PEAK HEIGHT VELOCITY OF GROWTH

INTRODUCTION
Maturational status of craniofacial region can have considerable
influence on diagnosis, treatment planning, treatment goals and the eventual outcome of
orthodontic treatment. A thorough knowledge of facial growth velocity is important
regarding use of extraoral traction forces, functional appliances, extraction versus
nonextraction treatment, or orthognathic surgery . Furthermore, an understanding of
percentage growth remaining after completion of orthodontic intervention may be
important in predicting post treatment rebound.
Prediction of both the times and the amounts of active growth, especially in the
craniofacial complex, would be useful to the orthodontist.
DEFINITION:
Growth:
Growth is the physiochemical process of living matter by which an organism
becomes larger .Meridith defines it as – entire series of sequential anatomic and
physiologic changes taking place from the beginning of prenatal life to senility.
Growth may result in increases or decreases in size, change in form or proportion,
complexity, texture and so forth ,
Development:
Development may be defined as the sequence of changes from cell fertilization to
maturity, It relates to the cell division, growth, differentiation and maturation. The
higher the state of its differentation, the earlier does the cell complete its growth.
Development manifests itself morphologically, physiologically and in behavioral
adjustment of the individual.
Maturation:
Maturation is the process of becoming fully developed-of
consolidating the gains made through growth and development.
Puberty :
Puberty is a period of development characterized by an acceleration and then a
deceleration in skeletal growth , changes in body composition such as muscular growth in
males and fat accumulation in females, complete development of organ systems,
development of gonads, reproductive organs and secondary sexual characteristics and the
maturation of complex neural and endocrinal systems which initiate and control all these
changes.
Adolescence:
The term adolescence tends to add the connotations of psychologic and sociological and
behavioral overtones.
Peak height velocity of growth:
 Peak height velocity is defined as the maximum adolescent rate of growth.
Chronological age
Chronological refers to time ("chronos").,as recorded by registration of birth date,
is referred to throughout an individual’s life
Morphologic age
consists on biological development prediction registering height and weight,
which are compared with standard measure tables.
Dental age
Eruption and calcification of dental tissues has been used to determine dental age .
Developmental age
is a measure of skeletal growth and or maturity, independent of an individual’s
actual chronological age.
Bone age
presents an indication of physical development and maturation of the skeleton.
Skeletal maturation refers to the degree of development of ossification in bone.

CONCEPTS OF GROWTH:

GROWTH PATTERN:
Pattern in growth represents a set of proportional relationships of the body at any
one time, and change in these proportional relationships over time. In other words, the
physical arrangement of the body at any one time is a pattern of spatially proportioned
parts.
Cephalocaudal gradient of growth explains the proportional relationships of the
body and how it changes with age. Development proceeds in a wave, from the cephalic
towards the caudal portion. The head in general develops before the extremities. The
limbs develop from the proximal to distal. This phenomenon is termed as the law of
developmental direction or cephalocaudal progression. This law of cephalocaudal
progression illustrates the concept of differential growth. Differential growth refers to the
fact that various tissues of the body grow at different rates. As a result each unit of the
body contributes unequally to the total size attainment at various points in time.

Differential somatic growth:

In fetal life, at about the third month of intra uterine development, the head takes
up almost fifty percentage of the total body length. At this stage the cranium is large
relative to the face and represents more than half the total head. In contrast, the limbs are
still rudimentary and the trunk is under developed.
 By the time of birth the trunk and the limbs have grown faster than head and face,
so that the proportion of the entire body devoted to the head has decreased to about
30% .The overall pattern of growth thereafter follows this course with the progressive
reduction of relative size of the head to about 12% of the adult. At birth the legs represent
about 1/3rd of the total body length, while in the adult they represent about half. There is
more growth of the lower limbs than the upper limbs during post natal life.
Differential Craniofacial growth:
In the face of the new born the largest to the smallest dimensions are width, height and
depth respectively. Postnatally, the face grows most rapidly in depth followed by height,
with the slowest rate of growth being found in width. The disproportionate increase in
these dimensions demonstrate a developmental gradient that brings about a change in the
form.
There is a gradient of growth in the depth of the face from cranial base to the
mandible. The early cessation of growth in the anterior cranial base following the
completion of growth of the maxilla (at 10-12 years of age) and the continuing growth of
the mandible are directly responsible for the altered spatial relationship between the
maxilla and the mandible. Differential growth occurs even within the same bone such as
mandible, in which the ramus and corpus increase in size at different rates .Further more
the upper and lower components of total anterior face height grow differently .
Scammon’s four dissimilar curves (1930) depict growth and general stature as well as
several types of body tissues: neural, lymphoid and genital. As with the general growth
curve for stature, these curves accelerate rapidly during the first trimester and then
decelerate between the second and third trimesters of intra uterine life.
There is an accelerating phase during the first trimester in utero and a decelerating
phase from the second trimester onward. During early childhood, growth of brain is very
rapid by the sixth year; the brain has reached 90-95% of adult size. Consequently neural
tissues do not exhibit an adolescent growth spurt. Thus the neural curve is characterized
by two phases.
During childhood the lymphoid tissues (adenoids, lymph nodes, thymus and
intestinal lymphoid masses grow very rapidly and by pre adolescence they achieve nearly
200% of final adult size. With the onset of puberty, lymphoid tissues begin a negative
growth phase & their size decreases tremendously, until adult proportions are reached
.thus the lymphoid tissues have a four stage curve; an accelerating phase in the first
trimester in utero, a decelerating phase until about four years of age and accelerating
phase until adolescence and a rapid decelerating phase.
A third pattern of differential growth is seen in genital tissues. These tissues grow
very slowly during childhood and with the onset of adolescence exhibit a tremendous
spurt of growth . Prior to the adolescent spurt, the genital tissues have only attained 20%
of final adult size.

GROWTH VARIABILITY:
Everyone is not alike in the way that they grow .It is clinically very important to decide
whether an individual is merely at the extreme of normal variation or falls outside the
normal range. .This can be done by the use of standard growth chart. The solid lines on
the graphs show the normal variability as derived from large scale studies of groups of
children,. An individual who stood exactly at the mid point of normal distribution would
fall along the 50% line of the graph. One who was larger than 90% of the population
would plot above the 90% line.
These charts provide a general guide line that if a child falls beyond the range of 97%
of the population should receive special study before being accepted as just an extreme of
normal population. It can also be used to follow a child overtime to evaluate whether
there is an unexpected change in the growth pattern. This means that a child s growth
should plot along the same percentile line at all ages.

GROWTH TIMING:
Variation in timing arises because the same event happens for different individuals
at different times or viewed differently.The biologic clocks of different individuals are set
differently, these are particularly evident in the human adolescents as early vs late
maturers.
Because of time variability, chronologic age is often not a good indicator of an
individuals growth status. Timing variability can be reduced by using developmental age
as an expression of individuals growth status.

GROWTH RHYTHM:
Human growth is not a steady and uniform process of accretion in which all parts
of the body enlarge at the same increment in successive years.There is a great individual
variation in the inception ,intensity and duration of various phases of growth rhythm .The
first and most rapid movement of growth rhythm extends in both sexes, from birth to the
fifth or sixth year. It is most intense and rapid during the first two years .There follows a
slower increase terminating in boys at about 10-12th year and in girls no later than 10th
year. Then both sexes enter upon another period of accelerated growth- adolescence –
which is completed in girls between 14 and 16th years , but extends in boys through 16th
or 18th year .the final period of slow growth ends between 18 th and 20th years in the
female sex but does not terminate in boys until up to 25th year
GROWTH SPURT:

Certain growth centers are responsible for a greater amount of increment than others.Not
all growth centers in an organ or a part are active at the same time; some complete their
growth activity when others are just beginning .This uneven activity is responsible for the
interpretation of growth as appearing in spurts.
JUVENILE ACCELERATION:

Although the jaw growth follows the curve for general body growth, the correlation is not
perfect. A significant number of individuals especially among the girls there is juvenile
acceleration in jaw growth that occurs 1-2 years before the adolescent growth spurt. This
juvenile acceleration can equal or even exceed the jaw growth that accompanies the
secondary sexual maturation . In boys , if a juvenile spurt occurs it is nearly always less
intense than the growth acceleration at puberty.

Sex hormones produced by the adrenal glands first appear at the age of 6 in both
sexes, primarily in the form of a weak androgen (DHEA-Dihydroepiandrosterone). This
activation of adrenal component of the system is referred to as adrenarche. DHEA
reaches a critical level at about age 10. Because of the greater adrenal component in the
early sexual development in girls the juvenile acceleration is more prominent in them.

SOMATIC CHANGES:
Adolescent growth stages vs secondary sexual characterics.

Girls
Total duration of adolescent growth: 3.5 years

Stage 1: Beginning of adolescent growth

Stage 2: ( about 12 months later) Noticable breast development, axillary hair more
pubic hair.
Peak velocity in height

Stage 3: (12-18 months later) Menarche,broadening of hips with adult

fat distribution, breast development completed
Growth spurt ending

BOYS
Total duration of adolescent growth: 5 years
 Stage 1: beginning of adolescent growth fat spurt,weight gain,feminine
fat distribution.

Satge2: (about 12 months later) redistribution of fat , reduction in fat, pubic hair ,
growth of penis.
Height spurt beginning

Stage3: (8-12 months later) facial hair hair appears on upper lip only, axillary
hair , muscular growth with harder and angular
Peak velocity in height
body form.

