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GROWTH
PREDICTION
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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• Introduction
• Handwrist radiographs
• Cervical vertebrae
• Mid-palatal suture
• Frontal sinus
• Mandibular canine calci...
• Even when excellent data from clinical trials are
available, it is difficult to predict how any one
individual will resp...
• At present, in the absence of
growth, treatment responses are
reasonably predictable.
Growth is not predictable.
www.ind...
Growth spurts - Graber
• Childhood growth spurt (3 yrs)
• Juvenile growth spurt
girls – 6 to 7 yrs
boys – 7 to 9 yrs
• Pub...
Pubertal growth spurt-girls
• Stage-I : beginning of growth spurt
10½ to 11½yrs
• Stage-II : peak velocity
lasts for 1 to ...
Pubertal growth spurt-boys
• Stage-I : beginning of growth spurt
lasts for 1 yr (fat spurt)
• Stage-II : fat redistributio...
Hand Wrist Radiographs
• Chronological age is often not sufficient for
assessing the developmental stage and
maturity of t...
• 1st hand wrist film was published by Sydney
Rowland in England in april 1890 (4 months
after discovery of x-rays).
Revie...
• In the early
1900s, Pryor(1907), Rotch(1908), and
Crampton(1908) began tabulating indicators
of maturity on sequential r...
• Flory in 1936, indicated that the beginning of
calcification of the adductor sesamoid was a
good guide to determining th...
• Fishman(1979) developed a system of hand-
wrist skeletal maturation indicators (SMIs)
using four stages of bone maturati...
• Hunter reported that carpal bones had proved
to be the best site for determining skeletal
maturation.
• Björk and Helm s...
Indications
• Prior to rapid maxillary expansion.
• Marked discrepancy between dental or
skeletal and chronological age.
•...
ANATOMY
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PA view
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Oblique view
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• The ossification events are localized in the
area of the phalanges, carpal bones, and
radius (R).
• Growth stages of the...
Three stages of ossification of
the phalanges
First stage
Second stage
Third stage
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9 stages:
Stage 1(males-10.6 yrs, females 8.1yrs):
epiphysis and diaphysis of proximal phalanx of
index finger are equal.
...
First Stage (PP2 = - Stage)
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Stage 2(males-12.0 yrs, females 8.1yrs):
epiphysis and diaphysis of middle phalanx of
middle finger are equal.
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Second Stage (MP3 = - Stage)
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Stage 3(males-12.6 yrs, females 9.6yrs): 3 stages
• Ossification of hamular process of hamate.
• Ossification of pisiform....
Third stage
(Pisi-, H1-, and R = - Stage)
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Stage 4(males-13.0yrs, females 10.6yrs):
Initial mineralization of ulnar sesamoid of
thumb.
Increased ossification of the ...
Fourth stage
(S- and H2-stage)
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Stage 5(males-14 yrs, females 11yrs):
Capping of diaphysis is seen in
• Middle phalanx of 3rd finger.
• Proximal phalanx o...
Fifth stage
(MP3cap ;PP1cap ;and Rcap-stage)
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Stage 6(males-15 yrs, females 13.3yrs):
Visible union of diaphysis and epiphysis at the
distal phalanx of the middle finge...
Sixth stage
(DP3u-stage)
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Stage 7(males-15.9 yrs, females 13.9 yrs):
Visible union of the epiphysis and diaphysis at
the proximal phalanx of middle ...
Seventh stage
(PP3u-stage)
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Stage 8(males-15.9 yrs, females 13.9yrs):
Union of epiphysis and diaphysis at middle
phalanx of middle finger.
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Eighth stage
(MP3u-stage)
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Stage 9(males-18.5 yrs, females 16 yrs):
Complete union of epiphysis and diaphysis of
radius.
Ossification of all bones is...
Ninth stage
(Ru-stage)
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An Overview
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Correlation table between ossification stages of
hand bones and the skeletal age for the period
between 8 and 18 years
www...
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Fishman’s skeletal maturity indicator
• In 1982 – Leonard Fishman gave system of
skeletal maturation assessment (SMA).
• 1...
11 SMI were divided into 4 stages
• Epiphysis as wide as diaphysis.
• Ossification.
• Capping of epiphysis.
• Fusion of ep...
Epiphysis as wide as diaphysis
1. Third finger-proximal phalanx
2. Third finger-middle phalanx
3. Fifth finger-middle phal...
Ossification
4. Adductor sesamoid of thumb.
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Capping of epiphysis
5. Third finger – distal phalanx.
6. Third finger – middle phalanx.
7. Fifth finger – middle phalanx....
Fusion of epiphysis and diaphysis
8. Third finger – distal phalanx.
9. Third finger – proximal phalanx.
10. Third finger –...
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• Accelerating growth velocity period (1–4)
• High growth velocity period (4–7)
• Decelerating velocity period (7–11)
www....
Conclusion
• SMI occurs at earlier chronological ages for girls.
• SMI make it possible to judge an individual
relative ti...
• Early maturers of both sexes exhibited almost
identical SMI duration values for SMI’s 1-5 & 7-
11. The only significant ...
• In late maturation groups, considerably less
correlation is found between male and female
groups, although duration of t...
Levels of maturation - FEMALE
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Levels of maturation - MALE
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Julien Singer method
Six stages are described:
• Stage 1 (early) :
Pisiform is absent.
Hook of hamate absent.
Epiphysis of...
• Stage 2 (prepubertal) :
Proximal phalanx of 2nd finger is equal to its
epiphysis.
Initial ossification of hook of hamate...
• Stage 3 (pubertal onset):
Calcification (beginning) of ulnar sesamoid.
Increased width of proximal phalanx of 2nd
finger...
• Stage 4 (pubertal stage):
Calcification of ulnar sesamoid.
Capping of diaphysis of middle phalanx of 3rd
finger by its e...
• Stage 5 (pubertal deceleration):
Full calcification of ulnar sesamoid.
Fusion of epiphysis of distal phalanx of 3rd fing...
• Stage 6 (growth completion):
No remaining growth site is seen.
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Maturation indications and pubertal
growth spurt
• Urban Hägg and John Taranger did a study in
1982 to investigate puberta...
Method of analysis
• Adolescent growth: was studied by graphic
analysis of the unsmoothed incremental
curves of standing h...
Method of analysis
• Dental
development was
assessed by
dental
emergence stages
(DES).
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Method of analysis
• Skeletal development in the hand and wrist was
analyzed from annual radiographs, taken
between the ag...
Method of analysis
• Pubertal development was assessed from 10
to 18 years by determining the occurrence of
menarche in gi...
3 stages of voice changes were used:
• PPV – prepubertal voice; the pitch of the
voice had not changed noticeably.
• PV – ...
Pubertal growth spurt
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Results
• The pubertal growth spurt – ONSET of spurt is the
annual increment from which there is a marked
continuous incre...
Results
• Dental development and pubertal growth
spurt - The dental development was more
advanced in boys than in girls at...
Results
• Skeletal development and the pubertal
growth spurt - Skeletal development at
ONSET and PHV was more advanced in ...
The skeletal stages were useful as indicators
of the pubertal growth spurt.
Skeletal stages:
• Sesamoid – it appeared duri...
Middle third phalanx:
• MP3-F - was attained before ONSET by about
40 percent of the subjects and at PHV by the
last subje...
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• MP3-G – the sides of the epiphysis have
thickened and also caps its metaphysis
forming a sharp edge distally at one or b...
Distal third phalanx:
• DP3-I – it is attained during the deceleration
period of the pubertal growth spurt. The
fusion of ...
Pubertal development and pubertal
growth spurt
• Pubertal development (menarche and voice
change) and pubertal growth even...
