Growth assessment /certified fixed orthodontic courses by Indian dental academy


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Growth assessment /certified fixed orthodontic courses by Indian dental academy

  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3.       Introduction Requirement of an ideal maturity indicator Clinical importance Different methods of growth assessment Interrelationship among the various maturity indicators conclusion
  5. 5.   Human growth shows considerable variation in the chronological ages at which individual children reach similar developmental events . Therefore, an understanding of growth events is of primary importance in the practice of orthodontics. Biological age, skeletal age, bone age, and skeletal maturations are nearly synonymous terms used to describe the maturation of a person.
  6. 6.   In the planning of orthodontic treatment, anticipation of future growth potential Of the facial skeleton is essential to ensure the successful out come of mechanotherapy, and in the treatment of dentofacial deformities. It can be important in myofunctionl appliances, borderline extraction cases, timing of headgear therapy or in the prognosis of skeletal class two or three discrepancies.
  8. 8. Requirement of an ideal maturity indicator          Should be safe and non invasive Require minimum radiation Should be accurate Stage of maturity should be well defined Easily identifiable Cost effective Require minimum armanterium Simple to conduct Valid overtime and across age group
  9. 9. CLINICAL IMPORTANCE  The key to successful 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 not be futile. Hence the knowledge of maturity indicator is important for;
  10. 10. To determine the potential vector of facial development  To evaluate the rate of growth  To decide the onset of treatment planning  To evaluate the treatment prognosis 
  11. 11. Different methods of growth assessment
  12. 12.   Biometrics—is defined as science of statistical biology ,the collection and statistical analysis of data regarding a living organism. Longitudinal methods —these imply serial measurements in the same individual or population over a long period of time. their advantage lie in the fact that individual patterns can be defined and the variation within the group can be analyzed . However these studies are more expensive and time consuming and more vulnerable to subject attrition.
  13. 13.    In a longitudinal growth study by Bjork with means of implant was done to find out the variation in growth pattern of the human mandible . Cross sectional method –groups of varying ages or at varying stages in development are examined only once. Semi longitudinal---monitoring age groups or subgroups at different level of development only for that period which separate one group from another.
  14. 14.   Radio isotopes —when injected into the tissues get incorporated into the developing bone and act as in vivo markers. Tc 33 is the most commonly used isotope. Vital staining —administration of certain dyes to the experimental animals which incorporated in the bones. e.g.—Alizarin red 5,tetracyclin.
  15. 15.    Natural markers —certain histological features present in the normal bone such as nutrient canals ,lines of arrested growth and certain prominent trabeculae can be used as natural markers. Steriopairs —is a computer analysis in which positional changes can be studied in a three dimensional system. Craniometry —metric study of cranial dimensions in dry skulls. less suitable for descriptive purpose.
  17. 17. SOMATIC    An standard growth chart is used to determine a growth of a child relative to peer group. Commonly used for height and weight. The normal variability is shown by solid line on the graph.
  18. 18.  INTERPRETATION    — plotted above the 90% child was larger than 90% of the population. Plotted below the 10% line child was smaller than 90% 0f the population An individual who stood exactly at the midpoint of the normal distribution would fall along the 50% line of the graph .
  19. 19.
  20. 20.   Growth can either be plotted either in height and weight at any age (black) known as distance curve or the amount of change in any given time (red line) ,called as velocity curve. Plotting velocity rather than distance makes it easier to see when accelerations or decelerations in the rate of growth occurred.
  21. 21.
  22. 22. Growth velocity curve for early, average and late maturating indicate that earlier the adolescent growth spurt occurs, the more intense it appear to be.
  23. 23. 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.
  24. 24. 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 . 
  25. 25. Late maturing –shorter than average in childhood and will be adults of average stature.  Genetically short —short in childhood and as adults as well.  Children who start puberty either very late or very early subsequently have either much less or much more growth in height than expected. 
