GROWTH ASSESSMENT

SUBMITTED TO: SUBMITTED BY:

DR. RITU JINDAL PADMA
HEAD OF DEPARTMENT BDS IV PROF
PEDODONTICS AND R NO. : 39
PREVENTIVE DENTISTRY
Craniofacial growth is a multidisciplinary
phenomenon and occurs at the
molecular, cellular, tissue and organ
levels.
In clinical pedodontics , data on
craniofacial growth gives dimensional
changes , relations between different
bones and growth mechanism.
Some of the methods commonly used for
this purpose are described as follows:

A. MEASUREMENT APPROACHES:

a) CRANIOMETRY
b) ANTHROPOMETRY
c) CEPHALOMETRIC RADIOGRAPHY
B. EXPERIMENTAL APPROACHES:

a) VITAL STAINING
b) AUTORADIOGRAPHY
c) RADIOISOTOPES
d) IMPLANT RADIOGRAPHY

a) CRANIOMETRY:

Measurement of skulls found among
human skeletal remains.

ADVANTAGE: Precise measurements can
be done on dry skulls.

DISADVANTAGE: Such a growth study
can only be cross sectional.



Measurement approach in craniometry :
b) Anthropometry:

A technique which involves measuring
skeletal dimensions on living individuals.

Landmarks established in the studies of dry
skull are measured in living individuals by
using soft tissue points overlying bony
landmarks.
Various landmarks present on dry
skull
ADVANTAGES:

Study can be longitudinal.

And the growth of an individual can be
followed directly over a period of time.

No damage to the subject.
c) X ray cephalometry :
A technique depending on precise
placement of the individual in a
cephalostat.
Precise control magnification can be done.
Combination of both CRANIOMETRY and
ANTHROPO METRY.
DISADVANTAGE: Produces a two
dimensional representation of a three
dimensional structures .

.
Position of patient and cephalometric X ray
EXPERIMENTAL APPROACHES:
a) Vital staining:
Depicts the pattern of the postnatal bone
deposition over an extended time period.
Gives the growth sites , the direction and
amount of growth , as well as the timing and
relative duration of growth at different sites.
Alizarin , and other vital dyes like procion
and tetracycline are used in bone research.

b) 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
After the film is developed , the location of
radiation indicates where growth is
occurring .

Autoradiography
Incubate tissue with
radioactive ligand
Expose to film
or emulsion
Isotope will emit
radiation (usually beta)
Radiation will hit silver grains in emulsion and expose them

c) RADIOISOTOPES:

In vivo markers are used for studying
bone growth.

Growth is measured by means of
Gieger counters or autoradiographic
techniques.

Tc-99
detects areas of rapid bone growth in
humans.






Femoral parts showing in vivo
markers
d) IMPLANT RADIOGRAPHY :

Inert metal pins are inserted anywhere in
the bony skeleton including face and jaws.

Use of biocompatible pins.

Superimposing radiographs on the implants
allow precise observation of both changes in
the position of one bone relative to another and
changes in external contour of the individual
bone.
VARIOUS IMPLANT SITES

IMPLANT SITES:
MAXILLA MANDIBLE
Hard palate behind primary
canines

Below anterior nasal spine

Two implants on either sides
of zygomatic process of maxilla

Borders between the hard
palatemedial to I molar&
alveolar proces

Anterior aspect of symphysis

2 pins on right side of
mandibular body

One pin on external aspect of
right ramus at the level of
occlusal surface of molars.

Other methods of studying growth
include:
1. Stereo pair images: In computer analysis
positional changes can be studied in a three
dimensional system.


2. Animal experiments:

To study specific pathological conditions
malformation or acquired defects and events
at cellular level of histological,
histochemical and biochemical technique.

Embryological research has been made
possible due to this experiments
3. Natural markers :

Persistence of certain developmental features of bone
used as natural markers.

Trabeculae ,nutrient canals and lines of arrested
growth can be used for reference to study deposition,
resorption and remodelling
Arrested growth lines and nutrient
canals
METHODS OF COLLECTING
GROWTH DATA
BIOMETRICS:
It is the science of statistical biology , the collection and
statistical analysis of data regarding a living organism.
The biometric methods used for recording dimensional
changes in the cranium during growth are:
LONGITUDINAL METHOD
CROSS SECTIONAL METHOD
SEMI LONGTUDINAL METHOD
LONGITUDINAL STUDIES
Advantages:

Studying the natural history of disease &its outcome.

