Growth Prediction (2) / Orthodontic Courses by Indian Dental Academy

GROWTH ASSESSMENT
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Introduction
An understanding of growth events is of primary
importance in the practice of clinical
orthodontics
Biological , skeletal age or bone age and skeletal
maturation are nearly synonymous terms used
to described the maturational stage of a person
Due to individual variation in growth timing ,
duration and velocity of growth, skeletal age
assessment is essential in formulating
orthodontic treatment plans.
Maturational status can have considerable influence on
diagnosis, treatment goals, treatment planning and
eventual outcome of orthodontic treatment.
Clinical decisions regarding use of extra oral traction
forces, functional appliances, extraction versus non
extraction treatment or Orthognethic surgery all are at
least partially based on growth considerations.
Prediction of both the time and amount of active growth
especially in the craniofacial complex would be useful to
the orthodontist.

Prediction/Assessment/Maturity
Indicator
Predict to say in advance.
Assessment
Analysis of the nature and amount of
growth that has taken place.
Prediction
To make a statement about the further
development of anatomical entity
Clinical Importance
To determine potential vector of facial development
To determine the amount of significant cranial growth
potential left
To evaluate the rate of growth
To decide the onset of treatment timing
To decide the type of effective treatment:
a) Orthopedic (removable or fixed )
b) Orthodontic
c) Orthognethic surgical procedure
d) Combination of above

To evaluate the treatment prognosis
To understood the role of genetics and environment on
the skeletal maturation pattern.
Ideal requirement of maturity indicator
Should be safe
Non invasive
Require minimum radiation
Should be accurate
Stages of maturity should be well defined and easily
identifiable
Cost effective
Minimum armamentarium and personal requirement
Method should be simple to conduct
Should be valid over time and across age groups.
LATE AND EARLY
DEVELOPMENT
Six type of skeletal development
1
st
group Average children
2
nd
group children who are tall in childhood only b/c
matured faster than average, not particularly
tall adults
3
rd
group not only early matures but are genetically tall
also and will be tall adults.
4rh group who are small b/c they mature late but will
eventually be of average stature.
5
th
group children who are both late developing and
genetically short in stature.
6
th
group indefinite group who start puberty much
earlier or much late than usual.
Indices of maturity
Neural age
Mental age
Physiological and biochemical age
Chronological age
Sexual/pubertal age
Dental age
Age determination using growth charts
Skeletal/anatomic/radiological age
Neural age
Gesell and his colleagues in America
have done great deal of work on the
neural development in humans.
Certain landmarks of development were
accounted.
Help us to understand that the patient is
mentally developed to understand the
need for treatment .
Neural Age
Developmental landmarks
Years Age (months)
2 follows moving object with eyes
4 can sit propped up for a short time, moves
head to inspect surroundings
6 grasps objects, begin to bang and shake them
8 may sit unaided
10 creeps, picks up small objects between fingers
and thumb, one/two words, tries to help with
feeding
1 cruises holding on to rail of cot, walks with one
hand held, throws objects on floor, cooperates
in dressing, waves good-bye
1.5 walks, runs awkwardly and stiffy, can trun pages
of book, abt 30 words, builds towers of 3-4 block

yrs

2 Runs without falling, uses three word sentences ,
can turn doorknob, obeys simple instructions, builds
towers of 6-7 blocks, bowel and bladder control
some times good.
3 walks erect. Stand on foot, climbs, can put on shoes
and unbutton some buttons, bowel and bladder
control is established.
4 Cleans teeth , washes and dried face and hands.
5 can tie shoe lasses and is beginning to use tools,
some are reading quite well, questions abt meaning
of wards
6 reads, balls are bounced and sometimes caught.
MENTAL AGE
Attempt to device performance tests, measures
intelligence by stanford binet test /or Wechsler
scale
Help in determining the outlook of the patient
towards treatment.
Also help In determining the expected level of
cooperation that can be expected from patient.
Mental age:
index of maturation of mind
increase at a rate that depends on many
intrinsic and environmental factors.

A) IQ which is the mental age expressed as a percentage of the
chronological age.
thus a child with a mental age of 12 yrs and a chronological
age of 10 would have an IQ of 120.

B) Ability to draw a human figure is often used to assess
development and the items the child includes can be scored
and rated in terms of mental age. This is good correlation
between assessments made between 5 and 11 years of age.

C) Use as the standard capacity of the child to read.
PHYSIOLOGICAL AND BIOCHEMICAL AGE
A) Girls show a spurt in systolic blood pressure which occurs
earlier than the corresponding spurt in the male
Resting mouth temperature which falls by 0.5 to 1 *c from
infancy to maturity and reaches its adult value earlier in
girls.
B) In the plasma, inorganic phosphate shows a steady fall
from the high levels of childhood to reach adult by the age
15 in girls and 17 in boys.
c) Alkaline phosphate rises significantly in parallel with
growth between the ages of 8-12 yrs in girls and 10-14yrs
in boys.
D) Ratio of creatinine in the urine
fall progressively with age after abt 14.5 yrs probably
under hormonal influences.

CHRONOLOGICAL AGE
Poor indicator of maturity
Little identifying stages of development from
adolescence to adulthood.
Help to categorize individual as
early , average, late maturer.

Enable an orthodontist to determine and predict
the rate and magnitude of facial growth
Help to decide time, duration and method of
treatment.

Age Determination Using Growth charts
Involves height, weight and chronological age of child.
Variation seen in boys and girls
Uses :
Use to understand growth patterns in terms of deviations
from the usual pattern to express variability quantitatively.
can be done by compare the child with standard
growth charts. And determine growth is
normal/abnormal and child is early/late maturer.
growth charts can be followed from birth to
adulthood to determine pattern, variability and
timing and predictability of growth.
3. Determine peak height velocity which is circum pubertal
maximum.
height and weight measurement are compare with
pubertal and skeletal age for growth assessment.
Sexual/pubertal Age
2 yrs earlier in girls than boys.
Begins later and extends over a longer period
of abt 5yrs in boys and 3.5yrs in girls.
According to HAGG & TARANGER (1980)
Pubertal development was assessed from
menarche in girls and the voice
change in boys.

Sexual Age
IN Girls :
if menarche has occurred, peak height velocity
(PHV) has been attained and growth rate is
decelerating.

In Boys,
3 stages of voice changes were used:
PPV prepubertal voice; the pitch of the voice
had not changed noticeably.
PV pubertal voice; the pitch of the voice had
changed noticeably but the voice had not yet
acquired adult characteristics.
MV male voice; the pitch of the voice had
acquired adult characteristics.

Growth spurts - Graber
Childhood growth spurt (3 yrs)
Juvenile growth spurt
girls 6 to 7 yrs
boys 7 to 9 yrs
Pubertal growth spurt
girls 10 to 13 yrs
boys 12 to 16 yrs
Pubertal growth spurt-girls
Stage-I : beginning of growth spurt
10 to 11yrs
Stage-II : peak velocity
lasts for 1 to 2yrs
Stage-III : menarche
deceleration and end of growth
spurt.

Pubertal growth spurt-boys
Stage-I : beginning of growth spurt
lasts for 1 yr (fat spurt)
Stage-II : fat redistribution, pubic hairs
lasts for 1 to 2yrs
Stage-III : peak velocity
lasts for 1 to 2yrs
Stage-IV : height stagnates
deceleration and end of growth spurt.


Anatomic Region
Region should be small to restrict
radiation exposure and expense.
Should have many ossification centers
which ossify at separate times and
which can be standardized.
Region should be easily accessible.

