Özet:

Growth-development (maturation) and bone age detection have an important place in many sciences, such as anthropology, pediatrics, judicial medicine, ortopedic endocrinology and dentistry, in light of medical and legal issues.1 In dentistry, it is necessary to determine growth-development from time to time for diagnosis and treatment for prediction, especially in the surgical, pedodontial and orthodontial sciences.2-4 Young individuals, in congenital or traumatic dental deficiencies, have no standard-defined chronological age for implant application. In cases in which growth continues, in the implants applied in parallel to the amount of growth of the individual, the relative intusion of the implant can occur. The right time for implantation in oral, dental and scalp surgery can be determined only by the detection of the growth and development period.3 In children and young adults, dental trauma is more common. The replant of the teeth completely out of the socket can give quite good results with the provision of suitable environments. In many cases, it is very difficult to provide the ideal conditions and reimplement the woman in the right time. The development of ankylosis is seen in the area concerned as a result of replantation where the ideal conditions are not provided. The speed of remodeling in the body, along with ankylosis, is associated with the speed of resorption in the root. After this, the speed continues to decline. In order to predict such circumstances in pedodontium, it is necessary to evaluate the growth-development period.4 The growth-development, which is one of the biological foundations of orthodontics, constitutes an important parameter in this field of science.2,6 The transition period from childhood to adulthood, which is the puberty breakthrough period, can be used for different stages to guide the growth. In treatment with growth modification, the optimum time of treatment should be determined by the detection of growth breakthrough. The study by Ruf and Pancherz7 indicated that puberty growth is the most suitable period for growth modification. In order to obtain more effective results than the functional apparates used in class 2 maloclution treatment, research has shown that treatment should be started during puberty growth period.8.9 In class 3 palatal expansion treatment, preference of late puberty period has been to provide more stable and effective results.10 Orthodontic therapy may be supported by surgical therapies because there will not be any noticeable skeletal changes after puberty period.11-15 For these reasons; when and when the puberty break begins and when it will be completed, how and how the retension will be done, maturity is important from the orthodontic perspective. 16 Orthodontist does not need to know the patient's skeletal age, the main thing to know is how much the level of growth-development that the individual will grow during the treatment period is at which level or how much percent of growth will occur during the treatment.17,18 Methods used in the determination of growth Morphological Methods Morphological growth-development and bone age in the determination of size extension, weight increase, chronological age and gender indicators (sound thickness, increased swelling, swelling extension, swelling age) are used by criteria such as the chronological age of the patient, defined as the age of the calendar, and the date of the birth of the patient. Chronological age is not seen as a reliable method used to identify the growth-development period. Between chronological age and bone age, there may be certain differences according to periods; these are recorded as ± 6 months between 0-2 years, ± 1 year between 2-4 years, ± 2 years between 4 years and puberty.22 Histological methods in age determination, histologically focused on histomorphological and histochemical methods, and are more commonly used in postmortem cases. These methods have been studied with various muscles and bones from muscle fiber types and heavy chains of myosine.23-26 Sex hormones, parathyroid hormones and calcitonin play a role in growth and development. Androgen and estrogen have been observed to affect the appearance and development times of osteoporosis centers. 23 Though less compared to these methods, it has been found that the agNOR method and cell proliferation can also be identified in the abdominal tissue samples taken from different age groups.26.27 Histological methods are more identified in the autopsy events; the disadvantages are that they are practical, accurate and not standardized enough to be used in clinical practice.28 Radiological methods: The radiological methods used in the determination of growth and development are classified as panaromic, sefalometric and hand-hand radiographs. 