SKELETAL MATURITY INDICATORS - Subharti Dental College

SKELETAL

MATURITY

INDICATORS

DEPARTMENT OF ORTHODONTICS SUBHARTI DENTAL COLLEGE

SWAMI VIVEKANAND SUBHARTI

UNIVERSITY

Presented By:

Dr Shalu Jain

Introduction

Ricketts

To take advantage of growth we

must have an idea of – first its magnitude,

second, its direction and the third element

the timing.

Dr Shalu Jain, Subharti Dental College, SVSU

Why study maturity indicators?

Key to successful treatment in growing

patients – harnessing of growth.

Without exact status of growth –

magnitude and direction- treatment

planning is futile.


Advantages of Maturity Indicators

Potential vector of facial development

determined.

Amount of significant craniofacial growth

potential left.

To decide the onset of treatment timing.


To decide the type of treatment:

1. Orthopedic

a) Removable

b) Fixed

2. Orthodontic

3. Orthognathic surgical procedure

4. Combination of any of above


To evaluate treatment prognosis

To understand role of genetics and

environment on skeletal maturation

pattern.


Various Growth Assessment

Methods

Chronologic age

Secondary sexual characteristics

Growth charts

Dental development

Skeletal maturation


Age

Expressed as:

Chronologic age

Age measured by years

lived since birth.

Dental age

Determined according to

teeth erupted, amount of root resorption

and amount of root formation.

Skeletal age

Determined by ossification

of various skeletal structures at different

time.


Dental age

Determined from :

Eruption time table

Nolla’s stages of tooth development

Demirjian’s stages of tooth

development


Eruption Time Table


Nolla’s stages of tooth development


Demirjian’s stages of tooth

development


Skeletal Age Assessment

Regions used for skeletal age assessment

should be ideally:

Small to restrict radiation exposure

Should have many ossification centres

that ossify at different times and which

can be standardized

Easily accessible


Regions Normally Used For Age

Assessment

Head and neck:

Skull

Cervical vertebrae

Upper limb:

Shoulder joint- scapula

Elbow

Hand wrist and fingers


Lower limb:

Femur

Hip joint

Knee

Ankle

Foot tarsals

Metatarsals

Phalanges


Hand Wrist Radiographs

Hand wrist – Numerous Small Bones

Predictable and scheduled pattern of

appearance, ossification and union from

birth to maturity

Most suited to study growth


Anatomy Of Hand Wrist

1. Radius

2. Ulna

3. Distal epiphysis of radius

4. Distal epiphysis of ulna

5. Trapezium

6. Trapezoid

7. Capitate

8. Hamular process of hamate

9. Hamate

10.Triquetral

11.Pisiform

12.Lunate

13.Scaphoid

14.Sesamoid

M = metacarpal

P = phalanx

Proximal Row

Carpal

Distal Row

Carpal


Stages of Ossification of

Phalanges 1.Epiphysis = Diaphysis

2.Epiphysis caps Diaphysis

3.Fusion of Epiphysis & Diaphysis

1 2 3


Radiological Methods of

Assessment and Prediction of

Growth

Greulich and Pyle method

Singer’s method

Fishman’s skeletal maturity indicators

Bjork, Grave and Brown method

Cervical Vertebrae Maturity Indicators

Maturation assessment by Hagg and

Taranger and the KR (Kansal and

Rajagopal) modified MP3 method


GREULICH AND PYLE METHOD

Published an atlas containing ideal

photographs of hand wrist radiographs.

Separate sets for male and female

patients.

Patients radiograph is matched in the

atlas.


SINGER’S METHOD FOR

ASSESSMENT

(Julian Singer, 1980)

Julian Singer, 1980

STAGE CHARACTERISTIC

One (early) Absence of pisiform &hook of hamate.

Epiphysis of proximal phalanx of second

finger narrower than its diaphysis

Two

(prepubertal)

Initial ossification of hook of hamate &

pisiform.

Proximal phalanx of second finger equal

to its epiphysis

Three

(pubertal

onset)

Beginning of calcification of ulnar

sesamoid, increased width of epiphysis

of proximal phalanx of second finger &

increased calcification of hook of hamate

& pisiform Dr Shalu Jain, Subharti Dental College, SVSU

STAGE CHARACTERISTIC

Four

(pubertal)

Calcified ulnar sesamoid.