Skeletal Age
Regions for Age Assessment
Head and neck: Skull
Cervical vertebrae

Upper limb : Shoulder joint- Scapula
Elbow
Hand wrist and finger

Lower limb : Femur and humerus
Hip joint
Knee joint
Ankle
Foot tarsals
Metatarsals
Phalanges
Skeletal maturity indicators
Handwrist radiographs
Cervical vertebrae
Mid-palatal suture
Frontal sinus
Mandibular canine calcification
Tooth mineralization
Symphysis as an predictor of direction of mandibular
growth
Antegonial notch as an predictor of direction of
mandibular growth
Craniocervical posture as an predictor of craniofacial
growth
Bjrks structural signs of growth prediction
Mesh diagram for growth prediction
Hand and Wrist Radiograph
X ray discovery
in 1895 by
Roentgen.
Review of literature

1
st
hand wrist film was published by
Sydney Rowland in England in april
1890 (4 months after discovery of x-rays).
1926 Carter reported a study of carpal
bones of children.
1929 2 comprehensive growth studies by
Weingate Todd and Harold Stuart
respectively.
Review of literature

Hunter reported that carpal bones had
proved to be the best site for determining
skeletal maturation.
Bjrk and Helm stated that appearance of
ulnar sesamoid on hand wrist film was
related to the onset of maximum pubertal
growth in height.
Helm elaborated on other structures in the
hand wrist film to pubertal growth spurt.
Hellman published his observations on the ossification of
epiphyseal cartilages of the hand in 1928

Todd compiled hand-wrist data that was further
elaborated on by Greulich and Pyle in atlas form 6 Flory
in 1936, indicated that the beginning of calcification of
the carpal sesamoid (adductor sesamoid) was a good
guide to determining the period immediately before
puberty

Fishman developed a system of hand-wrist skeletal
maturation indicators (SMIs) using four stages of bone
maturation at six anatomic sites

Hagg and Taranger created a method using the hand-
wrist radiograph to correlate certain maturity indicators
to the pubertal growth spurt .
Indications of handwrist
radiograph
Prior to rapid maxillary expansion.
Marked discrepancy between dental or skeletal and
chronological age.
Where maxillomandibular changes are indicated
e.g. skeletal class II or III or skeletal openbite.
Orthognathic surgery if undertaken between the
ages of 16-20 years.
To asses the skeletal growth in a patient whose
growth is affected by infection, neoplastic or
traumatic conditions.
To predict future skeletal maturation rate and
status.
To predict pubertal growth spurt.
ANATOMY
PA view
Oblique view
Hand and Wrist Radiograph
Made up of numerous small bones.
These bones have predictable and scheduled
pattern of appearance and ossification and union
from birth to maturity.
One of the most suited region to study growth
Disadvantage:
Away from the sight ( i.e. oral cavity)

ANATOMY
Made up of four groups of bones.
1. Distal ends of long bones of forearm
2. Carpals
3. Metacarpals
4. Phalanges

Distal ends of long bones of forearm
Distal ends of
radius and ulnar
Give rise to a
distal projection
on their respective
sides. c/d Ulna
styloid and radial
styloid.

Carpals
Eight small irregularly shaped
bones arranged in two raws,
proximal and distal raw
Proximal raw:
scaphoid, lunate, triquetral
and pisiform
Distal raw:
trapezium, trapezoid,
capitate and hamate
All bones osssifies from one
primary center.
Metacarpals
Five miniature long bones
forming the skeletal
framwork of the palm of
the hand from thumb to
little finger
Ossify from one primary
center ( in shaft ) and
secondary center on distal
end (except for first)

Phalanges
Small bones forming the
fingers
Three in numbers in each
fingers
In thumb only two
phalanges
Ossify in 3 stages
1. epiphysis = diaphysis
2. Epiphysis caps diaphysis
3. Fusion b/w epiphysis and
diaphysis
Sesmoid bone
Small nodular bone
most often present
embedded in tendons
in the region of the
thumb.
Methods
Atlas Method by Greulich and Pyle
Bjork, Grave and Brown Method
Fishmans Skeletal Maturity indicators
Hagg and Taranger Method
Julian Singers method
Bjrk, Grave and Browns
method
Bjork, 1972, divided the maturation process
of hand bones into developmental stages.
Brown, 1976, included six further ossification
centres in the hand radiograph.
According to Grave and Brown,
growth stages of the fingers are assessed
according to the relationship between the
epiphysis and diaphysis.
Appropriate chronological age for each of the
stages was given by Schopf in 1978
There are three stages of ossification of the
phalanges.
First Stage:
Epiphysis shows the same width as the diaphysis
(=)
Second Stage:
Capping stage (=cap); the epiphysis surrounds
the diaphysis like a cap.
Third Stage:
U-stage (=u); bony fusion of epiphysis and
diaphysis.

method
9 stages:
Stage 1(males-10.6 yrs, females
8.1yrs):
epiphysis and diaphysis of
proximal phalanx of index
finger are equal.
3 yrs before peak of pubertal
growth spurt.
AJO 1976
pp2
method
Stage 2(males-12.0 yrs,
females 8.1yrs):
epiphysis and diaphysis of
middle phalanx of middle
finger are equal.

MP3
method
Stage 3(males-12.6 yrs, females 9.6yrs):
3 stages
Ossification of hamular process of hamate.
Ossification of pisiform.
Epiphysis and diaphysis of radius has same
width.
H PiSi
R
method
Stage 4(males-13.0yrs, females
10.6yrs):
Initial mineralization of ulnar
sesamoid of thumb.
Increased ossification of the
hamular process of hamate.
Shortly before or at the
beginning of the pubertal
growth spurt.
US
H2
method
Stage 5(males-14 yrs, females 11yrs):
Capping of diaphysis is seen in
Middle phalanx of 3
rd
finger.
Proximal phalanx of thumb.
Radius.
marks the peak of pubertal growth.
Cap-MP3
PP1
R
method
Stage 6(males-15 yrs, females
13.3yrs):
Visible union of diaphysis and
epiphysis at the distal phalanx of
the middle finger.
Signifies end of pubertal
growth spurt.
DP3-U
method
13.3 yrs):
Visible union of the epiphysis
and diaphysis at the proximal
phalanx of little finger.
PP5-U
method
Stage 8(males-15.9 yrs, females 13.9yrs):
Union of epiphysis and diaphysis at
middle phalanx of middle finger.
MP3-U
method
16 yrs):
Complete union of epiphysis and
diaphysis of radius.
Ossification of all bones is
complete and skeletal growth is
complete.
R-U
Julian Singer method
In 1980, proposed a system of hand
wrist radiograph assessment that would
enable the clinician to rapidly and with
some degree of reliability help to
determine the maturational status of
the patient
Six stages of hand and wrist
development are described.
AO: 1980,oct-322-333
Six stages are described:
Stage 1 (early) :
Pisiform is absent.
Hook of hamate absent.
Epiphysis of proximal phalanx of 2
nd

finger being narrow than diaphysis.

AO: 1980,oct-322-333
Julien Singer method
Stage 2 (prepubertal) : ( pisi, H , PP2 )

Proximal phalanx of 2
nd
finger is equal to its
epiphysis.
Initial ossification of hook of hamate.
Initial ossification of pisiform.
Stage prier to adolescent growth spurt during
which significant amount of mandibular growth are
possible.
Maxillary orthodontic therapy in conjunction with
mandibular growth might aid correction of a cl II
relationship with considerable speed and ease.
Stage 3 (pubertal onset): (US and
stage2)

Calcification of ulnar sesamoid.
Increased width of proximal phalanx
of 2
nd
finger.
Increased calcification of hook of
hamate.
Increased calcification of pisiform.
Stage 4 (pubertal stage): (US , C-mp3)
Calcification of ulnar sesamoid.
Capping of diaphysis of middle phalanx
of 3
rd
finger by its epiphysis.(MP3-C)

Stage 5 (pubertal deceleration):
Full calcification of ulnar sesamoid.
Fusion of epiphysis of distal phalanx of 3
rd

finger with its diaphysis. (DP3-F)
Epiphysis of radius and ulnar not fused
completely with diaphysis.
Phalanges and carpals are fully calcified.

Period of growth when orthodontic
treatment might be completed and the
patient is in retention therapy.

Julien Singer method
Stage 6 (growth completion):
No remaining growth site is seen.

Fishmans skeletal maturity
indicator
In 1982 Leonard Fishman gave
system of skeletal maturation
assessment (SMA).
11 skeletal maturity indicators (SMIs)
were described.

