PRECEPTORS: PRESENTED BY:

DR. RAKESH SHARMA EMAD AHMAD ANIS

DR. MEENU GOEL P.G. 1 ST YEAR
CONTENTS:-
Introduction
Growth Pattern, Variability and Timing
Methods of gathering growth data
Types of growth data
Methods of studying growth
Growth studies
Conclusion
References

3
INTRODUCTION

The only constant in life is CHANGE

They are influenced by various factors.

Physical Growth is of key importance to an

orthodontist.
Different approaches have been utilized for the
study of both normal and abnormal growth.
Each has its own limitations.

MOYERS 4th edition page 10

DEFINITIONS OF GROWTH
Robert E. Moyers : Growth is the quantitative
aspect of biologic development and is
measured in units of increase per units of time.

J.S. Huxley: The self multiplication of living

substance.

Todd: An increase in size.

 Meridith: Entire series of sequential anatomic
and physiologic changes taking place from the
beginning of prenatal life to senility.

Moss: Change in any morphological parameter

which is measurable.

Krogman: Increase in size, change in

proportion and progressive complexity.
 Development:
Todd: It is the progress towards maturity
Rbert E MOYERS :It refers to all the naturally occurring
unidirectional changes in the life of an individual from
its existence as a single cell to its elaboration as a
multifunctional unit terminating in death.

Differentiation:
It is the change from a generalized cell or tissue to one
that is more specialized.
GROWTH

PATTERN
VARIABILITY

TIMING
PATTERN

The biologic usage applicable in

craniofacial growth is that which
defines pattern as a set of constraints
operating to preserve the integration of parts
under varying conditions or through time.
In orthodontics, use of the word pattern has
both a morphologic and a developmental
application
 For example
"That child has a Class 1 facial pattern" may be a
typical morphologic statement of pattern.

"Susie has a vertical growth pattern" is a statement

applying the definition to development.
DIFFERENTIAL GROWTH

The human body does not grow at the same

rate through out life.
Different organs grow at different rates to a
different amount at different times.
This is called differential growth.

1. Scammons curves of growth.

2. Cephalocaudal gradient of growth.

SCAMMONS GROWTH CURVE

Lymphoid
Neural

General

Genital
LYMPHOID TISSUE

Reaches 200% adult

size by 7-8 yrs.
By 18yrs the lymphoid
tissue undergoes
involution to reach
adult size.
NEURAL TISSUE

Growth is nearly
completed by 6-7 yrs.
Very little growth is
seen after 6-7 yrs of
age.
GENERAL TISSUE

Consists of muscles,
bones and other organs.
Exhibits a S shaped
curve with rapid growth
upto 2-3 yrs.
Slow phase between 3-10
yrs.
Rapid phase after 10th
year terminating at 18 to
20yrs.
GENITAL TISSUE

Consists of
reproductive organs.
Negligible growth until
puberty.
Rapid growth at
puberty reaching adult
size and cessation.
CEPHALOCAUDAL GRADIENT OF GROWTH

There is an axis of increased growth from head

towards the feet.
3rd month IU Birth Adult
Robbins WJ, Yale University
Head 50% 39% 12%
Lower Limbs rudimentary 30% 50%
 There is increased gradient of growth even within the head
and face.
At birth cranium is proportionally larger than the face.
Postnatally the face grows more than the cranium.
Mandible shows more growth than the maxilla postnatally.
There is much more growth of facial structures postnatally.
VARIABILITY

Variability is the law of nature.

Variations in response to environment cause increasing

differences among similar individuals with time.

Variability is demonstrated by the use of statistics, which

express quantitatively the range of differences found in a large
population of individuals of similar age, sex, socioeconomic
background, and race.
CONCEPTS OF NORMALITY

Normal refers to that which is usually expected,

is ordinarily seen, or is typical, but usage of the
word normal and the concept normality varies
and is often a source of misunderstanding.
 The standard deviation is a way of depicting the spread of
values around the mean (X).
Given a normal curve, 1 SD = 67% in all cases, 2 SD =
approximately 95%, 3 SD = approximately 98%.
AGE EQUIVALENCE
Because individuals develop in different
patterns, producing variability, all individuals of
a given chronologic age are neither necessarily
of the same size nor the same stage of
maturation and development.