29-34 In the images obtained by radiological methods, the changes of the teeth and bones of each period can be easily tracked, this method is preferred more than other growth-development and age-defining techniques.35 Panaromic methods Panoramic radiography is defined as a method of imaging that can include the mandibules and the axis and all the structures they support and the facal area can be tracked.36 Demirjian and arch.37 In 1973 the dental maturation, modifying the work they have done on the panaromic radiographs, grouped 8 different periods according to the root formation of the teeth and this method was translated as the literary Demirjian method. The validity of Demirjian method, which is a method commonly used today in determining dental maturity, has been tested for many different societies. In a study on its validity in the Turkish society, Tunç and Koyutürk38 panoramic radiographs taken from individuals aged 4-12 have been evaluated by the Demirjian method and that the periods of development of the teeth and chronological age are highly compatible.  However, the results are different by country, the experience of those who apply the method and the variation of the results even in different regions of the same country limit the use of the Demirjian method in growth-development and age determination.39.40 Dental maturity is not preferred in orthodontics because it only covers the first periods of life. 41,42,43 In the detection of the growth breakthrough period, it was noted that the completion of the root formation of the first small teeth of the lower neck dog can be used as a maturity indicator.44 In the period after the completion age of the individual's permanent teeth, it may be difficult to find measures to determine his physiological development. The relationship between the formation of the mandibular third molar teeth and the skeletal development has been evaluated and a strong correlation has been found between them; however, it has not been stated that this is sufficient in the detection of growth-development.45 One of the reasons why the calculation of dental maturation is not preferred in the determination of the growth-development period is that the time of denting is affected by many local factors, such as systemic diseases, nutritional failure. 46,47 Hand-bear radiographs: Four months after the appearance of X-ray, the first hand-bear radiograph was taken in London in 1896 by Sydney Rowland.48 Ranke49 is the first person to study the development of the skeleton from hand-bear radiographs. W. Greulich-Pyle created an atlas by studying hand-bear radiographs. In the Greulich-Pyle atlas (GP), there are hand-bear radiographs taken over 1 year intervals. To determine the bone age of any individual; the hand-bear radiography taken from the individual, compared with the current gender radiographic images of the atlas, the chronological age, which is the correspondence of the radiographic image that best suits the individual's radiograph, is the individual's bone age. Tanner and Ark. In 1962, a new method was developed to determine the age of the bone and maturity. This method was subsequently modified as Tanner Whitehouse 2 (TW2). In the TW2 method, hand-bear radiographs’ osteoporosis are scored separately by gender.32 The superiority of the TW2 method over the Greulich-Pyle method is that it is automated and there is no need for a specialist.50 The fact that it is not easy to calculate, the research is done on a single race and it takes time, is not much preferred (Avery 2002). The TW2 method was later developed and introduced as the Tanner Whitehouse 3 (TW3) method in 2001.33 The rating of each stage of the bones in radiography is the same in TW2 and TW3. Differences in TW3 reference values are based on samples taken from Europe, Argentina, Japan and America. From these atlases, growth-development detection methods have been developed.Fishman has developed a method that classifies 6 anatomical points in the 1st-third and 5th fingers and radios according to 4 different bone development processes. All the development of the adeolosan is evaluated as a scellular maturity indicator in 11 stages.51,52 These stages; 1.      In the proximal falks of the third finger, the epifysis diaphysis is equal to 2.      The middle flanks of the third finger is equal to the epifysis diaphysis.      In the middle flanks of the fifth finger, the epifysis diaphysis is equal to 4.      It has begun to be observed. and 5.      In the distal falanks of the third finger, the epifysis diaphysis is rotated 6. In the middle flanks of the third finger, the epifysis diaphysis surrounds 7.      In the middle flanks of the fifth finger, the epifysis diaphysis surrounds 8.      In the distal falanks of the third finger, the epifysis diaphysis is cooked 9.      In the proximal falamx of the third finger, the epifysis diaphysis is cooked 10.  In the middle flanks of the third finger, the epifysis diaphysis is swallowed 11.  Radiusta has been epiphysis and diaphysis swelling (Figure1) Hagg and Taranger, in their studies, have tried to develop the maturity stages with the maturity indicators of the middle finger middle falance (MP3) using hand-bear radiographs.11,12 In the method mainly the developmental changes in the epiphysis diaphysis area in the middle finger were studied in 5 stages.12 These stages; 1. MP3-F: Pubertal growth is at the beginning level. Epifysis and metaphysis are observed in the same width. 