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1. Skeletal Maturity indicators
INDIAN DENTAL ACADEMY
Leader in continuing dental education
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2. Introduction
Adolescence
It is the transitional period b/w juvenile stage and
adulthood during which the secondary sexual
characteristics appear, the adolescent growth
spurt takes place, fertility is attained, and
profound physiologic changes occur.(PROFFIT)
- Important period
- Treatment planning & outcome of treatment
Growth potential –important during
Adolescence and preadolescence
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3.
Chronological age is a poor indicator of specific
stages of maturation
BIOLOGICAL AGE -determined from skeletal, dental,
morphologic age and onset of puberty
Individual variation in timing, duration and the
velocity of growth, skeletal age assessment
essential
Skeletal maturation refers to the degree of
ossification in bone – closely related to sexual
maturity
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4.
During growth every bone goes through a series
of changes seen radiographically
Sequence relatively consistent for a given bone
The timing of changes varies – according
to biological clock
statural growth acceleration precedes facial
growth acceleration by 6-12 months
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5.
Developmental status of the child judged by :
i.
peak height velocity
ii.
menarche in case of girls
iii.
voice change in boys
iv.
dental development
v.
skeletal ossification
The orthodontist – has to work with growth
Assessment of skeletal age is important to
know whether any growth remains in
individual and what percentage of growth can
be expected.
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6. Growth spurts
A
spurt is defined as growth acceleration
up to a maximum where the annual
increment of growth exceeded the
previous one by at least 0.7mm
-Erkstrom.
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7. Normal growth spurts
infantile spurt – 3years
juvenile spurt – 7-8 years females,
8-10 years males.
Pubertal spurt – 10-13 years females,
13-15 years males.
Growth spurts – acceleration phase and
deceleration phase.
Growth modulation
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8.
The pubertal growth spurt most important for the
orthodontist :
as this spurt shows the maximum
growth changes (WOODSIDE)
According to ‘PROFFIT’ juvenile growth spurt in
girls may be as large, or even greater than the
pubertal growth spurt.
growth modulation – mixed dentition (girls)
early permanent dentition (boys)
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9. Best indicator for the
pubertal growth spurt
is the attainment of
the peak height
velocity
The clinician prefers to
start the treatment
during the
acceleration phase
Earlier in girls
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11. Skeletal maturity indicators
Hand and wrist radiographs,
Cervical vertebrae
Mid palatal suture
Corpus index
Tooth mineralization
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12. Hand and wrist radiographs
Chronological
age- not sufficient for assessing
the developmental stage and the somatic
maturity of the patient
Assessment of the skeletal age is made with
the help of hand radiographs which can be
considered as biological clock
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13. Standard
method for the evaluation of the
skeletal age
Easily
identifiable maturity indicators
Reliable
Serves
source of maturation process
as a useful diagnostic aid
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14. Roentgen
-1895
Rowland – 1896 growing bone as maturity
indicator –first H&W radiograph.
Proyr. Rotch and Crampton -1900 tabulated
indicators of hand and wrist.
Carter – 1926 study on carpal bones of children.
Hellman
- 1928 studied the ossification of the
epiphyseal cartilages of hand.
Todd and Stuart– 1929 – data on hand wrist
radiographs.
Greulich and Pyle -1936 studied the calcification
of carpal sesamoid
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15.
1959 – Atlas form
Flory 1936 – beginning of calcification of the carpal
sesamoid – determine the period immediately before
puberty
Bambha 1961-facial spurt occurred little later than the body
height spurt
Hunter 1966- carpel bones-most satisfactory for
determining skeletal maturation
Bjork 1972 – divided the maturation process of bones of
the hand b/w 9 – 17yr into 8 developmental stages
Grave & Brown 1976 – skeletal age determined with the
help of 6 ossification centers
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16. Leonard.s.Fishman
1982 developed a system
for evaluation of SMI’s in the hand & wrist.
Hagg
& Taranger 1982 – correlated maturity
indicators to the pubertal growth spurt.