Specific developmental pattern of an individual can be
studied.

Disadvantages:

Time

Expense

Attrition

CROSS-SECTIONAL STUDIES

Advantages:

Quicker

Allows repeating of studies more rapidly

Less cost.
GROWTH ASSESSMENT
PARAMETERS
Assessment is done for:

I. Identification of grossly abnormal growth or
even pathological growth.
II. Recognition and diagnosis of any significant
deviation from normal growth.
III. Planning of orthodontic or orthopedic
treatment.
IV. Determining efficacy of the treatment modality.
KROGMAN in 1970 defines five ages of
childhood considered as growth assessment
parameters:

1. Chronologic age:

Simply figured from the childs date of
birth.

Disadvantage: Each child has his or her
own characteristic growth time clock.
2. Somatotypic age:

Somatotype means a general body type.

SHELDON divides somatotype into three
categories:

ECTOMORPH
MESOMORPH
ENDOMORPH

3. Height and weight age:

BOYS :2height at 8 yrs =adult height

GIRLS :2height at 7.5 yrs= adultheight

BOYS :5weight at 2 yrs =adultweight

GIRLS :5weight at 1.5 yrs =adultweight


4. Dental age:

Simplest but least accurate dental age
indicator.

Involves recognizing teeth clinically present
and comparing them to the dental eruption
charts.

GLIESER and HUNT in 1955:

Advocated the calcification of a tooth as a
more meaningful indication of somatic
maturation than its clinical emergence.

As EMERGENCE of tooth is a FLEETING
event and its CALCIFICATION is a
continuous process which can be assessed
by permanent records such as X-rays.

DEMIRJIAN (1973):

A new approach based on absolute values ,
for the lengths of the crowns or the roots by
using a new technique of PANORAMIC
radiographs.
EIGHT stages of development , from
calcification of the tip of the cusp to the
closure of the apex were designated by
letters A to H.

5. Sexual age:
IN MALES
1. acceleration of growth of the testes &
scrotum.
2.appearance of pubic hair.
3.enlargement of genital organs
4.height spurt
5.appearance of facial & axillary hair
6.enlargement of larynx



IN FEMALES:
Appearance of breast buds & pubic hair

broadening of hips

Menarche, occurs almost after the maximal
height.

6. Facial age:
To differentiate between normal versus
abnormal facial development is
CEPHALOMETRIC ANALYSIS.


Other measurements for assessing
craniofacial developments are:

Head circumferences
Eye measurements :
o Inner canthal
o Interpupillary
o Outer canthal
Ear length
Philtrum length
Width of the commissures
Change in facial proportions:
Increase in facial proportions are seen as:
a. General facial growth from infancy to
adolescence and increase in size of dental
arches.
b. Increase in size of the muscles of
mastication and facial expression.
c. Growth of alveolar processes of maxilla
and mandible with development and
eruption of deciduous and permanent
dentition.

d) Increase in maxilla size and growth of
maxillary sinus.
e) Increase in mandible.
f ) Increase in size of nasal area and paranasal
sinuses.
g) Enlargement of orbits.
h) Expansion of ethmoid and sphenoid
bones.
7. Skeletal age:
The assessment of skeletal maturation has
been used as an indicator of the developmental
age.
Given by STANECU in 1977
Methods to assess skeletal maturation:
1.Handwrist radiographs
2.Cervical vertebrae
3.Clinical & radiographic examination of
different stages of tooth development.


The PA radiograph of the left hand and
wrist has been chosen as a standard.

DREIZEN et al (1957) stated that a 3 months
discrepancy occurred between the right and
left hand wrists in 13% and more than 6
months in only 1.5%.
The radiograph of the hand and wrist of the
child is compared to the atlas standards with
the same sex and nearest age.
The bones are assessed in a regular order:
Distal radius, ulna , carpels , metacarpels :
the proximal middle and distal phalanges.
Each center is given as skleletal age. Overall
average age is then taken
Carpel bones are taken as reliable
assessment parameters.
Radiograph depicting the relationship between the
proximal phalanx of second finger and initial cusp
calcification of 3
rd
molar in 11year boy:
TANNER and WHITEHOUSE gave a
method of scoring maturity of individual
bone to get the skeletal age:
a) RUS (radius ulna short bones) score rates
the radius , ulna , metacarpels of the digits
1 , 3 and 5 , proximal middle and distal
phalanges of digits 1 , 3 and 5.
b) Carpel bone method score rates the carpel
bone.