Angle Orthodontia:No. 3: 1987
11 SMI were divided into 4
stages
Epiphysis as wide as diaphysis.
Ossification of ulnar sesamoid of thumb.
Capping of epiphysis.
Fusion of epiphysis and diaphysis.

pp3
mp3
mp5
Us
C-dp3
C-mp3
C-mp5
F-dp3
F-pp3
F-mp3
R
Epiphysis as wide as diaphysis
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.
6. Third finger middle phalanx.
7. Fifth finger middle phalanx.
Fusion of epiphysis and
diaphysis
8. Third finger distal phalanx.
9. Third finger proximal phalanx.
10. Third finger middle phalanx.
11. Radius.
Accelerating growth velocity period (14)
High growth velocity period (47)
Decelerating velocity period (711)

Conclusion
SMI occurs at earlier chronological ages
for girls.
SMI make it possible to judge an individual
relative timing of maturation whether it
is early, average or late.
Comparison of boys and girls on
maturational time scale shows no sexual
differences in the percentages of
completion of incremental growth at same
SMI levels, regardless of chronological
age.
Conclusion

Early maturer of both sexes exhibited
almost identical SMI duration values for
SMIs 1-5 & 7-11. The only significant
difference in SMI duration for early
group is between SMI 5 & 6. Girls in
general reach the point of peak velocity
of growth at SMI 5, and boys at SMI 6.
Conclusion
In late maturation groups, considerably
less correlation is found between male
and female groups, although duration
of time between SMIs 1-2 and 10-11,
at beginning and end of adolescent
period, are very similar.

In regard to the comparisons of late
periods with early periods, the female late
group exhibits significantly longer time
between SMI periods 45, 69, and 10
11. The male late group exhibited longer
time periods between SMI 24, 910, and
1011.
Levels of maturation - FEMALE
Maturation stages : A: early, B and C :Average , D: late
Levels of maturation - MALE
Mean value for total sample
Maturation stages : A: early, B and C :Average , D: late
For both sexes, the early (level A) curves remained
within their boundaries or close to the border of level B
until SMI stage 8, at which time the A curve entered
well within the B range (within one SD of average),
approaching the mean values for their respective total
samples.
Those with late maturation (level D) also exhibited
similarities between the male and female sample, in
that the curves did not regress toward the total sample
mean values until SMI 10, late in the adolescent period
for both sexes.
Those with near-average maturation (B and C)
maintained a consistency in their maturational
progress, not departing outside their respective
boundaries. Toward the end of the maturation period
these two curves regressed even closer to the mean
values.

Maturation indications and
pubertal growth spurt
Urban Hgg and John Taranger did
a study in 1982 to investigate pubertal
growth spurt and dental, skeletal and
pubertal development.
Sample:212
Examination: birth to adulthood
Once a year
Am J Orthod: 82: oct 1982
Method of analysis
Adolescent growth:
was studied by graphic analysis of the
unsmoothed incremental curves of
standing height.
These curves were based on the
annual increments from 3 to 20 years.

Method of analysis
Dental development was assessed by dental emergence stages
(DES). (devised by Bjork and asso.)
Emergence stages:
Teeth anterior to molar
Des 1: 1to 7 incisors
Des 2: all incisors
Des 3: 1 to 11 canine &/or premolar
des 4: all canine and premolars
Molar teeth
Des m1: 1 to 3 1
st
molars
Des m2: all 1
st
molars
Des m3:1-3 2
nd
molars
Des m4: all 2
nd
molars
Des m5: 1-3 3
rd
molars
Des m6: all 3
rd
molars
Skeletal development
In the hand and wrist was analyzed from annual
radiographs, taken between the ages of 6 and 18
years,
Assessment of,
ossification of the ulnar sesamoid of the
metacarpophalangeal joint of the first finger (S)
certain specified stages of three epiphyseal
bones (closure of epiphyseal plates):
1) middle and distal phalanges of the third finger
(MP3 and DP3)
2) distal epiphysis of the radius (R).
Method of analysis
Pubertal development was assessed
from 10 to 18 years by determining the
occurrence of menarche in girls
and the voice change in boys.
3 stages of voice changes were used:
PPV prepubertal voice; the pitch of the
voice had not changed noticeably.
PV pubertal voice; the pitch of the
voice had changed noticeably but the
voice had not yet acquired adult
characteristics.
MV male voice; the pitch of the voice
had acquired adult characteristics.

Pubertal growth spurt

The individual unsmoothed incremental curves of height were based on annual
increments calculated between specified target ages. It should be pointed out that
height was recorded in millimeters, usually in the morning, by a trained examiner
using the stretching-up technique

Results
The pubertal growth spurt
ONSET is found by locating the smallest annual increment
(A) from which there is continuous increase in growth rate to
PHV.

Onset : 10yr in girls
12.1yr in boys
PHV : 12 yr in girls
14.1 yr in boys ( 2 yr after ONSET)
End : 14.8 yr in girls
17.1 yr in boys

Results
Dental development and pubertal
growth spurt - The dental
development was more advanced in
boys than in girls at all three pubertal
growth events.
The dental emergence stages were not
useful as indicators of the pubertal
growth spurt.
Results
Skeletal development and the pubertal
growth spurt
Skeletal development at ONSET and PHV
was more advanced in girls than in boys,
whereas at END the skeletal
development was more advanced in
boys.
The skeletal stages were useful as
indicators of the pubertal growth spurt.
Skeletal stages:
Sesamoid it appeared during the
acceleration period of pubertal growth
spurt (ONSET of PHV).
Middle third phalanx:
MP3-F - was attained before ONSET
by about 40 percent of the subjects
and at PHV by the others. The
epiphysis is as wide as metaphysis.

MP3-FG epiphysis is as wide as
metaphysis and there is distinct
medial and/or lateral border of the
epiphysis forming a line of
demarcation at right angle to distal
border. This stage is attained by 1yr
before or at PHV.
MP3-G the sides of the epiphysis
have thickened and also caps its
metaphysis forming a sharp edge
distally at one or both sides. This
stage is attained at or 1 yr after
PHV.
MP3-H fusion of epiphysis and
metaphysis has begun. It is attained
after PHV but before the END.
MP3-I - fusion of epiphysis and
metaphysis is complete. It was
attained before or at END in all
subjects.
Distal third phalanx:
DP3-I it is attained during the
deceleration period of the pubertal
growth spurt. The fusion of epiphysis
and metaphysis is complete.
Radius:

R-I it is attained 1 yr before or at the
END. Fusion of the epiphysis and
metaphysis has begun.
R-IJ- Fusion almost complete.
R-J - Fusion of the epiphysis and
metaphysis is complete.
Pubertal development and
pubertal growth spurt
Pubertal development (menarche and
voice change) and pubertal growth events
has a close relationship in both sexes.
Menarche occurred 1.1yr after peak height
velocity.
The pubertal voice was attained 0.2 yrs
before PHV .
male voice 0.9yrs after PHV.
Discussion
Reliable indications taken from skeletal
development were found for PHV and END but
not for beginning (ONSET) of pubertal growth
spurt.
During the end of the prepubertal period the
radiographic changes in the form of bones of
hand wrist are small. Therefore there is a lack of
indications during this period.
According to Bjrk,
pubertal growth spurt ends with the complete
fusion of the third distal phalanx (DP3-I).
Schouboe reported,
DP3-I in some girls coincided with PHV, which
was also found in this study.
In girls DP3-I is therefore not an absolute
indicator that PHV has been passed.

conclusion

There was a 2-year sex difference in age at the beginning, peak,
and end of the pubertal growth spurt. The individual variation
was about 6 years at each growth event in both sexes.
Dental development, assessed by means of dental emergence
stages, was not useful as an indicator of the pubertal growth
spurt.
Dental development in relation to the pubertal growth spurt was
more advanced in boys than in girls, but the individual variation
was great in both sexes.
The peak and end, but not the beginning, of the pubertal growth
spurt could be determined by means of indicators taken from
the skeletal development of the hand and wrist and the pubertal
development (menarche and voice change), which are suitable
for use in clinical orthodontics.


THANK YOU

SEM -2
Includes,
1. Cervical Vertebrae
2. Frontal sinus development
3. Maxillary mid palatal suture
approximation
4. Canine calcification stages
CERVICAL VERTEBRAE

The first seven vertebrae in the spinal
column constitute the cervical spine.
The first two, the atlas and the axis,
are quite unique, the third through
the seventh have great similarity.
Maturational changes can be
observed from birth to full maturity.

