Croissance et développement partie 4 estimation de la maturité physique

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Published on February 17, 2014

Author: sylvainchamberland

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Cours de Croissance et développement aux étudiants en médecine dentaire.
MDD 20049
Partie 4: Estimation de la maturité physique

Croissance et Développement MDD 20049 4-0 Estimation de la maturité physique

• Le développement dentaire est assez bien corrélé avec l’âge chronologique bien que survenant indépendamment • Le développement dentaire est moins bien corrélé avec le maturation physique • Estimation de l’âge squelettique ✦ Rx main-poignet ✦ Rx vertèbre cervicale ©Dr Sylvain Chamberland; sylvainchamberland.com 2

• Développement dentaire ✦ Indépendant de la maturité somatique ou sexuelle ✦ Faible association avec la maturité physique • Corrélation âge chronologique et développement physique: r = 0,8. ✦ Valeur explicative: 64% • Corrélation entre âge dentaire et chronologique: r =0,7 ✦ Valeur explicative: ~ 50% ©Dr Sylvain Chamberland; sylvainchamberland.com 3

Estimation de la maturité physique chez la fille Semin. Orthod. 1997; 3: 212-221 ©Dr Sylvain Chamberland 4

Estimation de la maturité physique chez le garçon Semin. Orthod. 1997; 3: 212-221 ©Dr Sylvain Chamberland 5

Rx main-poignet • Identification du sésamoïde ✦ Apparaît avant le pic de croissance • Si absence de cartilage entre épiphyse et diaphyse: Val, Pou 15a 5 m ✦ Croissance terminée ©Dr Sylvain Chamberland 6

• 2e phalange: capping de la diaphyse • Fusion de la phalange distale • Présence de cartilage entre épiphyse et diaphyse Shad, Labr 12a 5 m ✦ Croissance disponible ©Dr Sylvain Chamberland; sylvainchamberland.com 7

• Toutefois • Le pic de croissance à l’adolescence des dimensions faciales n’est pas corrélé de façon consistante avec la croissance de la stature et la maturité physique tel que déterminé par les rx de poignet ✦ Moore et al, Skeletal maturation and craniofacial growth, AJODO 1990; 98: 33-40 ©Dr Sylvain Chamberland; sylvainchamberland.com 8

• Le timing de certains types de traitement orthodontique à forte composante orthopédique (correction cl II ou cl III, expansion palatine) est intimement lié à l’identification d’accélération ou d’intensification de la croissance pouvant contribuer à la correction du débalancement squelettique • L’efficacité des thérapies fonctionnelles dépends de la réponse du cartilage condylien qui, à son tour, dépends du taux de croissance mandibulaire • L’évaluation de la maturation squelettique mandibulaire et du potentiel de croissance de l’individu fournit des informations essentielles sur l’anticipation du résultat du traitement ©Dr Sylvain Chamberland; sylvainchamberland.com 9

• Indicateur biologique de maturité squelettique ✦ Augmentation en hauteur (grandeur) du corps (stature) ✓ Présente le moins de variabilité dans l’estimation de l’âge squelettique ✦ Développement et éruption dentaire ✦ Caractères sexuels secondaires (menstruations, poitrine, mue de la voie) ✦ Maturation des vertèbres cervicaux ✓ ©Dr Sylvain Chamberland; sylvainchamberland.com Efficace pour démontrer le pic de croissance de l’adolescence tant pour le garçon que pour la fille 10

