16 Orthodontics January 2017

Goldie Songra Tarun K Mittal, Julie C Williams, James Puryer, Jonathan R Sandy and Anthony J Ireland

Assessment of Growth in
Orthodontics
Abstract: Being able to predict the likely timing and duration of growth accurately, in particular the pubertal growth spurt, is important in
orthodontic treatment planning. The different assessments of growth, their advantages and disadvantages will be described.
CPD/Clinical Relevance: A knowledge of the typical assessments of skeletal growth is important in the planning and execution of
orthodontic treatment.
Ortho Update 2017; 10: 16–23

Growth can be defined as an increase in
cellular size and number and can be linked
with development, including an increase
in specialization or function.1 It is certainly
an important factor in orthodontics as it
can both directly and indirectly influence
treatment. The obvious direct effect is
potential growth modification in both Class
22,3,4 and Class 3 skeletal cases.5,6 Similarly,
growth can have a direct and sometimes
adverse effect on the occlusion and therefore
delay treatment. For example, a Class III
skeletal pattern may become more severe,
as might an anterior open bite. In such cases,
treatment may have to be put on hold until
growth has essentially ceased. The presence
or absence of growth may also have a
less obvious and more indirect effect on
orthodontic treatment. For example, overbite
reduction is often easier in the growing child
and, more recently, it has been reported
that the rate of active tooth movement is
likely to be greater at times of rapid growth,
particularly around the time of the pubertal
growth spurt.7
As part of an orthodontic
assessment therefore, it is essential to
consider the likely direction, magnitude
and perhaps, most importantly, the timing
of growth in our patients. All children with
a normal pattern of growth will undergo a
pubertal growth spurt. For each individual,
however, there are differences in the
onset, duration, velocity and amount of
growth over this period.8,9,10 In an attempt
to predict growth, in particular the timing
of the pubertal growth spurt, a number of
assessment methods have been described.
These include chronological age, stage of
dental development, the plotting of standing
height measurement on growth charts, the
stage of development of secondary sexual
characteristics and radiographic measures of
skeletal maturation.
At this point it is perhaps worth
considering the properties of an ideal clinical
growth assessment tool. These include:
 Easy to use;
 Safe;
 Accurate;
 Reliable;
 Valid;
 Non invasive;
 Cost-effective.
Successful treatment in the
growing patient is often dependent on
knowing the growth status of the particular
individual. Therefore, an understanding of
growth predictors and maturity indicators
is paramount for the clinician. These will be
discussed in turn.
Chronological age
A number of variables including
mental maturity, physical capacity, height and
weight are sometimes estimated according
to chronological age.11 However, there can
be wide differences between individuals of
the same age, as a number of genetic and
environmental factors, including nutrition,
endocrine status, metabolic status and other
medical conditions, can affect development.12
Therefore, chronological age on its own
cannot be used as a valid parameter to
estimate facial growth or skeletal maturity.11
Dental development
Similarly, it has been
proposed that a link exists between dental
development, skeletal age and chronological
age.13 A technique has been described

