Transcript Unit C3: Assessment of Skeletal…

Growth and
Development
University of Maryland School of Dentistry
Department of Orthodontics
UNIT C2
Assessment of Skeletal and
Other Developmental Ages
Overview
• Clinical Assessment of Growth and
Development
– Hand wrist x-ray
– Cervical Vertebral Maturation
– Behavioral Development
• Dental development correlates reasonably well with
chronologic age but occurs relatively independently. Of all
the indicators of developmental age, dental age correlates
least well with the other developmental indices
• Physical growth status also varies from chronologic age
with many children but does correlate well with skeletal
age, which is determined by the relative level of maturation
of the skeletal system
• In planning orthodontic treatment it can be important to
know how much skeletal growth remains
• An assessment of skeletal age must be based on the
maturational status of markers with the skeletal system.
Dental Age vs. Chronologic Age
7 years old
Dental Age vs. Chronologic Age
11 years old
Dental Age vs. Chronologic Age
17 years old
• Dental development correlates reasonably well with
chronologic age but occurs relatively independently. Of all
the indicators of developmental age, dental age correlates
least well with the other developmental indices
• Physical growth status also varies from chronologic age
with many children but does correlate well with skeletal
age, which is determined by the relative level of maturation
of the skeletal system
• In planning orthodontic treatment it can be important to
know how much skeletal growth remains
• An assessment of skeletal age must be based on the
maturational status of markers with the skeletal system.
Hand Wrist x-ray
• For many years the standard for skeletal
development was assessing ossifications of the
bones of the hand and wrist
• A radiograph of the hand and wrist provides a
view so some 30 small bones  have predictable
sequence of ossification
• Hand-wrist radiograph of the patient is compared
with standard radiographic images in an atlas of
the development of the hand and wrist
(Tanner JM. Assessment of
Skeletal Maturity and Prediction of Adult Height. New York: WB Saunder; 2001
Hand-wrist skeletal maturation
forefin
ger
index
middle
finger
digitus
medius
ring finger
digitus
anularis
little finger
digitus
minimus
poll
ex
• Two general approaches to assessment
of hand-wrist radiograph:
• Comparison methods of Greulich and Pyle and
Tanner Whitehouse
• Greulich and Pyle: use atlas as standard of comparison
• Consists of plates of “typical” hand-wrist radiographs at 6-month intervals
of chronological age
• Each bone is compared and assigned an age ages are averaged to find
“mean age” of individual
• Tanner Whitehouse: compares individual with radiographic standards
of skeletal maturity of “normal” children of similar age and sex
• Individual bones are rated using biological weighted scoring system to
assign “skeletal age”
• Specific indicators to relate skeletal maturation to pubertal growth curve
• Focuses on the maturation evaluation of the individual rather than on
mean values
• Fishman developed a system for assessment of skeletal maturation on
basis of 11 discrete “skeletal maturity indicators” covering entire period of
adolescent development
• Provides graphs and tables to estimate individual’s relative growth rate
and percentage of total adolescent growth completed
Skeletal Maturity Indicators
SMI
Epiphyseal
Widening
1
2
3
Third finger – proximal phalanx
Third finger – middle phalanx
Fifth finger – middle phalanx
Ossification
4
Adductor sesamoid of thumb
Capping
5
6
7
Third finger – distal phalanx
Third finger – middle phalanx
Fifth finger – middle phalanx
Fusion
8
9
10
11
Third finger – distal phalanx
Third finger – proximal phalanx
Third finger – middle phalanx
Radius
Growth velocity curve
The approximate timing of these childhood and adolescent stages of maturation as related to an average developmental growth curve. Although small preadolescent growth spurts can occasionally occur, the late childhood period is usually one of relatively slow growth.
High
Velocity
Accelerating
Velocity
Decelerating
Velocity
Skeletal maturation as determined by
hand-wrist x-rays
• Burlington Growth Center
• Peak mandibular circumpubertal growth was more
closely related to Greulich-Pyle or TannerWhitehouse skeletal age than chronological age
• Ossification of sesamoid preceded peak mandibular
growth by 1.1 years in girls and 0.7 years in boys
(Pileski et al 1973)
• Brush-Bolton Growth Study
• Tofani (1972) reported that distal phalange fusion
was good predictor of maximum mandibular growth
Cervical Vertebral Maturation
• Recently, a similar assessment of skeletal age
based on the cervical vertebrae, as seen in
cephalometric radiograph, has been developed.
(Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics.
