Clinical and radiographic guidelines for prediction of growth

CLINICAL AND RADIOGRAPHIC
GUIDELINES FOR PREDICTION OF
GROWTH SPURTS
DR ADITI ACHARYA

CONTENTS
1. INTRODUCTION
2. DEFINITION
3. CONCEPTS OF STUDYING GROWTH
4. METHODS OF STUDYING GROWTH
5. TYPES OF GROWTH DATA
6. METHODS OF GATHERING GROWTH DATA
7. METHODS OF STUDYING BONE GROWTH
8. VARIABLE AFFECTING PHYSICAL GROWTH
9. GROWTH ASSESSMENT PARAMETERS
10. VISUAL TREATMENT OBJECTIVES
11. COMPUTERIZED GROWTH FORECASTING
12. CONCLUSION
13. REFERENCES

INTRODUCTION
❖As a pediatric dentist- thorough background of craniofacial growth is an important
factor as growth of the facial structures is one of the earliest to be completed in in
comparison with other parts of the body.
❖Knowledge about all these serves as tools of success in a dentist practicing
treatments related to malocclusion and facial esthetics

DEFINITIONS
GROWTH
Defined as a physiologic increase in size, weight and mass of a living organism.
All the naturally occurring unidirectional changes in the life of an individual from its
existence as a single cell to its elaboration as a multifunctional unit terminating in
death—Moyers.
At a macroscopic level – exemplified by an increase in height and weight
At microscopic level- increase in number of cells and their size.
Growth in multicellular organisms – allometric ( disproportional ) than isometric.

Refers to stage of growth and maturation encompassing morphogenesis, differentiation and acquisition of functionality.
Development = progression towards maturity.
Maturation is the stage of stabilization brought about by growth and development.
Moyers- stated that while an organ or organism grows, its tissues develop towards specific functions and become mature.
DEVELOPMENT = GROWTH+ DIFFERENTIATION+TRANSLOCATION
At cellular level – seen as differentiation and maturation of progenitor cells to terminally differentiated cell
( mesenchymal cells to mature odontoblasts)
At subcellular level- exemplified by self assembly of immature collagen fibrils or mineralization of osteoid to mature bone.
At clinical level- seen as increasing capacity of condyle to withstand mechanical stresses.
DEVELOPMENT

WHY DO WE NEED TO STUDY GROWTH ?
Assessment
of growth
reveals
about the
general
health of the
individual
In many
instances,
the first
suspicion of
an
underlying
disorder
may be
suspected in
view of
altered
growth.
May help in
predicting
and
anticipating
the ultimate
body size of
the child
including
craniofacial
region and
modifying the
treatment
according to
the expected
changes in the
facial form.
It may be
used to plan
the timing of
orthodontic
treatment.
Assessment
of
differential
growth helps
in identifying
the cause of
malocclusion
and thus the
treatment
maybe
planned
accordingly.

GROWTH PATTERN, VARIABILITY AND TIMING
growth pattern – reflects proportionality.
It is a complex set of proportional relationship which
happen over a period of time.
This has been explained through cephalocaudal
growth, Scammon's growth curve.

CEPHALOCAUDAL GRADIENT OF GROWTH
‘There is an axis of increased
growth extending from head
towards feet’

SCAMMON'S GROWTH CURVEDIFFERENTIAL GROWTH: different
part of the body grow at a different
rate at different periods of time.
And these tissue systems or body
parts are concentrated in different
parts of the body.

PATTERN OF FACIAL GROWTH
•As in cephalocaudal gradient of
growth, the growth away from the
head happens at a later pace.
•When the facial growth pattern is
viewed- mandible being away
from the brain tends to grow more
and later than maxilla, which is
closer.

VARIABILITY- DEVIATION FROM NORMAL PATTERN
It indicates the degree of difference between two growing individuals in all four
planes of space including the all-important time.
All of us do not grow equally, having said that;prediction of it can be difficult
clinically but it is important to decide whether the individual is merely at the extreme
of normal variation or falls outside normal range.
Rather than saying the growth is normal or abnormal, we should think of it in terms of
deviation from the usual pattern and express this variability (deviation from usual
pattern) quantitatively on growth chart.

In this chart child is evaluated
relative to its peers.
•Normal variability as
derived from large scale
studies of groups of children,
is shown by solid line on
graph for comparing.
•An individual who stood
exactly at the midpoint of
the normal distribution would
fall along the 50% line of
the graph.
One who was larger than
90% of the population would
plot above the 90% line
the one smaller than 90% of
the population would plot
below the 10% line.