CERVICAL VERTEBRAE

Vertrebral growth takes place from the cartilagenous layer on the
superior and inferior surfaces of the vertrebra.

Secondary ossification on the tips of bifid spinous
processes and transverse processes appear during
puberty.

After completion of endochondral ossification, growth of vertrebral
body takes place by periosteal apposition.

Todd and Pyle, Lanier, and Taylor made measurements from
lateral radiographs of the lower cervical vertrebra.

Lamparski studied changes in size and shape of cervical
vertrebra to create maturational standards for the cervical
vertrebra
1972 Lamparski was the 1
st

person to study cervical vertebrae and
he found them to be as reliable as hand
wrist film.
He found that cervical vertebrae
indicators were same for males and
females, but the females developed the
changes earlier.
1n 1995 Hassel and Farman modified
the Lamparski criteria by using C2, C3,
and C4 cervical vertebrae.
Lamparski method
Stage 1
The inferior borders of the bodies of all
cervical vertebrae are flat.
The superior borders are tapered from
posterior to anterior.
Stage 2 a concavity develops in the
inferior border of the second cervical
vertebrae. The anterior vertical height of
body is increase.
Lamparski method
Stage 3 a concavity develops in the
inferior border of the 3
rd
vertebrae.
Stage 4 a concavity develops in inferior
border of 4
th
vertebrae. Concavities in
lower border of 5
th
and 6
th
vertebrae are
beginning to form. The bodies of all
cervical vertebrae are rectangular in
shape.
Lamparski method

Stage 5 concavities are well defined in
the lower border of the bodies of all 6
cervical vertebrae. The bodies are nearly
square in shape.
Stage 6 all concavities have deepened.
The vertebral bodies are now higher than
they are wide.
Brent Hassel, Allan Farman

Objective of the study

create a method of evaluating biological
skeletal maturation of orthodontic patient with
cephalogram.

Correlation made between vertebrae maturation and
skeletal maturation of hand and wrist radiograph

Skeletal maturation :
degree of development of ossification in
bone.
AJODO: Jan 1995
Material and method

Sample of 10 group of 10 male and 10 female
(220 subject)
from 8 to 18 yrs

Radiograph
1. hand and wrist
2. lateral cephalogram
Cervical vertebrae maturation
indicators using C3 as guide.
Six distinct stages of CVM can be
related to the SMI developed by
Fishman
1. Initiation (SMI 1 and 2)
2. Acceleration (SMI 3 and 4)
3. Transition (SMI 5 and 6)
4. Deceleration (SMI 7 and 8)
5. Maturation (SMI 9 and 10)
6. Completion (SMI 11).
Category 1 (Initiation)

At this stage adolescent growth was just
beginning and 80% to 100% of the growth
was expected.
Inferior borders of C2, C3 and C4 were flat at
this stage.
Vertebrae are wedge shaped,
Superior vertebral border were tapered from
posterior to anterior.

Six stages in vertebral
development
CVMI 1

Category 2 (Acceleration)

growth acceleration was beginning at this
stage with 65% to 85% of adolescent growth
expected.
Concavities were developing in the inferior
border of C2, C3.

The inferior border of C4 was flat.

The bodies of C3 and C4 were nearly
rectangular in shape.
CVMI 2

Category 3 (Transition)

Adolescent growth was still accelerating at this
stage towards peak height velocity with 25%
to 65% of adolescent growth expected.
Distinct concavities were seen in the
inferior borders of C2 and C3.
Concavity was beginning to develop in the
inferior border of C4.
The bodies of C3 and C4 were rectangular in
shape.
CVMI 3
Category 4 (Deceleration)

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 andC4.
The vertebral bodies of C3 and C4 were
becoming more square in shape.
CVMI 4
C3,c4 (square)
Category 5 (Maturation)

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.
CVMI 5
Category 6 (Completion)

growth was considered to be complete
at this stage.

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.
CVMI 6
Square c3 and c4 vertebrae

1998 - PATRICIA GARCA-
FERNANDEZ,
HILDA TORRE,
LUIS FLORES,
JESUS REA.
To determine whether the maturation
of cervical vertebrae would correlate
with the maturation indicated by hand-
wrist x-rays in a Mexican population.

JCO:35:4:1998
Six distinct stages of growth can
be related to the SMI developed
by Fishman
1. Initiation (SMI 1 and 2)
2. Acceleration (SMI 3 and 4)
3. Transition (SMI 5 and 6)
4. Deceleration (SMI 7 and 8)
5. Maturation (SMI 9 and 10)
6. Completion (SMI 11).
Paloma San Roman, Juan Carlos Palma,
M Dolores Oteo and Esther Nevado:

AIM :
study to determine morphological
changes seen in cervical vertebrae are
as useful to determine growth stages
as maturation stages assessed on hand
and wrist radiograph.

EJO (24) June2002
Study consisting of 958 caucasian
subjects who attended orthodontic
department between 1980 and 1996.
3 parameters to Assess Skeletal
Maturation.
Anatomical changes observed in,
1. concavity of lower border
2. height
3. shape of vertebral bodies

Concavity of lower border
6 stages
1. All vertebrae have flat lower border.
2. Concavity C2 lower border.
3. Concavity C3 lower border.
4. C2 and C3 concavity increases and
concavity present in C4, C5 and C6.
5. Concavity increases in all vertebrae.
6. Deep concavity in all vertebrae and
inferior angles are rounded.
Vertebral body height
Calculated at middle of C3
and C4 body. Width also
calculated at the middle.
4 stages-
Height < 80% width.
Height between 80% and
99% of width.
Height = width.
Height > width.
Shape of vertebral bodies

Calculated at C3 and C4.
6 stages-
1. Upper border tapered from posterior to anterior
(wedge shaped).
2. Wedge shaped C3, nearly rectangular C4,
absence of superio-anterior angles.
3. Rectangular shaped bodies.
4. Nearly squared bodies.
5. Squared bodies.
6. Rectangular bodies with height greater than
width.
Cervical Vertebral Maturation
(CVM) Method for the Assessment of
Mandibular Growth
Greatest effects of functional appliances
take place when the peak in mandibular
growth is included in treatment period.
Tiziano Baccetti, Lorenzo Franchi,
James A. McNamara Jr.

Angle Orthod 2002;72:316323.
To provide a new version of the Cervical
Vertebral Maturation (CVM) method for the
detection of the peak in mandibular growth
based on the analysis of the second through
fourth cervical vertebrae in a single
cephalogram. (c2-c4)
The morphology of the bodies of the second
(odontoid process, C2), third (C3), and fourth
(C4) cervical vertebrae were analyzed in six
consecutive cephalometric observations.
AIM OF THE STUDY
Components of study
C2, C3 andC4.
706 subjects.
Co-Gn = total mandibular length.
Maximum increment between two
consecutive cephalograms defines peak in
mandibular growth at puberty.
Six consecutive cephalograms.
Observations for each subject consisted of
two consecutive cephalograms comprising
the interval of maximum mandibular
growth (as assessed by means of the
maximum increment in total mandibular
length, Co-Gn), together with two earlier
consecutive cephalogram and two later
consecutive cephalograms

Lambarskis CVM I and CVM II are merged
(CVMS I) because there is no distinct
demarcation is present between stage I
and II. And form CVMS I
CVMS = cervical vertebrae maturation
stage.
5 maturational stages.
CVMS I

Lower border of C2, C3 and C4 is
flat.
C2 may present slight concavity.
Bodies of C3 and C4 r trapezoidal.
Peak mandibular growth will
occur not earlier than 1yr after
this stage.
CVMS II
Concavities present at the lower
border of C2 and C3.
Bodies of C3 and C4 either
trapezoid or rectangular horizontal
in shape.
Peak in mandibular growth will occur
within 1yr after this stage.
The appearance of a visible concavity
at the lower border of the third
cervical vertebra is accounts for the
identification of the stage immediately
preceding the peak in mandibular
growth.