Discussion
• Reliable indications taken from skeletal
development were found for PHV and END but
not for beginning (ONSET)...
CERVICAL VERTEBRAE
MATURATION
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• 1972 – Lamparski was the 1st person to study
cervical vertebrae and he found them to be as
reliable as hand wrist film.
...
• 1n 1995 – Hassel and Farman modified the
Lamparski criteria by using C2, C3, and C4
cervical vertebrae.
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Lamparski method
• Stage 1 – the inferior borders of the bodies
of all cervical vertebrae are flat. The superior
borders a...
Lamparski method
• Stage 3 – a concavity develops in the inferior
border of the third vertebrae.
• Stage 4 – a concavity d...
Lamparski method
• Stage 5 – concavities are well defined in the
lower border of the bodies of all 6 cervical
vertebrae. T...
Cervical vertebrae maturation
indicators using C3 as guide.
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Brent Hassel, Allan Farman
• Category 1 (Initiation) – at this stage
adolescent growth was just beginning and
80% to 100% ...
CVMI 1
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Category 2 (Acceleration) – growth
acceleration was beginning at this stage with
65% to 85% of adolescent growth expected....
CVMI 2
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Category 3 (Transition) – adolescent growth
was still accelerating at this stage towards
peak height velocity with 25% to ...
CVMI 3
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Category 4 (Deceleration) – adolescent
growth began to decelerate dramatically at
this stage with 10% to 25% of adolescent...
CVMI 4
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Category 5 (Maturation) – final maturation
of the vertebrae took place during this
stage, with 5% to 10% of adolescent gro...
CVMI 5
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Category 6 (Completion) – growth was
considered to be complete at this stage.
• Deep concavities were seen in the inferior...
CVMI 6
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Cervical Vertebral Maturation
(CVM) Method for the Assessment of
Mandibular Growth
• Greatest effects of functional applia...
Components of study
• C2, C3 andC4.
• 706 subjects.
• Co-Gn = total mandibular length.
• Maximum increment between two
con...
• Lambarski’s CVM I and CVM II are merged
(CVMS I).
• CVMS = cervical vertebrae maturation stage.
• 5 maturational stages....
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CVMS I
• Lower border of C2, C3 and C4 is flat.
• C2 may present slight concavity.
• Bodies of C3 and C4 are trapezoidal.
...
CVMS II
• Concavities present at the lower border of C2
and C3.
• Bodies of C3 and C4 – either trapezoid or
rectangular ho...
CVMS III
• Concavities at the lower border of C2, C3 and
C4 are present.
• Bodies of C3 and C4 – rectangular horizontal
in...
CVMS IV
• Concavities at the lower border of C2, C3 and
C4 are present.
• At least one of the bodies of C3 and C4 is
squar...
CVMS V
• The concavities at the lower borders of
C2, C3, and C4 still are evident.
• At least one of the bodies of C3 and ...
Discussion
• When CVMS 1 is diagnosed in the individual
patient with mandibular deficiency, clinician
can wait least 1 yea...
Mid palatal suture region as an indicator of
maturity
• Revelo and Fishman in 1994 evaluated the
ossification pattern of t...
Key landmarks and planes
• Point A – most anterior point on premaxilla.
• Point B – most posterior point on the
posterior ...
Key landmarks and planes
• A-P – total dimension of the suture.
• A-B – anterior dimension of the suture.
• B-P – posterio...
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Results
• Significant correlation between maturational
development and beginning of ossification of
mid palatal suture.
• ...
Results
• SMI 4-7 i.e. ossification of adductor
sesamoid, capping with distal and middle
phalanx of 3rd finger, osseous in...
Results
• After SMI 8 i.e. fusion of distal phalanx of 3rd
finger, the suture demonstrates a marked
increase in rate of ap...
Results
• No difference in patterns of approximation
between males and females.
• Thus, best time to use orthopedic force ...
Frontal sinus development as an indicator
for somatic maturation at puberty
Am J Orthod Dentofac Orthop 1996; 110:476-82.
...
• Sabine Ruf and Hans Pancherz.
• The study was performed on 53 adolescent
boys, and the frontal sinus size development wa...
• In the adolescent, the stage of somatic maturity
may influence the selection of the appliance, the
course of treatment a...
Landmarks
• Sh – highest point on peripheral border of
frontal sinus.
• Sl – lowest point on peripheral border of
frontal ...
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• Average yearly body height growth velocity
(mm/yr) was calculated.
• Bp (body height peak) = maximum body
growth velocit...
Somatic maturity prediction
• Frontal sinus growth velocity at puberty is
closely related to body height growth velocity.
...
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Somatic maturity prediction
• Peak growth velocity in the frontal sinus of
atleast 1.3mm/yr is attained in 1 yr
observatio...
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Prediction procedure
• Frontal sinus growth velocity (Sv) in each
person was compared with T1 and
T2(threshold) values.
• ...
Prediction procedure
• If the Sv is lower than the T-value, it cannot be
said whether the subject is pre peak or post
peak...
Relationship between mandibular canine
calcification stages and skeletal maturity.
-Sandra Cortinho, Peter H. Buschang.
AJ...
• Handwrist radiographs and dental panoramic
radiographs of 200 boys and 215 girls were
assessed.
www.indiandentalacademy....
Stage D:
• Crown formation is complete down to C.E.
junction.
• Superior border of the pulp chamber in the
uniradicular te...
Canine development stage
• Stage D:
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Stage E:
• The walls of the pulp chamber now form
straight lines whose continuity is broken by
the presence of the pulp ho...
Stage E
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Stage F:
• The walls of the pulp chamber now form a
more or less an isosceles triangle. The apex
ends in a funnel shape.
•...
Stage F
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Stage G
• The walls of the root canal are now
parallel and its apical end is still partially
open.
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Stage H:
• The apical end of the root canal is completely
closed.
• The periodontal membrane has a uniform
width around th...
Stage H
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Results
• The initiation of spurt is indicated by canine
stage F i.e. the epiphysis of the 3rd and 5th middle
phalanges ar...
• In stage G, most show the adductor sesamoid.
• Capping of the diaphysis of the middle and distal
phalanges of the third ...
• Thus, stage F indicates puberty.
• Stage G indicates peak height velocity
(PHV).
• The intermediate stage between stage ...
Arcial growth prediction
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Principle
• A normal mandible grows by superior-anterior
apposition vertically at the Ramus on a curve or arc
which is a s...
Historical Review
• Hunter (1771) : Compared a series of dried
mandibles and concluded that, in order to attain
space for ...
• Humprey (1866): Tied wires around the Mandibles
of pigs and showed that the wire became
embedded in the posterior margin...
• Brash (1924): Fed pigs the madder plant root which
contains the red stain alizarin and therefore labeled
appositional gr...
THE COMPUTER (PRIMARY) STUDY
• Although the previous method was useful for
practical short term predictions, a method was
...
Locating a Cephalometric Central Core
Point Xi
• Located the following points on the Cephalogram :
R1 = deepest point on s...
• By using these points, the centroid of the Ramus is
selected by forming a rectangle and connecting the
corners.
• Occlus...
Suprapogonion
• Labeled as Pm for Protuberance Menti.
• It is a bony crest located at the antero-superior
contour of the S...
Point DC
• A point selected in the centre of the neck of the Condyle where the Basion-Nasion
plane crosses it.
Condyle Axi...
• By studying linear growth on these planes and the
form change as a change in the angulation between
the two, an interpre...
SAMPLE
• A five year growth study of the Mandible on the computer.
• Lateral and frontal cephalograms taken on 40 patients...