Satge 4 (15-24 months later) facial hair on chin and lip , adult distribution of
pubic and axillary hair , adult body form.
Growth spurt ending

CRANIOFACIAL CHANGES:
Mitani(AJO 1977) concluded both boys and girls experienced growth spurts in the linear
dimensions of the cranial base, maxilla, and mandible and that, on the average,
approximately 60% of the sample showed coincidence of timing of the maximum peak
occurrence. Similarly, Lewis et al.(AO 1985) reported that pubertal spurts were common
in both the cranial base and the mandible, occurring in 77% of the girls and 85% of the
boys.
CRANIAL BASE:
The cranial base is of considerable importance to the orthodontist as it serves as a
reasonably stable reference structure in roentgen-cephalometric analyses.
Lewis and Rocke (AO 1974) studied the sex difference in in the elongation of cranial
base during pubescence.He compared the growth spurt in the cranial base with the PHV,
skeletal age as assessed by hand wrist radiograph.
Rate of elongation of cranial base:
In boys the rate of elongation of Ba-N decelerated from 8.5 to
11.5 yrs but then accelerated markedly until about 13yrs;later in decelerated at an
increasing rate.Similar changes were seen in girls but occurred about 2 yrs earlier than
boys. The rate of elongation was more in boys (84 %) than girls (25 %);
The rate of elongation of S-N and Ba-S decelerated from 8.5 to 11.5 yrs in boys
and 8.5 to 9.5 yrs in girls;later there acceleration was acceleration at about 12.5 to 13.5
yrs in boys and 10.5 yrs in girls.The rate of elongation of S-N was more than 3 times the
minimum rate before puberty. For girls the maximum rate exceeded the minimum rate by
only 9 %; but only a small sex difference in rate of elongation for Ba-S.
Absolute change:
The absolute changes (mm/yr) for Ba-N and S-N(more striking) were
markedly greater in boys than girls,whereas the increase was similar in both sex for Ba-S.
Pubertal spurts in stature occurred at about 2 yrs later for boys than
girls.There was a similar sex difference in timing of pubertal spurts in cranial base
lengths.These sex difference in timing were markedly reduced when abiological age
based on onset of ossification of ulnar sesamoid, was substituted for chronological age.
Henneberke and Prahl-Andersen (AJO 1994) investigated the growth changes of the
cranial base (S-N, N-Ba, and S-Ba) between 7 to 14 years of age. According to the
examination of the whole group, the cranial base displayed sexual dimorphism in
absolute size, timing and amount of growth.

The velocity curves for the distances N-Ba and S-N in boys show a rapid decrease until
10.1 years of age for N-Ba and 10.31 years of age for S-N, followed by a rapid increase.
For S-Ba ,growth velocity is constant .

The girls' velocity curve of S-N shows deceleration followed by acceleration to a much
lesser extent: there is a slow decrease until 11.0 years of age followed by a slow increase
in velocity. For N-Ba and S-Ba ,growth velocity is constant .

All cranial base dimensions examined in this study were considerably greater in
boys than in girls. Girls did not show growth spurts in the cranial base distances, whereas
all boys showed growth spurts for S-N and N-Ba. Size differences between boys and girls
were largely established before 7 years of age and increased after 10.5 years of age,
especially for the distances S-N and N-Ba.

According to Ford(1958) individual segments of the cranial base follow

either the neural or the general skeletal pattern of growth, From nasion to foramen cecum
and from sella to basion general skeletal growth is present, whereas from sella to foramen
cecum neural growth is apparent. (Neural type of growth is characterized by very rapid
growth in the first 2 to 3 years, falling off rapidly and almost finished by the age of 7 to 8
years). Growth of the anterior part of the cranial base is still necessary after the brain has
virtually ceased to grow, at 7 to 8 years, to allow for facial growth, This growth takes
place almost entirely by increased pneumatization of the frontal and ethmoid bones, so
further increases in S-N are mainly contributed by growth of the frontal bone. Rapid
growth of the sinuses continues until the age of 12 years, when they reach nearly adult
size.

Histologic and microradiographic studies by Melsen and Thilander and

Ingervall showed that the increase in S-Ba length is ascribed primarily to growth activity
at the sphenooccipital synchondrosis. The age of obliteration at this junction is about 13
to 16 years in boys and 11 to 14 years in girls shown by laminagraphy,. This means, that
during the age range 7 to 14 yrs, the synchondrosis is still open but close to closure and
thus to the termination of growth in most of the subjects. It is to be expected therefore,
that the growth changes taking place in this synchondrosis are very small. According to
Ohtsuki et al. the length of the distance S-Ba increases slowly, but constantly, until early
adulthood (17 years).

MAXILLA:
Reilly (AO1979) conducted a longitudinal cephalometric study in girls to assess
the timing,amount and rate of maxillary growth during puberty and to determine whether
peak velocity ,menarche and onset of epiphyseal –diaphyseal fusion occurred before or
after the peak velocity in maxillary length.She concluded that a great individual
variability is present in the timing of maximum increment in ANS-PNS,The timing of the
maximum increment of growth for maxillary length ranged from 11 to 15yrs.The smallest
amount of growth at peak was 1.5 mm and the largest 3 mm. Duration of the spurt was 2
to 3 yrsThe maximum increment in maxillary length occurred before as well as after
menarche,onset of epiphyseal fusion and peak height velocity.The early maturing
individuals showed larger increments than the late maturing.
Bishara et al in AJO 1982 conducted a study to describe, on an annual basis from 8 to
17 years of age, (1) the anteroposterior changes in the size of the maxilla, A-Ptm,(2) the
anteroposterior changes in the relationship of the maxilla to the cranial base, SNA(3) the
anteroposterior changes in the relationship of the maxilla to the mandible,ANB and
NAPog(4) the relationship between changes in standing height with the changes in the
above parameters.Three periods of growth were also compared: premaximum, maximum,
and postmaximum.
The results showed that
1. The changes in standing height and various facial parameters were significantly
different in the maximum, premaximum, and postmaximum periods in both males and
females
2. The growth profile of standing height was significantly different from the parameters
describing maxillary length and relationship as well as maxillary-mandibular relationship.
3. Between the ages of 8 and 17 years there was a significant over-all change in all
parameters examined. The respective changes for males and females in standing height
were 48.3 and 36.7 cm.; for A-Ptm, 7.5 and 5.1 mm.; for SNA, 1.7 and 0.4 degrees; for
ANB, – 0.6 and – 1.0 degree; and for NAPog, – 3.8 and 3.6 degrees.
.4 . The changes in maxillary relationship were significantly different in the maximum
period in males only.
.5. Males exhibited significant increase in the prominence of the maxilla in relation to the
cranial base. There was a relatively greater increase in the prominence of the mandibular
dentition in relation to the maxillary dentition, and the bony chin was found to increase
more in prominence than the denture bases
8. The change in maxillary-mandibular relationship was not significantly different in the
three periods of growth.
9. Autocorrelation analysis revealed that the growth profile of the facial parameters could
not be predicted from the growth profile of standing height of the same individual; that is,
the growth profile of height was found to have a low predictive value in determining the
growth profile of any of the other parameters.
TRANSVERSE CHANGES
Melsen used autopsy material to histologically examine the maturation of the mid-palatal
suture at different developmental stages. In the ‘‘infantile’’ stage (up to 10 years of age),
the suture was broad and smooth, whereas in the ‘‘juvenile’’ stage (from 10 to 13 years) it
had developed into a more typical squamous suture with overlapping sections.Finally,
during the ‘‘adolescent’’ stage (13 and 14 years of age) the suture was wavier with
increased interdigitation..
As reported by Wertz, with increased age the fulcrum of maxillary separation tends to be
displaced more inferiorly, nearer to the activating force. In children, the fulcrum may be
as high as the frontomaxillary suture, whereas in adolescents the fulcrum is much lower.
These differential, age-dependent effects may be attributed to the increased resistance to
maxillary separation by the circummaxillary structures because of increased calcification
in the sutural skeletal structures.

MANDIBLE:
The adolescent growth spurt in the dentofacial structures, specifically
in the mandible, is one of the most frequently mentioned concepts in facial growth.
Clinicians have been told to gear their treatment timing so that it will coincide with the
adolescent growth spurt.
Björk (1955) examined the changes with age in the relationship of the maxilla to the
mandible and found that mandibular prognathism generally increased slightly during
adolescence, with a wide range of individual variation from the general growth pattern.
In the Bolton Standards, the ANB angle showed a rapid decrease from 1 to 3 years of age
and then continued to decline gradually through the age of 18 years. Similarly, NAPog
reflected a rapid increase in relative mandibular prognathism from 1 to 2 years and a
gradual increase through 18 years of age. The changes were very similar for males and
females.
The most accurate and reliable data on this subject can be obtained from
studies using metallic implants. In a 1963 study, Bjork, evaluated the growth of the
condyles in 45 boys between 7 and 21 years of age. Of the 45 boys evaluated in the study,
Bjork found that only 11 individuals (less than 25% of the sample) had what he was able
to describe as a ‘‘discernible pubertal growth variation.’
The magnitude of the spurt,
For 11 subjects, Bjork described a slower 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. For the rest of the 34 subjects in the study there was a more
steady annual condylar growth averaging 3.0 mm during the same period. As for the
timing of the spurt, the mean age for its occurrence was 14.0 years with a range between
12 and 15 years.