338 Franchi, Baccetti, and McNamara American Journal of Maturation des vertèbres cervicales A Fig 4. Distribution o stage 3 in cervica females (Cvs3 fema croissance • Pic de du temps) en hauteur ➙ CVS3-CVS4 (93,5% significant decelerat Cvs4 to Cvs5 when DISCUSSION B ✦ A: groupe complet(n= 24) ✦ B: sous-groupe de 15 filles (~ 11 ans) ✦ C: sous-groupe de 9 garçons (~ 12-13 ans) • Pic de croissance mandibulaire ➙ CVS3-CVS4 C Fig 3. Individual changes in body height at intervals between stages in cervical vertebral maturation (A) in 24 subjects examined, (B) in subgroup of 15 females, and (C) in subgroup of 9 males. Cvs4 when compared with the growth interval Cvs2 to Cvs3, and significant growth deceleration during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. Ramus height (Co-Goi) and S-Gn also showed The issue of mandibular deficien contemporary ortho ment timing in Class misleading variabl some kind of categ rather than individ demonstrated clearl skeletal maturity is pedics, as the greate appliances occur wh is included in the tr A few biologic appraisal of individ quently, for the detec the mandible.2,4,6,11 statural height prese assessment of skelet of growth, thus show logic indicator of sk tation of this method measurements repea months) to construc velocity. Radiograph overcome this limita skeletal maturation o The features of an i ✦ G:12 a 8 m à 14a 2 m ✦ F: 11 a 4 m à 12 a 10 m ©Dr Sylvain Chamberland 11

• Distribution de l’âge chronologique au stade 3 338 Franchi, Baccetti, and McNamara American Journal of Orthodontics and Dentofacial Orthopedics September 2000 ✦ Filles: 8a 6 m à 11a 5 m ✦ Garçons: 10a à 14 a A • Donc, l’âge chronologique n’est pas un bon indicateur Fig 4. Distribution of individual chronological age at stage 3 in cervical vertebral maturation (Cvs3) in females (Cvs3 females) and males (Cvs3 males). de la maturation squelettique et ainsi de l’estimation du timing du traitement orthodontique significant deceleration of growth during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. DISCUSSION B ©Dr Sylvain Chamberland; sylvainchamberland.com C Fig 3. Individual changes in body height at intervals between stages in cervical vertebral maturation (A) in 24 subjects examined, (B) in subgroup of 15 females, and (C) in subgroup of 9 males. Cvs4 when compared with the growth interval Cvs2 to Cvs3, and significant growth deceleration during the The issue of optimal treatment timing for mandibular deficiencies is a widely debated topic in contemporary orthodontics. The definition of treatment timing in Class II disharmony too often relies on misleading variables such as chronological age or some kind of categorization of dentitional phases rather than individual biologic factors. It has been demonstrated clearly that the evaluation of individual skeletal maturity is fundamental in dentofacial orthopedics, as the greatest effects of functional/orthopedic appliances occur when the peak in mandibular growth is included in the treatment period.1,8-10 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.2,4,6,11-17 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 12

