GROWTH - BASIC CONCEPT & ASSESSMENT OF GROWTH

GROWTH – BASIC
CONCEPT
& ASSESSMENT OF
GROWTH
Presented by :
Dr. Firdosh Rozy
Deptt. of orthodontics and
Dentofacial orthopaedics
1

CONTENTS
 Introduction
 Difference b/w growth and development
 Clinical importance of growth assessment
 Methods of assessment of growth
 Biological maturity indicators
 Radiological methods of assessment of skeletal growth
 Recent advancements
 Conclusion
 References
2

Introduction
Definition : Physiological increase in size, weight and mass of
a living organism.
(Kharbanda)
Increase in size (Todd)
Self multiplication of living substances (J.S. Huxley)
Change in any morphological parameter which is measurable.
(Moss)
GROWTH:
DEVELOPMENT:
Definition : It refers to a stage of growth & maturation
encompassing morphogenesis, differention, and
acquisition of functionality.
A progress towards maturity.
DEVELOPMENT = Growth + Differentiation + Translocation
3

Differences b/w Growth & Development :
GROWTH DEVELOPMENT
• Anatomic & physical
phenomenon
• Characterised by in physical
dimension.
• Usually unidirectional
• in quantitave
• Active growth stops after a
certain age.
• Anatomic & functional
phenomenon
• Characterised by differention
of function , acquisition of
functionality.
• Multidirectional
• Qualitative
• Continues
Kharbanda
4

An understanding of growth events is of primary
importance in the practice of clinical orthodontics.
 Maturational status can have considerable
influence on diagnosis, treatment goals, treatment
planning, and the eventual outcome of orthodontic
treatment.
Clinical decisions regarding use of extra oral traction
forces, functional appliances and orthognathic surgery are
based on growth considerations.
Prediction of both times and the amounts of active
growth, especially in the craniofacial complex, would be
useful to the orthodontist.
5

To determine potential vector of facial development.
To determine amount of significant facial cranial growth
potential left.
To evaluate rate (velocity) of growth.
To decide onset of treatment timing.
To decide type of effective treatment
a)orthopaedic-removal/fixed
b)orthodontic
c)orthognathic surgical procedure
d) combination of any of above
To evaluate treatment prognosis.
To understand role of genetics and environment on skeletal
maturation pattern.
CLINICAL IMPORTANCE:
Gurkreet
6

METHODS OF ASSESSMENT OF GROWTH:
Physical growth can be directly done by
1. Wt for age
2. Height for age
3. Height for wt
4. Mid arm circumference
1, 2, & 4 has less application in orthodontics.
Kharbanda
7

Biological Maturity Indicators:
 Neural age
 Mental age
 Physiological and biochemical age
 Chronological age
 Sexual and pubertal age
 Morphologic age
Gurkreet
11

 Age determination using growth charts
 Dental age
Tooth Mineralization
Tooth Eruption
 Skeletal age
Anatomical regions
Hand Wrist Radiographs
Cervical vertebral maturatinal status
12

NEURAL AGE
Gesell and his colleagues in America has done a great deal of
work on neural development in human.
Certain landmarks of development form important index of
maturity which can be correlated to chronological age, growth
and weight.
CLINICAL IMPORTANCE
Patient is mentally developed to understand need for treatment.
To what extend patient would be able to cooperate and follow
proper instructions.
13

MENTAL AGE :
Mental age is an index of maturation of mind.
It depends on many intrinsic and environmental
factors.
“Intelligence Quotient” by Stanford-Binet test/
Wechsler scale
Inteligence quotient (IQ)
-It is Mental age expressed as percentage of
chronological age. Thus child with mental age of 12 yrs
and chronological age of 10 yrs has IQ of 120
15

Originally developed, to help place children in
appropriate educational setting.
To Help in determine the level of intellectual &
cognitive functions
Diagnosis of learning disability
Level of co operation
CLINICAL IMPORTANCE :
16