2nd MP3-FG: Pubertal growth is accelerating. Epiphysis and metaphysis are observed in the same width, separated from the lateral and/or mesial part of the epiphysis, there is a demarcation line in the distal. and 3. MP3-G: Pubertal growth rate has reached its maximum. The corner of the epiphysis is thick and capping to the metaphysis by making sharp outputs to the distale at once in one or both corners. The fourth. MP3-H: The pubertal growth rate decreases. The epifysis and metaphysis fusion began. and 5. MP3-I: Pubertal growth is over. Epifysis and metaphysis fusion have been completed (Figure 2) in Björk and Helm53 studies have identified indicators that determine the development of the hand-bear bone in the ages of 9-17. Sesamoid bones were to be seen in hand-bear films in relation to the time when the maximum puberty breakthrough occurred. In many studies, a year after the observation of adductor sesamoid in the radiography, the growth breakthrough was at the maximum level.31, 53-55 Chapman56 the adductor sesamoid (AS) observed in the periodic radiographs taken from the hand-bear bones made the following classification according to the ossification level of the bone. (Figure 2 of 1. ASO: There is not yet a sesamoid oscillation seen in the radiography. 2nd AS1: Sesamoid oscillation in radiography is first observed at this stage. The diameter of the size to the end of the injection is about 1 mm wide. This period covers a period of 3 months. and 3. AS2: Ossification has progressed according to the first stage, but its limits are seen as unclear. This period includes a period of six months. The fourth. AS3: In this stage, the limits are clearly seen in the form of sesamoid seeds. Mendes and ark.3 implant have developed a method that they use the radial bone to show that the scellular maturity has come to the end before the application in this method, they have used oclusal radiographs placed under the arm area to evaluate the development of the alveol bone and the head face. In the radiographs taken in a way to look down inside the foam, the aim is to view the degree of maturation and fusion of the epifysis and diaphysis of the radius. These stages; 0: The radius bone epiphysic diaphysis is smaller or in the same width. Epiphysis and diaphysis are seen in equal width. Epiphysis and diaphysis begin to come together. 3: A light radiolusent line is seen together with epiphysis and diaphysis. 4: The fusion between epiphysis and diaphysis is completed (Figure 3). Sefalometric Radiographers Ruel and Bench57 first studied the growth of the cervical vertebrates and that the growth in the cervical vertebrates can be measured by sefalometric radiographs. They also pointed out that at about 2 years of age, the 1st, 2nd, and 3rd cervical vertebrates formed morphologies, and then all the vertebrates except atlas and axis grew more than one of them. Researchers did not detect growth-development with any vertebra.57 In addition to hand-bear radiographs, the sefalometric radiographs first found that bone age and growth-development can be detected from the cervical vertebrae by Lamparski30. Lamparski30 suggests that growth-development and age detection by cervical vertebrates is as reliable and effective as hand-bear radiographs. In his study, he developed a series standard for both girls and men in relation to the development periods of cervical vertebrates from lateral sefalometric 2nd vertebrate (C2) to 6th vertebrate (C6). According to these standards; Safha 1: The lower boundaries of all the vertebrates are straight, the upper boundaries are clearly inclined from back to forward. Vertebra shapes are correct, there is no entrance. Safha 2: an internal bullying has begun to form at the bottom border of the second vertebral (C2). There is an increase in the front vertical height. Safha 3: In the second vertebrae (C2) the third vertebrae (C3) has begun to form an inheritance at the bottom line. The other lower boundaries are fixed. Safha 4: The verticals in this stage are completely similar to the rectangular form. In the third vertebral (C3) the internal vertebral has increased and in the fourth vertebral (C4) the lower border has formed a certain internal vertebral. The fifth (C5) and sixth (C6) vertebrates are still at the beginning. Safha 5: Vertebrs have got almost a square shape. The distances between the vertebrates have been significantly reduced, the internal bulk in the sixth vertebrate is quite limited. Safha 6: The vertical height of all the vertebrates has increased. Their heights are greater than the widths, and all the inner depths are deepened (Figure 3). The Lamparski method, later attracted the interest of many researchers and conducted research on this, stated that changes in the vertebra body during the development of the skeletal maturity can be used to determine the growth-development bone age.17,58- 64 Hassel and Farman31 in another method developed by 8-18 years of age, 220 individuals, according to the changes in the body of the second, third and fourth cervical vertebra, formed 6 stages that define the skeletal growth-development. 1 . Safha: It is the beginning stage. Adolescent growth is just beginning. It is expected to grow from 80 to 100 percent. C2, C3 and C4 are in the shape of a tacos, with the upper boundaries tending from back to forward. 