RESULTS
• Samples were superimposed on the Corpus Axis and registered at
Xi point.
• Mandible was found to bend 0.5 each y...
The sample are superimposed on the corpus axis and registered at
Xi point as the mandible was found to bend about one half...
THE SECONDARY STUDY
• He sought a more detailed mechanism to explain
the development of the mandible.
• The fact that a be...
• Experiments were undertaken to determine a method
by which the form and size of the mandible, after a 5
year growth inte...
• The first arc was constructed in the Time 1 composite
through the three points :
Pm, Xi, Dc
• By extending this arc, the...
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• A second arc was made by joining the following
points:
1. tip of coronoid process
2. anterior border of ramus at its dee...
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• Hence, the characteristics of typical growth had been
bracketed by the two arcs produced.
• Therefore, an arc was constr...
• The use of this arc bent the mandible by a fraction too
much.
• Additionally, a radius selected from this point would
in...
• The mandible used for studying the stress lines was
850 years old.
• It had been weathered to a state of disintegration ...
Stress lines on Lateral side
• There is convergence of stress lines at the
protuberance menti.
• Stress lines swing downwa...
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Stress lines on Medial side
• Greater forking was present than laterally.
• Stresses followed the Mylohyoid ridge upward i...
• Further study of several dozen mandibles
led to the observation of small, nutritive
foramina immediately superior to thi...
Locating point Eva
• A line from Xi point to Sigmoid notch is bisected and a parallel
point ( RR ) is selected on the ante...
• This line is crossed by a second line selected
from a point midway at the base of the coronoid
process to Xi point.
• Th...
Locating point TR
• Point TR (true radius) is of equal distance from Point
Eva and Pm.
• The arc formed by joining Point E...
• When the size increase of the mandible as determined by the
computer study was incrementally added to the arc at the
sig...
Growth Prediction
• Head films of a male patient, age 9 years, were
chosen.
• The patient was observed until almost 19 yea...
• This was calculated from the previous study and
found to be an excellent population constant.
• Cutoff for growth= 14.5 ...
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Step 2
• Next, 20 longitudinal cases with a range of
duration of 5-12 years were measured.
• Study revealed that increases...
• The k factor for coronoid process growth was 0.8 mm
per year.
• The condylar k factor was variable.
• Long condyles = 0....
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Step 3
•In males, an addition of 0.2 mm per year is done
on the border of the mandible from the arc.
• No such addition is...
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Step 4
• The last step is to determine the space available
for the mandibular third molar at the anterior
border of the Ra...
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PARENTAL DATA
According to studies by Suzuki and Takahama “Facial
growth prediction based on parental data”, there is high...
• The genetic influence of parents of their
children appeared equal.
• Daughters seemed to be more affected
genetically th...
More precise prediction of individual growth
could be made by applying genetic data
obtained from similarities in craniofa...
• If the face of a young offspring resembles the
face of either parent, it will continue to
resemble that parent when the ...
There is high correlation between the
craniofacial form of an offspring and that of
his or her parents. The relationship b...
CRANIOFACIAL TEMPLATES
FOR ORTHODONTIC ANALYSIS
In recent years, direct comparison of patients
with templates derived from...
The measurements for comparison with the norms
should have several characteristics:
• It should be useful clinically in di...
Templates exist in two forms :
• Schematic – it shows the changing position of
landmarks with age on a single template.
• ...
• While selecting a template, two things have to
be kept in mind:
– Patient’s physical size
– Developmental age
www.indian...
• Cranial base superimposition, which allows
the relationship of the maxilla and mandible
to the cranium to be evaluated.
...
• Second superimpostion is on the maximum
contour of the maxilla to evaluate the
relationship of the maxillary dentition t...
• The third superimposition is on the symphysis
of the mandible along the lower border, to
evaluate the relationship of th...
Thank you
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For more details please visit
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Growth predictions /certified fixed orthodontic courses by Indian dental academy

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Transcript of "Growth predictions /certified fixed orthodontic courses by Indian dental academy "

  1. 1. GROWTH PREDICTION INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. • Introduction • Handwrist radiographs • Cervical vertebrae • Mid-palatal suture • Frontal sinus • Mandibular canine calcification • Arcial growth prediction • Parental Data • Craniofacial templates Content www.indiandentalacademy.com
  3. 3. • Even when excellent data from clinical trials are available, it is difficult to predict how any one individual will respond to particular plan of treatment .Variability must be expected. • In orthodontics, two interrelated factors contribute most of the variability: the patient’s growth pattern and the effect of treatment on the expression of growth. www.indiandentalacademy.com
  4. 4. • At present, in the absence of growth, treatment responses are reasonably predictable. Growth is not predictable. www.indiandentalacademy.com
  5. 5. Growth spurts - Graber • Childhood growth spurt (3 yrs) • Juvenile growth spurt girls – 6 to 7 yrs boys – 7 to 9 yrs • Pubertal growth spurt girls – 10½ to 13 yrs boys – 12½ to 16 yrs www.indiandentalacademy.com
  6. 6. Pubertal growth spurt-girls • Stage-I : beginning of growth spurt 10½ to 11½yrs • Stage-II : peak velocity lasts for 1 to 2yrs • Stage-III : menarche deceleration and end of growth spurt. www.indiandentalacademy.com
  7. 7. Pubertal growth spurt-boys • Stage-I : beginning of growth spurt lasts for 1 yr (fat spurt) • Stage-II : fat redistribution, pubic hairs lasts for 1 to 2yrs • Stage-III : peak velocity lasts for 1 to 2yrs • Stage-IV : height stagnates deceleration and end of growth spurt. www.indiandentalacademy.com
  8. 8. Hand Wrist Radiographs • Chronological age is often not sufficient for assessing the developmental stage and maturity of the patient. • Thus, biological age has to be determined. • Hand Wrist radiographs are an effective tool to assess the biological age. www.indiandentalacademy.com
  9. 9. • 1st hand wrist film was published by Sydney Rowland in England in april 1890 (4 months after discovery of x-rays). Review of literature www.indiandentalacademy.com
  10. 10. • In the early 1900s, Pryor(1907), Rotch(1908), and Crampton(1908) began tabulating indicators of maturity on sequential radiographs of the growing hand and wrist. • Todd(1937) compiled hand-wrist data that was further elaborated on by Greulich and Pyle(1959) in atlas form. www.indiandentalacademy.com
  11. 11. • Flory in 1936, indicated that the beginning of calcification of the adductor sesamoid was a good guide to determining the period immediately before puberty. • Peak height velocity follows adductor sesamoid appearance by approximately 1 year. www.indiandentalacademy.com
  12. 12. • Fishman(1979) developed a system of hand- wrist skeletal maturation indicators (SMIs) using four stages of bone maturation at six anatomic sites on the hand and the wrist. • Hagg and Taranger(1980) created a method using the hand-wrist radiograph to correlate certain maturity indicators to the pubertal growth spurt. www.indiandentalacademy.com