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17. Hand & wrist radiograph
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18. Indications for hand & wrist
radiographs
Prior
to rapid maxillary expansion
When
maxillomandibular changes are indicated
Marked
discrepancy b/w chronologic and dental
age
Orthodontic
patients requiring orthognathic
surgery between 16 &20 yrs of age.
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19. Most
commonly used, comprising of 28 – 30
separate centers of bone growth and
maturation
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20. Anatomy of skeleton of the hand
Distal ends of long bones
Carpals
Metacarpals
Phalanges
Carpel bones:
I. Trapezium
II. Trapezoid
III. Capitate
IV. Hamate
V. Hamular processof the hamate
VI. Triquetral
VII.Pisiform
VIII.Lunate
IX. Scaphoid
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21. Atlas method of Greulich & Pyle
Radiograph
is compared with a standard
series of films, representative of normal
children at different chronological ages
and for each sex.
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22. Bjork, Grave & Browns method
(1976 )
9
developmental stages
Area of ossification events
Area of phalanges
Carpel bones
Radius
This method describes the relationship b/w the
epiphyses and the diaphysis in 3 stages
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35. A clinically oriented method based
on hand &wrist films
leonard Fishman
angle orthodontist
1982
A system for the evaulation of skeletal
maturity from H&W radiographs is
developed & presented with complete
details for implementation in clinical
practice.
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36. SMA
This system uses;
- Only four stages of
maturation
- Six anatomic sites
located on the thumb,
third finger, fifth finger
radius.
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37. 11 discrete adolescent SMIs
System of SMA
-organized
-relatively simple
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38. widening of epiphysis relative to its
diaphysis
- First appears as a small center of
ossification centrally located in the
diaphysis.
- when developed to the width of diaphysis
Applicable as a SMI
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43. With
this approach key stages are
checked first.
Adductor sesamoid- whether seen or not.
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44. Materials and methods
Longitudinal
and cross sectional data
170 females &164 males-longitudinal gp.
Lateral cephalograms& hand wrist
radiographs
1040 radiographs-cross-sectional sample
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45. Measurements & evaulation
Maxillary
and mandibular measurements
made
S-A & Ar-A – maxilla
S-Gn & Ar-Gn -mandible
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46. Cronological age values for
adolescent skeletal maturity
indicators
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47. Results
The
sex difference in
time was approx.1yr
at maturity levels 1 &
2
2 yrs at SMI levels 7
&8
Decreased to 1.3 yr at
SMI level 11
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48. SMI level -6,50% of adolescent growth
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49. Summary
Growth
patterns including growth rates for
statural height and face were studied
Skeletal maturation age as measured with
SMI – more valid basis than cronological
age for grouping individuals
Alterations in maturational developments
are directly related to growth velocity
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50. Facial
growth as measured in max. and mand. –
close direct association between variations in
the rate of growth
Females
tended to achieve a higher percentage
of their total statural growth than males during
early adolescence
Female
showed greater growth velocities and
earlier maturation in stature and in max.
Mandibular
velocities highest in the males
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51. After
peak growth, velocities diminished
more rapidly in females than in males
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52. Physiological timing of Orthodontic
treatment
Julian Singer
Oct.1979,AO.
To take advantage of growth when the major
growth increments are likely to occur
Purpose of the paper
1.To enable the clinician to rapidly and with some
degree of reliability utilize the hand and wrist film
to determine the maturation status.
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53. 6 stages of hand & wrist
developement
Stage 1(early)
Absence of pisiform,
Hook of hamate.
Epiphysis of proximal phalanx
Of second digit narrower than
Its shaft
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54. Stage 2(prepubertal)
-Initial ossification of pisiform &
Hook of hamate.
-Proximal phalanx of second digit
And its epiphysis are equal in
width
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55. Stage
3( pubertal
onset)
Beginning of
calcification
of ulnar sesamoid
Increased ossification
of pisiform & hook of
hamate
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56. Stage
4(pubertal)
Calcified ulnar
sesamoid
Capping of shaft of
middle phalanx of
third digit by its
epiphysis-MP3cap.
