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Skeletal Maturity Indexes Growth prediction
Outline
OutlineGrowth prediction in OrthodonticsSkeletal Maturity Index          Hand-wrist radiographs              Greulich and ...
Growth Prediction in          orthodonticsIn orthodontic treatment planning, knowledge offacial growth velocity and percen...
Growth Prediction in orthodonticsClinical decisions regardingfunctional appliances ororthognathic surgeries aremodulated b...
Growth Prediction in orthodonticsMany studies have shown an association betweenpeak velocity of facial growth and peak vel...
Growth Prediction in orthodonticsGeneral skeletal maturity usually is used as anindicator to predict timing of mandibular ...
Growth Prediction in orthodonticschronological age alone is considered a poorindicator of the level of skeletal maturity d...
Growth Prediction in orthodonticsGrowth prediction can be assessed using physiologicalparameters such as   Peak growth vel...
Growth Prediction in orthodonticsSecondary sexual characteristics and physical bodymeasurements , cannot be used to predic...
Skeletal Maturity IndexHand-wrist radiographscervical vertebral maturation
Hand-wrist radiographs
Hand-wrist radiographsThe hand-wrist radiograph isconsidered to be the moststandardized method of skeletalmaturation asses...
Hand-wrist radiographsThe ossification sequence andtiming of the skeletal maturitywithin the hand-wrist areashow polymorphi...
Hand-wrist radiographsThe usual means by which to assess the hand-wristradiograph are  The comparison atlas of Greulich an...
Greulich and Pyle (1959)
Greulich and Pyle (1959)
Greulich and Pyle (1959)
Greulich and Pyle (1959)
Greulich and Pyle (1959)
Greulich and Pyle (1959)
Radiographic evaluation of Skeletal maturityA clinically orient method based on Hand-wrist filmsLeonard S. Fishman, Angle o...
Björk’s method of assessmentBjork utilized certain anatomical sites located onthe phalanges, abductor sesamoid, carpal and...
Method of Björk (1972)Skeletal maturation of each hand-wrist radiograph 9 stages       Stage 1 (PP2): Epiphysis of proxima...
Method of Björk (1972)Skeletal maturation of each hand-wrist radiograph 9 stages (method ofBjörk and Grave and Brown)   St...
Method of Björk (1972)Bjork 9 stages of skeletal maturation were reducedto five intervals and ranked 1 to 5 according togro...
Skeletal maturation determine    by cervical vertebrae         development.   Paloma San Roman et al.     European Journal...
Skeletal Maturation Assessment       (SMA) L.Fishman (1982)Based on the observation ofossification events localized inthe a...
Skeletal Maturation Assessment    (SMA) L.Fishman (1982)                     Radiographic evaluation of Skeletal maturity ...
Skeletal Maturation Assessment    (SMA) L.Fishman (1982)SMI 1: The third finger proximal phalanx shows equal width ofepiphy...
Skeletal Maturation Assessment    (SMA) L.Fishman (1982)SMI 5: Capping of epiphysis seen in distal phalanx of thirdfinger(D...
Skeletal Maturation Assessment      (SMA) L.Fishman (1982)SMI 8: Fusion of epiphysis and diaphysis in the distal phalanx o...
Skeletal Maturation Assessment      (SMA) L.Fishman (1982)Accelerating growth velocity period = SMI 1-4High growth velocit...
Skeletal Maturation Assessment (SMA)          L.Fishman (1982)PP3width appears approximately 3years before the peak of pub...
Skeletal Maturation Assessment (SMA)          L.Fishman (1982)PP3width appears approximately 3years before the peak of pub...
Skeletal Maturation Assessment (SMA)          L.Fishman (1982)PP3width appears approximately 3years before the peak of pub...
Skeletal Maturation Assessment (SMA)          L.Fishman (1982)Union of epiphysis and diaphysis atthe distal phalanx of the...
Skeletal Maturation Assessment (SMA)          L.Fishman (1982)   Union of epiphysis and diaphysis at   the distal phalanx ...
Hagg and Taranger Method(1982)      MP3 Ossification Stages: Hagg and Taranger Method1. MP3-E stage: Epiphysis is 3/4 wide ...
Skeletal maturation evaluation using cervical vertebraeBrent Hassel, BA, DDS, MS, and Allan G. Farman, BDS, PhD(odont), Di...
Conclusion                      MP3cap       MP3width   S                               Ru
Conclusion                      MP3cap       MP3width   S                               Ru
Conclusion                      MP3cap       MP3width   S                               Ru
Conclusion                      MP3cap       MP3width   S                               Ru
Use of Skeletal Maturation Based on Hand-Wrist Radiographic Analysis                            as a Predictor of Facial G...
USE OF SKELETAL MATURATION BASED ON HAND-WRIST RADIOGRAPHIC ANALYSIS                       AS A PREDICTOR OF FACIAL GROWTH...
USE OF SKELETAL MATURATION BASED ON HAND-WRIST RADIOGRAPHIC ANALYSIS                       AS A PREDICTOR OF FACIAL GROWTH...
Reliability of growth prediction with hand–wrist radiographs                Damian Verma, Timo Peltomäki and Andreas Jäger...
Reliability of growth prediction with hand–wrist radiographs                  Damian Verma, Timo Peltomäki and Andreas Jäg...
Reliability of growth prediction with hand–wrist radiographs               Damian Verma, Timo Peltomäki and Andreas JägerA...
Cervical Vertebral Maturation method(CVM)The cervical vertebral maturation method has proved effective inassessing the ado...
Cervical Vertebral Maturation method(CVM)The cervical vertebral maturation method has proved effectivein assessing the ado...
Cervical Vertebral Maturation method (CVM)Lamparski (1972) created method analyzed size and shapechanges in the bodies of ...
Cervical Vertebral Maturation method(CVM)Hassel and Farman (1995) compiled a new index of CVM,evaluated the second, third,...
