak height velocity which is circum pubertal maximum.maximum. height and weight measurement are compare withheight and weight measurement are compare with pubertal and skeletal age for growth assessment.pubertal and skeletal age for growth assessment. www.indiandentalacademy.comwww.indiandentalacademy.com
  18. 18. Sexual/pubertal AgeSexual/pubertal Age • 2 yrs earlier in girls than boys.2 yrs earlier in girls than boys. • Begins later and extends over a longer periodBegins later and extends over a longer period of abt 5yrs in boys and 3.5yrs in girls.of abt 5yrs in boys and 3.5yrs in girls. • According toAccording to HAGG & TARANGERHAGG & TARANGER (1980)(1980) • Pubertal development was assessed fromPubertal development was assessed from menarche in girls and the voicemenarche in girls and the voice change in boys.change in boys. www.indiandentalacademy.comwww.indiandentalacademy.com
  19. 19. Sexual AgeSexual Age • IN Girls :IN Girls : • if menarche has occurred, peak height velocityif menarche has occurred, peak height velocity (PHV) has been attained and growth rate is(PHV) has been attained and growth rate is decelerating.decelerating. • In Boys,In Boys, 33 stages of voice changes were used:stages of voice changes were used: • PPV –PPV – prepubertal voiceprepubertal voice ; the pitch of the voice; the pitch of the voice had not changed noticeably.had not changed noticeably. • PV –PV – pubertal voicepubertal voice; the pitch of the voice had; the pitch of the voice had changed noticeably but the voice had not yetchanged noticeably but the voice had not yet acquired adult characteristics.acquired adult characteristics. • MV –MV – male voicemale voice; the pitch of the voice had; the pitch of the voice had acquired adult characteristics.acquired adult characteristics.www.indiandentalacademy.comwww.indiandentalacademy.com
  20. 20. Growth spurts - GraberGrowth spurts - Graber • Childhood growth spurt (3 yrs)Childhood growth spurt (3 yrs) • Juvenile growth spurtJuvenile growth spurt girls – 6 to 7 yrsgirls – 6 to 7 yrs boys – 7 to 9 yrsboys – 7 to 9 yrs • Pubertal growth spurtPubertal growth spurt girls – 10½ to 13 yrsgirls – 10½ to 13 yrs boys – 12½ to 16 yrsboys – 12½ to 16 yrs www.indiandentalacademy.comwww.indiandentalacademy.com
  21. 21. Pubertal growth spurt-girlsPubertal growth spurt-girls • Stage-I : beginning of growth spurtStage-I : beginning of growth spurt 10½ to 11½yrs10½ to 11½yrs • Stage-II : peak velocityStage-II : peak velocity lasts for 1 to 2yrslasts for 1 to 2yrs • Stage-III : menarcheStage-III : menarche deceleration and end of growthdeceleration and end of growth spurt.spurt. www.indiandentalacademy.comwww.indiandentalacademy.com
  22. 22. Pubertal growth spurt-boysPubertal growth spurt-boys • Stage-I : beginning of growth spurtStage-I : beginning of growth spurt lasts for 1 yr (fat spurt)lasts for 1 yr (fat spurt) • Stage-II : fat redistribution, pubic hairsStage-II : fat redistribution, pubic hairs lasts for 1 to 2yrslasts for 1 to 2yrs • Stage-III : peak velocityStage-III : peak velocity lasts for 1 to 2yrslasts for 1 to 2yrs • Stage-IV : height stagnatesStage-IV : height stagnates deceleration and end of growth spurt.deceleration and end of growth spurt. www.indiandentalacademy.comwww.indiandentalacademy.com
  23. 23. • Anatomic RegionAnatomic Region • Region should be small to restrictRegion should be small to restrict radiation exposure and expense.radiation exposure and expense. • Should have many ossificationShould have many ossification centers which ossify at separatecenters which ossify at separate times and which can be standardized.times and which can be standardized. • Region should be easily accessible.Region should be easily accessible. Skeletal Age www.indiandentalacademy.comwww.indiandentalacademy.com
  24. 24. Regions for Age AssessmentRegions for Age Assessment • Head and neck:Head and neck: SkullSkull Cervical vertebraeCervical vertebrae • Upper limb :Upper limb : Shoulder joint- ScapulaShoulder joint- Scapula ElbowElbow Hand wrist and fingerHand wrist and finger • Lower limb :Lower limb : Femur and humerusFemur and humerus Hip jointHip joint Knee jointKnee joint AnkleAnkle Foot tarsalsFoot tarsals MetatarsalsMetatarsals PhalangesPhalanges www.indiandentalacademy.comwww.indiandentalacademy.com
  25. 25. Skeletal maturity indicatorsSkeletal maturity indicators • Handwrist radiographsHandwrist radiographs • Cervical vertebraeCervical vertebrae • Mid-palatal sutureMid-palatal suture • Frontal sinusFrontal sinus • Mandibular canine calcificationMandibular canine calcification • Tooth mineralizationTooth mineralization • Symphysis as an predictor of direction of mandibularSymphysis as an predictor of direction of mandibular growthgrowth • Antegonial notch as an predictor of direction ofAntegonial notch as an predictor of direction of mandibular growthmandibular growth • Craniocervical posture as an predictor of craniofacialCraniocervical posture as an predictor of craniofacial growthgrowth • Björk’s structural signs of growth predictionBjörk’s structural signs of growth prediction • Mesh diagram for growth predictionMesh diagram for growth predictionwww.indiandentalacademy.comwww.indiandentalacademy.com
  26. 26. Hand and Wrist RadiographHand and Wrist Radiograph X ray discovery in 1895 by Roentgen. www.indiandentalacademy.comwww.indiandentalacademy.com
  27. 27. Review of literatureReview of literature • 11stst hand wrist film was published byhand wrist film was published by SydneySydney Rowland in EnglandRowland in England in april 1890 (4in april 1890 (4 months after discovery of x-rays).months after discovery of x-rays). • 1926 –1926 – CarterCarter reported a study of carpalreported a study of carpal bones of children.bones of children. • 1929 – 2 comprehensive growth studies by1929 – 2 comprehensive growth studies by Weingate Todd and Harold StuartWeingate Todd and Harold Stuart respectively.respectively. www.indiandentalacademy.comwww.indiandentalacademy.com
  28. 28. Review of literatureReview of literature • HunterHunter reported that carpal bones hadreported that carpal bones had proved to be the best site for determiningproved to be the best site for determining skeletal maturation.skeletal maturation. • Björk and HelmBjörk and Helm stated that appearance ofstated that appearance of ulnar sesamoid on hand wrist film wasulnar sesamoid on hand wrist film was related to the onset of maximum pubertalrelated to the onset of maximum pubertal growth in height.growth in height. • HelmHelm elaborated on other structures in theelaborated on other structures in the hand wrist film to pubertal growth spurt.hand wrist film to pubertal growth spurt. www.indiandentalacademy.comwww.indiandentalacademy.com
  29. 29. • HellmanHellman published his observations on the ossification ofpublished his observations on the ossification of epiphyseal cartilages of the hand in 1928epiphyseal cartilages of the hand in 1928 • Todd compiled hand-wrist data that was furtherTodd compiled hand-wrist data that was further elaborated on byelaborated on by Greulich and PyleGreulich and Pyle in atlas form 6 Floryin atlas form 6 Flory in 1936, indicated that the beginning of calcification ofin 1936, indicated that the beginning of calcification of the carpal sesamoid (adductor sesamoid) was a goodthe carpal sesamoid (adductor sesamoid) was a good guide to determining the period immediately beforeguide to determining the period immediately before pubertypuberty • FishmanFishman developed a system of hand-wrist skeletaldeveloped a system of hand-wrist skeletal maturation indicators (SMIs) using four stages of bonematuration indicators (SMIs) using four stages of bone maturation at six anatomic sitesmaturation at six anatomic sites • Hagg and TarangerHagg and Taranger created a method using the hand-created a method using the hand- wrist radiograph to correlate certain maturity indicators towrist radiograph to correlate certain maturity indicators to the pubertal growth spurt .the pubertal growth spurt . www.indiandentalacademy.comwww.indiandentalacademy.com
  30. 30. Indications of handwristIndications of handwrist radiographradiograph • Prior to rapid maxillary expansion.Prior to rapid maxillary expansion. • Marked discrepancy between dental or skeletalMarked discrepancy between dental or skeletal and chronological age.and chronological age. • Where maxillomandibular changes are indicatedWhere maxillomandibular changes are indicated e.g. skeletal class II or III or skeletal openbite.e.g. skeletal class II or III or skeletal openbite. • Orthognathic surgery if undertaken between theOrthognathic surgery if undertaken between the ages of 16-20 years.ages of 16-20 years. • To asses the skeletal growth in a patient whoseTo asses the skeletal growth in a patient whose growth is affected by infection, neoplastic orgrowth is affected by infection, neoplastic or traumatic conditions.traumatic conditions. • To predict future skeletal maturation rate andTo predict future skeletal maturation rate and status.status. • To predict pubertal growth spurt.To predict pubertal growth spurt.www.indiandentalacademy.comwww.indiandentalacademy.com
  31. 31. ANATOMYANATOMY www.indiandentalacademy.comwww.indiandentalacademy.com
  32. 32. PA view www.indiandentalacademy.comwww.indiandentalacademy.com
  33. 33. Oblique view www.indiandentalacademy.comwww.indiandentalacademy.com
  34. 34. Hand and Wrist RadiographHand and Wrist Radiograph • Made up of numerous small bones.Made up of numerous small bones. • These bones have predictable and scheduledThese bones have predictable and scheduled pattern of appearance and ossification andpattern of appearance and ossification and union from birth to maturity.union from birth to maturity. • One of the most suited region to study growthOne of the most suited region to study growth • Disadvantage:Disadvantage: • Away from the sight ( i.e. oral cavity)Away from the sight ( i.e. oral cavity) www.indiandentalacademy.comwww.indiandentalacademy.com
  35. 35. ANATOMYANATOMY • Made up of four groups of bones.Made up of four groups of bones. 1.1. Distal ends of long bones of forearmDistal ends of long bones of forearm 2.2. CarpalsCarpals 3.3. MetacarpalsMetacarpals 4.4. PhalangesPhalanges www.indiandentalacademy.comwww.indiandentalacademy.com
