GROWTH PREDICTION METHODS

 As stated by Ricketts, to take the advantage of growth we must have an idea of - its
magnitude, its direction and its timing .
 By using the element of timing of maximum growth in conjunction with ones knowledge
of magnitude and direction, readily transforms orthodontics to a profession of “face
forming , as well as tooth positioning”.
 A number of growth assessment methods like chronological age, dental age,
morphological age, skeletal age & circumpubertal age are available.
 Chronological age is often not sufficient for assessing the developmental stage and
somatic maturity of the patient.
 The biological age is determined from the skeletal, dental and morphologic age and the
onset of puberty.
 Due to individual variations in timing, duration and velocity of growth, skeletal age
assessment is essential in formulating viable orthodontic treatment plans.

What is Prediction?

According to the Oxford dictionary, To predict = to say that something will happen in the future
i.e. to forecast.

What is Growth Prediction?

“Specifying the amount and direction of future growth in the context of a base line or
reference point”.

Why understanding of growth is so important?

During our practice, we may come across 2 different groups of patients:

Growing and
Nongrowing.
 For nongrowing patients, treatment planning could be a straight forward procedure and
outcome could be predicted. But in case of growing child, we need to know the changes brought
about by growth.
 Robert E. Moyers : The clinician is interested in assessing physical growth for the following
reasons :
o The identification of grossly abnormal pathologic growth.
o The recognition and diagnosis of significant deviation from normal growth.
o The planning of therapy.
o The determination of efficacy of treatment.
 If an attempt is made to assess the growth trend at an early stage, the information trend at an
early stage, can be used in designing the treatment or evaluating the problems that may arise
before growth is completed.
 A growth analysis consists essentially of three analysis consists essentially of three items, each
of which is clinically items, each of which is clinically significant
 An assessment of the development in shape of the face which implies changes
shape of the face which implies changes in the intermaxillary relationship.
 An assessment of whether the intensity of the facial growth in general is high or
low.
 An evaluation of the individual rate of maturation. This is important in
establishing whether puberty has been reached and when the growth may be
expected to be completed
 The large variability in the amount and direction of facial growth in different subjects and the
importance of facial growth for the success of orthodontic treatment has been generally
recognized over the past decade. This has led to a marked interest in methods for predicting the
amount and direction of facial growth in the individual patient..
 It is worthwhile mentioning the conclusion made by Brodie in 1938, "There seems to be a
definite correlation between success of treatment and growth. Apparently growth and
development accounts for a considerable part of change which take place during orthodontic
treatment."
 According to Hirschfeld and Moyers (AJO, 1971):
1. Future size of part: the prediction of future size, according to Burstone, his primarily a problem
of predicting future increments which are to be added to a size that is already known. Most of
the size dimension of interest to the orthodontist displays a combination growth curve through
time.
2. Relationship of parts: The most important prediction for the clinician is the future relationship
of parts, that is, future facial patterns. Pattern, however represented, is a summation of the
growth and size in several component regions.
3. Timing of growth events: Because growth does not proceed evenly, certain facial dimensions
demonstrate market changes in their velocity curve. These “spurts” make prediction much more
difficult. If one were to predict a spurt, he might want to predict the time of its onset, the
duration of the increased rate of growth, and the rate of growth during the spurt.
4. Vectors of growth: Most predictive methods thus far presume a continuation of the pattern first
seen therefore; the presumption is made that the vectors of growth presents at the time of
prediction will remain. There is much documentation that this presumption is not true.
Mandibles, which grow vertically for a period of time inexplicably, start to grow horizontally.
 5. Velocity of growth: It would be of use to know the future expected rate of growth. Prediction
of velocity is most important during the pubescent spurt.
6. The effect of orthodontic therapy on any of the above predicted parameters: It is not
unreasonable for clinician to be interested in predicting what effect the treatment will have on
the predicted and actual growth of one specific face.

Clinical Importance of Maturity Indicators

1. To determine the potential vector of facial development.

2. To determine the amount of significant facial cranial growth potential left.
3. To decide the onset of treatment timing and type of effective treatment.
4. To evaluate the treatment prognosis.
5. To understand the role of genetics and environment on the skeletal maturation pattern.