Capping of diaphysis of middle phalanx

of third finger to epiphysis.

Five (pubertal

deceleration)

Calcified ulnar sesamoid. Fusion of

epiphysis of distal phalanx of third finger

with its shaft.

Epiphysis of radius & ulna not fully fused

with respective shafts.

Six (growth

completion)

No remaining sites seen.

SINGER’S METHOD FOR

ASSESSMENT


Fishman’s Skeletal Maturity

Indicators

Keonord S Fishman, 1982

Used four anatomical sites on

Thumb

Third finger

Fifth finger

Radius


4 stages of bone maturation:

1. Epiphysis equal in width to diaphysis

2. Appearance of adductor sesamoid

3. Capping of epiphysis

4. Fusion of

epiphysis

Fishman’s Skeletal Maturity

Indicators


Eleven Discrete Adolescent Skeletal

Maturity Indicators


CERVICAL VERTEBRAE

MATURITY INDICATORS (CVMI)

Hassel & Farman

Shapes of cervical vertebrae are different at

different levels of skeletal development.


Skeletal maturation evaluation

using cervical vertebrae

Six categories of CV maturation


CVMI – 1: Initiation stage of cervical

vertebrae

1. C2,C3 and C4 inferior vertebral

body borders are flat

2. Superior vertebral body borders

are tapered from posterior to

anterior (wedge shape)

3. 80-100% of pubertal growth

remains


CVMI – 2: Acceleration stage of

cervical vertebrae

1. Concavities are developing in

lower borders of C2 and C3

2. Lower border of C4 vertebral

body is flat

3. C3 and C4 are more rectangular

in shape

4. 65-85% pubertal growth remains


CVMI-3 Stage: Transition stage of

cervical vertebrae

1. Distinct concavities seen in lower

borders of C2 and C3

2. Concavity is developing in lower

border of C4

3. C3 and C4 are rectangular in

shape

4. 25-65% of pubertal growth

remains


CVMI- 4: Deceleration stage of

cervical vertebrae

1. Distinct concavities seen in lower

borders of C2, C3 and C4.

2. C3 and C4 – nearly square in

shape

3. 10 – 25% of pubertal growth

spurt left.


CVMI-5: Maturation stage of cervical

vertebrae

1. Accentuated concavities of

C2,C3 and C4 inferior vertebral

borders

2. C3 and C4 square in shape

3. 5-10% pubertal growth remains


CVMI-6: Completion stage of

cervical vertebrae

1. Deep concavities present in C2,

C3 and C4 inferior vertebral

borders

2. C3 and C4 greater in height than

in width

3. Pubertal growth complete


Skeletal maturation evaluation

using cervical vertebrae


Bjork, Grave and Brown Method

9 stages of skeletal development.

Scoph associated each of these

stage to chronological age

Stage Male

age

Female

age

Characteristic

One 10.6 8.1 Equal epiphysis &

diaphysis of middle

phalanx of third finger Dr Shalu Jain, Subharti Dental College, SVSU

Stage Male

age

Female

age

Characteristic

Two 12 8.1 Equal epiphysis &

diaphysis of middle

phalanx of third finger


Stage Male

age

Female

age

Characteristic

Three 12.6 9.6 3 areas of ossification:

1. Hamular process of

hamate

2. Pisiform

3. Equal epiphysis &

diaphysis of radius

1 2 3


Stage Male

age

Female

age

Characteristic

Four 13 10.6 Marks

beginning of

pubertal growth

spurt.

1. Initial

mineralizati

on of ulnar

sesamoid

of thumb

2. Increased

ossification

of hamular

process of

hamate

bone

1

2


Stage Male age Female age Characteristic

Five 14 11 Marks peak of pubertal growth

spurt

Capping of diaphysis by

epiphysis seen in:

1. Middle phalanx of third

finger

2. Proximal phalanx of thumb

3. Radius

1 2 3


Stage Male

age

Female

age

Characteristic

Six 15 13 Marks end of

pubertal growth

spurt.