  36. 36. Distal ends of long bones of forearmDistal ends of long bones of forearm • Distal ends ofDistal ends of radius and ulnarradius and ulnar • Give rise to aGive rise to a distal projectiondistal projection on their respectiveon their respective sides. c/d Ulnasides. c/d Ulna styloid and radialstyloid and radial styloid.styloid. www.indiandentalacademy.comwww.indiandentalacademy.com
  37. 37. CarpalsCarpals • Eight small irregularly shapedEight small irregularly shaped bones arranged in two raws,bones arranged in two raws, proximal and distal rawproximal and distal raw • Proximal raw:Proximal raw: scaphoid, lunate, triquetralscaphoid, lunate, triquetral and pisiformand pisiform • Distal raw:Distal raw: trapezium, trapezoid,trapezium, trapezoid, capitate and hamatecapitate and hamate • All bones osssifies from oneAll bones osssifies from one primary center.primary center. www.indiandentalacademy.comwww.indiandentalacademy.com
  38. 38. MetacarpalsMetacarpals • Five miniature long bonesFive miniature long bones forming the skeletalforming the skeletal framwork of the palm offramwork of the palm of the hand from thumb tothe hand from thumb to little fingerlittle finger • Ossify from one primaryOssify from one primary center ( in shaft ) andcenter ( in shaft ) and secondary center on distalsecondary center on distal end (except for first)end (except for first) www.indiandentalacademy.comwww.indiandentalacademy.com
  39. 39. PhalangesPhalanges • Small bones forming theSmall bones forming the fingersfingers • Three in numbers in eachThree in numbers in each fingersfingers • In thumb only twoIn thumb only two phalangesphalanges • Ossify in 3 stagesOssify in 3 stages 1.1. epiphysis = diaphysisepiphysis = diaphysis 2.2. Epiphysis caps diaphysisEpiphysis caps diaphysis 3.3. Fusion b/w epiphysis andFusion b/w epiphysis and diaphysisdiaphysis www.indiandentalacademy.comwww.indiandentalacademy.com
  40. 40. Sesmoid boneSesmoid bone • Small nodular boneSmall nodular bone most often presentmost often present embedded inembedded in tendons in the regiontendons in the region of the thumb.of the thumb. www.indiandentalacademy.comwww.indiandentalacademy.com
  41. 41. MethodsMethods • Atlas Method by Greulich and PyleAtlas Method by Greulich and Pyle • Bjork, Grave and Brown MethodBjork, Grave and Brown Method • Fishman’s Skeletal Maturity indicatorsFishman’s Skeletal Maturity indicators • Hagg and Taranger MethodHagg and Taranger Method • Julian Singer’s methodJulian Singer’s method www.indiandentalacademy.comwww.indiandentalacademy.com
  42. 42. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod • Bjork, 1972Bjork, 1972,, divided the maturation processdivided the maturation process of hand bones into developmental stagesof hand bones into developmental stages.. • Brown, 1976Brown, 1976,, included six further ossificationincluded six further ossification centres in the hand radiograph.centres in the hand radiograph. • According to Grave and BrownAccording to Grave and Brown ,, growth stages of the fingers are assessedgrowth stages of the fingers are assessed according to the relationship between theaccording to the relationship between the epiphysis and diaphysisepiphysis and diaphysis.. • Appropriate chronological age for each of theAppropriate chronological age for each of the stages was givenstages was given by Schopf in 1978by Schopf in 1978 www.indiandentalacademy.comwww.indiandentalacademy.com
  43. 43. • There are three stages of ossification of theThere are three stages of ossification of the phalanges.phalanges. • First Stage:First Stage: • Epiphysis shows the same width as theEpiphysis shows the same width as the diaphysis (=)diaphysis (=) • Second Stage:Second Stage: • Capping stage (=cap); the epiphysis surroundsCapping stage (=cap); the epiphysis surrounds the diaphysis like a cap.the diaphysis like a cap. • Third Stage:Third Stage: • U-stage (=u); bony fusion of epiphysis andU-stage (=u); bony fusion of epiphysis and diaphysis.diaphysis. www.indiandentalacademy.comwww.indiandentalacademy.com
  44. 44. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod 9 stages:9 stages: Stage 1(males-10.6 yrs, femalesStage 1(males-10.6 yrs, females 8.1yrs):8.1yrs): • epiphysis and diaphysis ofepiphysis and diaphysis of proximal phalanx of indexproximal phalanx of index finger are equal.finger are equal. • 3 yrs before peak of pubertal3 yrs before peak of pubertal growth spurt.growth spurt. AJO 1976 pp2 www.indiandentalacademy.comwww.indiandentalacademy.com
  45. 45. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 2(males-12.0 yrs,Stage 2(males-12.0 yrs, females 8.1yrs):females 8.1yrs): • epiphysis and diaphysis ofepiphysis and diaphysis of middle phalanx of middlemiddle phalanx of middle finger are equal.finger are equal. MP3 www.indiandentalacademy.comwww.indiandentalacademy.com
  46. 46. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 3(males-12.6 yrs, females 9.6yrs):Stage 3(males-12.6 yrs, females 9.6yrs): 3 stages3 stages • Ossification of hamular process of hamate.Ossification of hamular process of hamate. • Ossification of pisiform.Ossification of pisiform. • Epiphysis and diaphysis of radius has sameEpiphysis and diaphysis of radius has same width.width. H PiSi R www.indiandentalacademy.comwww.indiandentalacademy.com
  47. 47. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 4(males-13.0yrs, femalesStage 4(males-13.0yrs, females 10.6yrs):10.6yrs): • Initial mineralization of ulnarInitial mineralization of ulnar sesamoid of thumb.sesamoid of thumb. • Increased ossification of theIncreased ossification of the hamular process of hamate.hamular process of hamate. • Shortly before or at theShortly before or at the beginning of the pubertalbeginning of the pubertal growth spurt.growth spurt. US H2 www.indiandentalacademy.comwww.indiandentalacademy.com
  48. 48. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 5(males-14 yrs, females 11yrs):Stage 5(males-14 yrs, females 11yrs): Capping of diaphysis is seen inCapping of diaphysis is seen in • Middle phalanx of 3Middle phalanx of 3rdrd finger.finger. • Proximal phalanx of thumb.Proximal phalanx of thumb. • Radius.Radius. marks themarks the peak of pubertal growthpeak of pubertal growth .. Cap-MP3 PP1 R www.indiandentalacademy.comwww.indiandentalacademy.com
  49. 49. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 6(males-15 yrs, femalesStage 6(males-15 yrs, females 13.3yrs):13.3yrs): • Visible union of diaphysis andVisible union of diaphysis and epiphysis at the distal phalanx ofepiphysis at the distal phalanx of the middle finger.the middle finger. • SignifiesSignifies end of pubertalend of pubertal growth spurt.growth spurt. DP3-U www.indiandentalacademy.comwww.indiandentalacademy.com
  50. 50. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 7(males-15.9 yrs, femalesStage 7(males-15.9 yrs, females 13.3 yrs):13.3 yrs): • Visible union of the epiphysisVisible union of the epiphysis and diaphysis at theand diaphysis at the proximalproximal phalanx of little finger.phalanx of little finger. PP5-U www.indiandentalacademy.comwww.indiandentalacademy.com
  51. 51. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 8(males-15.9 yrs, females 13.9yrs):Stage 8(males-15.9 yrs, females 13.9yrs): • Union of epiphysis and diaphysis atUnion of epiphysis and diaphysis at middle phalanx of middle finger.middle phalanx of middle finger. MP3-U www.indiandentalacademy.comwww.indiandentalacademy.com
  52. 52. Björk, Grave and Brown’sBjörk, Grave and Brown’s methodmethod Stage 9(males-18.5 yrs, femalesStage 9(males-18.5 yrs, females 16 yrs):16 yrs): • Complete union of epiphysis andComplete union of epiphysis and diaphysis of radius.diaphysis of radius. • Ossification of all bones isOssification of all bones is complete and skeletal growth iscomplete and skeletal growth is complete.complete. R-U www.indiandentalacademy.comwww.indiandentalacademy.com
  53. 53. Julian Singer methodJulian Singer method • In 1980In 1980, proposed a system of hand wrist, proposed a system of hand wrist radiograph assessment that would enableradiograph assessment that would enable the clinician to rapidly and with somethe clinician to rapidly and with some degree of reliabilitydegree of reliability help to determinehelp to determine the maturational status of thethe maturational status of the patientpatient • Six stagesSix stages of hand and wristof hand and wrist development are described.development are described. AO: 1980,oct-322-333 www.indiandentalacademy.comwww.indiandentalacademy.com
  54. 54. Julian Singer methodJulian Singer method Six stages are described:Six stages are described: • Stage 1 (early) :Stage 1 (early) : Pisiform is absent.Pisiform is absent. Hook of hamate absent.Hook of hamate absent. Epiphysis of proximal phalanx of 2Epiphysis of proximal phalanx of 2ndnd finger being narrow than diaphysis.finger being narrow than diaphysis. AO: 1980,oct-322-333 www.indiandentalacademy.comwww.indiandentalacademy.com
  55. 55. Julien Singer methodJulien Singer method • Stage 2 (prepubertal) :Stage 2 (prepubertal) : ( pisi, H , PP2 )( pisi, H , PP2 ) • Proximal phalanx of 2Proximal phalanx of 2ndnd finger is equal to itsfinger is equal to its epiphysis.epiphysis. • Initial ossification of hook of hamate.Initial ossification of hook of hamate. • Initial ossification of pisiform.Initial ossification of pisiform. • Stage prier to adolescent growth spurt duringStage prier to adolescent growth spurt during whichwhich significant amount of mandibular growth aresignificant amount of mandibular growth are possible.possible. • Maxillary orthodontic therapy in conjunction withMaxillary orthodontic therapy in conjunction with mandibular growth might aidmandibular growth might aid correction of a cl IIcorrection of a cl II relationship with considerable speed and ease.relationship with considerable speed and ease. www.indiandentalacademy.comwww.indiandentalacademy.com
  56. 56. Julian Singer methodJulian Singer method • Stage 3 (pubertal onset):Stage 3 (pubertal onset): (US and(US and stage2)stage2) • Calcification of ulnar sesamoid.Calcification of ulnar sesamoid. • Increased width of proximal phalanx ofIncreased width of proximal phalanx of 22ndnd finger.finger. • Increased calcification of hook ofIncreased calcification of hook of hamate.hamate. • Increased calcification of pisiform.Increased calcification of pisiform. www.indiandentalacademy.comwww.indiandentalacademy.com