Goldie Songra, BDS, DDS, MFDS, MOrth, FDS(Orth) RCSEng, Consultant Orthodontist, Kidderminster Hospital and Worcestershire Royal
Hospital, Tarun K Mittal, BDS, Specialty Registrar, Derriford Hospital, Plymouth, Julie C Williams, BDS, DDS, MOrth RCS, DPDS, MA(Ethics
of Healthcare), PGCertHE, FHEA, Academic Clinical Lecturer and Senior Registrar, School of Oral and Dental Sciences, University of Bristol
and Royal United Hospitals, Bath, James Puryer, BDS, DPDS, MFDS RCS(Eng), MSc, FHEA, Clinical Teaching Fellow in Restorative Dentistry,
School of Oral and Dental Sciences, Jonathan R Sandy, BDS, MSc, PhD(Lond), MOrth RCS, FDS RCS, FDS RCS(Ed), FFD RCS, Professor of
Orthodontics and Dean of Health Sciences and Anthony J Ireland, BDS, MSc, PhD(Lond), MOrth RCS, FDS RCS, Professor of Orthodontics,
School of Oral and Dental Sciences, University of Bristol, UK.
January 2017
whereby dental age is correlated with
skeletal age using a radiological assessment
of the degree of development of the root of
the lower canine and its stage of eruption.14
This method is, however, controversial as
dental eruption times can vary as a result of
a number of both local and general factors,
leading to observed differences between
a patient’s dental age, chronological age
and degree of skeletal maturity. Although
intra-oral and radiographic assessments of
the developing dentition, including degree
of root formation, can be quickly and easily
made, dental development indices are not
reliable measures for predicting growth and
skeletal maturity.8
Growth curves
In the 1920s, Richard Scammon15
proposed that the different tissues and
systems of the body have different growth
patterns and illustrated this by plotting the
percentage of the final adult size of the four
main tissues from birth to 20 years (Figure
1). These four tissue types were:
1. Neural;
2. Somatic;
3. Genital;
4. Lymphoid.
The somatic (general) curve
describes the growth of the body as a
whole, whilst the neural, genital and
lymphoid curves are more tissue specific.
The neural curve characterizes the growth of
the central nervous system and associated
structures and shows that around 95% of
neural growth is already attained by the age
of 7 years. The genital curve describes the
growth of the sexual characteristics. It shows
slight growth of the primary characteristics
in infancy, followed by a period of latency.
Rapid growth then takes place during
adolescence when both sexes develop their
secondary sexual characteristics. Finally, the
lymphoid curve describes the growth of the
lymph tissues and associated structures.
There is rapid growth of lymphatic tissues
during infancy and early childhood,
reaching a peak around the age of 11−13
years of age. The lymphoid tissue then
declines during the second decade of life
with shrinkage of the tonsillar tissue and
thymus gland.
From the orthodontic
perspective, maxillary and mandibular
growth follows a pattern that is part way
between neural and somatic growth, with
the mandible following the somatic curve
more closely than the maxilla. Although
useful in identifying the differential growth
of the tissues, these Scammon curves
cannot help predict when growth is going
to occur.
Height and weight
characteristics
Longitudinal growth
studies looking at various aspects of
growth associated with childhood and
adolescence16,17 have been carried out in both
North America and Europe. They have mostly
concentrated on the height and weight
characteristics of the individuals and the
data collected have led to the development
of growth charts. These charts can be used
by parents, clinicians and researchers to plot
an individual child’s height and weight. They
can also be used to describe the optimal
growth for healthy children, compare children
within a population, estimate adult height
and assess puberty. An example of such
a growth chart currently in use within the
United Kingdom is the UK-WHO Growth Chart
(Figure 2).18 This comprises two charts which
are gender specific and have been compiled
using data from both the World Health
Organization child growth standards19 and
the UK 1990 growth reference for children.20
Owing to secular trends for increased height
and weight, the UK-WHO Growth Chart has
replaced those originally described by Tanner
and Whitehouse in the 1960s and 1970s.21,22
In orthodontics it is standing
height rather than weight that is used in the
assessment of growth. A correlation exists
between changes in standing height and
the onset of the pubertal growth spurt.23
Standing height measurement is easy to
perform in the clinical setting, is minimally
invasive, has no side-effects and can be
done on numerous occasions. The method
of height measurement is standardized
using a stadiometer. In order to take the
measurement, the subject should be
standing (without shoes), their Frankfort
plane should be horizontal (parallel with
the floor) and, whilst the subject breathes
out, a linear measurement is made from the
floor to the top of the subject’s head to the
nearest millimetre (mm)24 (Figure 3). The
measurement obtained is then plotted on
the gender specific UK-WHO Growth Chart.
These age and sex specific height charts act
as a reference tool for the average male/
female and illustrate the wide range of
individual variation, by including different
lines representing different percentiles of
the population. Therefore, if a child’s plotted
height measurement is found to be on
the 5th percentile line at a particular age,
that child will be in the bottom 5% of the
population for height. Or, in other words, 95%
of children of the same gender and age will
be taller at that given time. It has been shown
that serial measures of a patient’s height can
be a clinically useful tool to predict the timing
of the pubertal growth spurt25 although,
Orthodontics 17
Figure 1. Scammon growth curves (redrawn
from Scammon RE, 1930).15
owing to individual variation, it needs to be
used with care.9
Growth rate (velocity) curve
The growth rate or velocity curve
is very different from a growth measurement
curve, such as the UK-WHO Growth Chart, as
it represents growth rate (eg centimetres per
year) rather than a static height measurement
at a particular time. A normal growth
measurement curve may indicate that a child
is still getting taller, whereas a velocity curve
might show that this is actually happening
at a progressively slower rate. Conversely, if
the rate is seen to be increasing on a growth
velocity curve, it may indicate that a child
is beginning his/her pubertal growth spurt.
The curve reaches a peak, known as the
peak height velocity (PHV), at the time of the
pubertal growth spurt (Figure 4) and it is at
this point that the maximum rate of growth
has been reached. Following this, there is a
rapid decrease in the rate of growth, but it is
important to understand that the individual
will still be growing, albeit at a much slower
rate until growth is complete. Longitudinal
studies have shown that PHV varies for each
individual, but usually follows pubertal onset
by about 2 years. The pubertal growth spurt
also occurs 2 years earlier in females than
males and is summarized in Table 1.22
Secondary sexual characteristics
The World Health Organization
has defined adolescence as the period
between the ages of 10 and 18 years. It
may be more appropriate, however, to
consider the age ranges of 8−19 in girls and
10−22 years in boys, as the limits of normal
variation.26 During this period most body
systems become adult, both structurally and
18 Orthodontics January 2017