❖These charts can be used in 2 ways:
1. We can compare where the individual stands in comparison to the growth potential of his
peers.
A general guideline is that 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.
2. Growth charts can be used to follow a child over time to evaluate whether there is an
unexpected change in growth pattern.
❖Pattern implies predictability: so, for this reason, child’s growth should plot along same
percentile line at all ages to evaluate that child over time.
❖If the percentage position line of that person is changed, we should suspect some growth
abnormality, indicating a need for intervention by a clinician.

TIMING
❖Variations in growth and development
because of timing is particularly evident in
human adolescence.
❖Some children grow rapidly and mature
early, thereby appearing on the high side of
developmental charts until their growth
ceases and their peers begin to catch up.
❖Others grow and develop slowly and so
appear to be behind, even though, given
time, they will catch up with and even surpass
children who once were larger.
❖So, this occurs because biological clocks of
different persons are set differently.
❖All children undergo a spurt of growth at
adolescence
❖It can be seen more clearly by plotting
change in height or weight, but the growth
spurt occurs at different times in different
individuals.

CLINICAL SIGNIFICANCE
➢While delivering a myofunctional
appliance there is often a debate as to
which is the appropriate time to deliver
it.
➢While most of the studies indicate that
early treatment is the key to treat most
the malocclusions.
➢There are studies which suggest that
treatment done during the late mixed
dentition period has shown better result.
➢One such example is the timing of twin
block therapy.
➢In a study done by Baccetti et al
2000where the best timing for twin
block T/n was studied concluded that
➢Optimum treatment timing for Twin-
block therapy of Class II disharmony
appears to be during or slightly after
the onset of the pubertal peak in
growth velocity.
➢Hence timing plays the most important
role in myofunctional therapy.

RHYTHM AND GROWTH SPURTS
Human growth is not a steady and uniform process in which all body parts enlarge at
the same rate and same increment per year.
The rate of growth is most rapid at the beginning of cellular differentiation, increases
until birth and decreases thereafter.
Postnatally growth does not occur in a steady manner. There are periods of sudden
rapid increases, which are termed as growth spurts.

GROWTH SPURTS
Growth spurts are periods of sudden rapid increase in growth velocity.
According to Woodside (1968) there are three main growth spurts that happens in a
growing child. These are:
1. Infantile growth spurts – boys and girls at 3 years
2. Mixed dentition growth spurt- boys 7-9 years, girls 6-7 years
3. Adolescent growth spurt – boys 14-15 years, girls 11-12 years

The first events of puberty occur in the brain. The brain cells of hypothalamus
produce releasing factors which are carried by pituitary portal system.
This stimulates the anterior pituitary to produce pituitary gonadotrophins.
These pituitary gonadotrophins stimulate the adrenal cortex and the developing sex
organs to produce sex hormones.

Adolescent growth spurt in
girls occurs in 3 stages:
Initiation of physical
growth is the 1st stage:
appearance of breast
buds
1year after stage 1, the
peak growth velocity is
attained, noticeable
breast development, pubic
and axillary hair present.
stage 3 occurs 1.5 years
after stage 2 and is
marked by onset of
menstruation. There is
noticeable broadening of
hips and breast
development is complete

Adolescent growth spurt in boys
occurs in 4 stages:
“fat spurt” where the
boy gains weight and
becomes cubby
1 year from stage1
spurt in height begins,
growth of penis
begins
8-12 months from
stage 2, peak height
velocity is attained
axillary hair and hair
on upper lip, penis
near adult size
4th stage occurs 15 -
24 months after stage
3, spurt in height
ends, growth of facial
hair and increase in
muscle strength.
The stages in boys are more difficult to define. The onset of puberty is later
and extends for longer time compared to girls i.e. 3.5 years in girls and 5
years in boys.

The adolescent growth spurt on an average occurs 2 years ahead of the boys in the
girls.
Because there are differences in individual maturity a child can be early or late
maturer.
Thus, chronological age cannot be taken as a reliable indicator in predicting the
growth spurts.
This phase of increased growth can be uniquely used to deliver orthodontic treatment
procedures by utilising the growth potential.
Hence,the sexual maturity indicators are good sign in judging the timing of the growth
spurts.