  57. 57. Julian Singer methodJulian Singer method • Stage 4 (pubertal stage)Stage 4 (pubertal stage):: (US , C-mp3)(US , C-mp3) • Calcification of ulnar sesamoid.Calcification of ulnar sesamoid. • Capping of diaphysis of middle phalanxCapping of diaphysis of middle phalanx of 3of 3rdrd finger by its epiphysis.(MP3-C)finger by its epiphysis.(MP3-C) www.indiandentalacademy.comwww.indiandentalacademy.com
  58. 58. Julian Singer methodJulian Singer method • Stage 5 (pubertal deceleration):Stage 5 (pubertal deceleration): • Full calcification of ulnar sesamoid.Full calcification of ulnar sesamoid. • Fusion of epiphysis of distal phalanx of 3Fusion of epiphysis of distal phalanx of 3rdrd finger with its diaphysis. (DP3-F)finger with its diaphysis. (DP3-F) • Epiphysis of radius and ulnar not fusedEpiphysis of radius and ulnar not fused completely with diaphysis.completely with diaphysis. • Phalanges and carpals are fully calcified.Phalanges and carpals are fully calcified. • Period of growth when orthodonticPeriod of growth when orthodontic treatment might be completed and thetreatment might be completed and the patient is in retention therapy.patient is in retention therapy. www.indiandentalacademy.comwww.indiandentalacademy.com
  59. 59. Julien Singer methodJulien Singer method • Stage 6 (growth completion):Stage 6 (growth completion): No remaining growth site is seen.No remaining growth site is seen. www.indiandentalacademy.comwww.indiandentalacademy.com
  60. 60. Fishman’s skeletal maturityFishman’s skeletal maturity indicatorindicator • In 1982In 1982 –– Leonard FishmanLeonard Fishman gavegave system of skeletal maturationsystem of skeletal maturation assessment (SMA).assessment (SMA). • 11 skeletal maturity indicators (SMI’s)11 skeletal maturity indicators (SMI’s) were described.were described. Angle Orthodontia:No. 3: 1987Angle Orthodontia:No. 3: 1987 www.indiandentalacademy.comwww.indiandentalacademy.com
  61. 61. 11 SMI were divided into 411 SMI were divided into 4 stagesstages • Epiphysis as wide as diaphysis.Epiphysis as wide as diaphysis. • Ossification of ulnar sesamoid of thumb.Ossification of ulnar sesamoid of thumb. • Capping of epiphysis.Capping of epiphysis. • Fusion of epiphysis and diaphysis.Fusion of epiphysis and diaphysis. www.indiandentalacademy.comwww.indiandentalacademy.com
  62. 62. pp3 mp3 mp5 Us C-dp3 C-mp3 C-mp5 F-dp3 F-pp3 F-mp3 R www.indiandentalacademy.comwww.indiandentalacademy.com
  63. 63. Epiphysis as wide asEpiphysis as wide as diaphysisdiaphysis 1.1. Third finger-proximal phalanxThird finger-proximal phalanx 2.2. Third finger-middle phalanxThird finger-middle phalanx 3.3. Fifth finger-middle phalanxFifth finger-middle phalanx www.indiandentalacademy.comwww.indiandentalacademy.com
  64. 64. OssificationOssification 4. Adductor sesamoid of thumb.4. Adductor sesamoid of thumb. www.indiandentalacademy.comwww.indiandentalacademy.com
  65. 65. Capping of epiphysisCapping of epiphysis 5. Third finger – distal phalanx.5. Third finger – distal phalanx. 6. Third finger – middle phalanx.6. Third finger – middle phalanx. 7. Fifth finger – middle phalanx.7. Fifth finger – middle phalanx. www.indiandentalacademy.comwww.indiandentalacademy.com
  66. 66. Fusion of epiphysis andFusion of epiphysis and diaphysisdiaphysis 8. Third finger – distal phalanx.8. Third finger – distal phalanx. 9. Third finger – proximal phalanx.9. Third finger – proximal phalanx. 10. Third finger – middle phalanx.10. Third finger – middle phalanx. 11. Radius.11. Radius. www.indiandentalacademy.comwww.indiandentalacademy.com
  67. 67. • Accelerating growth velocity period (1–4)Accelerating growth velocity period (1–4) • High growth velocity period (4–7)High growth velocity period (4–7) • Decelerating velocity period (7–11)Decelerating velocity period (7–11) www.indiandentalacademy.comwww.indiandentalacademy.com
  68. 68. ConclusionConclusion • SMI occurs at earlier chronological agesSMI occurs at earlier chronological ages for girls.for girls. • SMI make it possible to judge an individualSMI make it possible to judge an individual relative timing of maturation – whether it isrelative timing of maturation – whether it is early, average or late.early, average or late. • Comparison of boys and girls onComparison of boys and girls on maturational time scale shows no sexualmaturational time scale shows no sexual differences in the percentages ofdifferences in the percentages of completion of incremental growth at samecompletion of incremental growth at same SMI levels, regardless of chronologicalSMI levels, regardless of chronological age.age. www.indiandentalacademy.comwww.indiandentalacademy.com
  69. 69. ConclusionConclusion • Early maturer of both sexes exhibitedEarly maturer of both sexes exhibited almostalmost identical SMI duration values foridentical SMI duration values for SMI’s 1-5 & 7-11SMI’s 1-5 & 7-11. The only significant. The only significant difference in SMI duration for early groupdifference in SMI duration for early group is between SMI 5 & 6. Girls in generalis between SMI 5 & 6. Girls in general reach the point of peak velocity of growthreach the point of peak velocity of growth at SMI 5, and boys at SMI 6.at SMI 5, and boys at SMI 6. www.indiandentalacademy.comwww.indiandentalacademy.com
  70. 70. ConclusionConclusion • In late maturation groups, considerablyIn late maturation groups, considerably less correlation is foundless correlation is found between malebetween male and female groups, although duration ofand female groups, although duration of time between SMI’s 1-2 and 10-11, attime between SMI’s 1-2 and 10-11, at beginning and end of adolescent period,beginning and end of adolescent period, are very similar.are very similar. www.indiandentalacademy.comwww.indiandentalacademy.com
  71. 71. • In regard to the comparisons of lateIn regard to the comparisons of late periods with early periods, the female lateperiods with early periods, the female late group exhibits significantly longer timegroup exhibits significantly longer time between SMI periods 4–5, 6–9, and 10–between SMI periods 4–5, 6–9, and 10– 11. The male late group exhibited longer11. The male late group exhibited longer time periods between SMI 2–4, 9–10, andtime periods between SMI 2–4, 9–10, and 10–11.10–11. www.indiandentalacademy.comwww.indiandentalacademy.com
  72. 72. Levels of maturation - FEMALELevels of maturation - FEMALE Maturation stages : A: early, B and C :Average , D: latewww.indiandentalacademy.comwww.indiandentalacademy.com
  73. 73. Levels of maturation - MALELevels of maturation - MALE Mean value for total sample Maturation stages : A: early, B and C :Average , D: latewww.indiandentalacademy.comwww.indiandentalacademy.com
  74. 74. For both sexes, the earlyFor both sexes, the early (level A)(level A) curves remainedcurves remained within their boundaries or close to the border of level Bwithin their boundaries or close to the border of level B untiluntil SMI stage 8, at which time the A curve enteredSMI stage 8, at which time the A curve entered well within the B rangewell within the B range (within one SD of average),(within one SD of average), approaching the mean values for their respective totalapproaching the mean values for their respective total samples.samples. • Those with late maturation (Those with late maturation (level Dlevel D) also exhibited) also exhibited similarities between the male and female sample, insimilarities between the male and female sample, in that the curvesthat the curves did not regress toward the total sampledid not regress toward the total sample mean values until SMI 10mean values until SMI 10,, late in the adolescent periodlate in the adolescent period for both sexes.for both sexes. • Those with near-average maturation (Those with near-average maturation (B and CB and C)) maintained a consistency in their maturationalmaintained a consistency in their maturational progress, not departing outside their respectiveprogress, not departing outside their respective boundaries.boundaries. Toward the end of the maturation periodToward the end of the maturation period these two curves regressed even closer to the meanthese two curves regressed even closer to the mean values.values. www.indiandentalacademy.comwww.indiandentalacademy.com
  75. 75. Maturation indications andMaturation indications and pubertal growth spurtpubertal growth spurt • Urban Hägg and John TarangerUrban Hägg and John Taranger did a study in 1982 to investigatedid a study in 1982 to investigate pubertal growth spurt and dental,pubertal growth spurt and dental, skeletal and pubertal development.skeletal and pubertal development. • Sample:212Sample:212 • Examination: birth to adulthoodExamination: birth to adulthood • Once a yearOnce a year Am J Orthod: 82: oct 1982Am J Orthod: 82: oct 1982 www.indiandentalacademy.comwww.indiandentalacademy.com
  76. 76. Method of analysisMethod of analysis • Adolescent growth:Adolescent growth: was studied by graphic analysis of thewas studied by graphic analysis of the unsmoothed incremental curves ofunsmoothed incremental curves of standing height.standing height. These curves were based on theThese curves were based on the annual increments from 3 to 20 years.annual increments from 3 to 20 years. www.indiandentalacademy.comwww.indiandentalacademy.com
  77. 77. Method of analysisMethod of analysis • Dental development was assessed by dental emergence stagesDental development was assessed by dental emergence stages (DES). (devised by Bjork and asso.)(DES). (devised by Bjork and asso.) • Emergence stages:Emergence stages: • TTeeth anterior to molareeth anterior to molar Des 1: 1to 7 incisorsDes 1: 1to 7 incisors Des 2: all incisorsDes 2: all incisors Des 3: 1 to 11 canine &/or premolarDes 3: 1 to 11 canine &/or premolar des 4: all canine and premolarsdes 4: all canine and premolars • Molar teethMolar teeth Des m1: 1 to 3 1Des m1: 1 to 3 1stst molarsmolars Des m2: all 1Des m2: all 1stst molarsmolars Des m3:1-3 2Des m3:1-3 2ndnd molarsmolars Des m4: all 2Des m4: all 2ndnd molarsmolars Des m5: 1-3 3Des m5: 1-3 3rdrd molarsmolars Des m6: all 3Des m6: all 3rdrd molarsmolars www.indiandentalacademy.comwww.indiandentalacademy.com