99.6th 99.6th 99.6th

98th Very Overweight (obese) 98th 98th
91st Overweight 91st 91st
75th 75th 75th
50th BMI CENTILE FROM LOOKUP OVERLEAF 50th 50th
25th 25th 25th
9th 9th 9th
2nd 2nd 2nd
0.4th 0.4th 0.4th
145cm 145cm 185cm

GIR
1 1 1 1 1
3 /2 4 4 /2 5 5 /2 6 6 /2 7 7 /2 8

GIRLS 180
140 2-8 years 99
.6t
h 140 8-18
175
21/2 3
th

Puberty starting before 8 years is precocious

98
135 135 170

9 1st
165
130 130
th
75
160

125 th 125
50 155

t
Transit point
from UK-WHO th
25 150

h
to UK90 data.
120 120 h
.6t
99

g
9th 145

i
th
98

e
115 115
2n
d 140 st
91

h
th
0.4
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110 110
th
50
130
th
25
105 105cm
125
9th

120 d
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100 . 6t 50kg
99
th
0.4
th 115
98

Birth 95 st 45
91
centiles 110cm
t h
75 t h
Length 9 9.6
th 70kg
90 50 40
th
25
65
56
56 h
99.6th 9t
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85 35
98th
5544 d 60

Puberty starting before 8 years is precocious

91st 2n
75th 5522 t
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50th 0. 55
5500 80 30
25th

9th
4488 75th

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50 .6
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4466 99

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0.4th
75cm 50th 25
444cm
4cm
45
25th
th
98
9th 40
20kg 20
2nd
th
Weight 99.6 st
0.4th 91
98th
35
5
15 91st 15 h
99.6th 75t
98th 4.5 75th 30
50th
91st
4 50th
25th
75th
9th
3.5 25 25th
50th 10 2nd 10
0.4th
25th 9th
3
9th 2nd
20 0.4th
2nd 2.5
0.4th 5 Age in years 5
2kg
15
2 2 /2 3 3 /2 4 4 /2 5 5 /2 6 6 /2 7 7 /2 8 8
1 1 1 1 1 1