Hassel and Farman(1995)Six stages in evaluation of cervical vertebrae maturation according to method of Hassel and Farman(...
Hassel and Farman(1995)I.Initiation stage (CVMI 1) Very significantamount of adolescent growth expected     C2, C3, and C4 ...
Hassel and Farman(1995)III.! Transition stage (CVMI 3) Moderateamount of adolescent growth expected     Distinct concaviti...
Hassel and Farman(1995)V. Maturation stage (CVMI 5) Insignificantamount of adolescent growth expected    Accentuated concav...
Hassel and Farman
Baccetti et al 2002      An Improved Version of the Cervical Vertebral Maturation (CVM) Method for      the Assessment of ...
The Cervical Vertebral Maturation (CVM) Method for the Assessment       of Optimal Treatment Timing in Dentofacial Orthope...
The Cervical Vertebral Maturation (CVM) Method for the Assessment       of Optimal Treatment Timing in Dentofacial Orthope...
The Cervical Vertebral Maturation (CVM) Method for the Assessment       of Optimal Treatment Timing in Dentofacial Orthope...
Baccetti et al 2005Cervical stage 1The lower borders of all the threevertebrae (C2-C4) are flat.The bodies of both C3 and C...
Baccetti et al 2005Cervical stage 2A concavity is present at thelower border of C2 (in four of fivecases, with the remainin...
Baccetti et al 2005Cervical stage 3Concavities at the lower bordersof both C2 and C3 are present.The bodies of C3 and C4 m...
Baccetti et al 2005Cervical stage 4Concavities at the lower bordersof C2, C3, and C4 now arepresent.The bodies of both C3 ...
Baccetti et al 2005Cervical stage 5The concavities at the lowerborders of C2, C3, and C4 stillare present.At least one of ...
Baccetti et al 2005Cervical stage 6The concavities at the lowerborders of C2, C3, and C4still are evident. At least one of...
Baccetti et al 2005            The Cervical Vertebral Maturation (CVM) Method for the            Assessment of Optimal Tre...
The Cervical Vertebral Maturation (CVM) Method for the Assessment       of Optimal Treatment Timing in Dentofacial Orthope...
The Cervical Vertebral Maturation (CVM) Method for the Assessment       of Optimal Treatment Timing in Dentofacial Orthope...
Cervical vertebral maturation as a biologic indicator of skeletal maturity                                     A systemati...
Cervical vertebral maturation as a biologic indicator of skeletal maturity                                     A systemati...
Cervical vertebrae maturation method morphologic criteria: Poor                               reproducibility Trenton S. N...
Validity and reliability of a method for assessment of                      cervical vertebral maturation     Xiao-Guang Z...
Validity and reliability of a method for assessment of                           cervical vertebral maturation          Xi...
Validity and reliability of a method for assessment of                             cervical vertebral maturation          ...
Validity and reliability of a method for assessment of                            cervical vertebral maturation   Xiao-Gua...
Dental maturationTooth emergence, dental maturity detected throughradiographic methods has been investigated as a markerof...
Dental maturity VS Skeletal maturityDental maturity detected through radiographic methods appearsto be highly related to s...
Dental maturity VS Skeletal maturityIn contrast, one study failed to show significantcorrelations between dental maturation...
Dental Calcification Stages Using Demirjian Index                           (DI)                       Stage A Calcificatio...
Dental Calcification Stages Using Demirjian Index                           (DI)                     Stage E The root lengt...
Eruption of the maxillary canines in relation to skeletal maturityThis study was to assess the relationship between the er...
Eruption of the maxillary canines in relation to                  skeletal maturityEruption of the permanent maxillary can...
Relationships Between Dental Calcification Stages and   Skeletal Maturity Indicators in Thai Individualsthe canine stage F ...
Relationships Between Dental Calcification Stages and   Skeletal Maturity Indicators in Thai Individuals  This suggests tha...
ConclusionNo single method of assessing maturity level hasbeen shown to be effective and accurate in allpatients.The hand-...
ConclusionThe accuracy of predicting growth may beimproved if other parameters (morphologic,biological, or genetic indicat...
Conclusion Validity and reliability of CVM method : stillcontroversyThe CVM method should be used with other growthindicat...
If you look for the peak of growth
If you look for the peak of growthMP3cap
If you look for the peak of growthMP3cap
If you look for the peak of growthMP3cap
If you look for the peak of growth
If you look for the peak of growth CS 3
If you look for the peak of growth
If you look for the peak of growth
If you look for the peak of growth
If you look for the peak of growth2nd molar stage G     (Male)
If you look for the peak of growth2nd molar stage G     (Male)
If you look for the peak of growth2nd molar stage G     (Male)
If you look for the peak of growth
If you look for the peak of growth 2nd molar stageE(Female) : S stage
If you look for the peak of growth 2nd molar stageE(Female) : S stage
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  1. 1. Skeletal Maturity Indexes Growth prediction
  2. 2. Outline
  3. 3. OutlineGrowth prediction in OrthodonticsSkeletal Maturity Index Hand-wrist radiographs Greulich and Pyle (1959) Fishman LH (1982) Björk (1972) and Grave and Brown (1976) Hagg and Tanranger method (1982) Reviews of related studies Cervical vertebra maturation Hassel and Farman (1995) Baccetti et al.(2005) Reviews of related studies Dental age Reviews of related studies
  4. 4. Growth Prediction in orthodonticsIn orthodontic treatment planning, knowledge offacial growth velocity and percentage of facialgrowth remaining is very important for effectivegrowth modification interventions. Assessment of skeletal maturation is essential inplanning individual orthodontic treatment becauseof marked individual variations in timing, duration,and intensity of pubertal growth. Use of cervical vertebral maturation to determine skeletal age Ricky W. K. Wong,a Hessa A. Alkhal,b and A. Bakr M. Rabiec (Am J Orthod Dentofacial Orthop 2009;136:484.e1-484.e6)
  5. 5. Growth Prediction in orthodonticsClinical decisions regardingfunctional appliances ororthognathic surgeries aremodulated by the patient’sdegree of physiologicalmaturity.