CVMS III
Concavities at the lower
border of C2, C3 and C4 are
present.
Bodies of C3 and C4
rectangular horizontal in
shape.
Peak in mandibular growth
has occurred within two
years before this stage.
CVMS IV
Concavities at the lower
border of C2, C3 and C4 are
present.
At least one of the bodies of C3
and C4 is squared in shape.
The peak in mandibular growth
has occurred not later than one
year before this stage.
CVMS V
The concavities at the lower borders
of C2, C3, and C4 still are evident.
At least one of the bodies of C3 and
C4 is rectangular vertical in shape.
The peak in mandibular growth has
occurred not later than two years
before this stage. (means two years
after peak )
discussion
Cervical Vertebral Maturation can be useful as a
maturational index to detect the optimal time to
start treatment of mandibular deficiencies by
means of functional jaw orthopedics.
It has been demonstrated that the effectiveness
of functional treatment of Class II skeletal
disharmony strongly depends on the biological
responsiveness of the condylar cartilage, which in
turn is related to the growth rate of the mandible
Discussion
CVMS I wait for 1 yr.
CVMS II ideal time to begin treatment,
because peak in mandibular growth occur within
1 yr after this stage.
Total mandibular length exhibited an average
increase of 5.4 mm in the year following CVMS II, a
significantly greater increment when compared both
to the growth interval from CVMS I to CVMS II (about
2.4 mm) and to following between-stage intervals
(1.6 mm and 2.1 mm for the intervals from CVMS III
to CVMS IV and from CVMS IV to CVMS V,
respectively)
conclusion
The new CVM method is comprised of five
maturational stages with the peak in mandibular
growth occurring between CVMS II and CVMS III.
The pubertal peak has not been reached without
the attainment of both CVMS I and CVMS II.
The new method is particularly useful when
skeletal maturity has to be appraised on a single
cephalogram and only the second through fourth
cervical vertebrae are visible.

Mid palatal suture region as an
indicator of maturity
Revelo and Fishman in 1994
evaluated the ossification pattern of the
mid palatal suture.
purpose of this study was to determine
whether a positive correlation exists
between adolescent maturational
development and the approximation of
the midpalatal suture

Revelo, Fishman AJO: 105:mar 1994.
Methods and Materials
sample of 84 patients
8 to 18 years of age
X-RAY:
1. Standardized Occlusal radiographs
2. hand-wrist radiographs
Stages of ossification of the midpalatal
suture were compared with Fishman's
standards of skeletal maturation
indicators.

Key landmarks and planes
Point A most anterior
point on premaxilla.
Point B most posterior
point on the posterior wall
of the incisive foramen.
Point P point tangent to a
line connecting the posterior
walls of the greater palatine
foramen.
Key landmarks and planes
A-P total dimension of
the suture.
A-B anterior
dimension of the
suture.
B-P posterior
dimension of the
suture.
Results
Significant. correlation between maturational
development and beginning of ossification of
mid palatal suture
Before SMI 4 ( i.e. before ossification of
adductor sesamoid)
Very little or no midpalatal approximation
exists.
Suture is only 8% fused at SMI 3.
Anterior portion of suture is wide open.
Results
SMI 4-7 (i.e. ossification of adductor
sesamoid, capping with distal and middle
phalanx of 3
rd
finger & fifth finger )
osseous interdigitation is evident
with approximation in some areas.
This period occurs during the pubertal
growth spurt.
Results
After SMI 8 (i.e. fusion of distal phalanx of 3
rd

finger)
The suture demonstrates a marked increase in
rate of approximation.
Increments to approximately 25%
approximation at maturational age SMI
9.
At SMI 11 (i.e. fusion of radius )
50% of total midpalatal suture is
approximated.
High percentage of approximation occurs
posteriorly.
conclusion
No difference in patterns of approximation
between males and females.
Thus, best time to use orthopedic force for
expansion is before SMI 9 as percentage
of approximation is less.
Ideal time is SMI 1 to 4 as less orthopedic
force is required.
Frontal sinus development as an indicator
for somatic maturation at puberty
Sabine Ruf and Hans Pancherz-1996.
2 lateral head films from each subject
were analyzed on 1 or 2 yrs interval basis.
Lateral radiographs were traced with the
SN line.

AJO 110: Nov 1996.
AIM OF STUDY
predicting the stage of somatic maturity
by analyzing frontal sinus growth was
evaluated.
The study was performed on 53 adolescent
boys, and the frontal sinus size development
was assessed on lateral head films.
The accuracy of the prediction procedure was
tested by comparing the prediction stage with
the longitudinal growth data for body height of
the subjects
Landmarks
Sh highest point on
peripheral border of frontal
sinus.
Sl lowest point on
peripheral border of frontal
sinus.
Perpendicular to the
interconnecting line (Sh-
Sl), the maximum width
of the frontal sinus was
assessed.
Sh
Sl

Average yearly body height growth
velocity (mm/yr) was calculated.
Bp (body height peak) = maximum
body growth velocity at puberty
The body height growth data were used
only to test the accuracy of the
prediction of pubertal stage as assessed
from frontal sinus development.
Body height Velocity
Somatic maturity prediction
Frontal sinus growth velocity at puberty is
closely related to body height growth
velocity.
Well defined pubertal peak (Sp), on
average, occurs 1.4 years after the
pubertal body height peak (Bp).
Males average age at frontal sinus
peak is 15.1 years.
(Difference is 1.4 yrs)
Somatic maturity prediction
Peak growth velocity in the frontal sinus of
atleast 1.3mm/yr is attained in 1 yr observation.
In 2 yr observation interval, a peak velocity in
the frontal sinus of atleast 1.2mm/yr is attained.
These specific frontal sinus growth velocities
(1.3 mm/yr. for the 1-year interval and 1.2
mm/yr. for the 2-year interval) were assigned as
threshold values T1 and T2, respectively.

Prediction procedure
Frontal sinus growth velocity (Sv) in each
person was compared with T1 and
T2(threshold) values.
If Sv is as high as or higher than T value
(T1 or T2), it may be expected that the
frontal sinus peak was reached during
prediction interval.
Prediction procedure
If the Sv is lower than the T-value, it
cannot be said whether the subject is pre
peak or post peak in frontal sinus growth.
May be related to chronologic age (frontal
sinus peak at 15.1 years).
DISCUSSION
disadvantage

1. it requires two lateral head films taken at least at
a 1-year interval. Two radiographs are, however,
seldom available at the beginning of orthodontic
treatment .
2. If the 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%)
Canine calcification
Relationship between mandibular canine
calcification stages and skeletal
maturity.
Sandra Cortinho, Peter H. Buschang.

AJODO:104:sept 1993.
Sample:
200 boys and 215 girls

development of the mandibular canine was
assessed according to Demirjian's 9
stages of dental calcification.

Skeletal age was determined from hand-
wrist radiographs according to methods
described by
1. Greulich and Pyle.
2. Tanner and Whitehouse method.

Canine development stage
Stage D:

Canine development stage
Stage D:
Crown formation is complete down to
C.E. junction.
Superior border of the pulp chamber in
the uniradicular teeth has a definite
curved form being concave towards
cervical region.
The projection of pulp horns, if present
gives outline shaped like an umbrella
top.
Beginning of root formation is seen in
the form of a spicule.
CE
Junction
Stage E
Stage E:
The walls of the pulp
chamber now form straight
lines whose continuity is
broken by the presence of
the pulp horn, which is
larger than in the previous
stage.
The root length is less than
the crown height.
Pulp horn
Stage F
Stage F:
The walls of the pulp
chamber now form a more
or less an isosceles
triangle. The apex ends in
a funnel shape.
The root length is equal to
or greater than the crown
height.
Isosceles
triangle
Stage G

Stage G:
The walls of the root canal
are now parallel and its
apical end is still partially
open.
Parallel walls
Stage H
Stage H:

The periodontal apical end of
the root canal is completely
closed.

membrane has a uniform width
around the root and the apex.
Results

The initiation of spurt is indicated by canine
stage F (i.e. the epiphysis of the 3
rd
and 5
th
middle
phalanges are equal in length to their diaphysis.)

No appearance of adductor sesamoid.

The mean skeletal age for the presence of the adductor
sesamoid in the girls and the boys are 12.2 years and
13.2 years, respectively.

In stage G, most show the adductor sesamoid.

Capping of the diaphysis of the middle and distal
phalanges of the third finger, and capping of the proximal
phalanx of the fifth finger.