There are 4 available methods:

1. Theoretical.
2. Regression.
3. Experimental.
4. Time series.

THEORETICAL METHOD: Includes:

1. Collection of series of relevant datas.

2. Mathematical construction of a theoretical model.
3. Theoretical development of a hypothesis from the model.
4. Proving the hypothesis practically.

REGRESSION METHOD.

These methods serve to calculate a value for one variable called dependent, on the basis of its initial
states and the degree of its correlation with one or more independent variables.

Johnston has recently evaluated and reviewed regression methods of approach to craniofacial
prediction. Among his conclusions is that:

(1) The ultimate accuracy of cephalometric prediction may be limited to some extent by intrinsic errors
with the cephalometric method itself.

(2) Contemperory methods seem inadequate to provide an efficient estimate of individual changes
attributed only to growth. Burstone has reviewed some of the problems of attack and of selection of
independent variables with regard to growth prediction.

EXPERIMENTAL METHOD.
  It is based on the clinical experience of a single investigator who attempts to quantify his
observations of practice in such a way that they can be codified for use by others.
 Eg. Ricketts' growth prediction.

TIME SERIES METHOD.

 Because of the great interest in prediction of craniofacial growth and the limitations of the
methods thus far tried, it seems pertinent to ask whether there might be some other method of
prediction, as yet, untried on growth problems which would provide the desired accuracy,
efficiency and individuality for the clinician.
 Operations research has been concerned with the development of methods which are based on
individual not population behaviour.
 The methods are essentially two types
1. Time series analysis which extracts in a mathematical form the fundamental nature of the process as
it relates to time.
2.smoothing methods, either moving averages or exponential, which operate to give representative or
average values to the parameters of a previously derived time series equation .For purpose of analysis a
time series is considered to be composed of four parts. These are
1. Trend or long term movement
2. Oscillations about a trend
3. Cyclic or periodic events
4. Random compliments
The analysis consists of assessment of each of these parts by means of specific statistical tests. Time
series method offers more promise for craniofacial growth than any of the methods thus far used.
GROWTH SPURTS:
 Periods of sudden acceleration of growth.
 Due to physiological alteration in hormonal secretion.
 Timing-sex linked.
 Normal spurts are
1. Infantile spurt : at 3 years age
2. Juvenile spurt : 7-8 years (females); 8-10 years (males)
3. Pubertal spurt : 10-14 years (females); 12-17years (males)
Periodic Variations in Growth Rate
The typical growth pattern of a child is characterized by a growth rate
that decreases from birth with a minor midgrowth spurt at approx. 6-8
years of age, a prepubertal minimum and a pubertal or adolescent
growth spurt.
Pubertal growth spurt:
 Important period for orthodontic treatment.
 Initiated in the brain-secretion of releasing factors, pituitary
gonadotropins.
 Sex hormones released-physiological changes occur-classic growth cure pattern.
 Affected by genetic and environmental factors.
Adolescence
1. It can be defined as the period of life when sexual maturity is attained.
2. It is a transitional period between the juvenile stage and adulthood during which
adolescent growth spurt takes place.
3. This period is particularly important in orthodontic treatment, because the physical
changes at adolescence significantly affect the face and dentition.
4. Major events that occur during adolescence include-
- Exchange from mixed to permanent dentition
- Acceleration in overall rate of facial growth &
- Differential growth of jaws.
GIRLS
Total development of adolescent growth- 3½yrs
BOYS
Total development of adolescent growth- 5 yrs

