Growth spurts - orthodontics

GROWTH SPURTS
significance in orthodontics
Dr Ravikanth Lakkakula

CONTENTS
 Introduction.
 Definition of growth and development.
 Developmental growth periods.
 Methods of studying growth and methods of gathering growth data.
 Factors affecting growth and maturation.
 Concepts of growth.
Concept of normality
Rhythm of growth
Differential growth
Timing of growth : Growth spurts

 Biological maturity indicators
Morphological age
Chronological age
Dental age
Sexual age
Skeletal age
 Significance of growth spurts
 Conclusion

Introduction
• The current Orthodontics worries is about the early
correction of malocclusion, giving importance to the
harmonization of the bone bases in connection with the
discrepancy and positioning of the teeth, that can be
corrected in any time of life, for what is of great importance
is to know the biggest peak of growth.
 An understanding of growth events is of primary importance
in the practice of clinical orthodontics. Maturational status
can have considerable influence on diagnosis, treatment goals,
treatment planning, and the eventual outcome of orthodontic
treatment.

 Clinical decisions regarding use of extra oral traction forces,
functional appliances, extraction versus non-extraction
treatment, or orthognathic surgery are based on growth
considerations.
 For this reason, prediction of both the times and the
amounts of active growth, especially in the craniofacial
complex, would be useful to the orthodontist.

Definition of Growth
Author Definition
J s Huxley Self multiplication of living substance
Krogman Increase in size, change in proportion and progressive
complexity
Todd Growth refers to increase in size
Moyers Quantitative aspect of biological development per unit
time
Proffit Growth usually refers to an increase in size or number
Moss Change in any morphological parameter which is
measurable

Development
Author Definition
Todd It is the progress towards maturity.
Proffit Development is in complexity.
Moyers It refers to all the naturally occurring unidirectional
changes in the life of an individual from its existence as
a single cell to a multifunctional unit terminating in
death.
Enlow “Maturational process involving progressive
differentiation at the cellular and tissue levels”
Salzmann It is the sequences of changes from cell fertilization to
maturity. It relates to cell division, growth,
differentiation and maturation.Dr Ravikanth Lakkakula

 Morphogenesis – “A biologic process having an underlying control at the
cellular and tissue levels”.
 Differentiation
 The change from generalized cells or tissues to more specialized kinds
during development.
 The change in quality .
 Maturation
 Defined as the qualitative changes that occur with age.
 Translocation
 Change in position .

Correlation between growth and development
According to Proffit
 Growth is basically anatomic phenomenon and quantitative in
nature.
 Development is basically physiologic phenomenon and qualitative in
nature.
Development = growth + differentiation + translocation

 Growth is a dynamic process with a stable pattern of changes
result in increase in physical size and mass during its course of
development.
 Thus , growth is a three fold process “ self multiplication,
differentiation, organization” each according to its own kind . A
fourth dimension is : TIME.

A) Prenatal life (about 10 IU months).
1) Period of ovum : conception to 2 weeks.
2) Period of embryo : 2 – 8 weeks.
3) Period of fetus : 2 to 10 IU months.
B) Birth.
C) Postnatal life.
I. Infancy: (birth to about 1 year)
a) Neonatal period : birth, 1 to 2 weeks.
b) Infancy proper : 2 weeks to 1 year.
II. Childhood :
a) Early childhood (preschool) 1 – 6 years.
Developmental growth periods

b) Middle childhood (grade school) 6 to 9 or 10 years.
c) Late childhood or Prepubertal period (junior high school)
Girls : 9 or 10 to 12 or15 years.
Boys : 9 or 10 to 13 or 16 years.
III. Puberty :
a) Girls mean about 13 years
b) Boys mean about 14 years.
IV.Adolescence :
a) Girls : 13 – 18 years
b) Boys : 14 – 20 years.
V. Maturity: 18 or 20 to about 60 years
VI. Senility: beginning at about 60 years

Methods of Studying Growth
 Experimental approach
 Measurement approach
Method of gathering growth data
 Longitudinal study
 Cross sectional study
 Semi longitudinal study

A . Measurement approach :
 It is based on the techniques for measuring living animals,
humans.
Advantage:
 Does no harm the animal /human.
 Organism will be available for additional measurements at
another time.
Methods:
1. Craniometry.
2. Anthropometry.
3. Cephalometry.
4. Three dimensional imaging.

1. Craniometry:
 The first of the measurement approaches of anthropology.
 Based on measurements of skulls found among human
skeletal remains.
Advantage: precise measurements can be made on dry skulls.
Disadvantage: study can be only cross sectional.

2.Anthropometry:
 In anthropometry, various landmarks established in studies of
dry skulls are measured in living individuals simply by using
soft tissue points over lying these bony landmarks.
 Measurements obtained would be of different results because
the soft tissue thickness overlying both landmarks.
 Advantages: longitudinal , growth of an individual can be
followed over a period of time with repeated measurements.

3.Cephalometry:
 Is a standardized radiographic technique in craniofacial
region.
 Introduced by Broadbent in 1931.
 Cephalometric radiology, is of considerable importance not
only in the study of growth, but also in clinical evaluation of
orthodontic patients.

