skeletal maturity indicators /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


Introduction:
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One of the objective for treating skeletal
discrepancies, is to take advantage of the
patients growth spurt, which help to achieve
optimal results,within the short period of time.
Evaluation of individual biologic time table and
identification of period of accelerated growth is
essential for clinical decisions, regarding growth
modulation procedures for skeletal discrepancies,
extraction versus non extraction options,use of
extra oral orthopaedic forces and planning for
orthognathic surgery for skeletal malocclusions.

Introduction:
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As a results many investigators have attempted ,
to predict the duration ,magnitude, direction and
timing of the adolescent growth changes.
The developmental status of a child is usually
assessed in relation to events that take place
during progress of growth. Thus chronological
age, sexual maturational characteristics , dental
development (dental age), height and weight
measurements and skeletal age are some of the
biological indicators that have been used to
identify stages of growth.

Introduction:
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Chronological age is often not sufficient for assessing
the developmental stage and somatic maturity of the
patient,so that the biological age has to be determined.
The biological age is determined from the skeletal,
dental and morphologic age and onset of puberty.
Patient chronological age is defined as the time period
from the birth to till date.
Morphologic age is based on the height . A child’s
height can be compared with those of his same age
group and other age groups to determine where he
stands in relation to others. Height is useful as a
maturity indicator from late infancy to early adulthood.

Introduction:
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Dental age has been based on two different methods of
assessment.
1. Tooth eruption age.
2. Tooth mineralization stage.
Sexual age refers to development of secondary sexual
characteristics. This type of indicator is useful only for
adolescent growth.
Skeletal age Assessment is often made with the help of
hand - wrist radiograph which can be considered the
‘Biological clock ’.
Nine developmental stages are there according
BJork(1972), Grave and Brown (1976).The
ossification events are localized in the area of the
phalanges, carpal bones and radius.

BIOLOGICAL AGE
AND
HAND WRIST RADIO GRAPH
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Orthodontic treatment progresses more quickly
during growth spurts.
Generally
children experience a pattern of fast growth,
followed
by a slow growth in late childhood and
then accelerated and peak growth in
adolescence. Because children begin this
sequence of growth at different ages,
chronological age is a poor indicator of a
child’s development. Hand-wrist radiograph
is a useful tool for identifying a child’s
skeletal development.

HAND-WRIST RADIO GRAPHIC
EVALUATION
After Roentgen demonstrate his new radiographic discovery in 1895 Ronaldo, in 1896,
introduced the idea of using the comparative size and shape of the radiographic
shadows of growing bones as indicators of rate of growth and maturity.
In early 1900s, Pryor, Rotch and Crampton began tabulating indicators of maturity
on sequential radiographs of the growing hand and wrist.
Hellman published his observations on the ossification of epiphysial cartilage of the
hand in 1928.
Todd compiled hand –wrist data that was further elaborated on by Greulich and Pyle
in atlas form. In 1936 Flory indicated that beginning of calcification of the carpal
sesamoid was a good guide to determine the period immediately before puberty.
The appearance of the adductor sesamoid has been highly correlated to peak height
velocity and start of adolescent growth spurt.
Fishman developed a system of hand wrist skeletal maturation indicators using four
stages of bone maturation at six anatomic sites on the hand and the wrist.
Hagg and Taranger created a method using the hand wrist radiograph to correlate
certain maturity indicators to the pubertal growth spurt.

TOPOGRAPHIC ANATOMY OF THE
SKELETON OF THE HAND


TOPOGRAPHIC ANATOMY
OF
THE SKELETON OF THE HAND


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1. Epiphysis of the thumb.
2. Epiphysis of the proximal phalanx of the thumb.
3. Sesamoid of the adductor brevis muscle at the
metacarpophalangeal joint of the thumb.
4. Epiphysis of the distal phalanx of the index finger.
5. Epiphysis of the middle phalanx of the index finger.
6. Epiphysis of the proximal phalanx of the index finger.
7. Epiphysis of the distal phalanx of the middle finger.
8. Epiphysis of the middle phalanx of the middle finger.
9. Epiphysis of the proximal phalanx of the middle finger.
10. Epiphysis of the distal phalanx of the ring finger.
11. Epiphysis of the middle phalanx of the ring finger.
12. Epiphysis of the proximal phalanx of the ring finger.
13. Epiphysis of the distal phalanx of the little finger.
14. Epiphysis of the middle phalanx of the little finger.
15. Epiphysis of the proximal phalanx of the little finger.
16. Epiphysis of the metacarpal bone.
17. Epiphysis of the second metacarpal bone.

