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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
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Growth Predictions / orthodontic courses by Indian dental academy
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.
Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses. For details pls visit www.indiandentalacademy.com ,or call
0091-9248678078
Content www.indiandentalacademy.com Even when excellent data from clinical trials are available, it is difficult to predict how any one individual will respond to particular plan of treatment .Variability must be expected.
In orthodontics, two interrelated factors contribute most of the variability: the patients growth pattern and the effect of treatment on the expression of growth. www.indiandentalacademy.com At present, in the absence of growth, treatment responses are reasonably predictable. Growth is not predictable. www.indiandentalacademy.com 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 www.indiandentalacademy.com 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.
www.indiandentalacademy.com 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.
www.indiandentalacademy.com Hand Wrist Radiographs Chronological age is often not sufficient for assessing the developmental stage and maturity of the patient. Thus, biological age has to be determined.
Hand Wrist radiographs are an effective tool to assess the biological age. www.indiandentalacademy.com 1 st hand wrist film was published by Sydney Rowland in England in april 1890 (4 months after discovery of x-rays).
Review of literature www.indiandentalacademy.com In the early 1900s, Pryor(1907), Rotch(1908), and Crampton(1908) began tabulating indicators of maturity on sequential radiographs of the growing hand and wrist.
Todd(1937) compiled hand-wrist data that was further elaborated on by Greulich and Pyle(1959) in atlas form. www.indiandentalacademy.com Flory in 1936, indicated that the beginning of calcification of the adductor sesamoid was a good guide to determining the period immediately before puberty.
Peak height velocity follows adductor sesamoid appearance by approximately 1 year. www.indiandentalacademy.com Fishman(1979) developed a system of hand- wrist skeletal maturation indicators (SMIs) using four stages of bone maturation at six anatomic sites on the hand and the wrist.
Hagg and Taranger(1980) created a method using the hand-wrist radiograph to correlate certain maturity indicators to the pubertal growth spurt. www.indiandentalacademy.com
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. www.indiandentalacademy.com Indications 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. www.indiandentalacademy.com ANATOMY www.indiandentalacademy.com PA view www.indiandentalacademy.com Oblique view www.indiandentalacademy.com The ossification events are localized in the area of the phalanges, carpal bones, and radius (R).
Growth stages of the fingers are assessed according to the relationship between the epiphyses and the diaphyses. Bjrk, Grave and Browns method American Journal of Orthodontia. 1976; 69:611-20. www.indiandentalacademy.com Three stages of ossification of the phalanges First stage Second stage Third stage www.indiandentalacademy.com 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. www.indiandentalacademy.com First Stage (PP2 = - Stage) www.indiandentalacademy.com Stage 2(males-12.0 yrs, females 8.1yrs):
epiphysis and diaphysis of middle phalanx of middle finger are equal.
www.indiandentalacademy.com Second Stage (MP3 = - Stage) www.indiandentalacademy.com 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. www.indiandentalacademy.com Third stage (Pisi-, H1-, and R = - Stage) www.indiandentalacademy.com 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. www.indiandentalacademy.com Fourth stage (S- and H2-stage) www.indiandentalacademy.com 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. www.indiandentalacademy.com Fifth stage (MP3 cap ;PP1 cap ;and R cap -stage) www.indiandentalacademy.com 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. www.indiandentalacademy.com Sixth stage (DP3u-stage) www.indiandentalacademy.com Stage 7(males-15.9 yrs, females 13.9 yrs):
Visible union of the epiphysis and diaphysis at the proximal phalanx of middle finger. www.indiandentalacademy.com Seventh stage (PP3u-stage) www.indiandentalacademy.com Stage 8(males-15.9 yrs, females 13.9yrs):
Union of epiphysis and diaphysis at middle phalanx of middle finger. www.indiandentalacademy.com Eighth stage (MP3u-stage) www.indiandentalacademy.com Stage 9(males-18.5 yrs, females 16 yrs): Complete union of epiphysis and diaphysis of radius. Ossification of all bones is complete and skeletal growth is complete. www.indiandentalacademy.com Ninth stage (Ru-stage) www.indiandentalacademy.com An Overview www.indiandentalacademy.com Correlation table between ossification stages of hand bones and the skeletal age for the period between 8 and 18 years www.indiandentalacademy.com www.indiandentalacademy.com www.indiandentalacademy.com Fishmans skeletal maturity indicator In 1982 Leonard Fishman gave system of skeletal maturation assessment (SMA). 11 skeletal maturity indicators (SMIs) were described.
