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Leader in continuing dental education

Introduction  Histological background of Assessment  Why Orthodontist should be

interested in skeletal growth?  Clinical implication of growth  Requirements of Skeletal growth Assessment 

Methods of Assessing using radiograph

Introduction William K.Roentgen demonstrated his new radiographic discovery in 1895. Roland & Ranke (German professor and German researcher) 1896 introduced the idea of using the comparative size and shape of the radiograph shadows of growing bone as indicators of rate of growth and maturity. During growth, every bone goes through a series of changes that can be seen radio graphically. The timing of the changes varies because each person has his or her own biological clock.

Sequence of Assessment in growth •In the early 1905, Professor J. W. Pryor, Rotch and Crampton began tabulating indicators of maturity on sequential radiographs of the growing hand and wrist. Hellmann published his observations on the ossifications of epiphysical cartilages of the hand in 1928. •Todd was one of the first investigator to evaluate skeletal maturation, he compiled hand wrist data that was further elaborated by Greulich and Pyle in atlas form . •Flory in 1936, indicated that the beginning of calcification, if the carpal sesamoid (adductor sesamoid) was a good guide to determining the period immediately before puberty. •In 1937 Greulich and Pyle has created a radiographic atlas of the skeletal development of the hand wrist.

•Tanner reported about the TW1 &TW2 methods of scoring born maturity by biological weighted system •Ossification of various bones and hand wrist has been studied in relation to the puberal growth spurt. • Bjorke and Helm (1967) found a close correlation between the onset of ossification of the adductor sesamoid bone at the metcarpophalyngeal joint of the thumb and growth spurt. •Chapman (1972) confirmed that the duration of growth spurt coincides with the duration of development of the adductor sesamoid and ends with the fusion of epiphysis of the thumb. • Hand wrist ossification markers of puberal growth has been reported by Grave And Brown (1976, 1979)

•On the other hand Houston et al. (1979) and Houston (1980) have found that although the timings of certain ossification events are related to puberal growth spurt, there is considerable uncertainty in the predication of timings of growth spurt in individuals, which make the use of hand wrist radiograph of limited value for the purpose. •Chertkow (1980) has reported not only the commencement of the growth spurt was closely correlated to the time of certain ossification events in the hand and wrist but also that there was a high correlation between these events and the stage of mineralezation of the lower canine teeth •The prediction of skeletal height has been well documented by Tanner in (1981)

•In 1982 Fishman proposed the system of skeletal materlization

•Rune et al reported that facial changes were not related to skeletal pattern, chronological age, growth peak and treatment duration . •Sarnais also reported that the effect of maxillary protraction has no relation to the skeletal type, growth peak and treatment period •A different method of determination of the maximum growth period has been proposed by Sullivan (1983). It is based on consecutive measurements of standing height to determine changes in growth velocity, from which a predication of the time of maximum velocity is made. •Chmura (1984) reported that ossification of the ulna sesemoid was not found to predict the onset,duration or rate of the puberal growth spurt.

Why should an orthodontist be interested in skeletal growth? •Many malocclusion are, at lest in part, due to skeletal discrepancies between the jaws (maxilla and mandible). Such discrepancies are usually due to difference in the comparative growth of the jaws •. More severe malocclusions may be related to more distant skeletal discrepancies within the cranial base. Correctly identifying these growth features may be important in deciding upon a diagnosis and formulating a treatment plan. •The timing of orthodontic intervention is crucial,and the initiation of early treatment protocol varies according to malocclusion being treated, some are dependent on favorable growth for example, where surgery is being considered, it is important to be able to identify if the growth completed.

