Assessment of growth11 final

METHODS OF OSSIFICATION
AND ASSESSMENT OF BONE
GROWTH
RECENT ADVANCES
www.indiandentalacademy.com

INTRODUCTION
As with all practitioners in health arts,an
Orthodontists primary objective is to describe and
diagnose malocclusion he/she wishes to treat in
confirmity with the primary dictim of medicine
,primum,non nocere (first ,do no harm)irst ,do no harm)
The diagnosis can dictate the treatmentThe diagnosis can dictate the treatment
objectives and mechanotheraphy for a particularobjectives and mechanotheraphy for a particular
patient.patient.
The ability to predict patient’s facial growthThe ability to predict patient’s facial growth
early in life would enable the clinician to establish aearly in life would enable the clinician to establish a
correct diagnosis and identify the appropriatecorrect diagnosis and identify the appropriate
treatmenttreatment

METHODS
OF
OSSIFICATION

BONE FORMED BY TWO
MECHANISMS
Intramembranous ossification
Endochondral ossification

INTRAMEMBRANEOUS
OSSIFICATION
Within membranous,condensed plate
of mesenchymal cells
Mesenchymal cells lay down collagen – membrane
formed.
At initial site of ossification mesenchymal cells
differentiate into osteoblasts
Osteoblasts deposit osteoid
Osteoblasts located in lacunae within matrix
Collagen fibres – no preffered orientation – Woven
bone www.indiandentalacademy.com

Osteoid calcifies – primitive trabecular bone
Through reorganisation primitive trabecular
bone & compact bone converted to mature bone

ENDOCHONDRAL OSSIFICATION
Formed by transformation of cartilage “bone
models”
Mesenchymal condensation – cells become
chondroblasts,cells on surface of cartilage form
perichondrium
Intercellular substance calcify , nutrition cut off ,
cells die ,PRIMARY AREOLAE
Periosteal bud invades cartilage model &
progenitor cells enter cartilage

Periasteal bud eats away the calaified matrix-
large cavities – SECONDARY AREOLAE
Osteogenic cells become osteoblasts , lay down
osteoid
Bone deposited– lamellar bone – primary
ossification centre
Secondary ossification centre – future
epiphysis

Periosteal collar – around shaft of cartilage model
– woven bone

Distinct zones close to the zone of ossifying
cartilage
Reserve cartilage –
farthest from zone of
ossification
Zone of chondrocyte
proliferation
Zone of cartilage
maturation and
hypertrophy
Zone of cartilage
calcification

Between epiphysis and diaphysis – epiphyseal plate
Epiphyseal plate – basis for rapid growth of length of
bones
Removed by continued production of bone from
diaphyseal side

Bone formation & resorption go hand in hand
1st
deposited trabecular bone removed as zone of
ossification moves in direction of future epiphysis
Creates marrow cavity of the bones
Bone removed from endosteal surface & deposited
on periosteal surface of compact bone which forms
diaphysis
This results in growth of diameter of bone

REORGANISATION OF BONE
Change in size &
shape of bone during
growth
Key players –
osteoblasts &
osteoclasts
Cutting cone-Head of
osteoclasts,Tail of
osteoblasts
New secondary
osteons

METHODS OF ASSESSMENT
Direct measurements
Osteometry
vital staining
implant markers
histologic method
Indirect measurements
Photographs
models
radiographswww.indiandentalacademy.com

Indirect measurments in combination
X-ray + implants
X-ray + metaphyseal bands
Autoradiograhs
3D facial measurements
Stereophotogrammetry
Sassomis physioprint
Rabey’s morphanalysis
Holography
Moire topography
Contour photographywww.indiandentalacademy.com

MEASUREMENT APPROACHES
 Craniometry
 Anthropometry
 Animal experiments-1.Vital staining
2.Histology
3.Split line technique
4.Implants
 Radioactive tracers
 Auto radiographs
 Cephalometric roentgenography
 Photocephalometry
 Computerised cephalometrywww.indiandentalacademy.com

Roentgen stereophotogrammetry
Medical photogrammetry
Contour photography
Silhouette method
Study models
Facial masks
Laminagraphy
Electromyography
Xeroradiography for cephalometric
analysis

Measurements of landmarks on skull
Dried bones used
Static cross-sectional study
CRANIOMETRY

