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SKELETAL
MATURITY
INDICATORS
DEPARTMENT OF ORTHODONTICS SUBHARTI DENTAL COLLEGE
SWAMI VIVEKANAND SUBHARTI
UNIVERSITY
Presented By:
Dr Shalu Jain
Introduction
Ricketts
To take advantage of growth we
must have an idea of – first its magnitude,
second, its direction and the third element
the timing.
Dr Shalu Jain, Subharti Dental College, SVSU
Why study maturity indicators?
Key to successful treatment in growing
patients – harnessing of growth.
Without exact status of growth –
magnitude and direction- treatment
planning is futile.
Dr Shalu Jain, Subharti Dental College, SVSU
Advantages of Maturity Indicators
Potential vector of facial development
determined.
Amount of significant craniofacial growth
potential left.
To decide the onset of treatment timing.
Dr Shalu Jain, Subharti Dental College, SVSU
To decide the type of treatment:
1. Orthopedic
a) Removable
b) Fixed
2. Orthodontic
3. Orthognathic surgical procedure
4. Combination of any of above
Dr Shalu Jain, Subharti Dental College, SVSU
To evaluate treatment prognosis
To understand role of genetics and
environment on skeletal maturation
pattern.
Dr Shalu Jain, Subharti Dental College, SVSU
Various Growth Assessment
Methods
Chronologic age
Secondary sexual characteristics
Growth charts
Dental development
Skeletal maturation
Dr Shalu Jain, Subharti Dental College, SVSU
Age
Expressed as:
Chronologic age
Age measured by years
lived since birth.
Dental age
Determined according to
teeth erupted, amount of root resorption
and amount of root formation.
Skeletal age
Determined by ossification
of various skeletal structures at different
time.
Dr Shalu Jain, Subharti Dental College, SVSU
Dental age
Determined from :
Eruption time table
Nolla’s stages of tooth development
Demirjian’s stages of tooth
development
Dr Shalu Jain, Subharti Dental College, SVSU
Skeletal Age Assessment
Regions used for skeletal age assessment
should be ideally:
Small to restrict radiation exposure
Should have many ossification centres
that ossify at different times and which
can be standardized
Easily accessible
Dr Shalu Jain, Subharti Dental College, SVSU
Regions Normally Used For Age
Assessment
Head and neck:
Skull
Cervical vertebrae
Upper limb:
Shoulder joint- scapula
Elbow
Hand wrist and fingers
Dr Shalu Jain, Subharti Dental College, SVSU
Lower limb:
Femur
Hip joint
Knee
Ankle
Foot tarsals
Metatarsals
Phalanges
Dr Shalu Jain, Subharti Dental College, SVSU
Hand Wrist Radiographs
Hand wrist – Numerous Small Bones
Predictable and scheduled pattern of
appearance, ossification and union from
birth to maturity
Most suited to study growth
Dr Shalu Jain, Subharti Dental College, SVSU
Anatomy Of Hand Wrist
1. Radius
2. Ulna
3. Distal epiphysis of radius
4. Distal epiphysis of ulna
5. Trapezium
6. Trapezoid
7. Capitate
8. Hamular process of hamate
9. Hamate
10.Triquetral
11.Pisiform
12.Lunate
13.Scaphoid
14.Sesamoid
M = metacarpal
P = phalanx
Proximal Row
Carpal
Distal Row
Carpal
Dr Shalu Jain, Subharti Dental College, SVSU
Stages of Ossification of
Phalanges 1.Epiphysis = Diaphysis
2.Epiphysis caps Diaphysis
3.Fusion of Epiphysis & Diaphysis
1 2 3
Dr Shalu Jain, Subharti Dental College, SVSU
Radiological Methods of
Assessment and Prediction of
Growth
Greulich and Pyle method
Singer’s method
Fishman’s skeletal maturity indicators
Bjork, Grave and Brown method
Cervical Vertebrae Maturity Indicators
Maturation assessment by Hagg and
Taranger and the KR (Kansal and
Rajagopal) modified MP3 method
Dr Shalu Jain, Subharti Dental College, SVSU
GREULICH AND PYLE METHOD
Published an atlas containing ideal
photographs of hand wrist radiographs.
Separate sets for male and female
patients.
Patients radiograph is matched in the
atlas.
Dr Shalu Jain, Subharti Dental College, SVSU
SINGER’S METHOD FOR
ASSESSMENT
(Julian Singer, 1980)
Julian Singer, 1980
STAGE CHARACTERISTIC
One (early) Absence of pisiform &hook of hamate.
Epiphysis of proximal phalanx of second
finger narrower than its diaphysis
Two
(prepubertal)
Initial ossification of hook of hamate &
pisiform.