CLINICAL IMPLICATION OF GROWTH SPURTS
To differentiate
whether growth
changes are normal
or abnormal.
Treatment of skeletal
discrepancies (e.g.
Class II) is more
advantageous if
carried out in the
mixed dentition
period, especially
during the growth
spurt.
Pubertal growth spurt
offers the best time
for majority of cases
in terms of
predictability,
treatment direction,
management and
treatment time.
Orthognathic surgery
should be carried out
after growth ceases.
Arch expansion is
carried out during the
maximum growth
period.

METHODS OF GATHERING GROWTH
DATA

1. LONGITUDINAL:
Measurements made of same person of group at
regular intervals of time.
Long term studies
Advantages:
A. Variation in development among individuals can
be studied and compared.
B. Specific development pattern of an individual can
be studied and compared.
Disadvantages:
Time consuming
Attrition
Expensive

2. CROSS SECTIONAL:
Measurement made of different individuals or
different samples and studied at different
periods are cross sectional measurements.
Short duration
Cost effective
Large samples can be obtained as study period
is short
It is possible to repeat the study in case of any
flaw. This is not possible in longitudinal study.
Disadvantages:
• Variation of individual person or
group of people cannot be studied.

3. OVERLAPPING/SEMILONGITUDINAL DATA:
Combination of longitudinal and cross sectional such that advanatges of both the
methods of data collection is obtained

Opinions Observations
Rating and
rankings
Quantitative
measurements:
• Direct data
• Indirect data
• Derived data

• Crudest means of studying growth
• It is a clever guess of an experienced person
• Not scientific, should be avoided when better
methods are available.
OPINION
• They are used to study all or none phenomena
such as presence or absence of caries,
presence or absence of class II
OBSERVATIONS

RATINGS AND RANKINGS:
When quantification of data is difficult this method can
be used.
Rating uses standard, conventionally accepted scales for
classification.
Ranking involves- arrangement of data in an orderly
sequence based on the value.

QUANTITAIVE MEASUREMENTS:
DIRECT- data is obtained directly by taking measurements on living persons or
cadavers by means of scales, measuring tapes or callipers.
INDIRECT- growth measurements attained from photographs, radiographs or
dental casts.
DERIVED DATA- data derived after comparing two measurements. These two
sets of measurements can be of different time frames or of two different
samples.

MEASUREMENT
APPROACH
EXPERIMENTAL
APPROACH

MEASUREMENT APPROACHES
Disadvantage- all these data must be
cross-sectional, i.e. one individual can
be measured at only one point in time.
It has an advantage that precise
measurements can be made on dry
skulls.
It was used to study skulls which were
found in the European caves in the
18th and 19th centuries.
CRANIOMETRY

ANTHROPOMETRY
It is the science of
obtaining
systematic
measurements of
the human body.
It was first
developed in the
19th century as a
method employed
by physical
anthropologists for
the study of human
variation and
evolution in both
living and extinct
populations.
Landmarks
established in dry
skulls are
measured on soft
tissue points
overlying these
bony landmarks.
Example: length of
the cranium can be
measured from a
point at the bridge
of the nose to a
point at the
greatest convexity
of the rear of the
skull.
Soft tissue
measurement will
be varied from
that of the skull
Despite that
anthropometry
makes it possible
to follow the
growth of an
individual directly,
same
measurements can
be measured over
a period of time.

Disadvantage – 2D
The same individual can be
followed over a long time-
longitudinal
Allows direct measurement of
bony skeletal dimensions,
since bone can be seen
through soft tissue covering.
This approach can combine
the advantages of
craniometry and
anthropometry.
Plays an important role in
clinical diagnosis
CEPHALOMETRIC
RADIOGRAPHY

THREE-DIMENSIONAL IMAGING.
Computed axial tomography (CAT or just CT)
Allows 3-D reconstructions of the cranium and face.
Recently, cone beam rather than spiral CT has been
applied to facial scans, significantly reducing the
radiation dose and allowing scans of patients with
radiation exposure that is much closer to the dose from
cephalograms.

Superimposition of 3-d
images is much more difficult
than the superimpositions
used with 2-d cephalometric
radiographs, but methods
developed recently are
overcoming this difficulty.