317 IMPROVED CVM METHOD • Méthode initiale ✓ ✓ changes can be observed in the vertebrae during this entire interval, which covers the period when orthodontic/orthopedic treatment is typically performed in the growing patient. Based on the findings of earlier investigations22,23,27,28 in 1972, Lamparski29 created separate standards of cervical vertebral maturation for female and male subjects as related to both chronological age and skeletal maturation height, Franchi et al, Mandibular growth as related to cervical vertebra maturation and body observed in the hand-wrist radiograph. The method analyzed size and AJODO 2000; 118: 335-40 shape changes in the bodies of five cervical vertebrae (from the second one through the sixth). Hassel and Farman30 reviewed lateral cephalometric and left hand-wrist radiographs from the Bolton-Brush Growth Study at Case Western Reserve University to develop an index based on the Bacetti T. et al, The cervical vertebra maturation (CVM) method for the assessment of optimal lateral profiles of the second, third, and fourth cervical vertreatment timing in dentofacial orthopedics, Semin. Orthod. 2005; 11: 119-129 tebrae. These researchers, as well as Pancherz and Szyska31 who further evaluated Hassel and Farman’s index in relation to increases in body height, stated that the cervical vertebral analysis had a comparable high reliability and validity as the hand-wrist bone analysis in the assessment of individual skeletal maturity. As for the relationship of cervical vertebral maturation and mandibular growth changes, O’Reilly and Yanniello32 evaluated annual lateral cephalometric radiographs of 13 Caucasian girls from 9 to 15 years of age and found statistically significant increases in mandibular length, corpus length, and ramus height in association with specific maturation stages in the cervical vertebrae according to the method of Lamparski.29 More recently, Franchi and coworkers12,13 confirmed the validity of six CVM stages as a biologic indicator for both mandibular and somatic skeletal maturity in 24 growing untreated subjects. The original method by Lamparski29 was adopted with a modification allowing for the appraisal of skeletal age in both boys and girls, regardless of chronological age (Figure 1). The main features of the CVM method as described by Franchi and coworkers12,13 included: ✦ 6 stades de formations FIGURE 1. Developmental stages of cervical vertebrae. Stage 1 (Cvs 1): the inferior borders of the bodies of all cervical vertebrae are flat. The superior borders are tapered from posterior to anterior. Stage 2 (Cvs 2): a concavity develops in the inferior border of the second vertebra. The anterior vertical height of the bodies increases. Stage 3 (Cvs 3): a concavity develops in the inferior border of the third vertebra. Stage 4 (Cvs 4): a concavity develops in the inferior border of the fourth vertebra. Concavities in the lower borders of the fifth and of the sixth vertebrae are beginning to form. The bodies of all cervical vertebrae are rectangular in shape. Stage 5 (Cvs 5): concavities are well defined in the lower borders of the bodies of all 6 cervical vertebrae. The bodies are nearly square in shape and the spaces between the bodies are reduced. Stage 6 (Cvs 6): all concavities have deepened. The bodies are now higher than they are wide. (Modified from O’Reilly and Yanniello.31) ✦ La plus grande augmentation du corps en hauteur survient a protective radiation collar. (2) To avoid definitions of stages based on a comparative assessment of between-stage changes, so that stages can be identified easily in a single cephalogram. The aim of the present work, therefore, is to present an improved version of the CVM method and its validity for the appraisal of mandibular skeletal maturity in the individual patient. entre le stade 3 (quand une concavité se développe sous le bord inférieur de C3) et le stade 4 (quand une concavité se développe sur le bord inférieure de C4) chez le garçon et la fille a. In nearly 95% of North-American subjects, the growth interval between stage 3 and stage 4 in CVM coincides with the pubertal peak in both mandibular growth and body height. b. Reproducibility of recorded data (identification of CVM stages) is as high as 98.6%. c. The method is useful for the anticipation of the pubertal peak in mandibular growth. The peak has not been reached if either stage 1 or stage 2 in CVM is recorded in the individual patient. SUBJECTS AND METHODS The total sample (706 subjects) that comprises the cephalometric files of the University of Michigan Elementary and Secondary School Growth Study33 was evaluated. Due to the longitudinal nature and to the aim of the present investigation, subjects with less than six consecutive cephalometric observations (n 5 492) were excluded from the study. Total mandibular length (Co-Gn) was measured on the longitudinal sets of annual lateral cephalograms for each of the 214 remaining subjects. The lateral cephalograms were analyzed by means of a digitizing tablet (Numonics, Lansdale, Penn) and digitizing software (Viewbox, ver 2.6 Kafissa, Greece). The maximum increase in Co-Gn between 13 two consecutive cephalograms was used to define the peak in mandibular growth at puberty in the individual subjects. Two consecutive cephalograms comprising the interval of maximum mandibular growth, together with two earlier consecutive cephalograms and two later consecutive cephalograms had to be available for each subject and were ✦ Le pic de croissance de la stature entre cvs3 et cvs4 ©Dr Sylvain Chamberland; sylvainchamberland.com correspond à la plus grande augmentation de mesures mandibulaires However, a few improvements of the original CVM analysis were still needed to make the method easier and applicable to the vast majority of patients: (1) To use a more limited number of vertebral bodies to perform the staging (as suggested by Hassel and Farman30). In particular, the method should include only those cervical vertebrae (C2, C3, and C4) that can be visualized when the patient wears Angle Orthodontist, Vol 72, No 4, 2002