Mitani in 1977 A "growth spurt" occurred in the maxillary complex, as well as in the
mandibles of both boys and girls. The timing of the maximum peaks in craniomaxillary
and mandibular growth coincided in eleven of seventeen boys and seven of thirteen girls.
The magnitudes of the growth spurts and the total growth increments were greater in boys
than in girls. Mitani concluded that there is a tendency for the growth of the maxilla and
mandible to be correlated as a whole in both rate and timing to produce and maintain a
proper basal relationship of the dentures. He also noted that in the cases which did not
show synchronization, the amount and direction of growth would have a chief role in
determining the occlusal relationship.
Bishara et al in AJO 1981 conducted a study to (1) describe
the anteroposterior changes in the size of the mandible on an annual basis from 8 through
17 years of age, (2) describe the anteroposterior changes in the relationship of the
mandible to the cranial base on an annual basis from 8 through 17 years of age, and (3)
determine the relationship between changes in standing height and the changes in the
above parameters.
The results showed that
1. The growth profile of the absolute and incremental changes in standing height and the
various mandibular parameters were significantly different between boys and girls.
2. The ages for both the maximum and minimum period changes were earlier in girls.
3.The difference between the ages of minimum and maximum changes was greater in
boys.
4. Between the ages of 8 and 17 years there was a significant over-all change in all
parameters examined. The respective changes for boys and girls in standing height were
48.3 and 36.7 cm.; for Ar-Pog, 21.1 and 13.7 mm.; for SNB, 2.4 and 1.6 degrees; for
SNPog, 3.3 and 2.6 degrees; and for PWPog, 3.7 and 3.4 degrees. These findings indicate
an increased prominence of the chin point relative to point B. The same findings also
indicate that the changes at S and/or N tend to mask some of the changes at Pog.
5. The changes in standing height were significantly different in the maximum,
premximum, and postmaximum periods in both boys and girls.
The changes in standing height & mandibular length (Ar-Pog) were significantly different
in all 3 periods in both boys and girls.
7. The changes in mandibular relationship were not significantly different in the
maximum and premaximum periods in either boys or girls. The magnitude of change in
the postmaximum period tended to be smaller than in the other two periods.
8. The magnitude of change was significantly greater in boys than in girls for both
standing height and mandibular length but not for mandibular relationship.
9. Autocorrelation analysis indicated that the growth profile of Ar-Pog in girls had the
highest correlation with the growth profile of standing height .All correlations to
mandibular relationship were low.

Class II Malocclusion

Peter W. Ngan, in Seminars in Orthodontics 1997

Longitudinal records from the Ohio State University Growth Study were
used to compare the skeletal growth changes between Class II division 1 and Class I
female subjects between ages 7 and 14.
No significant difference was found in cranial base dimension between the
Class I and Class II subjects
. In Class II subjects, the maxilla (S-N-A) was found to be normally related to
the cranial base.
However, mandibular position (S-N-B and S-N-Pog) was found to be
significantly more retrusive in Class II when compared with Class I subjects. Mandibular
length (Ar-Gn) and corpus length (Go-Gn) were found to be shorter in Class II subjects.
The ratio of PFH to AFH was found to be smaller in Class II subjects. This is
particularly apparent during the pubertal growth period. The y-axis and mandibular plane
angle were more open in Class II subjects which also contributed to the retrusive position
of the mandible.
Maxillo-mandibular difference (A-N-B) between Class I and II subjects was
present at age 7 and persisted through puberty, maintaining a greater angle of convexity
(A-N-Pg) in Class II subjects. These results suggest that Class II malocclusion can be
detected early. The majority of the Class II cases showed mandibular skeletal retrusion or
a combination of horizontal and vertical abnormalities of the mandible rather than
maxillary protrusion. These skeletal differences remain through puberty without
orthodontic intervention. Individual variations were found within each type of
malocclusion.
Class III malocclusion
Sakamoto et al in 1996 did a 5 yr longitudinal cephalometric study on the
craniofacialgrowth pattern of skeletal Class III malocclusion during the pubertal growth
period in boys from 10 to 15 yrs. The pubertal growth peaks of all subjects, which was
evaluated by ossification events of hand-wrist roentgenograms and the incremental curve
of body height, were noted to be around the middle of the pubertal growth period. The
results were as follows:

Cranial base.
There was no significant difference in the total increase of anterior cranial base
(S-N) between the two groups. On the other hand, the total increase of posterior cranial
base (S-Ba) was significantly less in the Class III when compared with the Class I group.

Maxilla.
There was no significant difference in the size of maxillary length (A'-Ptm') between
the two groups. The average maxillary growth changes also showed no significant
difference between the two groups.

Mandible.
The mean values of the total mandibular length (Gn-Cd) and the body length
(Pog'-Go) of the Class III were significantly greater, whereas the ramus height
(Cd-Go) was not significantly greater than the Class I group. The average mandibular
growth changes measured at Cd-Gn were 17.7 mm in the Class III group and 16.1 mm in
the Class I group, showing no significant difference between the two groups.

Intermaxillary relationship.
The principal skeletal framework of the two groups was maintained
during the pubertal period. The occlusal plane angle (SN to OP) of Class III subject
remained unchanged. However, the occlusal plane angle in the Class I subjects showed
counterclockwise rotation during this growth period. There were significant differences in
the total change of the WITS appraisal between the two groups.
In conclusion, the skeletal Class III malocclusions showed neither excessive mandibular
growth nor deficient maxillary growth when compared with the Class I subjects. The
skeletal malocclusion seemed to have been established before the pubertal growth period
and maintained thereafter. The dentoalveolar disharmony, on the other hand becomes
more severe during this period.
SOFT TISSUE CHANGES:
The development of the soft tissue profile is a result of complex changes within the hard
and soft tissue structures of the face. Altemus found great variability in the soft tissue
thickness of individual faces. Growth changes in the integument of the face have also
been described by Subtelny,Burstone, Chaconas and Bartroff and Bishara et al.
Subtelny in AO 1961 reported that the lips tend to increase in length and
thickness as a result of growth until approximately age 15 years and that, after full
eruption of the maxillary and mandibular central incisors, a constant vertical relationship
was maintained to the edge of the incisors.
Ram S. Nanda et al in AO 1990 conducted a study to describe longitudinal growth
changes in the soft tissue profile between the ages of 7 and 18 in reference to the
pterygomaxillary vertical (PMV) plane drawn from the sphenoethmoid point (Se) to the
pterygomaxillary (ptm) point.(The sphenoethmoid synchrondrosis is a stable landmark
after the age of 4 years. Enlow, Kuroda and Lewis suggested that in craniofacial growth
studies, the pterygomaxillary vertical plane may be relatively more stable for
measurements.)
The results showed
Nose height:
At 7 years the median size of the upper nose height (n'-prn') was nearly the same in both
sexes Both sexes showed a rapid increase between seven and eight years. The increase
slowed down between 8 and 11 years, with prepubertal and pubertal accelerations in
growth at 11 years and during 14 to 17 years.
The lower nose height (prn'-ans") increased more in males than the females. The major
differential increase in this measurement for the males occurred at age 17. The female
lower nose height attained adult size by age 15 as compared to the male group that was
growing even at the age of 18. The upper nose to lower nose ratio was approximately 3:1
and remained nearly the same over the entire study period.
Nose depth and sagittal depth of the underlying skeleton:
Growth curves for nose depth (prn' to prn) show that from the age of 7 to 16 the median
growth curves for males and females run parallel to each other The size of the nose depth
is approximately similar but the curves begin to diverge from age 16 to 18, the male
group showing growth acceleration compared to the female group (nearly three
millimeters gain from 17 to 18 years).
At 7 years the ratio of nose depth (prn'-prn) to sagittal depth of the underlying skeleton
(PVM-prn') was 1:2 in both sexes. By 18 years, this ratio had changed to 1:1.5 in males
and 1:1.6 in females.
Inclination of the nose:
The angle of the dorsum of the nose to the PMV plane is dependent on the sagittal growth
of the nose.Between ages 8 to 16, the size of this angle was nearly similar in both sexes.
However, at 18 the male group showed an approximate 4.5 degree increase. Since the
nose depth in males showed continued growth, this angle would be even larger for the
adult males.
Growth changes in the inclination of the base of the nose, angle PMV-ans'-prn, were
rather small. There was an average increase of five degrees in the female and an even
smaller increase in the male sample indicating that the inclination of the nasal base in the
nasolabial angle changes little if any after seven years.

