Growth assessments

GROWTH ASSESSMENT AND
GROWTH PREDICTION
Dr.Tinet Mary Augustine. BDS,MDS
Pediatric Dentist
Dr.Tinet’s Pedorayz, Pediatric And Early Age Orthodontic Dental Clinic
DR.TINET MARY AUGUSTINE.BDS.MDS 1

CONTENTS
• INTRODUCTION
• GROWTH STUDIES
• GROWTH ASSESMENT
 CHRONOLOGICAL AGE
 BIOLOGICAL AGE
 SKELTAL AGE
 DENTAL AGE
 CIRCUMPUBERTAL AGE
• GROWTH PREDICTION
 DIFFERENT METHODS
 VTO
• ASSESING GROWTH OF DIFFERENT AREAS OF FACIAL GROWTH

GROWTH MEASUREMENTS
Growth Measurement
Measurement
Approaches
Craniometry
Anthropometry
Cephalometric
Radiology
3-D Radiology
Experimental
Approaches
Vital Staining
Radioactive Tracer
Auto Radiography
Implant
Radiography
Direct Approaches
Anthropometry
Vital Staining
Histology
Histochemical
Implants
Indirect Approaches
Impression Casts
Photography
Radio Autographs
Radiographs

ANTHROPOMETRY

CRANIOMETRY

CEPHALOMETRICS

3-D IMAGING
• CAT
• CBCT
• MRI
• 3D PHOTOGRAPHY

VITAL STAINING

RADIOACTIVE TRACER

AUTORADIOGRAPH

IMPLANT RADIOGRAPHY

GROWTH ASSESMENT
KROGMAN CLASSIFICATION
• CHRONOLOGICAL AGE
• BIOLOGICAL AGE
• BEHAVIOURAL AGE
• MENTAL AGE
• SELF CONCEPT AGE

CHRONOLOGICAL AGE

SOMATOTYPIC AGE

HEIGHT AND WEIGHT AGE

• 11.5 females and 14.5 in males

DENTAL AGE

DERMIJIAN AND GOLDSTEIN CLASSIFICATION
• 0-tooth germ without calcification
• A-calcification of single occclusion point
• B-fusion of mineralisation points
• C-calcification of crown and deposition of dentin
• D-crown formation upto CEJ
• E-root lengthshorter than crown
• F-root length larger than crown height
• G-root formation is finished . but open apical
foramen
• H-apical foramen closed

SEXUAL AGE
• GIRLS-STAGE 1-PHYSICAL GROWTH SPURT
STAGE 2-PEAK VELOCITY (AFTER 1YEAR)
STAGE 3-ONSET OF MENUSTRATION(1 ½ YRS)
• BOYS-SATGE 1-FAT SPURT
STAGE 2-HEIGHT SPURT(AFTER 1YEAR)
STAGE 3-PEAK VELOCITY(8-12YRS)
STAGE 4-END OF GROWTH SPURT OF
HEIGHT(AFTER 15-24MONTHS)

FACIAL AGE
7linear measurements(NANDA)
S-GN , N-GN, S-GO, GO-GN, S-N, N-PR, ID-GN
Initiation of the growth spurt in height and
enlargement of face occurred at an average skeltal
age of 12.5 years correlated with appearance of
sesamoid bone(BERGERSEN)

• Mandibular growth of female during puberty
exhibited a peak 10months before menarche
in early maturing females and 5months after
menarche in late maturing females(TOFANI)
• 50%of maximal facial increments occurred at
the same time as maximum growth in height
and only 29% occur after maximum(HUNTER)

SKELTAL AGE
SKELTAL AGE
ASSESMENT
CERVICAL
VERTEBRAE
FRONTAL
SINUSHAND WRIST
RADIOGRAPH
MID PALATINE
SUTURE

HAND WRIST RADIOGRAPH
• Provide clues to bone growth in the body as a
whole
• Ossification occur after birth and before maturity
• Less time consuming

• First to ossify is Capitate
• Last to ossify is the sesamoid

• INFANCY
birth to 10months in girls
birth to 14 months in boys
TODDLER
• Epiphyses of all metacarpals and
Phalanges are visible
Girls-10mnths-2yrs
Boys -14mnths to 3yrs
Hamate
Capitate

• PREPUBERTY
Girls-2-7years
Boys-3-9years
Increase in thickness and
width as metaphyses
first in distal phalages

• PUBERTY
Girls-7-13yrs
Boys-9-14yrs
Epiphyses>metaphyses
Begin to cap the metaphyses
Sesamoid in abductor began
can be recognised

• Late puberty
girls -13-15
boys-14-16
epiphyseal fusion of distal phalanges
carpal bones attained their adult
shape

• Post puberty
Girls-15-17,
Boys 17-19
Carpals, metacarpals and phalanges
are completely developed
Epiphyseal fusion of the ulna and
radius is recognised.