A number of "developmental ages" have been

suggested as a method of meeting this
problem.
BIOLOGIC MATURITY INDICATORS
Chronologic age
Skeletal age
Dental age
Morphological age
Sexual age

It often is better to compare individuals at the

same stage of biologic development rather than at
the same chronologic age.
VARIOUS SMI

HAND WRIST
CERVICAL VERTEBRAE MATURATION
INDICATOR
MID PALATAL SUTURE

FRONTAL SINUS
SIX TYPES OF HEIGHT GROWTH IN CHILDREN
1. Early maturing children: taller in childhood, mature faster, usually
not tall as adults.
2. Average growers: follow the middle range of distance curve and
comprise of 2/3 of all children.
3. Late maturing: Children shorter than average in childhood because
of their late maturing and will eventually be average adults
4. Genetically tall: taller than average children and will be tall adults
5. Genetically short: short as children and will be short as adults.
6. The sixth group of children either start puberty late or early and
subsequently have less or much more growth than expected.

Those children that enter puberty early finish growth earlier than
those who enter puberty at a later age.
 Growth effects because of timing variation can
be seen clearly in girls in whom the on set of
menstruation (menarche) indicates the arrival
of sexual maturity.
This is accompanied by a growth spurt.
Growth velocity curves for early, average and late maturing girls.
 Height gained per year of girls were plotted taking
menarche as reference time point.
It was seen that girls who mature early, average or late
follow a similar growth pattern.
 In each case, menarche came after the peak growth velocity .
This graph substitutes stage of sexual development for
chronologic time to produce a biologic time scale.
 Taking menarche as zero point.
A similar growth pattern can be seen.
 This shows that the pattern is expressed at
different times chronologically but not at
different times physiologically.
The effectiveness of biologic or developmental
age in reducing timing variability makes this
approach useful.
SIGNIFICANCE OF VARIABILITY

The significance of variation from the norm for

the group in which an individual is found can be
understood only if the individual's present
status is thought of in terms of progress toward
his or her own goal rather than rigidly
comparing this person's progress to the group
progress toward its goal.
 Thus it is necessary to appraise the growth of
the individual and to compare this pattern in
the light of his or her familial tendency and the
larger group to which he or she belongs .
Gross variation from the central tendency may
also be indicative of a pathologic condition.
 Think in terms of their deviation from the usual
pattern.
This can be done by evaluating a given child to
relative peers on a standard growth chart.
Although these charts are commonly used for
height and weight, the growth of any part of the
body can be plotted.
 Growth of a normal
girl plotted on the
chart for females.
This girl remained
at about 75th
percentile for height
and weight over the
entire period.
 De Montebeillards son 1759-1777

Height or weight at any age (black line) is called the distance curve.
The amount of change in any given interval (maroon line) is called the
velocity curve.
Plotting velocity rather than distance makes it easier to see when
accelerations and decelerations in the rate of growth occurred.
TIMING: GROWTH SPURTS
Woodside 1968, (Burlington study) later
modified by Arne Bjork 1975.
The periods when sudden acceleration of
growth occurs are termed as growth spurts.
The physiological alteration in hormonal
secretion is believed to be the cause for such
accentuated growth.
The timings of growth spurts differ in boys and
girls.
 Growth modifications by means of functional
appliances elicit better response during growth
spurts.
Surgical correction involving the maxilla and
mandible should be carried out only after
cessation of the growth spurts.
TIMING OF GROWTH SPURTS, BJORK 1975

Just before birth

One year after birth

Mixed dentition growth spurt

Boys: 8-11 yrs.
Girls: 7-9 yrs.

Pre- pubertal growth spurt

Boys: 14-16 yrs.
Girls: 11-13 yrs.
GROWTH SPURT: GRABER

Childhood growth spurt (3yrs)

Juvenile growth spurt
Girls6-7 yrs
Boys 7-9 yrs

Pubertal growth spurt

Girls10 to 13yr
Boys 12 to 16yrs
 These charts can be used in two ways to
determine whether growth is normal or
abnormal.
First, the location of an individual relative to
the group can be established.
Secondly, a child's growth can be monitored
over time to evaluate whether there is an
unexpected change in growth pattern.
 Growth of a baby boy
who developed a
medical problem that
affected growth.
The change in pattern
and crossover lines
reflect impact of serious
illness beginning at that
time; 10-11 years.
Recovery can be seen at
13 years of age.
METHODS OF STUDYING GROWTH DATA

1. METHODS OF GATHERING DATA

2. TYPES OF GROWTH DATA
3. EVALUATION OF GROWTH DATA

MOYERS 4th edition page 10

METHODS OF GATHERING GROWTH DATA

A. LONGITUDINAL
B. CROSS- SECTIONAL
C. OVERLAPPING OR SEMILONGITUDINAL

MOYERS 4th edition page 10

A) LONGITUDINAL:

Measurements made of same person/group at regular

intervals time are longitudinal measurement.