Stage G coincides with the eruption of the canine into
the oral cavity, occurs approximately 1 year before the
PHV in boys, but only 5 months before the PHV in
girls.

This may reflect hormonal changes which accompany
puberty.
stage H, indicating apical closure, is
generally associated with fusion of the
epiphyses to their respective diaphysis.

stage F indicates ONSET of puberty.
Stage G indicates peak height velocity
(PHV).
The intermediate stage between stage F and
G should be used to identify the early stages
of the pubertal growth spurt.
Canine development cannot or should not be
used as a sole criteria to predict development
landmarks.
conclusion

THANK YOU

Symphysis morphology as a predictor of
direction of mandibular growth
AJODO
Volume 1994 Jul (60 - 69): Symphysis
morphology as a predictor of direction of
mandibular growth
Aki, Currier, and Nanda


Determination of Height and Depth
A line tangent to point B was used as the long
axis of the symphysis, and a grid was formed
with the lines of the grid parallel and
perpendicular to the constructed tangent line.

The superior limit of the symphysis was taken at
point B with the inferior, anterior, and posterior
limits taken at the most inferior, anterior, and
posterior borders of the symphysis outline,
respectively
symphysis height was defined as the distance
from the superior to the inferior limit on the grid.
The symphysis depth was defined as the
distance from the anterior to the posterior limit
on the grid.
Symphysis ratio was calculated by dividing
symphysis height by symphysis depth. The
symphysis angle was determined by the
posterior-superior angle formed by the line
through menton and point B and the mandibular
plane

Aki, Nanda and Currier assessed the following
parameters in the Symphysis morphology.
1. Height
2. Depth Maximum anterio-posterior diameter of
the Symphysis.
3. Angle of Symphysis Angulations between
Go-Me and B-Gn.
4. Ratio Height/Depth
seven cephalometric measurements were used
to assess the direction of mandibular growth: (1)
SN to Y-axis angle, (2) SN-MP angle, (3) palatal
plane-mandibular plane angle (ANS-PNS to
mandibular plane), (4) gonial angle (Ar-Go-Me),
(5) sum of saddle (N-S-Ar), articulare (S-Ar-Go),
and gonial (Ar-Go-Me) angles, (6) percentage of
lower face height (ANS-Me) to total face height
(N-Me), and (7) posterior to anterior facial height
(S-Go/N-Me).
Discussion

The size and shape of the mandibular symphysis is an
important consideration in evaluation of orthodontic
patients.
1. With a larger symphysis, more protrusion of the incisors
is esthetically acceptable and therefore a greater
chance of a nonextraction approach to treatment.
2. Conversely, persons with greater symphysis height and
a small chin would be candidates for an extraction
treatment plan to compensate for arch length
discrepancies.

discussion

For anteriorly and posteriorly directed growth patterns,
several parameters used on cephalometric analyses
have been identified.
It is believed that a large symphysis ratio (height/ depth)
is associated with a receding chin, high mandibular
plane, high angle SN-MP, large saddle, articulare and
gonial angles, large anterior facial height, and a large
percentage lower facial height.
In the case of a small symphysis ratio, there is a large
chin, low mandibular plane, low angle SNMP, low
saddle, articulare and gonial angles, small anterior facial
height, and a small percentage lower facial height.
Ricketts has used the terms dolicofacial and brachyfacial
growth patterns

conclusion
After thorough study, they made the following
conclusions.

Symphysis ratio was strongly related to the
direction of mandibular growth in men.

Males posses stronger relationship between the
symphysis morphology and mandibular growth
direction than the females

Mandible with anterior growth direction is associated with
small height, large depth, small ratio and larger angle of
Symphysis.

Mandible with posterior growth direction is associated
with large height, small depth, large ratio and small angle
of Symphysis

There was continued change in the symphysis up to
adulthood in both female and male subjects, with the
female subjects having a smaller and earlier occurring
change compared with the male subjects.

Symphysis height, depth, and ratio increased while
symphysis angle decreased with age.

Antegonial notch as indicator of
growth
Singer, Mamandras, and Hunter
AJO-DO, Volume 1987 Feb (117 - 124):


This study was undertaken with the purpose of providing answers to
the following questions:
1. Does deep mandibular antegonial notching occur in conjunction
with a distinct craniofacial morphology?
2. Is a deep mandibular antegonial notch indicative of future
mandibular growth direction and/or potential?

Very deep (more than 3 mm) and very shallow (less than 1 mm
notch subjects were therefore examined cephalometrically in the
hope that any biologic relationships might be more readily apparent
in extremes of the population.

Antegonial notch depth
(ND) measured as the
distance along a
perpendicular line from
the deepest point of
notch concavity to a
tangent through the two
points of greatest
convexity on the inferior
border of the mandible,
either side of the notch.

Singer et al studied about the possibility of depth of antogonial
notch being used as an indicator of mandibular growth potential.
After elaborate studies, he concluded.

1. (deep mandibular antegonial notch is indicative of a diminished
mandibular growth potential and a vertically directed mandibular
growth pattern.)

2. 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.

3. The mandibular growth direction in deep notch patients; as
measured by facial axis and the mandibular plane angle, was
more vertically directed than for shallow notch patients.
conclusion
4) The deep notch subjects had longer total facial
height and longer lower facial height than the
shallow notch subjects.
5) The deep notch subjects had a smaller saddle
angle than did the shallow notch subjects.
6) The deep notch experienced less mandibular
growth.
7) Notch depth increased in deep notch group,
while it decreased slightly in shallow notch group
during the study period.
8) Deep notch patients required a longer duration
of orthodontic treatment than did shallow notch
patients.

Cervical and craniocervical posture as
predictors of craniofacial growth :

Solow and Siersbek-Nielson studied the
possibility of predicting growth changes in
craniofacial structure by the variables
expressing the postural relations of the
head and cervical column
Craniocervical Angle
The position of head in relation to the cervical column.
It is expressed by the angles between craniofacial
reference lines NSL, FH and NL and cervical column
reference lines OPT and CVT.
Craniocervical angulations
That is, the position of the head in relation to the true
vertical, was expressed by the angles between the
craniofacial reference lines, NSL, FH, and NL, and the
true vertical, (VER)

Cervical column inclination
Inclination of the cervical column is given by
OPT/HOR, CVT/HOR in relation to the horizontal plane.

Here four fiducial
points were used for
the computerized,
structure-based
analysis of growth
changes

AJO-DO Volume 1986
Feb (132 - 140): Growth
changes in posture and
morphology - Solow and
Siersbk -Nielsen


The reference line connecting the two fiducial points in
the cranial base was termed REFcrb and that connecting
the two fiducial points in the mandible was designated
REFml. Growth changes in the inclination of REFml
relative to REFcrb correspond in principle to the growth
change in inclination of the implant line used by Bjrk
and Skieller,13 although the method error would be
expected to be somewhat larger since implants were not
used. Changes in the angle REFcrb/REFml indicate the
rotation of the mandible


Normally this rotation is partly concealed by marked
remodeling of the lower mandibular border. Therefore,
during growth the mandibular plane ML rotates much
less than an implant line or a structure-based reference
line. To distinguish between the two measures of
mandibular rotation, use of the term true or total rotation
is suggested to indicate the rotation of an implant line or
a structure-based reference line; the term apparent
rotation is used for the rotation of the commonly used
mandibular plane in relation to the cranial base.




The technique revealed fields of significant
correlations between posture and subsequent facial
growth, namely, between cervical inclination and
craniocervical angulations and the subsequent
sagittal or vertical development of the face

prediction by the soft tissue stretching hypothesis
presented by Solow and Kreiborg. According to this
hypothetical model, obstruction of the upper airways
can lead to an increase in the craniocervical
angulations to facilitate respiration. This leads to a
stretching of the soft tissue layer covering the face
and throat, and the backward and downward
components of the strain in the soft tissue layer
restricts or redirects the forward component of facial
development in a more caudal direction.