Méthode simplifiée CVM • Bacetti T. et al, An improved version of the cervical vertebra maturation (CVM) method for the assessment of mandibular growth, A.O. 2002; 72: 295-301 338 Franchi, Baccetti, and McNamara American Journal of Orthodontics and Dentofacial Orthopedics September 2000 A Bacetti T. et al, Growth in the untreated cl III subjects, Semin. Orthod. 2007;13: 130-142 Fig 4. Distribution of individual chronological age at stage 3 in cervical vertebral maturation (Cvs3) in females (Cvs3 females) and males (Cvs3 males). ©Dr Sylvain Chamberland significant deceleration of growth during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. DISCUSSION B The issue of optimal treatment timing for mandibular deficiencies is a widely debated topic in contemporary orthodontics. The definition of treatment timing in Class II disharmony too often relies on misleading variables such as chronological age or 14

338 Franchi, Baccetti, and McNamara American Journal of Orthodontics and Dentofacial Orthopedics September 2000 A • CVMS 1 Fig 4. Distribution of individual chronological age at stage 3 in cervical vertebral maturation (Cvs3) in females (Cvs3 females) and males (Cvs3 males). significant deceleration of growth during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. DISCUSSION B C The issue of optimal treatment timing for mandibular deficiencies is a widely debated topic in contemporary orthodontics. The definition of treatment timing in Class II disharmony too often relies on misleading variables such as chronological age or some kind of categorization of dentitional phases rather than individual biologic factors. It has been demonstrated clearly that the evaluation of individual skeletal maturity is fundamental in dentofacial orthopedics, as the greatest effects of functional/orthopedic appliances occur when the peak in mandibular growth is included in the treatment period.1,8-10 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.2,4,6,11-17 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. The features of an ideal radiographic indicator should ✦ Bord inférieur des 3 vert.cerv. = plat ✦ Possibilité de concavité du bord inférieure de C2 dans la moitié Fig 3. Individual changes in body height at intervals between stages in cervical vertebral maturation (A) in 24 subjects examined, (B) in subgroup of 15 females, and (C) in subgroup of 9 males. Cvs4 when compared with the growth interval Cvs2 to Cvs3, and significant growth deceleration during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. Ramus height (Co-Goi) and S-Gn also showed des cas ✦ Le corps de C3 et C4 est trapézoïde (bord supérieur “taper” postéro-antérieurment) ✦ Le pic de croissance mandibulaire surviendra dans plus d’un an ©Dr Sylvain Chamberland; sylvainchamberland.com 15

338 Franchi, Baccetti, and McNamara American Journal of Orthodontics and Dentofacial Orthopedics September 2000 A • CVMS II Fig 4. Distribution of individual chronological age at stage 3 in cervical vertebral maturation (Cvs3) in females (Cvs3 females) and males (Cvs3 males). significant deceleration of growth during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. DISCUSSION B C The issue of optimal treatment timing for mandibular deficiencies is a widely debated topic in contemporary orthodontics. The definition of treatment timing in Class II disharmony too often relies on misleading variables such as chronological age or some kind of categorization of dentitional phases rather than individual biologic factors. It has been demonstrated clearly that the evaluation of individual skeletal maturity is fundamental in dentofacial orthopedics, as the greatest effects of functional/orthopedic appliances occur when the peak in mandibular growth is included in the treatment period.1,8-10 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.2,4,6,11-17 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. The features of an ideal radiographic indicator should ✦ Concavité sur le bord inférieur de C2 et C3 ✦ Corps de C3 et C4 sont soit trapézoïdes ou rectangulaires Fig 3. Individual changes in body height at intervals between stages in cervical vertebral maturation (A) in 24 subjects examined, (B) in subgroup of 15 females, and (C) in subgroup of 9 males. Cvs4 when compared with the growth interval Cvs2 to Cvs3, and significant growth deceleration during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. Ramus height (Co-Goi) and S-Gn also showed horizontalement ✦ Le pic de croissance mandibulaire survient moins d’un an après ce stade ©Dr Sylvain Chamberland; sylvainchamberland.com 16