These are thus long term studies.

Advantages
Variability in development among individuals within the
group is put in proper perspective.

MOYERS 4th edition page 10

 The specific development pattern of an individual can be
studied, permitting serial comparisons.
Temporary problems in sampling are smoothed out with
time and an unusual event or mistake is more easily seen
and corrections made.
Disadvantages
Time consuming
Expense
Attrition 50% in 15 years
Averaging

MOYERS 4th edition page 11

B) CROSS SECTIONAL

Measurement made of different individuals or different

samples and studied at different periods are cross sectional
measurements.
Thus, one may measure a group of 7yr. old boys and on the
same day, at the same school, measure a group of 8yr.old
boys.
Changes between 7& 8 yrs of age in boys at that school are
thus assumed after study of the data obtained. .
MOYERS 4th edition page 11
 Advantages
Quicker
Less costly

Statistical treatment of the data - made easier.

It allows repeating of studies more readily, in case

of any flaw.
Commonly used for cadaver and archeological
studies.

MOYERS 4th edition page 11

 Disadvantages:
It must always be assumed that the group being
measured and compared are similar.
Cross sectional group are averages, tend to obscure
individual variations.

MOYERS 4th edition page 11

C) OVERLAPPING OR SEMI LONGITUDINAL DATA

Longitudinal and cross sectional methods

combined to seek the advantages of each.

In this way one might compress 15yrs of study into

3yrs of gathering data, each sub sample including
children studied for the same number of years but
started at different ages. .

MOYERS 4th edition page 11

 For example,
subsample study A for Basic Concepts of Growth
and Development, it may go from 3 to 6 years of
age, sub sample B from 4 to 7, subsample C from 5
to 8, and so forth.

MOYERS 4th edition page 11

TYPES OF GROWTH DATA

A. Opinions
B. Observations
C. Ratings and Rankings
D. Quantitative Measurements

MOYERS 4th edition page 10

A) OPINION

Crudest method
Considered as a calculated guess based on
ones experience.
Unscientific and should be avoided when
possible.
For e.g.. One may be able to guess which one
of the two siblings may be taller by assessing
their previous growth. .
MOYERS 4th edition page 10
B) OBSERVATIONS

Useful for studying all or none phenomenon.

For example in cursory visual examination of
67 Eskimo children ranging between 15 to
18years Class II malocclusion was observed.

MOYERS 4th edition page 10

C) RATINGS AND RANKINGS
Ratings make use of comparisons with
conventional accepted scales or classifications,
rankings array data in ordered sequences
according to value.

Each individual is compared with these norms and

rated accordingly.

For e.g.. "When the ten tallest boys were compared

with the ten shortest boys in the sample it was
found
MOYERS 4th edition page 10
 Ranking : Certain data are difficult to quantify and thus
may be compared to conventional rating scales.
Such scales may be based on developmental stages or
typical forms or patterns.
Tooth shape (square, tapering, and ovoid), facial form,
and tooth development are common examples of the
use of rankings.
MOYERS 4th edition page 10
D) QUANTITATIVE APPROACH

Moyers
1. Direct Data.

2. Indirect Growth Measurements.

3. Derived Data.

Proffit
A. Measurement approach.

B. Experimental approach.

MOYERS 4th edition page 10

1) DIRECT GROWTH MEASUREMENTS

Direct data are derived from measurements

taken on the living person or cadaver by means
of calipers, scales, measuring tapes, and other
measuring devices.
For example craniometry, anthropometry.