  26. 26. However height and weight tables for determining developmental status have proved to be inadequate because of the factors such as     Heterogenicity of the population Genetic diversity Difference in levels of nutrition Environmental factors
  27. 27.   More ever in every population there are early and late maturing strains and there is wide variation in age at onset of puberty. Because of these factors, the developing status of a child can not be accurately predicted on the basis of these height and weight charts .
  29. 29. Characteristic body changes and secondary sexual characters are seen during the onset of puberty due to differential hormonal action.  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 
  30. 30. 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 closed to PHV and male voice is attained at PHV or after.
  32. 32. HAND WRIST RADIOGRAPH   The hand wrist region is made of numerous small bones which show predictable and scheduled pattern of appearance ,ossification, and union from birth to maturity. Generally left hand radiograph is taken.
  34. 34.
  35. 35. STAGES IN THE OSSIFICATION OF PHALANGES    Stage one —the epiphysis and diaphysis are equal. Stage two —the epiphysis caps the diaphysis by surrounding it like a cap. Stage three ---fusion occurs between the epiphysis and diaphysis.
  36. 36.
  37. 37. THE SESAMOID BONE   The sesamoid bone is a small nodular bone. Most often present embedded in the tendons in the region of the thumb.
  40. 40.    ATLAS METHOD BY GREULICH AND PYLE(1950) Greulich and Pyle published an atlas containing ideal skeletal age pictures of the hand wrist for different ages and for each sex. Each photograph in the atlas is representative of a particular skeletal age. The patient radiograph is now matched on an overall basis with one of the photographs in the atlas;
  41. 41. BJORK,GRAVE AND BROWN METHOD Have divided skeletal development into 9 stages; Schoph in 1978 associated each of these stages with a particular chronological age.
  42. 42.   Stage 1—(male-10.6y female-8.1)– the epiphyis and diaphysis of the proximal phalanx of index finger are equal.Occurs approx 3 years before the peak of pubertal growth spurt Stage 2-(male-12y female-8.1) –the epiphysis and diaphysis of the middle phalanx of the middle phalanx are equal.
  43. 43.  Stage 3 (Male-12.6y Female-9.6y)— 1.hamular process of the hamate exhibits ossification 2.Ossification of pisiform 3.The epiphysis and diaphysis of radius are equal
  44. 44.    Stage 4 (Male-13 y Female-1o.6y)-initial mineralization of the ulnar sesamoid of the thumb. Increased ossification of the hamular process of the hamate bone. Marks the beginning of pubertal growth spurt.
  45. 45.   Stage 5----(male14y; female-11y)marks the peak of the pubertal spurt. Capping of the diaphysis by the epiphysis is seen in middle phalanx of the third finger, Proximal phalanx of the thumb and In radius.
  46. 46. Stage 6 (male15y;female-13y)  Signifies the end of pubertal growth spurt  Union between diaphysis and epiphysis of distal phalanx of middle finger.
  47. 47.  Stage  7— (male-15.9 female- 13.9) Union between epiphysis and diaphysis proximal phalanx of little finger
  48. 48.  Stage  8– (male-15.9 female-13.9) Fusion between epiphysis and diaphysis of middle phalanx of the third finger
  49. 49.  STAGE 9 (Male-  18.5y Female16y) Fusion between epiphysis and diaphysis of the radius
  50. 50. SINGER METHOD OF ASSESSMENT  Six stages of hand wrist development are described
  51. 51.    Stage 1 (early) —absence of pisiform;hook of the hamate; epiphysis of proximal phalanx of second finger (PP2) being narrower than its diaphysis Stage 2- (prepubertal)- initial ossification of the hook of hamate, pisiform and diaphysis equal to epiphysis in proximal phalanx of second finger. Represents the period during which significant amount of growth of mandible is possible.
