Guidelines for assessing the growth and

development of orthodontic patients

Peter H. Buschang, Samuel I. Roldan, and Larry P. Tadlock

This paper provides guidelines for determining treatment objectives and

evaluating posttreatment outcomes. More specifically, it reviews our current
understanding of growth and maturation, focusing on the most salient
aspects that apply to individual patients. Pretreatment diagnostics and
treatment objectives will be addressed first, focusing initially on adjustments
necessary based on the patient’s somatic growth and maturity. Estimates of
craniofacial growth that can be applied to individual patients when
developing treatment objectives are then provided, along with the approach
used to apply them. It will be shown how the estimates are adjusted,
depending on the patient’s sex, age, and growth patterns. These adjusted
growth estimates are also used to evaluate posttreatment changes.
Orthodontists must be able to separate the treatment changes from the
growth changes that occur. The application of these guidelines will be
demonstrated on three patients. (Semin Orthod 2017; ]:]]]–]]].) & 2017
Published by Elsevier Inc.

Introduction have received little guidance on how to apply it.

The information usually does not go beyond the
M ost would agree that a basic understanding
of growth and development is an integral
and important part of every orthodontist’s edu-
classroom because most growth courses are not
oriented toward clinical implications or appli-
cations. There are few guidelines currently
cation. It is important because the practice of
available that can be effectively and efficiently
evidence-based orthodontics is predicated on the
used to evaluate individual patients. The fol-
clinician’s ability to apply this information,
lowing is intended to provide an overview of
especially when establishing treatment objectives
methods we are currently using to apply our
and evaluating posttreatment outcomes (Fig. 1).
understanding of growth and maturation to
Whether or not objectives are realistic and
individual patients. This overview is predicated
achievable depends in a large part on the
on the belief that orthodontists can “work
patient’s growth pattern and how growth might
smarter” by incorporating growth into their
be expected to influence treatment. As
treatment plans and evaluating treatment out-
important, orthodontists can only improve
comes rather than measuring the time spent.
their future treatments by carefully evaluating
Patient evaluations should be focused, thought-
their outcomes and being able to distinguish the
ful, and intentional investigations that collect and
relative contributions of growth from that of
analyze relevant information, using the best
treatment.
available methods and techniques, to answer
While most orthodontists have a basic
worthwhile questions.
understanding of growth and maturation, they
The first section of this paper provides an
overview of pretreatment diagnostics, initially
Department of Orthodontics, Texas A&M College of Dentistry, focusing on assessments of somatic growth and
Dallas, TX, USA; Department of Orthodontics, CES University, maturation. This information is necessary for
Medellin, Colombia; Department of Orthodontics, Texas A&M making adjustments based on the patient’s
University College of Dentistry, Dallas, TX. skeletal maturation, dental maturation, and
Address correspondence to Peter H. Buschang, PhD. E-mail:
PHBuschang@tamhsc.edu
overall body size. The second section provides
craniofacial growth estimates that are applied to
& 2017 Published by Elsevier Inc.
1073-8746/12/1801-$30.00/0 individual patients. They provide the ortho-
http://dx.doi.org/10.1053/j.sodo.2017.07.001 dontist with rough estimates of expected growth