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57. Stage
5(pubertal
decelaration)
Ulnar sesamoid fully
calcified
DP3u stage
All phalanges and carpals
fully calcified
Epiphyses of radius and
ulna not fully calcified with
respect to shafts
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59. Summary
As
quoted by Singer
Maximum mand growth-before
appearance of S.
Pileski et al
- Stages 3 or 4 frequently mentioned for
onset of treatment
- The peak of growth velocity may have
passed
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60. Armstrong-
tissue response most rapid in
mixed dentition stage
Judicious
use of hand and wrist film to
assess the developemental status –
effective correction in short period of
time(prepubertal)
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61. Stage
2 (prepubertal)- mandibular growth
in girls reached peak
Late growth of the mandible should be
considered
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62. Conclusions
Hand
and wrist film can be used as an indicator
of the maturational status of Orthodontic pt.
6 stages advocated as guidelines for t/t timing
Stage 2- important prepubertal period during
which Cl.II correction could be effectively
achieved
Stage 5-period of residual growth during which
post t/t changes could occur
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63. Maturation indicators and the
pubertal growth spurt
Urban Hagg, John Taranger
AJO Oct 1992.
Pubertal growth spurt and maturation of a sample
of 212 swedishchildren were analysed - 90 girls
&122 boys.
Factors studied
1.Definition of pubertal growth spurt,age at the
beginning ,peak and end of the pubertal growth
spurt.
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65. 2. Age at the attainment of specified
maturation level indicators
3.The association betn the specified
maturation level and pubertal growth spurt
By comparing with standard for age and
sex
- Average
- Accelerated
- Retarded
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66. Method
Subjects
examined once a year according to
planned schedule
- Data on standing height
- Tooth emergence
- Pubertal development
- Radiograph of the right hand and wrist
Menarche – 10 years + every 3 months
Voice change – 10 years + annual voice
assessment
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68. Method of analysis
Adolescent
growth studied
by graphic
analysis 320yrs
PHV
Onset
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69. Dental
development
was assessd by
dental emergence
stages ( DES)
Stages devised by
Bjork + 2 new stages
DESM3 & DESM5
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70. Skeletal
development- in the hand and
wrist – analysed by annual radiographs-6-18 yrs
Four bones - as indicators of skeletal
development
UlnarSesamoid
Middle phalanx of the third finger
Distal phalanx of third finger
Distal epiphysis of radius
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76. Results
1. Pubertal growth spurt
Large differences in the ages and growth
events.
Onset 10 & 12.1 yr,END at 14.8 &17.1 yr.
PHV 2 yrs after onset in both sexes.
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77. Dental development and pubertal
growth spurt
Weak
corelation
Clinical interest
DES2 attained or passed by all subjects at onset
DES3 attained or passed by all subjects at PHV
DES4 attained before end by all boys and At
End by all girls
DESM3 attained or passed by all boys at PHV
DESM4 attained or passed by all boys before
and by all girls at end
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78. Skeletal development and pubertal
growth spurt
Skeletal
Onset
PHV
End
development at
more advanced in girls
more advanced in girls
more advanced in boys
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79. Clinically important findings
S-
attained during acceleration period of
pubertal growth spurt
MP3 – F – attained before onset by 40%
MP3FG – 1 yr before or at PHV by 90%
MP3G- at or one yr after PHV by 90%
MP3H after PHV but before end by all
boys and 90% girls
MP3I before or at end in all subjects
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80. Distal third phalanx
DP3I
– during the deceleration period of
pubertal growth spurt
RADIUS
R.I- 1 yr before or at end by about 80% of
girls and 90% of boys
RIJ & RJ not attained before END by any
subject
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81. Pubertal development and the
pubertal growth spurt
Close
association
Girls – menarche – 1.1 yr after PHV
Boys – PV 0.2 yr before PHV
MV 0.9 yr after PHV
All girls – menarche at the end
All boys – male voice during pubertal
growth spurt.
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82. Summary
Bjork
,Grave &
Browns method S & H2 stagebeginning of pubertal
spurt.