  52. 52.   Stage 3(pubertal onset) —(1):begining of calcification of ulnar sesamoid. (2):increased width of epiphysis of PP2 (3):increased calcification of hook of hamate and pisiform. Stage 4(pubertal)----calcified ulnar sesamoid,fusion of epiphysis of DP3 with its shaft.
  53. 53.   Stage 5(pubertal deceleration) —1;fully calcified ulnar sesamoid. 2; fusion of epiphysis of distal phalanx of middle finger with its shaft; 3; epiphysis of radio and ulna are not fully fused with their respective shaft . Stage 6 (growth completion) - no remaining growth sites are seen.
  54. 54. FISHMAN SKELETAL MATURITY ASSESSMENT ANGLE ORTHODONTIST 1982  It uses of 4 anatomical site located on thumb, third finger ,fifth finger and radius.11 discrete adolescent maturity indicators covering the entire period of adolescent growth, are found on these sites.
  55. 55.
  56. 56.      This system of interpretation uses 4 stages of bone maturation 1-epiphysis equal in width to diaphysis 2—appearance of adductor sesamoid of the thumb 3-capping of epiphysis 4-fusion of epiphysis
  57. 57.
  58. 58.       The 11 skeletal maturity indicators (SMI) are as follows— Width of diaphysis equal to epiphysis SMI:1—proximal phalanx of middle finger SMI:2—middle phalanx of the middle finger SMI:3-middle phalanx of the little finger SMI 4 —OSSIFICATION of sesamoid
  59. 59. Capping of epiphysis Distal phalanx of middle finger SMI-5 Middle phalanx of third finger SMI-6 Middle phalanx of small finger SMI-7
  60. 60. FUSION OF EPIPHYSIS AND DIAPHYSIS SMI 8 SMI 9 distal phalanx of middle finger SMI 10 proximal phalanx of middle finger SMI 11 Middle phalanx of middle finger RADIUS
  61. 61.
  63. 63. HAGG AND TARANGER METHOD   Skeletal development in the hand and wrist is analyzed from annual radiograph , taken between the ages of 6 and 18 years, by the ossification of ulnar sesamoid of the thumb, and certain specified stages of three bones MP3 ,DP3, and epiphysis of radius Sesamoid- is usually attained during the acceleration period of the pubertal growth spurt
  64. 64.      Third finger middle phalanx— MP3F—epiphysis as wide as metaphysis. Ends of epiphysis are tapered and F stage rounded Metaphysis shows no undulation Radiolucent gap between epiphysis and metaphysis is wide
  65. 65.  Attained before onset of PHV by about 40% of individual and at PHV by many others
  66. 66.     MP3—FGepiphysis is as wide as metaphysis. Distinct medial and/or lateral border of the epiphysis forming a line of demarcation at right angle to the distal border. This is attained 1 year before or at p.H.V
  67. 67. Modified by R.Rajgopal and Sudhansu Kansal (JCO July 2002)   Metaphysis begin to show slight undulation Radiolucent gap between metaphysis and the epiphysis is wide
  68. 68.    MP3-G – Sides of the epiphysis are thickened and also caps its metaphysis,form ing a sharp edge distally at one or both sides. Attained at or 1 year after p.H.V.
  69. 69. modification   Marked undulation in the metaphysis gives it cupid’s bow appearance Radiolucent gap between epiphysis and metaphysic is moderate
  70. 70.    MP3 H— Fusion of epiphysis and metaphysis has begun. It is attained after PHV but before end of growth spurt by practically all boys and about 90% of all the girls.
  71. 71. MP3 –HI STAGE (new stage added by these authors)    Superior surface of epiphysis shows smooth concavity where as metaphysis shows smooth convex surface almost fitting into reciprocal concavity of the epiphysis No undulation is present in the metaphysis Radioluscent gap between the epiphysis and the metaphysis is insignificant.
  72. 72.    MP3 I Attained before or at the end of growth spurt in all the subjects except a few girls Fusion of epiphysis and metaphysis is complete.