Seminars in Orthodontics, Vol ], No ], 2017: pp ]]]–]]] 1

2 Buschang et al
Figure 1. The five steps involved in practicing evi-
dence-based orthodontics, emphasizing the role of
growth and developing in setting treatment objectives
and evaluating posttreatment outcomes. Note the
cyclical nature of the process, with improved post-
treatment evaluations leading to improved diagnostics,
leading to improved treatment objectives.
changes, followed by adjustments necessary
depending on his/her sex, age, and growth
patterns. The final section applies these growth
estimates to posttreatment evaluations. This is
when the treatment changes must be separated
from the growth changes that occur.
Pretreatment diagnostics
Maturation
In order to properly assess a patient’s growth
status (i.e., size, proportions, and relations
Figure 2. Eleven skeletal maturity indicators (SMIs), along with their relative times of occurrence on the growth
curve (modified from Fishman 19821). Statural velocity estimated from 2000 CDC growth charts.
attained at any given point in time), it is necessary
to determine his/her biological age. Chrono-
logical age is not the same as biological age.
Patients’ chronological and biological ages will
differ by more than ±1 years 32% of the time, and
by more than ±2 years roughly 5% of the time.
Skeletal maturation provides the best single
estimate of an individual’s biological age,
including the ages of the craniofacial bones and
muscles. Skeletal maturation is most accurately
measured by skeletal age, as assessed from hand–
wrist films (typically of the left hand). Since
accurate assessments of a skeletal age require
time and an attained level of expertise, most
orthodontists assess skeletal maturation based on
the subject’s estimated stage of skeletal maturity.
The skeletal maturity indicators (SMIs) are the
most commonly used and most accurate way of
estimating the patient’s stage of maturity. SMIs
are also derived from the patient’s hand–wrist
radiograph. The system most commonly used by
orthodontists was devised by Fishman.1 It consists
of 11 maturity indicators (Fig. 2).
Because additional radiographs are required
for estimating SMIs, orthodontists have devel-
oped methods to assess stages of skeletal maturity
using the cervical vertebrae captured on lateral
cephalograms. Cervical vertebrae stage assess-
ments require only one cephalogram. The most
recently introduced system evaluates six stages of
maturation—CS1–CS6—based on the cervical
vertebrae C2, C3, and C4.2 The occurrence of
each of these stages can also be related to the
adolescent growth curve (Fig. 3). While the CS
 Guidelines for accessing growth & development
Figure 3. Cervical stages (CS) 1–6, along with their
relative times of occurrence on the growth curve
(modified from Baccetti et al., 20052).
stages are convenient (i.e., they are relatively
simple and require no additional radiographs),
they are less accurate than either SMIs or skeletal
age.
The patient’s skeletal stage of development
are used to determine whether adjustments are
necessary when using somatic and craniofacial
growth standards. For example, if a male child is
chronologically 10 years of age, but 12 years of
age skeletally, he is advanced in his maturation
relative to other 10-year-old children. Fig. 4 shows
a hypothetical individual whose body size
approximates the 90th percentile of 10-year-
olds. However, he should be compared to his
12-year-old biological peers. Compared to them,
he closely approaches the 50th percentile. In
addition, he should be expected to attain peak
adolescent velocity and complete his growth
earlier than other 10-year-olds. Importantly,
cephalometric reference standards used to
assess his craniofacial growth need to be
adjusted to his 12-year-old status.
To determine the maturity of the dentition,
dental age must be assessed. While skeletal,
sexual, and somatic maturation are all interre-
lated and controlled by the same factor(s), dental
maturation is not. Dental age, which is based on
the calcification of teeth, is important for esti-
mating the ages of emergence. Dental age is
typically assessed using the first seven teeth on
the left side of the mandible.3 There are eight
stages of development (A–H) for each tooth
(Fig. 5). Importantly, there is a link between the
stages of tooth development and the emergence
3
of teeth.4 This is especially useful for
orthodontists waiting for the permanent
canines and premolars to emerge. The incisors
and first molars typically emerge after stage F
(i.e., when the walls of the pulp chamber form a
more or less isosceles triangle) and slightly before
stage G (i.e., when the calcified region of the
bifurcation has developed further down from its
semilunar stage; the wall of the canal attains a
parallel configuration but is not yet closed). The
canines and premolars emerge slightly before
stage G in early dental maturers, and slightly after
stage G in late maturers. The best way to estimate
the emergence of the canines and premolars is
based on both their stages of development and
their relative root lengths (root length/total
length). The mandibular canines emerge when
the root length equals 65–70% of their total
length; mandibular premolars emerge when root
length equals 60–65% of their total length.5
Assessments of overall body size
To assess overall size, both stature and weight
growth charts should be used (Fig. 4).
Assessments of overall body size are important
for two reasons. First, they provide orthodontist
the information needed to adjust their
assessments of craniofacial size (i.e., all linear
dimensions) based on to the patient’s overall
body size. For example, if the stature and weight
of a 12-year-old male both approximate the 5th
percentile, his craniofacial size measures should
also approximate the 5th percentile. Most
cephalometric programs use means and
standard deviations to assess craniofacial size.
As such, the size of the craniofacial complex can
be substantially over- or underestimated if
adjustments for overall body size have not been
made. The mandible and maxilla of the boy who
approximates the 5th percentile in body size
should not be average. If stature and weight
percentiles differ, the stature percentile should
be used as the better measure of overall body size
because it is more stable and less subject to
environmental influences. An alternative to
percentiles is the use of the patient’s z-score or
standard score, which provides the number of
standard deviations that the patient deviates from
the mean. z-Scores for overall body size and
craniofacial size should also be comparable. A
patient whose z-score for stature is −2.0 should be
4 Buschang et al

Figure 4. Adjustment necessary when assessing statural growth of a 10-year-old male who is 12 years of age
biologically (note the effects adjustments have on his percentiles).