  78. 78. Skeletal developmentSkeletal development • In the hand and wrist was analyzed from annualIn the hand and wrist was analyzed from annual radiographs, taken between the ages ofradiographs, taken between the ages of 6 and 186 and 18 yearsyears,, Assessment of,Assessment of, • ossification of the ulnar sesamoidossification of the ulnar sesamoid of theof the metacarpophalangeal joint of the first finger (S)metacarpophalangeal joint of the first finger (S) • certaincertain specified stages of three epiphysealspecified stages of three epiphyseal bonesbones (closure of epiphyseal plates):(closure of epiphyseal plates): 1) middle and distal phalanges of the third finger1) middle and distal phalanges of the third finger (MP3 and DP3)(MP3 and DP3) 2) distal epiphysis of the radius (R).2) distal epiphysis of the radius (R). www.indiandentalacademy.comwww.indiandentalacademy.com
  79. 79. Method of analysisMethod of analysis • Pubertal development was assessedPubertal development was assessed from 10 to 18 years by determining thefrom 10 to 18 years by determining the occurrence ofoccurrence of menarche in girlsmenarche in girls and the voice change in boys.and the voice change in boys. www.indiandentalacademy.comwww.indiandentalacademy.com
  80. 80. 3 stages of voice changes were used:3 stages of voice changes were used: • PPV – prepubertal voice; the pitch of thePPV – prepubertal voice; the pitch of the voice had not changed noticeably.voice had not changed noticeably. • PV – pubertal voice; the pitch of the voicePV – pubertal voice; the pitch of the voice had changed noticeably but the voicehad changed noticeably but the voice had not yet acquired adulthad not yet acquired adult characteristics.characteristics. • MV – male voice; the pitch of the voiceMV – male voice; the pitch of the voice had acquired adult characteristics.had acquired adult characteristics. www.indiandentalacademy.comwww.indiandentalacademy.com
  81. 81. Pubertal growth spurtPubertal growth spurt The individual unsmoothed incremental curves of height were based on annualThe individual unsmoothed incremental curves of height were based on annual increments calculated between specified target ages. It should be pointed out thatincrements calculated between specified target ages. It should be pointed out that height was recorded in millimeters, usually in the morning, by a trained examinerheight was recorded in millimeters, usually in the morning, by a trained examiner using the stretching-up techniqueusing the stretching-up technique www.indiandentalacademy.comwww.indiandentalacademy.com
  82. 82. ResultsResults • The pubertal growth spurt –The pubertal growth spurt – ONSET is found by locating the smallest annual incrementONSET is found by locating the smallest annual increment (A) from which there is continuous increase in growth rate to(A) from which there is continuous increase in growth rate to PHV.PHV. • Onset :Onset : 10yr in girls10yr in girls 12.1yr in boys12.1yr in boys PHV :PHV : 12 yr in girls12 yr in girls 14.1 yr in boys ( 2 yr after ONSET)14.1 yr in boys ( 2 yr after ONSET) End :End : 14.8 yr in girls14.8 yr in girls 17.1 yr in boys17.1 yr in boys www.indiandentalacademy.comwww.indiandentalacademy.com
  83. 83. ResultsResults • Dental development and pubertalDental development and pubertal growth spurt - The dental developmentgrowth spurt - The dental development was more advanced in boys than inwas more advanced in boys than in girls at all three pubertal growthgirls at all three pubertal growth events.events. • The dental emergence stages were notThe dental emergence stages were not useful as indicators of the pubertaluseful as indicators of the pubertal growth spurt.growth spurt. www.indiandentalacademy.comwww.indiandentalacademy.com
  84. 84. ResultsResults • Skeletal development and the pubertalSkeletal development and the pubertal growth spurt –growth spurt – • Skeletal development at ONSET andSkeletal development at ONSET and PHV was more advanced in girls than inPHV was more advanced in girls than in boys, whereas at END the skeletalboys, whereas at END the skeletal development was more advanced indevelopment was more advanced in boys.boys. www.indiandentalacademy.comwww.indiandentalacademy.com
  85. 85. The skeletal stages were useful asThe skeletal stages were useful as indicators of the pubertal growth spurt.indicators of the pubertal growth spurt. Skeletal stages:Skeletal stages: • Sesamoid – it appeared during theSesamoid – it appeared during the acceleration period of pubertal growthacceleration period of pubertal growth spurt (ONSET of PHV).spurt (ONSET of PHV). www.indiandentalacademy.comwww.indiandentalacademy.com
  86. 86. • Middle third phalanx:Middle third phalanx: • MP3-FMP3-F - was attained before- was attained before ONSET by about 40 percent of theONSET by about 40 percent of the subjects and at PHV by the others.subjects and at PHV by the others. TheThe epiphysis is as wide asepiphysis is as wide as metaphysis.metaphysis. • MP3-FGMP3-FG – epiphysis is as wide as– epiphysis is as wide as metaphysis and there is distinctmetaphysis and there is distinct medial and/or lateral border of themedial and/or lateral border of the epiphysis forming a line ofepiphysis forming a line of demarcation at right angle to distaldemarcation at right angle to distal border. This stage is attained by 1yrborder. This stage is attained by 1yr before or at PHV.before or at PHV. www.indiandentalacademy.comwww.indiandentalacademy.com
  87. 87. • MP3-GMP3-G – the sides of the epiphysis– the sides of the epiphysis have thickened and also caps itshave thickened and also caps its metaphysis forming a sharp edgemetaphysis forming a sharp edge distally at one or both sides. Thisdistally at one or both sides. This stage isstage is attained at or 1 yr after PHV.attained at or 1 yr after PHV. • MP3-HMP3-H – fusion of epiphysis and– fusion of epiphysis and metaphysis has begun. It is attainedmetaphysis has begun. It is attained after PHV but before the END.after PHV but before the END. • MP3-IMP3-I - fusion of epiphysis and- fusion of epiphysis and metaphysis is complete. It wasmetaphysis is complete. It was attained before or at END in allattained before or at END in all subjects.subjects. www.indiandentalacademy.comwww.indiandentalacademy.com
  88. 88. Distal third phalanx:Distal third phalanx: • DP3-IDP3-I – it is attained during the– it is attained during the deceleration period of the pubertaldeceleration period of the pubertal growth spurt. The fusion of epiphysis andgrowth spurt. The fusion of epiphysis and metaphysis is complete.metaphysis is complete. www.indiandentalacademy.comwww.indiandentalacademy.com
  89. 89. Radius:Radius: R-IR-I – it is– it is attained 1 yr before or at theattained 1 yr before or at the ENDEND. Fusion of the epiphysis. Fusion of the epiphysis andand metaphysis has begun.metaphysis has begun. R-IJR-IJ- Fusion almost complete.- Fusion almost complete. R-JR-J - Fusion of the epiphysis and- Fusion of the epiphysis and metaphysis is complete.metaphysis is complete. www.indiandentalacademy.comwww.indiandentalacademy.com
  90. 90. Pubertal development andPubertal development and pubertal growth spurtpubertal growth spurt • Pubertal development (menarche andPubertal development (menarche and voice change) and pubertal growth eventsvoice change) and pubertal growth events has a close relationship in both sexes.has a close relationship in both sexes. • Menarche occurred 1.1yr after peak heightMenarche occurred 1.1yr after peak height velocity.velocity. • The pubertal voice was attained 0.2 yrsThe pubertal voice was attained 0.2 yrs before PHV .before PHV . • male voice 0.9yrs after PHV.male voice 0.9yrs after PHV. www.indiandentalacademy.comwww.indiandentalacademy.com
  91. 91. DiscussionDiscussion • Reliable indications taken from skeletalReliable indications taken from skeletal development were found for PHV and END butdevelopment were found for PHV and END but not for beginning (ONSET) of pubertal growthnot for beginning (ONSET) of pubertal growth spurt.spurt. • During theDuring the endend of the prepubertal period theof the prepubertal period the radiographic changes in the form of bones ofradiographic changes in the form of bones of hand wrist are smallhand wrist are small. Therefore there is a lack of. Therefore there is a lack of indications during this period.indications during this period. www.indiandentalacademy.comwww.indiandentalacademy.com
  92. 92. According to Björk,According to Björk, pubertal growth spurt ends with the completepubertal growth spurt ends with the complete fusion of the third distal phalanx (DP3-I).fusion of the third distal phalanx (DP3-I). Schouboe reported,Schouboe reported, DP3-I in some girls coincided with PHV, whichDP3-I in some girls coincided with PHV, which was also found in this study.was also found in this study. In girls DP3-I is therefore not anIn girls DP3-I is therefore not an absolute indicator that PHV has beenabsolute indicator that PHV has been passed.passed. www.indiandentalacademy.comwww.indiandentalacademy.com
  93. 93. conclusionconclusion • There was a 2-year sex difference in age at the beginning, peak,There was a 2-year sex difference in age at the beginning, peak, and end of the pubertal growth spurt. The individual variationand end of the pubertal growth spurt. The individual variation was about 6 years at each growth event in both sexes.was about 6 years at each growth event in both sexes. • Dental development, assessed by means of dental emergenceDental development, assessed by means of dental emergence stages, was not useful as an indicator of the pubertal growthstages, was not useful as an indicator of the pubertal growth spurt.spurt. • Dental development in relation to the pubertal growth spurt wasDental development in relation to the pubertal growth spurt was more advanced in boys than in girls, but the individual variationmore advanced in boys than in girls, but the individual variation was great in both sexes.was great in both sexes. • The peak and end, but not the beginning, of the pubertal growthThe peak and end, but not the beginning, of the pubertal growth spurt could be determined by means of indicators taken fromspurt could be determined by means of indicators taken from the skeletal development of the hand and wrist and the pubertalthe skeletal development of the hand and wrist and the pubertal development (menarche and voice change), which are suitabledevelopment (menarche and voice change), which are suitable for use in clinical orthodontics.for use in clinical orthodontics.www.indiandentalacademy.comwww.indiandentalacademy.com