  73. 73.      THIRD FINGER DISTAL PHALANX—DP3 I –Fusion of epiphysis and metaphysis completed. Attained during the deceleration period of growth spurt by all subjects. CHANGES IN THE DISTAL EPIPHYSIS OF THE RADIUS R I- Fusion of epiphysis and metaphysis has begun and is attained 1 year before or at the end of growth spurt by about 80% of girls and about 90% of the boys. R-IJ- Fusion is almost completed RJ- Fusion of epiphysis and metaphysis
  74. 74.
  75. 75. CERVICAL VERTEBRAE MATURATION (CVM)   The first seven vertebrae in the spinal column constitute the cervical spine. The first two, atlas and axis are quite unique while the third through the seventh have great similarity. Lamparski(1972)-studied changes in size and shape of cervical vertebrae to create maturational standards.
  76. 76.   Hassel and Farman (ajo 1995) created a method of evaluating the skeletal maturation of the orthodontic patient using the cephalometric radiograph that is routinely taken with pretreatment records. 11 groups of 10 male and 10 female aged 8-- 18 years, taken from Bolton-brush growth center and placed in each SMI group numbered 1 to 11 ( FISHMAN SMI).
  77. 77.    The shape of the cervical vertebrae C2,C3 and C4 were seen to differ at each level of skeletal maturity. Shapes of vertebral bodies of C3 C4 changed some what from wedge shape to rectangular followed by square shape. In addition they become taller as maturity progressed. The inferior vertebral borders were flat when immature and concave when mature. Hassel and Farman have put forward six stages in the vertebral development.
  78. 78.    INITIATION. --This corresponded to a combination of SMI 1 and 2. At this stage, adolescent growth was just beginning and 80% to 100% of adolescent growth was expected. Inferior borders of C2, C3, and C4 were flat at this stage. The vertebrae were wedge shaped, and the superior vertebral borders were tapered from posterior to anterior
  79. 79.
  80. 80.    ACCELERATION.--- This corresponded to a combination of SMI 3 and 4. Growth acceleration was beginning at this stage, with 65% to 85% of adolescent growth expected. Concavities were developing in the inferior borders of C2 and C3. The inferior border of C4 was flat. The bodies of C3 and C4 were nearly rectangular in shape .
  81. 81.
  82. 82.    TRANSITION. --This corresponded to a combination of SMI 5 and 6. Adolescent growth was still accelerating at this stage toward peak height velocity, with 25% to 65% of adolescent growth expected. Distinct concavities were seen in the inferior borders of C2 and C3. A concavity was beginning to develop in the inferior border of C4. The bodies of C3 and C4 were rectangular in shape
  83. 83.
  84. 84.    DECELERATION. --This corresponded to a combination of SMI 7 and 8. 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, and C4. The vertebral bodies of C3 and C4 were becoming more square in shape .
  85. 85.
  86. 86.    MATURATION. This corresponded to a combination of SMI 9 and 10. 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
  87. 87.
  88. 88.    COMPLETION. --This corresponded to SMI 11. Growth was considered to be complete at this stage. Little or no adolescent growth was expected. 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.
  89. 89.
  90. 90.
  91. 91.      Tiziano Baccetti ,Franchi,McNamara (Seminars in orthod. 2005) have recently proposed an improve version of the cervical vertebrae maturation for the detection of the peak of the mandible growth based on the analysis of the second through fourth cervical vertebrae in single cephalogram. The new cervical vertebrae maturation stage(CVMS) presents 6 maturational stages CS1 and CS2 are prepeak stages , The peak in mandibular growth occurs between CS 3 and CS 4 CS6 is recorded at least 2 year after the mandibular peak.
