Growth assessment in Orthodontics

GROWTH ASSESSMENT
Arun Bosco Jerald
2018 Batch
Dept. of Orthodontics
Mar Baselios Dental College

Contents
• Introduction
• Methods of studying growth
• Assessment of age
– Chronologic age
– Somatotypic Age
– Morphologic Age
– Dental Age
– Sexual Age
– Facial Age
– Skeletal Age
• Hand Wrist Radiographs
• Cervical Vertebrae
• Midpalatal Suture
• Frontal Sinus
• Insulin like growth factor 1
• Alkaline phosphatase- A
• Conclusion
• References

Introduction
• Human growth is characterized by variation in the rate of
progress of different persons towards physiological
maturity.
• It is one of the most myriad variations in nature and plays
an important role in the etiology of malocclusion and
also in diagnosis, treatment planning, retention and
stability of any case.

• Robert Ricketts stated that to take advantage of growth
we must have an idea of :-
– first ; its magnitude ,
– second; its direction and
– third; the element of timing.
• By using the element of timing of maximum growth in
conjunction with the knowledge of magnitude and
direction, one can readily transform orthodontics to a
profession of face forming as well as tooth positioning.

• Key to successful orthodontic treatment in growing
patients is the harnessing of growth and unless we know
the exact status of growth both in magnitude as well as
in direction, treatment planning would be futile.
• The ability to predict patient’s facial growth early in life
would enable the clinician to establish a correct diagnosis
and identify the appropriate treatment

Clinical importance
Help us to :
1) determine the potential vector of facial development
2) determine the amount of significant craniofacial growth
potential left
3) evaluate the rate of growth
4) decide the onset of treatment

5) decide the type of treatment:
a) Orthopedic (removable or fixed)
b) Orthodontic
c) Orthognathic surgical procedure
d) Combination of any of the above
6) evaluate the treatment prognosis
7) understand the role of genetics and environment on
skeletal maturation pattern

GROWTH SPURTS
• Sudden increase in growth is termed growth spurt.
• Physiological alterations in hormonal secretion is
believed to be the cause for such accentuated growth.
• A spurt is defined as growth acceleration up to a
maximum where the annual increment of growth
exceeded the previous one by at least 0.7mm
- Ekstrom (1982)

Timings of growth spurts:
• differ in boys and girls
Woodside (1968; Burlington growth study, Torrento)
Growth spurt Girls Boys
Infantile / Childhood growth spurt 3 years 3 years
Juvenile / mixed dentition growth spurt 6-7 years 7-9 years
Pre-pubertal / adolescent growth spurt 11-12 years 14-15 years

Modified by Bjork (1975)
1. Pre-natal: Just before birth
2. Post natal:
Growth spurt Girls Boys
Infantile growth spurt One year after birth
Juvenile / mixed dentition growth spurt 7-9 years 8-12 years
Pre-pubertal / adolescent growth spurt 11-13 years 14-16 years

Methods of growth measurements
Proffit Sarnat in 1986
(longitudinal studies ) (cross sectional studies)

Anthropometry
• Is the systematized art of measuring and making
observations on man, his skeleton his brain or other organs
by the most reliable means and methods and for scientific
purposes. – Aleš Hrdlička
• The earliest work in anthropometry was done by Hippocrates
(460-357 BC)
• Alphonse Bertillon, in 1883, gave rise to a system of
identification based on the unchanging character of
measurement of parts of the human frame. This system came to
be called "Bertillonage" and laid the foundation for modern
anthropometry
• This science was further developed by Broca, Campor and
Morton.

• It includes the following branches:
a) Craniometry : Measurement of skulls.
b) Osteometry : Measurement of skeletal system.
c) Cephalometry : Measurement of head inclusive of soft
tissues
d) Somatometry : Measurement of living body tissues

Vital staining
• Leminus, in 1567 first mentioned the red staining
properties of the root of madder plant in bone
• Belchier in 1736, was one of the first ones to give an
account of the staining of bones of animals fed with
madder.
• Du Hamel (1742) demonstrated that only newly formed
bone was stained by madder and from his studies he
described the manner of growth of bones
• Hunter (1771, 1778) did studies on the growth of the
mandible in pig

• Brash (1924, 1934) repeated Hunter's work and came to
similar conclusions
• Dyes that stain hard tissues (occasionally soft tissues) are
injected into an animal, these dyes remain in the bones
and teeth and can be detected later after sacrifice of the
animal.
• Ground sections which are 25 to 50 μm thick are
prepared for the microscopic viewing of staining effects

• Under higher magnification and strong illumination, the
red lines (5-20 μm in width) are readily counted and the
distance between them can be accurately measured with
a micrometer eyepiece
• Dyes used for this purpose:
1.Alizarin S red
2.Tetracyline
3.Procion
4.Fluorochrome
5.Trypon blue
6.Lead acetate
7.Sodium fluoride

Histological studies
• Primarily qualitative in nature
• are used to elucidate processes responsible for growth
• Bone tissue is in a state of continuous change due to
interplay of apposition and resorption.
• Osteoblasts →cuboidal epithelium→ apposition
• Osteoclasts→ multinucleated giant cells found in
Howship's lacunae→resorption
• Enlow (1990), on the basis of extensive histologic studies,
reconstructed gross patterns of bone formation and
destruction