Magnetic resonance imaging (MRI)
Provides 3-D images that can be useful in studies of growth.
Advantage - that there is no radiation exposure with this technique.
This method has been applied to analyze the growth changes
produced by functional appliances.
A more detailed examination of 3-D changes in growing patients will
surely add to current knowledge of growth patterns in the near future.

EXPERIMENTAL APPROACHES
VITAL STAINING
John Hunter- observed
that pigs who were fed
with textile waste were
often stained in an
interesting and
eventually discovered
that the active agent
was alizarin.
Alizarin – reacts with
calcium at sites where
bone calcification is
occurring- since these
are the sites of active
skeletal growth- dye
marks this area-as bone
remodels rapidly areas
from which bone is
removed can also be
identified as vital
stained material has
been removed from
these areas.
Alizarin red 5
Acid alizarin blue
Trypon blue
Tetracycline
Lead acetate

GAMMA-EMITTING ISOTOPE 99mTC
❖With the development of radioactive tracers it has been possible to use almost any
radioactive element to detect areas of rapid bone growth.
❖Radioisotopes when injected into the tissue gets incorporated into the developing
bone and acts as an in vivo marker.
❖It is more useful for the diagnosis of localised growth problems than for studying
bone growth pattern.
❖Radioactively labelled materials in tissues are detected by- AUTORADIOGRAPHY.
❖Here, film emulsions are placed over a thin section of tissue containing isotope and
is exposed in the dark by radiation. Once it is developed the location of radiation
indicates the area where growth is occurring.

IMPLANT RADIOLOGY
❖This method of study was developed by Professor Arne Bjork and coworkers at the Royal Dental
College in Copenhagen, Denmark.
❖In this technique, inert metal pins are placed in bones anywhere in the skeleton, including the face
and jaws.
❖These metal pins are well tolerated by the skeleton and become permanently incorporated into
the bone without causing any problems
❖If metallic implants are placed in the jaws, a considerable increase in the accuracy of a
longitudinal cephalometric analysis of growth pattern can be achieved.
❖The metal pins stay where they were placed within the bones in the absence of infection or
inflammation, which is rarely a problem.
❖Superimposing cephalometric radiographs on the implanted pins allows precise observation of
both changes in the position of one bone to another and changes in the external contours of
individual bones.

Bjork incorporated the use of tantalum
implants of 1.5mm length and 0.5mm width.
Areas of implants placed in maxilla:
1. Hard palate behind the deciduous canines
( to avoid damage to the erupting tooth
buds)
2. Below anterior nasal spine( after eruption
of maxillary incisors)
3. 2 implants on the either sides of maxillary
process.

In the mandible:
1. Anterior aspects of symphysis, in the midline below
root tips
2. 2 pins on the right side of mandibular body
3. One pin under 1st and 2nd premolar
4. 1 pin on the external aspect of the right ramus at the
level of occlusal surface of molars.

VARIABLES AFFECTING PHYSICAL
GROWTH

FACTORS CONTROLLING SOMATIC GROWTH

GENETIC FACTORS
Every individuals basic pattern of growth is
dictated by their geome.
Ultimate size of different parts of the body,
rate of growth, functional differentiation,
development of tissue functions, the onset of
the pubertal spurt and circumpubertal
maximum are few of the areas where
genes may control body development.

ENVIRONMENTAL FACTORS
Nutrition
Illness
Injuries
Race
Climate
Socioeconomic
factors
Exercise
Order of birth
Secular trends

CANALIZED AND CATCH UP GROWTH
CANALISATION
(HOMEORRHESIS)
When an organism grows in
an unrestrained manner, the
growth would follow a
particular predefined curve,
largely dictated by the
genetic makeup until the
final size and shape is
attained.
This growth happens as if it
were channeled through a
predefined rate and form-
Waddington

❖It is also essential to know that no individual grows in an unrestrained environment.
❖Right from birth, any change in environment leads to certain adjustment periods when the
growth gets restrained.
❖Similarly illness, changes in season or nutritional factors etc are influential in molding growth.
❖Hence whenever the growth of an organism is disturbed due to environmental influences, the
body tends to respond by an exaggerated growth session when the circumstance becomes
favourable- CATCH-UP-GROWTH.
Growth that occurs following an insult or injury which leads to temporary cessation or reduction
of growth.
or
Height velocity that exceeds the normal limits for the age for at least 1yr after a period of
depressed growth.
❖Whether catch up growth is completely able to compensate for the growth hindered due to
functional disturbance is still debatable.