2nd Safha: It is a speed stage. The growth of youth is accelerated. It is expected to grow by 65-85 percent. The C2 and C3's lower boundaries begin with internal boundaries. The bottom limit of C4 is correct. C3 and C4 begin to look like a straight round. and 3. Safha is a phase of change. Adolescent growth increases rapidly towards the peak point. It is expected to grow between 25 and 65 percent. In the C2 and C3 lower boundaries, internal boundaries are manifested. In the C4 lower boundary begins internal boundaries. C3 and C4 take the form of a straight. The fourth. Safha: It is a slowing stage. Adolescent growth is very slow. It is expected to grow by 10-25%. In the lower boundaries of C2, C3 and C4 internal boundaries are manifested. C3 and C4 begin to look like a square. and 5. Safha is a stage of maturity. Adolescent growth is not important. It is expected to grow by 5-10%. Internal boundaries in the lower limits of C2, C3 and C4 are more noticeable. C3 and C4 are in the shape. 6 . Safha: It is a completion stage. Adolescent growth is completed, growth is not expected. The internal boundaries in the lower boundaries of C2, C3 and C4 are deeply deepened. C3 and C4 are in square shapes or their vertical dimensions are greater than the horizontal dimensions (Figure 4). Baccetti and ark.65 have determined the development periods of the cervical vertebra by calling them "Cervical Vertebra Development Saffles-Cervical Vertebra Maturation Stage (CVMS)" in 5 stages. In this evolution system, lateral sefalometric radiographs can be used to assess C2, C3 and C4. He pointed out that the 1st and 2nd stages of growth-development are difficult to distinguish, and that these levels can be considered as a single stage by combining (Figure 5). But in the years ahead Bacetti and Ark. 66 By modifying their own studies, lateral sephalograms in which the name C2, C3 and C4 was clearly observed were used in degeneration and the growth breakthrough according to cervical vertebrates was studied in 6 stages (Figure 6) . Computer-supported systems and growth development determination Growth-development bone age detection requires the development of computer software that will allow for faster, accurate and objective analysis due to the subjective, complexity of the TW method. The researchers aimed at obtaining more objective results by taking advantage of computer software and the advantages of digital images.67.68 Zhang and ark.69, 0-7 years of age 205 individuals worked with untouched logic on carpal bones to detect bone age. The research results showed that carpal bones are suitable for assessing bone age in children in this age group with the method developed on hand-bear radiographs. Jantan and Ark. They presented a system of bone age assessment based on foolish logic by extracting the characteristics of the radius and radius distal. As a result, children under the age of 14 have found that these bones have important qualities in determining bone development. Hasaltın and Beşdok71 have developed a semi-automatic system to determine the bone age of Turkish individuals using artificial nerve networks. This system examined the karpal bones of 307 children between 2 and 9 years of age. In addition to these studies on handheld radiographs, in recent years, especially in puberty period, sefalometric radiographs showed the growth-development determination of the neck spots as effective as handheld radiographs, this method has a clear advantage compared to handheld radiographs in terms of non-additional radiation doses to patients, the need for the elimination of an additional radiograph in the detection of growth-development.6,14,15,18,61,64,72-74 Half-automatic systems have been developed with regression analysis while age determination is done with Vertebrs. In the Mito and Ark.63 study, they formed an age group of 8 with ages ranging from 7,0 to 14,9 and 22 girls each studied the lateral sefalometric graphs of the individual. In total, 176 girls have determined the bone age by the regression analysis method of the individual. The study resulted in sephalometric graphs that the bone age determination was as reliable as the hand-bear bone age determination made by the Tanner Whitehouse 2 method and that the bone age determination made by this method was more objective by Beit and ark.75 examined 730 radiographs (sephalometry and hand-bear) of non-treated individuals (352 men, 378 girls; age range, 6-18 years) for each gender. The purpose of the study is to examine the scalable age assessment based on the radiographs of the arm, with the evaluation of the cervical vertebra. According to the Greulich and Pyle method, the bone age was detected in handheld radiographs and the vertebrates between C2 and C4 were morphometrically measured and the correlation with the GP method was tested. Results: Results: Growth development process and detection, as it is important in determining the correct diagnosis and form of treatment, will always bring the interest of doctors and dentists. The existing methods in our country can be multi-centered and the growth-development map of our population can also be transformed into easier to apply with the help of technology, while the multidisciplinary studies are also needed for the detection of different methods Key words: growth development, dental radiography, bone age detection, puberty, cervical vertebra Key words; Bone age measurement, cervical vertebrae, dental radiography, growth and development, puberty

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