  6. 6. Growth Prediction in orthodonticsMany studies have shown an association betweenpeak velocity of facial growth and peak velocityof statural growth during puberty (Bergerson EO.1972; Singh J1 et al.1967; Fishman LS.1979)Thompson G et al. (1974) demonstrated that thepattern of mandibular growth coincides with bodyheight growth in adolescents
  7. 7. Growth Prediction in orthodonticsGeneral skeletal maturity usually is used as anindicator to predict timing of mandibular growthvelocity peak
  8. 8. Growth Prediction in orthodonticschronological age alone is considered a poorindicator of the level of skeletal maturity due tosignificant individual growth variation (Roche AF.1978.;Fishman LS 1979.)
  9. 9. Growth Prediction in orthodonticsGrowth prediction can be assessed using physiologicalparameters such as Peak growth velocity in standing height Pubertal markers ( voice change in male,menarche in female etc. ) Dental development Radiological analysis of skeletal maturation. Hand-wrist radiographs Lateral cephalometric radiographs assessment cervical vertebral maturation
  10. 10. Growth Prediction in orthodonticsSecondary sexual characteristics and physical bodymeasurements , cannot be used to predict the timingof maximum growth due to their retrospective nature(Bjork A., Helm S. 1967)Dental development indicators are not reliablepredictors of an individual’s stage of skeletaldevelopment. (Demirjian A et al.,1985;Chertkow S.,1980)
  11. 11. Skeletal Maturity IndexHand-wrist radiographscervical vertebral maturation
  12. 12. Hand-wrist radiographs
  13. 13. Hand-wrist radiographsThe hand-wrist radiograph isconsidered to be the moststandardized method of skeletalmaturation assessment ( HasselB,Farman AG,1995.;Gandini P etal.2006)Assessment based upon timeand the sequence of appearanceof the carpal bones and certainossification events
  14. 14. Hand-wrist radiographsThe ossification sequence andtiming of the skeletal maturitywithin the hand-wrist areashow polymorphism and sexualdimorphism. (Bowden BD1976;Houston WJ 1980;SmithRJ 1980;Garn SM et al 1966)Hand-wrist radiograph of malepatient provide more valuableinformation for orthodontictreatment (Smith 1980)
  15. 15. Hand-wrist radiographsThe usual means by which to assess the hand-wristradiograph are The comparison atlas of Greulich and Pyle (1959) The processes that use specific indicators that relate skeletal maturation to the pubertal growth curve, such as the methods described by Bjork (1972), Fishman (1982), Hagg and Taranger (1982)
  16. 16. Greulich and Pyle (1959)
  17. 17. Greulich and Pyle (1959)
  18. 18. Greulich and Pyle (1959)
  19. 19. Greulich and Pyle (1959)
  20. 20. Greulich and Pyle (1959)
  21. 21. Greulich and Pyle (1959)
  22. 22. Radiographic evaluation of Skeletal maturityA clinically orient method based on Hand-wrist filmsLeonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982
  23. 23. Björk’s method of assessmentBjork utilized certain anatomical sites located onthe phalanges, abductor sesamoid, carpal andradius bone, which have predictable and consistenttime of onset of ossification.
  24. 24. Method of Björk (1972)Skeletal maturation of each hand-wrist radiograph 9 stages Stage 1 (PP2): Epiphysis of proximal phalanx of index finger (PP2) is same width as diaphysis Stage 2 (MP3): Epiphysis of middle phalanx of middle finger (MP3) is same width as diaphysis Stage 3 (Pisi-H1-R): Pisi, visible ossification of pisiform; H1: ossification of the hamular process of the hamatum; R, same width of epiphysis and diaphysis of radius Stage 4 (S-H2): S, first mineralization of ulnar sesamoid bone of metacarpophalangeal joint of hamatum; H2, progressive ossification of hamular process of hamatum Chronologic age and skeletal maturation of the cervical vertebrae and hand-wrist: Is there a relationship? Tancan Uysal,a Sabri Ilhan Ramoglu,b Faruk Ayhan Basciftci,c and Zafer Saric, Kayseri and Konya, Turkey (Am J Orthod Dentofacial Orthop 2006;130:622-8)
  25. 25. Method of Björk (1972)Skeletal maturation of each hand-wrist radiograph 9 stages (method ofBjörk and Grave and Brown) Stage 5 (MP3cap-PP1cap-Rcap): Diaphysis is covered by cap-shaped epiphysis; in MP3cap, process begins at middle phalanx of third finger; in PP1cap, at proximal phalanx of thumb; in Rcap, at radius Stage 6 (DP3u): Visible union of epiphysis and diaphysis at distal phalanx of middle finger (DP3) Stage 7 (PP3u): Visible union of epiphysis and diaphysis at proximal phalanx of little finger (PP3) Stage 8 (MP3u): Union of epiphysis and diaphysis at middle phalanx of middle finger is clearly visible (MP3) Stage 9 (Ru): Complete union of epiphysis and diaphysis of radius Chronologic age and skeletal maturation of the cervical vertebrae and hand-wrist: Is there a relationship? Tancan Uysal,a Sabri Ilhan Ramoglu,b Faruk Ayhan Basciftci,c and Zafer Saric, Kayseri and Konya, Turkey (Am J Orthod Dentofacial Orthop 2006;130:622-8)
  26. 26. Method of Björk (1972)Bjork 9 stages of skeletal maturation were reducedto five intervals and ranked 1 to 5 according togrowth completion. 1.Growth preceeding acceleration = Bjork stage 1-3 2.Stage of growth acceleration = Bjork stage 4 3.Stage of peak growth = Bjork stage 5 4.Stage of growth deceleration = Bjork stage 6-7 5.Stage of growth completion = Bjork stage 8-9
  27. 27. Skeletal maturation determine by cervical vertebrae development. Paloma San Roman et al. European Journal ofOrthodontic 24 (2002) 303-311