Timing of Puberty
 Velocity curves for growth at adolescence shows difference in timing between boys and
girls.
 Pubertal growth spurt occurs on an average nearly 2 years earlier in girls than boys.
 Sex hormones are produced in adrenals by 6 years-‘adrenarche’.
 More prominent in girls due to greater adrenal component.
Important clinically - careful assessment of physiologic age - plan orthodontic treatment
Treatment must begin during
- mixed dentition-for girls.
- Near completion of permanent dentition-for boys- Proffit.
HAND WRIST RADIOGRAPHS AND SKELETAL MATURITY
 The first recorded Hand-wrist radiograph film was published by Sydney Rowland of London in
1896. This was just 4 months after the announcement of the discovery of the X-Ray by
Roentgen.
 In 1926 Carter reported on a radiographic study of carpal bones in children.
  Howard (1928) using hand X-rays, reported on the physiologic changes of bone centers in a large
group of male and female children from ages 5to16.
 The concept that facial growth was in some way related to general body growth was reported by
Nanda(1955) .
 Johnston(1965) demonstrated a relationship between skeletal and facial growth and
emphasized that there were, in addition to normal growth patterns, retarded as well as
accelerated types which required special attention.
 Bjork and Helm(1967) stated that the appearance of the ulnar sessamoid on the Hand-wrist
radiograph was significantly related to the onset of maximum puberal statural growth in height.
The sessamoid appeared before maximal puberal statural growth,and menarche in girls
occurred after the maximum puberal growth.
 Brown, Barrett &Grave (1971) found that two other events occurred significantly at least one
year prior to peak growth velocity. They were initial ossification of hook of hamate as well as of
pissiform.
 Grave and Brown (1976) suggested that the epiphyseal union of radius could be used to assess
the duration of retentive phase of treatment.
 Grave and Brown (1979) described the use of hand wrist film in orthodontic treatment to take
advantage of the puberal growth spurt.
 Assessment of the skeletal age is often made with the help of a hand wrist radiograph which can
be considered the “Biological clock.”
 Hand wrist region is made up of numerous small bones. These bone show a predictable and
scheduled pattern of appearance, ossification and union from birth to maturity. Hence, this
region is one of the most suited to study growth.
 For the analysis of skeletal maturity up to the age of 9 years, the stage of mineralization of the
carpel bones must be determined; thereafter the development of metacarpal bones & phalanx
should be evaluated.
 Thus by merely comparing a patient’s hand-wrist radiograph with standard radiographs that
represent different skeletal ages, we will be able to determine the skeletal maturation status of
that individual.

Indications for hand-wrist radiogrphs

1) In patients who exhibit major discrepancy between dental and chronologic age.
2) Determination of skeletal maturity status prior to treatment of skeletal malocclusion such as
skeletal Class II or Class III malocclusion

3) To assess the skeletal age in patient whose growth is affected by infections, neoplastic or
traumatic conditions.

4) Serial assessment of skeletal age using hand-wrist radiographs helps not only in assessing the
growth of an individual, but also helps predict future skeletal maturation rate and status.

5) To predict the pubertal growth spurt.

6) It is a valuable aid in research aimed at studying the role of heredity, environment, nutrition
etc., on the skeletal maturation pattern.

7) It is indicated in patients with skeletal malocclusion needing orthognathic surgery, if undertaken

between 16-20 years so s to assess the growth status.

ANATOMY OF HAND – WRIST

The hand – wrist region is made up of the following four groups of bones.

1. Distal ends of long bones of forearm : The distal ends of radius and ulna, which are long bones
of the forearm, form the first group of bones

2. Carpals: They consist of eight small, irregularly shaped bones arranged in two rows, a proximal
row and a distal row. The bones of the proximal row are scaphoid, lunate, triquetral and pisiform. The
distal row of bones include trapezium, trapezoid, capitate, and hamate.

3. Metacarpals: They are 5 miniature long bones forming the skeletal

framework of the palm of the hand. They are numbered 1-5 from the thumb
to the little finger.

4. Phalanges : They are small bones forming the fingers. They are three
in number in each finger, except the thumb which has only two phalanges.
The three bones are referred to as the proximal, middle (absent in thumb)
and the distal phalanges.

The phalanges ossify in 3 stages.

Stage 1: The epiphysis and diaphysis are equal.

Stage 2: The epiphysis caps the diaphysis by surrounding it like a cap.

Stage 3: Fusion occurs between the epiphysis and diaphysis.

The sesamoid bone: is a small nodular bone most often present embedded in
tendons in the region of the thumb.
A number of methods have been described to assess the skeletal maturity using hand-wrist radiographs.