A preliminary list of possible predictors of undesirable craniofacial
development such as downwards and backwards growth of the face
was given by Solow and Kreiborg

conclusion
A small craniocervical angle and a backward-inclined
upper cervical column was associated with horizontal
facial development characterized by reduced backward
displacement of the temporomandibular joint (TMJ),
large maxillary growth in length, increased facial
prognathism, and larger than average true forward
rotation of the mandible

A large craniocervical angle and an upright position of
the upper cervical column was associated with vertical
facial development characterized by large backward
displacement of the TMJ, reduced growth in length of the
maxilla, reduced facial prognathism, and less than
average true forward rotation of the mandible

children with NSL/OPT larger than 113 (mean +2 SD)
would be expected to display a vertical growth pattern of
the lower face, and children with NSL/OPT smaller than
79 (mean 2 SD) a horizontal growth pattern. These
findings could be of clinical predictive value in subjects
with extreme cervical and craniocervical postural
relationships

In other words, a small craniocervical angle was, on the
average, associated with a horizontal facial growth
pattern, whereas a large craniocervical angle, on the
average, was associated with a vertical facial
development.
Rotation of mandible
Implant studies:
In 1960, by bjork and coworkers in copenhagen
Tow types

Internal rotation:
rotation that occurs in the core of each jaw
mandible rotates forward and more growth posteriorly than
anteriorly
External rotation:
surface changes result in external rotation
rotation is backward and more growth anteriorly than
posteriorly.

it can be observed that in most individuals the core of the
mandible rotates during growth in a way that would tend to
decrease the mandibular plane angle ( up anteriorly and
down posteriorly)
Core of the mandible is the
bone that surrounds the
inferior alveolar nerve.
Rest of the mandible
consists of its several
functional processes.
Ex. Alveolar processes,
muscular processes

Internal rotation divided in to two types
Matrix rotation ( around condyle)
Intramatrix rotation ( within the body of mandible)
Internal rotation of mandible is the variation between
individuals ranging up to 10 to 15 degrees.
So, there is -15* internal rotation from age 4 to adult
life. Of this 25% matrix and 75% intramatrix rotation.
On an average, there is abt 15 degree internal , forward
rotation and 11 to 12 degree of external, backward
rotation producing 3 to 4 degree decrease in mandibular
plane angle observed in the average individual during
childhood to adolescence.
In maxilla,
if implant is placed in the maxillary alveolar process,
one can observe that maxilla that undergoes a small and
variable degree of rotation, forward or backward
In this internal rotation is analogous to the intramatix
rotation of the mandible.
Also there are varying degree of resorption of bone on
the nasal side and apposition of bone on the palatal side
in the anterior and posterior parts of the palate. This
explain external rotation.
So, in most patient external rotation is equal and
opposite in direction to the internal rotation. So, net
result is zero.
Short face type individual
Characterized by,
short anterior face height
Excessive forward rotation of mandible
Horizontal palatal plane and mandibular
morphology
Square face
Low mandibular plane angle
Deep bite malocclusion and crowded anteriors

Long face individuals
Characterized by,
Excessive lower anterior face height
Palatal plane rotate down posteriorly creating a negative
rather than normal positive inclination to true horizontal.
Backward rotation of mandible
Increase mandibular plane angle
Lack of normal intramatrix rotation
Malocclusion associated with anterior open bite and
retrusive mandible
Backward rotation also associated with abnormalities or
pathology associated with TMJ .
Structural signs of growth
rotation/prediction
A growth analysis consists essentially of three
items, each of which is clinically significant:

1. An assessment of the development in shape of
the face which, in the first place, implies
changes in the intermaxillary relationship,
2. An assessment of whether the intensity of the
facial growth in general is high or low,
3. An evaluation of the individual rate of
maturation.
Bjrk, AJO: 1969
pattern of mandibular growth is thus
generally characterized by an upward- and
forward-curving growth at the condyles,
while at the same time there is resorption
on the lower aspect of the gonial angle
and some apposition below the
symphysis.
Growth prediction
Three methods
longitudinal, metric, and structural
1. Prediction by the longitudinal
method,
following the course of development in
annual x-ray cephalometric films
remodeling masks rotation.

2. The metric method
metrically from a single x-ray film.
However, statistical studies of the
possibility of predicting the intensity or
direction of subsequent development
from size or shape at childhood
indicate that this is not feasible

The structural method
based on remodeling processes of the mandible
during growth, gained from the implant studies
principle is to recognize specific structural features
that develop as a result of the remodeling in a
particular type of mandibular rotation
various types of rotation of the mandible that may be
recognized with the implant method
Three forward rotation
Two backward rotation
Type I.
forward rotation about centers
in the joints which gives rise to
a deep-bite,
lower dental arch is pressed into
the upper, resulting in
underdevelopment of the
anterior face height.
The cause may be occlusal
imbalance due to loss of teeth
or powerful muscular pressure.
This lowering of the bite may
occur at any age.

Forward rotation may occur in the
following three ways:
Type II.
Forward growth rotation of the
mandible about a center
located at the incisal edges of
the lower anterior teeth is due
to the combination of marked
development of the posterior
face height and normal
increase in the anterior height.
The posterior part of the
mandible then rotates away
from the maxilla.
marked resorption below the
gonial angle

Type III.
forward rotation of the
mandible with the center of
rotation displaced backward
in the dental arch, to the
level of the premolars.
Anterior face height
becomes underdeveloped
when the posterior face
height increases.
The dental arches are
pressed into each other and
basal deep-bite develops.
Types II and III the
mandibular Symphysis
swings forward to a marked
degree, and the chin
becomes prominent

Backward rotation of the mandible
Type I
center of the backward
rotation lies in the
temporomandibular joints
underdevelopment of the
posterior face height leads
to a backward rotation of
the mandible,
overdevelopment of the
anterior face height and
possibly open-bite as a
consequence

Type II.
Backward rotation here
occurs about a center
situated at the most distal
occluding molars
symphysis is swung
backward and the chin is
drawn back below the face
Basal open-bite may
develop
Because of the backward
rotation of the mandible,
the interpremolar and
intermolar angles are small

Clinical importance
Seven structural signs of extreme Growth Rotation
inclination of the Condylar Head,
Curvature of the Mandibular Canal,
shape of the lower border of the mandible (Antegonial
Notch indicating a Posterior Growth Rotator),
Inclination of the Symphysis,
Interincisal Angle,
Inter-premolar or Inter-molar angles, and
Anterior Lower Face Height.

(1) A forward or backward inclination of the condylar
head is a characteristic sign, but it may not be easy to
identify on the cephalometric radiogram, where part of
the condyle is masked, as is (2) The curving of the
mandibular canal may also be a clear sign. In the
vertical type of condylar growth, the curvature of the
canal tends to be greater than that of the mandibular
contour, including the angle of the jaw, whereas in the
sagittal type the opposite is generally the case. The
canal may then be straight or, in pathologic cases, it
may even curve in the opposite direction. (3) The
shape of the lower border of the mandible is highly
characteristic. In vertical condylar growth, the
pronounced apposition below the symphysis and the
anterior part of the mandible produces an anterior
rounding, with a thick cortical layer, while the
resorption at the angle produces a typical concavity. In
sagittal growth, the anterior rounding is absent and the
cortical layer is thin, while the lower contour at the jaw
angle is convex.
Forward Backward
Rotation Rotation
typeIII Basal
Basal Openbite
Deep backward
Bite condylar
growth
(4) The inclination of the symphysis is an important
feature. In the vertical type of growth, the symphysis
swings forward in the face and the chin is prominent,
while in the sagittal type it is swung back, with a
receding chin. The evaluation is complicated by the
simultaneous remodeling of the alveolar process in the
opposite direction, as is exemplified by the cranium
with the open-bite.

(5) The difference in the interincisor angle is evident, in
spite of the compensatory tipping of the lower incisors.

6) The difference in the interpremolar and intermolar
angles in the two growth types is also clear.

(7) A compression or overdevelopment of the lower
face is likewise typical. In the living subject there is a
difference in the posture of the lips.

In the case of pronounced forward rotation, there
is a major risk of deepite developing. This can be
prevented by means of a stabilizing appliance,
such as a bite plane, introduced before puberty.
After treatment, such stabilization may be
necessary until the growth of the jaws is
completed.

In the case of backward rotation, opening of the
bite is difficult to prevent. It has been our policy to
postpone treatment until the pubertal growth
spurt is nearly over and to delay extractions until
then.