  28. 28. Skeletal Maturation Assessment (SMA) L.Fishman (1982)Based on the observation ofossification events localized inthe area of the fingerphalanges, carpal bone andradius.There is a close correlationbetween sequence of hand-wrist ossification andmandibular growth status Radiographic evaluation of Skeletal maturity A clinically orient method based on Hand-wrist films Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982
  29. 29. Skeletal Maturation Assessment (SMA) L.Fishman (1982) Radiographic evaluation of Skeletal maturity A clinically orient method based on Hand-wrist films Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982
  30. 30. Skeletal Maturation Assessment (SMA) L.Fishman (1982)SMI 1: The third finger proximal phalanx shows equal width ofepiphysis and diaphysis(PP3width)SMI 2: Width of epiphysis equal to that of diaphysis in the middlephalanx of third finger(MP3Width)SMI 3: Width of epiphysis equal to that of diaphysis in the middlephalanx of fifth finger (MP5Width)SMI 4: Appearance of adductor sesamoid of the thumb (S) Radiographic evaluation of Skeletal maturity A clinically orient method based on Hand-wrist films Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982
  31. 31. Skeletal Maturation Assessment (SMA) L.Fishman (1982)SMI 5: Capping of epiphysis seen in distal phalanx of thirdfinger(DP3cap)SMI 6: Capping of epiphysis seen in middle phalanx of thirdfinger(MP3cap)SMI 7: Capping of epiphysis seen in middle phalanx of fifthfinger(MP5cap) Radiographic evaluation of Skeletal maturity A clinically orient method based on Hand-wrist films Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982
  32. 32. Skeletal Maturation Assessment (SMA) L.Fishman (1982)SMI 8: Fusion of epiphysis and diaphysis in the distal phalanx ofthird finger(DP3fuse)SMI 9: Fusion of epiphysis and diaphysis in proximal phalanx ofthird finger (PP3fuse)SMI 10: Fusion of epiphysis and diaphysis in middle phalanx of thirdfinger (MP3fuse)SMI 11: Fusion of epiphysis and diaphysis seen in the radius (Rfuse) Radiographic evaluation of Skeletal maturity A clinically orient method based on Hand-wrist films Leonard S. Fishman, Angle orthodontist Vol. 52,No.2,April 1982
  33. 33. Skeletal Maturation Assessment (SMA) L.Fishman (1982)Accelerating growth velocity period = SMI 1-4High growth velocity period = SMI 4-7Decelerating growth velocity period = SMI 7-11
  34. 34. Skeletal Maturation Assessment (SMA) L.Fishman (1982)PP3width appears approximately 3years before the peak of pubertalgrowth spurt(SMI 1)Ossification of adductor sesamoid ofthumb (S) occurs shortly before or atthe beginning of the pubertal growthspurt. (SMI 4)The MP3cap stage marks the peak ofthe pubertal growth.(SMI 6) Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005
  35. 35. Skeletal Maturation Assessment (SMA) L.Fishman (1982)PP3width appears approximately 3years before the peak of pubertalgrowth spurt(SMI 1)Ossification of adductor sesamoid ofthumb (S) occurs shortly before or atthe beginning of the pubertal growthspurt. (SMI 4)The MP3cap stage marks the peak ofthe pubertal growth.(SMI 6) Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005
  36. 36. Skeletal Maturation Assessment (SMA) L.Fishman (1982)PP3width appears approximately 3years before the peak of pubertalgrowth spurt(SMI 1)Ossification of adductor sesamoid ofthumb (S) occurs shortly before or atthe beginning of the pubertal growthspurt. (SMI 4)The MP3cap stage marks the peak ofthe pubertal growth.(SMI 6) Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005
  37. 37. Skeletal Maturation Assessment (SMA) L.Fishman (1982)Union of epiphysis and diaphysis atthe distal phalanx of the middlefinger (DP3fusion) signify the end ofpubertal growth. (SMI 8)Complete union of epiphysis anddiaphysis of the radius (R fusion)indicate that skeletal growth isfinished. (SMI 11) Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005
  38. 38. Skeletal Maturation Assessment (SMA) L.Fishman (1982) Union of epiphysis and diaphysis at the distal phalanx of the middle finger (DP3fusion) signify the end of pubertal growth. (SMI 8) Complete union of epiphysis and diaphysis of the radius (R fusion) indicate that skeletal growth is finished. (SMI 11) Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs Antana S et al. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005
  39. 39. Hagg and Taranger Method(1982) MP3 Ossification Stages: Hagg and Taranger Method1. MP3-E stage: Epiphysis is 3/4 wide as diaphysis.2. MP3-F stage: Start of the curve of pubertal growth spurt Epiphysis is as wide asmetaphysis. Radiolucent gap between epiphysis and metaphysis is wide.3. MP3-FG stage: Acceleration of the curve of pubertal growth spurt.Distinct medialand/or lateral border of epiphysis forms line of demarcation at right angle to distalborder.4. MP3-G stage: Maximum point of pubertal growth spurt Sides of epiphysis havethickened and cap its metaphysis, forming sharp distal edge on one or both sides.Marked undulations in metaphysis give it “Cupid’s bow” appearance.5. MP3-H stage: Deceleration of the curve of pubertal growth spurt.Fusion of epiphysisand metaphysis begins. Radiolucent gap between epiphysis and metaphysic is narrower.6. MP3-I stage: End of pubertal growth spurt Fusion of epiphysis and metaphysiscomplete
  40. 40. Skeletal maturation evaluation using cervical vertebraeBrent Hassel, BA, DDS, MS, and Allan G. Farman, BDS, PhD(odont), Dip ABOMR, EdS, MBA(AMJ ORTHOD DENTOFAC ORTHOP 1995;107:58-66.)