PHYSIOLOGICAL & BIOCHEMICALAGE :
 Girls shows a spurt in systolic blood pressure which
occurs earlier than the corresponding spurts in male.
Resting mouth temperature which falls by 0.5 – 1ºc from
infancy to maturity and reaches its adult value earlier in
girls.
 In the plasma inorganic phosphate shows a steady fall
from the high levels of childhood to reach adult by the age
15 in girls &17 in boys.
17

 Alkaline phosphatase rises significantly in parallel
with growth b/w the ages of 8-12 yrs in girls and
10-14 yrs in boys.
 Ratio of creatinine in the urine fall progressively
with age after about 14.5 yrs probably under
hormonal influences.
18

CHRONOLOGICALAGE :
Defined as age measured by years lived since birth.
Its poor indicator of maturity.
It helps to categorize individual as
-early
-average
-late maturer
CLINICAL IMPORTANCE
Enables orthodontist to determine and predict the rate
and magnitude of facial growth.
Helps to decide the time, duration and method of
treatment
19

SEXUALAND PUBERTALAGE :
Stage of development of
secondary sexual characteristics
provides a physiologic calendar of
adolescence that correlates with
individuals ’s physical growth
status.
Puberty begins 2 years earlier in
girls than in boys and extends over
5 years in boys and 3 ½ in girls.
photo
20

GROWTH SPURTS:
 Period of sudden acceleration of growth.
Due to physiological alteration in hormonal secretion.
Timing - sex linked
 Normal spurts are
Infantile spurt – at 3 yrs of age
Juvenile spurt - 7-8 yrs females
8-10 yrs males
Pubertal spurt - 10-11 yrs females
15-18 yrs in males
photo
21

GROWTH SPURTS IN BOYS:
Total development of adolescent growth – 5 yrs
• Fat spurt
• Weight gain
• Fat distribution
STAGE 1
Beginning of
adolescent
growth
• Redistribution or reduction in
fat
• Pubic hair
STAGE 2
12 Months later
Height spurt begins
22

• Facial hair
• Axillary hair
• Muscular growth
STAGE 3
8-12 Months later
Peak velocity of
height
• Facial hair on chin & lip
• Adult body form
STAGE 4
15-24Months later
Growth spurt
ending
23

Total development of adolescent growth – 3 ½ yrs
• Appearenceof breast bud
• Initial pubic hair
STAGE 1
Beginning of adolescent
growth
• Noticeable breast development
• Auxillary hair
STAGE 2
12 months later
Peak velocity in
height
• Mense
• Broadning of hips
• Adult fat distribution
• Breast completed
STAGE 3
12-18 Months later
Growth spurt ending
GROWTH SPURTS IN GIRLS
:
24

Dental Age:
• Dental age is determined by observing the stages of dental
development and comparing it to known population standards.
• For assessment of dental age following point are used :-
 Number of erupted and unerupted teeth
 Stage of dentition(deciduous ,mixed or permanent)
 Stage of crown formation of developing teeth
 Stage of root formation of all erupted teeth
 The amount of resorption of the roots of primary teeth
25

Tooth
Calcification begins Crown completed Eruption Root completed.
Max Mand Max Mand Max Mand Max Mand
Central incisor 3 M 3 M 4 ½ Y 3 ½ Y 7 ¼ Y 6 ¼ Y 10 ½ Y 9 ½ Y
Lateral incisor 11 M 3 M 5 ½ Y 4 Y 8 ¼ Y 7 ½ Y 11 Y 10 Y
Canine 4 M 4 M 6 Y 5 ¾ Y 11 ½ Y 10 ½ Y 13 ½ Y 12 ¾ Y
1st premolar 20 M 22 M 7 Y 6 ¾ y 10 ½ Y 10 ½ Y 13 ½ Y 13 ½ Y
2nd premolar 27 M 28 M 7 ¾ Y 7 ½ y 11 Y 11 ¼ Y 14 ½ Y 15 Y
1st molar 32 W 32 W 4 ¼ Y 3 ¾ y 6 ¼ Y 6 Y 10 ½ Y 10 ¾ Y
2nd molar 27 M 27 M 7 ¾ Y 7 ½ y 12 ½ Y 12 Y 15 ¾ Y 16 Y
3rd molar 8 Y 9 Y 14 Y 14 Y 20 Y 20 Y 22 Y 22 Y
AVG CHRONOLOGY OF PERM. TOOTH DEVELOPMENT
26