•Greater the growth activity, movement of tooth is more rapid. •Inopportune or poorly timed extractions performed by the dentist during growth may have an unfortunate consequence on the developing occlusion. •More particularly, The dentist should be able to identify abnormal occlusal development at an early stage in order to undertake suitable interceptive orthodontics treatment where appropriate. •Most important, precise estimates of a child’s maturity status helps to identify the optimal time for certain type of orthopedic treatment. •It aids the interdisciplinary health teams assessing patients with various types of short statures,endocrine disorders,and/or metabolic diseases;its utility is well established for syndrome identification and

Clinical implication of growth assessment o

Prior to rapid maxillary expansion


When maxillomandibular changes are indicated in the treatment of class III cases, skeletal class II cases skeletal opens bites


In patients with marked discrepancy between dental and chronological age


Orthodontic patients requiring orthognathic surgery if undertaken between the ages of 16 and 20 years

Requirements for assessing skeletal growth • Should be safe • Non-invasive • Requires minimal radiation • Should be accurate • Stage of maturity should be well defined and easily identifiable • Cost effective • Method should be simple to conduct • Should be valid over a time and across age groups

Methods of assessing maturity using radiograph  Growth spurt  Hand wrist radiograph  MP3  Cervical Vertebral  Assessment by tooth development –mandibular canine.  Frontal Sinus  Antigonial notch  Implant samples

Growth Rhythm curve (Bjork)

Description of Hand Wrist X-ray

Description of Hand Wrist X-ray P








Sesamoid Bone Trapezoid Bone Trapezium Bone




Hamate Process


Capitate Bone

Tricuetral Bone Lunate Bone

Scaphoid Bone Radius

Hamate Bone

Pisi Form Bone


Development of the ring finger, row by row. The image top-left is from a baby; the image at the lower right is from a nineteen year old. In the fifth image, the epiphysis appears, which becomes wider and in the final images fuses with the metaphysis. These images are taken from the Greulich and Pyle atlas.

Bjork – (1972), Grave & Brown (1976)

1.The epiphysis of the proximal phalanx of the index finger (PP2)has the same width as the diaphysis

2.Epiphysis of the middle phalanx of the middle finger (MP3) is of the same width as the diaphysis

Pisi stage=Visible ossification of the pisiforme H1 stage=Ossification of the hamular process of the hamatrum R= stage.same width of epiphysis and diaphysis of thr radius

4.S-stage=first mineralisation of the metacarpophalangeal joint of the thumb H2-stage=ossification of the hamular process of the hamatum

5.The diaphysis is covered by the capshaped epiphysis In the MP3 cap stage,the processs begins at the middle phalanx of the third finger; In the PP1 cap stage ,at the proximal phalanx of the thumb;and in the Rcap stage, at the radius

6.Visible union of epiphysis and diaphysis at the distal phalanx of the middle finger(DP3)

7.Visible union of epiphysis at the proximal phalanx of the little finger(PP3) 8.Union of epiphysis and diaphysis at the middle phalanx of the middle finger is clearly visible(MP3) 9.Complete union of epiphysis and diaphysis of the radius. The ossification of all the hand bones is completed and skeletal growth is finished

Fishman’s Maturation Index

Hagg & Taranger’s - MP3

Skeletal Age assessment by Schopf - 1978 Growth Period

♂ ♀

1. PP2=

2. MP3=

3. Pisi H1 R=

4. S H2

5. 6. MP3cap DP3 R cap PP1 cap



















7. PP3u

8. MP3u

9. Ru

Cervical Vertebrate maturation indicators

1. Initiation (SMI 1&2) • Very significant amount of the adolescent growth expected • C2, C3 and C4 inferior vertebral body borders are flat • Superior vertebral borders are tapered posterior to anterior

2. Acceleration (SMI 3&4) • Significant amount of adolescent growth expected • Concavities developing in lower borders of C2 and C3 • Lower borders of C4 vertebral body is flat • C3 and C4 are more rectangular in shape

3. Transition (SMI 5&6) • Moderate amount of adolescent growth is expected • Distinct concavities of the lower borders of C2 and C3 • C4 developing concavity in lower border of body • C3 and C4 are rectangular in shape

4. Deceleration (SMI 7&8) • Small amount of adolescent growth is expected • Distinct concavities in lower borders of C2,C3 and C4 • C3 and C4 are nearly square in shape

5. Maturation (SMI 9&10) • Insignificant amount of adolescent growth expected • Accentuated concavities in lower borders of C2,C3,C4 • C3 and C4 are square in shape

6. Completion (SMI 11) • Adolescent growth is completed • Deep concavities are present for inferior vertebral body borders of C2,C3 and C4 • C3 and C4 heights are greater than widths