  13. 13. • Hunter reported that carpal bones had proved to be the best site for determining skeletal maturation. • Björk and Helm stated that appearance of ulnar sesamoid on hand wrist film was related to the onset of maximum pubertal growth in height. • Helm elaborated on other structures in the hand wrist film to pubertal growth spurt. www.indiandentalacademy.com
  14. 14. Indications • Prior to rapid maxillary expansion. • Marked discrepancy between dental or skeletal and chronological age. • Where maxillomandibular changes are indicated e.g. skeletal class II or III or skeletal openbite. • Orthognathic surgery if undertaken between the ages of 16-20 years. www.indiandentalacademy.com
  15. 15. ANATOMY www.indiandentalacademy.com
  16. 16. PA view www.indiandentalacademy.com
  17. 17. Oblique view www.indiandentalacademy.com
  18. 18. • The ossification events are localized in the area of the phalanges, carpal bones, and radius (R). • Growth stages of the fingers are assessed according to the relationship between the epiphyses and the diaphyses. Björk, Grave and Brown’s method American Journal of Orthodontia. 1976; 69:611-20.www.indiandentalacademy.com
  19. 19. Three stages of ossification of the phalanges First stage Second stage Third stage www.indiandentalacademy.com
  20. 20. 9 stages: Stage 1(males-10.6 yrs, females 8.1yrs): epiphysis and diaphysis of proximal phalanx of index finger are equal. 3 yrs before peak of pubertal growth spurt. www.indiandentalacademy.com
  21. 21. First Stage (PP2 = - Stage) www.indiandentalacademy.com
  22. 22. Stage 2(males-12.0 yrs, females 8.1yrs): epiphysis and diaphysis of middle phalanx of middle finger are equal. www.indiandentalacademy.com
  23. 23. Second Stage (MP3 = - Stage) www.indiandentalacademy.com
  24. 24. Stage 3(males-12.6 yrs, females 9.6yrs): 3 stages • Ossification of hamular process of hamate. • Ossification of pisiform. • Epiphysis and diaphysis of radius has same width. www.indiandentalacademy.com
  25. 25. Third stage (Pisi-, H1-, and R = - Stage) www.indiandentalacademy.com
  26. 26. Stage 4(males-13.0yrs, females 10.6yrs): Initial mineralization of ulnar sesamoid of thumb. Increased ossification of the hamular process of hamate. Shortly before or at the beginning of the pubertal growth spurt. www.indiandentalacademy.com
  27. 27. Fourth stage (S- and H2-stage) www.indiandentalacademy.com
  28. 28. Stage 5(males-14 yrs, females 11yrs): Capping of diaphysis is seen in • Middle phalanx of 3rd finger. • Proximal phalanx of thumb. • Radius. marks the peak of pubertal growth. www.indiandentalacademy.com
  29. 29. Fifth stage (MP3cap ;PP1cap ;and Rcap-stage) www.indiandentalacademy.com
  30. 30. Stage 6(males-15 yrs, females 13.3yrs): Visible union of diaphysis and epiphysis at the distal phalanx of the middle finger. Signifies end of pubertal growth spurt. www.indiandentalacademy.com
  31. 31. Sixth stage (DP3u-stage) www.indiandentalacademy.com
  32. 32. Stage 7(males-15.9 yrs, females 13.9 yrs): Visible union of the epiphysis and diaphysis at the proximal phalanx of middle finger. www.indiandentalacademy.com
  33. 33. Seventh stage (PP3u-stage) www.indiandentalacademy.com
  34. 34. Stage 8(males-15.9 yrs, females 13.9yrs): Union of epiphysis and diaphysis at middle phalanx of middle finger. www.indiandentalacademy.com
  35. 35. Eighth stage (MP3u-stage) www.indiandentalacademy.com
  36. 36. Stage 9(males-18.5 yrs, females 16 yrs): Complete union of epiphysis and diaphysis of radius. Ossification of all bones is complete and skeletal growth is complete. www.indiandentalacademy.com
  37. 37. Ninth stage (Ru-stage) www.indiandentalacademy.com
  38. 38. An Overview www.indiandentalacademy.com
  39. 39. Correlation table between ossification stages of hand bones and the skeletal age for the period between 8 and 18 years www.indiandentalacademy.com
  40. 40. www.indiandentalacademy.com
  41. 41. www.indiandentalacademy.com
  42. 42. Fishman’s skeletal maturity indicator • In 1982 – Leonard Fishman gave system of skeletal maturation assessment (SMA). • 11 skeletal maturity indicators (SMI’s) were described. Maturational patterns and prediction during adolescence. Leonard Fishman. Angle Orthodontist: No. 3: 1987:178-193 www.indiandentalacademy.com
  43. 43. 11 SMI were divided into 4 stages • Epiphysis as wide as diaphysis. • Ossification. • Capping of epiphysis. • Fusion of epiphysis and diaphysis. www.indiandentalacademy.com
  44. 44. Epiphysis as wide as diaphysis 1. Third finger-proximal phalanx 2. Third finger-middle phalanx 3. Fifth finger-middle phalanx www.indiandentalacademy.com
  45. 45. Ossification 4. Adductor sesamoid of thumb. www.indiandentalacademy.com
  46. 46. Capping of epiphysis 5. Third finger – distal phalanx. 6. Third finger – middle phalanx. 7. Fifth finger – middle phalanx. www.indiandentalacademy.com
  47. 47. Fusion of epiphysis and diaphysis 8. Third finger – distal phalanx. 9. Third finger – proximal phalanx. 10. Third finger – middle phalanx. 11. Radius. www.indiandentalacademy.com
  48. 48. www.indiandentalacademy.com
  49. 49. • Accelerating growth velocity period (1–4) • High growth velocity period (4–7) • Decelerating velocity period (7–11) www.indiandentalacademy.com
  50. 50. Conclusion • SMI occurs at earlier chronological ages for girls. • SMI make it possible to judge an individual relative timing of maturation – whether it is early, average or late. • Comparison of boys and girls on maturational time scale shows no sexual differences in the percentages of completion of incremental growth at same SMI levels, regardless of chronological age. www.indiandentalacademy.com
  51. 51. • Early maturers of both sexes exhibited almost identical SMI duration values for SMI’s 1-5 & 7- 11. The only significant difference in SMI duration for early group is between SMI 5 & 6. Girls in general reach the point of peak velocity of growth at SMI 5, and boys at SMI 6. www.indiandentalacademy.com
  52. 52. • In late maturation groups, considerably less correlation is found between male and female groups, although duration of time between SMI’s 1-2 and 10-11, at beginning and end of adolescent period, are very similar. www.indiandentalacademy.com
  53. 53. Levels of maturation - FEMALE www.indiandentalacademy.com
  54. 54. Levels of maturation - MALE www.indiandentalacademy.com
  55. 55. Julien Singer method Six stages are described: • Stage 1 (early) : Pisiform is absent. Hook of hamate absent. Epiphysis of proximal phalanx of 2nd finger being narrow than diaphysis. Angle orthodontist: 1980, 322-333www.indiandentalacademy.com
  56. 56. • Stage 2 (prepubertal) : Proximal phalanx of 2nd finger is equal to its epiphysis. Initial ossification of hook of hamate. Initial ossification of pisiform. • Stage of adolescent growth spurt during which significant amount of growth is possible. www.indiandentalacademy.com
  57. 57. • Stage 3 (pubertal onset): Calcification (beginning) of ulnar sesamoid. Increased width of proximal phalanx of 2nd finger. Increased calcification of hook of hamate. Increased calcification of pisiform. www.indiandentalacademy.com
  58. 58. • Stage 4 (pubertal stage): Calcification of ulnar sesamoid. Capping of diaphysis of middle phalanx of 3rd finger by its epiphysis. www.indiandentalacademy.com
  59. 59. • Stage 5 (pubertal deceleration): Full calcification of ulnar sesamoid. Fusion of epiphysis of distal phalanx of 3rd finger with its diaphysis. Epiphysis of radius and ulna not fused completely with diaphysis. Phalanges and carpels are fully calcified. www.indiandentalacademy.com
  60. 60. • Stage 6 (growth completion): No remaining growth site is seen. www.indiandentalacademy.com
  61. 61. Maturation indications and pubertal growth spurt • Urban Hägg and John Taranger did a study in 1982 to investigate pubertal growth spurt and dental, skeletal and pubertal development. Am J Orthod: 82: oct 1982 www.indiandentalacademy.com
  62. 62. Method of analysis • Adolescent growth: was studied by graphic analysis of the unsmoothed incremental curves of standing height. These curves were based on the annual increments from 3 to 20 years. www.indiandentalacademy.com
  63. 63. Method of analysis • Dental development was assessed by dental emergence stages (DES). www.indiandentalacademy.com