  92. 92. CLINICAL APPLICATION    Class II treatment is most effective when it includes the peak in the mandibular growth (CS3 ,CS4) Class III treatment with maxillary expansion and protraction is effective in the maxilla only when it is performed before the peak (CS1,CS2) where as it is effective in the mandible during both prepubertal and pubertal stages. Deficiency of mandibular ramus height can be enhanced significantly when orthopedic treatment is performed at the peak of the mandibular growth (CS3).
  93. 93.    Mc Namara,Franchi et al (AJO 2000) Used the CVM method to define the optimum timing for treatment of class two malocclusion with twin block. The subject in the early treated group started twin block therapy in stage 1 or 2 and were compared with subjects treated during or slightly after stage 3 The more favorable mandibular skeleton modifications were induced in the group that started therapy in stage three group which is concurrent with the onset of the peak in mand growth.
  94. 94.  DENTAL MATURITY INDICATORS TOOTH ERUPTION TOOTH FORMATION however tooth eruption is much more variable in its timing than other skeletal maturity indicators (Nolla1960,Vanderliden1979) tooth formation is also reported to be more variable than calcification sequence- Nolla 1960. Demirjian,Goldstein,Tanner(1973) —proposed a method for estimating dental maturity by radiographic appearance of seven teeth on the left side of the mandible.
  95. 95.      STAGE A -cusp tips are calcified but not yet fused. STAGE B –cusp tips are united so an occlusal out line can be determined. STAGE C —enamel formation is complete at occlusal surface. Dentin deposition has commenced. Outline of pulp chamber is curved. STAGE D —crown complete till CEJ. Pulp chamber curved being concave toward cervical region in single rooted tooth. In molars pulp chamber-trapezoid form. Pulp horns are beginning to differentiate. Root formation is seen STAGE E –pulp chambers are more straight. Horns more differentiated .Root length is less than crown.
  96. 96.    STAGE F —wall of pulp chamber form an triangle; root length equal or> than crown. Root bifurcation has developed suffice to give root a distinct outline and funnel shape endings. STAGE G - Root canal walls are parallel, apical end is partially opened. STAGE H- Apical end is completely closed. The pdl has uniform width around the root and the apex.
  97. 97.
  98. 98.    CHERTKOW(AJO 1979) Studied the relationship between tooth mineralization and early radiographic evidence of the ulnar sesamoid in children of Caucasoid origin. Calcification of adductor sesamoid was closely related to stage g of mandibular canine . No significant sex difference in the state of maturation of this tooth in relation to this particular stage of skeletal development. So this stage may be used as maturity indicator for the commencement of circumpubertal growth spurt.
  99. 99.
  100. 100.
  101. 101.     Coutinho, Buschang, Miranda (ajo 1993) also studied the relationship between mandibular canine and skeletal maturity indicators; according to authorsCANINE STAGE F Initiation of puberty CANINE STAGE G concides with MP3 CAP; PP5 Cap . Presence of adductor sesamoid. it is indicative of PHV. Stage G which indicates eruption of canine occurs approx 1 year before PHV in boys and 5 month before in girls;
  102. 102.   kralassiri et al (AO 2002) studied Thai individuals and found mand 2nd premolar to show highest correlation. Vysal et al (AO 2004) studied on Turkish individuals, found mand molar to show highest correlation .
  104. 104.  HAGG AND TARANGER(AJO 1982)-Investigated the pubertal growth spurt and the dental skeletal and pubertal development in a longitudinal study of 212 Swedish children. They found 2 year sex difference in age in the beginning of peak and end of growth spurt . Dental development was not found as an useful indicator .The peak and end but not the beginning of the pubertal growth spurt could be determined from the skeletal development of hand wrist and pubertal development.
  105. 105. Inter-relationship among somatic ,skeletal ,dental, and sexual maturity (Demirjian, Buschang et al ajo 1985)     The interrelationship among all these measures for 50 French Canadian girls were evaluated. There was significant correlation among ages of PHV, menarche and 75% skeletal maturity. Age of menarche was most closely related to PHV. 90% of the dental development in the subjects did not show significant relationship with other maturity indicators; The results imply that dental developments are independent of other maturity indicators.