MOYERS 4th edition page 10

2) INDIRECT GROWTH MEASUREMENTS

Indirect growth measurements are those taken

from images or reproductions of the actual
person. For example, measurements made
from
photographs,

dental casts,
cephalograms

skeletal maturity indicators

MOYERS 4th edition page 10

3) DERIVED DATA

Derived data are obtained by comparing at least

two other measurements.
"When we say that a person's mandible grew 2
mm between ages 7 and 8
The 2 mm have not actually been measured;
rather, the mandibular length at 7 years has been
subtracted from the mandibular length at 8 years.
The increment thus derived is assumed, to
represent growth.
MOYERS 4th edition page 10
 Measurement approach
1. Craniometry
2. Anthropometry
3. Cephalometric radiography
Experimental
1. Vital staining
2. Autoradiography
3. Radioisotopes
4. Implant radiography
5. Natural markers
CRANIOMETRY

Itis based on measurements of skulls found

among human skeletal remains.
From such skeletal material it has been
possible to piece together a great deal of
knowledge about extinct populations and to
get some idea of their pattern of growth by
comparing one skull with another. .

Proffit page 26
Measurements done on
dry skulls using Vernier
calipers

Comparison of different
skulls of primates
 Advantage : Precise measurements can be
made on dry skulls.

Disadvantage : By necessity, all these growth

data must be cross sectional.

Proffit page 26
ANTHROPOMETRY
In this technique various landmarks
established in studies of dry skulls
are measured in living individuals by
using soft tissue points overlying
these bony landmarks .
For e.g., it is possible to measure the
length of the cranium from a point at
the bridge of the nose to a point at
the greatest convexity of the rear of
the skull.
Proffit page 26
 This measurement can be made on either a dried skull
or a living individual, but results would be different
because of the soft tissue thickness overlying both
landmarks.
Proffit page 26
 Advantages:
Itis possible to follow the growth of an individual
directly, making the same measurements
repeatedly at different times.
This produces longitudinal data; repeated
measures of the same individual.
Farkas anthropometric studies have provided
valuable new data for human facial proportions and
their change over time.
Proffit page 26
FARKAS ANTHROPOMETRIC STUDY
The set of anthropometric measurements of the face in the
population studied was gathered by an international team of
scientists.
The normal range in each resultant database was then
established, providing valuable information about major facial
characteristics.
Comparison of the ethnic groups' databases with the
established norms of the North America whites (NAW) offered
the most suitable way to select a method for successful
treatment.

J Craniofac Surg. 2005 Jul;16(4):615-46

 The study group consisted of 1470 healthy
subjects (18 to 30 years),
750 males and 720 females.
The largest group (780 subjects, 53.1%) came
from Europe,(Caucasians).
Three were drawn from the Middle-East (180
subjects, 12.2%),
Five from Asia (300 subjects, 20.4%) and
Four from peoples of African origin (210 subjects,
14.3%).
J Craniofac Surg. 2005 Jul;16(4):615-46
 Their morphological characteristics were determined by 14
anthropometric measurements.
In the regions with single measurements, identical values to
NAW in forehead height, mouth width, and ear height were
found in 99.7% in both sexes, while in those with multiple
measurements, vertical measurements revealed a higher
frequency of identical values than horizontal ones.
The orbital regions exhibited the greatest variations in
identical and contrasting measurements in comparison to
NAW.
Nose heights and widths contrasted sharply: in relation to
NAW the nose was extremely significantly wide in both sexes
of Asian and Black ethnic groups.
J Craniofac Surg. 2005 Jul;16(4):615-46
CEPHALOMETRIC RADIOLOGY
Cephalometric Radiology is of importance not only
in the study of growth but also in clinical evaluation
of orthodontic patients.
Depends on precisely orienting the head before
making a radiograph with equally precise control of
the magnification

Proffit page 26
 Advantages:
This approach can combine the
advantage of craniometry and
anthropometry.
It allows a direct measurement of
bony skeletal dimensions, since
the bone can be seen through soft
tissue covering in a radiograph.

Proffit page 26
 Italso allows the same individual to be followed
over time. Therefore their serial cephalograms is
possible in longitudinal study.
Disadvantages
Metric radiograph is that it produces a two
dimensional representation of a three dimensional
structure.
Magnification errors.

X ray radiation exposure.