Upper lip height

The mean measurements from soft tissue subnasale (Sn) and upper lip stomion from ages
7 to 18 years increased 2.7 millimeters in females and 1.15 millimeters in males .A large
part of this increment occurred between 9 and 13 years for females and 9 and 15 years for
males and the percentage incremental changes after 11 years were similar in both sexes.
Lower lip height
Lower lip height was measured from lower lip stomion to the soft tissue B' point. The
lower lip in the males increased 4.2 millimeters but only 1.5 millimeters in females. The
major increase in lower lip length in the male group occurred between 10–11 years and
13–18 years. The females, however, experienced major growth increment from 11–13
years. This can assist in treatment planning because estimated growth changes can project
the most esthetic and functional vertical and sagittal position of the incisors.
Thickness of the lips
The variability in thickness of the upper and lower lips can affect the degree of facial
convexity. Due to the variability of lip thicknesses at various points along the facial
profile, upper and lower lip thicknesses were determined at four points.
1.Upper lip thickness at point A (A-A') There was an average increase of 4.7 millimeters
in males and 3.5 millimeters in females, i.e. from 12.5 millimeters at 7 years to 17.2
millimeters at 18 years and from 11.4 millimeters at 7 years to 14.9 millimeters at 18
years, respectively.
2.Upper thickness at labrale superius (Ls to Ls'):
The mean thickness of the upper lip at labrale superius increased from 13.9 millimeters to
17.1 millimeters in the males and 11.8 millimeters to 12.5 millimeters in the females from
7 to 18 years. The increase in thickness for the males was relatively much larger than the
increase in females (3.2 millimeters to 0.7 millimeter). From the growth of this dimension
in the males, it appeared that the thickness was still increasing at age 18 years as
compared to the female growth curves that had levelled off at 14 years
3.Lower lip thickness at labarale inferius (Li-Li'):
The mean thickness of the lower lip at labrale inferius at 7 years was 13.3 millimeters in
males and 11.4 millimeters in females. This increased by 2.4 millimeters and 1.4
millimeters in the two sexes, respectively. Females, as a rule, displayed thinner lips at
labrale inferius than males and reached a peak in thickness at 13 years as compared to 18
years for males
4.Lower lip thickness at B point (B-B'):
The mean increase in thickness at B point was 2.8 millimeters in males and 1.6
millimeters in females. Males had thicker lips at B point than females. This became more
pronounced after the age of 14 (Figure 13).
Growth at the chin
The soft tissue thickness at the chin was measured along two points: Pgs, the soft tissue
pogonion and Pg', a point at the level of skeletal pogonion (Pg).
The soft tissue thickness at the level of the soft tissue pogonion showed a total increase of
2.7 millimeters in males and 2.0 millimeters in females.
Sagittal measurements along the pogonion line:
The perpendicular line drawn to PMV through pogonion (Pg) touches the soft tissue
profile at Pg' and the posterior border of the symphysis at point pg". Three linear
measurements were made: soft tissue thickness at pogonion (pg to pg'); thickness of the
symphysis (pg-pg"); and skeletal length of the mandibular corpus from posterior border
of the symphysis (pg") to the PMV plane The latter measurement reflects the amount of
anterior displacement of pogonion.
In both sexes all three distances increased continuously, males showing larger increments
than females. Over the period studied, the total growth increments for Pg" to PMV, Pg to
pg' and pg to pg" were 16.1 millimeters, 2.4 millimeters and 1.5 millimeters for the male
group and 11.7 millimeters, 1.5 millimeters and 0.8 millimeter for the female group,
respectively. The largest increments recorded were for displacement of the symphysis in
the sagittal direction and the smallest for thickness of the mandibular symphysis.
The corpus measurement from the posterior border of the symphysis (Pg") to the PMV
plane showed a steady increase between 7 and 18 years. The size for both sexes was
approximately similar at 7 years, and the curves progressed parallel to each other until 15
years when the male sample had larger increments than the female sample. The values
show that the corpus length of the mandible Pg" to PMV plane experienced larger
proportionate increase than Pg to Pg' and Pg to Pg".
Inclination of the hard tissue chin (Pg-B-PMV) and soft tissue chin (Pgs-B'-PMV)
Both of the angles show considerable amount of variation at all age periods. The central
trend indicates that these angles increased by approximately seven degrees over the
period of this study, which indicates that the slope of the chin became more oblique.
Although the inclination of the hard tissue chin was greater in males than females, the
soft tissue chin inclination was approximately the same in both sexes.
Measurements of the lips to the esthetic plane
An evaluation of the upper lip relative to the esthetic plane (Ls-E) indicated a gradual
retrusion of the lip relative to this plane in both sexes In males, the means were -0.8
millimeter at 7 years and -4.2 millimeters at 18 years. In the females, the means were -0.9
millimeter at 7 years and -5.4 millimeters at 18 years. The amount of retrusion of upper
lip in both sexes was nearly the same.
The lower lip to esthetic plane (Li-E) measurement in the males was -0.4 millimeter at 7
years and -2.7 millimeters at 18 years, whereas in the females it was -0.6 millimeter at 7
years and -2.5 millimeters at 18 years
The means for upper and lower lip to the esthetic plane values suggest an increasing
retrustion of the lips relative to the nose and chin with age. These changes can be
accounted for by the increase in nasal depth and height accompanied by anterior growth
displacement of the chin. It is reasonable to assume that the mean values of this variable
at age 18, as indicated in this study, should not be considered final. It is apparent from
this work that growth of mandible, nose and chin was not completed by age 18 years
especially in the male group. Any additional anterior movement of the nose and chin is
likely to increase the linear measurements from the lips to the E-plane.
Nasolabial angle (Cm-Sn-Ls)
The nasolabial angle decreased slightly from 7 to 18 years in both sexes. The means at 7
years were 107.8±9.4 degrees for males and 114.7±9.5 degrees for the females. At 18
years the means were slightly reduced to 105.8±9.0 and 110.7±10.9 degrees
Mentolabial angle (Li-B'-Ct)
The mean in the males at 7 years was 125.3±8.4 and 18 years 125.1±12.9 degrees. In the
females, it was 136.1±11.6 at 7 years and 127.1±12.9 degrees at 18 years.
. The slightest change in the posture of the lips can cause large variations. The amount of
decrease in these angles is not significant in view of the large standard deviation. It will
suffice to note that the growth changes noted are small over the period of this study.
The position of the lips is largely dependent upon the incisor inclination. Uprighting the
maxillary and mandibular incisors enlarges the nasolabial and mentolabial angles. The
inclination of the columella (Cm) and tip of the nose can profoundly affect the nasolabial
angle.
Sex differences in size of the soft tissue measurements, suggest that the age at
which orthodontic treatment is commenced will be important, especially in patients
requiring orthognathic surgery in conjunction with orthodontic treatment.