  106. 106.  Lewis, Roche ,Wagner (AO,1985)—found that timing of pubertal growth spurt in cranial base and mandible occurred after the onset of ossification of ulnar sesamoid but before PHV and menarche.
  107. 107. Association between Growth Stunting with Dental Development and Skeletal Maturation Stage (AO 2005)
  108. 108.    A study was done by Carlos Flores-Mira; et al to determine the skeletal maturity. stage of the middle phalanx of the third finger (MP3) and the dental development of the left mandibular canine in 280 high school children (140 stunted and 140 normal controls) between 9.5 and 16.5 years of age, from a representative Peruvian school. A high correlation was found between maturity indicators regardless of the nutritional status Growth stunting was not associated with dental development and skeletal maturity stages in Peruvian school children. ( Angle Orthod 2005;.)
  109. 109. Relationship between growth pattern and the maturation stage of permanent teeth (AO,Nov,2005)   A study by Neves et al was done on 256 individuals using lateral cephalograms to assess the growth pattern and OPGs were used to asses the dental maturation age at the age of 8 years. A significant correlation was found between the dental ages of the vertical and horizontal group, with the vertical group having a more advanced dental age. It was concluded that subjects with vertical growth patterns should be expected to mature dentally earlier than horizontal growers.
  110. 110. Midpalatal region as an indicator of maturity
  111. 111.    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 ,delayed based on Fishman skeletal maturity indicators and occlusal radiograph were taken to assess the sutural approximation. Sample consisted of 39 male and 45 female(age8-18 year)
  112. 112.  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.
  113. 113. Frontal sinus development as an indicator for somatic maturity at puberty.
  114. 114.    A study was done by Sabine Ruf Hans et al to evaluate the possibility of the frontal sinus development as an indicator for somatic maturity at puberty. The subject consisted of 53 samples with angle class II div I malocclusion who treated orthodontically during growth period . Lateral head film covering at least two year interval and longitudinal body height growth data existed for all the subjects.
  115. 115.
  116. 116.  Frontal sinus growth was compared with longitudinal body height growth.
  117. 117.   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 years after the pubertal body height peak (Bp).
  118. 118.  It was concluded that if only prediction was whether the pubertal growth peak in height has been passed the precision of the method was rather high (approximately 90%). However, if the age of body height peak was to be predicted, the method accuracy was lower (approximately 55%).
  119. 119. Lower third molar development in relation to skeletal maturity and chronological age—Christer Engstrom et al –AO,1983.
  120. 120.   None of the earlier studies included the development of third molar in relation to the skeletal maturity. However some of the great variability found in previous studies on third molar development might be due to the fact that the development was related to chronological age rather than the skeletal age.
  121. 121.   221 (123 girls,88 boys) were selected at random. the developmental stages of third molar were categorized into one of the following classes:-A—tooth germ visible as a rounded radioluscency. B—cusp mineralization complete. C—crown formation complete. D —root half formed. E—root formation complete but apex not closed.
  122. 122.
  123. 123.  A hand wrist was also taken and skeletal development was classified as PP2 Epiphysis as wide as diaphysis MP3 cap DP3 u Epiphysi Epiphyseal union s caps diaphysis Ru Epiphyseal union
  124. 124.
  125. 125.     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—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.
  126. 126.   Ru—crown completed in one third, half of the root development in one third, and had reached full length in another one third. Absence of one or both lower third molar was observed in 11% of the subjects.
  127. 127.   A large no of dental stages makes it very difficult to discriminate the tooth development and may adversely affect the possibility of identifying the relationship between tooth development and maturation. In this study different tooth development stages of the third molar were chosen long enough to span the various skeletal stages and so provide a meaningful comparison.