Sem Orthod 11:119-129, 2005)
• Since cephalometric radiographs are obtained
routinely for orthodontic patients, this method
has the advantage that a separate radiograph is
not needed, and the assessment of skeletal age
from vertebral development seems to be as
accurate as with hand-wrist radiographs
• The best way to determine the cessation of
growth is serial cephalometric radiographs*
Cervical Vertebrae (C1-C7)
C1 (Atlas), C2 (Axis), C3, C4
C1 (Atlas) – responsible for “yes” motion of the head
C2 (Axis) – responsible for rotation or “no” motion of the head
2
3
4
Cephalometric Xray
Cervical Vertebrae
2
3
4
• Three primary ossification centers develop in each
cartilaginous vertebra, one in the body and one in
each half of the vertebral arch. At birth, each
typical vertebra consists of three bony parts, united
by hyaline cartilage
• Typical vertebrae begin to ossify toward the end of
the embryonic period (7 to 8 weeks)
• The halves of the vertebral arch begin to fuse in the
cervical region during the first year
• Fusion of the body with the vertebral arches occurs
during childhood (5 to 8 years)
• During puberty, five secondary ossification centers
develop
• Evaluate the cervical maturation by
changes in the concavity of the lower
border, height, and shape of the vertebral
body**
Cervical Vertebral Maturation
Growth prediction from cervical vertebrae
1. Initiation
Inferior borders of the second,
third and fourth cervical vertebrae
are flat at this stage. The third
and fourth vertebrae are wedgeshaped, and the superior
vertebral borders are tapered
from posterior to anterio r. 100%
of pubertal growth remains.
2. A cceleration
(This
(This corresponds
corresponds to
to aa combination
combination of
of SMI
SMI 11 and
and 2.)
2.)
(This
(This corresponds
corresponds to
to aa combination
combination of
of SMI
SMI 33 and
and 4.)
4.)
3. Transition
Distinct concavities are shown on
the inferior borders of second and
third vertebrae. A concavity
begins to develop on the inferior
border of fourth. Vertebral bodies
of third and fourth are rectangular
in shape. 25 to 65% of pubertal
growth remains.
4. Deceleration
Distinct concavities can be
observed on the inferior borders
of second, third and fourth
cervical vertebrae. Vertebral
bodies of third and fourth begin to
be more square in shape. 10 to
25% of pubertal growth remains.
(This
(This corresponds
corresponds to
to aa combination
combination of
of SMI
SMI 55 and
and 6.)
6.)
5. Maturation
Marked concavities are observed
on the inferior borders of the
second, third and fourth cervical
vertebrae. Vertebral bodies of
third and fourth are almost square
in shape. 5 to 10% of pubertal
growth remains.
(This
(This corresponds
corresponds to
to aa combination
combination of
of SMI
SMI 99 and
and 10.)
10.)
Concavities on the inferior borders
of second and third vertebrae
begin to develop. Inferior border
of fourth vertebrae remains flat.
Vertebral bodies of third and
fourth are nearly rectangular in
shape. 65 to 85% of pubertal
growth remains.
(This
(This corresponds
corresponds to
to aa combination
combination of
of SMI
SMI 77 and
and 8.)
8.)
6. Completion
Deep concavities are observed on
the second, third and fourth
cervical vertebrae. Vertebral
bodies are greater vertically than
horizontally. Pubertal growth has
been completed.
(This
(This corresponds
corresponds to
to SMI
SMI 11.)
11.)
*
*
*
*CVMS 1, 2 & 3 Are the best times for growth modification
*CVMS 2 & 3 usually corresponds with the beginning of the
pubertal growth spurt
CVMS Examples
CVMS 2
CVMS 1
CVMS 3
CVMS 3-4
CVMS 5
• The use of the CVM method enables the clinician
to identify optimal timing for the treatment of a
series of dentoskeletal disharmonies in all three
planes of space
• The concern for optimal timing for dentofacial
orthopedics is linked closely to the identification
of periods of accelerated growth that can
contribute significantly to the correction of
skeletal imbalances in the individual patient
Behavioral Development
• Physical growth can be viewed as the outcome on an
interaction between genetically controlled cell
proliferation and environmental influences that modify
the genetic program
• Similarly, behavior can be considered the result of an
interaction between innate or instinctual behavioral
patterns and behaviors learned after birth
• In humans the great majority of behavior is learned
• For this reason it is less easy to construct stages of
behavioral development in humans than stages of
physical development
Stages of Emotional and Cognitive Development
1.
Emotional Development
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–
–
–
–
–
2.
Development of basic trust (birth to 18 months)
Development of Autonomy (18 months to 3 years)
Development of Initiative (3 to 6 years)
Mastery of Skill (Age 7 to 11 years)
Development of Personal Identity (Age 12 to 17 years)
Development of Intimacy (Young Adult)
Guidance of the next generation (Adult)
Attainment of Integrity (Late Adult)
Cognitive Development
–
–
–
–
Sensorimotor Period (first 2 years of life)
Preoperational Period ( 2 to 7 years)
Period of Concrete Operation (7 to 11 years)
Period of Formal Operation (11 to Adult)
Summary
• The correlation between developmental ages of all types and
chronologic age is quite good, as biologic correlations go
• For most developmental indicators, the correlation coefficient
between developmental status and chronologic age is about 0.8
• The correlation of dental age with chronologic age is not quite as
good, about 0.7, which means that there is about a 50% chance of
predicting the stage of dental development from the chronologic
age
• What will actually occur in any one individual is subject to the
almost infinite variety of human variation, and the magnitude of
the correlation coefficients must be kept in mind