Figure 5. Eight stages of dental maturation (modified from Demirjian et al., 19733). Most teeth emerge between
stages F and G; canines and premolars emerge just before or just after stage G.
 Guidelines for accessing growth & development
Figure 6. Velocity growth curve for a patient estimated from annual measurements of stature.
expected to have jaws that are substantially
smaller than average. As previously indicated,
most cephalometric programs would flag this
patient’s maxilla and mandible as being
abnormally small, when in fact the linear
dimensions may be appropriate for his overall
body size.
Secondly, measures of overall body size can be
used to estimate where the patient is on his/her
growth velocity curves. This requires multiple
yearly or 6-monthly recordings of stature or
weight. Longitudinal information pertaining to
body size can be used in lieu of skeletal maturity
assessments; they are more accurate and practical
than longitudinal cephalometric assessments.
Body size of patients can be reliably and
affordably measured by staff members. For new
patients, longitudinal information may be
derived from parental or physician records. To
determine the patient’s position on the velocity
curve, his/her longitudinal stature measure-
ments must be changed to yearly velocities and
plotted on a growth curve. For example, even 3
years of longitudinal data makes it possible to
determine when patients started adolescence or
when they attained peak growth velocity (Fig. 6).
Future growth
Knowing the patients’ maturational status and
overall body size also provides information about
their future growth potential. Based on large data
sets used by the CDC to construct their statural
growth charts, the adolescent growth phase
starts at approximately 9.5 and 10.5 years of
age for females and males, respectively. Once
5
adolescence starts, growth rates accelerate until
peak velocity is attained, after which rates
decelerate. The amount of growth that remains
after peak velocity is often not appreciated.
Greater cumulative amounts of growth occur
after peak velocity, than between the start of
adolescence and peak velocity (Fig. 2).
Remember, the child is growing at
approximately the same rate 1 year after the
peak as he/she was growing 1 year before the
peak. If the patient’s skeletal age or longitudinal
records indicate that he is at peak adolescent
velocity, approximately 3 more years of clinically
meaningful craniofacial growth should be
expected.
Craniofacial growth estimates
Average estimates of growth changes that occur
While a variety of reference standards are avail-
able for evaluating craniofacial growth, the
charts, tables, and listings typically provided are
cumbersome, difficult to apply in clinical sit-
uations, and often overwhelming. More impor-
tantly, there is very little reference material
available concerning the actual growth changes
that occur in untreated subjects. In order to
provide easy-to-use estimates of growth for
orthodontists, we developed two charts. The data
used for the linear and angular estimates (Fig. 7)
come from Riolo et al6 and Bhatia and Leighton7
The yearly velocities were based on the mean
growth changes that occur between 6 and 16
years of age. The data for the superimpositions
(Fig. 8) come from various sources.8–11 Both
6 Buschang et al
Figure 7. Estimated yearly changes for typically used linear and angular estimates (calculated from Riolo et al.,
19796 and Bhatia and Leighton, 19937).
charts should be used to estimate future growth
when treatment planning and for evaluating
treatment outcomes.
Maxilla
The annualized changes in maxillary size and
position that occur are less than commonly
thought (Fig. 7). Because nasion is displaced and
drifts anteriorly, the SNA angle changes only
slightly over time (o0.1°/yr), despite the fact
that the maxilla is being displaced anteriorly
slightly less than 1.0 mm/yr (ANS-PNS increases
0.8 mm/yr). Most of the increase in ANS-PNS is
due to growth at PNS (0.7 mm/yr); ANS
undergoes less than 0.1 mm/yr of anterior drift
(Fig. 8). Inferior displacement and inferior drift
of the anterior maxilla combine to increase
upper face height (N-ANS) approximately
1.2 mm/yr.
During childhood and adolescence, the pos-
terior maxilla is displaced inferiorly more than
the anterior maxilla (i.e., it rotates forward
slightly). Simultaneously, the entire maxilla
undergoes anterior displacement. As the maxilla
is being displaced, growth occurs at the cirum-
and intermaxillary sutures and cortical modeling
occurs on the bones’ surfaces, particularly on the
posterior surfaces. The modeling and sutural
growth that occur are largely in response to the
displacements (Fig. 8). The landmark orbitale
drifts in a superior (0.3 mm/yr) and posterior
(0.3 mm/yr) direction. To compensate for the
maxilla’s anterior displacement (≈0.7 mm/yr),
bone is added at PNS. Inferior drift of the
posterior nasal floor (≈0.3 mm/yr) is less than
the inferior drift of the anterior nasal floor
(≈0.6 mm/yr), both of which are also associated
with the maxillary displacement.
Mandible
The posterior aspect of the mandible is displaced
down substantially more than its anterior aspect
(i.e., it rotates forward more than the maxilla).
The rotation that occurs is the primary deter-
minant of chin projection and anterior dis-
placement of the mandible (Buschang and Jacob
2014).12 In response to the displacements that
occur, the ramus drifts in a posterior/superior
direction. The inferior aspect of the ramus is
resorptive, with almost equal amounts of superior
(0.9 mm/yr) and posterior (1.0 mm/yr) drift of
gonion. Importantly, there should be
approximately 1 mm of posterior condylar
growth for every 8–9 mm of superior growth.
 Guidelines for accessing growth & development 7