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18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.

Epiphysis of the third metacarpal bone.
Epiphysis of the fourth metacarpal bone.
Epiphysis of the fifth metacarpal bone.
Trapezium.
Trapezoid bone.
Capitate bone.
Hamate bone.
Hamular process of the hamate bone.
Triquetral bone.
Pisiform bone.
Lunate bone.
Scaphoid bone.
Distal epiphysis of the radius.
Distal epiphysis of the ulna.

Hand-wrist radiographs
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Atlas
Sesamoid bone(Flory,Bjork,Chapman)
Julian Singer (1980)
Fishman(1982)
Hagg & Taranger(1982)
Leite &O’Reilly(1985)
Abdel Kader(1998)

Hand-wrist radiograph:


SKELETAL MATURATION
ASSESSMENT
.
LEONARD S.FISHMAN 1982 outlined four stages of bone maturation found
at six anatomical sites located on the thumb, third finger, fifth finger and
radius. Eleven skeletal maturity indicators are found in these six anatomic sites.
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


Fishman’s skeletal maturity indicators


Hagg

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and

Taranger skeletal maturity indicators

They described a method in which skeletal development
is assessed by
ossification of the ulnar sesamoid of
the metacarpophalangeal joint of the first finger (S) and
certain specified stages of three epiphyseal bones; the
middle and distal phalanges of the third finger (MP3 and
DP3) and the distal epiphysis of the radius (R ). All the
four bones to be used as indicators of the skeletal
development were choosen according to Bjork. Eight of the
ten indicators were already defined by others. In order to
obtain maturation indicators of shorter duration, two new
epiphyseal stages were defined. One stage in the middle
phalanx of the third finger,denoted MP3-FG,and one stage
in the distal end of the radius,denoted R-IJ.
Sesamoid: sesamoid is usually attained during the
acceleration period ofwww.indiandentalacademy.com spurt(onset of
the pubertal growth

Hagg

and

Taranger


BIOLOGICAL AGE

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HAND WRIST RADIO
GRAPH
AND

Growth stages of the fingers are assessed according to
the relationship between the epiphysis and diaphysis.

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There are three stages of ossification of the phalanges.
FIRST STAGE:
Epiphysis shows the same width as the diaphysis.
SECOND STAGE:(CAPPING STAGE)
The epiphysis surrounds the diaphysis like a cap.
THIRD STAGE:(U-STAGE)


MP3 STAGES


BIOLOGICAL AGE AND HAND WRIST RADIO
GRAPH
There are nine developmental stages.
1.First stage of maturation :(PP2= stage)
The epiphysis of the proximal phalanx of
the index finger has the same width as
the diaphysis.
This stage occurs approximately 3 years
before the peak of the pubertal growth
spurt.
2.second stage :(MP3=stage)
Epiphysis of the middle phalanx of the
middle finger is of the same width as
the diaphysis.

BIOLOGICAL AGE
GRAPH

AND

HAND WRIST RADIO

4. Fourth stage :(S-and H2-stage)
S-stage: First mineralization of the ulnar sesamoid bone of the
metacarpophalangeal joint of the thumb.
H2-stage: Progressive ossification of the hamular process of the
hamatum.
The fourth stage is reached shortly before or at the beginning of the
pubertal growth spurt.


BIOLOGICAL AGE
GRAPH

AND

HAND WRIST RADIO

3. Third stage:(Pisi-,H1-,and R= stage)
This stage of development can be identified by three distinct ossification
areas. These show individual variations but appear at the same time
during the process of the maturation.
Pisi-stage: Visible ossification of the pisiforme.
H1-stage : Ossification of the hamular process of the hamatum.
R-stage : Same width of epiphysis and diaphysis of the radius.


BIOLOGICAL AGE
GRAPH

AND

HAND WRIST RADIO

5. Fifth stage:( MP3cap–,PP1cap-,and Rcap-stage)
During this stage ,the diaphysis covered by the cap shaped epiphysis.
MP3cap–stage: The process begins at the middle phalanx of the third
finger.
PP1cap-stage : At the proximal phalanx of the thumb.
Rcap-stage
: At the radius.
This stage of ossification marks the peak of the pubertal growth spurt.