Histochemical studies
• valuable in obtaining further information about the
nature of bone formation.
• By this method, for instance, the importance and the
localization of enzymes (alkaline and acid phosphatase
and other substances like glycogen and glycoprotein) are
studied

Implants
• Duhamel (1742) introduced implants in the study of
growth of bones
• Hunter(1770) inserted two Lead pellets in the shaft of
the tarsus of a young pig. The distance b/n them
remained same after the tarsus was grown→interstitial
growth in bone.
• Implantation of Au, Ag, dental silver amalgam, SS,
vitallium, and tantalum→ screw, pegs, pins, clips, or
wires within a single bone → study of bone growth
→distance between the implants and the outer borders
of the bone (Sarnat 1968, Sarnat and Selman 1978).

• Humphrey (1863) placed wire loops around the ramus of
pig mandible, and demonstrated resorption on anterior
border of ramus and deposition on the posterior border.
• Serial data is not provided by this method without
reoperation or killing the animal.
• This method has also been used to determine sutural
growth by placing implants on either side of the suture

• Impressions and study casts:
with the plaster of Paris, hydrocolloid,
thoikol rubber, low fusing metal, stone or
other material.
(Sarnat et al 1953)
• Photographs:
Photographs taken under controlled
conditions with the subjects placed against a
graduated grid have permitted morphologic
classification.

Radio autographs
• Obtained by injecting radioactive isotopes and by placing
a photographic emulsion for suitable exposure period in
close contact.
• Alpha or beta rays emitted from the radioactive material
affect the AgBr crystals on the photographic emulsion in
a manner similar to that of light.
• After development, dark areas correspond to distribution
of radioactive material (Bartelstone, 1950) which indicate
the sites of growth
• Substances used include: sodium, calcium, strontium,
fluorine, chlorine, iodine, plutonium, uranium,
americium, and gallium.

• Now radioactive isotope 99mTc or 45Ca can be used to
detect areas of rapid bone growth. This method is more
useful in the diagnosis of localized growth problems than
in studies of growth pattern.
• They can be detected by means of Geiger counter.
• Studies in autoradiography in bone and cartilage have
been done by Long et al in 1968 and Gross et al in 1951.
• Dixon and Hoyte (1963) compared the autoradiographic
and alizarin techniques in the study of bone growth.

Radiographs
• 1912, Tandler suggested the use of X-ray films in the
studies of anthropometry.
• In 1931, Broadbent and Hofrath, simultaneously but
independently, described a technique of cephalometric
radiography.
• In 1937 Broadbent described the findings from his
studies on growing children.
• This was a cross-sectional method but by serial super
positioning with serial radiographic tracings on stable
bony landmarks provided longitudinal data.

• In 1941, Brodie was the first to apply Broadbent's
method to a longitudinal growth study of human males
from the third month to the eighth year of life.
• The accuracy of the method depends on standardization
of technique.
• However, selection of a stable anatomic base, for
superimposing the radiographic tracings is the key to
reliable findings

Serial cephalometric radiography
and implantation
• More accurate and reliable approach for a dynamic
longitudinal study of the growth of bone(s).
• Robinson and Sarnat in 1955 used this method in growth
study of the mandible in the pig
• McNamara and Graber (1975) and Bjork (1963) used it in
humans.
• Bjork in 1968 and Bjork et al in 1983 have studied about
the growth rotations of the mandible using implant
radiography

Advantages
• Increase in size and the change in proportion can be
recorded.
• A stable base for superpositioning the serial radiographic
tracings is obtained by inserting two or more radio-
opaque implants.
• The measurements are valid only if the implants do not
extrude into the surrounding soft tissues and
• foreshortening of implants must be avoided for which
the implant must lie parallel to the X-ray film.

• Growth assessment is of primary concern in planning
orthopedic correction and surgical treatment of skeletal
malocclusion.
• Estimation of growth potential requires the assessment
of the developmental age of the individual patient.
• Developmental age classified by Krogman - five types

Chronological age
• Is the measurement by the period of time (years and
months) for which someone has existed.
• Little validity for identifying the stages of development
progression through adolescence to adulthood; hence
it is a poor indicator of maturity.
• Helps to categorize the individual as early, average or
late maturer.
• Helps to decide the time, duration and method of
treatment

Morphologic Age
• Is based on height. A child’s height can be compared with
those of his same age group and other age groups to
determine where he stands in relation to others.
• Height, or morphologic age, is useful as a maturity
indicator from late infancy to early adulthood.
• This is determined, using growth charts for the particular
population standards.
• It can also be used to follow a child overtime to evaluate
whether there is an unexpected change in growth
pattern.

• USES :
➢ To predict whether growth is normal or abnormal.
➢ To establish a location of individual relative to the group.
➢ Child who falls beyond the range of 97% of the population
should receive special study before being accepted as just
an extreme of the normal population.
➢ To predict any unexpected change in growth pattern.