ANTHROPOMETRY
 Measure skeletal dimensions on living subjects.
 Camphor,Morton ,Broca
 Longitudinal data
 John Hunter-first to apply anthropometry using
mandible
 Mandible lengthened posteriorly
 Coronoid and condyle superiorly
 Resorption along anterior border of ramus
 Deposition along posterior border
 Increase in width of ramus

ANIMAL EXPERIMENTS
VITAL STAINING
Madder feeding
Leninus(1567)-staining property of root in bone
Belchier(1736)-accurate account
Duhannel(1742)-only newly formed bone
stained
Hunter-wide alternate red & white band of bone
Brash – 5 pigs of different age

Alizarin red injections
Reveals rate,procedure,nature of calcification.
Single i.p /i.v -2%solution of alizarin red
Reacts strongly with calcium at sites of
calcification.
Invasive study
Ground sections used
Wet specimen is ground,cleaned ,dehydrated ,
xylene treated and mounted.

HISTOLOGY
Qualitative processes responsible for growth
Direct measurements-Optical superimposition
Indirect-Micro photographs
Enlow-reconstructed 2Dimages of mandible
Site ,direction &pattern of bone growth
Localisation of
enzymes,glycogen&glycoproteins
Osteoclasts – Bone resorption
Osteoblasts – Bone deposition

SPLIT LINE TECHNIQUE
Benninghoff(1925)-superficial trabecular
bone pattern
Bones decalcified,penetrated with needle
Indian ink diffuses to fix fine trabecular
bone pattern

IMPLANTS
Duhamel(1742) – silver stylets
Hunter(1770) – lead shots in tibia of pigs
Au,Ag,Amalgam,SS,Vitalium,Tantalum-
pins,clips,pegs,screws,plates,wires
1st
dental study – Humphery(1864) – pig
mandible – wire loops around ramus
- resorption in anterior border
-deposition in posterior
border www.indiandentalacademy.com

Indirect studies – using x-rays
Grans Robinson,Sarnath – Silver amalgam implants
 Bjork – Tantalum pins & wires
- serial x-rays taken
Adv: - no interference with diet
- non invasive,
- new bone formation&resorption
measured
 Disadv: - sum total is demonstrated
- intervening changes not revealedwww.indiandentalacademy.com

RADIOACTIVE TRACERS
Radiophosphorous,RadioNa,RadioCa,Stro
ntium,RaFluoride,RaChloride,Iodine,Carb
on,Plutonium, Americanum,Gallium
Incorporated into tissue as a sort of vital
stain.
i.v.injection of isotope,detected by weak
radiation it emits

AUTORADIOGRAPHS
 Placing tissue of an animal injected with
radioactive substance close to a photographic
emulsion
 Exposed to radiation in dark
 Distribution of radioactive material-dark.

ROENTGENOGRAPHS
 Superimposition of successive x-rays
 Krogman & Sassouni(1957)-measurments from
shadows of bone &soft tissue landmarks on
radiographic images
 1922-Paccini –Teleradiographic image
 1912 -Tandler- x-ray film in Anthropometry
 Serial hand wrist x-rays to detect growth
changes
 Greulich&Pyle/ Tanner&Whitehouse-
comparing the stages with standard norms-
amount of growth left assessed.

CEPHALOMETRIC ROEOTGENOGRAPHY
 1931-Broadbent &Hoffrath
 Krogman,Savara,Meridth,Popovitch,Bjork,&
Woodside Longitudinal studies
 Stable anatomic base for superimposing
 Rate ,amount,&relative direction of bone growth
 Distinguish horizontal &vertical growth patterns
 Unilateral condylar hypoplasia-marked mandibular notching
on the affected side
 Does not reveal sites or mode of growth
 Solow &Kreiborg-Multiprojection cephalometry
 EDP(Electronic data processing)
 Disadv-2D representation of a 3D structure
 PACeph projection-Moorees,Moyers Chierici&Faber.