Advantages:
1. Allows direct measurement of skeletal dimensions, as the bone can be
seen through the soft tissue covering in a radiograph.
Disadvantages:
1.Two-dimensional representation of a three-dimensional structure.
2.The technique depends on precisely orienting the head before making a
radiograph, with equally precise control of magnification.
3.Even with precise head positioning, not all measurements are possible.

4.Three-dimensional imaging:
 New information now is being obtained with the application of
three-dimensional imaging techniques. Computed axial
tomography (CT) allows 3-D reconstructions of the cranium
and face.
 This method has been applied for several years to plan surgical
treatment for patients with facial deformities.
Example of a 3D imaging for hemifacial microsomiaDr Ravikanth Lakkakula

b. Experimental approach:
 This approach uses experiments in which growth is
manipulated in some way. This implies that the subject of the
experiment is available for study in some detail and the
detailed study may be destructive.
 Animals may be sacrificed for experimental purpose.
 For this reason, such experimental studies arc largely
restricted to Non-human species.

1.Vital staining:
 Uses dyes that stain mineralizing tissues (occasionally
soft tissues) are injected into an animal, these dyes
remain in the bones and teeth and can be detected later
after sacrifice of the animal.
 This method was originated by the great English
anatomist John Hunter in the 18th century.

 John Hunter observed that the bones of pigs that
occasionally were fed textile waste often stained in an
interesting way, discovered that the active agent was a dye
called alizarin.
 Alizarin reacts strongly with calcium at sites where bone
calcification is occurring (sites of active skeletal growth).

 Bone remodels rapidly, and areas from which bones being
removed also can be identified by the fact that vital stained
material has been removed from these locations.
Dyes used for this purpose:
1.Alizarin red
2.Tetracyline
3.Trypon blue
4. Lead acetate

2.AUTORADIOGRAPHY:
 It is a technique in which a film emulsion is placed over a thin
section of tissue containing radioactive isotope, and then is
exposed in the dark by radiation.
 The location of radiation in the film indicates the site of
growth.
Commonly used autoradiographic labels are:
A. 3 H thymidine.
B. 3 H proline.
C. Bromodeoxyuridine.

3.Radioisotopes :
 Radioisotopes of certain elements or compounds are often
used as in vivo markers .
 When injected into the body they get incorporated in the
developing bone.
 They can be detected by means of Geiger counter.
E.g.,
1. Technetium 99
2. Calcium 45

4. Implant radiology:
 Used extensively by Bjork.
 In this technique, inert metal pins generally made of
titanium are placed in growing bones of the skeleton,
including the face and jaws.

 These metal pins are well tolerated by the skeleton and
become permanently incorporated into the bone.
 These serve as reference points to study the amount,
direction and manner of growth.

Longitudinal studies.
These are measurements made of the same person or group at regular
intervals through time.
Advantages: 1.Temporary problems are smoothed with time,
2.Variability in development within a group is put in
proper perspective,
3.Serial comparison makes study of specific developmental
pattern of individual possible.
Disadvantages: Time consuming, Expensive, Sample loss .

Cross sectional studies
These are measurements made of different samples or different
individuals and studied at different periods.
ADVANTAGES
1.Quicker.
2.Less expensive.
3. Statistical treatment of data is easier.
4.Studies can be readily repeated.
5.Method can be used in archeological data.
DISADVANTAGES
1.Variation in development among individuals within the sample
cannot be studied.

Semi longitudinal studies.
Longitudinal and cross sectional studies can be combined to seek the
advantages of both. In this way one might compress 15 years of study
into 3 years of gathering growth data.

FACTORS AFFECTING GROWTH AND MATURATION
Heredity
 The basic control of growth, both in magnitude and timing is
located in the genes. The potential for growth is genetic. The
actual outcome of growth depends on the interaction between
the genetic potential and environment influences.
 Twin studies shown that body size, body shape, deposition of fat
and pattern of growth are under genetic control than
environmental. Hereditary controls both ends result and rate of
progress toward the end result.

 Genetic factors most likely play a leading role in male and female
growth differences.The marked advancement of girls over boys in
the rate of maturation is attributed to the delaying action of theY
chromosomes in males. By delaying growth, theY chromosome
allows grows males to grow longer period than females, therefore
marking possible greater overall growth.
 Individuals with the chromosome pattern XXY (klinefelter’s
syndrome) are long legged and have a growth pattern similar to
males even with the presence of two X-chromosomes.

 Individuals withTurner’s syndrome having only one X
chromosome, develop with a female pattern of growth
becoming more like a female at adulthood. Individual with an
XYY chromosome constitution are vary tall (6 feet or more),
which lends supports to hypothesis that theY chromosome has
a delaying effect on growth.

Hormones
 The anterior lobe of the pituitary gland produces a hormone called
growth hormone or somatotropin. Growth hormone maintains the
normal rate of protein synthesis and appears to inhibit the synthesis
of fat and the oxidation of carbohydrate.
 It is necessary for proliferation of cartilage cells thus it has a great
effect on bone growth and consequently height growth. Its growth
functions becomes ineffective when the epiphyses close but it
probably maintains its effects on protein synthesis through out life.
An excess of growth hormone produces a gigantism and a
deficiency of the hormone produces a pituitary dwarf.