• Roche (1980)categorized six type of height growth in
children
➢ Average growers -follows middle range distance curve and
comprise two third of all the children.
➢ Early maturing -taller in child hood as matured faster not
particularly tall as adults.
➢ Genetically tall —taller than average children and will be tall
as adults .
➢ Late maturing –shorter than average in childhood and will be
adults of average stature.
➢ Genetically short —short in childhood and as adults as well.

Dental age
▪ Dental age can be correlated to skeletal and
chronological age but controversy arises as eruption
time table can be altered due to general and local
factors.
▪ Spier (1918) was the first to associate tooth eruption to
growth stature.
▪ Nanda, in his study, found a poor correlation
▪ Bambha and Natta found no evidence of association
between the time of tooth eruption and the time of
skeletal maturation.

• Demisch and Wartman found a high correlation between
calcification of the mandibular third molar and skeletal
and chronological age
Dental age is determined from three characteristics.
1. which are the teeth that have erupted
2. amount of resorption of the roots of primary teeth and
3. amount of development of the permanent teeth

• Average chronology of permanent tooth development

• Stages of tooth calcification by Carmen M. Nolla
Journal of Dentistry for Children(1960):

DEMIRJIAN's method :
• To determine the dental age by scoring the stage of
calcification of seven teeth on the left side of the
mandible and the construction of dental maturity
standard curves.
• Each tooth is given a point value according to the state of
development.
• The sum of the individual points gives the developmental
value, which can be transferred into the dental age with
the aid of standard tables.

Nine relevant stages of dental development:
0 - Tooth germ without signs of calcification.
A- Calcification of single occlusal points without fusion of
different calcifications.
B- Fusion of mineralization points; the contour of the
occlusal surface is recognizable.
C- Calcification of the crown is complete, beginning of
dentin deposits.

D- Crown formation is complete up to the cemento-enamel
junction
E- Root length shorter than crown length.
F- Root length larger than crown length.
G- Root formation us finished. Apical foramen is still open.
H- Apical foramen is closed

Classification of the degree of
mineralization of teeth
according to Demirjian et al.

Sexual age
• During the time of puberty, various hormones yield
characteristic body changes.
• The stages of secondary sexual characteristics provide a
physiological calendar of adolescence that correlates
with the individual's physical growth status.
• Adolescence in girls can be divided into three stages,
based on the extent of sexual development.
• The first stage occurs at about the beginning of the
physical growth spurt (appearance of the breast buds,
early stages of pubic hair development),

• Stage II after one year of stage I during which peak
velocity of growth occurs.
• The third stage, 1 to 1½ years after stage II, is marked by
the onset of menstruation (menarche).
• The stages of sexual development in boys are very
difficult to specify
• Stage I characterized by "fat spurt" which is marked by
gain in body weight and an increase in the size of the
scrotum.

• Stage II begins one year after stage I and marks the
beginning of the height spurt
• Stage III (8-12 months) marked by peak velocity in body
height.
• Stage IV which occurs 15 to 24 months after stage III , is
difficult to pinpoint and is marked by the end of spurt of
growth in height

• Tanner in 1962 outlined the stages of secondary sexual
character with their relation to pubertal growth spurt
categorizing them into 5 stages. Stage 1 being
prepubertal and stage 5 being mature.
• Hagg and Taranger (AJO 1982) found that attainments of
menarche and voice changes in girls and boys
respectively are reliable indicators of the pubertal growth
spurt.
• In girls menarche usually does not occur before peak
height velocity (PHV) . In boys pubertal voice is attained
closer to PHV and male voice is attained at PHV or after.

Facial age
• Nanda in one of his studies measured seven linear
measurements—S-Gn, N-Gn, S-Go, Go-Gn, S-N, N-Pr and
Id-Gn.
• And plotted on a graph versus chronological age.
• These curves have the same basic form as the standard
height curves
– S-Gn and N-Gn were most like the other skeletal growth curves
– S-N appeared to be a composite of both skeletal and neural
growth
– N-Pr and Id-Gn correlated with the emergence of the
permanent teeth.
• The final body height reached before the peak in facial
growth.

• Bergersen : initiation of the growth of the face occurred
at an average skeletal age of 12.5 years → appearance of
sesamoid bone.
• Bjork : completion of upper facial height occurs at DP3 U
• Tofani : mandibular growth of females during puberty
exhibited a peak 10 months before menarche in early
maturing females and 5 months after menarche in late
maturing females.
• Hunter : 50% of the maximal facial increments occurred
at the same time as maximum growth in height and only
29% occurred after the maximum.

• Skeletal age is considered to be most reliable age for
assessment of growth for orthodontic purposes
• A number of methods are available to assess the skeletal
maturity of an individual. These include:
a) Use of hand-wrist radiographs
b) Radiographs of cervical vertebrae
c) Clinical and radiographic examination of different
stages of tooth development

• Bone age: is an indication of physical development and
maturation of the skeleton.
• Standards obtained by means of roentgenograms are
employed to determine the order, time of appearance,
and progress of ossification of various centers of
skeletal ossification.
• Bone age can be calculated by the absence or presence
of various osseous centers in several regions of the body
and compared with the standards.