  41. 41. Conclusion MP3cap MP3width S Ru
  42. 42. Conclusion MP3cap MP3width S Ru
  43. 43. Conclusion MP3cap MP3width S Ru
  44. 44. Conclusion MP3cap MP3width S Ru
  45. 45. Use of Skeletal Maturation Based on Hand-Wrist Radiographic Analysis as a Predictor of Facial Growth: A Systematic Review Carlos Flores-Mir, DDS, MSc, Cert Orth, PhDa; Brian Nebbe, BDS, Mdent, FFD(SA)Ortho, PhDb; Paul W. Major, DDS, MSc, MRCD(c)The purpose of this systematic review was to evaluate the predictive value of hand-wrist radiographic assessment of skeletal maturity in estimating facial growthtiming and velocity.A search of PubMed, Medline, Cochrane Database of Systematic Reviews, Embase,Web of Sciences, and Lilacs16 articles that met the following inclusion criteria: use of hand-wrist radiographs for skeletal maturation determination facial growth evaluated through cephalometric radiographs and cross-sectional or longitudinal studies.Five articles were rejected because of major methodological issues. Most of theremaining articles had small sample size, and there was no report of randomizationor method error. Angle Orthod 2004;74:118–124.
  46. 46. USE OF SKELETAL MATURATION BASED ON HAND-WRIST RADIOGRAPHIC ANALYSIS AS A PREDICTOR OF FACIAL GROWTH: A SYSTEMATIC REVIEWCARLOS FLORES-MIR, DDS, MSC, CERT ORTH, PHDA; BRIAN NEBBE, BDS, MDENT, FFD(SA)ORTHO, PHDB; PAUL W. MAJOR, DDS, MSC, MRCD(C) Angle Orthod 2004;74:118–124.
  47. 47. USE OF SKELETAL MATURATION BASED ON HAND-WRIST RADIOGRAPHIC ANALYSIS AS A PREDICTOR OF FACIAL GROWTH: A SYSTEMATIC REVIEWCARLOS FLORES-MIR, DDS, MSC, CERT ORTH, PHDA; BRIAN NEBBE, BDS, MDENT, FFD(SA)ORTHO, PHDB; PAUL W. MAJOR, DDS, MSC, MRCD(C) Skeletal maturity determined by hand-wrist radiographic analysis was well related to overall facial growth velocity. Maxillary and mandibular growth velocities were related to skeletal maturity, but their relationship was less robust than that for overall facial growth. Angle Orthod 2004;74:118–124.
  48. 48. Reliability of growth prediction with hand–wrist radiographs Damian Verma, Timo Peltomäki and Andreas JägerThe aim of this study was to investigate the validity ofhand–wrist radiographic analysis in estimating the amount ofremaining craniofacial growth.The material and method cephalograms of 22 males and 27 females with a Class I malocclusion. The median age of the females at the beginning (T1) was 11 years 10 months and at the end (T2) of treatment 14 years 7 months The median age of the males at the beginning (T1) was 12 years 6 months and at the end (T2) of treatment 15 years 3 months, respectively. European Journal of Orthodontics 31 (2009) 438–442
  49. 49. Reliability of growth prediction with hand–wrist radiographs Damian Verma, Timo Peltomäki and Andreas JägerThe results showed a highly significant correlation betweenstatural growth increases and growth prediction assessed from thehand–wrist radiographs (females: r = 0.68; males: r = 0.7).Concerning craniofacial structures, the increase in mandibularcorpus (Go-Gn) showed the highest correlation with growthprediction (females: r = 0.21; males: r = 0.52), but this associationwould not allow a reliable growth prediction.There was no significant correlation between growth increases ofthe cranial base, the maxilla, the ramus, and the effective lengthof the mandible (Co-Gn) and growth prediction assessed with thehelp of hand–wrist radiographs. European Journal of Orthodontics 31 (2009) 438–442
  50. 50. Reliability of growth prediction with hand–wrist radiographs Damian Verma, Timo Peltomäki and Andreas JägerAs each patient has an individual growth pattern and differentcraniofacial structures show individual growth potential, it isquestionable if quantitative craniofacial growth prediction withthe help of hand–wrist radiographs is reliable.However, in an individual case for the assessment of the timingof the growth process, a hand–wrist radiograph can contributeto treatment planning. European Journal of Orthodontics 31 (2009) 438–442
  51. 51. Cervical Vertebral Maturation method(CVM)The cervical vertebral maturation method has proved effective inassessing the adolescent growth peak both in body height andmandibular size. Hellsing (1991) found significant correlation between height and length of the cervical vertebral bodies and statural height. Mitani and Sato (1992) reported changes in the cervical vertebrae correlated significantly with increases in mandibular size. Mappes et al (1992) indicated that predominant ethnic origin, climate, nutrition, socioeconomic level, and urbanization are causative factors of these racial variations.
  52. 52. Cervical Vertebral Maturation method(CVM)The cervical vertebral maturation method has proved effectivein assessing the adolescent growth peak both in body heightand mandibular size. Hassel and Farman (1995) and Garcia-Fernandez et al (1998) found high correlations between cervical vertebral maturation and the skeletal maturation of the hand-wrist. Franchi and coworkers (2000) confirmed the validity of six CVM stages as a biologic indicator for both mandibular and somatic skeletal maturity in 24 growing untreated subjects
  53. 53. Cervical Vertebral Maturation method (CVM)Lamparski (1972) created method analyzed size and shapechanges in the bodies of five cervical vertebrae (from thesecond one through the sixth).Thereafter, several cervical vertebral maturation (CVM)methods were proposed, and some modifications were madeand improvements achieved.