  64. 64. Method of analysis • Skeletal development in the hand and wrist was analyzed from annual radiographs, taken between the ages of 6 and 18 years, by assessment of the ossification of the ulnar sesamoid of the metacarpophalangeal joint of the first finger (S) and certain specified stages of three epiphyseal bones (closure of epiphyseal plates): the middle and distal phalanges of the third finger (MP3 and DP3) and the distal epiphysis of the radius (R). www.indiandentalacademy.com
  65. 65. Method of analysis • Pubertal development was assessed from 10 to 18 years by determining the occurrence of menarche in girls and the voice change in boys. www.indiandentalacademy.com
  66. 66. 3 stages of voice changes were used: • PPV – prepubertal voice; the pitch of the voice had not changed noticeably. • PV – pubertal voice; the pitch of the voice had changed noticeably but the voice had not yet acquired adult characteristics. • MV – male voice; the pitch of the voice had acquired adult characteristics. www.indiandentalacademy.com
  67. 67. Pubertal growth spurt www.indiandentalacademy.com
  68. 68. Results • The pubertal growth spurt – ONSET of spurt is the annual increment from which there is a marked continuous increase in growth rate of PHV (peak height velocity). ONSET is found by locating the smallest annual increment (A) from which there is continuous increase in growth rate to PHV. On average, the pubertal growth spurt began (ONSET) at 10.0 & 12.1 yrs. and ended (END) at 14.8 & 17 yrs in girls and boys respectively. In both sexes PHV occurred 2 yrs ONSET, i.e. at 12.0yrs in girls and 14.1yrs in boys. www.indiandentalacademy.com
  69. 69. Results • Dental development and pubertal growth spurt - The dental development was more advanced in boys than in girls at all three pubertal growth events. • The dental emergence stages were not useful as indicators of the pubertal growth spurt. www.indiandentalacademy.com
  70. 70. Results • Skeletal development and the pubertal growth spurt - Skeletal development at ONSET and PHV was more advanced in girls than in boys, whereas at END the skeletal development was more advanced in boys. www.indiandentalacademy.com
  71. 71. The skeletal stages were useful as indicators of the pubertal growth spurt. Skeletal stages: • Sesamoid – it appeared during the acceleration period of pubertal growth spurt (ONSET - PHV). www.indiandentalacademy.com
  72. 72. Middle third phalanx: • MP3-F - was attained before ONSET by about 40 percent of the subjects and at PHV by the last subjects. The epiphysis is as wide as metaphysis. • MP3-FG – epiphysis is as wide as metaphysis and there is distinct medial and/or lateral border of the epiphysis forming a line of demarcation at right angle to distal border. This stage is attained by 1yr before or at PHV. www.indiandentalacademy.com
  73. 73. www.indiandentalacademy.com
  74. 74. • MP3-G – the sides of the epiphysis have thickened and also caps its metaphysis forming a sharp edge distally at one or both sides. This stage is attained at or 1 yr after PHV. • MP3-H – fusion of epiphysis and metaphysis has begun. It is attained after PHV but before the END. • MP3-I - fusion of epiphysis and metaphysis is complete. It was attained before or at END in all subjects. www.indiandentalacademy.com
  75. 75. Distal third phalanx: • DP3-I – it is attained during the deceleration period of the pubertal growth spurt. The fusion of epiphysis and metaphysis is complete. Radius: • R-I – it is attained 1 yr before or at the END. Fusion of the epiphysis and metaphysis has begun. • R-J - Fusion of the epiphysis and metaphysis is complete. www.indiandentalacademy.com
  76. 76. Pubertal development and pubertal growth spurt • Pubertal development (menarche and voice change) and pubertal growth events has a close relationship in both sexes. • Menarche occurred 1.1yr after peak height velocity. The pubertal voice was attained 0.2 yrs before PHV and male voice 0.9yrs after PHV. www.indiandentalacademy.com
  77. 77. Discussion • Reliable indications taken from skeletal development were found for PHV and END but not for beginning (ONSET) of pubertal growth spurt. • During the end of the prepubertal period the radiographic changes in the form of bones of hand wrist are small. Therefore there is a lack of indications during this period. www.indiandentalacademy.com
  78. 78. CERVICAL VERTEBRAE MATURATION www.indiandentalacademy.com
  79. 79. • 1972 – Lamparski was the 1st person to study cervical vertebrae and he found them to be as reliable as hand wrist film. • He found that cervical vertebrae indicators were same for males and females, but the females developed the changes earlier. www.indiandentalacademy.com
  80. 80. • 1n 1995 – Hassel and Farman modified the Lamparski criteria by using C2, C3, and C4 cervical vertebrae. www.indiandentalacademy.com
  81. 81. Lamparski method • Stage 1 – the inferior borders of the bodies of all cervical vertebrae are flat. The superior borders are tapered from posterior to anterior. • Stage 2 – a concavity develops in the inferior border of the second cervical vertebrae. The anterior vertical height of bodies increase. www.indiandentalacademy.com
  82. 82. Lamparski method • Stage 3 – a concavity develops in the inferior border of the third vertebrae. • Stage 4 – a concavity develops in inferior border of 4th vertebrae. Concavities in lower border of 5th and 6th vertebrae are beginning to form. The bodies of all cervical vertebrae are rectangular in shape. www.indiandentalacademy.com
  83. 83. Lamparski method • Stage 5 – concavities are well defined in the lower border of the bodies of all 6 cervical vertebrae. The bodies are nearly square in shape. • Stage 6 – all concavities have deepened. The vertebral bodies are now higher than they are wide. www.indiandentalacademy.com
  84. 84. Cervical vertebrae maturation indicators using C3 as guide. www.indiandentalacademy.com
  85. 85. Brent Hassel, Allan Farman • Category 1 (Initiation) – at this stage adolescent growth was just beginning and 80% to 100% of the growth was expected. Inferior borders of C2, C3 and C4 were flat at this stage. The vertebrae are wedge shaped, and the superior vertebral border were tapered from posterior to anterior. AJODO: Jan 1995 www.indiandentalacademy.com
  86. 86. CVMI 1 www.indiandentalacademy.com
  87. 87. Category 2 (Acceleration) – growth acceleration was beginning at this stage with 65% to 85% of adolescent growth expected. • Concavities were developing in the inferior border of C2, C3. • The inferior border of C4 was flat. • The bodies of C3 and C4 were nearly rectangular in shape. www.indiandentalacademy.com
  88. 88. CVMI 2 www.indiandentalacademy.com
  89. 89. Category 3 (Transition) – adolescent growth was still accelerating at this stage towards peak height velocity with 25% to 65% of adolescent growth expected. • Distinct concavities were seen in the inferior borders of C2 and C3. • Concavity was beginning to develop in the inferior border of C4. • The bodies of C3 and C4 were rectangular in shape. www.indiandentalacademy.com
  90. 90. CVMI 3 www.indiandentalacademy.com
  91. 91. Category 4 (Deceleration) – adolescent growth began to decelerate dramatically at this stage with 10% to 25% of adolescent growth expected. • Distinct concavities were seen in the inferior borders of C2, C3 andC4. • The vertebral bodies of C3 and C4 were becoming more square in shape. www.indiandentalacademy.com
  92. 92. CVMI 4 www.indiandentalacademy.com
  93. 93. Category 5 (Maturation) – final maturation of the vertebrae took place during this stage, with 5% to 10% of adolescent growth expected. • More accentuated concavities were seen in the inferior borders of C2, C3 and C4. • The bodies of C3 and C4 were nearly square to square in shape. www.indiandentalacademy.com
  94. 94. CVMI 5 www.indiandentalacademy.com
  95. 95. Category 6 (Completion) – growth was considered to be complete at this stage. • Deep concavities were seen in the inferior borders of C2, C3 and C4. • The bodies of C3 and C4 were square or were greater in vertical dimension than in horizontal dimension. www.indiandentalacademy.com
  96. 96. CVMI 6 www.indiandentalacademy.com