PHOTO CEPHALOMETRY
Superimposition of co-ordinated
head films with photographs
Photo images on skin of patient-
accurately superimposed on
corresponding markers in a
cephalogram
Adv: Soft tissues seen

COMPUTERISED CEPHALOMETRICS
1970 in U.S.A
Computer fed with all data regarding norms &
standards of all analysis
Less time consuming,increased reliability by double
digitization & easy storage of information

XERORADIOGRAPH FOR
CEPHALOMETRIC ANALYSIS
 1971
 Selenium containing plates in plastic cassette
 Reconstruction of cephalomatric planes
&points made on tracing paper applied over
the picture
 Adv:All densities displayed
Edge enhancement effect

CONTOUR PHOTOGRAPHY
Cobb(1972),Lovesy
(1974),Robertson(1976)
Light sectioning technique
Equal width grids
projected on face producing
contour pattern
Convex telecentric lenses
are placed in paths of
projected beams & of
recording camera www.indiandentalacademy.com

SILHOUETTE’S METHOD
Light projected on patient from a
predetermined distance
Shadow on a smooth ,fixed screen
Lontitudinal study

STUDY MODELS
 Duplication with plaster,thiokol,hydrocolloid,stone
 Permanent records,longtitudinal studies possible
 Model analysis done & growth changes measured
FACIAL MASKS
 Impression of face taken at regular intervals
 Standard measurements – Zygoma-zygoma,
Gonion-Gonion.

LAMINAGRAPHY
Assess peri-chondroblastic activity of
secondary cartilage in reaction to stress on
mandibular condyle,by using lamina
&examined under microscope

ELECTROMYOGRAPHY
Assess electric potentials in response to external
stimuli of muscle spindles
Deep & surface electrodes
Kinesograph-movements of muscle spindles
Principle – bone yields to muscle pressure
 Studying the role of muscle influence on bone
growth
Caliberated metre – records the potential
elicited during movements
Amount needed to elicit response – amount of
growth judged www.indiandentalacademy.com

SKELETAL INDICATORS
OF MATURITY
Hand wrist radiographs
Cervical vertebrae
Canine calcification

HAND WRIST RADIOGRAPHS
P-A radiograph of left hand & wrist
Todd , followed by Greulich & Pyle – Atlas of
standard hand & wrist films at various ages
Systematic comparison of left hand & wrist to
atlas standards
Bones assessed in regular order
Each centre is given a skeletal age , an overall
average age is determined
Good index of overall biologic maturationwww.indiandentalacademy.com

•Tanner & Whitehouse method – “maturity
points”,scores given
•Bjork – capping of epiphysis of 3rd
middle
phalanx closely related to P.H.V

GREULICH & PYLE METHOD –
Comparison with standard x-rays
TANNER & WHITEHOUSE METHOD –
“Maturity points”,scores given
ANTHROPOMETRIC METHOD
U/L Segment ratio

Tanner & Whitehouse method
3 methods
1.RUS
2.Carpal bone method
3.TW2 method – each growth centre –
maturity rating on a scale of 8
( A toH) except Radius ( A to I)
Numerical score for each centre
Total gives overall maturity ratingwww.indiandentalacademy.com

OSSIFICATION OF ABDUCTOR
SESAMOID & MP3
Taranger &Hass
Sesamoid usually attained during acceleration
period of pubertal growth spurt
MP3 – third finger middle phalanx

Chapman – Standard size dental
films to assess development of 1st
metacarpal joint
 Abductor sesamoid ossification –
beginning of adolescent spurt in
height
Bjork,Holm – 7 Maturational
events
-Bone development to growth
velocity

CERVICAL VERTEBRAE
Sato – appearance of epiphyseal plate of odontoid
process – indicator of growth peak
Lampraski – atlas that stimulated morphologic
changes in cervical vertebral bodies in puberty
Hassel & Farman , Garcia – Fernandez –
pubertal growth based on cephalometric
radiographs
O Rielly & Yaniello (1998) – increase in corpus
length , ramus height & mandibular length during
stages of cervical vertebral maturation

CANINE CALCIFICATION
Garn,Engstrom & co workers –
relationship between tooth mineralisation
& skeletal development
Mandibular canine - to estimate timing of
pubertal growth spurt
Assessed according to Demirjian’s stage of
dental calcification
Maturity of mandibular canine is more
closely related to PHV than other toothwww.indiandentalacademy.com

A.Initial cusp
B.Cusp coalesence
C.Crown ¾th formed
D.Formed upto CEJ
E.Root smaller
than crown
F.Root & crown equal
G. Apex still open
H.Fully erupted