DENTAL AGE DETERMINATION ACCORDING TO
THE STAGE OF MINERALIZATION
Classified into 9 stages by Demirjian et al in 1973
27

28
Stage E & F – 25-65 % of pubertal growth remaining
Stage G – 25% pubertal growth remaining
Stage H – indicate complition of growth spurt.

Relationships between mandibular canine
calcification stages and skeletal maturity
Coutinho S, et al. (1993)
Most children having attained canine stage
G showed presence of
 the adductor sesamoid (81%),
 capping of diaphysis of third middle
phalanx (77%)
 capping of the fifth proximal phalanx
(87%)
They concluded that a close association
exists between mandibular canine
calcification stage and skeletal maturity,
and canine calcification could serve as a
useful tool for evaluating children’s
skeletal maturation.
30

Stage E(Fig. 27)
 The walls of pulp chamber now
form straight lines, whose
continuity is broken by the
presence of the pulp horn, which is
larger in the previous stage.
 The root length is less than the
crown height.
31

STAGE F
Canine stage F indicates the
initiation of puberty
STAGE G
The timing of stage G is indicative
of peak height velocity(PHV)
The intermediate stage between
stages F and G is used to identify
the early stages of the pubertal
growth spurt
32

Basis for skeletal age assessment by radiographs :
is that different ossification centers appear and mature at
different times.
The order, rate, time of appearance and progress of ossification
in various ossification centers occurs in a predictable sequence
Methods to assess the skeletal maturity of an individual
include :
-Hand and wrist radiographs.
-Skeletal maturation evaluation using cervical vertebrae.
-Assessment of maturity by clinical and radiographic
examination of different stages of tooth development.
34

History:
The first recorded Hand-wrist radiograph film was
published by Sydney Rowland of London in 1896
This was just 4 months after the announcement of the
discovery of the X-Ray by Roentgen
35

X-RAY OF HAND & WRIST :
Carpals
Metacarpals
37

Stages of Ossification of the Phalanges :
Epiphysis
narrower than
diaphysis
38

Stage 2
Epiphysis width equal to
diaphysis
39

Stage 3 : capping stage
Epiphysis surrounds diaphysis
Like a cap.
40

Stage 4 : fusion stage
Bony fusion of epiphysis
& diaphysis
41

RADIOLOGICAL METHODS OF ASSESSMENT OF
SKELETAL GROWTH :
Greulich and Pyle method
Singer’s method of assessment
Bjork, Grace and Brown
Fishman’s skeletal maturity indicator
Hagg and Taranger
Hassel and Farmer
44

GREULICH & PYLE METHOD (1959)
•The sex of the patient is one of the most important piece of
information, because females develop quicker than males.
• The atlas “ATLAS OF SKELETAL MATURITY OF HAND” is
divided into two parts, one for the male patients and one for the
female patients.
•Each part contains standard radiographic images of the left hand of
children ordered by chronological age.
•The first step in an analysis is to compare the given radiograph with
the image in the atlas that corresponds closest with the chronological
age of the patient.
45

SINGER’S METHOD OF ASSESSMENT :
JULIAN SINGER 1980
Quiker & easier under routine clinical circumstances
6 stages of hand wrist development
Early
Pre pubertal
Pubertal Onset
Pubertal
Pubertal deceleration
Growth complition
47

Stage 1 (Early):
Absence of Pisiform
Absence of Hook of Hamate
Epiphysis of proximal phalanx of
second digit (PP2) being narrower
than its shaft
Just 1 yr before beginning of
peak pubertal
48

Stage 2 (Prepubertal):
Initial ossification of hook of
hamate .
Initial ossification of pisiform.
Proximal phalanx of second digit
and its epiphysis are equal in width
(PP2)
Represents period prior to
adolescent growth spurt.
At this stage significant amount
of mandibular growth possible.
49