 The anterior lobe of pituitary gland also secretes thyrotrophic
hormone, which affects growth by stimulating the thyroid gland to
secrete the hormones of the thyroid gland, thyroxine and tri-
iodothyronine, both stimulate general metabolism and are important
in growth of the bones, teeth and brain. Deficiency in childhood of
the thyroid hormones produces a mentally retarded dwarf.
 The timing sequence of maturation is undoubtedly under hormonal
control. Bone and dental growth from birth to the adolescent spurt
are under thyroid control. At adolescence bones fall under
increasing influence of the gonadal hormones.

Sufficient intake of nutritious foods is essential for normal growth.
Malnutrition may affect all aspects of growth including size of parts,
body proportions, quality and texture of tissues, and onset of growth
events.
Malnutrition involves deficiency in calories and required food
elements.Undernutrition tends to accentuate the normal differential
growth of the body tissues. Growth of teeth takes precedence over
bone growth and bone grow better than soft tissues such as muscle
and fat.
Nutrition

The effects of malnutrition are reversible to a certain extent as
children have fine recuperative powers. If the adverse effects are
not too severe, the growth process accelerates when proper
nutrition is provided.This is called “Catch-up growth”.

Race
Differences in growth among different races can be attributed
to other Nutritional and environmental factors, there seem to
be some evidence that race does play a role in growth
process.
Eg: InAmerican blacks, calcification and eruption of teeth
occurs almost a year earlier than their white counterpart.

Disease :
 The effects of disease are similar to those of malnutrition. After an
illness, a catch up growth period usually brings the child back to the
predetermined growth curve.
 Disease that slow growth probably have the effect of reducing
growth hormone production as a result of increased production of
cortisone during the disease.
 Cartilage cell growth is stopped temporarily and the result is seen
on x-rays as a line of arrested growth. Similar lines can be found in
the teeth.

Socio- economic factors
Children brought up in affluent and favorable socio-economic
conditions show earlier onset of growth events.They also grow to
a larger size that children living in unfavorable socio-economic
environment.
Family size and birth order
First born babies tend to weigh less at birth and have smaller
stature but higher I.Q.The smaller the family size, the better
would be the nutrition and other favorable conditions.

Season and circadian Rhythm :
Growth in height is faster in the spring than in autumn on the
contrary, city children tend to mature faster than rural ones,
especially in less developed countries.
Weight and growth proceeds faster in the autumn than in the
spring.
There is evidence that growth in height and eruption of teeth is greater
at night than in the daytime.
The reason for these differences is probably related to fluctuations in
hormone release.

Secular trend :
Although children are growing at a faster rate they are also stopping
Growth sooner.The adolescent height spurt is earlier now, but not
more accentuated today than in past.
An interesting feature of secular trend is the progressive advancement
in the timing of menarche.This change may be related to better
nutrition.

Concepts of growth
Concept of normality
Rhythm of growth
Differential growth
Timing of growth : Growth spurts

Normality
 According to , normal refers to that which is usually expected , is
ordinarily seen , or is typical.
 It had Range & Ideal values, these are fixed value.
 On comparison with normal, a variable can be measured.
 Normality may not necessarily be ideal. Deviation from usual pattern can
be used to express quantitative variability. This can be done by using
“growth charts”.

Rhythm of growth
According to Hooton,“ Human growth is not a steady & uniform
process wherein all parts of die body enlarge at the same rate &
the increments of one year arc equal to that of the proceeding
or succeeding year”.
 This growth rhythm is most clearly seen in stature or body height.

Differential Growth:
The human body does not grow at the same rate throughout life. Different
organs grow at different rates to a different amount and at different times.
This is termed differential growth.
Here it would be best to mention two important aspects of growth, both of
which help us understand the concepts of differential growth more clearly.
These are:
1. Scammon’s curve of growth
2. Cephalo caudal gradient of growth.

Scammon’s curve of growth
The body tissues can be broadly classified into four types. They are lymphoid
tissue, neural tissue, general tissue and genital tissue. Each of these tissues
grows at different times and rate .
Lymphoid tissue proliferates rapidly in late childhood and reaches almost
200% of adult size. This is an adaptation to protect children from infection,
as they are more prone to them. By about 18 years of age, lymphoid tissue
undergoes involution to reach adult size.

Neural tissue grows very rapidly and almost reaches adult size by 6-7
years of age. Very little growth of neural tissue occurs after 6-7 years.
This facilitates intake of further knowledge.
General tissue or visceral tissue consists of the muscles, bones and
other organs. These tissues exhibit an “S” shaped curve with rapid growth
upto 2-3 years of age followed by a slow phase of growth between 3-
10years. After the tenth year, a rapid phase of growth occurs terminating
by the 18-20th year.

Genital tissue consists of the reproductive organs. They show
negligible growth until puberty. However, they grow rapidly at
puberty reaching adult size after which growth ceases.