Proffit page 26
A number sequential cephalograms in succession
3D IMAGING

Computed axial tomography (CT), allows 3D

reconstruction of the cranium and face.
This method has been applied to plan surgical
treatment for patients with facial deformities.
CBCT allows scans of patients with radiation
exposure and that is much closer to the dose
from cephalograms.
 Superimposition of 3D images is much more
difficult than 2D
 Magnetic Resonance Imaging (MRI) also
provides 3D images that can be useful with the
advantage of no radiation exposure to the
patients.
This method has been applied to the analysis
of the growth changes produced by functional
appliances.
EXPERIMENTAL APPROACH

1. Vital Staining
2. Implant Radiography
VITAL STAINING

A technique in which dyes that stain

mineralizing tissues are injected into an
animal.
These dyes remain in the bones and teeth and
can be detected later.
This method was originated
by the English anatomist
John Hunter in the 18th
century.
He discovered that the
active agent was a dye
called alizarin, which is still
used for vital staining
studies.
 Alizarin reacts strongly with calcium at sites
where bone calcification is occurring.
Since these are the sites of active skeletal
growth, the dye marks the locations at which
active growth was occurring when it was
injected.
 Bone remodels rapidly, and areas from which
bone is being removed also can be identified by
the fact that vital stained material has been
removed from these locations.
Vital staining studies are not possible in
humans.
 The mandible of a
growing rat that
received four
injections of alizarin
(red-blue-red-blue) at
2 weekly intervals.
The animal was
sacrificed 2 weeks
after the last injection.
The new bone formed
white.
 Section through the
zygomatic arch from the
same animal shows
outward growth by
apposition of bone on
the outer surface and
removal on the inner
surface.
 Various children
treated with tetracycline
in the late 1950 s
resulted in
discolouration of incisor teeth.

Later is was discovered that tetracycline is an

excellent vital stain that binds to calcium at
growth sites.
 Antibiotic tetracycline is also used as vital bone
markers Other dyes used are :
(i) Acid alizarin blue
(ii) Trypon blue
(iii) Procion .
AUTORADIOGRAPHY
Radioactively labeled materials in tissues of
experimental animals are detected by this
technique.
A film emulsion is placed over a thin section of
tissue containing the isotope and then in the
dark by the radiation.
Then film is developed; the location of the
radiation that indicates growth is observed by
looking at the tissue section through the film.
RADIOACTIVE TRACERS

Radioactivity labeled metabolite becomes

incorporated into the tissues as a sort of vital
stain .
The location is detected by the weak
radioactivity given off at the site when the
material was incorporated. .
 The gamma emitting isotope 99m Tc
(TECHNECIUM) can be used to detect areas of
rapid bone growth in humans.
but these images are more useful in diagnosis
of localized growth problems than for studies of
growth patterns.
Others used are Calcium 45 and Potassium 32.
IMPLANT RADIOGRAPHY
In this technique, inert metal pins are placed in
bones anywhere in the skeleton, including the
face and jaws.
Considerable increase in the accuracy of a
longitudinal cephalometric analysis of growth
pattern can be achieved.
Method was developed by Professor Arne Bjork
and co workers at Royal Dental College in
Copenhagen, Denmark 1969.
Proffit 5th Edition page 31
 Superimposing cephalograms on the implanted
pins allows precise observation of both
changes in the external contours of individual
bones.
Precise evaluation of dentofacial growth in
humans still is done best by implant
radiography .
SITES OF IMPLANT PLACEMENT MAXILLA
Hard Palate behind deciduous
canines.
Below the anterior nasal spine.
Two implants on either side
of zygomatic process of
maxilla.
Border between hard palate & alveolar
process medial to the first molar.
SITES OF IMPLANT PLACEMENT MANDIBLE

Mandible: Anterior aspect of symphysis, in the

midline below the root tips.
2 pins on the right side of the mandibular body.

One under the first premolar & the other below

the second premolar or first molar.
One pin on the external aspect of right ramus in
level with the occlusal surface of molars. .
SITES OF IMPLANT PLACEMENT MAXILLA & MANDIBLE
 Bjork 1969 presented a survey of experience
with the implant method in the study of facial
growth ,with particular emphasis on prediction
of mandibular growth rotation.
The three methods discussed were:
1. Longitudinal Method
2. Metric Method
3. Structural Method
1. LONGITUDINAL

It consists of following the course of

development by annual X-ray cephalograms
shown to be of limited use for this purpose, as
the remodeling process at the lower border of
the mandible to a large extent masks the actual
rotation. .
2. METRIC METHOD