  94. 94. THANK YOUTHANK YOU www.indiandentalacademy.comwww.indiandentalacademy.com
  95. 95. • SEM -2SEM -2 • Includes,Includes, 1.1. Cervical VertebraeCervical Vertebrae 2.2. Frontal sinus developmentFrontal sinus development 3.3. Maxillary mid palatal sutureMaxillary mid palatal suture approximationapproximation 4.4. Canine calcification stagesCanine calcification stages www.indiandentalacademy.comwww.indiandentalacademy.com
  96. 96. CERVICAL VERTEBRAECERVICAL VERTEBRAE – The first seven vertebrae in the spinal column constitute the cervical spine. – The first two, the atlas and the axis, are quite unique, the third through the seventh have great similarity. – Maturational changes can be observed from birth to full maturity. www.indiandentalacademy.comwww.indiandentalacademy.com
  97. 97. CERVICALCERVICAL VERTEBRAEVERTEBRAE • Vertrebral growth takes place from the cartilagenous layer on theVertrebral growth takes place from the cartilagenous layer on the superior and inferior surfaces of the vertrebra.superior and inferior surfaces of the vertrebra. • Secondary ossification on the tips of bifid spinousSecondary ossification on the tips of bifid spinous processes and transverse processes appear duringprocesses and transverse processes appear during pubertypuberty .. • After completion of endochondral ossification, growth of vertrebralAfter completion of endochondral ossification, growth of vertrebral body takes place by periosteal apposition.body takes place by periosteal apposition. • Todd and Pyle, Lanier, and Taylor made measurements fromTodd and Pyle, Lanier, and Taylor made measurements from lateral radiographs of the lower cervical vertrebralateral radiographs of the lower cervical vertrebra.. • Lamparski studied changes in size and shape ofLamparski studied changes in size and shape of cervical vertrebra to create maturational standards forcervical vertrebra to create maturational standards for the cervical vertrebrathe cervical vertrebrawww.indiandentalacademy.comwww.indiandentalacademy.com
  98. 98. • 1972 – Lamparski1972 – Lamparski was the 1was the 1stst person to study cervical vertebrae andperson to study cervical vertebrae and he found them to be as reliable as handhe found them to be as reliable as hand wrist film.wrist film. • He found that cervical vertebraeHe found that cervical vertebrae indicators were same for males andindicators were same for males and females, but the females developed thefemales, but the females developed the changes earlier.changes earlier. www.indiandentalacademy.comwww.indiandentalacademy.com
  99. 99. • 1n 1995 – Hassel and Farman modified1n 1995 – Hassel and Farman modified the Lamparski criteria by using C2, C3,the Lamparski criteria by using C2, C3, and C4 cervical vertebrae.and C4 cervical vertebrae. www.indiandentalacademy.comwww.indiandentalacademy.com
  100. 100. Lamparski methodLamparski method • Stage 1 –Stage 1 – The inferior bordersThe inferior borders of the bodies of allof the bodies of all cervical vertebrae are flat.cervical vertebrae are flat. The superior bordersThe superior borders are tapered fromare tapered from posterior to anterior.posterior to anterior. • Stage 2 – a concavity develops in theStage 2 – a concavity develops in the inferior border of the second cervicalinferior border of the second cervical vertebrae. The anterior vertical height ofvertebrae. The anterior vertical height of body is increase.body is increase. www.indiandentalacademy.comwww.indiandentalacademy.com
  101. 101. Lamparski methodLamparski method • Stage 3 – a concavity develops in theStage 3 – a concavity develops in the inferior border of the 3inferior border of the 3rdrd vertebrae.vertebrae. • Stage 4 – a concavity develops in inferiorStage 4 – a concavity develops in inferior border of 4border of 4thth vertebrae. Concavities invertebrae. Concavities in lower border of 5lower border of 5thth and 6and 6thth vertebrae arevertebrae are beginning to form. The bodies of allbeginning to form. The bodies of all cervical vertebrae arecervical vertebrae are rectangular inrectangular in shapeshape.. www.indiandentalacademy.comwww.indiandentalacademy.com
  102. 102. Lamparski methodLamparski method • Stage 5 – concavities are well defined inStage 5 – concavities are well defined in the lower border of the bodies of all 6the lower border of the bodies of all 6 cervical vertebrae. The bodies are nearlycervical vertebrae. The bodies are nearly square in shape.square in shape. • Stage 6 – all concavities have deepened.Stage 6 – all concavities have deepened. The vertebral bodies are now higher thanThe vertebral bodies are now higher than they are wide.they are wide. www.indiandentalacademy.comwww.indiandentalacademy.com
  103. 103. Brent Hassel, Allan FarmanBrent Hassel, Allan Farman • Objective of the studyObjective of the study • ““ create a method ofcreate a method of evaluating biologicalevaluating biological skeletal maturationskeletal maturation of orthodontic patient withof orthodontic patient with cephalogram.”cephalogram.” • Correlation made between vertebrae maturation andCorrelation made between vertebrae maturation and skeletal maturation of hand and wrist radiographskeletal maturation of hand and wrist radiograph • Skeletal maturation :Skeletal maturation : ““degree of development of ossification indegree of development of ossification in bone”.bone”. • AJODO: Jan 1995AJODO: Jan 1995www.indiandentalacademy.comwww.indiandentalacademy.com
  104. 104. Material and methodMaterial and method • Sample of 10 group of 10 male and 10 femaleSample of 10 group of 10 male and 10 female (220 subject)(220 subject) from 8 to 18 yrsfrom 8 to 18 yrs www.indiandentalacademy.comwww.indiandentalacademy.com
  105. 105. RadiographRadiograph 1.1. hand and wristhand and wrist 2.2. lateral cephalogramlateral cephalogram www.indiandentalacademy.comwww.indiandentalacademy.com
  106. 106. Cervical vertebrae maturationCervical vertebrae maturation indicators using C3 as guide.indicators using C3 as guide. www.indiandentalacademy.comwww.indiandentalacademy.com
  107. 107. Six distinct stages of CVM can beSix distinct stages of CVM can be related to the SMI developed byrelated to the SMI developed by FishmanFishman 1.1. Initiation (SMI 1 and 2)Initiation (SMI 1 and 2) 2.2. Acceleration (SMI 3 and 4)Acceleration (SMI 3 and 4) 3.3. Transition (SMI 5 and 6)Transition (SMI 5 and 6) 4.4. Deceleration (SMI 7 and 8)Deceleration (SMI 7 and 8) 5.5. Maturation (SMI 9 and 10)Maturation (SMI 9 and 10) 6.6. Completion (SMI 11).Completion (SMI 11). www.indiandentalacademy.comwww.indiandentalacademy.com
  108. 108. • Category 1 (Category 1 (InitiationInitiation) –) – • At this stage adolescent growth was justAt this stage adolescent growth was just beginning and 80% to 100% of the growth wasbeginning and 80% to 100% of the growth was expected.expected. • Inferior borders of C2, C3 and C4 were flat atInferior borders of C2, C3 and C4 were flat at this stage.this stage. • Vertebrae are wedge shaped,Vertebrae are wedge shaped, • Superior vertebral border were tapered fromSuperior vertebral border were tapered from posterior to anterior.posterior to anterior. Six stages in vertebralSix stages in vertebral developmentdevelopment www.indiandentalacademy.comwww.indiandentalacademy.com
  109. 109. CVMI 1CVMI 1 www.indiandentalacademy.comwww.indiandentalacademy.com
  110. 110. • Category 2 (Category 2 (AccelerationAcceleration) –) – • growth acceleration was beginning at thisgrowth acceleration was beginning at this stage with 65% to 85% of adolescent growthstage with 65% to 85% of adolescent growth expected.expected. • Concavities were developing in the inferiorConcavities were developing in the inferior border of C2, C3.border of C2, C3. • The inferior border of C4 was flat.The inferior border of C4 was flat. • The bodies of C3 and C4 were nearlyThe bodies of C3 and C4 were nearlywww.indiandentalacademy.comwww.indiandentalacademy.com
  111. 111. CVMI 2CVMI 2 www.indiandentalacademy.comwww.indiandentalacademy.com
  112. 112. • Category 3 (Category 3 (TransitionTransition) –) – • Adolescent growth was still accelerating at thisAdolescent growth was still accelerating at this stage towards peak height velocitystage towards peak height velocity with 25% towith 25% to 65% of adolescent growth expected.65% of adolescent growth expected. • Distinct concavities were seen in theDistinct concavities were seen in the inferior borders of C2 and C3inferior borders of C2 and C3 .. • Concavity was beginning to develop in theConcavity was beginning to develop in the inferior border of C4.inferior border of C4. • The bodies of C3 and C4 were rectangular inThe bodies of C3 and C4 were rectangular in shape.shape. www.indiandentalacademy.comwww.indiandentalacademy.com
  113. 113. CVMI 3CVMI 3 www.indiandentalacademy.comwww.indiandentalacademy.com
  114. 114. • Category 4 (Category 4 (DecelerationDeceleration) –) – • adolescent growth began to decelerateadolescent growth began to decelerate dramatically at this stage with 10% todramatically at this stage with 10% to 25% of adolescent growth expected.25% of adolescent growth expected. • Distinct concavities were seen in theDistinct concavities were seen in the inferior borders of C2, C3 andC4.inferior borders of C2, C3 andC4. • The vertebral bodies of C3 and C4 wereThe vertebral bodies of C3 and C4 were becoming morebecoming more square in shapesquare in shape.. www.indiandentalacademy.comwww.indiandentalacademy.com
  115. 115. CVMI 4CVMI 4 C3,c4 (square) www.indiandentalacademy.comwww.indiandentalacademy.com