Maturational patterns and prediction during adolescence. Leonard Fishman. Angle Orthodontist: No. 3: 1987:178-193 www.indiandentalacademy.com 11 SMI were divided into 4 stages Epiphysis as wide as diaphysis. Ossification. Capping of epiphysis. Fusion of epiphysis and diaphysis. www.indiandentalacademy.com Epiphysis as wide as diaphysis 1. Third finger-proximal phalanx 2. Third finger-middle phalanx 3. Fifth finger-middle phalanx
www.indiandentalacademy.com Ossification 4. Adductor sesamoid of thumb. www.indiandentalacademy.com Capping of epiphysis 5. Third finger distal phalanx. 6. Third finger middle phalanx. 7. Fifth finger middle phalanx. www.indiandentalacademy.com Fusion of epiphysis and diaphysis 8. Third finger distal phalanx. 9. Third finger proximal phalanx. 10. Third finger middle phalanx. 11. Radius. www.indiandentalacademy.com www.indiandentalacademy.com Accelerating growth velocity period (14) High growth velocity period (47) Decelerating velocity period (711)
www.indiandentalacademy.com 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. www.indiandentalacademy.com Early maturers 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com Levels of maturation - FEMALE www.indiandentalacademy.com Levels of maturation - MALE www.indiandentalacademy.com Julien Singer method 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.
Angle orthodontist: 1980, 322-333 www.indiandentalacademy.com Stage 2 (prepubertal) : Proximal phalanx of 2 nd finger is equal to its epiphysis. Initial ossification of hook of hamate. Initial ossification of pisiform. Stage of adolescent growth spurt during which significant amount of growth is possible. www.indiandentalacademy.com Stage 3 (pubertal onset): Calcification (beginning) of ulnar sesamoid. Increased width of proximal phalanx of 2 nd
finger. Increased calcification of hook of hamate. Increased calcification of pisiform. www.indiandentalacademy.com Stage 4 (pubertal stage): Calcification of ulnar sesamoid. Capping of diaphysis of middle phalanx of 3 rd
finger by its epiphysis.
www.indiandentalacademy.com Stage 5 (pubertal deceleration): Full calcification of ulnar sesamoid. Fusion of epiphysis of distal phalanx of 3 rd finger with its diaphysis. Epiphysis of radius and ulna not fused completely with diaphysis. Phalanges and carpels are fully calcified. www.indiandentalacademy.com Stage 6 (growth completion): No remaining growth site is seen.
www.indiandentalacademy.com 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.
Am J Orthod: 82: oct 1982 www.indiandentalacademy.com 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.
www.indiandentalacademy.com Method of analysis Dental development was assessed by dental emergence stages (DES).
www.indiandentalacademy.com Method of analysis Skeletal development in the hand and wrist was analyzed from annual radiographs, taken between the ages of 6 and 18 years, by assessment of the ossification of the ulnar sesamoid of the metacarpophalangeal joint of the first finger (S) and certain specified stages of three epiphyseal bones (closure of epiphyseal plates): the middle and distal phalanges of the third finger (MP3 and DP3) and the distal epiphysis of the radius (R). www.indiandentalacademy.com 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. www.indiandentalacademy.com 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.