Indications
• Prior to RME
• When maxillomandibular expansions are
indicated for class 111,skeltal class 11, and
skeltal open bite treatments
• In patients with marked discrepency between
dental and chronological age
• For planning growth modification treatments

DIFFERENT METHODS
Fishman Method
Greulich and Pyle
Method
Bejork Grave and
Brown Method
Hagg and Taranger
Method
Tanner and
Whitehouse Method

ATLAS OF GREULICH AND PYLE (1959)

Consist of atlas method and bone
specific method

FISHMAN SKELTAL MATURITY
INDICATOR(1982)
• Thumb
• Middle Finger (Proximal, Middle and Distal
Phalanges)
• Little Finger
• Radius

Stage 1
• Width of Epiphysis equal to that of Diaphysis
• i.e E = D
Stage 2
• Appearance of adductor sesamoid of the thumb
Satge 3
• Capping of Epiphysis
Stage 4
• Fusion of Epiphysis

4.OssificationAdductor
Sesamoid
No
1. Width
Proximal
Phalanx III
2. Width Middle
Phalanx III
3. Width Middle
Phalanx V
Yes
8. Fusion Distal
Phalanx III
No
5. Capping Distal
Phalanx III
6. Capping
Middle Phalanx
III
7. Capping Of
middle phalanx
of vth
Yes
9. Fusion
Proximal
Phalanx III
10. Fusion
Middle Phalanx
III
11. Fusion in
radius

BJORK,GRAVE AND BROWN METHOD
• The pubertal growth spurt ends even earlier ,with
complete fusion of third distal phalanges

• PP2-10.6years male;8.1years in females
3years before pubertal growth spurt
• MP3-12years in males;8.1years in females
• PISI,HI,R STAGE-12.6yearsin male,9.6 in
females
• S and H2 Stage-13years IN MALES;10.6 in
females
Shortly before or at the beginning of pubertal
growth spurts

• MP3 cap ,PPIcap,Rcap
Peak of pubertal growth spurt
• DP3U-End of pubertal spurts
• PP3U-15.9in males ;13.9 in females
• MP3U-SAME
• RU STAGE-18.5 in males 16 in females

HAGG AND TARANGER METHOD
• ossification of ulnar sesamoid of the first finger(s)
and certain specified stages of middle /distal
phalenges of third finger (MP3 and DP3) and the
distal epiphyses of the radius(R)DR.TINET MARY AUGUSTINE.BDS.MDS 42

CERVICAL VERTEBRAE AS SKELTAL
MATURITY INDICATOR
• Suggested by Lamparski in 1972.

VARIABLES
CONCAVITY SHAPE

HASSEL AND FARMAN(1995)
STAGE 1 (INITIATION) STAGE 2(ACCELERATION)
(PEAK IN MAND. AFTER 2 YEARS) (MAX.EXPANSION,MAND-WITHIN 1 YEAR)
Brent Hassel and Allan Farman. Skeletal maturation evaluation using cervical vertebrae,
AJODO 1995:107:58-66

STAGE 3(TRANSITION) STAGE 4(DECCELERATION)
(IDEAL FOR JAW ORTHOPEDICS AND VER.CORRECTION) (PEAK)
AJODO 1995:107:58-66

STAGE 5(MATURATION) STAGE 6 (COMPLETION)
AJODO 1995:107:58-66

Modified by Mc Namara,Bacetti,and
Franchi(2005)

STAGES AND APPROXIMATE AGES

CO-RELATION OF HAND WRIST AND
CERVICAL VERTEBRAE MATURATION
STAGES
(Garcia fernandez. The cervical vertebrae as maturational indicators, JCO APRIL
1998) DR.TINET MARY AUGUSTINE.BDS.MDS 50