Stage 3 (Pubertal onset):
Characterized by beginning of
calcification of Ulnar
sesamoid
Increased width of epiphysis
of Proximal phalanx of
second digit(PP2)
Increased calcification of
hamate hook and pisiform
50

Stage 4 (Pubertal):
Characterized by Calcified ulnar
sesamoid.
Capping of shaft of middle
phalanx of third digit by its
epiphysis (MP3cap)
This stage signifies accelerating
phase of pubertal growth spurt.
51

Stage 5 (Pubertal Deceleration):
Ulnar sesamoid fully calcified.
Calcification of the shaft of middle
phalanx of third digit by its epiphysis.
All phalanges and carpals fully
calcified.
Epiphysis of radius and ulna not
fully calcified with respective shafts.
This stage represents period of
growth when orthodontic treatment
might be completed and patient is in
retention therapy.
52

Stage 6 (Growth Complition )
No remaining growth sites
53

Stage Characteristic feature Relation of epiphysis and diaphysis Inference Stage
1 (early) 1.Absence of pisiform 2.absence of hook of hamate Epiphysis of
proximal phalanx of second finger being narrower than its diaphysis 1year
before beginning of peak pubertal growth Stage 2 (prepubertal) 1.Initial
ossification of hook of hamate 2.Initial ossification of pisiform PP2= Just
beginning of pubertal growth spurt. Mandibular growth potential is possible
Stage 3 (pubertal onset) 1.Begining of calcification of ulnar sesamoid
2.Increased calcification of hook of hamate and pisiform Increased width of
epiphysis of proximal phalanx of second finger Onset of pubertal growth spurt.
Stage 4 (pubertal) calcified ulnar sesamoid MP3 cap Accelerating phase of
pubertal growth spurt Stage 5 (pubertal deceleration) Fully calcified ulnar
sesamoid 1.DP3-U 2.Radius and ulna not fully fused with respect to shaft This
stage represent that period of growth when orthodontic treatment might be
completed and patient is on retention therapy Stage 6 No remaining growth
sites R-U Growth completed
STAGE
CHARACTERISTIC
FEATURE
RELATION OF
EPIPHYSIS &
DIAPHYSIS
INFERENCE
Stage 1 (early) 1.Absence of pisiform
2.absence of hook of hamate
Epiphysis of proximal
phalanx of second finger
being narrower than its
diaphysis
1 year before beginning of
peak pubertal growth
Stage 2 (prepubertal ) 1.Initial ossification of hook of
hamate
2.Initial ossification of pisiform
PP2 Just beginning of pubertal
growth spurt. Mandibular
growth potential is possible
Stage 3 (pubertal
onset)
1.Begining of calcification of ulnar
sesamoid
2.Increased calcification of hook of
hamate and pisiform
Increased width of
epiphysis of proximal
phalanx of second finger
Onset of pubertal growth
spurt
Stage 4 (pubertal) calcified ulnar sesamoid MP3 cap Accelerating phase of
pubertal growth spurt
Stage 5 (pubertal
deceleration)
Fully calcified ulnar sesamoid 1.DP3-U
2.Radius and ulna
not fully fused with
respect to shaft
This stage represent that
period of growth when
orthodontic treatment might
be completed and patient is
on retention therapy
Stage 6 No remaining growth sites R-U Growth completed
Article
54

BJORK, GRAVE & BROWN METHOD :
Skeletal development into 9 stages.
Appropriate chronological age for each stage was given by
Schoph in 1978.
STAGE 1
Male 10.6
Female 8.1
Epiphysis &
diaphysis of
proximal phalanx
of index finger are
equal.
55

STAGE 2
Male 12
female 8.1
Epiphysis & diaphysis
of middle phalanx of
middle finger are equal
56

FISHMAN’S SKELETAL MATURITY INDICATOR :
64

Fishman (1974) has given 11 Skeletal Maturity
Indicators(SMI)
Epiphysis as wide as
Diaphysis
1.Third finger – proximal phalanx
2.Third finger –middle phalanx
3. Fifth finger- middle phalanx
Ossification
4. Adductor Sessamoid of thumb
65