A mathematical model to predict
course of craniofacial growth.

Todd:AJO:Jan 1981


Cephalometrics has usually attempted to characterize
growth in terms of the rate, amount, and direction of
movement of craniofacial landmarks (points), as well as
changes in angles and ratios which are based on the
positions of those points.
Numerous methods and conventions for their
implementation have been used to describe craniofacial
growth.
For example, Walker superimposed tracings of
successive head films (registered on sella turcica and
oriented on a line from the base of the occipital bone to
the center of the palate) -and plotted the positions of
various landmarks throughout the growth period. The
"track'' produced by each landmark was averaged over
many individuals to produce a normative ''picture" of
growth in a given pop


second method D'Arcy Thompson's method of
coordinate transformations.
rectangular grids are constructed on a facial
profile by inscribing the face in a rectangle and
drawing horizontal and vertical lines through
selected anatomic landmarks
Changes in the initial profile due to growth can
be represented by deforming the original
rectangular grid in the same manner as the
facial profile.


Each method has to employ certain
arbitrary conventions for registering and
orienting profiles.
Unfortunately, different frames of
reference often result in conflicting
geometric descriptions and assessments of
the same phenomena.

Many cephalometricians have recognized the important implication
of "orientation" and ''registration" conventions for the interpretation
of cephalograms.
Krogman and Sassouni's emphasizes that assessment of a given
profile with Frankfort horizontal or the sella turcica-nasion line is
taken as the reference line.
Moorrees and Kean, in evaluating the profile of an 11-year-old boy
for example, point out that, because of the downward inclination of
the cranial base, the severe protrusion of the maxillary incisors is
masked and a slight mandibular retrusion is exaggerated, if a
horizontal reference line is taken to be sella turcica-nasion, rather
than a ''true vertical" that coincides with the direction of gravitation
force.
it has been argued that the use of metal implants reveals relevant
orofacial changes which often go unnoticed because implants
establish a frame of reference whereby rotations of the mandible or
maxilla are not masked by compensatory remodeling of those facial
structures.
A number of conventions are commonly used for orienting
and registering profiles

Attempt to find an orientation that approximates "natural head
position'' the position of the head when the visual axis is
horizontal,11 averaged over small variations due to postural
adjustments, respiration, etc
most widely used "anatomic conventions" dictate that profiles are
superimposed on either the Frankfort horizontal or the sella
turcica-nasion line, with registration at porion or sella turcica,
respectively.

Moorrees and determine natural head position by asking subjects
to look at the image of their eyes in a mirror located at eye level.
Their findings revealed that the head position obtained with this
procedure was ''remarkably constant at two observations within a
week" this results in less variation than anatomic conventions for
establishing a frame of reference.

3. Rabey's conventions for establishing a frame of
reference as based on fixed relations among
certain anatomic landmarks.
The frontal view, for example, is taken in such a
manner that orbitale lies on a line connecting
the right and left ear holes
All of these methods are entirely
arbitrary
Two types of coordinate system is used to revels the
changes
Rectangular
Polar coordinate systems
First change depicts a process which preserves all
parallel lines of the rectangular grid and distances
between all points with the same y coordinate, while
changing the distance between all points with the same
x coordinate
none of these properties are revealed when the same
change is represented in polar coordinates
second change are more easily apprehended in polar
coordinates A polar coordinate system allows us to see
that the radial axes maintain their positions, a property
that is not revealed directly in the deformation of a
rectangular grid
. In selection of a coordinate system to represent a
given change, the goal is to find a coordinate system
that is privileged (in the sense that it reveals geometric
relations which are preserved over that specific change.)
Disadvantage of rectangular grid
system
anatomic landmarks move along straight
lines that radiate from the vicinity of the
cranial base;
A rectangular coordinate system, in
contrast, cannot depict radial growth
directly.

The problem of describing change
There are at least two major problems with this ''normative"
approach:
First, it does not adequately describe the changes that occur
between landmarks.
Second, it is uneconomical; in order to represent a reasonable
number of landmarks at different ages, the resulting table of
cephalometric norms becomes large, cumbersome, and difficult to
use.

Walker has suggested an alternative method for describing
craniofacial change
The positions of identifiable landmarks are plotted over time within
a Cartesian coordinate system and the trajectory of each landmark
is averaged over many individuals.
Another problem with this analysis is that the motion of each
landmark is considered to be an independent event, clearly a
misrepresentation of what normally occurs during development

A more reasonable hypothesis, first suggested by D'Arcy Thompson,
is that the head grows as a single unit so that the global outcome of
growth can be described by a single mathematical transformation.
Thompson's primary evidence for this claim was his ability to
represent apparently complex changes in morphology as the
geometric distortion of a grid placed over an evolving or growing
organism

Disadv :
Thompson rarely offered physical or biologic explanations for the
phenomena he was modeling, and in most cases he did not even
attempt to describe these phenomena formally with mathematical
equations

Thompson's grid method has recently been proposed by Bookstein.
In order to compare two homologous forms,
Bookstein uses specially constructed biorthogonal grids, in which all
lines intersect at right angles so that the angles of intersection are
unaffected by the particular transformation relating the two forms.
This reduces the underlying change to graded dilatations along the
principal axes of the grid.


Broadbent's work, it has become an
accepted practice to examine the effects
of growth by superimposing lateral
cephalograms of a single individual taken
at different ages.

Todd, Mark, Shaw, and Pittenger21 have
recently demonstrated that radial
transformations of human facial profiles, such as
the one depicted in Fig. 2, A are generally
perceived as growth by nave observers,
whereas other classes of transformation, such as
the one depicted in Fig. 2, B, are almost never
perceived as growth.7,22-24

Pattern of craniofacial growth is surprisingly
stable across individuals.
It has typically been observed that if one
adopts a frame of reference that is roughly
coincident with the cranial base, then most
anatomic landmarks tend to move along
straight lines emanating from a single point
somewhere in the vicinity of sella turcica,
and the amount of displacement tends to
increase monotonically from the top of the
head to the bottom.
what explanation could there be for heads
growing in such a globally regular manner?
Genetic plan.
Biomechanical influences Wolffs law.
States that once the general form of a
bone is established, "The bone elements
place or displace themselves in the
direction of functional pressure and
increase or decrease their mass to reflect
the amount of functional pressure.


In order to appreciate the over-all regularity of gravitational pressure,
it is useful to consider the human skull as a spherical tank filled with
fluid. From elementary hydrostatics, we know that the amount of
pressure (P) at any point (R,q) on the surface of the tank is uniquely
determined by its vertical distance from the top of the sphere .The
direction of pressure is normal (perpendicular) to the surface at every
point, and the amount of pressure can be expressed as a function of
position by the following equation:
P = a R (1 -cos q) (1)
where a is a constant representing the product of the force of gravity
and the density of the fluid. Thus, if all bone elements were placed or
displaced in the direction of gravitational pressure, as suggested by
Wolff's law, then they would all move outward along radial lines
emanating from the center of the sphere. Moreover, if changes in mass
reflect the amount of gravitational pressure, then the displacement
along these radial lines of growth would increase monotonically over
time as a function of pressure. If both of these assumptions are viable,
then the over-all pattern of change can easily be expressed in polar
coordinates with a single pair of equations:

q' = q (2)
R' = R + b P (3)

where b is an increasing function of tim


This analysis, of course, is oversimplified.
Heads are not perfectly spherical, there are other sources of stress
operating on the craniofacial complex besides the force of gravity.
Relative orientation of the head with respect to gravity does not
remain absolutely fixed.
The resulting model should be thought of as a kind of ideal case,
similar to analyzing the motion of a falling body without considering
air resistence. Such a model can be quite useful if it helps us to
appreciate the global influences on craniofacial growth or provides a
means of approximating the course of growth in any given
individual. This latter suggestion could have important applications
for treatment planning and will be developed further in the next
section.

conclusion

was shown to make reasonably accurate growth
predictions over a span of about 10 to 15 years.

Pedictions that were made with this growth
model were not totally accurate because of
mechanical sources of error and, perhaps, oral
habits.

Different frames of reference can result in
different descriptions of how the
craniofacial complex changes as a function
of growth.


Thank you

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