Anatomical regions :
• Should be small to restrict radiation exposure and expense.
• Should have many ossification centers which ossify at
separate times and which can be standardized.
• Should be easily accessible.
Regions normally used for age assessment:
• Head and neck: Skull, cervical vertebrae
• Upper limb: Shoulder joint, scapula, elbow, hand-wrist and
fingers
• Lower limb: Femur, hip joint, knee, ankle, foot-tarsals,
meratarsals, phalanges.

Hand-wrist radiographs
• The bones of the hand-wrist region show a predictable
and scheduled pattern of appearance, ossification and
union from birth to maturity.
• Hence this region is one of the most suited to study
growth.

• Ranke in 1896, introduced the idea of using the
comparative size and shape of the radiographic shadows
of growing bones as indicators of rate of growth and
maturity.
• In the early 1900s, Pryor, Rotch, and Crampton began
tabulating indicators of maturity on sequential
radiographs of the growing hand and wrist.
• Hellman published his observations on the ossification of
epiphysial cartilages of the hand in 1928.

• Todd compiled hand-wrist data that was further
elaborated on by Greulich and Pyle in atlas form
• Flory in 1936, indicated that the beginning of calcification
of the carpal sesamoid (adductor sesamoid) was a good
guide to determining the period immediately before
puberty
• Chapman was the first to use periapical X-ray film to
evaluate ossification of the ulnar sesamoid bone as
skeletal maturity marker.
• Abdel-Kader applied this idea to recording MP3 stages.

• Most authors agree that peak height velocity follows
adductor sesamoid appearance by approximately 1 year.
• Fishman 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 created a method using the hand-
wrist radiograph to correlate certain maturity indicators
to the pubertal growth spurt.

Anatomy of Hand-wrist
Made up of four groups of bones
1) Distal ends of Radius and Ulna of the forearm
2) Carpals :
were first named by Lyser in 1683.
Each carpal bone except the pisiform has six surfaces:
proximal, distal, volar, dorsal, lateral and medial
Proximal row : Scaphoid, Lunate, Triquetral and Pisiform
Distal row : Trapezium, Trapezoid, Capitate and Hamate
Each of these carpal bones ossifies from one primary center
which appears in a predictable pattern.

3) Metacarpals :
• 5 miniature long bones forming the skeletal framework
of the palm
• numbered 1 to 5 from the thumb to the little finger
• All metacarpals ossify from one primary ossifying center
located in their shafts and a secondary center on their
distal end; except the first metacarpal where it appears
at the proximal end.

4) Phalanges :
• Small bones that form fingers
• Three phalanges in each finger
• Thumb has only two phalanges
• The bones of the phalanges are referred to as proximal,
middle (absent in thumb) and distal phalanges.
• They ossify in three stages :
– Epiphyses show the same width as the diaphysis
– epiphysis surrounds the diaphysis like a cap
– epiphysis fuses with the diaphysis

5) Sesamoid bone :
a small nodular bone most often present embedded in
tendons in the region of the thumb

• Advantages of using hand-wrist radiographs in assessing
skeletal maturation:
– Carpal bones, epiphysis and phalanges provide a clue to
bone growth in the body as a whole.
– Ossification occurs in the period after birth and before
maturity.
– The bones are easily accessible.
– Clothing need not be removed.
– Less time consuming technique

Indications of Hand-wrist radiographs :
• Prior to rapid maxillary expansion
• When maxillo-mandibular expansion changes are
indicated in the treatment of class III cases, skeletal class
II or skeletal open bites
• In patients with marked discrepancy between dental and
chronological age
• Orthodontic patients requiring orthognathic surgery if
undertaken between the ages of 16 and 20 years
• For planning of growth modification treatment.

Greulich and Pyle method
• Involved two specific steps, the atlas and the bone
specific methods (1959)
• Atlas method:
– Comparing a hand-wrist film with the standard film of
the same sex and nearest chronological age.
– The film would then be compared with adjacent
standards, both older and younger
– Finally, the standard which appears most closely to
resemble the film in question is chosen

• Bone specific method :
– After selecting the appropriate standard, proceed to
make a more detailed comparison of the individual
bones and epiphyses.
– The bones of the hand-wrist complex should be
considered in a regular order: distal ends of the radius
and ulna, carpals(Capitate, Hamate, Triquetral, Lunate,
Scaphoid, Trapezium, Trapezoid, Pisiform),
metacarpals, and finally phalanges
– Each center is given a skeletal age and overall age is
then determined.

Tanner and Whitehouse Method
• Suggested three methods of scoring of individual bones
to determine skeletal age.
1. Radius, ulna, short (RUS) bone score:
• rates the radius, ulna,
metacarpals of digits 1,3 and 5;
middle phalanges and distal phalanges of
digits 3 and 5
2. Carpel bone method:
• scores Capitate, Hamate, Triquetral, Lunate,
Scaphoid, Trapezium and Trapezoid.

3. TW2 method:
• Consider 20 regions of interest (RIO) located in the
main bones
• Each RIO is divided into 3 parts:
Epiphysis, metaphysis and diaphysis.

• The development of each ROI is divided into discrete
stages and each stage is given a letter (A, B, C, D… H)
• A numerical score is associated with each stage for each
bone.
• By adding the scores of all ROIs, an overall maturity score
is obtained.