Reliability of cervical maturation for
assessing mandibular growth
• Billie Jean Rainey et al concluded that the CVM stage
influence the reliability of the CVM method for the
assessment of mandibular growth.
(Reliability of cervical vertibral maturation staging – Billie et al - AJODO July 2016)

Assessment of Optimal Treatment
Timing in DentofacialOrthopedics
• Class II treatment is most effective when it includes the peak in mandibular
growth.
• Class III treatment with maxillary expansion and protraction is effective in the
maxilla only when it is performed before the peak (CS1 or CS2), whereas it is
effective in the mandible during both prepubertal and pubertal stages.
• Skeletal effects of rapid maxillary expansion for the correction of transverse
maxillary deficiency are greater at prepubertal stages, while pubertal or
postpubertal use of the rapid maxillary expander entails more dentoalveolar
effects.
(The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal
Treatment Timing in DentofacialOrthopedics,TizianoBaccetti, Lorenzo Franchi, and James
A. McNamara, Jr.)

FRONTAL SINUS
• Ruf and Pancherz (1996)
• Sabine Ruf, Hans Pancherz. Frontal Sinus Development as an indicator
for somatic maturity at puberty?, AJODO 1996;110:476-82

• Frontal sinus growth velocity at puberty is closely
related to body height growth velocity.
• Frontal sinus growth shows a well-defined pubertal
peak (Sp) which on the average occurs 1.4 yr after
body ht. peak
• 1year=1.3mm:2year=1.2mm:peak in 15.1year

MID PALATINE SUTURE
• Amount of approximation of the midpalatal suture
compared with stages of ossification of the hand-wrist
according to the Fishman’s system
• Bernal Revalo, Fishman. Maturational evaluation of ossification of the mid palatal suture,
AJO MARCH 1994

LANDMARKS
 Point A→ most anterior point of premaxilla
 Point B→ most posterior point on the posterior wall of the
incisive foramen
 Point P→ Point on the line tangent to the posterior walls of the
greater palatine foramen

• Increase in sutural approximation as SMI stages progressed.
• SMI 1&2- decreased sutural approx.
• After SMI 9- significant increase in the sutural approx.
• No significant difference b/n sexes.
• Conclusion-ideal time is between SMI-SM4,Less orthopedic
force required

Stages
• Stage A- straight high density suture line
with no or little interdigitation
• Stage B-scalloped appearance
• Stage C-two parallel scalloped high density
lines seperated in some areas by
small low density spaces
• Stage D-fusion completed in palatine bone with no
evidence of a suture
• Stage E-complete anterior fusion in the maxilla
(Angelina et al, Diagnostic performance of skeltal maturity for assesment of mid
palatal suture maturation(AJODO Dec 2015)

Using CVM method
Prepubertal
• CS1 and CS2-midpalatal maturational stages A and
B.
• CS3 in CVM -stage C in maturation of the
midpalatal suture.
• CS5 in CVM -stages D and E in midpalatal suture
• CS4 and CS5, -assessment of the mid palatal
suture with CBCT should be undertaken, since
13.5% of patients at CS5 presumably could be
treated with conventional RME.
(Diagnostic performance of skeltal maturity for assesment of mid palatal suture
maturation(AJODO dec 2015)DR.TINET MARY AUGUSTINE.BDS.MDS 59

CONCLUSION
• Growth assessment indicates the growth status of
the patient at a particular time and provide an
assesment of the percentage of the growth left
• The proper assessing and predicting helps the
clinician to design the proper treatment plan for
the skeltal or dental deformities

Thank you

References
• Contemporary orthodontics. William R. Proffit. 4th edition 2007.
• Orthodontics—Current Principles and techniques. Thomas M
Graber, Brainard F Swain, 1982. The CV Mosby Company
• Garcia fernandez. The cervical vertebrae as maturational
indicators, JCO APRIL 1998
• Radiographic cephalometry. Alexander Jacobson.1995
• Brent Hassel and Allan Farman. Skeletal maturation evaluation
using cervical vertebrae, AJODO 1995:107:58-66
• Textbook of craniofacial growth-S.Premkumar
• Bernal Revalo, Fishman. Maturational evaluation of ossification
of the mid palatal suture, AJO MARCH 1994
• Diagnostic performance of skeltal maturity for assesment of mid
palatal suture maturation(AJODO dec 2015)
• Handbook of orthodontics :Robert Moyers:4th Edition

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