Proximal phalanx of second finger equal
to its epiphysis
Three
(pubertal
onset)
Beginning of calcification of ulnar
sesamoid, increased width of epiphysis
of proximal phalanx of second finger &
increased calcification of hook of hamate
& pisiform Dr Shalu Jain, Subharti Dental College, SVSU
STAGE CHARACTERISTIC
Four
(pubertal)
Calcified ulnar sesamoid.
Capping of diaphysis of middle phalanx
of third finger to epiphysis.
Five (pubertal
deceleration)
Calcified ulnar sesamoid. Fusion of
epiphysis of distal phalanx of third finger
with its shaft.
Epiphysis of radius & ulna not fully fused
with respective shafts.
Six (growth
completion)
No remaining sites seen.
SINGER’S METHOD FOR
ASSESSMENT
Dr Shalu Jain, Subharti Dental College, SVSU
Fishman’s Skeletal Maturity
Indicators
Keonord S Fishman, 1982
Used four anatomical sites on
Thumb
Third finger
Fifth finger
Radius
Dr Shalu Jain, Subharti Dental College, SVSU
4 stages of bone maturation:
1. Epiphysis equal in width to diaphysis
2. Appearance of adductor sesamoid
3. Capping of epiphysis
4. Fusion of
epiphysis
Fishman’s Skeletal Maturity
Indicators
Dr Shalu Jain, Subharti Dental College, SVSU
Eleven Discrete Adolescent Skeletal
Maturity Indicators
Dr Shalu Jain, Subharti Dental College, SVSU
CERVICAL VERTEBRAE
MATURITY INDICATORS (CVMI)
Hassel & Farman
Shapes of cervical vertebrae are different at
different levels of skeletal development.
Dr Shalu Jain, Subharti Dental College, SVSU
Skeletal maturation evaluation
using cervical vertebrae
Six categories of CV maturation
Dr Shalu Jain, Subharti Dental College, SVSU
CVMI – 1: Initiation stage of cervical
vertebrae
1. C2,C3 and C4 inferior vertebral
body borders are flat
2. Superior vertebral body borders
are tapered from posterior to
anterior (wedge shape)
3. 80-100% of pubertal growth
remains
Dr Shalu Jain, Subharti Dental College, SVSU
CVMI – 2: Acceleration stage of
cervical vertebrae
1. Concavities are developing in
lower borders of C2 and C3
2. Lower border of C4 vertebral
body is flat
3. C3 and C4 are more rectangular
in shape
4. 65-85% pubertal growth remains
Dr Shalu Jain, Subharti Dental College, SVSU
CVMI-3 Stage: Transition stage of
cervical vertebrae
1. Distinct concavities seen in lower
borders of C2 and C3
2. Concavity is developing in lower
border of C4
3. C3 and C4 are rectangular in
shape
4. 25-65% of pubertal growth
remains
Dr Shalu Jain, Subharti Dental College, SVSU
CVMI- 4: Deceleration stage of
cervical vertebrae
1. Distinct concavities seen in lower
borders of C2, C3 and C4.
2. C3 and C4 – nearly square in
shape
3. 10 – 25% of pubertal growth
spurt left.
Dr Shalu Jain, Subharti Dental College, SVSU
CVMI-5: Maturation stage of cervical
vertebrae
1. Accentuated concavities of
C2,C3 and C4 inferior vertebral
borders
2. C3 and C4 square in shape
3. 5-10% pubertal growth remains
Dr Shalu Jain, Subharti Dental College, SVSU
CVMI-6: Completion stage of
cervical vertebrae
1. Deep concavities present in C2,
C3 and C4 inferior vertebral
borders
2. C3 and C4 greater in height than
in width
3. Pubertal growth complete
Dr Shalu Jain, Subharti Dental College, SVSU
Skeletal maturation evaluation
using cervical vertebrae
Dr Shalu Jain, Subharti Dental College, SVSU
Bjork, Grave and Brown Method
9 stages of skeletal development.
Scoph associated each of these
stage to chronological age
Stage Male
age
Female
age
Characteristic
One 10.6 8.1 Equal epiphysis &
diaphysis of middle
phalanx of third finger Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male
age
Female
age
Characteristic
Two 12 8.1 Equal epiphysis &
diaphysis of middle
phalanx of third finger
Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male
age
Female
age
Characteristic
Three 12.6 9.6 3 areas of ossification:
1. Hamular process of
hamate
2. Pisiform
3. Equal epiphysis &
diaphysis of radius
1 2 3
Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male
age
Female
age
Characteristic
Four 13 10.6 Marks
beginning of
pubertal growth
spurt.
1. Initial
mineralizati
on of ulnar
sesamoid
of thumb
2. Increased
ossification
of hamular
process of
hamate
bone
1
2
Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male age Female age Characteristic
Five 14 11 Marks peak of pubertal growth
spurt
Capping of diaphysis by
epiphysis seen in:
1. Middle phalanx of third
finger
2. Proximal phalanx of thumb
3. Radius
1 2 3
Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male
age
Female
age
Characteristic
Six 15 13 Marks end of
pubertal growth
spurt.