338 Franchi, Baccetti, and McNamara American Journal of Orthodontics and Dentofacial Orthopedics September 2000 A Fig 4. Distribution of individual chronological age at stage 3 in cervical vertebral maturation (Cvs3) in females (Cvs3 females) and males (Cvs3 males). • CVMS III significant deceleration of growth during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. DISCUSSION B The issue of optimal treatment timing for mandibular deficiencies is a widely debated topic in contemporary orthodontics. The definition of treatment timing in Class II disharmony too often relies on misleading variables such as chronological age or some kind of categorization of dentitional phases rather than individual biologic factors. It has been demonstrated clearly that the evaluation of individual skeletal maturity is fundamental in dentofacial orthopedics, as the greatest effects of functional/orthopedic appliances occur when the peak in mandibular growth is included in the treatment period.1,8-10 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.2,4,6,11-17 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. The features of an ideal radiographic indicator should ✦ Concavité du bord inférieur de C2, C3 et C4 C ✦ Les corps de C3 et C4 sont rectangulaires horizontalement Fig 3. Individual changes in body height at intervals between stages in cervical vertebral maturation (A) in 24 subjects examined, (B) in subgroup of 15 females, and (C) in subgroup of 9 males. Cvs4 when compared with the growth interval Cvs2 to Cvs3, and significant growth deceleration during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. Ramus height (Co-Goi) and S-Gn also showed ✦ Le pic de croissance mandibulaire est survenu entre 1 et 2 ans avant ce stade ©Dr Sylvain Chamberland; sylvainchamberland.com 17

338 Franchi, Baccetti, and McNamara A American Journal of Orthodontics and Dentofacial Orthopedics September 2000 • CVMS IV Fig 4. Distribution of individual chronological age at stage 3 in cervical vertebral maturation (Cvs3) in females (Cvs3 females) and males (Cvs3 males). significant deceleration of growth during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. DISCUSSION B The issue of optimal treatment timing for mandibular deficiencies is a widely debated topic in contemporary orthodontics. The definition of treatment timing in Class II disharmony too often relies on misleading variables such as chronological age or some kind of categorization of dentitional phases rather than individual biologic factors. It has been demonstrated clearly that the evaluation of individual skeletal maturity is fundamental in dentofacial orthopedics, as the greatest effects of functional/orthopedic appliances occur when the peak in mandibular growth is included in the treatment period.1,8-10 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.2,4,6,11-17 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. The features of an ideal radiographic indicator should ✦ Concavité des bords inférieurs de C2, C3, C4 encore visible ✦ Au moins une des deux vertèbres C3 ou C4 a une forme carré C Fig 3. Individual changes in body height at intervals between stages in cervical vertebral maturation (A) in 24 subjects examined, (B) in subgroup of 15 females, and (C) in subgroup of 9 males. ✦ S’il n’est pas carré, le l’autre vertèbre est encore rectangulaire Cvs4 when compared with the growth interval Cvs2 to Cvs3, and significant growth deceleration during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. Ramus height (Co-Goi) and S-Gn also showed horizontale ✦ Le pic de croissance mandibulaire est terminé depuis moins de 1 an avant ce stade ©Dr Sylvain Chamberland; sylvainchamberland.com 18