Capping of Epiphysis
5.Third finger- Distal phalanx
6.Third finger- Middle phalanx
7.Fifth finger- Middle phalanx
Fusion of epiphsis and
Diaphysis
8.Third finger- Distal phalanx
9.Third finger –Proximal phalanx
10.Third finger- Middle phalanx
11.Radius
67

Accelerating growth velocity period. SMI 1 -4
High growth velocity period. SMI 4- 7
Decelerating growth velocity period. SMI 7 –11
Girls generally reach point of peak growth velocity
at SMI-5 and boys at SMI- 6
Boys do not take a longer time to mature. They
simply do it at a later chronologic age
68

SIGNIFICANCE :
SMI 1,2,3 : Occur app 3 yrs before the pubertal growth spurt.
SMI 4 : this stage occurs shortly before or at the beginning of
pubertal growth spurt.
SMI 5,6,7 : this stage accurs at the peaks of the pubertal growth spurt.
SMI 8, 9, 10,11 : this ossification of all hand bones is completed &
skeletal growth is finished.
70

CERVICAL VERTEBRAE METHOD
Was developed by HASSEL AND FARMAN
-According to him shapes of cervical vertebrae are seen
to differ at each level of skeletal development.
-provide means to determine whether possibility of
potential growth existed.
-he put forward 6 stages in vertebral development.
Lamparski (1972) was the first to use cervical vertebrae as
indicators for skeletal maturation. Cervical vertebrae C2 to
C6 were used in this study.
Since these vertebrae were already recorded in the routine
lateral cephalogram, there was no need for additional
radiographic exposures.
71

Cervical vertebrae maturation
indicators (CVMI)
1.Stage-1 Initiation
 Very significant amount of adolescent
growth expected 80% to 100%
 C2, C3 and C4 inferior vertebral body
borders are flat
 Superior vertebral borders are tapered
posterior to anterior
The mandible growth will reach its peak
1 year after this stage with a 6-month
margin of error
72

2. Stage 2 Acceleration ( get ready
stage)
 Significant amount of adolescent
 Concavities developing in lower
borders of C2 and C3
 Lower border of C4 vertebral body is
flat
 C3 and C4 retain a trapezoidal shape
It marks the onset of the maximum
mandible spurt; therefore, 90%of the
patients will reach the peak of
mandibular growth within 1 year.
73

3. Stage 3 Transition
 Moderate amount of adolescent
 Distinct concavities in lower
borders of C2 and C3
 C4 developing concavity in lower
border of body
 C3 and C4 are rectangular in shape
This stage is the simplest to be
checked and marks the end of the
maximum growth-spurt year
74

4. Stage-4 Deceleration
 Small amount of adolescent
 Distinct concavities in lower
borders of C2, C3 and C4
 C3 and C4 are nearly square in
shape
The mandibular acceleration peak
ended at least 1 year earlier
75

5. STAGE-5 Maturation
 Insignificant amount of
adolescent growth expected 5% to
10%
 Accentuated concavities of
inferior vertebral body borders of
C2, C3 and C4
 C3 and C4 are square in shape
The mandibular accelerated growth
ended 1 year earlier
76

6. Stage-6 Completion
 Adolescent growth is completed
Deep concavities are present for
inferior vertebral body borders of
C2, C3 and C4
 C3 and C4 heights are greater
than width
77

HAGG AND TARANGER
This method includes 9 stages of bone ossification at
anatomic sites on the radius and the third finger
 The radius represents 3 growth events:
onset, peak, and end of the pubertal growth spurt
81