Cephalocaudal Gradient of Growth
Cephalocaudal gradient of growth simply means that there is an axis of
increased growth extending from head towards the feet.

a)The head takes up about 50% of the total body length around the
third month of intra uterine life. At the time of birth, the trunk and
the limbs have grown more than the head, thereby reducing the head to
about 30% of body length. The overall pattern of growth continues
with a progressive reduction in the relative size of the head to about
12% in the adult.
3rd month of IU Birth Adult
Head 50% 39% 12%
Limbs
(Lower)
rudimentary 30% 50%

b) The lower limbs are rudimentary around the 2nd month of intrauterine
life. They later grow and represent almost 50% of the body length at
adulthood.

c)There is increased gradient of growth evidence even within
the head and face .
At birth, cranium is proportionally larger than face ,
Post natally the face grows more than cranium.
 Mandible shows more growth than maxilla post natally.

 Hellman pointed out that , of all 3 dimensions grew in different
order i.e.,
 Face : Width > Depth > Height
 Cranium : Height >Width >Depth

GROWTH SPURTS:
 There are periods of sudden rapid increase, which are termed as
growth spurts.There is a period of rapid increase of growth just
before birth and another just before, and at beginning of
puberty.
 The rate of growth is more rapid at the beginning of cellular
differentiation, increases until birth and decrease there after.
This uneven activity is responsible for the interpretation of
growth as appearing in “spurts”.
 Believed to be due to physiological changes in hormonal
secretion.Dr Ravikanth Lakkakula

Woodside (1968)in his study of Burlington study Group
Torrento , showed
Name of growth spurt Girls Boys
Infantile/childhood growth spurt 3 yrs 3 yrs
Juvenile/mixed dentition growth Spurt 6-7yrs 7-9yrs
Pre Pubertal/adolescent growth spurt 11-12yrs 14-15yrs

Modified by Bjork (1975)
1. Prenatal -- Just before birth.
2. Postnatal
One year after birth.
Mixed dentition growth spurt
Females : 7- 9 years.
Males : 8-11 years.
Pre Pubertal growth spurt
Females: 11-13 years.
Males: 14-16 years.

Timing of Puberty
 Velocity curves for growth at adolescence shows difference in
timing between boys and girls.
 Pubertal growth spurt occurs on an average nearly 2 years
earlier in girls than boys.
 Sex hormones are produced in adrenals by 6 years-‘adrenarche’.
 More prominent in girls due to greater adrenal component.

 Growth effects because of timing variation can be seen
particularly clearly in girls, in whom the onset of menstruation,
often referred to as menarche, gives an excellent indicator of the
arrival of sexual maturity.
 Sexual maturation is accompanied by a spurt in growth. When the
growth velocity curves for early (M1), average (M2), and late(M3)
maturing girls are compared, the marked differences in size
between these girls during growth are apparent.

 At age 11, the early(M1)maturing girl is already past the peak of
her adolescent growth spurt, whereas the late-maturing girl (M3)
has not even begun to grow rapidly.This sort of timing variation,
which occurs in many ways other than that shown here, can be an
important contributor to variability.

 The timing of puberty makes an important difference in
ultimate body size, in a way that may seem paradoxical at first,
the earlier the onset of puberty, the smaller the adult size, and
vice versa.
Growth in height depends on endochondral bone growth at the
epiphyseal plates of the long bones, and the impact of the sex
hormones on endochondral bonegrowth is twofold.

First, the sex hormones stimulate the cartilage to grow faster,
and this produces the adolescent growth spurt. But the sex
hormones also cause an increase in the rate of skeletal
maturation, which for the long Bones is the rate at which
cartilage is transformed into bone.
The acceleration in maturation is even greater than the
acceleration in growth.Thus during the rapid growth at
adolescence, the cartilage is used up faster than it is replaced.
Toward the end of adolescence, the last of the cartilage is
transformed into bone, and the epiphyseal plates close.At this
point growth potential is lost and growth stops.

 Early cessation of growth after early sexual maturation is
particularly prominent in girls. It is responsible for much of the
difference in adult size between men and women.
 Girls mature earlier on the average, and finish their growth
much sooner. Boys are not bigger than girls until they grow for
a longer time at adolescence.The difference arises because
there is slow but steady growth before the growth spurt, and so
when the growth spurt occurs, for those who mature late, it
takes off from a higher plateau.
 The epiphyseal plates close more slowly in males than in
females, and therefore the cutoff in growth that accompanies
the attainment of sexual maturity is also more complete in
girls.

 Growth of the jaws usually correlates with the physiologic
events of puberty in about the same way as growth in height.
There is an adolescent growth spurt in the length of the
mandible, though not nearly as dramatic a spurt as that in body
height, and a modest though discernible increase in growth at
the sutures of the maxilla.
 The cephalocaudal gradient of growth, which is part of the
normal pattern, is dramatically evident at puberty.

 More growth occurs in the lower extremity than in the upper,
and within the face, more growth takes place in the lower jaw
than in the upper.This produces an acceleration in mandibular
growth relative to the maxilla and results in the differential
jaw growth referred to previously.
 The maturing face becomes less convex as the mandible and
chin become more prominent as a result of the differential jaw
growth.

• Growth in width is completed first, then growth in length,
and finally growth in height.
• Growth in width of both jaws, including the width of the
dental arches, tends to be completed before adolescent
growth spurt.
• Growth in width at the palatal suture occurs during the first 5
years of age, mostly at the intermaxillary and interpalatine
suture.
• Intercanine width more likely to decrease than increase after
age 12.