MP3cap,PP1cap &
Rcap stage- peak of
pubertal spurt.
DP3u stage-end of
pubertal spurt.
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84. Hagg &Taranger method
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.
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85. Ossification of the distal phalanx of the first digit
as a maturity indicator for initiation of orthodontic
treatment of class III malocclusion in Japanese
women
Shigemi Goto, et al.,
AJO Nov 1996
Japanese female patients
Purpose: stage of skeletal maturation of the first
digit of the distal phalanx as an indicator of the
residual growth potential in patients with mild to
moderate class III malocclusions
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86. Ossification
of the epiphyses of the distal
phalanx – occurs from 1-3 yrs after the
pubertal growth peak.
Closely
associated with declining growth
rate of mandibular condyles
Indication for initiation of orthodontic
treatment in subjects with mild to
moderate class III malocclusion
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88. Results:
Complete
fusion of the distal phalanx
occurs after 90% of the total growth in
length of the cranial base and the maxillary
and mandibular lengths is over
Minimal
craniofacial growth was left after
the stage particularly in females.
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90. Conclusions
Determination
of the stage of skeletal
maturation of the distal phalanx of the first
digit may provide quick and useful clinical
method for assessing the residual growth
potential
Helpful
in patients whose continued
mandibular growth could be detrimental to
the stability of t/t result
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91. Mandibular
growth may still continue in
more severe skeletal discrepancy-ANB >
-6
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95. Cervical vertebrae
Lamparski-1972
O
reilly & Yanniello(1988)-used CVMA
Hassel
&Farman(1995)-skelatal maturity can be
evaluated at any given time using CVMI.
Garcia Fernandez(1998)- mexican population.
Raja Gopal & Kansal(2002)- found a high
correlation bn six MP3 stages & six stages of CV
maturation.
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96. Skeletal maturation evaluation using cervical
vertebrae-AJO 1995
BRENT HASSEL& FARMAN
Bolton brush growth centre
Cervical vertebrae maturation index – 2,3 & 4 cervical vertebrae
Sample: 220 subjects 8- 18 yrs
Anomalies were checked for.
Fractures
Ankylosis
Infections
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97. Method
Fishmans
system- H & W radiograph
Lateral ceph. & H&W radiograph
Dens(odontoid process)
Body of C3
Body of C4
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100. CATEGORY 1(initiation)
Corresponds
80-100%
to SMI 1&2.
of growth expected
Inferior
borders of C2,C3 & C4
were flat
Vertebrae
Tapered
wedge shaped
from post. to Ant.
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109. A comparision of modified MP3stages &the
cervical vertebrae as maturity indicators
RAJAGOPAL and KANSAL
JCO JULY 2002
Aim :determine whether the 6 modified MP3
stages could be correlated with the 6 stages of
CVMI’s.
Materials
75 males &75 females– Age-9-17yrs
Lateral cephalograms & periapical
radiographs
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118. conclusions
Modified
MP3 stages using periapical Xray film can be an accurate & simple
growth indicator.
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119. Maturational evaluation of ossification
of the mid palatal suture
BERNAL REVALO,FISHMAN
AJO MARCH 1994
PURPOSE:positive correlation b/n adolescent maturation
development and the approximation of the mid palatal
suture.
Method- H&W radiographs – Fishman’s method
Occlusal radiographs-Approx. of mid palatal suture.
Sample
39 males & 45 females- 8-18 yrs
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125. Results
Significant
correlation b/n maturational
development & beginning of ossification.
At
SMI 3(MP5) only 8% fused.
At
SMI 9(PP3u) –approx. 25% of fusion.
At
SMI 11(Rf)- 50% of fusion.
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126. Conclusion
Best
to accomplish ME-before SMI 9.
Ideal
time- SMI 1- 4
Less
orthopedic force required.
Mid
palatal approx. occurs more
posteriorly.
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127. Tooth mineralization as an indicator of
the pubertal growth spurt
CHERTKOW
AJO 1980
AIM:To investigate the relationship b/n stages of
mineralization of various teeth & other
maturational indicators of pubertal growth spurt.