www.indiandentalacademy.com Pubertal growth spurt www.indiandentalacademy.com Results The pubertal growth spurt ONSET of spurt is the annual increment from which there is a marked continuous increase in growth rate of PHV (peak height velocity). ONSET is found by locating the smallest annual increment (A) from which there is continuous increase in growth rate to PHV. On average, the pubertal growth spurt began (ONSET) at 10.0 & 12.1 yrs. and ended (END) at 14.8 & 17 yrs in girls and boys respectively. In both sexes PHV occurred 2 yrs ONSET, i.e. at 12.0yrs in girls and 14.1yrs in boys. www.indiandentalacademy.com 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com 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 - PHV). www.indiandentalacademy.com Middle third phalanx: MP3-F - was attained before ONSET by about 40 percent of the subjects and at PHV by the last subjects. 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. www.indiandentalacademy.com
www.indiandentalacademy.com 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. www.indiandentalacademy.com 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-J - Fusion of the epiphysis and metaphysis is complete. www.indiandentalacademy.com 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 and male voice 0.9yrs after PHV. www.indiandentalacademy.com 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. www.indiandentalacademy.com
CERVICAL VERTEBRAE MATURATION www.indiandentalacademy.com 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. www.indiandentalacademy.com 1n 1995 Hassel and Farman modified the Lamparski criteria by using C2, C3, and C4 cervical vertebrae. www.indiandentalacademy.com 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 bodies increase. www.indiandentalacademy.com Lamparski method Stage 3 a concavity develops in the inferior border of the third 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com Cervical vertebrae maturation indicators using C3 as guide. www.indiandentalacademy.com Brent Hassel, Allan Farman 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. The vertebrae are wedge shaped, and the superior vertebral border were tapered from posterior to anterior.
AJODO: Jan 1995 www.indiandentalacademy.com CVMI 1 www.indiandentalacademy.com 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. www.indiandentalacademy.com CVMI 2 www.indiandentalacademy.com 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. www.indiandentalacademy.com CVMI 3 www.indiandentalacademy.com 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. www.indiandentalacademy.com CVMI 4 www.indiandentalacademy.com 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. www.indiandentalacademy.com CVMI 5 www.indiandentalacademy.com 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. www.indiandentalacademy.com CVMI 6 www.indiandentalacademy.com 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com Lambarskis CVM I and CVM II are merged (CVMS I). CVMS = cervical vertebrae maturation stage. 5 maturational stages. www.indiandentalacademy.com www.indiandentalacademy.com www.indiandentalacademy.com CVMS I Lower border of C2, C3 and C4 is flat. C2 may present slight concavity. Bodies of C3 and C4 are trapezoidal. Peak mandibular growth will occur not earlier than 1yr after this stage. www.indiandentalacademy.com 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com Discussion When CVMS 1 is diagnosed in the individual patient with mandibular deficiency, clinician can wait least 1 year for a radiographic re- evaluation aimed to start treatment with functional appliances. CVMS 2 represents the ideal stage to begin functional jaw orthopedics. www.indiandentalacademy.com Mid palatal suture region as an indicator of maturity Revelo and Fishman in 1994 evaluated the ossification pattern of the mid palatal suture. Maturational evaluation was accomplished by examining the hand wrist radiographs with Fishmans system of SMA.
Revelo, Fishman AJO: 105:mar 1994. www.indiandentalacademy.com 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com www.indiandentalacademy.com 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. www.indiandentalacademy.com Results SMI 4-7 i.e. ossification of adductor sesamoid, capping with distal and middle phalanx of 3 rd
finger, osseous interdigitation is evident with approximation in some areas. This period occurs during the pubertal growth spurt. www.indiandentalacademy.com Results After SMI 8 i.e. fusion of distal phalanx of 3 rd
finger, the suture demonstrates a marked increase in rate of approximation. At maturational age SMI 11 i.e. fusion of radius, 50% of total midpalatal suture is approximated. High percentage of approximation occurs posteriorly. www.indiandentalacademy.com Results 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. www.indiandentalacademy.com Frontal sinus development as an indicator for somatic maturation at puberty
Am J Orthod Dentofac Orthop 1996; 110:476-82.
www.indiandentalacademy.com Sabine Ruf and Hans Pancherz.
The study was performed on 53 adolescent boys, and the frontal sinus size development was assessed on lateral head films.
Two head films from each subject were analyzed on a 1- or 2-year interval basis. Thus, two prediction intervals of 1 (T1) and 2 years (T2) were formed.
www.indiandentalacademy.com In the adolescent, the stage of somatic maturity may influence the selection of the appliance, the course of treatment and the mode of retention after therapy.
For the assessment of the status of the pubertal growth period, longitudinal records of the body height development (velocity growth curves) have been recommended.
www.indiandentalacademy.com 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. www.indiandentalacademy.com www.indiandentalacademy.com Average yearly body height growth velocity (mm/yr) was calculated.