Union between

epiphysis and

diaphysis of distal

phalanx of third

finger Dr Shalu Jain, Subharti Dental College, SVSU

Stage Male

age

Female

age

Characteristic

Seven 15.9 13.3 Union between

epiphysis and

diaphysis of little

finger


Stage Male

age

Female

age

Characteristic

Eight 15.9 13.9 Union between

epiphysis and

diaphysis of

middle phalanx of

middle finger


Stage Male

age

Female

age

Characteristic

Nine 18.3 16 End of skeletal

growth.

Union between

epiphysis and

diaphysis of radius


Hagg and Taranger method

Hagg & Taranger

Analysed yearly hand wrist radiographs of

individuals from age 6 to 18 years.

Studied the ossification of the sesamoid

(S), the middle and distal phalanges of

the third finger (MP3 and DP3) and the

distal epiphysis of the radius.


Five stages of MP3 growth:

F- onset of the curve of pubertal growth spurt

FG-acceleration part of the curve of pubertal

growth spurt.

G- peak of the curve.

H-deceleration part of the curve of pubertal

growth spurt

I-end of the pubertal growth spurt.


Comparison between modified

the MP3 indicators and CVMI

described by Hassel and

Farman.


MP3-F Stage

Start of the curve of pubertal growth spurt

Epiphysis is as wide as metaphysis

End of epiphysis are tapered and rounded.

Radiolucent gap is wide between epiphysis & diaphysis.

Initiation stage of cervical vertebrae

C2,C3 and C4 inferior vertebral

body borders are flat.

Superior vertebral borders are tapered from

posterior to anterior [wedge shape]

80-100% of pubertal growth remains.

CVMI-1


Acceleration of the curve of pubertal growth spurt.

Epiphysis is as wide as metaphysis.

Distinct medial and/or lateral border of epiphysis forms line of demarcation at right angle to distal border.

Metaphysis begins to show slight undulation.

Radiolucent gap between metaphysis

and epiphysis is wide.

Acceleration stage of cervical vertebrae.

Concavities are developing in lower

borders of C2 and C3.

Lower border of C4 vertebral body

is flat.

C3 and C4 are more rectangular in

shape.

65-85% of pubertal growth

remains.

MP3-FG Stage CVMI-2


Maximum point of pubertal growth spurt.

Sides of epiphysis have thickened and cap its metaphysis, forming sharp distal edge on one or both sides.

Marked undulations in metaphysis give it “Cupid’s bow’’ appearance.

Radiolucent gap is moderate.

Transition stage of cervical vertebrae

Distinct concavities are seen in lower

borders of C2 and C3.

Concavity is developing in lower

border of C4.

C3 and C4 are rectangular in shape.

25-65% of pubertal growth remains.


Deceleration of the curve of pubertal growth spurt.

Fusion of epiphysis and metaphysis begins.

Side of epiphysis form obtuse angle to distal border.

Epiphysis is beginning to narrow.

Slight convexity under central part of metaphysis.

Typical Cupid’s bow appearance is absent

Radiolucent gap is narrow.

Deceleration stage of cervical

vertebrae.

Distinct concavities are seen in

lower borders of C2, C3 and C4.

C3 and C4 are nearly square in

shape.


remains.


Maturation of the curve of pubertal growth spurt

Superior surface of epiphysis shows smooth concavity.

Metaphysis shows smooth, convex surface, almost fitting into reciprocal concavity of epiphysis.

No undulation present in metaphysis.

Radiolucent gap is insignificant.

Maturation stage of cervical vertebrae.

Accentuated concavities of C2, C3

and C4 inferior vertebral body

borders are observed.

C3 and C4 are square in shape.


remains.


End of pubertal growth spurt

Fusion of epiphysis and metaphysis complete.

No radiolucent gap.

Dense, radiopaque epiphyseal line

forms integral part of proximal

portion of middle phalanx.

Completion stage of cervical vertebrae.

Deep concavities are present in C2,

C3 and C4 inferior vertebral body

borders.

C3 and C4 are greater in height than

in width.

Pubertal growth is completed.


SKELETAL MATURITY INDICATORS - Subharti Dental College

Documents

Transcript of SKELETAL MATURITY INDICATORS - Subharti Dental College