Bishara et al in AJO1985 evaluated the soft

tissue parameters between the ages of 5 and 25 years
1, Angle of total facial convexity (Gl'-PrPog')
2, Angle of facial convexity with the nose not included (Gl'- SLC-Pog'
3. Holdaway's soft-tissue angle (LS-Pog': NB)
4. Merrifield's Z angle
5. Ricketts' esthetic plane to the upper lip, in millimeters (Pr-Pog': LS)
6. Ricketts' esthetic plane to the lower lip, in millimeters (Pr-Pog': LI).
The subjects of this study consisted of 20 males and 15 females for whom lateral
cephalograms taken were available.
Results
Total facial convexity
In all male and female subjects, total facial convexity increases with age This increase in
total facial convexity has been shown to be due primarily to a greater increase in nasal
prominence relative to the rest of the soft-tissue profile with growth. There is a significant
increase in facial convexity occurs from age 5 to age 9. From age 9 to age 13 facial
convexity remains relatively stable, and then it decreases from 13 years to adulthood.
Holdaway's soft-tissue angle
Holdaway11 suggested that, with a normal ANB angle of 1° to 3°, his soft-tissue angle
should be 7° to 9°. The larger the ANB angle, the larger Holdaway's soft-tissue angle,
unless there is soft-tissue compensation.
The findings suggest that Holdaway's soft-tissue angle might be an age-dependent
variable. Thirty-four subjects demonstrated a decreasing Holdaway soft-tissue angle with
age, while one subject demonstrated an increase in this angle with age.
Merrlfield's Z angle
Merrifield found that, in the 11 to 15-year age group, the average Z angle was 78° ± 5°,
with females demonstrating higher Z angle values than males. In adults, he found the
average Z angle to be 80° ± 5°, with males exhibiting higher values than females.
In the present study, no sexual differences were found in either age group. The average Z
angle values were considerably lower than those reported by Merrifield. The average
values found in this study ranged from a low of 66.5° to a high of 73 .7°. Of the 35
subjects examined, 2 demonstrated no change in the Z angle with growth, 5 demonstrated
a decrease of 1° to 4° in the Z angle, and 28 demonstrated an increase in the Z angle with
growth. The discrepancy between these results and those presented by Merrifield can be
attributed to sample selection. Merrifield chose for his sample the 30 "best" cases with
normal FMA, IMPA, FMIA, and ANB angles as defined by Tweed.
Relative position of the upper lips to Pr-Pog'
Ricketts suggested this measurement to evaluate the position of the upper lip relative to a
tangent between the soft-tissue chin and tip of the nose. He found the upper lip to be
ideally 4.0 mm posterior to this plane for adult females. while in males it should be
slightly more retracted. The adult values of our study were much in agreement with those
given by Ricketts.But from the ages of 5 to 17 years, males consistently demonstrated a
more protrusive upper lip than females.
This finding is important in the planning of treatment of patients with orthodontic
problems. Specifically, the orthodontist should not attempt to treat an adolescent to the
adult standards, since in some persons the remaining growth might cause unfavorable
changes.
Relative position of the lower lip to Pr-Pog'
Ricketts found the lower lip to be ideally 2.0 mm posterior to the esthetic plane (Pr-Pog')
in adult females and slightly more posterior in males. The lower lip in females was found
to be, on the average, 2.08 mm posterior to the esthetic plane. The lower lip in males was
found to be slightly more posterior to the plane (3.98 mm). The lower lip becomes more
retrusive with age in both males and females.
In AJO 1996 the longitudinal growth and development of the soft tissue drape for boys
and girls with long and short vertical patterns was examined from age 7 to 17 years by
Nanda and Nanda. The sample was taken from the Denver Growth Study and consisted
of 32 subjects who were selected on the basis of their percentage of lower anterior
vertical face height. The sexual dimorphism was evident as anticipated for several soft
tissue measurements. The boys showed continued growth through age 16 years in
contrast to the girls who attained the adult size of the soft tissue integument around 14
years.
Upper lip height.
 The growth curves for the upper lip height showed that the male and female
subjects with long vertical patterns had a longer upper lip when compared with those with
short vertical patterns. Accordingly, they showed the greatest overall growth, increasing
by 3.3 mm (16.3%), whereas those boys with short vertical patterns showed a 1.5 mm
(7.7%) increase. The male and female subjects with long vertical patterns had less growth
completed at age 8 years than those with short vertical patterns. In addition, the female
short vertical pattern group was relatively more mature at age 8 years, with 95% of
growth completed.
Upper lip thickness at A point.
The boys with long vertical patterns had the thickest amount of soft tissue
from age 8 to 16 years. All groups showed steady growth to age 12 or 13 years, at which
time the female groups tended to plateau whereas the male groups continued to show
growth up to age 16 years. Overall mean growth changes from 8 to 16 years amounted to
an increase of 3.6 mm (28.7%) for the boys with long vertical patterns, whereas the boys
with short facial patterns increased 3.1 mm (25.3%). The girls showed slightly less
growth with 2.9 mm (25.3%) for those with long facial patterns and 2.3 mm (19.2%) for
those with short patterns. Both female groups had completed at least 85% of their growth
by age 8, whereas the male groups had completed between 82% and 83% at that time.
The girls with short vertical patterns were quick to mature and had completed growth by
age 13 years, whereas both male groups showed steady growth throughout the period of
investigation
Upper lip thickness at labrale superius:
The thickness of the upper lip at labrale superius showed relatively little change over
the period of study.The boys with short vertical facial patterns showed an overall increase
in thickness at 0.9 mm (6.5%), and the boys with long faces increased 0.8 mm (5.5%)
between the ages of 7 and 17 years. The girls with long-face patterns showed a reduction
of 1.1 mm (8.2%) and those with short facial types decreased 0.5 mm (4.1%) during the
same period. The boys and girls with long vertical facial patterns exhibited a thicker
drape at labrale superius than their counterparts with short vertical patterns. The
percentage growth completed curves showed that all groups were at least 95% complete
in their growth by age 8 years, and the girls with long vertical facial patterns were greater
than 100% complete at that time.
Upper lip to esthetic plane:
The growth curves for the upper lip to the esthetic plane revealed that the boys and girls
with long vertical patterns exhibited more protrusive lips at all age intervals. The overall
trend was for the lip to become more retrusive with age, and the boys and girls with short
vertical facial patterns showed the greatest amount of change from age 8 to 16 years.
These readings amounted to a 4.7 mm decrease for the boys and a 4.5 mm change for the
girls. The subjects with long vertical patterns exhibited a smaller decrease that was 1.7
mm for the boys and 3.0 mm for the girls.
Nasolabial angle:
Changes in the nasolabial angle with growth showed large variability. The
male subjects with short faces demonstrated a net increase of 4.02° in this angle between
the ages of 7 and 17 years, whereas those with long-face patterns increased by 1.89°. The
female subjects with short faces showed a net decrease of 0.96° in this angle, whereas
those with long faces, who showed the smallest mean readings throughout this period,
increased by 4.06°.
Lower lip height.
The trends noted for the lower lip were similar to those of the upper lip. The
boys and girls with long vertical patterns showed a greater vertical height of the lower lip
when compared with those with short vertical patterns. The subjects with long vertical
patterns also showed statistically significant changes over time with increments of 5.2
mm (35.1%) for the boys and 3.4 mm (24.8%) for the girls between the ages of 7 and 17
years. The boys with short faces grew 1.8 mm (12.9%), whereas the girls with short
patterns increased less than 1 mm (6.5%) in the same time period. At age 8 years, the
largest percentage of growth completed for the lower lip was for the girls with short
faces, with 95% completion, as compared with the males with long faces who were the
least with only 80% completion.
Lower lip thickness at labrale inferius.
The thickness of the lower lip at labrale inferius also revealed a similar
trend to that seen with the upper lip at labrale superius .The boys and girls with long
vertical patterns showed a thicker lower lip than those with short facial types throughout
much of the investigation. Mean overall growth changes were greater for the boys and
girls with short facial patterns who displayed 2.3 mm (20.0%) and 2.4 mm (20.8%)
increases, respectively. The girls with long facial patterns showed 1.2 mm (9.2%) and the
boys 0.8 mm (5.9%) increment between the ages of 7 and 17 years. The boys and girls
with long vertical patterns had a greater amount of growth completed at age 8 years than
those with short patterns, i.e., 93% for those with long faces as compared with 87% for
those with short faces. In addition, growth was completed for the long facial types by age
13 years, whereas those with short facial types continued to increase to age 16 years.
Lower lip thickness at B point:
The boys and girls with long faces exhibited larger mean values than the
short-face subjects throughout the study period The girls showed slow growth through
age 14 years when a plateau was reached. The boys continued to grow through age 16
years. Overall mean changes for the boys with short faces amounted to a 4.1 mm (48.0%)
increase from age 7 to 17 years, whereas those with long faces grew 3.8 mm (38.7%).
The girls with long vertical patterns showed the next largest mean increase at 3.4 mm
(34.2%), whereas those with short vertical patterns showed a 2.0 mm (22.9%) increase.
The boys and girls with short vertical patterns had slightly more growth at age 8 than
those with long vertical patterns. A rapid increase between ages 9 and 10 years was
detected for the boys and girls with long vertical patterns. The female groups had
essentially completed growth by age 14 years, whereas the male groups showed growth
through age 16 years.
Lower lip to esthetic plane.
The overall trend for the lower lip to esthetic plane showed that the lower lip
tended to become more retrusive with time and, as was seen with the upper lip, the boys
and girls with long vertical facial patterns had a more protrusive lower lip when
compared with those with short facial patterns In addition, the girls showed more
protrusive lips as compared with the boys, and their growth curves tended to flatten past
the age of 15 years whereas the male lips continued to become more retrusive through
age 16 years.
Mentolabial angle.
The mean value for the long-face male subjects was 124.3° at age 7 years and increased
by 4.3° until age 17, whereas that for the long-face female subjects was 129.8° at age 7
years and increased by 1.53°. However, the mean mentolabial angle in the short-face
subjects decreased that amounted to 11.46° for the boys and 15.82° for the girls. The
mean mentolabial angle at age 7 years for the long-face male and female subjects was
124.3° and 129.8° and for the short-face subjects was 120.2° and 135.3°, respectively.
Except at age 7 years, when the mentolabial angle for the short-face female subjects was
large, the male and female subjects with long-face patterns had the largest mean values
for this angle.
Growth of the soft tissue chin
The growth of the soft tissue chin was assessed from a line perpendicular to the pterygoid
vertical plane through hard tissue pogonion to its intersection with the soft tissue outline.
The growth curves for this measurement revealed that the boys and girls with long
vertical patterns had a thicker soft tissue drape than their counterparts with short facial
types throughout the investigatory period .The boys with short vertical patterns showed a
substantial growth spurt from age 13 to 16 years, whereas the remaining groups showed a
deceleration in the rate of growth during that time period. Consequently, the boys with
short patterns showed the greatest amount of overall change (2.9 mm, 33.3%), whereas
the boys with long patterns showed relatively little change at 0.8 mm (8.3%) between the
ages of 7 and 17 years. The girls with long vertical patterns showed an increase of 1.88
mm (18.6%), whereas those with short vertical patterns showed 0.8 mm (7.8%) of growth
in the same period. The curves for the percentage of growth completed revealed that the
boys with long vertical patterns were the most mature at age 8 years with greater than
92% of growth completed. Both female groups were about 88% completed at the same
age, whereas the male groups with short vertical patterns showed less than 82% of
completed growth. By age 12 years the boys with long facial types and both of the female
groups showed growth to be nearly complete, whereas the boys with short patterns were
only about 88% completed. This group, however, showed 12% of growth between ages
13 and 16 years.

Those with short facial patterns have a thinner soft tissue drape that may attempt to mask
the strong appearance of the mandible in profile. Conversely, those with long vertical
patterns have a thicker integumental profile which may be compensatory for the lack of
skeletal support.
The subjects with long vertical facial patterns experienced their pubertal growth spurt
earlier than the short-face subjects. This may have clinical implications in the timing of
orthodontic intervention and treatment.
CONSTITUTIONAL DELAY OF GROWTH AND PUBERTY(CDGP)
Prader defined CDGP as: constitutional delay of growth occurring in otherwise healthy
adolescents with stature reduced for chronological age,but generally appropriate for bone
age and stage of pubertal development, both of which are usually delayed.
Styne (1991) defined delayed puberty as the lack of development of secondary sex
characteristics by 14 yrs of age or failure to complete sexual maturation within 4.5 to 5yrs
after its onset. The age of onset of puberty varies greatly among the normal adolescents,
with 95% of boys entering puberty between 9.2 -13.8 yrs of age.(Tanner 1978).
Puberty concerns an interaction in the hypothalamo-pituitary –gonadal axis.Both sex
steroids and growth hormone are required for puberty .Individual with CDGP have a
delay in the progressive increase of sex steroid secretion. This is more common in boys
than girls and tends to have familial pattern.
CDGP is not a disease but condition in which puberty and its associated growth spurt
occur at an age that is near or beyond the extreme of normal range. These boys appear
remarkably healthy, but are shorter than their age matched peers through childhood.
Reassurance that puberty will occur on its own may be all that is needed. If they are older
than14yrs of age , a low dosage of testosterone can be offered so that they appear more
mature with no restriction of adult height.(Wilson et al 1998,Uruena et al 1992).
Verdonk (EJO 1999) observed that have shorter craniofacial dimensions compared to
healthy control boys.The observed growth delay in cranial base ,mandible and anterior
facial height can be explained,as the growth of these structures has been associated with
the pubertal growth spurt in height.Low dose testosterone in these subjects not only
accelerates the height growth rate,but also those of craniofacial parameters. The
exogenous testosterone may influence the growth directly or by enhancing the secretion
of growth hormone.The effect on growth rate of height is thought to result from
combination of these two effects on long bone and vertebral growth. As both GH and
testosterone are known to contribute to the mandibular growth ,the accelerated growth of
mandible is probably caused by combination of direct and indirect testosterone effects.
The development of the dentition is an integral part of craniofacial growth, even though it
is marginally related to other maturational processes. Dental maturation has been shown
to be mildly ,but consistently delayed in patients with delayed development.(Garn et al
1955;Kellar et al 1970; Pirinen et al 1995),but to a lesser degree than skeletal
maturation.Verdonck et al EJO 1999 evaluated dental age in boys with delayed puberty &
compared them with normal healthy boys. Dental age was assessed using the Demerjian
method .The results revealed that the dental age in CDGP boys are delayed significantly
than normal boys.