THIRD FINGER MIDDLE PHALANX
(1) MP3-F, the epiphysis is as wide as the metaphysis;
(2) MP3-FG, same as stage F, but the medial or lateral border of the epiphysis forms
a line of demarcation at right angles to the distal border. This stage is attained 1yr
before or at P.H.V
(3) MP3-G, the sides of the epiphysis have thickened, forming cap at its metaphysis,
with a sharp edge distally on at least 1 side; attained at or 1 yr after P.H.V
(4) MP3-H, fusion of the epiphysis and metaphysis has begun; attained before end of
growth spurt
(5) MP3-I, fusion of the epiphysis and metaphysis is completed
Wong, Alkhal, and Rabie American Journal of Orthodontics and Dentofacial
Orthopedics
October 2009
82

1 ye before p.h.v.
1 yr after p.h.v
Before end of
Growth spurt
83

THIRD FINGER DISTAL PHALANX
(6)DP3-I,Fusion of epiphysis and metaphysis
is complete.It is attained during deceleration
period of pubertal growth spurt.
RADIUS
(7) R-I, fusion of the epiphysis and the
metaphysis has begun;
(8) R-IJ, fusion is almost completed, but there
is still a gap in at least one or both margins;
and
(9) R-J, fusion of the epiphysis and
metaphysis is completed.
84

Assessing skeletal maturity by using
blood spot insulin-like growth factor I (IGF-I) testing
In 1957, IGF-I was discovered by Salmon and Daughaday as a mediator of GH
function.
A study by Mohan et al on mice deficient in IGF-I, IGF-II, and GH showed
that GH and IGF-I, but not IGF-II, are important for the pubertal growth spurt.
Blood spot IGF-I measurement is a relatively new, minimally invasive
technique and has excellent correlation with regular serum IGF-I.
American Journal of Orthodontics and Dentofacial Orthopedics
August 2008
Mohamed Masoud,a Ibrahim Masoud,b Ralph L. Kent, Jr,c Nour
Gowharji,d
86

It is shown that IGF-I levels are low at the prepubertal stages of
cervical development.
This is consistent with previous studies that showed that IGF-I
levels peak in late puberty
87

RICKETTS ANALYSIS
Also known as Ricketts’ summary
descriptive analysis.
Given by RM Ricketts in 1961.
The mean measurements given are those of
a normal 9 year old child.
jacobson
88

Mc NAMARAANALYSIS
Given By Mc Namara JA, 1984
89

91
Korean J Orthod. 2014 Mar;44(2):77-87.
Soft tissue

RECENT ADVANCEMENTS
Computed Tomography
Occlusograms
Digital substraction radiography
Digi Graphs
Laser holography
Photocephalometry
Cineradiography
Cone beam computed tomography(CBCT)
96

THREE DIMENSIONAL IMAGING
• Keen interest in esthetics has resulted in an interest in 3 D
visualization and diagnosis to plan treatment through 3-D
structure.
• For 3-d representation of oral tissues, dental cast must be
integrated into facial images.
• All 3-d imaging systems captures z-axis and this is achieved
by counting number of slices into which image is divided.
97

METHODS OF 3-D CRANIO FACIAL
SKELETAL IMAGING
3-D cephalometry
3-D Laser scanning
3-D facial morphometry
Moire topography
3-D Cone beam
stereophotogrammetry
98

Digigraph allows any cephalometric point to be
located within 3 planes of space
102

CONCLUSION
As we Orthodontists nowadays deal with more and more mixed dentition cases,
many of whom may present with a skeletal malocclusion
Wide variation in chronological age for different maturity levels suggests that
chronological age is a poor indicator of maturity
Skeletal maturity indicators provide a more valid basis than chronological age for
growth status of individuals.
It is a great challenge therefore to diagnose and to plan an ideal treatment for these cases
keeping in mind their growth potential
However we should not forget that every individual is unique in his own aspect
Better therapeutic decisions could be made regarding timing and length of the treatment,
appliance selection, extraction pattern and possible need for surgery
104

Textbook Of Orthodontics – Gurkeerat Singh
Orthodontics - Kharbanda
Contemporary Orthodontics – William R. Proffit
Orthodontics, The art & science – S.I.Balajhi
Radiographic Cephalometrics – Alex Jacobson
Orthodontic Cephalometry – Athanasios E Athanasiou
105

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