The following are the most commonly used methods:

A) Atlas methods by Greulich and Pyle

B) Bjork, Grave and Brown Method

C) Fishman’s Skeletal Maturity Indicators

D) Hagg nd Taranger MethodsFISHMAN Skeletal maturity indicators (SMI)

Fishman’s Skeletal Maturity Indicators

Proposed by Leonard S Fishman in 1982.

Make use of anatomical sites located on thumb, third finger, fifth finger and Radius .

The Fishman’s system of interpretation Uses four stages of bone maturation

1. Epiphysis equal in width to diaphysis

2. Appearence of adductor sesamoid of thumb

3. Capping of epiphysis.

4. Fusion of epiphysis

Width of epiphysis as wide as diaphysis

1. Third finger – Proximal phalanx.

2. Third finger – Middle phalanx

3. Fifth finger – Middle phalanx

Ossification

4. Adductor sesamoid of thumb

Capping of epiphysis

5. Third finger – Distal phalanx

6. Third finger – Middle phalanx

7. Fifth finger – Middle phalanx

Fusion of epiphysis and diaphysis

8. Third finger – Distal phalanx

9. Third finger – Proximal phalanx

10. Third finger – Middle phalanx

11. Radius

Significance

SMI 1,2,3 :- Occur approximately 3 years before the pubertal growth spurt.

SMI 4 :- This stage occurs shortly before or at the beginning of pubertal growth spurt.

SMI 5,6,7 :- This stage occurs at the peak of the pubertal growth spurt.

SMI 8,9,10,11 :- The ossification of all hand bones is completed and skeletal growth is finished.

Maturation Assessment by Hagg and Taranger

• Hagg and Taranger in 1980 described 5 stages of MP3 growth , based primarily on epiphyseal
changes.

• Skeletal development in the hand-wrist is analyzed from annual radiographs, taken between the
ages of 6 and 18 years, by assessment of the ossification of the ulnar sesamoid of the
metacarpophalangeal joint of first finger (S) and Certain specified stages of 3 epiphyseal bones:

- Middle and distal phalanges of third finger (MP3 and DP3)

 - distal epiphysis of Radius (R).

Sesamoid

• Sesamoid is usually attained during the acceleration period of the pubertal growth spurt (onset
of peak height velocity)

Third Finger Middle Phalanx

MP3-F Stage: Start of the curve of pubertal growth spurt and Epiphysis is as wide as metaphysis

MP3-FG Stage: Acceleration of the curve of pubertal growth spurt, Epiphysis is as wide as metaphysic,
Distinct medial and lateral border of epiphysis forms line of demarcation at right angle to distal border.

MP3-G Stage: Maximum point of pubertal growth spurt, Sides of epiphysis have thickened and cap its
metaphysis, forming sharp distal edge on one or both the sides.

MP3-H Stage: Deceleration of the curve of pubertal growth spurt, Fusion of epiphysis and metaphysis
begins.

MP3-I Stage: End of pubertal growth spurt, Fusion of epiphysis and metaphysis complete.

Third finger distal phalanx

DP3-1:Fusion of Epiphysis and Metaphysis is completed. This is attained during the deceleration period
of pubertal growth spurt.

Cervical Vertebrae as Maturational Indicators

 The development of the cervical vertebrae showed similarities with skeletal maturity indicators
found in the hand wrist area and could as such offer an alternative method of assessing maturity
without the need for a hand-wrist radiograph.
 LAMPARSKI in 1972 was the first person to study cervical vertebrae and he developed a series of
standards for assessing skeletal age in both males and female based on cervical vertebrae.
He found that cervical vertebrae indicators were same for males and females, but the females
developed the changes earlier
 Hassel and Farman (1995) modified his criteria and gave 6 stages of cervical vertebrae
development. Hassel and Farman modified the Lamparski criteria by using C2, C3, and C4
cervical vertebrae.
 Garcia –Fernandez (1998) related these stages with the SMI given by Fishman.

 The shapes of the cervical vertebrae were found to be different at different levels of skeletal
development.