BIOLOGICAL AGE
GRAPH

AND

HAND WRIST RADIO

6. Sixth stage :(DP3u-stage)
Visible union of the epiphysis and diaphysis at the distal phalanx of the
middle finger.
This stage of development constitutes the end of the puberal growth.


BIOLOGICAL AGE
GRAPH
7.

AND

HAND WRIST RADIO

Seventh stage:(PP3u-stage)
Visible union of the epiphysis and diaphysis at the proximal phalanx
of the little finger.


BIOLOGICAL AGE
GRAPH

AND

HAND WRIST RADIO

8. Eighth stage :(MP3u-stage)
Visible union of the epiphysis and diaphysis at the middle
phalanx of the middle finger is clearly seen.


BIOLOGICAL AGE
GRAPH

AND

HAND WRIST RADIO

9. Ninth stage:(Ru-stage)
Complete union of the epiphysis and diaphysis of the radius.
The ossification of all the hand bones is completed and
skeletal growth is completed.


Growth period
1.

2.

3.

4.

5.

6.

7.

8.

9.

PP2

MP3

Pisi

S

MP3

Ru

H2

PP3
u

MP3

H1

DP3
u

15.
0
13.
0

15.
9
13.
3

15.
9
13.
9

R=

cap

R

u

cap

PP1

males

females

10.
6
8.1

12.
2
8.1

12.
6
9.6

13.
0
10.
6

cap

14.
0
11.
0


18.
5
16.
0

Cervical vertebrae maturation indicators
The first seven vertebrae in the spinal column constitute
the cervical spine. The first two, the atlas and the axis
are quite unique, the third through the seventh have great
similarity. Maturational changes can be observed from birth
to full maturity.
Vertebral growth takes place from the cartilagenous layer on
the superior and
inferior surface of each vertebrae.
Secondary ossification nuclei on the tips of the bifid spinous
processes and transverses appear during puberty. Secondary
ossification nuclei unite with the spinous processes when
vertebral growth is complete.
After completion of endochondral ossification, growth of
the vertebral body takes place by periosteal apposition. It
appears to take place only at the front and sides. Todd and
Pyle , Lanier and Taylor made measurements from lateral
radiographs of the lower cervical vertebrae. Lamparski

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The standard method of evaluating skeletal maturity has
been to use a hand- wrist x-ray to compare the bones of
an individual’s hand with those in published atlases.
To avoid taking an additional x-ray,some researchers
sought to relate maturation with dental and skeletal
features other than the bones in the hand and wrist.
The use of cervical vertebrae to determine skeletal
maturity is not new.
In 1972, Lamparski concluded that the cervical
vertebrae ,as seen on the routine lateral cephalograms ,
were as statistically and clinically reliable in assessing
skeletal age as the hand-wrist technique.
He found that the cervical vertebral indicators were the
same for females and males, but that females developed
the changes earlier.

The use of cervical vertebrae to determine skeletal
maturity was
suggested by Lamparski in
1972.
He concluded that the cervical vertebrae, as seen
on routine lateral cephalograms,were as statistically
and clinically reliable in assessing skeletal age as
the hand-wrist technique. He found that the cervical
vertebral indicators were the same for the females
and males, but that females developed the changes
earlier.


-Lamparski

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Six stages of cervical vertebral maturation were described.
Stage 1:
All inferior borders of the bodies are flat. The superior
borders
are strongly tapered from posterior to
anterior.
Stage 2: A concavity has developed in the inferior border of the
second vertebrae.the anterior vertical heights of the bodies have
increased.
Stage 3:A concavity has developed in the inferior border of the
third vertebra. The other inferior borders are still flat.
Stage 4: All bodies are now rectangular in shape. The concavity
of the third vertebra has increased, and a distinct concavity has
developed on the fourth vertebra. Concavities on 5 and 6 are just
beginning to form .
Stage 5: The bodies have become nearly square in shape and
the space between the bodies are visibly smaller.concavities are
well defined on all six bodies.
Stage 6: All bodies have increased in vertical height and
are


Cvs1

cvs2

cvs3

cvs4


cvs6


STAGES


1. Initiaton:
• Inferior borders of 2nd 3rd and 4th cervical
vertebrae are flat at this stage.
• The third and fourth vertebrae are wedge
shaped and the superior vertebral borders
are tapered from posterior to anterior.
• 100% of pubertal growth remains.
• Very significant amount of adolescent
growth expected.