Bp (body height peak) = maximum body growth velocity at puberty (used to test the accuracy of prediction of pubertal stage as assessed from frontal sinus development). www.indiandentalacademy.com 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. www.indiandentalacademy.com www.indiandentalacademy.com 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. www.indiandentalacademy.com www.indiandentalacademy.com 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. www.indiandentalacademy.com 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). www.indiandentalacademy.com Relationship between mandibular canine calcification stages and skeletal maturity.
-Sandra Cortinho, Peter H. Buschang.
AJODO:104:sept 1993. www.indiandentalacademy.com Handwrist radiographs and dental panoramic radiographs of 200 boys and 215 girls were assessed. www.indiandentalacademy.com 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. www.indiandentalacademy.com Canine development stage Stage D:
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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. www.indiandentalacademy.com Stage E www.indiandentalacademy.com
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. www.indiandentalacademy.com Stage F www.indiandentalacademy.com Stage G The walls of the root canal are now parallel and its apical end is still partially open. www.indiandentalacademy.com Stage H: The apical end of the root canal is completely closed. The periodontal membrane has a uniform width around the root and the apex. www.indiandentalacademy.com Stage H www.indiandentalacademy.com 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. www.indiandentalacademy.com 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. www.indiandentalacademy.com
Thus, stage F indicates 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 and should not be used as a sole criteria to predict development landmarks. www.indiandentalacademy.com Arcial growth prediction www.indiandentalacademy.com Principle A normal mandible grows by superior-anterior apposition vertically at the Ramus on a curve or arc which is a segment formed from a circle.
The radius of this circle is determined by using the distance from Mental Protruberance to a point at the forking of the stress lines at the terminus of the oblique ridge on the medial side of the Ramus (Point Eva). www.indiandentalacademy.com Historical Review Hunter (1771) : Compared a series of dried mandibles and concluded that, in order to attain space for the development of permanent molar teeth, the mandible must grow by posterior apposition of the Ramus accompanied by anterior Ramal resorption.
www.indiandentalacademy.com Humprey (1866): Tied wires around the Mandibles of pigs and showed that the wire became embedded in the posterior margin and free in the anterior area of the Ramus which seemed to be verify the Hunters hypothesis. www.indiandentalacademy.com Brash (1924): Fed pigs the madder plant root which contains the red stain alizarin and therefore labeled appositional growth.
He concluded that apposition occurred posteriorly and superiorly on the Ramus of the growing pig mandible. www.indiandentalacademy.com THE COMPUTER (PRIMARY) STUDY Although the previous method was useful for practical short term predictions, a method was sought whereby mandibular growth patterns could be identified with greater certainty.
Next move towards improving the method was to identify a central core cephalometrically as external mandibular forms for reference are unsuitable. www.indiandentalacademy.com Locating a Cephalometric Central Core Point Xi Located the following points on the Cephalogram : R1 = deepest point on subcoronoid incisure R2 = directly opposite R1 on the posterior border of the Ramus R3 = at the depth of the sigmoid notch R4 = a point directly inferior to R3 on the lower border of the Ramus www.indiandentalacademy.com By using these points, the centroid of the Ramus is selected by forming a rectangle and connecting the corners.
Occlusal plane has a strong tendency to pass through the Xi point.
Xi also represents the entrance of the neuro trophic bundle into the Mandible. www.indiandentalacademy.com Suprapogonion Labeled as Pm for Protuberance Menti. It is a bony crest located at the antero-superior contour of the Symphysis.
On the cephalogram, it is the point selected on the anterior border of the Symphysis between Point B and Pogonion where the curvature changes from concave to convex. Accepted as the most stable reference for anterior- most basal bone in the mandible. ( Bjork ) www.indiandentalacademy.com Point DC A point selected in the centre of the neck of the Condyle where the Basion-Nasion plane crosses it. Condyle Axis Formed by connecting Points DC and Xi. Corpus Axis Formed by joining Xi to Pm. www.indiandentalacademy.com
By studying linear growth on these planes and the form change as a change in the angulation between the two, an interpretation could be gained regarding the characteristics of growth in a given patient as well as for groups with age and sex differences.
www.indiandentalacademy.com SAMPLE A five year growth study of the Mandible on the computer.
Lateral and frontal cephalograms taken on 40 patients.