Bjork, Grave and Brown method
(1976)
• They divided the skeletal
developmnent into 9 stages;
each of which represents a
level of skeletal maturity
• Appropriate chronological
age for each of the stages
was given by Schopf in 1978

1. PP2 stage: {male 10.6y female 8.1y}
– The epiphysis of PP2 has the same width as the
diaphysis.
approximately occurs 3 years before the peak of the
pubertal growth spurt.
2. MP3 stage: (males 12.0y, females 8.1y)
– Epiphysis of MP3 is of the same width of the
epiphysis.
noticed prior to the beginning of pubertal growth
spurt

3. Pisi, H1 and R stage: ( males 12.6y, females 9.6y)
– Three distinct ossification areas appear at the same
time during the process of maturation.
– Pisi stage = visible ossification of the pisiform.
– H1 stage = ossification of
the hamular process of
the hamatum.
– R stage = same width of
the epiphysis and the
diaphysis.

4. S and H2 stage (males 13.0, females10.6y)
– S stage = first mineralization of the ulnar sesamoid
bone of the metacarpophalangeal joint of the
thumb.
– H2 stage = progressive ossification of the hamular
process of the hamatum.
This stage is reached shortly before or at the
beginning of the pubertal growth spurt.

5. MP3cap, PP1cap & R cap stage {males 14y, females 11.y}
– Capping of diaphysis by the epiphysis is seen in :
MP3, PP1 & R
Reaches the peak of pubertal growth spurt.
6. DP3u stage (males 15.9 y, females 13.0 y) :
– Visible union of epiphysis and diaphysis at DP3.
– constitutes the end of pubertal growth

7. PP3u stage ( males 15.9 y, females 13.3 y):
– Visible union of the epiphysis and diaphysis at the PP3.
– Seen a year after the growth spurt
8. MP3u stage ( males 15.9 y, females 13.9y):
– Union of epiphysis and diaphysis at the MP3.
9. Ru stage ( males 18.5 y, females 16 y):
– Complete union of the epiphysis and diaphysis of the
radius.

Singer's Method
• By Julius Singer in 1980.
• Six stages are described.
• Stage one (early):
– absence of the pisiform
– absence of hook of hamate, with
– the epiphysis of PP2 being narrower than its diaphysis.

• Stage two (pre pubertal):
– characterized by
• initial ossification of hook of the hamate
• initial ossification of the pisiform and
• diaphysis of PP2 equal to its epiphysis.
– represents the period prior to adolescent growth spurt
→ significant amounts of mandibular growth possible.
– Maxillary orthodontic therapy in conjunction with
mandibular growth might aid correction of a class II
relationship with considerable speed and ease.

• Stage three (pubertal onset):
– beginning of calcification of ulnar sesamoid, increased
width of epiphysis of PP2 and increased calcification
of hook of hamate and pisiform.
– Signifies the onset of pubertal growth spurt
• Stage four (pubertal)
– presence of calcified ulnar sesamoid and capping of
the diaphysis of the MP3 by its epiphysis.
– signifies the accelerating phase of pubertal growth
spurt

• Stage five (pubertal deceleration):
– fully calcified ulnar sesamoid, fusion of epiphysis of
DP3 with its shaft, and epiphyses of radius and ulna
not fully fused with respective shafts.
– Represents the period of growth when orthodontic
treatment might be completed and the patient is in
retention therapy
• Stage six (Growth completion):
– No remaining growth sites are seen.

Fishman Skeletal Maturity Indicator
• Developed by Leonard S Fishman in 1982.
• Make use of anatomical sites located on :
thumb, 3rd finger, 5th finger and radius.
• This system of uses four stages of bone maturation:
– Epiphysis equal in width to diaphysis.
– Appearance of adductor sesamoid of the thumb.
– Capping of epiphysis and
– Fusion of epiphysis.

Eleven SMIs
• S.M.I 1- The third finger proximal
phalanx shows equal width of
epiphysis and diaphysis
• S.M.I 2- Width of epiphysis equal to
that of diaphysis in the middle phalanx
of third finger
• S.M.I 3- width of epiphysis equal to
that of diaphysis in the middle phalanx
of fifth finger
• S.M.I 4- Appearance of adductor
sesmoid of the thumb
• S.M.I 5- Capping of epiphysis seen in
distal phalanx of third finger

Eleven SMIs
• S.M.I 6-Capping of epiphysis seen in
the middle phalanx of third finger
• S.M.I 7-Capping of epiphysis seen in
the middle phalanx of fifth finger
• S.M.I 8-Fusion of epiphysis and
diaphysis in the distal phalanx of third
finger
• S.M.I 9-Fusion of epiphysis and
diaphysis in the proximal phalanx of
third finger
• S.M.I 10-fusion of epiphysis &
diaphysis in the middle phalanx of the
third finger
• S.M.I 11-Fusion of epiphysis &
diaphysis seen in the radius

CLINICAL IMPLICATIONS:
• SMI 1,2,3 – occurs approximately 3 years before pubertal
growth spurt.
• SMI 4 – occurs before or at the beginning of pubertal
growth spurt.
• SMI 5,6,7 – occurs at the peak of pubertal growth spurt.
• SMI 9,10,11 – ossification of all hand bones are completed
(skeletal growth complete).