MORPH ANALYSIS
Centroid-based pattern of orientation
Dental,skeletal & soft tissues identified by
non-numeric graphic approach
CGA-centro graphic analysis –
cephalometric radiograph to demonstrate
growth changes
Facial centroid axis was formulated to
provide a better , stable reference plane

CO-ORDINATE GRIDS FOR 3D
FACIAL MEASURMENTS
Leivesley(1983)
Volumetric measurements & rectangular co-
ordinates
Two grids available-
Uniformly spaced grids with predetermined
interval
Proportionally spaced grids

 Superimposition – measurement in
those areas lacking natural landmark
 Grid intersections – used to define
artificial , constructed landmarks

FOURIER ANALYSIS
Mathematical method , allows quantitative
analysis of shape and it’s changes
Reconstruct outlines , landmark
identification and fourier analysis of these
outlines through a set of equations enables
detection of variations in soft tissues and
growth changes over a period of time

NMR SPECTROSCOPY
New method of obtaining 3D cross
sectional pictures of thin slices of human
head - using resonance of hydrogen nuclei
Radio tracers of P,Na,Mg - growth studies
on non invasive plane

COMPUTER AIDED TOMOGRAPHY
Image of the subject is processed by a
computer , assessing cranio facial growth
and numerical investigations regarding
growth

COMPUTER LASER SCAN
SYSTEMS
Regular cephalostat
for taking
cephalograms with
specialised coated films
He & Ne Lasers -
used to activate
Delinate hard & soft
tissues

LASER
Rapid 3D for facial
morphology study
Scan face in 6
seconds,gives image in
4 min
Adv:contact free ,
data memory,rapidity
Dis adv:costly

DIGIGRAPH
Sonic digitizing probe
Pressing button – sound elicited & land
mark recorded by microphone array
Dolphin imaging
systems(California,USA)

Lighthly touching the
probe to patient’s skin
Electronic circuitory
Head holder
2 video camera

Ceph measurements recorded by
microphone array in X-Y-Z co-ordinate
Calculating time between sonic wave
emission & detection

FINITE ELEMENT ANALYSIS
In 1985, Melvin moss ,introduced a method to
analyse a cephalogram that uses partial differential
equations to asign loading values for intermediary
points in irregular structures by dividing into a set
of regular geometric shapes
Generate a mathematical matrix of transformation
related to both size & shape
Finite element for analysis of serial,lateral
cephalometric radiographs
Useful tool for morphometric analysis in
craniofacial biology

By reducing the structure to a group of
appropriately connected small elements
of known mechanical behaviour,the
response of entire structure to loading
can be estimated

ANTEGONIAL NOTCH FOR GROWTH
PREDICTION
Singer , Mamandras & Hunter
Presence of prominent antegonial notch-arrested
growth of mandibular condyles
Apposition Resorption
Forward rotating symphysis Angle
Backward rotating Angle Symphysis
So deep antegonial notch – Backward rotating
mandible.

FRONTAL SINUS & MANDIBULAR
GROWTH PREDICTION(AJO DO
1991 DEC)
Rassouw,Lombard & Harris
Correlation between max & mand length,
symphysis width,condylar length & frontal sinus
on lateral ceph
Frontal sinus bud present at birth in ethmoid
region
Rapid growth to adult size at 12 years
Tunner-Annual height growth increments
reached a plataeu at ages when frontal sinus
enlargement ceasedwww.indiandentalacademy.com

Brown,Molleson & Chinn – study on lateral ceph
The surface area(sq.mm) of frontal sinus –
assessed by summagraphic decoder linked to a
microcomputer
Negative ANB angle – small maxilla & large
mandible coincided with large frontal sinus
Frontal sinus size though influenced by external
environment & muscle attachments is a valuable
indicator of excessive mandibular growth.