0kg 0kg 10kg

 January 2017 Orthodontics 19

99.6th
Very Overweight (obese)
99.6th
Parent Height Comparator
98th 98th
91st Overweight 91st Mother’s
height
75th 75th
ft/in cm Father’s
50th BMI CENTILE FROM LOOKUP OVERLEAF 50th
6’1”
height
185
25th 25th cm ft/in
6’7”
9th 9th
6’ Mid-parental 200
2nd 2nd centile 6’6”
0.4th 0.4th
5’11” 180 91st
145cm 185cm 185cm 195 6’5"

GIRLS
8 10 11 12 13 14 15 16 17 18
5’10” 6’4”
180 99.6th 180 5’9” 175 190 6’3"
140 8-18 years 98th 6’2"
5’8”
175 175 75th
9
170 185 6’1"
91st 5’7”

Puberty completing after 16 years is delayed

Puberty starting before 8 years is precocious

Puberty is delayed if no signs are present by 13 years

135 170 170 6’
5’6”

t
75th

h
180 5’11”

ig
5’5” 165
165 165

he
50th 50th 5’10”
130
5’4”
175 5’9”
160 25th 160
5’3” 160
5’8”
9th
125 155 155 5’2” 170 5’7”
25th
2nd 5’1” 155 5’6”
150 150 165 5’5”
120 h 0.4th 5’
.6t
99 5’4”
145 145 4’11” 150
t h 160 5’3”
98 9th
115 4’10”
140 st 140 5’2”
91 145
4’9” 155 5’1”
th
135 75 135cm
110 Father’s height: ____________
th
50
130 95kg Mother’s height: ___________
th
25 Mid-parental Centile
105cm • Plot the the Mother’s and
125 th 90
9th 0.4 Father’s heights on their
u berty 99.6th
Pre-p respective scales and join the
120 d 85 two points with a line. The
2n
50kg mid-parental centile is where
th
this line crosses the centile line
0.4 in the middle.
115 80 • Compare the mid-parental
98th
For all Children centile to the child’s current
45 plotted in this height centile, plotted on the
110cm 75 adult height predictor centile
shaded area see
instructions. scale.
• Nine out of ten children’s
70kg 91st 70 height centiles are within
40 ±two centile spaces of the
mid-parental centile.
65 65
75th Adult Height Predictor
35 ft/in cm

ight
60 60 5’9” 99.6th 175
Puberty starting before 8 years is precocious

Puberty completing after 16 years is delayed

Puberty is delayed if no signs are present by 13 years

50th
5’8” 98th

we
55 55
30
25th 5’7” 91st 170
50 .6
t h 50 5’6”
99 9th 75th
25
45 45
5’5” 165
2nd 50th
th 5’4”
98 0.4th 25th
20 40 40
5’3” 160
9th
st
91 5’2”
35 35
2nd
15 75t
h 5’1” 155
30 30 0.4th
50th 5’0”
25 25th 25 4’11” 150
10
9th
Predicted Adult Height
2nd • Plot the most recent height
20 0.4th
20
centile on the relevant centile
5 Age in years line and
• Read off the predicted adult
15 15 height for this centile.
8 8 9 10 11 12 13 14 15 16 17 18
• Four out of five children will
be within ±6 cm of this value.
0kg 10kg 10kg