Method &materials197 patients
Panoramic radiographs
H & W radiographs
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128.
Max. & mandibular
canines,1&2 premolars &
mandibular second
molars
Appearace of
sesamod,MP3cap &
calcification of hook of
hamate.
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130. Results
Uniformity
of development of mand.
canine
No sexual dimorphism.
Marked racial differences.
Mand. Canine – calcification pattern
similar in boys & girls.
Definite relationship b/n development of
mandibular canine & other indicators of
pubertal growth spurt.
Caucasian population- stage G coincided
with other maturity indicators.
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132. Conclusion
Completion
of root formation of mand
canine,prior to apical closure
Maturity
indicator
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133. Mandibular skeletal maturity
assessment
Santosh C Verghese
J M Jayraj
U S Krishna Nayak
Jios June 2003
Purpose : Deduce a simpler method of estimating
the skeletal maturity of mandible using corpus
index obtained from transverse slicing section of
the mandible
- Correlating values of the corpus index to
cervical maturation stages
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138. RESULTS
Corpus
index scoring of 1.8 – pubertal
growth potential of 65 to 85 %
Scoring of 2.03 – pubertal growth potential
of 25-65%
Scoring of 2.15 – 10-25% pubertal growth
Scoring of 2.35 – 5-10% pubertal growth
Scoring of 2.5- completion of pubertal
growth
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139. Conclusion
Orthopedic
t/t can be accomplished - pt
shows a corpus index of 1.8
2.05 – fixed functional orthopedic t/t
2.17 – orthopedic appliances minimal
skeletal & more of dental changes
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140. Frontal sinus development as an indicator of
somatic maturity at puberty
Pancherz &Sabine Ruf
AJO NOV 1996
To
evaluate the possibility of predicting the
stage of somatic maturity by analyzing frontal
sinus growth.
Sample size-53 boys
Method: analysis of lateral headfilms.
-2 lateral headfilms-1yr or 2yrs
-2 prediction intervals T1&T2
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142. Previous study results
Frontal
sinus growth velocity at puberty is
closely related to body height growth
velocity
Frontal sinus growth shows a well defined
pubertal peak(Sp) which on the average
occurs 1.5 yr after body ht. peak
In males – average age at frontal sinus
peak is 15.1 yrs
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143. Previous study results
1
yr interval,peak growth velocity T11.3mm/yr.
2 yr interval,peak growth velocity T21.5mm/yr.
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144. Prediction procedure
If
SV greater than T value (T1or T2)frontal sinus peak was reached during
prediction interval & Bp 1.4 yr before.
If SV less than T value – prepeak or
postpeak ?
Chronological age used
If <15.1 yrs Sp not been reached Bp not
reached or occured less than 1.4 yr before
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145. Prediction procedure
>
15.1 yrs Sp has occurred and Bp also
occurred more than 1.4 yr before the
beginning
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146. Accuracy of prediction
If
only prediction was whether the pubertal
growth maximum has passed the
precision of the method was high-90%.
If incidence of body ht. peak was to be
predicted – accuracy was much lower55.5%(1yr) & 57.7% (2yrs).
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147. References
Hassel B, Farman A G.”Skeletal maturation evaluation
using cervical vertebrae” Am J Orthod,1995; 107:58-61
Julian Singer “ Physiologic timing of orthondic
treatment”. Angle Orthod, 1980;50:320-333.
Hagg U,Taranger J “ Maturational indicators and the
pubertal growth spurt”. Am J Orthod, 1982; 88:299-309
Revelo B,Fishman LS,” Maturational evaluation of
ossification of midpalatal suture”. Am J
Orthod,1994;105:288-292
Ruf S,Pancherz,” Frontal sinus development as an
indicator for somatic maturity at puberty”. Am J Orthod ;
1996; 110: 476-82
Fishman L S,” Radiographic evaluation of skeletal
maturation”. Angle Orthod ; 1982; 52:89-111
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