Union between
epiphysis and
diaphysis of distal
phalanx of third
finger Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male
age
Female
age
Characteristic
Seven 15.9 13.3 Union between
epiphysis and
diaphysis of little
finger
Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male
age
Female
age
Characteristic
Eight 15.9 13.9 Union between
epiphysis and
diaphysis of
middle phalanx of
middle finger
Dr Shalu Jain, Subharti Dental College, SVSU
Stage Male
age
Female
age
Characteristic
Nine 18.3 16 End of skeletal
growth.
Union between
epiphysis and
diaphysis of radius
Dr Shalu Jain, Subharti Dental College, SVSU
Hagg and Taranger method
Hagg & Taranger
Analysed yearly hand wrist radiographs of
individuals from age 6 to 18 years.
Studied the ossification of the sesamoid
(S), the middle and distal phalanges of
the third finger (MP3 and DP3) and the
distal epiphysis of the radius.
Dr Shalu Jain, Subharti Dental College, SVSU
Five stages of MP3 growth:
F- onset of the curve of pubertal growth spurt
FG-acceleration part of the curve of pubertal
growth spurt.
G- peak of the curve.
H-deceleration part of the curve of pubertal
growth spurt
I-end of the pubertal growth spurt.
Dr Shalu Jain, Subharti Dental College, SVSU
Comparison between modified
the MP3 indicators and CVMI
described by Hassel and
Farman.
Dr Shalu Jain, Subharti Dental College, SVSU
MP3-F Stage
Start of the curve of pubertal growth spurt
Epiphysis is as wide as metaphysis
End of epiphysis are tapered and rounded.
Radiolucent gap is wide between epiphysis & diaphysis.
Initiation stage of cervical vertebrae
C2,C3 and C4 inferior vertebral
body borders are flat.
Superior vertebral borders are tapered from
posterior to anterior [wedge shape]
80-100% of pubertal growth remains.
CVMI-1
Dr Shalu Jain, Subharti Dental College, SVSU
Acceleration of the curve of pubertal growth spurt.
Epiphysis is as wide as metaphysis.
Distinct medial and/or lateral border of epiphysis forms line of demarcation at right angle to distal border.
Metaphysis begins to show slight undulation.
Radiolucent gap between metaphysis
and epiphysis is wide.
Acceleration stage of cervical vertebrae.
Concavities are developing in lower
borders of C2 and C3.
Lower border of C4 vertebral body
is flat.
C3 and C4 are more rectangular in
shape.
65-85% of pubertal growth
remains.
MP3-FG Stage CVMI-2
Dr Shalu Jain, Subharti Dental College, SVSU
Maximum point of pubertal growth spurt.
Sides of epiphysis have thickened and cap its metaphysis, forming sharp distal edge on one or both sides.
Marked undulations in metaphysis give it “Cupid’s bow’’ appearance.
Radiolucent gap is moderate.
Transition stage of cervical vertebrae
Distinct concavities are seen in lower
borders of C2 and C3.
Concavity is developing in lower
border of C4.
C3 and C4 are rectangular in shape.
25-65% of pubertal growth remains.
Dr Shalu Jain, Subharti Dental College, SVSU
Deceleration of the curve of pubertal growth spurt.
Fusion of epiphysis and metaphysis begins.
Side of epiphysis form obtuse angle to distal border.
Epiphysis is beginning to narrow.
Slight convexity under central part of metaphysis.
Typical Cupid’s bow appearance is absent
Radiolucent gap is narrow.
Deceleration stage of cervical
vertebrae.
Distinct concavities are seen in
lower borders of C2, C3 and C4.
C3 and C4 are nearly square in
shape.
10-25% of pubertal growth
remains.
Dr Shalu Jain, Subharti Dental College, SVSU
Maturation of the curve of pubertal growth spurt
Superior surface of epiphysis shows smooth concavity.
Metaphysis shows smooth, convex surface, almost fitting into reciprocal concavity of epiphysis.
No undulation present in metaphysis.
Radiolucent gap is insignificant.
Maturation stage of cervical vertebrae.
Accentuated concavities of C2, C3
and C4 inferior vertebral body
borders are observed.
C3 and C4 are square in shape.
5-10% of pubertal growth
remains.
Dr Shalu Jain, Subharti Dental College, SVSU
End of pubertal growth spurt
Fusion of epiphysis and metaphysis complete.
No radiolucent gap.
Dense, radiopaque epiphyseal line
forms integral part of proximal
portion of middle phalanx.
Completion stage of cervical vertebrae.
Deep concavities are present in C2,
C3 and C4 inferior vertebral body
borders.
C3 and C4 are greater in height than
in width.
Pubertal growth is completed.
Dr Shalu Jain, Subharti Dental College, SVSU