Hagg and Taranger method
• They analyzed yearly hand wrist radiographs of individuals
from age 6 to 18 & studied the ossification of:
– ulnar sesamoid of metacarpophalangeal joint of thumb (S)
– and certain specified stages of three epiphyseal bones:
MP3, DP3 and the distal epiphysis of the radius (R)
• Kansel & Rajagopal modified the MP3 indicators further &
compared it to the cervical vertebrae maturation indices
(CVMI) as described by Hassel and Farman

➢ Sesamoid:
• Appearance of the ulnar sesamoid is seen during the
acceleration period of pubertal growth spurt ( onset of
Peak height velocity- PHV) in 86% of girls and 92% of
boys

➢ Third finger middle phalanx :
▪ MP3-F stage :
• The epiphysis is as wide as metaphysis
• Ends of epiphysis are tapered
• Metaphysis show no undulation
• Radiolucent gap (representing cartilaginous
epiphyseal growth plate) between
epiphysis and metaphysis is wide
Corresponds to the start of the curve of
pubertal growth spurt

▪ MP3-FG stage :
• The epiphysis is as wide as the metaphysis
• Distinct medial and/or lateral border of the epiphysis
forms line of demarcation at right angles to the distal
border.
• Metaphysis begins to show slight undulation
• Radiolucent gap between epiphysis and
metaphysis is wide
• Acceleration of the curve of

▪ MP3-G stage :
• The sides of epiphysis have thickened and also cap its
metaphysis, forming a sharp edge distally at one or both
sides.
• Marked undulations in metaphysis giving it
a "Cupid's Bow" appearance.
• Radiolucent gap betweenthe epiphysis and
metaphysis is moderate
• Maximum point of pubertal growth spurt

▪ MP3-H stage :
• Fusion of epiphysis and metaphysis has begun
• One or both sides of epiphysis form obtuse angle to distal
border
• epiphysis is beginning to narrow
• Cupid's bow appearance is absent,
but slight undulation is present
• Radiolucent gap between epiphysis
and metaphysis is narrower
• Deceleration of the curve of
pubertal growth spurt.

▪ MP3-HI stage :
• "new stage"
• Superior surface of the epiphysis shows smooth curve
• metaphysis shows smooth, convex surface, almost fitting
into reciprocal concavity of epiphysis
• No undulation is present in metaphysis
• Radiolucent gap between epiphysis and
metaphysis is insignificant
Maturation of the curve of

▪ MP3-I stage :
• Fusion of the epiphysis and metaphysis is completed
• Attained before or at the end of pubertal growth spurt in
all subjects except a few girls

➢ Distal Third Phalanx
▪ DP3-I:
• the fusion of epiphysis and diaphysis is completed.
• This stage was attained during the deceleration period of
the pubertal growth spurt (PHV-END) by all subjects

➢ Radius :
▪ R-I stage :
• Fusion of epiphysis and metaphysis has begun.
• attained 1 year before or at end of the pubertal growth
spurt by about 80 percent of the girls and about 90
percent of the boys
▪ R-IJ stage :
• Fusion is almost completed but, there is still a small gap
at one or both the margins
▪ R-J stage :
• Characterized by fusion of the epiphysis and metaphysis
• R-IJ and R-J are not attained before the end of the
pubertal growth spurt by any subject.

Limitations of hand wrist radiographs
▪ Agenesis of some hand wrist bones
▪ The validity of hand wrist skeletal maturity in the
evaluation of craniofacial growth has been questioned .
▪ Moore pointed out that most of the bones of the body
develop by endochondral ossification. The bones of the
face are formed by intramembranous ossification .So, the
growth of the face may be regulated by factors other
than those responsible for growth of long bones.

Cervical Vertebrae as Skeletal Maturity
Indicators
• Hassel and Farman (1995) found that the shapes of
cervical vertebrae seen to differ with different levels of
skeletal development . And they have put forward the
following six stages in vertebral development

1) Initiation :
• Inferior borders of the C2, C3 and C4 are flat shaped
• The third vertebra is wedge shaped and
• the superior vertebral borders are tapered from posterior
to anterior
• 100% pubertal growth remains

2) Acceleration :
• Concavities on the inferior borders of C2 and C3 begin to
develop
• inferior borders of the C4 remain flat.
• Vertebral bodies of C3 and C4 are nearly
rectangular in shape.
• 65%-85% of pubertal growth remains

3) Transition :
• Distinct concavities are shown on the inferior borders of
C2 and C3
• A concavity begins to develop on the inferior border of
C4
• vertebral bodies of C3 and C4 are
rectangular in shape
• 25-65% of growth remains.

4) Deceleration :
• Distinct concavities can be observed on the inferior
borders of C2, C3 and C4.
• Vertebral bodies of C3 and C4 begin to be more square in
shape.
• 10-25% of pubertal growth remains

5) Maturation :
• Marked concavities are observed on the inferior borders
of C2, C3 and C4
• Vertebral bodies of C3 and C4 are almost square in shape
• 5-10% of pubertal growth remains.

6) Completion :
• Deep concavities are observed on the C2, C3 and C4.
• Vertebral bodies are greater vertically than horizontally
• Pubertal growth has been completed.