Cranium
Maxilla
Mandible
1 to 5 years
85%
45%
40%
5 to 10 years
11%
20%
25%
10 to 20 years
4%
35%
35%
According to Graber Percentage of craniofacial growth completed
at different stages.

Mandibular length changes
 Growth of the mandible continues at a relatively steady rate before
puberty. On the average, ramus height increases 1 to 2 mm per year
and body length increases 2 to 3 mm per year.

 Growth in length and height of both jaws continues through the
period of puberty. In girls, the maxilla grows slowly downward and
forward to age 14 to 15 on the average (more accurately, by 2 to 3
years after first menstruation), then tends to grow slightly more
almost straight forward .
 In both sexes, growth in vertical height of the face continues longer
than growth in length, with the late vertical growth primarily in the
mandible.

 Increases in facial height and concomitant eruption of teeth
continue throughout life, but the decline to the adult level
which for vertical growth is surprisingly large often does not
occur until the early 20’s in boys, somewhat earlier in girls.
 Growth of the jaws correlates with physiologic events of
puberty in about the same way as growth in height. It is
important clinically to careful assessment of physiologic age to
plan orthodontic treatment.

 According to proffit, growth modifications must begin in girls
during mixed dentition period rather than after all succedaneous
teeth have erupted, due to the adolescent growth spurt often
preceds the final transition of dentition, so by the time second
premolars and molars erupt growth get completed.
 In slow maturing boys on the other hand the dentition can be
relatively complete while a considerable amount of physical
growth remains.

Biological Maturity Indicators
Morphologic Age: Is based on height.
 A child’s height can be compared with those of his same age
group and other age groups to determine where he stands in
relation to others. Height, or morphologic age, is useful as a
maturity indicator from late infancy to early adulthood.
 Everyone is not alike in the way that they grow. It can be
difficult, but is important to decide whether the individual is
merely an extreme of the normal variation or falls outside
the normal range.

 This is determined, using growth charts for the particular
population standards. Growth charts can be used to plot an
individuals growth. These charts provide information regarding
the position of the individual with relation to the group, and it
can also be used to follow a child overtime to evaluate whether
there is an unexpected change in growth pattern.

INTERPRETATION —
 Plotted above the 90% shows child was larger than 90% of the
population.
 Plotted below the 10% line shows child was smaller than 90% 0f
the population.
 An individual who stood exactly at the midpoint of the normal
distribution would fall along the 50% line of the graph.

Chronological age
 The most obvious and easily determined developmental age
parameter.
 Simply calculated from the child date of birth to till
examination of the patient date.
 Because of the wide variation among individuals in the timing
of the pubertal growth spurt, chronologic age cannot be used
in the evaluation of growth potential(Fiani,1998).

Dental Age:
 Dental age is determined from three characteristics;
 The first is which teeth have erupted. The second and third,
which are closely related, are the amount of resorption of the
roots of primary teeth and the amount of development of the
permanent teeth.
For e.g. At dental age 10 there is a greater amount of both
resorption of the primary canines and molars, and root
development of their permanent successors.

 At dental age 10, approximately one half of the roots of the
mandibular canine and mandibular first premolar have been
completed, nearly half the root of the upper first premolar is
complete, and there is significant root development of the
mandibular second premolar, maxillary canine, and maxillary
second premolar.

Average chronology of permanent tooth development
Tooth
Calcification begins Crown completed Eruption Root completed.
Max Mand Max Mand Max Mand Max Mand
Central incisor 3 M 3 M 4 ½ Y 3 ½ Y 7 ¼ Y 6 ¼ Y 10 ½ Y 9 ½ Y
Lateral incisor 11 M 3 M 5 ½ Y 4 Y 8 ¼ Y 7 ½ Y 11 Y 10 Y
Canine 4 M 4 M 6 Y 5 ¾ Y 11 ½ Y 10 ½ Y 13 ½ Y 12 ¾ Y
1st premolar 20 M 22 M 7 Y 6 ¾ y 10 ½ Y 10 ½ Y 13 ½ Y 13 ½ Y
2nd premolar 27 M 28 M 7 ¾ Y 7 ½ y 11 Y 11 ¼ Y 14 ½ Y 15 Y
1st molar 32 W 32 W 4 ¼ Y 3 ¾ y 6 ¼ Y 6 Y 10 ½ Y 10 ¾ Y
2nd molar 27 M 27 M 7 ¾ Y 7 ½ y 12 ½ Y 12 Y 15 ¾ Y 16 Y
3rd molar 8 Y 9 Y 14 Y 14 Y 20 Y 20 Y 22 Y 22 Y

Stages of tooth calcification by Nollas(1960)
10.Root apex completed.
9.Root almost completed,open apex.
8.Two thirds of root completed.
7.One third of root completed.
6.Crown completed.
5.Crown almost completed.
4.Two thirds of crown completed.
3.One third of crown completed.
2.Initial calcification.
1.Crypt present.
0.Crypt absent.

The radiographs are compared with the drawings, and each tooth
is given a developmental scores according to the drawing that it
most closely approximates. If the development of the tooth
should lie between two stages, half values or plus scores are used.