2. Acceleration:
• Concavities on the inferior borders of
second and third vertebrae begin to
develop.
• Inferior border of fourth vertebrae remains
flat.
• Vertebral bodies of third and fourth are
nearly rectangular in shape.
• 65-85% of pubertal growth remains.

3. Transition :
• Distinct concavities are shown on the
inferior borders of second and third
vertebrae.
• A concavity begins to develop on the
inferior border of fourth vertebrae.
• Vertebral bodies of third and fourth
are rectangular in shape.

4. Deceleration stage:
• Distinct concavities can observed on
the inferior borders of second third
and fourth cervical vertebrae.
begin to be more square in shape.


5. Maturation stage:
• Marked concavities are observed
on the inferior borders of second,
third and fourth cervical vertebrae.
are almost square in shape.


6. Completion:
• Deep concavities are observed on
the second, third and fourth cervical
vertebrae.
• Vertebral bodies are greater vertically
than horizontally.
• Pubertal growth has been completed.


Assessment of skeletal
maturation
The 5 distinct stages of MP3 as
described by HAGG & TARANGER (1980),
and 6 th stage (between MP3-H and MP3-I
which is called as MP3-HI stage) which was
introduced by our
prof. Dr.Raja gopal and Dr. Kansal were to
be evaluated and compared with six
stages of cervical vertebrae which were
described by HASSEL & FARMAN(1995).

COMPARISON BETWEEN
MP3-F & INITIATION STAGE
MP3-F STAGE

INITIATION STAGE

It represents the onset or the start 1.C2, C3 and C4 inferior vertebral
of the curve of pubertal growth
body borders are flat.
spurt.
2.Superior vertebral borders are
FEATURES:
tapered from posterior to
Epiphysis is as wide as
metaphysis.

anterior. (Wedge shape).
3.100% of pubertal growth
remains.


COMPARISON BETWEEN
MP3-FG & ACCELERATION STAGE
MP3-FG STAGE

ACCELERATION STAGE

It represents the acceleration part of 1.Concavities developing in lower
the curve of pubertal growth
bordres of C 2 & C 3 .
spurt.
2.Lower border of c4 vertebral body
FEATURES:
is flat.
1.Epiphysis is as wide as
metaphysis
3.c3 & c4 are more rectangular in
shape.
2.There is a distinct medial and or
lateral border of the

epiphysis

forming a line of demarcation at

4.65-85 % of pubertal growth
remains.

right angle to the distal border.


COMPARISON BETWEEN
MP3-G & TRANSITION STAGE
MP3-G STAGE

TRANSITION STAGE

It represents the point of maximum
pubertal growth spurt.
FEATURES:
Sides of epiphysis have thickened
and cap its metaphysis forming a
sharp edge distally at one or both
sides.

1.Distinct concavities in lower borders
of

c2 and c3 are seen.

2.Developing concavity in lower border
of body of c4 is seen.
3.c3 and c4 are rectangular in shape.
4.25-65% of pubertal growth remains.


COMPARISON BETWEEN
MP3-H & DECELERATION STAGE
MP3-H STAGE

DECELERATION STAGE

It represents the deceleration part of 1.Distinct concavities in the lower
the Curve of pubertal growth
bordrs of c2,c3 and c4 are seen.
spurt.
2.c3 and c4 are nearly square in
FEATURES:
shape.
Fusion of epiphysis and metaphysis
has begun.

3.10-25% of pubertal growth
remains.


COMPARISON BETWEEN
MP3-HI & MATURATION STAGE
MP3-HI STAGE

MATURATION STAGE

It represents the maturation part of
the curve of pubertal growth spurt.
FEATURES:
1.Superior surface of the epiphysis
shows a smooth concavity.
2.Metaphysis shows a smooth convex
surface

almost fitting into the

reciprocal concavity of epiphysis.

1. Accentuated

concavities of

inferior vertebral body borders
of c2,c3,and c4 are seen.
2. c3 and c4 are square in shape.
3. 5-10% of pubertal growth
remains.

3.Radiolucent gap between epiphysis
and metaphysis is insignificant.


COMPARISON BETWEEN
MP3-I & COMPLETION STAGE
MP3-I STAGE

COMPLETION STAGE

It represents the end of pubertal

1. Deep concavities present

on

growth Spurt.
FEATURES:
1.Fusion of epiphysis and
metaphysis is completed.

inferior vertebral body borders of

c2,c3 and c4.
2. c3 and

c4 heights

are greater

than widths.
3. Pubertal growth has been
completed.