Figure 8. Estimated yearly changes in typically used craniofacial distances and ages. Estimated from Buschang et al
1988,8 Buschang and Martins 1998,9 Buschang and Gandini 2002,10 and Buschang 2014.11.

While B-point resorbs slightly, there is little or no
modeling at the tip of the chin.
The modeling that occurs at the lower border
of the mandible (i.e., substantial posterior
resorption and slight anterior deposition) almost
negates the true rotation of the mandible. The
net difference is a 03–0.4°/yr decrease of the
mandibular plane angle. The SNB angle
increases 0.2°/yr, which decreases the ANB angle
by slightly more than 0.2°/yr. Overall mandibular
length increases approximately 2.4 mm/yr,
which is almost entirely accounted for by growth
at condylion.
Dentoalveolar development
One of the most underappreciated aspects of
craniofacial growth is the amount of tooth
movement that occurs after the teeth have
erupted into functional occlusion. Tooth move-
ments occur throughout growth. The mandible
undergoes substantially greater inferior dis-
placements than the maxilla and the teeth erupt
to fill the space created. Individual patients who
undergo greater inferior growth displacement
exhibit greater eruption than those who undergo
less inferior displacement. Because posterior
displacement is greater than anterior displace-
ment, there is slightly greater posterior eruption.
The posterior teeth also migrate mesially to
compensate for spaces created by changes in the
dentition (e.g., leeway space during the late
mixed dentition, anterior crowding, or wear).
The mandibular incisors erupt in a superior/
anterior direction.
During adolescence, the maxillary molars and
incisors erupt more than their mandibular
counterparts (≈1.2 vs 0.9 mm/yr and ≈1.0 vs
0.9 mm/yr, respectively). Combined, the upper
and lower molars erupt more than 2.0 mm/yr.
The upper molars migrate mesially (0.6 mm/yr)
slightly more than the mandibular molars
8 Buschang et al
(0.5 mm/yr). The maxillary and mandibular
incisors exhibit similar amounts for mesial
migration (0.3 mm/yr), which is at least partially
due to proclination associated with true man-
dibular rotation.
Necessary adjustments
The values provided in Figs. 7 and 8 are based on
average changes that occur between 6 and 16
years of age. They provide starting values that
need to be adjusted up or down depending on
the patient’s sex, age, and growth patterns.
Sex differences
Prior to adolescence, males are only slightly
larger than females. During adolescence, the size
of the maxilla increases more in males than
females. As such, average annual rates of growth
for maxillary length and height need to be
increased by approximately 0.3 mm/yr for males
and decreased by 0.3 mm/yr for females.
There are also sex differences in mandibular
growth that require adjustments during adolescence.
Rates of overall mandibular length (Co-Me) requires
the greatest adjustment (increasing 0.7 mm/yr
for males and decreasing 0.7 mm/yr for females),
followed by ramus height (increasing 0.5 mm/yr
for males and decreasing 0.5 mm/yr for females)
and corpus length (increasing 0.4 mm/yr for males
and decreasing 0.4 mm/yr for females).
Adolescent spurt
Because there is no adolescent growth spurt for the
angular and anteroposterior linear measures, only
the vertical estimates require adjustments. For
maxillary height, rates increase approximately 0.2
and 0.1 mm/yr for males and females, respectively,
between the initiation of adolescence and the
attainment of peak velocity. They decrease at similar
rates thereafter. Adjustments are again greater for
the mandible. For males, growth velocities increase
Table 1. Cephalometric indicators of good and poor growers (adapted from Skieller et al., 198413)
Good grower
Gonial angulation Smaller than average
Mandibular plane angulation Smaller than average
Posterior/anterior facial height ratio Larger than average
Antegonial notching None or decreased
Condylar growth direction Superior and only slightly posterior or anterior
Symphyseal morphology Short and broad
by approximately 0.5 mm/yr between the initiation
of adolescence and the peak; females rates increase
by approximately 0.2–0.3 mm/yr over the same time
period.
Growth patterns
It is also necessary to determine whether the
patient has “good” or “poor” growth potential.
Good growth potential refers to hypodivergent
patients who exhibit greater than average for-
ward (i.e., horizontal) growth potential. In con-
trast, poor growers are hyperdivergent,
exhibiting less than average forward rotation,
and greater than average vertical growth poten-
tial. This determination is based on a number of
different, but related, measures (Table 1).
In good growers, maxillomandibular relations
(e.g., ANB, Wits, and maxillomandibular differ-
ential) should be expected to improve over time.
They improve because the mandible rotates and is
displaced anteriorly more than the maxilla. Good
growers show greater improvements in AP skeletal
relationships during childhood (±0.4°/yr) than
adolescence (±0.2°/yr). They also show greater
reductions of the gonial and mandibular plane
angles, and less vertical dentoalveolar development
than average and poor growers.
Maxillomandibular relations of poor growers
worsen over time, due to greater anterior dis-
placement of the maxilla than mandible. AP rela-
tions of poor growers worsen approximately
0.2–0.4°/yr during childhood and 0.5°/yr during
adolescence. AP relations of adolescent females
worsen more than male relations. The gonial and the
mandibular plane angles of poor growers increase.