Figure 2. The UK-WHO Growth Chart for Girls (reprinted with permission from WHO UK Growth charts, Girls 2−18, www.rcpch.ac.uk/system/files/protected/page/
NEW%20Girls%202-18yrs(4TH%20JAN%202012).pdf) © 2012/13 Royal College of Paediatrics and Child Health. A similar chart exists for males, which is coloured blue.
20 Orthodontics
Figure 3. Measurement of standing height in a
clinical environment using a stadiometer.
functionally.
Assessing whether an individual
is undergoing puberty can be carried out
by taking an appropriate history, or by
carrying out a clinical examination. Signs
and symptoms include the development of
secondary sexual characteristics, growth of
axillary/pubic hair and, in addition, in girls the
onset of menarche and in boys the deepening
of the voice and growth of facial hair. Some of
these changes have been summarized in five
stages and describe different periods of an
adolescent’s puberty:
 Stage 1: Pre-pubertal;
 Stage 2 & 3: Undergoing puberty;
 Stage 4 & 5: Completing puberty or
puberty complete.27,28
It is rare in orthodontics that
we would wish to determine such personal
information about our patients, particularly
as other less intrusive and more reliable
methods of predicting the puberty of an
individual are available within our clinical
environment.
Radiological skeletal assessment
A radiological assessment of
the skeleton is considered to be the most
reliable method of assessing skeletal maturity
with respect to growth for orthodontic
purposes.29 Clinicians can accurately
determine the different stages of growth
using methods based on the indicators of
skeletal maturation. Suitable regions for the
assessment of skeletal maturity should be:
 Small in order to restrict the radiation
exposure;
 Have several ossification centres which
Figure 4. Peak height velocity curve for boys and
girls (redrawn from Tanner et al, 1966).21
ossify at different times;
 Be easily accessible;
 Use radiological views that can be
standardized.
A number of regions have
been suggested for the purposes of such
radiological assessment and these are
outlined in Table 2.
Hand-wrist radiographs
The hand and wrist comprise
a number of small bones that all show
a predictable and uniform pattern of
appearance, ossification and union from birth
to maturity. Therefore, it is a region that has
been extensively studied in relation to the
assessment of growth.
The region is made up of four
groups of bones, namely:
1. The distal ends of the radius and ulna;
2. Carpals;
3. Metacarpals;
4. Phalanges.
A number of methods have
been described in the literature regarding
the radiological assessment and prediction
of skeletal growth using hand-wrist
radiographs.30,31,32 One of the most popular
was the publication of an atlas containing
ideal photographs of hand-wrist radiographs
of children of various chronological ages.30
There are separate photos for males and
females and the clinician matches his/her
patient’s radiograph with one of the photos in
the atlas. For each radiograph, a chronological
age corresponding to the skeletal age is
assigned. This method can indicate the
peak and end of growth, but cannot tell
January 2017
the clinician when the growth spurt is
about to begin. Therefore, other evaluation
systems were developed, which used similar
radiographs and described discrete stages
of hand-wrist development. These were
characterized by specific stages of skeletal
maturity ranging over the entire period
of adolescence.31,32 This makes it possible
to assess whether a patient is early, pre-
pubertal, pubertal onset, pubertal, pubertal
deceleration or at the growth completion
phase of skeletal maturity.
Other methods of assessing
skeletal maturation have also been developed
to aid clinicians who may not be familiar
with, or confident in the interpretation of, the
anatomy and sequence of calcification of the
bones of the hand. These methods include
the appearance of the sesamoid ulnar bone in
the metacarpophalangeal joint of the thumb,
and/or the capping between the epiphysis
and diaphysis of the proximal and middle
phalanges of the index and the middle
fingers. Radiographic assessment of these
areas can also be carried out using smaller
periapical radiographs, thus reducing the
radiation dose to the patient.33
Despite suggestions that the
use of hand-wrist radiographs to establish
the extent of skeletal development is an
unreliable method for the prediction of the
pubertal growth spurt,34 it is still an extremely
popular method of growth prediction and is
utilized in many countries around the World.
In the United Kingdom, however, the ‘British
Orthodontic Society Radiography Guidelines’
do not support the use of hand-wrist
radiographs as it is deemed to expose the
patient to additional radiation unnecessarily
for little purpose.35
Cervical vertebrae
In recent years, there has been
renewed interest in the use of the maturation
of the cervical vertebrae as an assessment
of growth. This is because these bones are
readily visible on the lateral cephalogram,
an X-ray that is routinely used in orthodontic
clinical practice. Lamparski initially developed
such a system of skeletal maturation
determination using the cervical vertebrae.36
The author described how the shapes of the
individual and specific cervical vertebrae were
found to be different at different stages of
skeletal maturation and development.
This was further modified by
Hassel and Farman,37 who described each
stage of cervical vertebrae maturation
(CVM) in much more detail and this was
further refined by Bacetti et al,38 who used
longitudinal data to relate the cervical
vertebrae changes to the increment in total
mandibular length. They therefore developed
22 Orthodontics January 2017

a method of assessing the potential onset Simple questioning older siblings?