  54. 54. Cervical Vertebral Maturation method(CVM)Hassel and Farman (1995) compiled a new index of CVM,evaluated the second, third, and fourth cervical vertebrae.Baccetti et al (2002) devised new CVM method,comprised offive maturationa stage (CVMS I through CVMS V instead ofCvs 1 through Cvs 6 in the former CVM method)Baccetti et al (2005) present a further modified and refinedversion of the CVM method
  55. 55. Hassel and Farman(1995)Six stages in evaluation of cervical vertebrae maturation according to method of Hassel and Farman(1995) I.Initiation stage (CVMI 1) Very significant amount of adolescent growth expected C2, C3, and C4 inferior vertebral body borders are flat Superior vertebral borders are tapered posterior to anterior II. Acceleration stage (CVMI 2) Significant amount of adolescent growth expected Concavities developing in lower borders of C2 and C3 Lower border of C4 vertebral body is flat C3 and C4 are more rectangular in shape III.! Transition stage (CVMI 3) Moderate amount of adolescent growth expected Distinct concavities in lower borders of C2 and C3 C4 developing concavity in lower border of body C3 and C4 are rectangular in shape IV. Deceleration stage (CVMI 4) Small amount of adolescent growth expected Distinct concavities in lower borders of C2, C3, and C4 C3 and C4 are nearly square in shape V. Maturation stage (CVMI 5) Insignificant amount of adolescent growth expected Accentuated concavities of inferior verte- bral body borders of C2, C3, and C4 C3 and C4 are square in shape VI. Completion stage (CVMI 6) Adolescent growth is completed Deep concavities are present for inferior vertebral body borders of C2, C3, and C4 C3 and C4 heights are greater than widths
  56. 56. Hassel and Farman(1995)I.Initiation stage (CVMI 1) Very significantamount of adolescent growth expected C2, C3, and C4 inferior vertebral body borders are flat Superior vertebral borders are tapered posterior to anteriorII. Acceleration stage (CVMI 2) Significantamount of adolescent growth expected Concavities developing in lower borders of C2 and C3 Lower border of C4 vertebral body is flat C3 and C4 are more rectangular in shape
  57. 57. Hassel and Farman(1995)III.! Transition stage (CVMI 3) Moderateamount of adolescent growth expected Distinct concavities in lower borders of C2 and C3 C4 developing concavity in lower border of body C3 and C4 are rectangular in shapeIV. Deceleration stage (CVMI 4) Small amountof adolescent growth expected Distinct concavities in lower borders of C2, C3, and C4 C3 and C4 are nearly square in shape
  58. 58. Hassel and Farman(1995)V. Maturation stage (CVMI 5) Insignificantamount of adolescent growth expected Accentuated concavities of inferior vertebral body borders of C2, C3, and C4 C3 and C4 are square in shapeVI. Completion stage (CVMI 6) Adolescentgrowth is completed Deep concavities are present for inferior vertebral body borders of C2, C3, and C4 C3 and C4 heights are greater than widths
  59. 59. Hassel and Farman
  60. 60. Baccetti et al 2002 An Improved Version of the Cervical Vertebral Maturation (CVM) Method for the Assessment of Mandibular Growth (Angle Orthod 2002;72:316–323.)
  61. 61. The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics Tiziano Baccetti,Lorenzo Franchi,and James A. McNamara, Jr. The aim of the present article is to present a further modified and refined version of the CVM method and its validity for the appraisal of mandibular skeletal maturity in the individual patient in light of the findings of recent studies in which the CVM method has been used to assess optimal timing for the treatment of malocclusions in the transverse, sagittal, and vertical planes of space. Semin Orthod 11:119–129 © 2005
  62. 62. The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics Tiziano Baccetti,Lorenzo Franchi,and James A. McNamara, Jr. Subjects and Methods The total 30 sujects (18 males, 12 females) that comprises the cephalometric files of the University of Michigan Elementary and Secondary School Growth Study was evaluated. Total mandibular length (Co-Gn) was measured on the longitudinal sets of lateral cephalograms The maximum increase in Co-Gn between two consecutive annual 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, The morphology of the bodies of the second (C2 odontoid process), third (C3), and fourth (C4) cervical vertebrae were analyzed in the six consecutive annual observations (T1 through T6). The analysis consisted of both visual and cephalometric appraisals of morphological characteristics of the cervical vertebrae. Semin Orthod 11:119–129 © 2005
  63. 63. The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics Tiziano Baccetti,Lorenzo Franchi,and James A. McNamara, Jr. Semin Orthod 11:119–129 © 2005
  64. 64. Baccetti et al 2005Cervical stage 1The lower borders of all the threevertebrae (C2-C4) are flat.The bodies of both C3 and C4 aretrapezoid in shape (the superiorborder of the vertebral body istapered from posterior toanterior).The peak in mandibular growth willoccur on average 2 years after thisstage.
  65. 65. Baccetti et al 2005Cervical stage 2A concavity is present at thelower border of C2 (in four of fivecases, with the remaining subjectsstill showing a cervical stage 1).The bodies of both C3 and C4 arestill trapezoid in shape.The peak in mandibular growthwill occur on average 1 year afterthis stage.
  66. 66. Baccetti et al 2005Cervical stage 3Concavities at the lower bordersof both C2 and C3 are present.The bodies of C3 and C4 may beeither trapezoid or rectangularhorizontal in shape.The peak in mandibular growthwill occur during the year afterthis stage.
  67. 67. Baccetti et al 2005Cervical stage 4Concavities at the lower bordersof C2, C3, and C4 now arepresent.The bodies of both C3 and C4are rectangular horizontal inshape.The peak in mandibular growthhas occurred within 1 or 2 yearsbefore this stage.
  68. 68. Baccetti et al 2005Cervical stage 5The concavities at the lowerborders of C2, C3, and C4 stillare present.At least one of the bodies of C3and C4 is squared in shape. If notsquared, the body of the othercervical vertebra still isrectangular horizontal.The peak in mandibular growthhas ended at least 1 year beforethis stage.
  69. 69. Baccetti et al 2005Cervical stage 6The concavities at the lowerborders of C2, C3, and C4still are evident. At least one of the bodiesof C3 and C4 is rectangularvertical in shape. If notrectangular vertical, thebody of the other cervicalvertebra is squared.The peak in mandibulargrowth has ended at least 2years before this stage.