Weight for
age
Height for
age
Height for
weight
Mid-arm
circumference
Weight for age
Height for weight
Mid arm circumference
for Studying
nutritional status

HEIGHT FOR AGE INDEX
This index measures the height in respect to the age of an individual.
Since changes in height are correlated closely to physical growth, measurement of the
height can be used to study the pattern of development as well as identify the
growth spurts.
Height of the person can be measured in either standing, sitting or lying down
position.
The value obtained is compared with the standard charts provided for that particular
state or country.
Deviations are measured in terms of population percentiles
A child falling out of two standard deviations on either sides of the mean of the
population is considered to be unhealthy and would need medical attention.

GRAPHICAL REPRESENTATION OF HEIGHT:
Obtained by charting the heights of various subjects of a particular race/community
at different time intervals.
When an individual is to be evaluated, his/her data can be plotted on a graph and
compared with populations means in two ways:
DISTANCE CURVE:
a) indicates the total amount of height gained.
b) by comparing this we can predict the future growth of the individual

VELOCITY CURVE:
Amount of change in any given point of time.
a) Indicates rate of gain in height over a period of
time
b) These charts are particularly useful in recognizing
the onset of growth spurts.
c) Height velocity- expressed in cm/yr

PEAK HEIGHT VELOCITY
Is the period of time in which a child experiences their fastest growth in their stature.
Peak height velocity is attained 2 years after the onset of pubertal development in
boys and girls.
Excellent indicator for somatic and skeletal growth and a good indicator of facial
growth.
However, its use in orthodontics has its own limitations:
1. Evaluating whether PHV is reached or not requires a long term follow up which
may not be possible in every case
2. Longitudinal follow up requires time cost and resources.
3. By the time one can realise the onset of PHV at least 1yr of growth spurt has
already been lost, thus limiting the extent to which facial growth can be altered.

GRAPHICAL REPRESENTATION OF GROWTH DATA
When height measurements from a group of individuals are plotted
certain observations become apparent:
1. Growth data from individuals when plotted independently shows sharp
spikes and falls representing the changes in gain in height from birth to
adultood.
However when mean growth data from a population is plotted the spikes
are lost or smoothened out
2. Since every individual has his own growth rate, this case comparison
with a population growth chart can bring about a wide variation
leading to a large standard deviation .
This would not necessarily mean that there is some underlying disorder
unless the childs growth has fallen below 2SD ( 2nd to 98th percentile)

With regard to height chart the following observations were made by tanner et al:
1. When the distance curves of boys and girls are compared, girls curve crosses boys curve
at about 10yrs age indicating the onset of pubertal spurt.
2. From 10-13yrs of girls are on average taller than boys. At age 14 boys overtake girls in
height.
3. Rate of growth is seen to decrease from birth to adolescence with marked increase in
height in both sexes at the time of adolescent spurt.
4. Pubertal acceleration occurs earlier in girls
5. During the spurt boys grow about 8inches in height whereas girls grow in 6inches
6. In girls, menache follows PHV which is characterized by sudden slowing of growth
7. In girls, 98% of their final height is attained by 16.5yrs whereas boys reach the same
stage between 17 and 18yrs.

However due to secular change in trends and inherent variation in population some
differences have been found and these include:
1. Adolescent growth spurts show high variability in onset in both sexes (avg age of
onset 10-12yrs in girls, 13-14yrs in boys)
2. The spurts in both sexes last around 3-3.5yrs with longer duration in boys
3. After 16yrs in girls and 18yrs in boys a little gain in height can be expected.

CLINICAL IMPLICATION
•Precocious Puberty has traditionally been defined as pubertal changes occurring
before age 8 years in girls and 9 years in boys and is possibly associated with the
premature maturation.
•In a study done by Junior et al 2018- it was seen that dental and craniofacial
development may be associated with PP in young girls, which may be considered in
the diagnosis and treatment decisions for orthopaedic/ orthodontic intervention.