  128. 128. Ossification of the distal phalanx of the first digit as a maturity indicator for the initiation of the treatment of class III malocclusion ( AJO-DO 1996)
  129. 129.    Orthodonic treatment of mild(0 to -2ANB) to moderate(-3 to-5 ANB) skeletal class III malocclusions should begin in the early mixed dentition so that disharmony can be corrected with growth modifications. So a reliable indicator of the stage of skeletal maturation and the potential for further craniofacial growth especially residual mandibular growth in these group of individuals would be useful. In a study done by Shigemi Goto , Takehumi , Negoro et al in japanes female( AJO-DO 1996) it was concluded that ossification of the distal phalanx of the first digit occurs after the pubertal growth peak
  130. 130.    This event is closely related with declining growth rate of the mandibular condyles especially in the girls. They also found that the stage immediately before fusion of the distal epiphysis was associated with a minimal amount of craniofacial growth. The results of these studies showed that the maturation stage characterized by complete fusion of the epiphysis and diaphysis of the first digit always occurred after the pubertal growth spurt.
  131. 131.
  132. 132.
  133. 133.   As much as 90% of the total growth in length of the cranial base and maxillary and mandibular length had already been achieved at this stage that minimal craniofacial growth was left after this stage, particularly in females. However these findings seem to contradict the results recently reported by Battage (Eur J Orthod 1993;). who showed some continued mandibular growth in British females with Class III malocclusion after puberty.
  134. 134.   She reported that when comparing groups of female patients with Class I and Class III malocclusions, those with Class III malocclusions continued to grow longer in the mandible. This difference may be associated with differences in ethnicity and needs further investigation.
  135. 135.   Results of this study suggest that determination of the stage of skeletal maturation of the first digit of the distal phalanx may provide a quick and useful clinical method for assessing the residual growth potential in female patients with mild to moderate Class III malocclusions. This method is potentially helpful in patients where continued mandibular growth could be detrimental to the stability of the treatment result .
  136. 136.   However, caution should be exercised, as mandibular growth may still continue after closure of the distal phalanx of the first digit, especially in more severe Class III malocclusions that are due to mandibular prognathism. In those patients with more severe skeletal discrepancies, other methods should be applied to determine remaining growth, such as analysis of serial head films or nuclear bone scanning, to more accurately determine the condylar bone activity.
  137. 137. Physiological and biological age
  138. 138.    Many physiological and biological changes during growth show sex difference in timing and are more closely related to other indices of maturation than the chronological age. Girls show a spurt in systolic blood pressure which occurs earlier than the corresponding spurt in the male. The resting mouth temp. which falls by 0.5 to 1% from infancy to maturity, reaches its adult value earlier in boys than in girls.
  139. 139.     In the plasma inorganic phosphate shows a steady fall from the high levels of childhood to reach adult figures by the age of 15 in girls and 17 in boys. The alkaline phosphatase rises significantly in parallel with growth velocity between the ages of 8-12 in girls and 10-14 in boys and thereafter it falls rapidly to adult level. Ratio of creatine to creatinine in the urine is thought to fall progressively with age after about the age of 14 ½ years. Girls maturing early have a lower ratio than those of the same chronological age maturing late.
  140. 140. Assessment of physical maturation and somatomedin level during puberty
  141. 141.    Since the pubertal period is initiated by gonadal secretions controlled by FSH AND LH. So appearance of these hormones may serve as indicator to the onset of the adolescence. (Odell W.D et al 1967) The role of growth hormone has been described as an indirect because of its action through SULFATION factor. Sulfation factor acts directly on the cartilege and has got long half life in the plasma which makes it rational to look for changes in plasma level during puberty.
  142. 142.   A pilot study was done on 27 Caucasian girls and there developmental status was classified as prepubertal,circumpubertal and post pubertal by an qualified pediatrician. An orthodontic assessment was made including clinical dental examination ,lat.ceph,wrist radiograph of left hand and height and weight determination.blood samples were taken to determine the plasma somatomedin levels.