of the pubertal growth spurt. Bacetti and his
team describe six distinct and consecutive
stages of assessment using the shapes of
the cervical vertebrae C2, C3 and C4, which
correlate to the peak mandibular growth and
with a range of two years before and two
years after it has occurred (Figure 5, Table 3).38
They suggest that cervical stage (CS3) is the
ideal time for orthodontic treatment, as the
peak in mandibular growth will occur within a
year after this particular observation.
There is some doubt, however, as
to how reproducible this method is because
of difficulties in classifying the shape of the
vertebral bodies of C3 and C4.39 Although this
method may help inform the clinician when
the peak of growth is going to take place, it
does not tell the clinician how much growth
is going to occur.
Sometimes just asking patients
or their parents about their children’s growth
can help clinicians to assess the stage of
skeletal growth. Simple questions that can be
asked at the consultation appointment that
can aid diagnosis and treatment planning
include:
 When did the child’s shoe size last
change?;
 Is the child still getting taller?;
 Is the child as tall as your Mother/Father/
Gender Pubertal Growth Spurt
Female 12 years +/- 2 years
Male 14 years +/- 2 years
Table 1. Average pubertal growth spurt age and duration for males and females.
The advantage of this simple
method is that, although it is subjective, it
will provide useful information about an
individual’s growth at the time. It will not
necessarily provide information enabling an
accurate prediction of growth, ie whether the
pubertal growth spurt is approaching, or is
complete.
Secular trends
Evidence suggests that
Duration
2 years
3.5 years

Head & Neck Skull

Cervical Vertebrae
Upper Limb Shoulder Joint/ Scapula
Elbow
Wrist
Carpals
Metacarpals
Phalanges
Lower Limb Femur
Hip Joint
Knee
Ankle
Tarsals
Metatarsals
Phalanges
Table 2. Anatomical regions normally used for
Figure 5. Schematic showing the six stages of CVM (redrawn from Bacetti et al, 2005).38 skeletal maturation assessment.

Cervical C2 − Lower Border C3 − Lower border C4 − Lower border Peak Mandibular Growth
Stage C3 − Body C4 − Body

Flat Flat On average 2 years after this

1 Flat
Trapezoid Trapezoid stage
Flat Flat On average 1 year after this
2 Concave
Trapezoid Trapezoid stage
Concave Flat During the year after this
3 Concave trapezoid or rectangular trapezoid or rectangular stage
horizontal horizontal
Concave Concave Within 1−2 years before this
4 Concave rectangular horizontal rectangular horizontal stage
Concave Concave Finished at least 1 year before
5 Concave rectangular horizontal or square rectangular horizontal or this stage
square
Concave Concave Finished at least 2 years
6 Concave square or rectangular vertical square or rectangular vertical before this stage
Table 3. The six cervical stages of maturation and their relation to peak mandibular growth.
January 2017
children are growing faster now than their
counterparts did in the past.40,41.Data have
shown that boys in the developed Western
World have, on average, grown taller by
½ inch every 10 years between 1873 and
1943.42 These trends have also demonstrated
that adolescents are not only growing
faster, but they are also experiencing their
pubertal growth spurt and completing
growth much sooner than adolescents 100
years ago. Potentially, this can be ascribed
to better nutrition, balanced diets and
better healthcare. More recently, it has
been shown that this secular trend has now
started to plateau in the Western World. This
is important in the context of the data from
the literature that are used for the prediction
of the pubertal growth spurt in individuals.
The data in the majority of the longitudinal
studies are over 50 years old and therefore
need to be considered in the context of
current assessments.
Conclusions
There is no single method that
can be used to predict when individuals are
about to undergo their pubertal growth spurt
accurately. Each method of prediction has its
advantages and disadvantages. Growth is a
fluid process and therefore a combination of
a number of valid methods that complement
each other will help the clinician confirm
whether an individual is growing or not.
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