  116. 116. • Category 5 (Category 5 (MaturationMaturation) –) – • Final maturation of the vertebrae tookFinal maturation of the vertebrae took place during this stage, with 5% to 10%place during this stage, with 5% to 10% of adolescent growth expected.of adolescent growth expected. • More accentuated concavities werewere seen in the inferior borders of C2, C3seen in the inferior borders of C2, C3 and C4.and C4. • The bodies of C3 and C4 were nearlyThe bodies of C3 and C4 were nearly square to square in shape.square to square in shape. www.indiandentalacademy.comwww.indiandentalacademy.com
  117. 117. CVMI 5CVMI 5 www.indiandentalacademy.comwww.indiandentalacademy.com
  118. 118. • Category 6 (Category 6 (CompletionCompletion) –) – • growth was considered to be completegrowth was considered to be complete at this stage.at this stage. • Deep concavities were seen in theDeep concavities were seen in the inferior borders of C2, C3 and C4.inferior borders of C2, C3 and C4. • The bodies of C3 and C4 were squareThe bodies of C3 and C4 were square or wereor were greater in vertical dimensiongreater in vertical dimension than in horizontal dimension.than in horizontal dimension.www.indiandentalacademy.comwww.indiandentalacademy.com
  119. 119. CVMI 6CVMI 6 Square c3 and c4 vertebrae www.indiandentalacademy.comwww.indiandentalacademy.com
  120. 120. • 1998 - PATRICIA1998 - PATRICIA GARCÍA-GARCÍA- FERNANDEZ,FERNANDEZ, • HILDA TORRE,HILDA TORRE, • LUIS FLORES,LUIS FLORES, • JESUS REAJESUS REA.. • To determine whether the maturationTo determine whether the maturation of cervical vertebrae would correlateof cervical vertebrae would correlate with the maturation indicated by hand-with the maturation indicated by hand- wrist x-rays in a Mexican population.wrist x-rays in a Mexican population. JCO:35:4:1998JCO:35:4:1998 www.indiandentalacademy.comwww.indiandentalacademy.com
  121. 121. Six distinct stages of growth canSix distinct stages of growth can be related to the SMI developedbe related to the SMI developed by Fishmanby Fishman 1.1. Initiation (SMI 1 and 2)Initiation (SMI 1 and 2) 2.2. Acceleration (SMI 3 and 4)Acceleration (SMI 3 and 4) 3.3. Transition (SMI 5 and 6)Transition (SMI 5 and 6) 4.4. Deceleration (SMI 7 and 8)Deceleration (SMI 7 and 8) 5.5. Maturation (SMI 9 and 10)Maturation (SMI 9 and 10) 6.6. Completion (SMI 11).Completion (SMI 11). www.indiandentalacademy.comwww.indiandentalacademy.com
  122. 122. • PalomaPaloma San RomanSan Roman, Juan Carlos, Juan Carlos Palma, M DoloresPalma, M Dolores OteoOteo andand EstherEsther NevadoNevado:: • AIM :AIM : • study to determine morphologicalstudy to determine morphological changes seen in cervical vertebrae arechanges seen in cervical vertebrae are as useful to determine growth stagesas useful to determine growth stages as maturation stages assessed onas maturation stages assessed on hand and wrist radiograph.hand and wrist radiograph. EJO (24) June2002EJO (24) June2002 www.indiandentalacademy.comwww.indiandentalacademy.com
  123. 123. • Study consisting ofStudy consisting of 958 caucasian958 caucasian subjectssubjects who attended orthodonticwho attended orthodontic department betweendepartment between 1980 and 1996.1980 and 1996. • 3 parameters to Assess Skeletal3 parameters to Assess Skeletal MaturationMaturation.. • Anatomical changes observed in,Anatomical changes observed in, 1.1. concavity of lower borderconcavity of lower border 2.2. heightheight 3.3. shape of vertebral bodiesshape of vertebral bodies www.indiandentalacademy.comwww.indiandentalacademy.com
  124. 124. Concavity of lower border –Concavity of lower border – 6 stages6 stages 1.1. All vertebrae have flat lower border.All vertebrae have flat lower border. 2.2. Concavity – C2 lower border.Concavity – C2 lower border. 3.3. Concavity – C3 lower border.Concavity – C3 lower border. 4.4. C2 and C3 concavity increases andC2 and C3 concavity increases and concavity present in C4, C5 and C6.concavity present in C4, C5 and C6. 5.5. Concavity increases in all vertebrae.Concavity increases in all vertebrae. 6.6. Deep concavity in all vertebrae andDeep concavity in all vertebrae and inferior angles are rounded.inferior angles are rounded. www.indiandentalacademy.comwww.indiandentalacademy.com
  125. 125. Vertebral body heightVertebral body height Calculated at middle of C3Calculated at middle of C3 and C4 body. Width alsoand C4 body. Width also calculated at the middle.calculated at the middle. 4 stages-4 stages- • Height < 80% width.Height < 80% width. • Height between 80% andHeight between 80% and 99% of width.99% of width. • Height = width.Height = width. • Height > width.Height > width. www.indiandentalacademy.comwww.indiandentalacademy.com
  126. 126. Shape of vertebral bodiesShape of vertebral bodies Calculated at C3 and C4.Calculated at C3 and C4. 6 stages-6 stages- 1.1. Upper border tapered from posterior to anteriorUpper border tapered from posterior to anterior ((wedge shapedwedge shaped).). 2.2. Wedge shaped C3, nearlyWedge shaped C3, nearly rectangularrectangular C4,C4, absence of superio-anterior angles.absence of superio-anterior angles. 3.3. Rectangular shaped bodies.Rectangular shaped bodies. 4.4. NearlyNearly squared bodies.squared bodies. 5.5. Squared bodies.Squared bodies. 6.6. Rectangular bodies with height greater thanRectangular bodies with height greater than width.width. www.indiandentalacademy.comwww.indiandentalacademy.com
  127. 127. Cervical Vertebral MaturationCervical Vertebral Maturation (CVM) Method for the Assessment(CVM) Method for the Assessment of Mandibular Growthof Mandibular Growth • Greatest effects of functional appliancesGreatest effects of functional appliances take place when the peak in mandibulartake place when the peak in mandibular growth is included in treatment period.growth is included in treatment period. • Tiziano Baccetti, LorenzoTiziano Baccetti, Lorenzo Franchi,Franchi, James A.James A. McNamara Jr.McNamara Jr. Angle OrthodAngle Orthod 2002;72:316–323.2002;72:316–323. www.indiandentalacademy.comwww.indiandentalacademy.com
  128. 128. • To provide a new version of the Cervical Vertebral Maturation (CVM) method for the detection of the peak in mandibular growth based on the analysis of the second through fourth cervical vertebrae in a single cephalogram. (c2-c4) • The morphology of the bodies of the second (odontoid process, C2), third (C3), and fourth (C4) cervical vertebrae were analyzed in six consecutive cephalometric observations. AIM OF THE STUDY www.indiandentalacademy.comwww.indiandentalacademy.com
  129. 129. Components of studyComponents of study • C2, C3 andC4.C2, C3 andC4. • 706 subjects.706 subjects. • Co-Gn = total mandibular length.Co-Gn = total mandibular length. • Maximum increment between twoMaximum increment between two consecutive cephalograms definesconsecutive cephalograms defines peak inpeak in mandibular growth at puberty.mandibular growth at puberty. • Six consecutive cephalograms.Six consecutive cephalograms. www.indiandentalacademy.comwww.indiandentalacademy.com
  130. 130. • Observations for each subject consisted of two consecutive cephalograms comprising the interval of maximum mandibular growth (as assessed by means of the maximum increment in total mandibular length, Co-Gn), together with two earlier consecutive cephalogram and two later consecutive cephalograms www.indiandentalacademy.comwww.indiandentalacademy.com
  131. 131. • Lambarski’s CVM I and CVM II areLambarski’s CVM I and CVM II are merged (CVMS I) because there is nomerged (CVMS I) because there is no distinct demarcation is present betweendistinct demarcation is present between stage I and II.stage I and II. And form CVMS IAnd form CVMS I • CVMS = cervical vertebrae maturationCVMS = cervical vertebrae maturation stage.stage. • 5 maturational stages.5 maturational stages. www.indiandentalacademy.comwww.indiandentalacademy.com
  132. 132. www.indiandentalacademy.comwww.indiandentalacademy.com
  133. 133. www.indiandentalacademy.comwww.indiandentalacademy.com
  134. 134. CVMS ICVMS I • Lower border of C2, C3 and C4 isLower border of C2, C3 and C4 is flat.flat. • C2 may present slight concavity.C2 may present slight concavity. • Bodies of C3 and C4 rBodies of C3 and C4 r trapezoidal.trapezoidal. • Peak mandibular growth willPeak mandibular growth will occur not earlier than 1yr afteroccur not earlier than 1yr after this stage.this stage. www.indiandentalacademy.comwww.indiandentalacademy.com
  135. 135. CVMS IICVMS II • Concavities present at the lowerConcavities present at the lower border of C2 and C3.border of C2 and C3. • Bodies of C3 and C4 – eitherBodies of C3 and C4 – either trapezoid ortrapezoid or rectangular horizontal inrectangular horizontal in shape.shape. • Peak in mandibular growth will occurPeak in mandibular growth will occur within 1yr after this stage.within 1yr after this stage. • The appearance of a visible concavity at the lower border of the third cervical vertebra is accounts for the identification of the stage immediately preceding the peak in mandibular growth. www.indiandentalacademy.comwww.indiandentalacademy.com
  136. 136. CVMS IIICVMS III • Concavities at the lowerConcavities at the lower border of C2, C3 and C4border of C2, C3 and C4 are present.are present. • Bodies of C3 and C4 –Bodies of C3 and C4 – rectangular horizontal inin shape.shape. • Peak in mandibular growthPeak in mandibular growth has occurred within twohas occurred within two years before this stage.years before this stage. www.indiandentalacademy.comwww.indiandentalacademy.com
  137. 137. CVMS IVCVMS IV • Concavities at the lowerConcavities at the lower border of C2, C3 and C4 areborder of C2, C3 and C4 are present.present. • At least one of the bodies of C3At least one of the bodies of C3 and C4 isand C4 is squared in shape.in shape. • The peak in mandibular growthThe peak in mandibular growth has occurred not later than onehas occurred not later than one year before this stage.year before this stage. www.indiandentalacademy.comwww.indiandentalacademy.com
  138. 138. CVMS VCVMS V • The concavities at the lower bordersThe concavities at the lower borders of C2, C3, and C4 still are evident.of C2, C3, and C4 still are evident. • At least one of the bodies of C3 andAt least one of the bodies of C3 and C4 isC4 is rectangular verticalrectangular vertical in shape.in shape. • The peak in mandibular growth hasThe peak in mandibular growth has occurred not later than two yearsoccurred not later than two years before this stage.before this stage. (means two years(means two years after peak )after peak ) www.indiandentalacademy.comwww.indiandentalacademy.com