338 Franchi, Baccetti, and McNamara A American Journal of Orthodontics and Dentofacial Orthopedics September 2000 • CVMS V Fig 4. Distribution of individual chronological age at stage 3 in cervical vertebral maturation (Cvs3) in females (Cvs3 females) and males (Cvs3 males). significant deceleration of growth during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. DISCUSSION B ✦ La concavité des bords inférieurs de C2, C3, C4 est encore The issue of optimal treatment timing for mandibular deficiencies is a widely debated topic in contemporary orthodontics. The definition of treatment timing in Class II disharmony too often relies on misleading variables such as chronological age or some kind of categorization of dentitional phases rather than individual biologic factors. It has been demonstrated clearly that the evaluation of individual skeletal maturity is fundamental in dentofacial orthopedics, as the greatest effects of functional/orthopedic appliances occur when the peak in mandibular growth is included in the treatment period.1,8-10 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.2,4,6,11-17 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. The features of an ideal radiographic indicator should visible C ✦ Au moins une vertèbre de C3 ou de C4 est rectangulaire Fig 3. Individual changes in body height at intervals between stages in cervical vertebral maturation (A) in 24 subjects examined, (B) in subgroup of 15 females, and (C) in subgroup of 9 males. Cvs4 when compared with the growth interval Cvs2 to Cvs3, and significant growth deceleration during the interval Cvs4 to Cvs5 when compared with Cvs3 to Cvs4. Ramus height (Co-Goi) and S-Gn also showed verticalement ✦ Si elle n’est pas rectangulaire, l’autre vertèbre est carrée ✦ Le pic de croissance mandibulaire est terminé environ 2 ans avant ce stade ©Dr Sylvain Chamberland; sylvainchamberland.com 19

• SI CVMS 1 est observé ✦ Attendre au moins 1 an avant de débuter un tx orthopédique • CVMS II: Stade idéal pour débuté tx orthopédique ✦ Md augmente de ~5,4 mm dans l’année suivante (CVMS II ➙ CVMS III) • Entre CVMS 1 et CVMS II ➙ Md augmente de ~2,4 mm • Entre CVMS III et CVMS IV ➙ Md augmente de 1,6 mm • Entre CVMS IV et CVMS V ➙ Md augmente de 2,1 mm ©Dr Sylvain Chamberland; sylvainchamberland.com 20

• Les traitements des classes II seront le plus efficace si fait durant le pic de croissance mandibulaire • Les traitements de cl III avec expansion maxillaire et protraction sont efficaces sur le maxillaire si c’est fait avant le pic mandibulaire (CS 1 et CS 2) • Les effets squelettiques de l’expansion palatine rapide pour corriger une déficience transverse sont plus grand si fait aux stades prépubertaires alors que si c’est fait durant la puberté ou après, les effets seront plutôt dento-alvéolaires ©Dr Sylvain Chamberland; sylvainchamberland.com 21

• Concavité sur le bord inférieur • C2, C3, C4: taper • C3: carrée Sha.La.12a5m ©Dr Sylvain Chamberland; sylvainchamberland.com 22

• C2: bord inférieur concave • C3, C4: bord inférieur plat • C3 et C4: taper, trapézoïde • C3 et C4: rectangulaire horizontal ©Dr Sylvain Chamberland; sylvainchamberland.com Gu.Ma.12a4m 23

• Concavité du bord inférieur • C3: forme rectangulaire horizontale • C4: forme carré Va.Po.15a5m ©Dr Sylvain Chamberland; sylvainchamberland.com 24

• C2, C3, C4: bord inférieur plat • C3 et C4: taper, trapézoïde Ly.Tr. 10a10m ©Dr Sylvain Chamberland; sylvainchamberland.com 25

• C3: concavité bord inférieur • C3: carré horizontal, taper antérieurement Ch.Cô. 13a8m ©Dr Sylvain Chamberland; sylvainchamberland.com 26

• C2, C3, C4: rectangulaire vertical • Concavité du bord inférieur Fr.Fe.18a4m ©Dr Sylvain Chamberland; sylvainchamberland.com 27

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