 The shapes of the cervical bodies of C3 & C4 changed from somewhat wedge shaped, to
rectangular, followed by square shape.
  The inferior vertebral borders were flat when immature, & they were concave when mature.

Lamparski method

Stage 1 – the inferior borders of the bodies of all cervical vertebrae are flat. The superior borders are
tapered from posterior to anterior.

Stage 2 – a concavity develops in the inferior border of the second cervical vertebrae. The anterior
vertical height of bodies increase.

Stage 3 – a concavity develops in the inferior border of the third vertebrae.

Stage 4 – a concavity develops in inferior border of 4th vertebrae. Concavities in lower border of 5th
and 6th vertebrae are beginning to form. The bodies of all cervical vertebrae are rectangular in
shape.

Stage 5 – concavities are well defined in the lower border of the bodies of all 6 cervical vertebrae.
The bodies are nearly square in shape.

Stage 6 – all concavities have deepened. The vertebral bodies are now higher than they are wide.

Hassel and Farman put forward 6 stages in vertebral development using C2,C3, & C4 cervical vertebrae.

Category 1 (Initiation) – at this stage adolescent growth was just beginning and 80% to 100% of the
growth was expected. Inferior borders of C2, C3 and C4 were flat at this stage.the vertebrae are wedge
shaped, and the superior vertebral border were tapered from posterior to anterior.

Category 2 (Acceleration) – growth acceleration was

beginning at this stage with 65% to 85% of adolescent
growth expected.

Concavities were developing in the inferior border of C2, C3.

The inferior border of C4 was flat.

The bodies of C3 and C4 were nearly rectangular in shape.

Category 3 (Transition) – adolescent growth was still

accelerating at this stage towards peak height velocity with
25% to 65% of adolescent growth expected.

Distinct concavities were seen in the inferior borders of C2 and C3.

Concavity was beginning to develop in the inferior border of C4.

The bodies of C3 and C4 were rectangular in shape.

Category 4 (Deceleration) – adolescent growth began to decelerate dramatically at this stage with 10%
to 25% of adolescent growth expected.

Distinct concavities were seen in the inferior borders of C2, C3 andC4.

The vertebral bodies of C3 and C4 were becoming more square in shape.

Category 5 (Maturation) – final maturation of the vertebrae took place during this stage, with 5% to 10%
of adolescent growth expected.

More accentuated concavities were seen in the inferior borders of C2, C3 and C4.

The bodies of C3 and C4 were nearly square to square in shape.

Category 6 (Completion) – growth was considered to be complete at this stage.

Deep concavities were seen in the inferior borders of C2, C3 and C4.

The bodies of C3 and C4 were square or were greater in vertical dimension than in horizontal dimension.

Six distinct stages of growth can be related to the SMI developed by Fishman

 Initiation (SMI 1 and 2)

 Acceleration (SMI 3 and 4)
 Transition (SMI 5 and 6)
 Deceleration (SMI 7 and 8)
 Maturation (SMI 9 and 10)
 Completion (SMI 11).
MIDPALATAL SUTURE REGION AS AN INDICATOR OF MATURITY

In 1982, Fishman developed the system of skeletal maturation assessment (SMA) which involves the
identification of 11 skeletal maturity indicators on H/W radiographs that occur serially from the onset to
termination of adolescence.

All measurements associated with the growth of the mandible correlate in intensity and timing with
growth in stature. The maxilla demonstrates less conformity.

Therefore knowing more about the development of the maxilla can help a clinician to better time
procedures like maxillary expansion.

Fishman in 1994 conducted a study to evaluate the ossification pattern of the mid-palatal suture and
whether this could be used as a maturity indicator

Stages of ossification of mid-palatal suture were compared with Fishman’s SMI stages.

Certain landmarks were identified on the occlusal films which formed the basis of comparision

Point A - Most anterior point on premaxilla

Point B – Most posterior point on the posterior wall of

the incisive foramen.

Point P – point tangent to a line connecting the posterior

walls of greater palatine foramen.

All measurements were made for –

a. Length

b. Percentage of development.