Development stage of Cervical Vertebrae



C4 C5 C6

Cvs 1

Cvs 2

Cvs 3

Cvs 4

Cvs 5

Cvs 6

lcification & Mineralisation of toothMandibular Canine (Demirjian &


Eight relevant stages of dental development

Eight relevant stages of dental development

A – Calcification if single occlusal points without fusion of different calcifications

B – Fusion of the materialization points the contour of the occlusal surface is recognizable

C – Calcification of the crown is complete: beginning of dentin deposits. The pulp chamber is curved, and no pulp horns are visible. D - Crown formation is complete up to the cement enamel junction. Root formation has commenced. The pulp horns are beginning to differentiate, but the wall of the pulp remain curved. E – Root length shorter than crown height .The walls of the pulp chamber are straight, and the pulp horn have become more differentiated than in the previous stage .In molars the radicular bifurcation has commenced to calcify.

F – Root length larger than crown height the walls of the pulp chamber now form an isosceles triangle. In molars the bifurcation has developed sufficiently to give the root a distinct form. G – Root formation finished. Apical foramen still open, the walls of the root canal are now parallel. In molars only the distal root is rated. H – Apical foramen is closed the periodontal membrane surrounding the root and apex is uniform in width throughout.

Frontal sinus • The frontal sinus bud is present at birth in the ethmoid region but is not evident radio graphically until the fifth year, when it projects above the rim. Rapid growth of the sinuses continues until the age of 12 years, when they reach nearly adult size. • Joffe found frontal sinus enlargement to be associated with prognathic subjects, but no indication was given as to the correlations with growthprediction indicators. • Tanner found that the annual height (stature) growth increments in children reached at 16 years in boys and 14 years, and it was thought that these too, are the ages at which frontal sinus enlargement ceased.

Antigonial notch 1. Deep notch subjects had a more retrusive mandible with a shorter corpus, less ramus height, and a greater gonial angle than did shallow notch subjects. 2. The mandibular growth direction in deep notch patients, as measured by the facial axis and the mandibular plane angle, was more vertically directed than for shallow notch patients. 3. The deep notch had longer total facial height and longer

4. The deep notch subjects had a smaller saddle angle than did the shallow notch subjects. 5. The deep notch sample experienced less mandibular growth during the study period examined as evidenced by (1) a smaller increase in total mandibular length, (2) corpus length, and (3) less displacement of the chin in a forward direction as compared to the shallow notch sample. 6. Notch depth increased in the deep notch group, while it decreased slightly in the shallow notch group during the study period. 7. Deep notch patients required a longer duration of orthodontic treatment than did shallow notch patients.

Implant Sample ∀• Implants were used to estimate the possibility of predicting the direction and the amount of growth rotation of the mandible on the basis of morphologic criteria observed on a single profile radiograph at pubertal age. ∀• Morphologic features from the first profile radiograph were compared with the observed growth changes over a period and their predicting values calculated.

∀• Cephalometric growth analysis has generally been based on conventional measurement of the facial morphology, without taking into account the remodeling processes at the bony surfaces.

• The mandibular growth rotation is composed of a complex system of movements. In a recent report by BjÜrk and Skieller the bony mandibular corpus and its soft-tissue covering, the matrix, have been considered as independent tissue systems capable of independent rotation • Both forward and backward rotation was divided into three components: total rotation, referring to the rotation of the mandibular corpus (implant line or reference line) relative to the anterior cranial base; matrix rotation, referring to the rotation of the soft-tissue matrix of the mandible (tangential line to lower mandibular border) relative to the anterior cranial base; and intramatrix rotation, referring to the rotation of the mandibular corpus within its soft-tissue matrix (or the difference between reference lines), expressing the amount of remodeling at the lower border of the mandible.

Conclusion Though there are different standardization for assessing skeletal growth and maturation all reach the same goal in the forward advance of events in treatment plan . To take full advantage, the specific roles and degree of inter relationship is required.

Thank You !

Conclusion Lamons and Gray compared the all the developmental indices to a company of soldiers who are moving at a constant rate of speed. Now one pair walk together, then they divide and walk with other. Some run ahead, others lag behind and even stop to rest; yet all reach the same goal in the forward advance of events. To take full advantage of the soldiers’ potential, information about their specific roles and degree of inter relationship is required.

Thank You ! Leader in continuing dental education

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