• Hand wrist x-ray and cervical vertrebral maturation
indicators are correlated as follows:

Modified Stages of Cervical Vertebral
Maturation
• Given by Tiziano Baccetti, Lorenzo Franchi and James A.
McNamara Jr. (Semin Orthod 11:119–129 © 2005)
• Lorenzo Franchi and James A. McNamara Jr.(AO,vol:88,Jan
2018)
• The six stages are defined as follows :
• Cervical stage 1 (CS1):
– The lower borders of all the three vertebrae (C2-C4) are
flat.
– The bodies of both C3 and C4 are trapezoid in shape
(the superior border of the vertebral body is tapered
from posterior to anterior).

– C2 and C3 resemble wedge of cheese
– The peak in mandibular growth will occur on an
average two years after this stage.

• Cervical stage 2 (CS2): get-ready stage
– A concavity is present at the lower border of C2.
– The bodies of both C3 and C4 are still trapezoid in
shape.
– The peak in mandibular growth will occur, on an
average within one year after this stage.
– 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.

– Concavities at the lower borders of both C2 and C3
are present.
– The bodies of C3 and C4 may be either trapezoid or
rectangular horizontal in shape.
– Stage CS3 represents the ideal stage to begin
functional jaw orthopedics, as the peak in mandibular
growth will occur within the year or after this stage.
– CS3 is also the appropriate age for treatment of
vertical malocclusion, because peak in mandibular
growth occurs during this stage.

– Concavities at the lower borders of C2, C3, and C4 are
now present.
– The bodies of both C3 and C4 are rectangular and
horizontal in shape. (Credit card or bar of soap)
– The peak in mandibular growth has occurred within
one or two years before this stage.

– The concavities at the lower borders of C2, C3, and C4
still are present.
– At least one of the bodies of C3 and C4 is square in
shape (marshmallow). If not square, the body of the
other cervical vertebra is still rectangular and
horizontal.
– The peak in mandibular growth ends at least one year
before this stage.

– 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
and vertical in shape.
– If not rectangular and vertical, the body of the other
cervical vertebra is square.
– The peak in mandibular growth end at least two years
before this stage.

Mandibular Canine Calcification as an
Indicator of Skeletal Maturation
• Coutinho, Buschang, Miranda (AJO 1993) studied the
relationship between mandibular canine and skeletal
maturity indicators;
• CANINE STAGE F → Initiation of puberty.
• CANINE STAGE G → coincides with MP3 Cap; PP5 Cap,
Presence of adductor sesamoid. it is indicative of peak
height velocity (PHV)

Eruption of maxillary canine and
skeletal maturity
• In a study conucted in Florence by Tiziano Bacceti el.al
(AJODO, May 2008), the conclusions were:
1. Eruption of the permanent maxillary canine can occur
at any stage in skeletal maturation before the end the
pubertal growth spurt (CS1-CS4). A postpubertal stage
(CS5 or CS6) without an erupted maxillary canine
indicates delayed canine eruption and suggests canine
impaction.
2. Eruption of the permanent maxillary canine occurs
more frequently in the prepubertal stages of skeletal
development in subjects with increased vertical skeletal
relationships.

Lower third molar development in relation
to skeletal maturity and chronological age
- Christer Engstrom et al (Angle Orth,1983)
• A strong correlation was found between the skeletal
maturation, chronological age, and the developmental
stages of the third molar.
• PP2—complete crown mineralization in majority of the
subjects.
• MP3 cap—complete crown formation in most of the
individuals and beginning of the root development.

• DP3u– crown was still incomplete in some, but it had
already attained full root length in others.
• Ru—crown completed in one third, half of the root
development in one third, and had reached full length in
another one third of the subjects
• Absence of one or both lower third molar was observed
in 11% of the subjects.

Midpalatal region as an indicator of
maturity
• This study was done by Bernel Revelo et al to determine
whether a positive correlation exist between adolescent
maturation development and the approximation of the
mid palatal suture.
• Hand wrist radiograph were taken and individual were
classified as accelerated, average and delayed based on
Fishman SMI and occlusal radiograph were taken to
assess the sutural approximation.
• Sample consisted of 39 male and 45 female(age8-18
year)

• The results of this study revealed that there is significant
correlation between maturational development and the
beginning of ossification of the midpalatal suture;
however, a great amount of variation exists in the way
this suture closes.

Landmarks on the occlusal radiographs
• Point A- Most ant point on Premaxilla
• Point B- Most posterior point on posterior wall of the
incisive foramen
• Point P- Point tangent to a line connecting the posterior
walls of the greater palatine foramens.

• RESULTS
• At SMI 3, 8% of total midpalatal suture is approximated
• At SMI 9, 25% of total midpalatal suture is approximated
• At SMI 11, 50% of total midpalatal suture is
approximated
• An ideal time to initiate orthopedic expansion is during
the early maturational stage, SMI 1 to 4

Frontal sinus as skeletal maturity
indicator (Ruf and Pancherz-1996)
• In this method, the cephalometric radiographs are used
for measuring the size of the frontal sinus at yearly
intervals.
• Radiographs were oriented with the nasion-sella line
horizontally

• The maximum width of the sinus was assessed
• Then the average yearly growth velocity (in millimeters
per year) was calculated
• Radiographic magnification of 7% is not taken into
account
• The average yearly body height growth velocity (in
millimeters per year) was calculated and the relationship
with the sinus growth rate is studied.