DENTAL AGE DETERMINATION ACCORDINGTOTHE
STAGE OF MINERALIZATION
o.Tooth germ without signs of calcification.
A. Calcification of single occlusal points without
fusion of different calcification.
B. Fusion of mineralization points.The contour
of the occlusal surface is recognizable.
C. Calcification of the crown is complete;
beginning of dentin deposits.
D. Crown formation is complete up to the
Cemento-enamel junction.
E. Root length shorter than crown height.
F. Root length larger than crown height.
G. Root formation finished.Apical foramen
still open.
H.Apical foramen is closed.

Conversion chart for dental age determination, calculated
according to the score-system of dental formation
The overall figure for assessment of dental age is obtained by adding together
the separate values for 7 teeth for each quadrant.Dr Ravikanth Lakkakula

 Dental development indicators are also NOT RELAIBLE
predictors of an individual’s stage of skeletal development
because of difference in timing of their eruption and
development , congenital absence of teeth.
 But one study (Krailassir et al, Angle Orthod 2002) shows
that the canine stage F for both sexes coincided with the MP3
stage and indicated the onset of a period of accelerating
growth. The findings of this study indicate that tooth
calcification stages might be clinically used as a maturity
indicator of the pubertal growth period.

Sexual Age:
 This is based on development of secondary sexual characters
both boys and girls.
 This type of indicator is useful only for assessment of
adolescent growth.

Adolescent Growth Stages versus Secondary Sexual
Characteristics
Total Duration of Adolescent Growth : 3 ½ years period
Stage 1
Beginning of adolescent
Growth
Appearance of breast buds, initial
pubic hair.
Stage 2 (About 12 Months Later)
Peak velocity physical growth (in
height)
Noticeable breast development,
axillary hair, darker/more abundant
pubic hair.
Stage 3 (12-18 Months Later)
Growth spurt ending
Menses, broadening of hips with
adult fat distribution, breasts
completed.
Girls

BoysTotal Duration of Adolescent Growth : 5 years period
Stage 1
Beginning of adolescent
growth
“Fat spurt” weight gain, feminine
fat distribution.
Stage 2 (About 12 Months Later)
Height spurt beginning
Redistribution/reduction in fat,
pubic hair, growth of penis.
Peak velocity in height
Facial hair appears on upper lip
only, axillary hair, muscular
growth with harder/more angular
body form.
Growth spurt ending
Facial hair on chin and lip, adult
distribution/color of pubic and
axillary hair, adult body form.
Boys

 Recent research has shown that sexual development really begins
much earlier than previously thought. Sexhormones produced by
the adrenal glands first appear at age 6 in both sexes, primarily in
the form of a weak androgen (dehydroepiandrosterone ,
[DHEA]).This activation of the adrenal component of the system is
referred to as adrenarche.
 DHEA reaches a critical level at about age 10 that correlates with the
initiation of sexual attraction.It is likely that a juvenile acceleration in
growth is related to the intensity of adrenarche and not surprising
that a juvenile acceleration is more prominent in girls because of the
greater adrenal component of their early sexual development.

Skeletal age assesment
Hand wrist radiographs
The hand – wrist region is made up of numerous small bones.
These bones show a predictable and scheduled pattern of
appearance, ossification and union from birth to maturity.There
by merely comparing a patient’s hand-wrist radiograph with
standard radiographs that represent different skeletal ages, we
will be able to determine the skeletal maturation status of that
individual.

 We all know end of long bones grow at their end called
epiphysis.
 The newly formed bone starts getting mineralised at the
metaphysis and the most matured bone seen at the
diaphysis.
The epiphysis initially forms a cartilage tissue which later ossifies
and fuses with the metaphysis as it matures.

A number of methods have been described to assess the skeletal
maturity using hand-wrist radiographs.The following are the most
commonly used methods:
 Atlas methods by Greulich and Pyle
 Bjork, Grave and Brown Method
 Fishman’s Skeletal Maturity Indicators
 Hagg andTaranger Methods

GREULICH AND PYLE METHOD
 Greulich and Pyle published an atlas containing ideal skeletal
age pictures of the hand-wrist for different chronological ages
and for each sex. Each photograph in the atlas is representative
of a particular skeletal age. The patient’s radiograph is matched
on an overall basis with one of the photographs in the atlas.

BJORK, GRAVE AND BROWN
They have divided skeletal development into 9 stages. Each of
these stages represents level of skeletal maturity.Appropriate
chronological age for each of the stages was given by Schopf in
1978.
Stage One (males 10.6 years,Females 8.1 years):The epiphysis and
diaphysis of the proximal phalanx of index finger are equal. It occurs
approximately three years before the peak of pubertal growth spurt.

 StageTwo (males 12.0 years,Females 8.1 years):
The epiphysis and diaphysis of the middle phalanx of the middle
finger are equal.

StageThree (Males 12.6 years,Females 9.6 years):This stage is
characterized by presence of 3 areas of ossification:
 The hamular process of the hamate exhibits ossification.
 Ossification of pisiform.
 The epiphysis and diaphysis of radius are equal.