  70. 70. Baccetti et al 2005 The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics Tiziano Baccetti,Lorenzo Franchi,and James A. McNamara, Jr. Semin Orthod 11:119–129 © 2005
  71. 71. The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics Tiziano Baccetti,Lorenzo Franchi,and James A. McNamara, Jr. Semin Orthod 11:119–129 © 2005
  72. 72. The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics Tiziano Baccetti,Lorenzo Franchi,and James A. McNamara, Jr. Application to Dentofacial Orthopedics 1. Class II treatment is most effective when it includes the peak in mandibular growth (CS3) 2. Class III treatment with maxillary expansion and protraction is effective when performed before the peak (CS1 or CS2), whereas it is effective in the mandible during both prepubertal and pubertal stages; 3. skeletal effects of rapid maxillary expansion for the correction of transverse maxillary deficiency are greater at prepubertal stages(CS1-CS3), 4. deficiency of mandibular ramus height : the peak in mandibular growth (CS3). Semin Orthod 11:119–129 © 2005
  73. 73. Cervical vertebral maturation as a biologic indicator of skeletal maturity A systematic reviewRodrigo Ce ́sar Santiagoa; Luiz Felipe de Miranda Costaa; Robert Willer Farinazzo Vitralb; Marcelo Reis Fragac; Ana Maria Bolognesed; Lucianne Cople Maiae (Angle Orthod. 0000;00:000–000.)
  74. 74. Cervical vertebral maturation as a biologic indicator of skeletal maturity A systematic reviewRodrigo Ce ́sar Santiagoa; Luiz Felipe de Miranda Costaa; Robert Willer Farinazzo Vitralb; Marcelo Reis Fragac; Ana Maria Bolognesed; Lucianne Cople Maiae There was a moderate to high reproducibility of the CVM method Although some studies indicate that the CVM method shows good correlation with the HWM method, with considerable levels of reproducibility These parameters are not good enough for determining the validity of the CVM method. Furthermore, these conclusions were based on six articles, which points to a low level of evidence, and The biggest question remains unanswered: How reliable is CVM staging for predicting the pubertal spurt? (Angle Orthod. 0000;00:000–000.)
  75. 75. Cervical vertebrae maturation method morphologic criteria: Poor reproducibility Trenton S. Nestman,Steven D. Marshall, Fang Qian, Nathan Holton,Robert G. Franciscus, and Thomas E. Southardf Brighton, Colo, and Iowa City, IowaThe weakness of the CVM methodDifficulty in classifying the vertebral bodies of C3 andC4 as trapezoidal, rectangular horizontal, square, orrectangular vertical.This led to the overall poor reproducibility of the CVMmethod and our inability to support its use as a strictclinical guideline for the timing of orthodontictreatment. (Am J Orthod Dentofacial Orthop 2011;140:182-8)
  76. 76. Validity and reliability of a method for assessment of cervical vertebral maturation Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGaThe reliability of the CVM method was strong interobserveragreement and substantial intraobserver agreement.The percent of Interobserver agreement was below 50% atboth times. Percent intraobserver agreement varied widelyamong observers (range, 40.7%–79.1%).The validity of the CVM method was moderate agreementbetween the gold standard and observer staging at the initialtime. Percent agreement, especially at cervical stage 3, left much tobe desired.The CVM method should be used with other growth indicators inthe evaluation of skeletal maturation. (Angle Orthod. 2012;82:229–234.)
  77. 77. Validity and reliability of a method for assessment of cervical vertebral maturation Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGa The accuracy and reproducibility of the CVM method leave much to be desired. Factors that affect them are listed as follows.1) The ‘‘measurements’’ are purely subjective. It is difficult to define and identify the gradual appearance of the concavity in the inferior border of the vertebral bodies. The difference between horizontally rectangular, square, and vertically rectangular shapes depends on the researcher’s arbitrary decision (Angle Orthod. 2012;82:229–234.)
  78. 78. Validity and reliability of a method for assessment of cervical vertebral maturation Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGa The accuracy and reproducibility of the CVM method leave much to be desired. Factors that affect them are listed as follows.2) The shapes of cervical vertebrae show marked variation from subjectto subject. Sometimes the shape and inferior borders of C2–C4 cannot fulfill the definition of a cervical stage at the same time. Furthermore, The shapes of C3 and C4 bodies were still horizontally rectangular in some adult patients (Angle Orthod. 2012;82:229–234.)
  79. 79. Validity and reliability of a method for assessment of cervical vertebral maturation Xiao-Guang Zhaoa; Jiuxiang Linb; Jiu-Hui Jiangc; Qingzhu Wanga; Sut Hong NGa The accuracy and reproducibility of the CVM method leave much to be desired. Factors that affect them are listed as follows.3) Could the mandibular growth rate be taken as a reference toestablish the CVM method ?Controversy about the relationship between facial (mandibular) growthand general bodily growth continues (Angle Orthod. 2012;82:229–234.)
  80. 80. Dental maturationTooth emergence, dental maturity detected throughradiographic methods has been investigated as a markerof skeletal maturityTooth emergence has been investigated as a marker ofskeletal maturity; however, this has been shown to bepoorly correlated with individual skeletal maturity (Bjorkand Helm, 1967; Hagg and Taranger, 1982; Franchi et al.,2008).
  81. 81. Dental maturity VS Skeletal maturityDental maturity detected through radiographic methods appearsto be highly related to skeletal maturity (Sierra, 1987; Coutinhoet al., 1993; Krailassiri et al., 2002; Uysal et al., 2004; Basaran etal., 2007).The maturity of several mandibular teeth, excluding the thirdmolar, has been reported to be correlated with the skeletalmaturation phases, with correlation coefficients of 0.63–0.81(Sierra, 1987), 0.56–0.69 (Krailassiri et al., 2002), 060–0.91(Basaran et al., 2007), and 0.63–0.84 (Uysal et al., 2004).