  97. 97. Cervical Vertebral Maturation (CVM) Method for the Assessment of Mandibular Growth • Greatest effects of functional appliances take place when the peak in mandibular growth is included in treatment period. • Tiziano Baccetti, Lorenzo Franchi, James A. McNamara Jr. Angle Orthod 2002;72:316–323. www.indiandentalacademy.com
  98. 98. Components of study • C2, C3 andC4. • 706 subjects. • Co-Gn = total mandibular length. • Maximum increment between two consecutive cephalograms defines peak in mandibular growth at puberty. • Six consecutive cephalograms. www.indiandentalacademy.com
  99. 99. • Lambarski’s CVM I and CVM II are merged (CVMS I). • CVMS = cervical vertebrae maturation stage. • 5 maturational stages. www.indiandentalacademy.com
  100. 100. www.indiandentalacademy.com
  101. 101. www.indiandentalacademy.com
  102. 102. CVMS I • Lower border of C2, C3 and C4 is flat. • C2 may present slight concavity. • Bodies of C3 and C4 are trapezoidal. • Peak mandibular growth will occur not earlier than 1yr after this stage. www.indiandentalacademy.com
  103. 103. CVMS II • Concavities present at the lower border of C2 and C3. • Bodies of C3 and C4 – either trapezoid or rectangular horizontal in shape. • Peak in mandibular growth will occur within 1yr after this stage. www.indiandentalacademy.com
  104. 104. CVMS III • Concavities at the lower border of C2, C3 and C4 are present. • Bodies of C3 and C4 – rectangular horizontal in shape. • Peak in mandibular growth has occurred within two years before this stage. www.indiandentalacademy.com
  105. 105. CVMS IV • Concavities at the lower border of C2, C3 and C4 are present. • At least one of the bodies of C3 and C4 is squared in shape. • The peak in mandibular growth has occurred not later than one year before this stage. www.indiandentalacademy.com
  106. 106. CVMS V • The concavities at the lower borders of C2, C3, and C4 still are evident. • At least one of the bodies of C3 and C4 is rectangular vertical in shape. • The peak in mandibular growth has occurred not later than two years before this stage. www.indiandentalacademy.com
  107. 107. Discussion • When CVMS 1 is diagnosed in the individual patient with mandibular deficiency, clinician can wait least 1 year for a radiographic re- evaluation aimed to start treatment with functional appliances. • CVMS 2 represents the ideal stage to begin functional jaw orthopedics. www.indiandentalacademy.com
  108. 108. Mid palatal suture region as an indicator of maturity • Revelo and Fishman in 1994 evaluated the ossification pattern of the mid palatal suture. • Maturational evaluation was accomplished by examining the hand wrist radiographs with Fishman’s system of SMA. Revelo, Fishman AJO: 105:mar 1994.www.indiandentalacademy.com
  109. 109. Key landmarks and planes • Point A – most anterior point on premaxilla. • Point B – most posterior point on the posterior wall of the incisive foramen. • Point P – point tangent to a line connecting the posterior walls of the greater palatine foramen. www.indiandentalacademy.com
  110. 110. Key landmarks and planes • A-P – total dimension of the suture. • A-B – anterior dimension of the suture. • B-P – posterior dimension of the suture. www.indiandentalacademy.com
  111. 111. www.indiandentalacademy.com
  112. 112. Results • Significant correlation between maturational development and beginning of ossification of mid palatal suture. • Before SMI 4 i.e. before ossification of adductor sesamoid, very little or no midpalatal approximation exists. • Suture is only 8% fused at SMI 3. • Anterior portion of suture is wide open. www.indiandentalacademy.com
  113. 113. Results • SMI 4-7 i.e. ossification of adductor sesamoid, capping with distal and middle phalanx of 3rd finger, osseous interdigitation is evident with approximation in some areas. • This period occurs during the pubertal growth spurt. www.indiandentalacademy.com
  114. 114. Results • After SMI 8 i.e. fusion of distal phalanx of 3rd finger, the suture demonstrates a marked increase in rate of approximation. • At maturational age SMI 11 i.e. fusion of radius, 50% of total midpalatal suture is approximated. • High percentage of approximation occurs posteriorly. www.indiandentalacademy.com
  115. 115. Results • No difference in patterns of approximation between males and females. • Thus, best time to use orthopedic force for expansion is before SMI 9 as percentage of approximation is less. • Ideal time is SMI 1 to 4 as less orthopedic force is required. www.indiandentalacademy.com
  116. 116. Frontal sinus development as an indicator for somatic maturation at puberty Am J Orthod Dentofac Orthop 1996; 110:476-82. www.indiandentalacademy.com
  117. 117. • Sabine Ruf and Hans Pancherz. • The study was performed on 53 adolescent boys, and the frontal sinus size development was assessed on lateral head films. • Two head films from each subject were analyzed on a 1- or 2-year interval basis. Thus, two prediction intervals of 1 (T1) and 2 years (T2) were formed. www.indiandentalacademy.com
  118. 118. • In the adolescent, the stage of somatic maturity may influence the selection of the appliance, the course of treatment and the mode of retention after therapy. • For the assessment of the status of the pubertal growth period, longitudinal records of the body height development (velocity growth curves) have been recommended. www.indiandentalacademy.com
  119. 119. Landmarks • Sh – highest point on peripheral border of frontal sinus. • Sl – lowest point on peripheral border of frontal sinus. • Perpendicular to the interconnecting line (Sh-Sl), the maximum width of the frontal sinus was assessed. www.indiandentalacademy.com
  120. 120. www.indiandentalacademy.com
  121. 121. • Average yearly body height growth velocity (mm/yr) was calculated. • Bp (body height peak) = maximum body growth velocity at puberty (used to test the accuracy of prediction of pubertal stage as assessed from frontal sinus development). www.indiandentalacademy.com
  122. 122. Somatic maturity prediction • Frontal sinus growth velocity at puberty is closely related to body height growth velocity. • Well defined pubertal peak (Sp), on average, occurs 1.4 years after the pubertal body height peak (Bp). • Males – average age at frontal sinus peak is 15.1 years. www.indiandentalacademy.com
  123. 123. www.indiandentalacademy.com
  124. 124. Somatic maturity prediction • Peak growth velocity in the frontal sinus of atleast 1.3mm/yr is attained in 1 yr observation. • In 2 yr observation interval, a peak velocity in the frontal sinus of atleast 1.2mm/yr is attained. www.indiandentalacademy.com
  125. 125. www.indiandentalacademy.com
  126. 126. Prediction procedure • Frontal sinus growth velocity (Sv) in each person was compared with T1 and T2(threshold) values. • If Sv is as high as or higher than T value (T1 or T2), it may be expected that the frontal sinus peak was reached during prediction interval. www.indiandentalacademy.com
  127. 127. Prediction procedure • If the Sv is lower than the T-value, it cannot be said whether the subject is pre peak or post peak in frontal sinus growth. • May be related to chronologic age (frontal sinus peak at 15.1 years). www.indiandentalacademy.com
  128. 128. Relationship between mandibular canine calcification stages and skeletal maturity. -Sandra Cortinho, Peter H. Buschang. AJODO:104:sept 1993. www.indiandentalacademy.com
  129. 129. • Handwrist radiographs and dental panoramic radiographs of 200 boys and 215 girls were assessed. www.indiandentalacademy.com
  130. 130. Stage D: • Crown formation is complete down to C.E. junction. • Superior border of the pulp chamber in the uniradicular teeth has a definite curved form being concave towards cervical region. • The projection of pulp horns, if present gives outline shaped like an umbrella top. • Beginning of root formation is seen in the form of a spicule. www.indiandentalacademy.com
  131. 131. Canine development stage • Stage D: www.indiandentalacademy.com
  132. 132. Stage E: • The walls of the pulp chamber now form straight lines whose continuity is broken by the presence of the pulp horn, which is larger than in the previous stage. • The root length is less than the crown height. www.indiandentalacademy.com
  133. 133. Stage E www.indiandentalacademy.com