HAND WRIST RADIOGRAPHS
Hand- wrist region is made up of numerous small bones which show predictable and
scheduled pattern of appearance, ossification and union from birth to maturity.
Many methods have been proposed:
Greulich-Pyle method
Tanner-whitehouse method
Fisherman
Bjork and helm
Hagg-taranger
Singer’s method
Commonly used methods

1. GREULICH-PYLE METHOD:
Developed in Cleveland in 1903 based on hand wrist
radiograph of 1000 white children of above avg socio
economic and education status with no systemic
disturbances.
This method involves comparison of hand-wrist
radiograph of the left hand of subject to the standard
radiographs given in the Greulich-Pyle atlas
The R/F in atlas which most closely resembles the
radiograph of the subject determines skeletal age.
Both qualitative and quantitative analysis can be
made.
Most accepted universally and most commonly used
method for skeletal age estimation.
Disadvantages:
• May not be applicate to all
populations
• Interobserver variation
• R/F in atlas are not taken at
standard intervals
• Some children do not follow the
same sequence as majority of the
population does.

2.TANNER-WHITEHOUSE METHOD
Uses modern computerized mathematical procedures and adds a level of refines to
Greulich-Pyle Method.
The same standards are used for girls and boys and depends on 10
predefined landmarks on 20 bones in hand-wrist R/F
For each patient- landmarks are identified and specific code is given and
these codes are assorted into 1 of the 8 given categories of code as specified
by authors and these codes are then converted into numeric scores as given
given by Tanner whitehouse atlas
The scores can be added to get skeletal age in months and years.
Advantage- it takes into account the individual variation in formation of each
bone and the method is accurate for prediction of bone age upto 0.1yr

3. BJORK AND HELM (1967)
According to the studies done by Bjork and helm it
was noticed that the ossification of the ulnar sesamoid
of the thumb was noticed at maximum pubertal
growth.
When taken individually the ossification either
preceded or coincided with the maximum pubertal
growth spurt.
Thus, the onset of ossification of the ULNAR
SESAMOID OF THE THUMB was an indication that
the skeletal growth spurt was attained or it has
passed.

4.FISHMAN
The method uses 4 stages of bone
maturation :
Widening of epiphyses
1. Third finger – proximal phalanx
2. Third finger – middle phalanx
3. Fifth finger – middle phalanx

Ossification:
4. Adductor sesamoid of thumb

Capping of epiphysis
5. Third finger -distal phalanx
7. Fifth finger- middle phalanx

Fusion of epiphysis and diaphysis
8. Third finger – distal phalanx
9. Third finger – proximal phalanx
11. Radius

CLINICAL IMPLICATION
Three quick indicators of growth completion are the appearance of adductor
sesamoid of the thumb, capping of the epiphysis of the middle phalanx of the third
finger and fusion of the epiphysis and diaphysis of the radius.
As the skeletal growth of the long bones is complete, facial growth too stops, or it is
safe to assume that it is near completion

CERVICAL VERTEBRAE
Hassel and Farman developed this system.
The shapes of cervical vertebrae were seen to differ in each stage of growth.
Advantage- Of using the cervical vertebrae more specifically the C3 in assessing the
skeletal maturity is that additional radiograph can be avoided, as it is visible on the
lateral cephalogram used in orthodontic evaluation.

Hassel and Farman categorized it into 6
stages.
1ST STAGE - initiation - where the vertebrae
is wedge shaped and the inferior borders
were flat in c2, c3 and c4.
80 to 100 % adolescent growth was
expected in this stage
2ND STAGE –acceleration- where bodies of
c3 and c4 were nearly rectangular in shape
and
65-85% of adolescent growth expected in
this stage.
3RD STAGE –transition - with growth still
accelerating in peak velocity.Distinct
concavities at inferior border of C2 and C3
seen and C3 and C4 rectangular in shape
25-65% growth still remining.

STAGE 4 is deceleration- distinct concavities
at inferior border and C3 and C4 becoming
square in shape
Growth decreases dramatically, 10-25% of
growth is remaining
STAGE 5 is maturation- concavities at inferior
border and C3 and C4 nearly square in
shape.
5-10% growth remaining.
STAGE 6 is completion;
Growth is said to be complete at this stage

CLINICAL CORRELATION
In a study done by Singh et al 2010 to identify the stage of skeletal maturity, as
depicted by the Cervical Vertebrae Maturity Index at which the maximal response to
myofunctional therapy could be expected.
It was concluded that maximum response to myofunctional therapy could be expected
in patients during the stages 3 to 4 of cervical vertebrae maturation index, i.e.,
during or slightly after the pubertal peak.