Conclusions:
• Frontal sinus growth velocity at puberty is closely
related to body height growth velocity
• Frontal sinus growth shows a well-defined pubertal
peak which on average, occurs 1.4 years after the
pubertal body height peak
• In males, the average age at frontal sinus peak is 15.1
years
• In a one-year observation interval, a peak growth
velocity in the frontal sinus of at least 1.3 mm per year
is attained by 84 percent of the subjects.

• In a two-year observation interval, a peak growth
velocity in the frontal sinus of at least 1.2 mm per year is
attained by 70 percent of the subjects
• These specific frontal sinus growth were assigned as
threshold values T1 and T2, respectively, for growth
prediction

Insulin like growth factor 1 and skeletal
maturity
• Ramy Abdul Rahman Ishaq et al.; Cairo (AJODO 2012, Vol 142)
• Insulin-like growth factor (IGF-I) is a polypeptide
hormone synthesized mainly by the liver.
• It is considered a mediator of growth-hormone function.
• It is involved in the growth of almost every organ and
plays a major role in postnatal growth and precisely in
the process of longitudinal bone growth.

• Low in the prepubertal stages followed by a sharp
increase at puberty and, after pubertal growth had
ceased, returning to lower base line values.
• ELISA is used for detection of IGF 1.
• Masoud et al used radioimmuno assay for detection of
IGF1 in their studies.
• IGF-I serum levels peaked at stage 4 of the cervical
vertebral maturation index with a mean value of
835.6ng/mL.

Salivary Alkaline phosphatase - A
for growth prediction
• Dr. Sujatha M Tarvade et al. (Indian Journal of Basic and
Applied Medical Research, June 2015)
• levels of salivary ALP levels in girls as well as in boys
correlated with G stage of MP3 at the age of 13.
• Thus a strong correlation of salivary ALP levels with
growth spurt was established
• Concluded that the salivary ALP levels can be used as
strong chemical biomarkers for identification of skeletal
maturational stages.

Conclusion
• 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.

References
❑ WILLIAM R.PROFFIT,HENERY W.FIELDS, JR.— CONTEMPORARY
ORTHODONTICS,4th EDITION
❑ Sridhar Premkumar ,Textbook of Craniofacial Growth
❑ Madhu S, Hedge AM, Munshi AK.-- The development stages of the middle
phalanx of the third finger (MP3): a sole indicator in assessing the skeletal
maturity?--- J Clin Ped Dent 2003; 27:.page- 149–156
❑ Julian Singer—Physiological Timing of Orthodontic Treatment—Am J
Orthod. Oct 1980.vol-50,no.4,page322-333 Calvin J Hunter –The
correlation of facial growth with body height and skeletal maturation at
adolescence. Am j Orhod .,January,1966,vol.36,no.1,page.44-54
❑ Urban Hagg and John Taranger--Maturation indicators and the pubertal
growth spurt —Am J Orthod, Oct 1982—vol.82,no-4,page-299—308.

❑ Leonard S.Fishman—Radiographic Evaluation of Skeletal Maturation-The
Angle Orthodontist – April 1982,vol-52,no-2,page-88-112
❑ K.C.Grave and T.Brown—Skeletal ossification and the adolescent growth
spurt.--- Am J Orthod, June 1976-vol-69,no-6,page-611—619.
❑ Sandra Coutinho et al –Relationship between mandibular canine
calcification stages and skeletal maturity Am.J.Orthod, Sep 1993,vol104,n0-
3,page.263-268.
❑ Tiziano Baccetti , McNamara et al—An improved version of the cervical
vertebral maturation method for the assessment of mandibular growth-
Feb 2002,VOL-72,NO.4,page,316-323
❑ Sabine Ruf et al-- Frontal sinus development as an indicator for somatic
maturity at puberty --.Am J Orthod. Nov 1996 (476 - 482):
❑ Bernal Revelo et al- Maturational evaluation of ossification of the
midpalatal suture-- Am J Orthod March,1994 (288 - 292):

❑ Nanda RS-The rate of growth several facial components measured from
serial cephalometric roentgenograms.-1955-Am J orthod. VOL- 41 Page-
658-673.
❑ Hussam M. Abdel-Kader –The reliability of dental xray film in assessment
of MP3 stages of the pubertal growth spurt-Am.J .Orthod.Oct1998,vol-
114,no4,page,427-429.
❑ Christer Engstrom et al-Lower third molar development in relation to
skeletal maturity and chronological age.-The Angle Orthodontist .April
1983,vol.53,no.2,page,97-106.
❑ K.S.Negi, Vijay P .Sharma et al-Assessment of growth impetus using MP3
maturation and its correlation with CVMI and dental age. J Ind
Orthod.Soc,2003. 36,page,204-213.
❑ R.RAJAGOPAL,SUDHANSU KANSAL—A comparison of of modified MP3
stages and the cervical vertebrae as growth indicators.JCO,July
2002,vol.XXXVI.No.7.page,398-40

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