METHODS OF ASSESSING THE MATURATION:

The developmental status of a child may be best assessed not by
chronologic age .Children of the same chronological age vary in their maturity. Variation
in growth arises because biological clock for same events during growth are set
differently for different individuals.Racial diversity and environmental influences have a
marked effect on the rate of development of prepubertal child and adolescent with the
result that the chronological age need not necessarily reflect the progress which an
individual has made toward physiological maturity .Because of the wide individual
variation in the timing of the pubertal growth spurt, chronologic age cannot be used in the
evaluation of pubertal growth.
The various assessment methods of growth and development are as follows:
1, evaluation of increments in height,
2, the secondary sexual characteristics using the menarche and the pubertal voice, and
3, evaluation of skeletal age by maturation of the hand-wrists or vertebrae. ,
4, scoring of dental age using calcification and eruption stage of the developing dentition,
STANDING HEIGHT:
Peak growth velocity in standing height is the most valid representation
of rate of overall skeletal growth. It forms a useful historic longitudinal measure of an
individual's growth pattern but has little predictive value for future growth rate or
percentage of total growth remaining. Longitudinal measurements used to calculate peak
standing height growth velocity do provide the “gold standard” to assess the validity of
growth predictors.
Wetzel’s grid is an objective method of evaluating the physical fitness by using
the measurements of age , height and weight of children which are plotted in what he
terms as grids or channel system. Wetzel has shown that healthy children tend to develop
along given channels or preferred paths, without undergoing alteration of physique or
departing significantly from their own age schedules of development.
Many studies have shown a strong correlation between the peak of facial
growth and peak height velocity. Longitudinal records of height can therefore be used for
evaluation of the facial growth rate during puberty.
LIMITATION:
In the clinical context, longitudinal growth records of height for a
child are seldom available. Even with adequate records, it may be difficult to locate the
pubertal growth spurt before it is passed, since the increase in growth rate is often too
small, especially in many girls, to be clinically discernible.Most of the time the clinician
must base his judgment on a single examination and, therefore, determine the status of
the individual by cross-sectional evaluation alone. Stature alone is not an indicator of
maturity. Thus, additional information is necessary to estimate the maturation level of the
individual. Such information can be obtained from the dental, skeletal, and pubertal
development.
The Iowa Growth Study by Drs Meredith and Higley
The growth changes in standing height between 5 and 25 years as well as those
for various craniofacial parameters were divided arbitrarily into 3 stages, specifically: 5–
10,10–15 and 15–25 years. Standing height is usually used as a standard or indicator of
skeletal body maturation and was included in these evaluations. Approximately 40% of
the total change in standing height occurred between 5 and 10 years, another 40%
occurred between 10 and 15 years, and the balance occurred after 15 years. When the
females are compared to the males, the females have relatively greater growth increments
between 5 and 10 years than between 10 and15 years. These relative differences in the
magnitude of the changes in standing height between males and females are also found in
most linear facial dimensions such as face height and depth, but not as readily observed
when the facial relationships were evaluated.
In orthodontics it is more relevant to evaluate the individual's
maturation in relation to his or her own pubertal growth spurt. This presupposes
knowledge of relationships in time between maturation indicators and pubertal growth
events. Suitable maturation indicators for clinical orthodontics have been devised, and the
associations between these indicators and the peak of growth have been reported.
Hand wrist Radiograph:
Among various physiologic ages, bone age is indicative of trends in
pubertal growth and the assessment of a handwrist radiograph has proven to be a
satisfactory method of determining skeletal age.
Todd was one of the first investigators to evaluate skeletal maturation, in
1937.Greulich and Pyle have created a radiographic atlas of the skeletal development of
the hand and wrist. Tanner et al reported about the TW1 and TW2 methods of scoring
bone maturity by biologic weighted system.Julian Singer (1980) has described 6 stages
of development on the hand wrist radiograph. In 1982, Fishman proposed the System of
Skeletal Maturation Assessment (SMA) that identifies main skeletal maturity indicators
(SMIs) that are related to the adolescent period of development. Hagg and Taranger
skeletal maturity indicators (AJO 82) They described a method in which skeletal
development is assessed by ossification of the ulnar sesamoid of the metacarpophalangeal
joint of the first finger (S) and certain specified stages of three epiphyseal bones; the
middle and distal phalanges of the third finger (MP3 and DP3) and the distal epiphysis
of the radius R
Cervical vertebral age:
The use of cervical vertebrae to determine skeletal maturity was suggested by
Lamparski in 1972.
Six stages of cervical vertebral maturation were described
Stage 1: All inferior borders of the bodies are flat. The superior borders are strongly
tapered from posterior to anterior.
Stage 2: A concavity has developed in the inferior border of the second vertebrae and
the anterior vertical heights of the bodies have increased.
Stage 3:A concavity has developed in the inferior border of the third vertebra. The
other inferior borders are still flat.
Stage 4: All bodies are now rectangular in shape. The concavity of the third vertebra
has increased, and a distinct concavity has developed on the fourth vertebra. Concavities
on 5 and 6 are just beginning to form .
Stage 5: The bodies have become nearly square in shape and the space between the
bodies are visibly smaller concavities are well defined on all six bodies.
Stage 6: All bodies have increased in vertical height and are higher than they are
wide . All concavities have deepened.
HASSEL & FARMAN AJO 1995

Initiation:
Inferior borders of 2nd 3rd and 4th cervical vertebrae are flat at this stage.The third
and fourth vertebrae are wedge shaped and the superior vertebral borders are tapered
from posterior to anterior.100% of pubertal growth remains.
2. Acceleration:
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. 65-85% of pubertal growth remains
3. Transition :
Distinct concavities are shown on the inferior borders of second and third
vertebrae. A concavity begins to develop on the inferior borderof fourth vertebrae.
Vertebral bodies of third and fourth are rectangular in shape. 25-65% of pubertal growth
remains.
4. Deceleration stage:
Distinct concavities can 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.10-25% of pubertal growth remains.
5. Maturation stage:
Marked concavities are observed on the inferior borders of second, third and fourth
cervical vertebrae.Vertebral bodies of third and fourth are almost square in shape.5-10%
of pubertal growth remains
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.

Franchi, Bacetti & McNamara (2005 – Seminars in orthodontics ) presented an

improved version of the CVM method .
CVMS I: the lower borders of all the three vertebrae are flat, with the possible exception
of a concavity at the lower border of C2 in almost half of the cases. The bodies of both
C3 and C4 are trapezoid in shape (the superior border of the vertebral body is tapered
from posterior to anterior). The peak in mandibular growth will occur not earlier than one
year after this stage.
CVMS II: Concavities at the lower borders of both C2 and C3 are present. The bodies of
C3 and C4 may be either trapezoid or rectangular horizontal in shape. The peak in
mandibular growth will occur within one year after this stage.
CVMS III: Concavities at the lower borders of C2, C3, and C4 now are present. The
bodies of both C3 and C4 are rectangular horizontal in shape. The peak in mandibular
growth has occurred within one or two years before this stage.
CVMS IV: The concavities at the lower borders of C2, C3,and C4 still are present. At
least one of the bodies of C3 and C4 is squared in shape. If not squared, the body of the
other cervical vertebra still is rectangular horizontal. The peak in mandibular growth has
occurred not later than one year before this stage.
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. If not rectangular
vertical, the body of the other cervical vertebra is squared. The peak in mandibular
growth has occurred not later than two years before this stage.
Cervical vertebral maturation appears to be an appropriate
method for the appraisal of mandibular skeletal maturity in individual patients on the
basis of a single cephalometric observation and without additional x-ray exposure. The
accuracy of the cervical vertebral method in the detection of the onset of the pubertal
spurt in mandibular growth provides helpful indications concerning treatment timing of
mandibular deficiencies.

Dental age:
Dental age has been based on two different methods of assessment. 1.
Tooth eruption age.2. Tooth mineralization stage.Interrelationships between skeletal,
somatic and sexual maturity have been shown to be consistently strong. Associations with
dental maturation have been inconsistent. Studies assessing dental age according to the
number of teeth present in the oral cavity and studies based on dental calcification of
multiple teeth, usually show little or no correlation between these dental and other
maturity indicators.
Nevertheless, relationships between dental maturity and bone age have been
reported. Garn and coworkers in AO 1962 showed only weak correlations between
third molar and skeletal development.DEMISCH AND WARTMANN (1956)
LILLIEQUIST AND LUNDBERG (1971) and Engström and coworkers in AO 1983
reported a high correlation between dental and skeletal ages. The lack of concordance
among the results of previous studies may be due, at least in part, to the different methods
of assessing skeletal and dental maturity and due to the fact that many of the centers of
ossification in the hand exhibit considerable variation in the timing of their onset. So it
may be argued that attention should be focused on those ossific centers that are least
variable in the timing of their onset.
Sierra in AO 1987 evaluated correlations between the developmental stages of those
individual ossific centers that exhibit the least variability in their onset of ossification,
and the calcification of the upper and lower cuspids, bicuspids, and second molars in the
permanent dentition.
The pantographs were used to determine the stage of development of the teeth on the left
side of each subject, according to NOLLA (1960) In this procedure, the developmental
stage of each tooth is compared to a series of standardized drawings depicting 10 stages
of tooth calcification. A comparable procedure was used for the hand-wrist films, based
on the maturity indicators for the individual bones developed by GREULICH AND
PYLE (1959).The eight ossific centers assessed in this investigation were selected
because they exhibit the least variability in timing of the onset of ossification. (epiphyses
of the proximal phalanges of the 2nd, 3rd, 4th, and 5th fingers, the epiphysis of the 2nd
and 3rd metacarpals, the epiphysis of the middle phalanx of the 4th finger, and the
epiphysis at the distal end of the radius)
The correlations found between calcification of the teeth (Dental Age, DA) and skeletal
age as assessed by the eight ossific center method (OCM) were quite high.The strongest
correlations were obtained between the ossific centers and the lower cuspid, followed
closely by the upper first bicuspid. The second bicuspid seems least reliable in terms of
the strength of its correlations with the ossific centers. Most of the correlations were
slightly higher for the females
Chertkow in AJO 1980 studied whether tooth mineralization could be used as an
indicator of the pubertal growth spurt
He found that the Mandibular canine calcification stage G, (stage of root
formation prior to closure of the apices), corresponded with the maturational stage
characterized by,
1) Adductor sesamoid ossification,
2) Ossification of the Hook of the Hamate,
3) Capping of the Epiphyses of the Middle Phalanx of the 3rd finger,
These stages characterize the onset of Pubertal Growth spurt.
Unfortunately, racial variations exist in the relationship between the state of
maturity of this tooth and other parameters of development. Caution should be exercised
in the application of this finding to other racial groups.
Buschang and Miranda in AJO 1993 assessed relationship between the
developmental stages of the mandibular canine and skeletal ,maturity indicators of the
pubertal growth spurt using Hand wrist radiographs The results showed that Canine stage
F (The walls of the pulp chamber now form an isosceles triangle, and the root length is
equal to or greater than the crown height.& in molars the bifurcation has developed
sufficiently to give the roots a distinct form.)indicates the initiation of puberty. The
timing of stage G coincides with the presence of the adductor sesamoid (81%), capping
of the diaphysis of the third middle phalanx (77%), and capping of the fifth proximal
phalanx (87%). which are indicative of PHV. The intermediate stage between stages F
and G should be used to identify the early stages of the pubertal growth spurt.Moreover,
administration of testosterone propionate to the male rhesus monkey causes an
acceleration of the canine eruption suggesting that the earlier occurrence of stage G
relative to PHV for boys may reflect the high levels of circulating testosterone.