ROENTGEN
STEREOPHOTOGRAMMETRY
Selvik(1974)
Davidson,Hedley & Payne – 3D localisation procedures
from radiopgraph
Bone markers – Tantalum spheres,balls or pins
Aromo,Selvik & Holst – implantation instruments with a
needle & adjustable stop clock
2 markers – longitudinal growth registration
3 markers – kinetic studies
Growth is calculated from distancewww.indiandentalacademy.com

Distance changes - from 3D co-ordinates of
implants using the 3D pythogorean theorem
Biologic mechanism of growth – spatial
co-ordination from 2D film co-ordinates
RAD – below normal
New & exact information on skeletal growth
No technical problems – differential
enlargement , definition of landmarks , image
interpretation problems , orientation errors
Skull cephalostats avoidedwww.indiandentalacademy.com

CASMAS - COMPUTER AIDED
SKELETAL MATURITY
ASSESSMENT SYSTEM
Digital hand atlas with large set of normal set of
hand & wrist images that reflect skeletal maturity ,
race , sex difference & current child development
Digital hand atlas will be used for computer aided
bone age assessment via web
Medical university California designed and
partially implemented a computer aided diagnostic
system for web based bone age assessment

The system consists of digital hand atlas , a
relational image data base & web based interface
The digital atlas is based on a large set of normal
hand & wrist images with extracted bone objects
& quantitative features
The image database uses a content based
indexing to organise the hand images & their
attributes & present to user in a structural way
Allows users to interact with hand image data
base from browsers
Users can use a web browser to push a clinical
hand image to CAD server for a bone age
assessment

Quantitative features on the examined
image, which can reflect the skeletal
maturity will be extracted & compared
with patterns from atlas database to assess
the bone age
The relevant reference images and the
final assessment report will be sent back to
user’s browser via web

THREE DIMENSIONAL FACIAL
GROWTH STUDIED BY OPTICAL
SURFACE SCANNING
The optical scanner – rapid accurate data
collection in 3D
Assosiated software creates a visual image
Dis adv – high cost
Recently,video-capture stereoscopic method of
imaging
2 pairs of stereo camera – curved facial
structures are imaged


The system allows photo realistic image
generation of the face that can be viewed
from any direction
Study the 3D alterations in the facial
morphology with increasing age

CONCLUSION
Dynamics of growth is a complex process
The Orthodontist , if he is to evaluate properly
the role he plays in correcting malocclusion ,
must have the opportunity to examine
the conditions over which he has the least
control , namely growth & development during
correction of malocclusion
With the use of the recent techniques
available accurate information about growth
can be obtained

REFERENCES
1.Profitt – Contemporary Orthodontics
2.White & Goaz – The Dental Radiology
3. Athanasiou – Orthodontic Cephalometry
4.Thomas Rakosi – Cephalometric Radiography
5.Inderbir Singh – Textbook of human histology
6.Hassel & Farman – Skeletal maturation evaluation using skeletal vertebra- AJO DO
1995,107,pg:58-66
7.Bernard G. Sarnath – Growth pattern of mandible – AJO DO 1986 pg:221-233
8.Garcia – fernandez,The cervical vertebra as Maturational indicator- JCO April 1998
9.Leivesly – Reliability of Contour Photography for facial measurements- BJO 1983, pg:34-
37
10.Tashinaro Mito & Sato – Cervical vertebral bone age in girls – AJO DO 2002,122,pg:380-
385
11.Hagg & Taranger – Maturity &Pubertal growth spurts – AJO 1982,82,pg:299-309
12.Nute & Moss – 3D facial growth studied by optical scanning – JO 2000 vol
27,pg:31-38

13.Chertkow – Tooth mineralisation as an indicator of the pubertal growth spurt –
AJO DO 1980 ,pg:79-91
14.Sato & Mito – An accurate method of predicting mandibular growth potential
based on bone maturity – AJO DO 2001 , 120, pg :286-290
15.Sierra – Assessment of dental & skeletal maturity – A new approach,AO
1987,pg:194 –208
16.Abdul Khadher – The potential of dental didital Radiography in recording
adductor sesamoid & MP3 – BJO 1999,VOL:26,291-293
17.Kolodziej,southard – Evaluation of Ante gonial notch depth for growth
prediction – AJO DO 2002,121,pg:357-363
18.Melesio.r.Leite, O’Rielly – Skeletal assessment using 1sty , 2nd
& 3rd
fingers of
hand – AJO DO – 1987,pg:492-498
19.Sandro Coutinno – relationship between mandibular canine calcification stages
& skeletal maturity – AJO DO 1993, pg:262 -268

THANK YOU

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