Age: T1= 8 years (avg) +/- 2 T2= 13 years
Sex: Males= 20 Females= 20
Occlusion: Class I= 20 Class II= 20
www.indiandentalacademy.com RESULTS Samples were superimposed on the Corpus Axis and registered at Xi point. Mandible was found to bend 0.5 each year. Lower facial height ( ANS-Xi-Pm) was found to be highly stable. It does not change during normal growth. www.indiandentalacademy.com The sample are superimposed on the corpus axis and registered at Xi point as the mandible was found to bend about one half degree each year. www.indiandentalacademy.com THE SECONDARY STUDY He sought a more detailed mechanism to explain the development of the mandible.
The fact that a bending was occurring in an orderly fashion was recognized. Therefore, greater the magnitude of growth, greater the bending. Apparently, a growth arc was operative. www.indiandentalacademy.com Experiments were undertaken to determine a method by which the form and size of the mandible, after a 5 year growth interval, could be predicted with use of only the first X-ray as a reference.
The size increases and form alterations were available from the previous study. www.indiandentalacademy.com The first arc was constructed in the Time 1 composite through the three points : Pm, Xi, Dc
By extending this arc, the size increase was produced but not enough bending was produced. The mandible became more obtuse than was the actual behaviour. www.indiandentalacademy.com www.indiandentalacademy.com A second arc was made by joining the following points: 1. tip of coronoid process 2. anterior border of ramus at its deepest curve 3. suprapogonoin
The extension of this curve exhibited in the segment of the circle too small in radius. Showed excessive bending of the mandible. www.indiandentalacademy.com www.indiandentalacademy.com Hence, the characteristics of typical growth had been bracketed by the two arcs produced. Therefore, an arc was constructed bisecting these previous two arcs.
Established a halfway point between Xi and R1 points and using the distance from this point to Pm as a radius of a circle, an arc could be produced.
www.indiandentalacademy.com The use of this arc bent the mandible by a fraction too much. Additionally, a radius selected from this point would increase with the size of the mandible and a changing arc would result.
Next, he thought that perhaps the stress lines of the mandible might be useful. www.indiandentalacademy.com The mandible used for studying the stress lines was 850 years old. It had been weathered to a state of disintegration of the interprismatic substance of the external cortical bone.
Hence, it clearly showed the stress lines in the outer and inner plates. Hoped that these functional stress lines could yield clues about mandibular development. www.indiandentalacademy.com Stress lines on Lateral side There is convergence of stress lines at the protuberance menti. Stress lines swing downward and then upward and backward and outward through the external oblique ridge
An irregular gnarled area was present at the base of the coronoid process as the stress seemed to divide forward or backward in respect to condylar or coronoid demands. www.indiandentalacademy.com www.indiandentalacademy.com www.indiandentalacademy.com Stress lines on Medial side Greater forking was present than laterally. Stresses followed the Mylohyoid ridge upward into a thick mass to terminate at a Y-shaped bony prominence.
www.indiandentalacademy.com Further study of several dozen mandibles led to the observation of small, nutritive foramina immediately superior to this area medially.
Hypothesized that this could be an important mandibular growth area. www.indiandentalacademy.com Locating point Eva A line from Xi point to Sigmoid notch is bisected and a parallel point ( RR ) is selected on the anterior border of the Ramus. RR point is connected to Point R3 at the lower border of the sigmoid notch.
www.indiandentalacademy.com This line is crossed by a second line selected from a point midway at the base of the coronoid process to Xi point.
The crossing of these two lines is called as Point Eva.
This point approximates the center of the upward and forward quadrant of the Ramus. It also almost exactly coincides with the forking of the stress lines on the internal and outer table of the Ramus. www.indiandentalacademy.com Locating point TR Point TR (true radius) is of equal distance from Point Eva and Pm. The arc formed by joining Point Eva and Pm with Point TR as the center of the circle represents the true arc for the growth of the mandible.
The point of intersection of the arc with the border of the sigmoid notch is called as Mu.
www.indiandentalacademy.com When the size increase of the mandible as determined by the computer study was incrementally added to the arc at the sigmoid notch, the predicted mandible was almost absolutely correct in size and form when compared with the final composite.
www.indiandentalacademy.com Growth Prediction Head films of a male patient, age 9 years, were chosen. The patient was observed until almost 19 years of age and no orthodontic treatment was rendered.