CONCLUSION:
1. The developmental stages of the middle
phalanx of the third finger (MP3) could be
used as a sole indicator in assessing the
skeletal maturity.
2. The method proposed was highly reliable
and its correlation with the known standard
method like CVMA was found to be of high
statistical significance.
3. The MP3 stages could be further classified
into
pre-peak (MP3 F, MP3 FG)
peak (MP3 G)
postpeak (MP3 H, MP3 I)
stages of pubertal growth spurt respectively.
4. This simple and reliable method could be
used as an alternative to the hand-wrist
and cervical vertebrae radiographs in
assessing the skeletal maturity.
Ideal time to start Growth Modification Prognosis may not be favorable at this stage
Initiation of gm is CI During this stage

A visualized treatment objective (VTO) is a cephalometric tracing representing the changes
that are expected (desired) during treatment.
In the 1980s, manually-prepared VTOs were advocated as a treatment planning tool.
For a child, the VTO would have to incorporate the expected growth, any growth changes
induced by treatment, and any repositioning of the teeth from orthodontic tooth movement.
In a child with normal facial proportions, average growth increments is likely to happen and
growth modification is not likely to be part of treatment, so growth changes can be predicted
fairly well.
For a skeletally normal child, preparing a VTO using average growth increments can be quite
helpful in understanding the amount of tooth movement needed to correct the malocclusion.
For a child with a skeletal problem, given the uncertainty of both the growth pattern and the
response to treatment, a VTO often is more a presentation of what is hoped for than what
is likely to happen.

Permits development of alternate treatment plan
Helps the orthodontist decide how far he can go with the mechanics and orthopedics
to achieve his goal, whether it is possible to achieve them and what the alternatives
are.

COMPUTERIZED GROWTH
FORECASTING

Recent technical advancements have led to the use of computer assisted imaging systems in treatment planning
for orthognathic surgical cases.
Cephalometric radiographs have become an essential tool in the orthognathic surgery procedure.
Traditionally, cephalometric images have been analyzed by tracing the radiograph manually, which is time-
consuming and has the disadvantage of random and systematic error when locating landmarks
Computer technology has made digital tracing possible, either by direct or indirect digitization of the
radiograph
Orthognathic prediction tracing is important for several reasons:
1. The actual procedure and the required anteroposterior and vertical movements may be decided upon by
the model surgery.
2. The change of soft tissue responding to hard tissue movement may be ascertained.
3. To determine whether or not an adjunctive surgical procedure like genioplasty is necessary.
4. By superimposition of the photographs, patients may be given an idea of the surgical outcome.

Computer-aided diagnosis and treatment planning has become more common in the
recent years and it has been shown that predictive software works well in usual cases.
Dolphin Imaging has become increasingly popular among surgeons and orthodontists.
After programming of the hard tissue movement into the Dolphin System, the outline
of the soft tissue is changed based on ratios which have been explained and included
into the system before
After the cephalograms are scanned, the Dolphin Imaging Software implies the
indirect digitization of dental, skeletal and soft-tissue landmarks.
In order to help landmark position, the image may be improved and magnified
Since the change in soft tissue profile is directly related to the hard tissue changes,
this system is able to accurately predict hard tissue changes.

Akhoundi et al (2012) conducted a study to examine and compare the ability and
reliability of digitization using Dolphin Imaging Software with traditional manual
techniques .The result of the study was as follows
The nasal tip presented the least predicted error and higher reliability.
The least accurate regions in vertical plane were subnasal and upper lip, and
subnasal and pogonion in horizontal plane.
Hence, Computer-generated image prediction was suitable for patient education and
communication.
However, efforts are still needed to improve accuracy and reliability of the
prediction program and to include changes in soft tissue tension and muscle strain.

CONCLUSION
❖A thorough understanding of craniofacial region helps in imparting purposeful
manipulation of growth patterns in young patients.
❖This approach can reduce or potentially eliminate future esthetic complaints of the
patients which may require surgery or invasive orthodontic procedures.
❖The addition of clinical and radiographic indicators of physical maturation to the
dental record of children and adolescents may be simple, and findings may be useful
for referral, diagnosis, planning and prognosis of the treatment of certain types of
malocclusion.
❖The inclusion of such information in routine examinations may provide a general
overview of the patient as an integrated organism.

Clinical and radiographic guidelines for prediction of growth

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Clinical and radiographic guidelines for prediction of growth

Similar to Clinical and radiographic guidelines for prediction of growth (20)

Recently uploaded

Recently uploaded (20)

Clinical and radiographic guidelines for prediction of growth