FRONTAL SINUS
Frontal sinus development (AJO 1996) SABINE RUF & HANS PACHERZ
Advocated the use of Frontal sinus as an indicator of growth .The growth velocity at
puberty is closely related to body height growth velocity. It shows a well-defined pubertal
peak (Sp), which on the average, occurs 1.4 years after the pubertal body height peak
(Bp).In male subjects, the average age at frontal sinus peak is 15.1 years.
FACTORS IN GROWTH DISTURBANCES:
1) Genetic/ Constitutional:-
Retardation of growth may be the result of organizer hormone deficiency which
interferes with tissue differentiation during embryonic stage. These effects are manifested
later in intra-uterine life/ after birth.
Genetic Influence is strong on Height & weight which is related to Nutrition.
Eg of genetic disorders are
a) Achondroplasia
b) Mongolism
c) Primordial dwarfism
d) Hereditary craniofacial dysostosis
e) Ovarian agenesis

2) Nutritional deficiency:-
Growth requires properly utilized adequate diet. Nutritional deficiencies result from
defects in organs responsible for absorption, transportation, assimilation / excretion of
essential food substances & their metabolites.
3) Metabolic disturbances:-
Disturbed calcium – phosphorous metabolism interferes with growth as in childhood
diabetes & Hypocalcaemia.
Metabolic disorders occurring during embryonic period & in childhood - alter the
growth & development in 2 ways.
a) by modifying the differentiation of tissues
b) by changing the growth & development at a later stage
and thereby result in marked deviation in the somatic pattern.

4) Chronic diseases:-
Celiac diseases, Hepatic insufficiency, allergy, rickets, chronic renal diseases, cystic
fibrosis of pancreas etc.

5) Blood dyscrasias:-
Chondrodystrophy, dysostosis & osteogenesis imperfecta.

6) Circulatory diseases:-
Pulmonary deficiency, cardiac malformations

7) Endocrinal disturbances:-

a) Hypothyrodism :- characterized by
1) Stunting of growth
2) Infantile skeletal proportions
3) Delayed & defective tooth development
4) Epiphyseal dysgenesis

Hypothyroidism occurs congenitally & in childhood. When occurring congenitally – it

affects the bones which are both cartilagenous & intra-membranous in origin.
Cretinism-Hypothyroidism occurs at 6yrs/ below. Here the patient has a large head, face
is coarse, and presents a dull & infantile facial expression & the nasal area appear
shrunken. Dental changes seen are – delay of ossification of the tooth buds due to delay
in Endochondral ossification.The characteristic features are
a) retardation in normal rate of calcium deposition in bones & in tooth buds.
b) Delayed carpal & epiphyseal calcification
c) Disharmonies in the eruption of teeth.
d) Incomplete unfolding of the nasal area & inadequate development of the maxilla.
e) Prolonged retention of the deciduous teeth.
f) Delayed eruption of the permanent teeth
g) Abnormal dental calcification & root resorption.
Hyperthyroidism – produces an increase in rate of maturation. Characterized by
a) Premature eruption & resorption of roots of deciduous teeth.
b) Early eruption of permanent teeth
c) Fragility of the bones
 d) Increased salivary secretion
e) Acceleration of skeletal ossification
f) Osteoporosis may be present which contra indicates orthodontic treatment.

Growth Hormone:-
Hypersecretion:- termed as gigantism in childhood & acromegaly in adulthood. If this
condition occurs – growth may extend up to 25/ 30 yrs.
Clinical features are,
1) enlargement of the supra orbital ridges & changes in the jaws especially the
mandible.
2) Increase in the mandibular prognathism
3) Enlargement & spacing between the teeth of the maxillary arch.
4) Both the jaws show increased labial inclination of the incisors.
5) Head appears coarse, the ears , nose & the lips are thick, soft tissues are thickened.
6) Mandible:- greater increase in the length of the ramus of the mandible as a result of
the type of ossification of the condyle. There’s an over apposition of the bone at alveolar
crest which increases the height of the mandibular body leading to marked enlargement
of entire mandible.
7) Spacing occurs in the mandibular dentition.
In Hyposecretion, there’s retardation of tooth development & eruption.
Adrenal Gland:-
1) In Adrenogenital syndrome – the teeth show acceleration of development & eruption.
2) Tumours of the Adrenals at the time of tooth development may produce premature
eruption of permanent teeth.
3) Adrenocortic Hyperfunction brings about a reduction in protein body mass,
including the bony matrix into which calcium is deposited when bone is formed thereby
interfering with bone formation.
Precocious puberty:-
Sexual precocity may be due to disturbances in the brain, pituitary, adrenals/ gonads.The
features are, growth is accelerated at first but advanced epiphyseal closure finally arrests
growth.This precocious sexual development has been found to depend in one instance on
a sex linked autosomal gene. Precocious sexual development due to constitutional causes
shows accelerated height & weight. Adolescent symptoms occur at much earlier
age.Bone age is advanced.

CLINICAL SIGNIFICANCE OF GROWTH SPURT:

Validity of Maturation indicators and the pubertal growth spurt:
Validity of PHV
Bergersen AO 1972 concluded that a significant correlation exists between onset of male
adolescent growth spurt in all facial dimension and standing height.No significant
difference exists between the onset of male adolescent growth spurt represented by total
facial height,the y axis, mandibular length and standing height. The metacarpal sesamoid
is significantly correlated with onset of male adolescent growth spurt in face and in
standing height.There is no significant difference in the intensity of growth between the 2
yrs of adolescent growth spurt in face and in standing height.
Grave(1973) and Thompson and Popovich(1973) concluded that peak height velocity and
maximum facial growth are coincident.
Bjork (AO1967) an Hagg and Taranger (1980) concluded that in the majority of subjects,
the peak in the adolescent increments in maxillary and mandibular size occurs at the same
time as does the growth peak in height. According to Nanda, the changes in body height
show the least variability for the assessment of skeletal age throughout the progression of
growth (the predictive efficiency of height age at 9 years of age for SGn length at 13
years of age is 94%).
In contrast, Bambha(1961) Baughan (1979) have reported that the
maximum facial growth lags behind peak height velocity by variable amounts of time.
Bishara et al., using the Facial Growth Study at the University of Iowa, found
that pubertal spurts in the mandible were uncommon and, when they did occur, were
unpredictable. The literature, then, does not agree on the existence of a facial growth
spurt, the timing or magnitude of such a spurt, or the predictability of changes in facial
dimensions in relation to general somatic and skeletal growth events.
Validity of skeletal maturity indicators:
Hellsing in 1991 demonstrated that during adulthood there is significant correlation
between height and length of the cervical vertebral bodies and statural height. Similar
results were found by Mitani and Sato, (AO1992) who also reported that changes in the
cervical vertebrae correlated significantly with increases in mandibular size. The
effectiveness of the cervical vertebrae as maturational indicator has been corroborated by
Hassel andFarman(AJO 1995) and Garcia-Fernandez et al,(JCO1998) who found a high
correlation between cervical vertebral maturation and the skeletal maturation of the hand-
wrist.
Bacetti and Mc Namara(AJO 2000)conducted a study to analyze the validity of 6 stages
of cervical vertebral maturation (Cvs1 throughCvs6) as a biologic indicator for skeletal
maturity .The method was able to detect the greatest increment in mandibular and
craniofacial growth during the interval from vertebral stage Cvs3 to Cvs4, when the peak
in statural height also occurred. The prevalence rate of examined subjects who presented
with the peak in body height at this interval was 100% for boys and 87% for girls. Both
Statural height and total mandibular length (Co-Gn) showed significant increments
during the growth interval Cvs3 to Cvs4 when compared to that Cvs2 to Cvs3, and
significant growth deceleration occurred during Cvs4 to Cvs5 when compared with Cvs3
to Cvs4. Ramus height (Co-Goi) and S-Gn also showed significant deceleration of
growth during the interval Cvs4 to Cvs5
Grave et al (Aus Jou Ortho 2003) conducted a study to relate the hand wrist
ossification events and cervical vertebral maturation stages to the timing of peak statural
and mandibular growth. Results showed that for majority of children the peak velocity in
mandibular growth coincided with peak velocity in stature. There is a significant
correlation between growth spurt and these skeletal maturity indicators.
The validity of hand-wrist skeletal maturity in the evaluation of craniofacial
growth has been questioned. Moore (sem 1997) pointed out that most of the bones of the
body are preformed in cartilage and develop by endochondral ossification. The bones of
the face are formed by intramembranous ossification without cartilaginous precursors.
Growth of the face may be regulated by factors other than those responsible for growth of
the long bones. Furthermore, the craniofacial structures include several functional
regions, which may have different growth responses to systemic and local environmental
conditions.