  139. 139. discussiondiscussion • Cervical Vertebral Maturation can be useful as a maturational index to detect the optimal time to start treatment of mandibular deficiencies by means of functional jaw orthopedics. • It has been demonstrated that the effectiveness of functional treatment of Class II skeletal disharmony strongly depends on the biological responsiveness of the condylar cartilage, which in turn is related to the growth rate of the mandible www.indiandentalacademy.comwww.indiandentalacademy.com
  140. 140. DiscussionDiscussion • CVMS I – wait for 1 yr.CVMS I – wait for 1 yr. • CVMS II – ideal time to begin treatment,CVMS II – ideal time to begin treatment, because peak in mandibular growth occur withinbecause peak in mandibular growth occur within 1 yr after this stage1 yr after this stage.. • Total mandibular length exhibited an average increase of 5.4 mm in the year following CVMS II, a significantly greater increment when compared both to the growth interval from CVMS I to CVMS II (about 2.4 mm) and to following between-stage intervals (1.6 mm and 2.1 mm for the intervals from CVMS III to CVMS IV and from CVMS IV to CVMS V, respectively) www.indiandentalacademy.comwww.indiandentalacademy.com
  141. 141. conclusionconclusion • The new CVM method is comprised of five maturational stages with the peak in mandibular growth occurring between CVMS II and CVMS III. • The pubertal peak has not been reached without the attainment of both CVMS I and CVMS II. • The new method is particularly useful when skeletal maturity has to be appraised on a single cephalogram and only the second through fourth cervical vertebrae are visible. www.indiandentalacademy.comwww.indiandentalacademy.com
  142. 142. Mid palatal suture region as anMid palatal suture region as an indicator of maturityindicator of maturity • Revelo and FishmanRevelo and Fishman inin 19941994 evaluated the ossification pattern of theevaluated the ossification pattern of the mid palatal suture.mid palatal suture. • purpose of this study was to determinepurpose of this study was to determine whether a positive correlation existswhether a positive correlation exists between adolescent maturationalbetween adolescent maturational development and the approximation ofdevelopment and the approximation of the midpalatal suturethe midpalatal suture Revelo, Fishman AJO: 105:mar 1994.Revelo, Fishman AJO: 105:mar 1994. www.indiandentalacademy.comwww.indiandentalacademy.com
  143. 143. Methods and MaterialsMethods and Materials • sample of 84 patientssample of 84 patients • 8 to 18 years of age8 to 18 years of age • X-RAY:X-RAY: 1.1. Standardized Occlusal radiographsStandardized Occlusal radiographs 2.2. hand-wrist radiographshand-wrist radiographs • Stages of ossification of the midpalatal suture were compared with Fishman's standards of skeletal maturation indicators. www.indiandentalacademy.comwww.indiandentalacademy.com
  144. 144. Key landmarks and planesKey landmarks and planes Point APoint A – most anterior– most anterior point on premaxilla.point on premaxilla. Point BPoint B – most posterior– most posterior point on the posterior wall ofpoint on the posterior wall of the incisive foramen.the incisive foramen. Point PPoint P – point tangent to a– point tangent to a line connecting the posteriorline connecting the posterior walls of the greater palatinewalls of the greater palatine foramen.foramen. www.indiandentalacademy.comwww.indiandentalacademy.com
  145. 145. Key landmarks and planesKey landmarks and planes A-P – total dimension ofA-P – total dimension of the suture.the suture. A-B – anteriorA-B – anterior dimension of the suture.dimension of the suture. B-P – posteriorB-P – posterior dimension of the suture.dimension of the suture. www.indiandentalacademy.comwww.indiandentalacademy.com
  146. 146. ResultsResults • Significant. correlation between maturationalSignificant. correlation between maturational development and beginning of ossification ofdevelopment and beginning of ossification of mid palatal suturemid palatal suture • Before SMI 4Before SMI 4 (( i.e. before ossification ofi.e. before ossification of adductor sesamoid)adductor sesamoid) VeryVery little or no midpalatal approximationlittle or no midpalatal approximation exists.exists. Suture is onlySuture is only 8% fused at SMI 3.8% fused at SMI 3. Anterior portion of suture is wide open.Anterior portion of suture is wide open. www.indiandentalacademy.comwww.indiandentalacademy.com
  147. 147. ResultsResults • SMI 4-7SMI 4-7 (i.e.(i.e. ossification of adductorossification of adductor sesamoid, capping with distal and middlesesamoid, capping with distal and middle phalanx of 3phalanx of 3rdrd finger & fifth finger )finger & fifth finger ) osseous interdigitationosseous interdigitation is evidentis evident with approximation in some areas.with approximation in some areas. This period occurs during theThis period occurs during the pubertalpubertal growth spurt.growth spurt. www.indiandentalacademy.comwww.indiandentalacademy.com
  148. 148. ResultsResults • After SMI 8After SMI 8 (i.e. fusion of distal phalanx of 3(i.e. fusion of distal phalanx of 3rdrd finger)finger) The suture demonstrates a marked increase inThe suture demonstrates a marked increase in rate of approximation.rate of approximation. Increments to approximately 25%Increments to approximately 25% approximation at maturational age SMIapproximation at maturational age SMI 9.9. • AtAt SMI 11SMI 11 (i.e. fusion of radius )(i.e. fusion of radius )  50% of total midpalatal suture is50% of total midpalatal suture is approximatedapproximated..  High percentage of approximation occursHigh percentage of approximation occurs posteriorly.posteriorly. www.indiandentalacademy.comwww.indiandentalacademy.com
  149. 149. conclusionconclusion • No difference in patterns of approximationNo difference in patterns of approximation between males and females.between males and females. • Thus, best time to use orthopedic force forThus, best time to use orthopedic force for expansion isexpansion is before SMI 9 as percentagebefore SMI 9 as percentage of approximation is less.of approximation is less. • Ideal time isIdeal time is SMI 1 to 4 as less orthopedicSMI 1 to 4 as less orthopedic force is required.force is required. www.indiandentalacademy.comwww.indiandentalacademy.com
  150. 150. Frontal sinus development as anFrontal sinus development as an indicator for somatic maturation atindicator for somatic maturation at pubertypuberty • Sabine RufSabine Ruf andand Hans Pancherz-Hans Pancherz- 19961996.. • 2 lateral head2 lateral head films from each subjectfilms from each subject were analyzed onwere analyzed on 1 or 2 yrs interval basis1 or 2 yrs interval basis.. • Lateral radiographs were traced with theLateral radiographs were traced with the SN line.SN line. AJO 110: Nov 1996.AJO 110: Nov 1996. www.indiandentalacademy.comwww.indiandentalacademy.com
  151. 151. AIM OF STUDYAIM OF STUDY • predicting the stage of somatic maturitypredicting the stage of somatic maturity by analyzing frontal sinus growth wasby analyzing frontal sinus growth was evaluated.evaluated. • The study was performed onThe study was performed on 53 adolescent53 adolescent boysboys, and the frontal sinus size development, and the frontal sinus size development was assessed onwas assessed on lateral head films.lateral head films. • The accuracy of the prediction procedure wasThe accuracy of the prediction procedure was tested by comparing the prediction stage withtested by comparing the prediction stage with the longitudinal growth data for body height ofthe longitudinal growth data for body height of the subjectsthe subjects www.indiandentalacademy.comwww.indiandentalacademy.com
  152. 152. LandmarksLandmarks • ShSh – highest point on– highest point on peripheral border of frontalperipheral border of frontal sinus.sinus. • SlSl – lowest point on– lowest point on peripheral border of frontalperipheral border of frontal sinus.sinus. • Perpendicular to thePerpendicular to the interconnecting line (interconnecting line (Sh-Sh- SlSl), the), the maximum widthmaximum width of the frontal sinus wasof the frontal sinus was assessed.assessed. Sh Sl www.indiandentalacademy.comwww.indiandentalacademy.com
  153. 153. www.indiandentalacademy.comwww.indiandentalacademy.com
  154. 154. • Average yearly body height growthAverage yearly body height growth velocity (mm/yr) was calculated.velocity (mm/yr) was calculated. • BpBp (body height peak) = maximum body(body height peak) = maximum body growth velocity at pubertygrowth velocity at puberty • The body height growth data were usedThe body height growth data were used onlyonly to test the accuracy of the predictionto test the accuracy of the prediction of pubertal stageof pubertal stage as assessed fromas assessed from frontal sinus development.frontal sinus development. Body height VelocityBody height Velocity www.indiandentalacademy.comwww.indiandentalacademy.com
  155. 155. Somatic maturity predictionSomatic maturity prediction • Frontal sinus growth velocity at puberty isFrontal sinus growth velocity at puberty is closely related to body height growthclosely related to body height growth velocity.velocity. • Well defined pubertal peak (Sp), onWell defined pubertal peak (Sp), on average, occurs 1.4 years after theaverage, occurs 1.4 years after the pubertal body height peak (Bp).pubertal body height peak (Bp). • Males – average age at frontalMales – average age at frontal sinus peak is 15.1 years.sinus peak is 15.1 years. www.indiandentalacademy.comwww.indiandentalacademy.com
  156. 156. (Difference is 1.4 yrs)(Difference is 1.4 yrs) www.indiandentalacademy.comwww.indiandentalacademy.com