Comparison
of
MP3 and CVMI


Correlation of hand-wrist
and

cervical vertebral maturation stages
A comparative evaluation of hand-wrist and cervical vertebrae was
done in our department by Prof.Dr.shyamala and Dr.Akshay gupta
to find out the validity of the cervical vertebrae as maturation marker.
The following conclusions were drawn:
1. Wide variation in chronological age for different maturity levels
suggests that chronological age is a poor indicator of maturity.
Skeletal maturity indicators provide a more valid basis than
chronological age for grouping of individuals.
2. Females are ahead of males at all levels of skeletal maturity.,
indicating early age of maturation for female group.
3. Females tend to achieve a higher percentage of their total growth
than male especially during mid-adolescence. Early and late
adolescence show less variation in percentage of growth completed .
4. cervical vertebrae can be used as an alternative method for
evaluation of skeletal maturity, with the same confidence as hand
wrist radiographs.

Correlation of hand-wrist
and

cervical vertebral maturation stages
Hand –wrist

Cervical
vertebral stages

Pubertal growth
remaining

1-2

Initiation

85-100%

3-4

Acceleration

65-85%

5-6

Transition

25-65%

7-8

Deceleration

10-25%

9-10

Maturation

5-10%

11

completion

0%

SMI


STAGES OF TOOTH CALCIFICATION-NOLLA(1960)
10.Root apex completed.
9.Root almost completed,open apex.
8.Two thirds of root completed.
7.One third of root completed.
6.Crown completed.
5.Crown almost completed.
4.Two thirds of crown completed.
3.One third of root completed.
2.Initial calcification.
1.Crypt present.
0.Crypt absent.


Dental age determination according to the stage of mineralization
Demirjian et al., in 1973 divided tooth mineralization into nine stages.
o. Tooth germ without signs of calcification.
A. Calcificaion of single occlusal points without
fusion of different calcification.
B. Fusion of mineralization points. The contour
of the occlusal surface is recognizable.
C. Calcification of the crown is complete;
beginning of dentin deposits.
D. Crown formation is complete up to the
cemento enamel junction.
E. Root length shorter than crown height.
F. Root length larger than crown height.
G. Root formation finished. Apical foramen
still open.
H. Apical foramen is closed.


Single rooted tooth

Multi rooted tooth

Scores of different dental formation stages

The table was made for the left mandibular quadrant.

Conversion chart for dental age determination,calculated
according to the score-system of dental formation

The overall figure for assessment of dental age is obtained by adding
together the separate values for 7 teeth in the lower left quadrant.

DENTAL FORMATION STAGES
D-H OF MANDIBULAR CANINE


Tooth mineralization as an indicator of the pubertal
growth spurt

Diagrammatic appearance of stages C to H of tooth
development for uni and multi radicular teeth.


OPG:


Mandibular growth changes
&
Maturation of cervical vertebrae
Maria T o’Reilly & Gary J Yanniello conducted a study on
relationship of cervical vertebral maturation and mandibular
growth changes using lateral cephalometric radiographs in
females age group of 9-15 years.
They found that cervical vertebral stages of maturation are
related to mandibular growth changes during puberty. An
analysis of variance for repeated measurements and
Scheffee’s tests reveal significant increase between stages
1 and 2, 2 and 3 and 3 and 4 for mandibular length; between
1 and 2 and 2 and 3 for corpus length; and between 1 and 2
for ramus height.On the average, stages1 through 3 occurred
prior to peak velocity, with 2 and 3 in the year preceeding
peak growth velocity.

Clinical significance:
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1. Treatment involving modification of skeletal growth seems to demand
as much as information as possible about patient’s growth potential.
2. Orthodontic appliances such as the mandibular protraction appliance,
Herbst appliance, Frankel, Bionator, Twin block and activator.
3. In cases where patient require orthopedic changes using head gears and
protraction masks.
4. Prior to rapid maxillary expansion.
5. In patients with marked discrepancy between dental and chronological
age.
6. Orthodontic patients requiring orthognathic surgery if under taken during
growth period.
7. When maxillo mandibular changes are indicated in the treatment of class
III cases, skeletal class II cases or skeletal open bites.

LATERAL CEPHALOGRAM:


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