  134. 134. Stage F: • The walls of the pulp chamber now form a more or less an isosceles triangle. The apex ends in a funnel shape. • The root length is equal to or greater than the crown height. www.indiandentalacademy.com
  135. 135. Stage F www.indiandentalacademy.com
  136. 136. Stage G • The walls of the root canal are now parallel and its apical end is still partially open. www.indiandentalacademy.com
  137. 137. Stage H: • The apical end of the root canal is completely closed. • The periodontal membrane has a uniform width around the root and the apex. www.indiandentalacademy.com
  138. 138. Stage H www.indiandentalacademy.com
  139. 139. Results • The initiation of spurt is indicated by canine stage F i.e. the epiphysis of the 3rd and 5th middle phalanges are equal in length to their diaphysis. • No appearance of adductor sesamoid. • The mean skeletal age for the presence of the adductor sesamoid in the girls and the boys are 12.2 years and 13.2 years, respectively. www.indiandentalacademy.com
  140. 140. • In stage G, most show the adductor sesamoid. • Capping of the diaphysis of the middle and distal phalanges of the third finger, and capping of the proximal phalanx of the fifth finger. • Stage G coincides with the eruption of the canine into the oral cavity, occurs approximately 1 year before the PHV in boys, but only 5 months before the PHV in girls. • This may reflect hormonal changes which accompany puberty. www.indiandentalacademy.com
  141. 141. • Thus, stage F indicates puberty. • Stage G indicates peak height velocity (PHV). • The intermediate stage between stage F and G should be used to identify the early stages of the pubertal growth spurt. • Canine development cannot and should not be used as a sole criteria to predict development landmarks. www.indiandentalacademy.com
  142. 142. Arcial growth prediction www.indiandentalacademy.com
  143. 143. Principle • A normal mandible grows by superior-anterior apposition vertically at the Ramus on a curve or arc which is a segment formed from a circle. • The radius of this circle is determined by using the distance from Mental Protruberance to a point at the forking of the stress lines at the terminus of the oblique ridge on the medial side of the Ramus (Point Eva). www.indiandentalacademy.com
  144. 144. Historical Review • Hunter (1771) : Compared a series of dried mandibles and concluded that, in order to attain space for the development of permanent molar teeth, the mandible must grow by posterior apposition of the Ramus accompanied by anterior Ramal resorption. www.indiandentalacademy.com
  145. 145. • Humprey (1866): Tied wires around the Mandibles of pigs and showed that the wire became embedded in the posterior margin and free in the anterior area of the Ramus which seemed to be verify the Hunter’s hypothesis. www.indiandentalacademy.com
  146. 146. • Brash (1924): Fed pigs the madder plant root which contains the red stain alizarin and therefore labeled appositional growth. • He concluded that apposition occurred posteriorly and superiorly on the Ramus of the growing pig mandible. www.indiandentalacademy.com
  147. 147. THE COMPUTER (PRIMARY) STUDY • Although the previous method was useful for practical short term predictions, a method was sought whereby mandibular growth patterns could be identified with greater certainty. • Next move towards improving the method was to identify a “central core” cephalometrically as external mandibular forms for reference are unsuitable. www.indiandentalacademy.com
  148. 148. Locating a Cephalometric Central Core Point Xi • Located the following points on the Cephalogram : R1 = deepest point on subcoronoid incisure R2 = directly opposite R1 on the posterior border of the Ramus R3 = at the depth of the sigmoid notch R4 = a point directly inferior to R3 on the lower border of the Ramus www.indiandentalacademy.com
  149. 149. • By using these points, the centroid of the Ramus is selected by forming a rectangle and connecting the corners. • Occlusal plane has a strong tendency to pass through the Xi point. • Xi also represents the entrance of the neuro trophic bundle into the Mandible. www.indiandentalacademy.com
  150. 150. Suprapogonion • Labeled as Pm for Protuberance Menti. • It is a bony crest located at the antero-superior contour of the Symphysis. • On the cephalogram, it is the point selected on the anterior border of the Symphysis between Point B and Pogonion where the curvature changes from concave to convex. • Accepted as the most stable reference for anterior- most basal bone in the mandible. ( Bjork )www.indiandentalacademy.com
  151. 151. Point DC • A point selected in the centre of the neck of the Condyle where the Basion-Nasion plane crosses it. Condyle Axis • Formed by connecting Points DC and Xi. Corpus Axis • Formed by joining Xi to Pm. www.indiandentalacademy.com
  152. 152. • By studying linear growth on these planes and the form change as a change in the angulation between the two, an interpretation could be gained regarding the characteristics of growth in a given patient as well as for groups with age and sex differences. www.indiandentalacademy.com
  153. 153. SAMPLE • A five year growth study of the Mandible on the computer. • Lateral and frontal cephalograms taken on 40 patients. • Age: T1= 8 years (avg) +/- 2 T2= 13 years • Sex: Males= 20 Females= 20 • Occlusion: Class I= 20 Class II= 20 www.indiandentalacademy.com
  154. 154. RESULTS • Samples were superimposed on the Corpus Axis and registered at Xi point. • Mandible was found to bend 0.5 each year. • Lower facial height ( ANS-Xi-Pm) was found to be highly stable. • It does not change during normal growth. www.indiandentalacademy.com
  155. 155. The sample are superimposed on the corpus axis and registered at Xi point as the mandible was found to bend about one half degree each year. www.indiandentalacademy.com
  156. 156. THE SECONDARY STUDY • He sought a more detailed mechanism to explain the development of the mandible. • The fact that a bending was occurring in an orderly fashion was recognized. • Therefore, greater the magnitude of growth, greater the bending. • Apparently, a growth arc was operative. www.indiandentalacademy.com
  157. 157. • Experiments were undertaken to determine a method by which the form and size of the mandible, after a 5 year growth interval, could be predicted with use of only the first X-ray as a reference. • The size increases and form alterations were available from the previous study. www.indiandentalacademy.com
  158. 158. • The first arc was constructed in the Time 1 composite through the three points : Pm, Xi, Dc • By extending this arc, the size increase was produced but not enough bending was produced. • The mandible became more obtuse than was the actual behaviour. www.indiandentalacademy.com
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  160. 160. • A second arc was made by joining the following points: 1. tip of coronoid process 2. anterior border of ramus at its deepest curve 3. suprapogonoin • The extension of this curve exhibited in the segment of the circle too small in radius. • Showed excessive bending of the mandible. www.indiandentalacademy.com
  161. 161. www.indiandentalacademy.com
  162. 162. • Hence, the characteristics of typical growth had been bracketed by the two arcs produced. • Therefore, an arc was constructed bisecting these previous two arcs. • Established a halfway point between Xi and R1 points and using the distance from this point to Pm as a radius of a circle, an arc could be produced. www.indiandentalacademy.com
  163. 163. • The use of this arc bent the mandible by a fraction too much. • Additionally, a radius selected from this point would increase with the size of the mandible and a changing arc would result. • Next, he thought that perhaps the stress lines of the mandible might be useful. www.indiandentalacademy.com
  164. 164. • The mandible used for studying the stress lines was 850 years old. • It had been weathered to a state of disintegration of the interprismatic substance of the external cortical bone. • Hence, it clearly showed the stress lines in the outer and inner plates. • Hoped that these functional stress lines could yield clues about mandibular development. www.indiandentalacademy.com