Aims at prediction based on a metric

description of the facial morphology at a single
stage .
Predicting the intensity or direction of
subsequent development from size or shape at
childhood was not feasible with any
cephalometric analysis .
3. STRUCTURAL METHOD

This method was hence described by which it

may be possible to predict, from a single
cephalogram ,the course of rotation, where this
feature is marked.
This method is based on information gained
from implant studies of the remodeling process
of the mandible during growth. .
 When evaluating mandibular morphology, Bjork
listed seven areas on the cephalogram that
should be evaluated to help predict future
mandibular growth direction:
1. The inclination of the condyle as an indication of its growth
direction, vertically or sagittally. For example, with vertical
condylar growth, the mandible rotates forward.
2. The curvature of the mandibular canal (i.e., the more curved
the canal is the more forward mandibular rotation will be).
3. Inclination of the symphysis. If it is inclined lingually, the
mandible rotates forward.
4. Shape of the lower border of the mandible.
5. The interincisal angle, which is more acute in forward rotators.
6. The interpremolar or molar angles are also more acute in
forward rotators.
7. The anterior lower face height.
 Later Skieller, Bjork, and Linde- Hansen refined
this prediction approach by quantifying it.
They found that the combination of four
variables gives the best prognostic estimate of
future mandibular growth direction.
The variables were
(1) Mandibular inclination measured as MP:SN angle
or as the ratio of posterior/ anterior face heights,
(2) The inter molar angle,
(3) the shape of the lower border of the mandible
measured as the angle between Go-Me and a
tangent to the lower border of the mandible, and
(4) the inclination of the symphysis measured as the
angle between the tangent of the anterior surface
of the symphysis and the SN.
IS THERE A MANDIBULAR GROWTH SPURT
AND HOW OFTEN DOES IT OCCUR?

Bjork evaluated the growth of the condyles on

45 boys between 7 and 21 years of age.
Of the 45 boys evaluated, only 11 individuals
(less than 25%) had what was able to be
described as a discernible puberal growth
variation.
WHAT IS THE MAGNITUDE OF THE SPURT?

For the 11 subjects in Bjork's 1963 study

11 showed a slower condylar growth rate
around 12 years of age, amounting to a mean
of 1.5 mm and a spurt 2.0 years later that
averaged 5.5 mm and ranged between 4.0 and
8.0 mm (Table 7-3).
For the rest of the 34 subjects in the study,
there was a more steady annual growth.
BJORK'S FINDINGS AND CONCLUSIONS

There was a discernible, but not necessarily

significant, spurt in condylar growth in less
than 25% of the sample.
The magnitude, duration, and timing of the
spurt varied widely even in this selected
subsample of 11 subjects.
There was no relationship between the
intensity of the growth and its direction.
GROWTH STUDIES

Various Growth Studies Among the main

resources of the craniofacial research
community are the collections of longitudinal
growth records that were accumulated at
considerable economic and human cost by
dedicated investigators.
VARIOUS GROWTH STUDIES

1. BoltonBrush Growth Study Case Western

Reserve University Cleveland, Ohio
2. Burlington Growth Study University of
Toronto Toronto, Ontario, Canada
3. Denver Growth Study University of
Oklahoma Oklahoma City, Oklahoma
4. Fels Longitudinal Study Wright State
University Dayton, Ohio Forsyth
5. Twin Sample Forsyth Institute Cambridge,
Massachusetts
6. Iowa Facial Growth Study University of Iowa
Iowa City, Iowa
7. Matthews Growth Study University of the
Pacific San Francisco, California
8. Michigan Growth Study University of Michigan
Ann Arbor, Michigan
9.Oregon Growth Study Oregon Health and
Science University
CONCLUSION
Growth and development show wide variability of
expression within a population.
This variability is the source of many clinical
problems.
The analysis of many skeletal deformities can be
aided greatly by the application of the methods
studying growth of bones.
The basis of skeletal maturity index and
physiological time scale is more accurate than
other methods.
REFERENCES

Robert E. Moyers 4th edition

Tetbook of Orthodontics Samir E. Bishara

Proffit 4th edition.

Orthodontics Current Principles and

Techniques- 5th edition Graber Vandersdall
J Craniofac Surg. 2005 Jul;16(4):615-46