  157. 157. Somatic maturity predictionSomatic maturity prediction • Peak growth velocity in the frontal sinus ofPeak growth velocity in the frontal sinus of atleast 1.3mm/yr is attained in 1 yr observation.atleast 1.3mm/yr is attained in 1 yr observation. • In 2 yr observation interval, a peak velocity inIn 2 yr observation interval, a peak velocity in the frontal sinus of atleast 1.2mm/yr is attained.the frontal sinus of atleast 1.2mm/yr is attained. • These specific frontal sinus growth velocitiesThese specific frontal sinus growth velocities (1.3 mm/yr. for the 1-year interval and 1.2(1.3 mm/yr. for the 1-year interval and 1.2 mm/yr. for the 2-year interval) were assigned asmm/yr. for the 2-year interval) were assigned as threshold values T1 and T2, respectively.threshold values T1 and T2, respectively. www.indiandentalacademy.comwww.indiandentalacademy.com
  158. 158. Prediction procedurePrediction procedure • Frontal sinus growth velocity (Frontal sinus growth velocity (SvSv) in each) in each person was compared with T1 andperson was compared with T1 and T2(threshold) values.T2(threshold) values. • IfIf SvSv is as high as or higher than T valueis as high as or higher than T value (T1 or T2), it may be expected that the(T1 or T2), it may be expected that the frontal sinus peak was reached duringfrontal sinus peak was reached during prediction interval.prediction interval. www.indiandentalacademy.comwww.indiandentalacademy.com
  159. 159. Prediction procedurePrediction procedure • If theIf the SvSv is lower than the T-value, itis lower than the T-value, it cannot be said whether the subject is precannot be said whether the subject is pre peak or post peak in frontal sinus growth.peak or post peak in frontal sinus growth. • May be related to chronologic age (frontalMay be related to chronologic age (frontal sinus peak at 15.1 years).sinus peak at 15.1 years). www.indiandentalacademy.comwww.indiandentalacademy.com
  160. 160. DISCUSSIONDISCUSSION • disadvantagedisadvantage 1.1. it requiresit requires two lateral head films taken at leasttwo lateral head films taken at least at a 1-year intervalat a 1-year interval. Two radiographs are, however,. Two radiographs are, however, seldom available at the beginning of orthodonticseldom available at the beginning of orthodontic treatment .treatment . 2.2. If the only prediction was whether the pubertal growthIf the only prediction was whether the pubertal growth peak in height has been passed ,the precision of thepeak in height has been passed ,the precision of the method was rather highmethod was rather high (approximately 90%).(approximately 90%). However, if the age of body height peak was to beHowever, if the age of body height peak was to be predicted, the method accuracy was lowerpredicted, the method accuracy was lower (approximately 55%)(approximately 55%) www.indiandentalacademy.comwww.indiandentalacademy.com
  161. 161. Canine calcificationCanine calcification • Relationship between mandibularRelationship between mandibular canine calcification stages and skeletalcanine calcification stages and skeletal maturity.maturity. Sandra Cortinho, Peter H.Sandra Cortinho, Peter H. BuschangBuschang.. AJODO:104:sept 1993.AJODO:104:sept 1993.www.indiandentalacademy.comwww.indiandentalacademy.com
  162. 162. • Sample:Sample: 200 boys and 215 girls200 boys and 215 girls • development of the mandibular canine wasdevelopment of the mandibular canine was assessed according toassessed according to Demirjian's 9Demirjian's 9 stages of dental calcification.stages of dental calcification. • Skeletal ageSkeletal age was determined from hand-was determined from hand- wrist radiographs according to methodswrist radiographs according to methods described bydescribed by 1.1. Greulich and PyleGreulich and Pyle .. 2.2. Tanner and Whitehouse method.Tanner and Whitehouse method. www.indiandentalacademy.comwww.indiandentalacademy.com
  163. 163. Canine development stageCanine development stage • Stage D:Stage D: www.indiandentalacademy.comwww.indiandentalacademy.com
  164. 164. Canine development stageCanine development stage Stage D:Stage D: • Crown formation is complete down toCrown formation is complete down to C.E. junction.C.E. junction. • Superior border of the pulp chamber inSuperior border of the pulp chamber in the uniradicular teeth has a definitethe uniradicular teeth has a definite curved form being concave towardscurved form being concave towards cervical region.cervical region. • The projection of pulp horns, if presentThe projection of pulp horns, if present gives outline shaped like an umbrellagives outline shaped like an umbrella top.top. • Beginning of root formation is seen inBeginning of root formation is seen in the form of a spicule.the form of a spicule. CE JunctioJunctio nn www.indiandentalacademy.comwww.indiandentalacademy.com
  165. 165. Stage EStage E www.indiandentalacademy.comwww.indiandentalacademy.com
  166. 166. Stage E:Stage E: • The walls of the pulpThe walls of the pulp chamber now form straightchamber now form straight lines whose continuity islines whose continuity is broken by the presence ofbroken by the presence of the pulp horn, which isthe pulp horn, which is larger than in the previouslarger than in the previous stage.stage. • The root length is less thanThe root length is less than the crown height.the crown height. Pulp horn www.indiandentalacademy.comwww.indiandentalacademy.com
  167. 167. Stage FStage F www.indiandentalacademy.comwww.indiandentalacademy.com
  168. 168. Stage F:Stage F: • The walls of the pulpThe walls of the pulp chamber now form a more orchamber now form a more or less anless an isoscelesisosceles triangletriangle. The apex ends in. The apex ends in a funnel shape.a funnel shape. • The root length is equal to orThe root length is equal to or greater than the crowngreater than the crown height.height. IsoscelesIsosceles triangletriangle www.indiandentalacademy.comwww.indiandentalacademy.com
  169. 169. Stage GStage G www.indiandentalacademy.comwww.indiandentalacademy.com
  170. 170. Stage G:Stage G: • The walls of the root canalThe walls of the root canal are now parallel and itsare now parallel and its apical end is still partiallyapical end is still partially open.open. Parallel wallsParallel walls www.indiandentalacademy.comwww.indiandentalacademy.com
  171. 171. Stage HStage H www.indiandentalacademy.comwww.indiandentalacademy.com
  172. 172. Stage H:Stage H: • The periodontal apical end ofThe periodontal apical end of the root canal is completelythe root canal is completely closed.closed. • membrane has a uniform widthmembrane has a uniform width around the root and the apex.around the root and the apex. www.indiandentalacademy.comwww.indiandentalacademy.com
  173. 173. ResultsResults • TheThe initiation of spurt is indicated by canineinitiation of spurt is indicated by canine stagestage FF (i.e. the epiphysis of the 3(i.e. the epiphysis of the 3rdrd and 5and 5thth middlemiddle phalanges are equal in length to their diaphysis.)phalanges are equal in length to their diaphysis.) • No appearance of adductor sesamoid.No appearance of adductor sesamoid. • The mean skeletal age for the presence of the adductorThe mean skeletal age for the presence of the adductor sesamoid in the girls and the boys are 12.2 years andsesamoid in the girls and the boys are 12.2 years and 13.2 years, respectively.13.2 years, respectively. www.indiandentalacademy.comwww.indiandentalacademy.com
  174. 174. • In stage G,In stage G, most show the adductor sesamoid.most show the adductor sesamoid. • Capping of the diaphysis of the middle and distalCapping of the diaphysis of the middle and distal phalanges of the third finger, and capping of the proximalphalanges of the third finger, and capping of the proximal phalanx of the fifth finger.phalanx of the fifth finger. • Stage GStage G coincides with the eruption of the canine intocoincides with the eruption of the canine into the oral cavity, occurs approximatelythe oral cavity, occurs approximately 1 year before the1 year before the PHV in boys, but only 5 months before the PHVPHV in boys, but only 5 months before the PHV in girls.in girls. • This may reflect hormonal changes which accompanyThis may reflect hormonal changes which accompany puberty.puberty. www.indiandentalacademy.comwww.indiandentalacademy.com
  175. 175. • stage Hstage H, indicating apical closure, is, indicating apical closure, is generally associated with fusion of thegenerally associated with fusion of the epiphyses to their respective diaphysis.epiphyses to their respective diaphysis. www.indiandentalacademy.comwww.indiandentalacademy.com
  176. 176. • stage F indicates ONSET of puberty.stage F indicates ONSET of puberty. • Stage G indicates peak height velocityStage G indicates peak height velocity (PHV).(PHV). • The intermediate stage between stage F andThe intermediate stage between stage F and G should be used to identify the early stagesG should be used to identify the early stages of the pubertal growth spurt.of the pubertal growth spurt. • Canine development cannot or should not beCanine development cannot or should not be used as a sole criteria to predict developmentused as a sole criteria to predict development landmarks.landmarks. conclusionconclusion www.indiandentalacademy.comwww.indiandentalacademy.com
  177. 177. THANK YOUTHANK YOU www.indiandentalacademy.comwww.indiandentalacademy.com
  178. 178. Symphysis morphology as a predictor ofSymphysis morphology as a predictor of direction of mandibular growthdirection of mandibular growth • AJODOAJODO • Volume 1994 Jul (60 - 69): SymphysisVolume 1994 Jul (60 - 69): Symphysis morphology as a predictor of direction ofmorphology as a predictor of direction of mandibular growth –mandibular growth – • Aki, Currier, and NandaAki, Currier, and Nanda www.indiandentalacademy.comwww.indiandentalacademy.com
  179. 179. www.indiandentalacademy.comwww.indiandentalacademy.com
  180. 180. Determination of Height and DepthDetermination of Height and Depth • A line tangent to point B was used as the long axis of the symphysis, and a grid was formed with the lines of the grid parallel and perpendicular to the constructed tangent line. • The superior limit of the symphysis was taken at point B with the inferior, anterior, and posterior limits taken at the most inferior, anterior, and posterior borders of the symphysis outline, respectively www.indiandentalacademy.comwww.indiandentalacademy.com

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