Stage Four (Males 13.0 years,Females 10.6 years):This stage
marks the beginning of the pubertal growth spurt. It is
characterized by:
 Initial mineralization of the ulnar sesamoid of the thumb.
 Increased ossification of the hamular process of the hamate
bone.

stage 5 (male 14 years ,female 11 years ): It is a peak of
pubertal growth spurt. Capping of epiphysis and diaphysis seen in
a. Middle phalanx of 3rd finger.
b. Proximal phalanx of thumb.
c. Radius.

Stage six (Males 15.0 years,Female 13.0 years):This stage
signifies the end of the pubertal growth spurt. It is characterized
by union between epiphysis and diaphysis of the distal phalanx of
the middle finger.

 Stage Seven (Males 15.9 years, Females 13.3 years): Union
of epiphysis and diaphysis of the proximal phalanx of the little
finger occurs.

 Stage Eight (Males 15.9 years,Females 13.9 years):This
stage shows fusion between the epiphysis and diaphysis of the
middle phalanx of the middle finger.

 Stage Nine (Males 18.5 years,Females 16.0 years): This is
the last stage and it signifies the end of skeletal growth. It is
characterized by fusion of epiphysis and diaphysis of the radius.

SINGER’S METHOD OF ASSESSMENT
Julian Singer in 1980 proposed a system of hand wrist radiograph
assessment that would enable the clinician to rapidly and with some
degree of reliability help determine the maturational status of the
patient. Six stages of hand wrist development are described.
The stages and their characteristics are:

Stage one (Early):
 Absence of the pisiform
 Absence of the hook of the hamate and
 Epiphysis of proximal phalanx of second digit (PP2) narrower
than its shaft.
StageTwo (Prepuberal):
 Proximal phalanx of second digit and its epiphysis are equal in
width ,
 Initial ossification of hook of the hamate and
 Initial ossification of the pisiform.

StageThree (Puberal onset):
 Beginning calcification of ulnar sesamoid,
 Increased width of epiphysis of PP2 and
 Increased calcification of hamate hook and pisiform .
Stage Four (Puberal):
 Calcified ulnar sesamoid and
 Capping of shaft of the middle phalanx
of third digit by its epiphysis (MP3cap).

Stage Five (Puberal deceleration):
 ulnar sesamoid fully calcified and
 Fusion of epiphysis of distal phalanx of 3rd finger with its shaft
and epiphysis of radius and ulnar no fully calcified fused with
respective shaft.
Stage Six (Growth completion):
 No remaining growth sites.

FISHMAN’S SKELETAL MATURITY INDICATORS
A system for evaluation of skeletal maturation was proposed by
Leonord S. Fishman in 1982.
System Fishman uses only four stages of bone maturation, all found
at six anatomical sites located on the thumb, third finger, fifth finger
and radius.

 Fishman system uses 4 stages of bone maturation.They are

11 Adolescent skeletal maturational indicator’s (SMI’s) covering
the entire period o adolescent development.
Skeletal maturity indicators (SMI)
Width of epiphysis as wide as diaphysis
SMI 1.Third finger – Proximal phalanx.
SMI2.Third finger – Middle phalanx
SMI 3. Fifth finger – Middle phalanx

Ossification
SMI 4.Adductor sesamoid of thumb
Capping of epiphysis
SMI5 - Third finger – Distal phalanx
SMI6 - Third finger – Middle phalanx
SMI 7 - Fifth finger – Middle phalanx

Fusion of epiphysis and diaphysis
SMI 8.Third finger – Distal phalanx
SMI 9.Third finger – Proximal phalanx
SMI 10.Third finger – Middle phalanx
SMI 11. Radius

Approximate chronological age and percentage of growth completed
corresponding to SMI

HAGG ANDTARANGER METHOD(1982)
Skeletal age assessment of
1) The ossification of sesamoid.
2) The middle and distal phalanges of the third finger.
3) The distal epiphysis of the radius.
Sesamoid
 Sesamoid is usually attained during the acceleration period of
the pubertal growth spurt (onset of P.H.V.).

Third finger middle phalanx(MP3)
MP3-F:
The epiphysis is as wide as the metaphysis.
This stage is attained before onset of P.H.V. by about 40 percent
of the subjects and P.H.V. by many others.

MP3-FG:
The epiphysis is as wide as the metaphysis and there is distinct
medial and / or lateral border of the epiphysis forming a line of
demarcation at right angles to the distal border.This stage is
attained 1 year before or at P.H.V.

MP3-G: ( the point of maximum pubertal growth spurt)
The sides of the epiphysis have thickened and also cap its metaphysic,
forming a sharp edge distally at one or both sides.This stage is attained
at or 1 year after P.H.V.

MP3-H: (deceleration part of the curve of pubertal growth
spurt);
Fusion of the epiphysis and metaphysis has begun and is attained after
PHV but before end of growth spurt by practically all boys and about
90 percent of the girls.

MP3-I:
Is attained before or at en of growth spurt in all subjects except a few
girls.

Third finger distal phalanx
DP3 - I: Fusion of the epiphysis and metaphysic is completed.This
stage signifies the fusion of the epiphysis and metaphysic and is attained
during the acceleration period of the pubertal growth spurt (i.e. end
of P.H.V.) by all subjects.

Radius
R-I:
Fusion of the epiphysis and metaphysis has begun.This stage is attained
1 year before or at the end of growth spurt by about 80% of the girls
and about 90% of the boys.
R-IJ:
Fusion is almost completed but there is still a small gap at one or both
margins.
R-J:
Is characterized by fusion of the epiphysis and metaphysic.These stages
were not attained before end PHV by any subject.