Dentoalveolar development, especially maxillary, is
excessive, due to supraeruption of the teeth.
Mandibular growth direction
The Y-axis, whether estimated relative to sella-
nasion (S-N) or the Frankfurt Horizontal (FH),
Poor grower
Larger than average
Larger than average
Smaller than average
Increased
Superior and more posterior
Long and narrow
 Guidelines for accessing growth & development
provides important information about future man-
dibular growth direction. A patient whose Y-axis
approximates the mean should be expected to
continue growing down and forward along that
same axis during the course of treatment. However,
a patient whose Y-axis is smaller than average (i.e.,
horizontal growers) should be expected to become
slightly more horizontal (i.e., Y-axis will decrease)
over time; a patient whose Y-axis is larger than
average should be expected to become more over
time. Combined, the patient’s growth direction
(Y-axis) and pattern (good, average, and poor)
provide important information for determining
future growth changes.
Case examples of growth evaluation
before and after treatment
Case #1
Pretreatment evaluation and planning
Prior to treatment, Mary was 10.5 years of age,
61 in tall and weighed 91 lbs. Her cervical ver-
tebrae indicates a CS stage 2, based on the slight
Figure 9. Case #1: (A) cervical vertebrae, (B) hand–wrist radiograph, (C) growth chart, and (D) panoramic
radiograph of a 10.5-year-old female patient, treated for 2 years and 4 months with RPE and upper premolar
extractions.
9
curvature evident at the base of C2 and the
trapezoidal shaped C3 and C4 (Fig. 9A). Her
hand–wrist film showed that the distal phalanx of
her middle finger is capping, which puts her at
SMI 5. This information suggests that she is
approximately 11.6 years of age biologically. After
adjusting for her maturational age, Mary
approximates the 80% tile for stature and the
50% tile for weight (Fig. 9C). We should expect
her adjusted cephalometric linear dimensions to
approximate the 80% tile.
The apicies of her mandibular second pre-
molars are open, with divergence of the pulpal
canal, indicating a stage F (Fig. 9D). Eruption of
these teeth should occur within 1–1.5 years. The
apex of the unerupted left maxillary canine is
almost closed, indicating it is at the end of stage
G. This tooth should be emerging or should have
already emerged; the right canine apex is open
with slight divergence of the pulpal walls,
indicating that it is at the end of stage F and
should be erupting within months.
Since her biological age is 11.6 years, Mary
should be very close to attaining her peak
10 Buschang et al
Figure 10. Lateral cephalometric radiograph and tracing of Case #1.
adolescent growth velocity, with 2–3 years of
clinically relevant craniofacial growth remaining.
Because her Y-axis was only slightly larger
than average, mandibular growth should be
expected to continue along that same direction,
or perhaps become slightly more vertical
(Fig. 10). Her larger than average mandibular
plane angle, slightly larger gonial angle, smaller
posterior-to-anterior face height ratio and
somewhat more posteriorly directed condylar
growth all indicate mild hyperdivergence (i.e.,
average or slightly poor growth pattern). Due to
Mary’s vertical tendencies, in addition to being a
female, it was especially important to use
mechanics that control vertical development
during treatment.
Posttreatment assessment
Mary was treated nonextraction for 28 months,
starting with RPE, and then working up through
a series of archwires. Class II, triangle and
crossbite elastics were worn for finishing. Based
on her overall superimposition, the changes that
occurred during treatment were mostly vertical,
substantially increasing her initial hyperdivergent
tendencies (Fig. 11). There was less anterior and
more inferior displacement of the maxilla than
expected. The mandible rotated clockwise, with
posterior condylar growth and no anterior chin
projection, all of which were treatment related.
The upper molar erupted less than expected and
the lower molar erupted slightly more than
expected, indicating a partial treatment effect.
The upper incisor eruption that occurred was
growth related; its retroclination represents a
treatment effect. The vertical change of the lower
incisor was greater than expected, suggesting a
treatment effect; lower incisor retroclination was
treatment rather than growth related.
Case #2
Pretreatment evaluation and planning
Charles was 11.1 years of age chronologically at
the start of treatment. He is 60 in tall and
weighed 115 lb. The second and third vertebrae
show concavities, and C3 is rectangular hori-
zontal, indicating that Charles has at least 1 year
before attaining peak adolescent velocity
(Fig. 12). His hand–wrist radiograph shows that
he has attained SMI 2, and is about to attain SMI
3, indicating that he is 12.0 years of age skeletally.
This makes him almost 1 year more mature than
his chronological age. After adjusting for his
biological age, Charles approximates the 74% tile
for stature and the 76% tile for weight. His
maxillary canines were at stage G, indicating that
they are about to emerge.
Since his biological age was approximately 12
years, Charles should attain peak adolescent
velocity in approximately 1.5 years. For his
cephalometric analysis, he should be compared
to 12-year-olds rather than 11-year-olds. Charles
has 3.5–4.5 more years of clinically meaningful
craniofacial growth remaining. The cephalo-
metric measures indicate that Charles is hyper-
 Guidelines for accessing growth & development 11