  165. 165. Stress lines on Lateral side • There is convergence of stress lines at the protuberance menti. • Stress lines swing downward and then upward and backward and outward through the external oblique ridge • An irregular gnarled area was present at the base of the coronoid process as the stress seemed to divide forward or backward in respect to condylar or coronoid demands. www.indiandentalacademy.com
  166. 166. www.indiandentalacademy.com
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  168. 168. Stress lines on Medial side • Greater forking was present than laterally. • Stresses followed the Mylohyoid ridge upward into a thick mass to terminate at a Y-shaped bony prominence. www.indiandentalacademy.com
  169. 169. • Further study of several dozen mandibles led to the observation of small, nutritive foramina immediately superior to this area medially. • Hypothesized that this could be an important mandibular growth area. www.indiandentalacademy.com
  170. 170. Locating point Eva • A line from Xi point to Sigmoid notch is bisected and a parallel point ( RR ) is selected on the anterior border of the Ramus. • RR point is connected to Point R3 at the lower border of the sigmoid notch. www.indiandentalacademy.com
  171. 171. • This line is crossed by a second line selected from a point midway at the base of the coronoid process to Xi point. • The crossing of these two lines is called as Point Eva. • This point approximates the center of the upward and forward quadrant of the Ramus. • It also almost exactly coincides with the forking of the stress lines on the internal and outer table of the Ramus. www.indiandentalacademy.com
  172. 172. Locating point TR • Point TR (true radius) is of equal distance from Point Eva and Pm. • The arc formed by joining Point Eva and Pm with Point TR as the center of the circle represents the true arc for the growth of the mandible. • The point of intersection of the arc with the border of the sigmoid notch is called as Mu. www.indiandentalacademy.com
  173. 173. • When the size increase of the mandible as determined by the computer study was incrementally added to the arc at the sigmoid notch, the predicted mandible was almost absolutely correct in size and form when compared with the final composite. www.indiandentalacademy.com
  174. 174. Growth Prediction • Head films of a male patient, age 9 years, were chosen. • The patient was observed until almost 19 years of age and no orthodontic treatment was rendered. Step 1 • The amount of growth of the mandible on the arc from the point Mu on the Sigmoid notch is 2.5 mm each year. www.indiandentalacademy.com
  175. 175. • This was calculated from the previous study and found to be an excellent population constant. • Cutoff for growth= 14.5 years (females) 19 years (males) • Apposition at the lower border of the symphysis of the males occurs at about 1mm every 8 years. www.indiandentalacademy.com
  176. 176. www.indiandentalacademy.com
  177. 177. Step 2 • Next, 20 longitudinal cases with a range of duration of 5-12 years were measured. • Study revealed that increases in condylar and coronoid processes were different when measured from Point Mu. • The condylar and coronoid processes grow upward and outward in a direction as a function of the curve of the original arc. www.indiandentalacademy.com
  178. 178. • The k factor for coronoid process growth was 0.8 mm per year. • The condylar k factor was variable. • Long condyles = 0.4 mm per year Short and weak condyles = 0 mm Average condyles = 0.2 mm per year. www.indiandentalacademy.com
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  180. 180. Step 3 •In males, an addition of 0.2 mm per year is done on the border of the mandible from the arc. • No such addition is done in case of females. • The gonial angle drifted posteriorly on the arc one half the total increase in mandibular growth on the arc. www.indiandentalacademy.com
  181. 181. www.indiandentalacademy.com
  182. 182. Step 4 • The last step is to determine the space available for the mandibular third molar at the anterior border of the Ramus. • With normal anatomic contouring, the coronoid process is connected to RR point. It determines the ramal width. • Slightly below this point, the External oblique ridge shows apposition of 0.4 mm per year. www.indiandentalacademy.com
  183. 183. www.indiandentalacademy.com
  184. 184. PARENTAL DATA According to studies by Suzuki and Takahama “Facial growth prediction based on parental data”, there is high level of significance of correlation between parents and offsprings and siblings regarding craniofacial dimension. • The craniofacial forms of children with a certain degree of bone maturity were significantly correlated with those of their parents. www.indiandentalacademy.com
  185. 185. • The genetic influence of parents of their children appeared equal. • Daughters seemed to be more affected genetically than sons by their parents. • The co-efficient of correlation of craniofacial forms between children and their parents increased from childhood to adulthood. www.indiandentalacademy.com
  186. 186. More precise prediction of individual growth could be made by applying genetic data obtained from similarities in craniofacial characteristics between children and their parents • The face of the offspring often resembles that of at least one of his or her parents. www.indiandentalacademy.com
  187. 187. • If the face of a young offspring resembles the face of either parent, it will continue to resemble that parent when the offspring becomes an adult. That is, the phenotype of facial appearance does not change with growth. • If the craniofacial type of an offspring resembles that of the father or the mother in the early growing stage, its adult craniofacial type will be nearly like that of the same parent. Thus the craniofacial form of offspring can be predicted from parental data. www.indiandentalacademy.com
  188. 188. There is high correlation between the craniofacial form of an offspring and that of his or her parents. The relationship becomes closer with growth, so it is better to use the parental information than to use average growth curves when the individual growth of a child is to be determined. www.indiandentalacademy.com
  189. 189. CRANIOFACIAL TEMPLATES FOR ORTHODONTIC ANALYSIS In recent years, direct comparison of patients with templates derived from various growth studies has become a reliable method of analysis, with the considerable advantage that compensatory skeletal and dental deviations within an individual can be observed directly. www.indiandentalacademy.com
  190. 190. The measurements for comparison with the norms should have several characteristics: • It should be useful clinically in differentiating patients with skeletal and dental characteristics of malocclusion. • It should not be affected by the size of the patient. • It should be unaffected by the age of the patient. www.indiandentalacademy.com
  191. 191. Templates exist in two forms : • Schematic – it shows the changing position of landmarks with age on a single template. • Anatomically complete- it is a different one for each age, they are convenient for direct visual comparison of a patient with reference group while accounting for age. www.indiandentalacademy.com
  192. 192. • While selecting a template, two things have to be kept in mind: – Patient’s physical size – Developmental age www.indiandentalacademy.com
  193. 193. • Cranial base superimposition, which allows the relationship of the maxilla and mandible to the cranium to be evaluated. www.indiandentalacademy.com
  194. 194. • Second superimpostion is on the maximum contour of the maxilla to evaluate the relationship of the maxillary dentition to the maxilla. www.indiandentalacademy.com
  195. 195. • The third superimposition is on the symphysis of the mandible along the lower border, to evaluate the relationship of the mandibular dentition to the mandible. www.indiandentalacademy.com
  196. 196. Thank you www.indiandentalacademy.com For more details please visit www.indiandentalacademy.com

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