These were recorded for the following dimensions :

A-P - total dimension of the suture

A-B - anterior dimension of the suture

B-P - posterior dimension of the suture

The results reveled that there is significant

correlation b/n maturational development and the
beginning of ossification of the mid-palatal suture.
No differences were seen in the pattern of approximation b/w males and females.

This study has also verified the fact that midpalatal approximation occurs more posteriorly during the
entire adolescent period

Clinical implication :

An ideal time to initiate orthopedic expansion is during the early maturational stage, SMI 1 to 4.

Theoretically less orthopedic force values would be required if treatment is initiated early.

Symphysis morphology as a predictor of the direction of mandibular

growth

 Nanda et al determined in their study that Symphysis morphology

could be used as a predictor of the direction of mandibular
growth.
 The mandibular symphyseal dimensions studied were height,
depth, ratio (height/depth), and angle.
 The Symphysis height was defined as the distance from the
superior to the inferior limit on the grid.
 The Symphysis depth was defined as the distance from the
anterior to the posterior limit on the grid
 Symphysis ratio was calculated by dividing Symphysis height by
depth.
 The Symphysis angle was determined by the posterior-superior
angle formed by the line through menton and point B and the
mandibular plane.
 Large Symphysis ratio – receding chin, high mandibular plane, high angle SN-MP, large saddle,
articulare & gonial angles, large anterior facial height, large percentage lower facial height
 Small Symphysis ratio – large chin, low mandibular plane, low angle SN-MP, low saddle,
articular & gonial angles, Small anterior facial height, Small percentage lower facial height
 Growth changes in Symphysis continued up to adulthood in both female and male subjects, with
the female subjects having a smaller and earlier occurring change compared with the male
subjects.
 Symphysis height, depth, and ratio increased while Symphysis angle decreased with age.

Ante gonial Notch – As an indicator of mandibular growth potential

The presence of a prominent mandibular ante gonial notch is a commonly reported finding in subjects
with disturbed or arrested growth of the mandibular condyles.

In unilateral condylar hypoplasia, marked mandibular notching develops only on the affected side.
Bjork’s implant studies have showed that in forward rotating mandibles apposition occurs below the
Symphysis and resorption takes place under the angle. Conversely, in backward mandibular rotation
apposition beneath the angle is common and resorption underneath the Symphysis is possible.

The direction of mandibular growth rotation is reflected in the location and degree of remodeling on the
inferior surface of the mandible and most pronounced area of remodeling is below the angular region.

Singer and Hunter( 1987) did a study to compare the craniofacial characteristics and growth potential of
orthodontically treated patients with deep mandibular ante gonial notch; with those of a similar group
of shallow notch subjects by use of lateral cephalometric radiographs.

> 3 mm - Very deep mandibular ante gonial notch

< 3 mm - Very shallow mandibular ante gonial notch

These extremes were examined by them with the hope that any biologic
relationship might be more readily apparent in extremes of population.

Concluding remarks were:

Deep notch subjects –

more retrusive mandible with short corpus, less ramus height, and a greater gonial angle than did
shallow notch subjects.

Mandibular growth direction was more vertically directed

Longer total facial height and longer lower facial height

Smaller saddle angle

Required a longer duration of orthodontic treatment (extractions 3 times the frequency, high-pull and
straight-pull head gear, shallow notch subjects – wore low pull head gear exclusively)

During the average 4-year period examined, the deep notch subjects experienced less mandibular
growth as evidenced by-

1. a smaller increase in total mandibular length.

2. corpus length, and

3. less displacement of the chin in a horizontal direction than did the shallow notch subjects.

Clinical implication

The results of this study suggest that the clinical presence of a deep mandibular ante gonial notch is
indicative of a diminished mandibular growth potential and a vertically directed mandibular growth
pattern.
An explanation for this could be when the growth of the mandibular condyle fails to contribute to the
lowering of the mandible, the masseter and medial pterygoid by their continued growth, cause the bone
in the region of the angle to grow downward, producing notching.