SKELETAL MATURATION EVALUATION USING CERVICAL
VERTEBRAE
Hassel and Farman (1995) developed a system of skeletal
maturation determination using the cervical vertebrae.
The shapes of the cervical vertebrae were seen to differ at each level of
skeletal development.This provided a means to determine the skeletal
maturity of a person and thereby determine whether the possibility of
potential growth existed.

The shapes of the vertebral bodies of C3 and C4 changed from
somewhat wedge shaped, to rectangular, followed by square shape.
They became taller as skeletal maturity progressed.
The inferior vertebral borders were flat when immature, and they
were concave when mature.The curvatures of the inferior vertebral
borders were seen to appear sequentially from C2 to C3 to C4 as the
skeleton matured.The concavities became more distinct as the person
matured.

Hassel and Farman have put forward the following six stages in
vetribral development.
Stage 1:
This stage called initiation, corresponds to beginning of adolescent
growth with 80% to 100% of adolescent growth expected. Inferior
borders of C2, C3 and C4 were flat at this stage.The vertebrae were
wedge shaped, and the superior vertebral borders were tapered from
posterior to anterior.

Stage 2:
The second stage is called acceleration. Growth acceleration begins at
this stage, with 65% to 85% of adolescent growth expected.
Concavities were developing in the inferior borders of C2 and C3.The
inferior border of C4 was flat.The bodies of C3 and C4 were nearly
rectangular in shape.

Stage 3:
The third stage called transition, corresponded to acceleration of
growth towards peak height velocity with 25% to 65% of adolescent
growth expected. Distinct concavities were seen in the inferior
borders of C2 and C3.A concavity was beginning to develop in the
inferior border of C4.The bodies of C3 and C4 were rectangular in
shape.

Stage 4:
This stage called deceleration corresponds to deceleration of adolescent
growth spurt with 10% to 25% of adolescent growth expected.
Distinct concavities were seen in the inferior borders of C2, C3 and
C4.The vertebral bodies of C3 and C4 were becoming more square in
shape.

Stage 5:
The fifth stage is called 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.

Stage 6:
This stage called completion, corresponds to completion of growth.
Little or no adolescent growth could be expected. Deep concavities
were seen in the inferior borders of C2, C3 and C4.The bodies of
C3 and C4 were square or were greater in vertical dimension than in
horizontal dimension.

Hand –wrist
SMI
Cervical
vertebral stages
Pubertal growth
remaining
1-2 Initiation 85-100%
3-4 Acceleration 65-85%
5-6 Transition 25-65%
7-8 Deceleration 10-25%
9-10 Maturation 5-10%
11 completion 0%
Correlation of hand-wrist and cervical vertebral maturation stages

Significance of Growth Spurts in Orthodontics
 Pubertal increments offers best time for, determining the
predictability, growth direction, patient management and total
treatment time.
 Understanding the growth, predictability of future growth of
maxilla, mandible and alveolar process helps in diagnosing and
achieving excellent results of the malocclusion.

Functional jaw orthodontic therapy takes advantages of redirection of
remaining growth of craniofacial region. Functional appliances like
Twin block, Bionator, Frankel appliances are given for class II skeletal
correction. Effectiveness of these appliances to modify skeletal
growth is minimal after pubertal growth spurt.

 Orthopaedic appliances like headgears are also advantageous to
correct maxillary prognathism during growing stage of the patient.
Maxillary horizontal growth is completed much earlier than
mandible and so the use of headgear to restrict or redirect its
growth should be started much before pubertal growth spurt in
mixed dentition period.

 Maxillary expansion procedures in cases of jaw constriction should
be carried out during early mixed dentition. Growth in width of
maxilla occurs by sutural growth in interpalatine and intermaxillary
sutures. Maximum growth occurs in first 5 years.The skeletal
expansion procedures should be carried out before the fusion of
palatal sutures, i.e. by 10 years.

 Orthopaedic appliances like facemask and chin cup are used for the
treatment of skeletal class III malocclusions early during the mixed
dentition period. However, the continuing growth of mandible and its
pubertal growth spurt can lead to development of malocclusion after
early interventions.

 Active growth cessation is prerequisite for Orthognathic surgery
particularly in cases with mandibular prognathism.

Conclusion
 As we Orthodontists nowadays deal with more and more mixed
dentition cases, many of whom may or may not present with a
skeletal malocclusion. It is very important for us to determine
the magnitude and direction of growth if we are to treat these
cases with a fair amount of success.
 It is a great challenge therefore to diagnose and to plan an ideal
treatment for these cases keeping in mind their growth
potential.

 However we should not forget that every individual is unique in
his own aspect and therefore we should not jump to conclusions
but study our patients over time and treat them to their
individual requirements.
 The pubertal growth spurt of is an advantageous period in the
orthodontic treatment and it should be kept in mind in
connection with the planning of the treatment. One of the
objectives of the orthodontic treatment during the adolescence,
in the cases with skeletal discrepancies is to take advantage of
the changes of growth of the patient.

Growth spurts - orthodontics

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