c) The TW2 method scores all the bones.
Each growth center is given a maturity rating
on a scale of 8 (A-H) except the radius which
has 9(A-I). A number is given to each center
in an attempt to allow biologic variability. A
total is achieved and this gives the overall
maturity rating
8. Basal metabolic rate:
There is direct relationship between BMR
and growth.
A mathematical expression can be
developed by means of which is possible to
construct ideal curves of cumulative gain in
height and basal heat production from fetal
stage to adulthood.
i. Genetic factors:

It is believed that size at birth relates to
about :
a) 18% to the genome of foetus,
b) 20% to the maternal genome ,
c) 32% to maternal environmental factors
d) and the remaining 20% to the unknown
factors.
After birth infant growth rate is no longer
dependent on maternal factors but related
to its own genetic makeup.
In 1-2 years postnatal shift has a significant
relationship to the genetic background of
the child reflected of mid palatine height
During adolescence growth correlates with
the parental side more strongly
2. Extracranial and intracranial
pressure:
The signs and symptoms related to increase
intra cranial pressure depend on the age of
the patient at the onset.
During infancy rapid ventricular dilatation
and increased cranial circumference results.
If the raised pressure is longstanding ,
sutural margins develop deep
interdigitation with spiky appearance.

Later when the sutures are closed
volumetric expansion in the neurocranium
results in an excessive resorption of the
inner table of cranial vault.

This manifestation is quite evident when
hydrocephaly occurs in conjugation with
pathologic sutural obliteration as in
CROUZAN and APERT syndrome.
APERT AND CROUZON SYNDROME
3. Nutrition:
Lack of nutrition delays growth and may
affect size , body proportions , chemistry ,
quality and texture of some tissues.
It may delay growth and the adolescent
growth spurts.
In children , during rather short periods of
malnutrition they exhibit fine recuperative
powers where growth slows up ad waits for
a better time , and with the return of good
nutrition growth takes place unusually fast
until the genetically determined curve is
neared once more.
4. Hormones:
Hormones responsible for growth
GROUP I:
Hormones influencing skeletal growth bone
are:
a) GROWTH HORMONE
b) INSULIN
c) THYROTROPIC HORMONE
GROUP II
Hormones responsible for ossification of
long bones:
a) PARATHORMONE
GROUP III
Hormones responsible for pubertal growth
spurts:
a) ANDROGENS
b) PROGESTORONE and ESTROGEN.
GROUP IV
PROLACTIN HORMONE

5. MUSCULAR FUNCTIONS:
The close relationship between the muscles
and the bone growth is seen due to the fact
that the muscle influence the growth both
as a tissue affecting the vascular supply and
as a force element.

The importance of masticatory muscle
function has been observed in
anthropological studies in which a low
frequency of malocclusion was found in
population with primitive living conditions
The increased loading of the jaws due to
masticating muscle hyperfunction may lead
to increased sutural growth and bone
apposition resulting in an increased
transverse growth of maxilla and border
base of dental arches.
Increase in function of masticatory muscles
is associated with anterior growth rotation
pattern of mandible.

6. Growth factors:
Growth factors are peptides that transmit
signals within and between the cells and
play a comprehensive role in modulation of
tissue growth and development

These factors regulate cell activity by a
number of mechanism such as mitogenic
migration , differentiation and gene
regulation.

7.Illness:
Systemic disease has an effect on child
growth .
Serious prolonged debilitating illness have a
marked effect on growth and processes

8 CLIMATE AND SEASONAL
FACTORS:

Those living in cold climate usually have
greater proportion of adipose tissue.
Large amount of skeletal variation
associated with variation in climate ,
seasonal variation in growth rate of children
and in a weight of new born are present.


9. Socioeconomic factors:
Children living in favorable socioeconomic
conditions tend to be larger , display
different types of growth and shows a
variation in timing of growth.
10. Exercise:
Useful for development of motor skills for
increase in muscle mass , for a general well
being and fitness. But has no favorable effect
on linear growth.