Growth trends Growth trends

 Tweed recorded lateral
cephalograms of all young Type A Type B Type C
patients undergoing pre-
orthodontic guidance program, 25% 15% 60%
and again after 12-18 months.
 The tracings of these films were superimposed on SN, with S as reference point.
 He stated that if this procedure is done before the start of any mechanical treatment
procedure, it would be possible to determine the type of facial growth trend that must
be contended with during treatment.
 It was important to ascertain the type of facial growth trend as early as possible, for it
concerns the prognosis, when to begin treatment and length of treatment time.
 The face of all children grow downward and forward in one of the three ways.
 Type A, Type B and Type C.

Type A growth trend.

 The middle and lower third of the face are growing in unison downwards and forwards,
with no change in the size of the ANB angle.
 Growth is approximately equal in both vertical and horizontal dimensions. 25% of the
patients present this type of growth trend.
 If the case is class I with ANB not exceeding 4.5* ,no treatment is indicated until the full
eruption of all permanent cuspids.

Type A Subdivision

 If the case is class II and ANB exceeds 4.5*,the patient has a type A subdivision growth
trend.
 Treated with Kloehn headgear to restrict the maxillary growth and continued till the
completion of serial extraction procedure till the class II molar relationship have been
corrected
 Prognosis is good as the point B moves forward and point A posteriorly
 Facial changes are good as mandibular incisors remain stable and free from crowding
 ANB relationship remains the same
 Treatment completed in 15-21 months.
2] Type B

 Type B growth trend

 Cases accompanied by ANB readings from 6* to 12*.
 Pre orthodontic tracings reveal that growth is downward and forward,with the middle
face growing more rapidly than the lower as designated by an increase in the size of
ANB-the growth trend is type B and undesirable.
 If the ANB is less than 4* the prognosis is fair
 Seen in 15% patients.

Type B Subdivision

 If ANB 7°-12° then prognosis is poor

 Patients must be treated at early age
 Extraction of all 4 premolars is mandatory with increased ANB
 Point B always drop downward and forward and point A follows it
 To attain FMIA 65° is not possible
 It treatment complete before cessation of growth Kloehn headgear must be used till
active treatment
 Treatment time is 36-42months
 Growth of the middle and lower face is predominantly in the vertical dimension.

Type C growth trend.

 Lower face is growing downward and forward more rapidly than the middle face,with a
decrease in the size of the ANB reading ,the growth is type C.
 Because the lower face is growing forward at a more rapid pace than the mid face,the
cutting edges of the mandibular incisors engage the lingual surfaces of the maxillary
incisors.
 The mandibular incisors are tipped lingually or the maxillary incisors are tipped labially.
 60% of all patients have type C growth trends.
 Regardless of the size of the FMA,when growth is virtually confined to the horizontal
dimensions,with little vertical growth,the growth trend is classified ae Type C
subdivision.

GROWTH SITE

 Growth Sites is a term proposed by Baume. (Baume, Louis J, 1961)

 Growth Sites serve as a location in the bone where the actual growth occurs.
 Growth sites are dependent on the growth centers for growth.
  Growth site: regions of periosteal or sutural bone formation and modeling resorption
adaptive to environmental influences. i.e. merely location at which growth occurs.
 Some examples include sutures of cranial vault, lateral cranial base and maxilla.

GROWTH CENTRE

 Growth Centers is an area in the bone that controls the overall growth of the bone from
its locations through different signaling mechanisms.
 Growth at these centers are genetically controlled.
 Growth Centre- site of endochondral ossification with tissue-separating force
(genetically controlled) growth occurs. , contributing to the increase of skeletal mass.
i.e. location at which independent growth occurs
 All growth centers can be growth sites but not all growth sites can be growth centers.
 Some examples include membranous bones of cranium, mandibular condyle.

GROWTH SITE

1)These are a growth fields that have a special significance in the growth of a particular bone.

2)Growth occurs as a secondary,compensatory effect.

3)Lacks direct genetic influence.

4)All growth sites are growth centres.

VS

GROWTH CENTRE

1)These are special growth sites,which control the overall growth of the bone.

2)Growth is primarily under the control of heredity.

3)Have intrinsic genetic potential.

4)All growth centres are not always growth site.