Figure 11. Case #1: total, maxillary, and mandibular superimposition of a 10.5-year-old female patient, treated for
2 years and 6 months with RPE and upper premolar extractions.

divergent, with a FMA of 41°, a MPA of 45.5°, and over time. Charles has a poor growth pattern.
a 13 mm excess in anterior facial height (Fig. 13). Without treatment, we would expect him to
Since his Y-axis is approximately 10° larger than become more hyperdivergent over time, with
average, it should be expected to further increase his AP skeletal relations worsening.

Figure 12. Case #2: (A) cervical vertebrae, (B) hand–wrist radiograph, (C) growth chart, and (D) panoramic radiograph
of an 11.1-year-old male patient, treated for 2 years and 8 months with RPE and upper premolar extractions.
12 Buschang et al

Figure 13. Lateral cephalometric radiograph and tracing of Case #2.

Posttreatment assessment superior growth, further indicating a loss of

Charles was treated nonextraction for 2 years and
8 months. His lower arch was bonded 7–7 (0.16 ×
0.22 heat-activated NiTi). His upper arch was
bonded following RPE. The treatment plan
called for Class 2 elastics and extractions of one
upper premolar. Based on his overall super-
impositions, the maxilla was displaced inferiorly
more than expected and it rotated anteriorly
more than expected (Fig. 14). The mandible
was displaced posteriorly and it rotated
posteriorly more than expected, increasing the
MPA by approximately 2°. The condyles
underwent almost as much posterior as
vertical control. Charles’ ANB angle worsened
slightly (Fig. 14).
The upper and lower molars erupted sub-
stantially more than the condyle grew vertically.
This indicates supraeruption, especially for the
maxillary molars. The maxillary incisors erupted
and were retracted. The mandibular incisor was
proclined during treatment, which is not
expected for a mandible that rotates posteriorly.
In other words, this was a treatment effect. The
mandibular incisors erupted substantially more
than expected for untreated growing individuals.
The negative sequelae that occurred were both
growth and treatment related.