Step 1 The amount of growth of the mandible on the arc from the point Mu on the Sigmoid notch is 2.5 mm each year.
www.indiandentalacademy.com This was calculated from the previous study and found to be an excellent population constant. Cutoff for growth= 14.5 years (females) 19 years (males)
Apposition at the lower border of the symphysis of the males occurs at about 1mm every 8 years. www.indiandentalacademy.com www.indiandentalacademy.com Step 2 Next, 20 longitudinal cases with a range of duration of 5-12 years were measured. Study revealed that increases in condylar and coronoid processes were different when measured from Point Mu.
The condylar and coronoid processes grow upward and outward in a direction as a function of the curve of the original arc. www.indiandentalacademy.com The k factor for coronoid process growth was 0.8 mm per year. The condylar k factor was variable.
Long condyles = 0.4 mm per year Short and weak condyles = 0 mm Average condyles = 0.2 mm per year. www.indiandentalacademy.com www.indiandentalacademy.com Step 3 In males, an addition of 0.2 mm per year is done on the border of the mandible from the arc. No such addition is done in case of females.
The gonial angle drifted posteriorly on the arc one half the total increase in mandibular growth on the arc. www.indiandentalacademy.com www.indiandentalacademy.com Step 4 The last step is to determine the space available for the mandibular third molar at the anterior border of the Ramus. With normal anatomic contouring, the coronoid process is connected to RR point. It determines the ramal width. Slightly below this point, the External oblique ridge shows apposition of 0.4 mm per year. www.indiandentalacademy.com www.indiandentalacademy.com PARENTAL DATA According to studies by Suzuki and Takahama Facial growth prediction based on parental data, there is high level of significance of correlation between parents and offsprings and siblings regarding craniofacial dimension.
The craniofacial forms of children with a certain degree of bone maturity were significantly correlated with those of their parents. www.indiandentalacademy.com The genetic influence of parents of their children appeared equal.
Daughters seemed to be more affected genetically than sons by their parents.
The co-efficient of correlation of craniofacial forms between children and their parents increased from childhood to adulthood.
www.indiandentalacademy.com More precise prediction of individual growth could be made by applying genetic data obtained from similarities in craniofacial characteristics between children and their parents
The face of the offspring often resembles that of at least one of his or her parents. www.indiandentalacademy.com If the face of a young offspring resembles the face of either parent, it will continue to resemble that parent when the offspring becomes an adult. That is, the phenotype of facial appearance does not change with growth.
If the craniofacial type of an offspring resembles that of the father or the mother in the early growing stage, its adult craniofacial type will be nearly like that of the same parent. Thus the craniofacial form of offspring can be predicted from parental data.
www.indiandentalacademy.com There is high correlation between the craniofacial form of an offspring and that of his or her parents. The relationship becomes closer with growth, so it is better to use the parental information than to use average growth curves when the individual growth of a child is to be determined. www.indiandentalacademy.com CRANIOFACIAL TEMPLATES FOR ORTHODONTIC ANALYSIS
In recent years, direct comparison of patients with templates derived from various growth studies has become a reliable method of analysis, with the considerable advantage that compensatory skeletal and dental deviations within an individual can be observed directly. www.indiandentalacademy.com The measurements for comparison with the norms should have several characteristics: It should be useful clinically in differentiating patients with skeletal and dental characteristics of malocclusion.
It should not be affected by the size of the patient.
It should be unaffected by the age of the patient. www.indiandentalacademy.com Templates exist in two forms : Schematic it shows the changing position of landmarks with age on a single template.
Anatomically complete- it is a different one for each age, they are convenient for direct visual comparison of a patient with reference group while accounting for age.
www.indiandentalacademy.com While selecting a template, two things have to be kept in mind: Patients physical size Developmental age
www.indiandentalacademy.com Cranial base superimposition, which allows the relationship of the maxilla and mandible to the cranium to be evaluated. www.indiandentalacademy.com Second superimpostion is on the maximum contour of the maxilla to evaluate the relationship of the maxillary dentition to the maxilla. www.indiandentalacademy.com The third superimposition is on the symphysis of the mandible along the lower border, to evaluate the relationship of the mandibular dentition to the mandible. www.indiandentalacademy.com Thank you www.indiandentalacademy.com
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