  82. 82. Dental maturity VS Skeletal maturityIn contrast, one study failed to show significantcorrelations between dental maturation and otherindices of skeletal maturation (Demirjian et al.,1985). However, this last study recorded dentalmaturity as 90 per cent of development of the wholedentition rather than using individual tooth maturity.
  83. 83. Dental Calcification Stages Using Demirjian Index (DI) Stage A Calcification of single occlusal pointsA without fusion of different calcifications Stage B Fusion of mineralization points; theB contour of the occlusal surface is recognizable Stage C Enamel formation has been completedC at the occlusal surface, and dentin formation has commenced The pulp chamber is curved,and no pulp horns are visibleD Stage D Crown formation has been completed to the level of the cementoenamel junction Root formation has commenced. The pulp horns are beginning to differentiate, but the walls of the
  84. 84. Dental Calcification Stages Using Demirjian Index (DI) Stage E The root length remains shorter than the crown height. The walls of the pulp chamber are straight, and theE pulp horns have become more differentiated than in the previous stage. In molars, the radicular bifurcation has commenced to calcify.F Stage F The walls of the pulp chamber now form an isosceles triangle, and the root length is equal to or greater than the crown height. In molars, the bifurcation has developed sufficiently to give the roots a distinct formG Stage G The walls of the root canal are now parallel, but the apical end is partially open. In molars, only the distal root is rated.H Stage H The root apex is completely closed (distal root in molars). The periodontal membrane surrounding the root and apex is uniform in width throughout..
  85. 85. Eruption of the maxillary canines in relation to skeletal maturityThis study was to assess the relationship between the eruption of the permanent maxillary caninesand skeletal maturity in subjects with different skeletal relationships in the sagittal and verticalplanes.Methods: A sample of 152 subjects (63 boys, 89 girls) with erupting permanent maxillary canineswas analyzed. On the lateral cephalograms, the stage of cervical vertebral maturation was assessed.The subjects were divided into prepeak (before the pubertal growth spurt, cervical stage [CS]1 and CS2) peak (during the pubertal growth spurt, CS3 and CS4) postpeak (after the pubertal growth spurt, CS5 and CS6) groups.Skeletal relationships in the sagittal and vertical planes were evaluated, and relationships to timingof canine eruption were tested statistically Tiziano Baccetti, Lorenzo Franchi, Simona De Lisa, and Veronica Giuntini (Am J Orthod Dentofacial Orthop 2008;133:748-51)
  86. 86. Eruption of the maxillary canines in relation to skeletal maturityEruption of the permanent maxillary canine can occurat any stage in skeletal maturation before the end thepubertal growth spurt (CS1-CS4).A post- pubertal stage (CS5 or CS6) without anerupted maxillary canine indicates delayed canineeruption and suggests canine impaction.Eruption of the permanent maxillary canine occursmore frequently in the prepubertal stages of skeletaldevelopment in subjects with increased verticalskeletal relationships. Tiziano Baccetti, Lorenzo Franchi, Simona De Lisa, and Veronica Giuntini (Am J Orthod Dentofacial Orthop 2008;133:748-51)
  87. 87. Relationships Between Dental Calcification Stages and Skeletal Maturity Indicators in Thai Individualsthe canine stage F may represent the MP3widthstage evaluating the onset of the acceleratinggrowth period.The second molar stage E for female subjects,coinciding with the S stagethe second molar stage G for male subjects,coinciding with the MP3cap stage, were indicativeof a very high rate of growth acceleration. Suleekorn Krailassiri, DDS; Niwat Anuwongnukroh, DDS, MSD; Surachai Dechkunakorn, DDS, D Ortho (Angle Orthod 2002;72:155–166.)
  88. 88. Relationships Between Dental Calcification Stages and Skeletal Maturity Indicators in Thai Individuals This suggests that tooth calcification stages from panoramic radiographs might be clinically useful as a maturity indicator of the pubertal growth period However, further study is recommended in a larger sample size, and future studies should address development of the canines and second molars Suleekorn Krailassiri, DDS; Niwat Anuwongnukroh, DDS, MSD; Surachai Dechkunakorn, DDS, D Ortho (Angle Orthod 2002;72:155–166.)
  89. 89. ConclusionNo single method of assessing maturity level hasbeen shown to be effective and accurate in allpatients.The hand-wrist radiograph is considered to bethe most standardized method of skeletalmaturation assessmentAdditonal radiation exposure to the patient shouldbe concernIn an individual case, for the assessment of thetiming of growth process, hand-wrist radiographcan contribute for treatment plan
  90. 90. ConclusionThe accuracy of predicting growth may beimproved if other parameters (morphologic,biological, or genetic indicators), in addition tohand-wrist radiographic evaluation are used. Sato K, Mito T, Mitani H. An accurate method of predicting man- dibular growth potential based on bone maturity. Am J Orthod Dentofacial Orthop. 2001;120:286–293.
  91. 91. Conclusion Validity and reliability of CVM method : stillcontroversyThe CVM method should be used with other growthindicator in the evaluation of skeletal maturationSo do dental maturity index
  92. 92. If you look for the peak of growth
  93. 93. If you look for the peak of growthMP3cap
  94. 94. If you look for the peak of growthMP3cap
  95. 95. If you look for the peak of growthMP3cap
  96. 96. If you look for the peak of growth
  97. 97. If you look for the peak of growth CS 3
  98. 98. If you look for the peak of growth
  99. 99. If you look for the peak of growth
  100. 100. If you look for the peak of growth
  101. 101. If you look for the peak of growth2nd molar stage G (Male)
  102. 102. If you look for the peak of growth2nd molar stage G (Male)
  103. 103. If you look for the peak of growth2nd molar stage G (Male)
  104. 104. If you look for the peak of growth
  105. 105. If you look for the peak of growth 2nd molar stageE(Female) : S stage
  106. 106. If you look for the peak of growth 2nd molar stageE(Female) : S stage
  107. 107. Thank you

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