TREATMENT TIMING FOR CLASS II MALOCCLUSION:

(McNamara Sem in Ortho 2005)
A fundamental concept underlying cl;assII correction is that this type of intervention
should be undertaken when the likelihood for a maximum growth response is high ie,
during the circumpubertal period.
The appearance of definite concavity of lower border of C2 indicates the
growth spurt is approaching and can start approximately 1 year after this stage. CS3
represents the ideal stage to begin the functional jaw orthopedics as the peak in the
mandibular growth will occur within 1 year of this observation. A series of short term
studies has demonstrated statistically and clinically significant correction of class II
occurs when the treatment was done in the growth spurt (CS3, CS4). The supplementary
growth of the mandible in treated verses untreated ranges from 2.4mm to 4.7mm,
whereas the net difference in the supplementary growth of the mandible in treated verses
untreated ranges between 0.4 mm and 1.8 mm when started early (CS1).
Timing of cervical headgear treatment
Fishman et al (AJO 1993) investigated 41 patients with clinically diagnosed Class II,
Division I malocclusions with midface prognathism treated with Kloehn-type cervical
headgear. All cases included both longitudinal series of lateral cephalometric radiographs
and hand-wrist films taken before, during, and after treatment. Maturation was assessed
by Fishman’s method .He concluded that most optimum treatment time is between
maturational stages SMI 4 to 7, a very high velocity period of growth. The next most
desirable time to treat is during the accelerating velocity period between stages SMI 1 to
3, and the least desirable time is during the decelerating velocity period between
maturational stages SMI 8 to 11.
Treatment timing for Twin-block therapy
Bacetti and McNamara in AJO 2000 did a cephalometric study to evaluate skeletal
and dentoalveolar changes induced by the Twin-block appliance in2 groups of subjects
with Class II malocclusion treated at different skeletal maturation stages in order to
define the optimal timing for this type of therapy. Skeletal maturity in individual patients
was assessed on the basis of the stages of cervical vertebrae maturation(Lamparski)
. The early-treated group (ETG) consisted of subjects presenting with either stage 1 or
stage 2 in cervical vertebrae maturation (ie, before the onset of the pubertal growth spurt).
The late-treated group (LTG) consisted of subjects presenting with stages in cervical
vertebrae maturation ranging from stage 3 to stage 5( ie during or slightly after the onset
of the pubertal growth spurt)
The findings of this short-term cephalometric study indicate that optimal timing
for Twin-block therapy of Class II disharmony is during or slightly after the onset of the
pubertal peak in growth velocity. When compared with treatment performed before the
peak, late Twin-block treatment produces more favorable effects that include: (1) greater
skeletal contribution to molar correction, (2) larger increments in total mandibular length
and in ramus height, and (3) more posterior direction of condylar growth, leading to
enhanced mandibular lengthening and to reduced forward displacement of the condyle in
favor of effective skeletal changes. TREATMENT TIMING FOR HERBST APPLIANCE
Pancherz(AJO 1985) : Mandibular treatment changes were related to somatic
maturation in 70 consecutive cases of Class ll malocclusion treated with the Herbst
appliance.The somatic maturity level of the patients was assessed by means of
longitudinal growth records of standing height. The treatment period was related to the
peak height velocity by dividing the patients into three growth-period groups: prepeak,
peak, and postpeak.. Results showed as follows: (1) sagittal condylar growth was most
pronounced in the peak period, (2) anterior molar movement was equally large in all
growth periods, and (3) anterior incisor movement was most extensive in the postpeak
period. To take advantage of the increase in condylar growth response and to reduce the
time of posttreatment retention, it is suggested that Herbst therapy be instituted close to
peak height velocity.

TREATMENT TIMING FOR CLASS III MALOCCLUSION:

The clinical understanding that classIII malocclusion is established early in life and that it
is not a self correcting disharmony has led to the recommedation of intervention as early
as in the deciduous dentition. Prepubertal orthopedic treatment of Class III malocclusion
is effective both in maxilla and in the mandible whereas the treatment of class III
malocclusion at puberty is effective at the mandibular level only.(McNamara Sem in
Ortho 2005)
TREATMENT TIMING FOR FACE MASK:
Kyung-Suk Cha, (Angle Orthod 2003)
This cephalometric study evaluated skeletal and dentoalveolar changes
produced by rapid maxillary expansion and facial mask therapy in subjects exhibiting a
Class III malocclusion with a retruded maxilla. The skeletal maturity of individual
patients was assessed on the basis of Fishman’s skeletal maturity indicator (SMI), using
hand-wrist radiographs at the initiation of treatment, to determine the relationship
between the effect of maxillary protraction and skeletal age. Patients were divided into
three groups: prepubertal growth peak group (SMI 1–3), pubertal growth peak group
(SMI 4–7), and postpubertal growth peak group (SMI 8–11). The major findings of this
cephalometric study were as follows: (1) there was no difference in the effects of
maxillary advancement after maxillary protraction between the prepubertal growth peak
and the pubertal growth peak group, but there was a decrease in the postpubertal growth
peak group; (2) in the postpubertal growth peak group, there was a decrease in maxillary
skeletal advancement, whereas the dentoalveolar effect was increased; (3) the
posteroinferior rotation of mandible, the increase of lower facial height, and the eruption
of maxillary molars showed no correlation with skeletal age.
Treatment Timing for Rapid Maxillary Expansion:
Bacetti and McNamara AO 2001 evaluated the short-term and long-term treatment
effects of rapid maxillary expansion in 2 groups of subjects treated with the Haas
appliance.Treated and control samples were divided into 2 groups according to individual
skeletal maturation. The early-treated and early-control groups had not reached the
pubertal peak in skeletal growth velocity (CVM 1 to 3), whereas the late-treated and late-
control groups were during or slightly after the peak (CVM 4 to 6). The group treated
before the pubertal peak showed significantly greater short-term increases in the width of
the nasal cavities. In the long-term, maxillary skeletal width, maxillary intermolar width,
lateronasal width, and lateroorbitale width were significantly greater in the early-treated
group. The late-treated group exhibited significant increases in lateronasal width and in
maxillary and mandibular intermolar widths.
Hence they concluded that Rapid Maxillary Expansion treatment before the peak in
skeletal growth velocity is able to induce more pronounced transverse craniofacial
changes at the skeletal level. Patients treated before the pubertal peak exhibit significant
and more effective long-term changes at the skeletal level in both maxillary and
circummaxillary structures. When RME treatment is performed after the pubertal growth
spurt, maxillary adaptations to expansion therapy shift from the skeletal level to the
dentoalveolar level.

RETENSION & STABILITY:

Relapse of the corrected position of the teeth after successful orthodontic
treatment is fully recognized by the clinician. However, skeletal changes that occur
during retention may attenuate, exaggerate, or maintain the dentoskeletal relationship.
Little or no consideration is given to post treatment skeletal changes due to growth and
the effect on the final outcome.
Many patients at the completion of orthodontic treatment may still be
going through the pubertal growth spurt, or have not even entered the period of
accelerated pubertal growth. This observation is of greater significance in boys than in
girls, since boys generally mature later. Hence, failure to recognize the continuing effect
of dentofacial growth after the completion of orthodontic treatment may jeopardize long-
term stability of the orthodontic result.
Short face syndrome.:
These persons may require dentoalveolar compensations, such as an anterior
biteplate during the retention phase until maxillomandibular growth is completed. Failure
to recognize the dominant morphogenetic horizontal pattern of growth of the person may
result in a "dished-in-face," with or without extractions of teeth.The effect of the
additional soft tissue growth, particularly in the nose of the patient with a deep bite and a
short, vertical facial height accentuate the concave facial pattern.
Long-face syndrome:
They may require a high-pull face-bow headgear to hold the position of molars and to
prevent further dentolaveolar growth downward and backward, autorotation, and
worsening of the physiognomy.In some cases even the dental relationships of the teeth
deteriorate, with a noticeable relapse of dental open bite due to the lack of ramal growth
or excessive vertical dentoalveolar growth.
Severe skeletal dysplasia:
The pubertal growth spurt in patients with skeletal deep bite within each sex is shifted 1½
to 2 years later than in the patients with open bite. This is true even when the effect of
sexual dimorphism is recognized because girls grow earlier and complete their growth
before boys. These patients require a longer retention period than the skeletal open-bite
subjects do.
Facial development may result in secondary crowding especially in extreme growth
patterns such as forward mandibular growth rotation where increased lingual movement
of lower incisors may be seen.(Bjork 1972 Schudy 1974)

CONCLUSION:
A few biologic indicators are available for the appraisal of individual
skeletal maturity and, consequently, for the detection of the pubertal growth spurt in the
mandible. Among these, the changes in statural height present with the least variability
for the assessment of skeletal age throughout the progression of growth, thus showing the
highest reliability as biologic indicator of skeletal maturity. The practical limitation of
this method, however, is that it requires several measurements repeated at regular
intervals (eg, every 3 months) to construct an individual curve of growth velocity.
Radiographic methods have been proposed to overcome this limitation that
allow for an appraisal of skeletal maturation on the basis of a single observation.Cervical
vertebrae method has been found to be a valid method in describing individual skeletal
maturity. The informations provided are in agreement with that derived from a reliable
indicator-the changes in body height(PHV);it does not require supplementary
radiographic exposure since the lateral cephalogram that is needed for orthodontic
diagnosis and treatment planning can be used. It also has been found to be efficient in
detecting the peak in mandibular growth.
Assessment and prediction of dentofacial growth are perhaps the most
essential, yet to a great extent the most subjective, aspects of clinical orthodontics. The
craniofacial changes are complex because each person has a unique growth pattern
influenced by their genetic make-up (ie, the biological or internal environment) as well as
external environmental factors such as function, disease, habits, and orthodontic
treatment.
Cephalometric superimpositions often demonstrate dramatic dental,
skeletal, and soft tissue changes during orthodontic treatment. Many orthodontists give
themselves full credit when they take advantage of the patient’s favorable growth
combined with a reasonable orthodontic treatment plan. These same clinicians, however,
blame unfavorable growth and lack of patient cooperation when the treatment results are
anything short of their expectations.
Since growth can be either a friend or a foe, it is important to
determine the timing, magnitude, and direction of facial growth. Such an understanding
enables orthodontists to better plan the treatment of skeletal discrepancies in their attempt
to achieve a more stable and pleasing result. Therefore, it behooves all clinicians to
discern between the science and the fiction in facial growth, or as Professor Koski once
said ‘‘the facts and fallacies’’ in facial growth.