Figure 14. Case #2: total, maxillary, and mandibular superimposition of an 11.1-year-old male patient, treated for
2 years and 8 months with RPE and upper premolar extractions.
 Guidelines for accessing growth & development 13

Figure 15. Case #3: (A) cervical vertebrae, (B) hand–wrist radiograph, (C) growth chart, and (D) panoramic
radiograph of an 11.6-year-old male patient, treated for 2 years and 7 months with a nonextraction with a cervical-
pull headgear and Class II elastics.

Case #3 based on the slight concavity at the base of C3 and

Pretreatment evaluation and planning
At the start of treatment, John was 11.6 years of
age. He weighed 80lb and was 59 in tall (Fig. 15).
His cervical vertebrae indicate a CS stage 3. This is
its horizontal rectangular appearance, indicating
that John is within 1 year of peak growth velocity.
However, John’s hand–wrist radiograph indicates
a SMI of 3, which makes him approximately 12.2-
year-old biologically. Since SMIs provide a more

Figure 16. Lateral cephalometric radiograph and tracing of Case #3.

14 Buschang et al
Figure 17. Case #3: total, maxillary and mandibular superimposition of an 11.6-year-old male patient, treated for 2
years and 7 months with a nonextraction with a cervical-pull headgear and Class II elastics.
accurate assessments of skeletal development
than CS stages, John’s stature and weight will
need to be adjusted by approximately 0.6 years,
placing him at the 50% tile for stature and the
25% tile for weight. For John, the average values
used by most cephalometric programs will be
appropriate (i.e., they do not need to be
adjusted). The upper right E and lower left E
are still present, but not for long. The unerupted
second premolars are both at stage F, close to
attaining stage G, indicating that they are about to
emerge into the oral cavity.
Based on his hand–wrist radiograph, John has
3–4.5 years of clinically significantly craniofacial
growth remaining. His Y-axis is 7° smaller than
average, and it should be expected to decrease
over the next few years (Fig. 16). John is a “good”
grower, his mandibular plane and gonial angles
are substantially smaller than average, his
posterior-to-anterior facial height ratio is much
larger than average, he has a short and broad
symphyseal morphology, there is no real
antegoinial notching, and his condyle is
growing in a superior direction. Growth should
be expected to help with John’s treatment.
Posttreatment assessment
John was treated nonextraction for 2 years and 7
months with a cervical-pull headgear during the
first half, and with Class II elastics during the
second half. Based on his overall superimpositon,
the maxilla underwent inferior and anterior
displacement, but not as far anterior as expected
(Fig. 17). The mandibular plane and gonial
angles increased approximately 2°, neither of
which was expected of “good” growers. In other
words, there was some treatment-related loss of
vertical control, probably due to the Class II
elastics. Fortunately, John’s growth potential
made it possible to overcome these negative
effects. Most of the molar correction and profile
improvements that occurred were due to forward
mandibular rotation. Based on his initial growth
patterns, his chin should have come forward even
more than it did. Changes in incisor angulation
and position were mostly treatment related.
Conclusions
As originally indicated, these guidelines pertain
to our ongoing efforts to apply our under-
standing of growth and development to indi-
vidual patients. Pretreatment growth evaluations
help the orthodontic make adjustments for
body size and maturity status, which are essential
for qualifying and quantifying patients’ treat-
ment objectives. Growth is also important for
determining when to treat and what to expect
when treating future patients Posttreatment
growth evaluations show whether the intended
results were achieved, whether it was worth
the costs, whether there may be a better
treatment approach, and perhaps most impor-
tantly, whether your performance is improving.
Performance improvements are predicated on
 Guidelines for accessing growth & development
monitoring and evaluating outcomes. Perform-
ance improvements should make the ortho-
dontist more effective by identifying best
practices. This requires being able to separate the
actual treatment outcomes from the growth
changes that occurred.
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