  143. 143.   The results showed that there was significant difference between the somatomedin levels in the plasma of circumpubertal and postpubertal females. however no significant difeerence was found the between the prepubertal and the circumpubertal group. In addition the skeletal age appeared to be better indicator of the physical maturity than the chronological age.
  144. 144. CONCLUSION     Maturational development embodies the overall biologic progression through life. In the growing years indicators of level of maturational development of the individual provide the best means for evaluating the biologic age. Maturational development can be accurately assessed with the help of all the indicators previously described. However it must be kept in the mind that every child demonstrates a unique sequential pattern of events. No child is same as the other. The growth factor is a critical variable in orthodontic treatment .The purpose of assessment of pubertal growth spurt is that there is growth of facial dimensions during this period.
  145. 145.     Skeletal indicators of maturation have been proved to be the most reliable . A combination of skeletal and dental indicators tend to give a very accurate picture of each child’s developmental status. Finally it must be kept in the mind that in orthodontic practice it may be more relevant to evaluate the development of the patient in relation to his own growth potential in order to assess whether peak velocity growth is imminent, present, or completed. The choice of indicators to be used finally depends upon an orthodontist‘s preference.
  146. 146. References:-     WILLIAM R.PROFFIT,HENERY W.FIELDS, JR.— CONTEMPORARY ORTHODONTICS,3rd EDITION Carlos Flores-Mira;et al--- Association between Growth Stunting with Dental Development and Skeletal Maturation Stage.-- The Angle Orthodontist Nov 2005 , Vol 75, No 6, page, 935 --942 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; 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
  147. 147.     Neves et al—Comparative study of the maturation of permanent teeth in subjects with horizontal and vertical growth patterns.-Am J Orthod. Nov 2005,page-619—623. 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.
  148. 148.    Seymour Chertkow—Tooth mineralization as an indicator of the pubertal growth spurt-Am J Orthod, January 1980 ,vol77,no.-1,page-79—92. PATRICIA GARCIA-FERNANDEZ et al--The cervical Vertebrae as Maturational Indicator, JCO April 1998-vol-XXXII,no4,page-221-225. Brent Hassel et al-Skeletal maturation evaluation using cervical vertebrae-Am J Orthod, January 1995,vol-107,no-1,page58-66.
  149. 149.     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 et al-The cervical vertebral maturation method for the assessment of optimal treatment timing in dentofacial orthopedics. Seminar in ORTHODONTICS,2005,11:Page,119-129 . 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 Tiziano Baccetti et al-Treatment timing for twin – block therapy. Am.J.Orthod,Aug.2000.vol.118,no.2,page.159170.
  150. 150.     A.Demirjian et al-Interrelationship among measures of somatic, skeletal, dental, and sexual maturity.- Am J Orthod ,Nov,1985,vol-88,no-5,page- 433-438. Nanda RS-The rate of growth several facial components measured from serial cephalometric roentgenograms.-1955-Am J orthod. VOL- 41 Page- 658-673. Leonard H.Rothenberg et al-Physical maturation and somatomedin levels during puberty-Am J Orthod.June,1977.vol-71,n0.4,page ,666-676. 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.
  151. 151.     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. Heloiso R.Leite et al-skeletal age assessment using the first,second and third fingers of the hand.Am J Orthod, December,1987.vol-92,n06,page,492-498. R.RAJAGOPAL,SUDHANSU KANSAL—A comparison of of modified MP3 stages and the cervical vertebrae as growth indicators.JCO,July 2002,,398-406
  152. 152.    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): Shigemi Goto et al --Ossification of the distal phalanx of the first digit as a maturity indicator for initiation of orthodontic treatment of Class III malocclusion in Japanese women-Am j Orthod ,Nov 1996, Volume (490 - 501):
  153. 153. Thank you Leader in continuing dental education