Skeetal maturity indicators
- 1. Skeletal Maturity Indicator Dr. Shweta Kolhe BDS, MDS(Orthodontist)
- 2. • Skeletal age is considered as the most reliable method as it is closely related to physical growth • The timing of changes vary as each individual has his/her own “Biological Clock” • Maturation status have influence on: diagnosis, treatment goals, treatment planning, eventual outcome of treatment, decisions regarding use of extra oral traction forces, functional appliance, extraction versus non-extraction treatment or orthognathic surgery. Introduction
- 3. Biological Age Chronological age Sexual Age Maturity Indicators Morphological age Dental age Circumpubertal age Skeletal age 1. Hand - Wrist Radiographs 2. Cervical Vertebrae 3. Different stages of tooth development.
- 4. Hand and wrist radiographs • The hand - wrist region is made up of numerous small bones. • Show a predictable & scheduled pattern of appearance, ossification & union from birth to maturity. • Methods to asses skeletal maturity : 1. Atlas Method By Greuich & Pyle. 2. Bjork, Grave & Brown Method 3. Fishman’s Skeletal Maturity Indicator. 4. Hagg & Taranger Method.
- 5. Indications Of Hand And Wrist Radiographs: • Useful in patients exhibit major discrepancy between dental and chronological age. • Before start of treatment of skeletal malocclusion. • To assess skeletal age whose growth is affected by infection, neoplastic or traumatic condition. • Predict future skeletal maturation rate and status. • To predict the pubertal growth spurt. • Indicated in patient with orthognathic surgery. • For research purpose.
- 6. Anatomy Of Hand - Wrist
- 7. The Carpals • Consist of 8 small, irregularly shaped bones arranged in two rows, a proximal row & a distal row. • Bones of proximal rows – Scaphoid, Lunate, Triquetral & Pisiform. • Bones of distal rows – Trapezium, Trapezoid, Capitate & Hamate. • Each of these 8 carpe bones ossifies from one primary center, which appears in a predictable pattern.
- 8. The Metacarpals • 5 miniature long bones forming the skeletal framework of the palm. • They are numbered 1-5 from the thumb to the little finger. • Each metacarpal ossifies from one primary center (in its shaft) and a secondary center on the distal end ( except for the first metacarpal where it appears at the proximal end).
- 9. The sesamoid bone • The sesamoid bone is a small nodular bone most often present embedded in tendons in the region of the thumb.
- 10. Phalanges Phalanges ossify in 3 stages : • STAGE 1: The epiphysis and diaphysis are equal. • STAGE 2: The epiphysis caps the diaphysis by surrounding it like a cap. • STAGE 3: Fusion occurs between the epiphysis and diaphysis.
- 11. Atlas method of Greulich & Pyle • 1929, studies at the Western Reserve University School of Medicine in Ohio. • In 1937 an “Atlas of Skeletal Maturation of the Hand ” was published by Todd based on the data collected in the study. • Greuich & Pyle based their atlas partly on the atlas by Todd. • Radiograph is compared with a standard series of films, representative of normal children at different chronological ages and for each sex.
- 12. Width of Epiphysis = Diaphysis PP2 Stage 1- 3 year before peck of pubertal growth spurt. MP3 Stage 2 – Prior to the beginning of puberta growth spurts ♂ - 10.6 yrs. ♀ - 8.1 yrs. ♂ - 12 yrs. ♀ - 8.1 yrs. Bjork, Grave & Brown Method (1972) • 9 STAGES • Width of Epiphysis = Diaphysis
- 13. Pisi – stage: Visible ossification Pisiform Bone. H1 – stage: Ossification of Hamular Process of Hamet R – stage Epiphysis = Diaphysis of Radius ♂ - 12.6 yrs. ♀ - 9.6 yrs. Stage 3
- 14. S – stage: First mineralization of Sisamoid Bone H2 – stage: Progressive Ossification of Hamular Process of Hamet ♂ - 13 yrs. ♀ - 10.6 yrs. Beginning of pubertal growth spurts Stage 4
- 15. Capping of Epiphysis PP1cap - stage MP3cap - stage ♂ - 14 yrs. ♀ - 11 yrs. Peak of the Pubertal growth Rcap - stage Stage 5
- 16. Union of Epiphysis ♂ - 15 yrs. ♀ - 13 yrs. • Union of epiphysis and diaphysis at the distal phalanx of middle finger • End of pubertal growth. DP3u - stage Stage 6
- 17. • ♂ - 15.9 yrs. ♀ - 13.3 yrs. • Union of epiphysis and diaphysis at the proximal phalanx of middle finger • Seen 1 year after growth spurts PP3u - stage Stage 7
- 18. • ♂ - 15.9 yrs. ♀ - 13.9 yrs. • Union of epiphysis and diaphysis at the middle phalanx of the middle finger MP3u - stage Stage 8
- 19. • ♂ - 18.5 yrs. ♀ - 16 yrs. • Complete union of epiphysis and diaphysis of the radius • Skeletal growth is finished Ru - stage Stage 9
- 21. 1st – 3rd Stage 4th & 5th Stage 6th – 9th Stage - Corresponds to 3 years before the peak pubertal growth period. - Prognosis is good if growth modification is planned. - Residual growth potential - Fixed functional appliances can be planned. - Union stage - No chance for functional appliance therapy.
- 22. Singer’s Method of Assessment • 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.
- 23. 6 stages • Absence of pisiform, • Hook of hamate. • Epiphysis of proximal phalanx Of second digit narrower than Its shaft Stage 1(Early) -Initial ossification of pisiform & Hook of hamate. -Proximal phalanx of second digit And its epiphysis are equal in width Stage 2 (Prepubertal)
- 24. • Beginning of calcification of ulnar sesamoid. • Increased ossification of pisiform & hook of hamate. • Calcified ulnar sesamoid. • Capping of shaft of middle phalanx of third digit by its epiphysis-MP3cap. Stage 3( Pubertal Onset) Stage 4 (Pubertal)
- 25. • Ulnar sesamoid fully calcified • DP3u stage • All phalanges and carpals fully calcified • Epiphyses of radius and ulna not fully calcified with respect to shafts Stage 5 (Pubertal Deceleration) No remaining growth sites. Stage 6 (Growth Completion)
- 26. • Hand and wrist film can be used as an indicator of the maturational status of Orthodontic patient. • 6 stages advocated as guidelines for t/t timing • Stage 2- Important prepubertal period during which Class II correction could be effectively achieved • Stage 5-Period of residual growth during which post t/t changes could occur
- 27. Fishman’s Skeletal Maturity Indicators • Leonard S. Fishman, angle orthodontist 1982 • A system for the evaluation of skeletal maturity from H&W radiographs is developed & presented with complete details for implementation in clinical practice. This system uses; - Only four stages of maturation - Six anatomic sites located on the thumb, third finger, fifth finger radius.
- 28. 4 Stages of Bone Maturation Epiphysis equal in width to diaphysis Appearance of adductor sesamoid of the thumb Capping of epiphysis Fusion of epiphysis 1st Stage 2nd Stage 3rd Stage 4th Stage
- 29. 6 Anatomical Sites Thumb - Sesamoid Third finger – PP3, MP3, DP3 Fifth finger – MP5 Radius
- 30. SMI 1: The third finger proximal phalanx shows equal width of epiphysis and diaphysis. SMI 2: Width of epiphysis equal to that of diaphysis in the middle phalanx of third finger. SMI 3: Width of epiphysis equal to that of diaphysis in the middle phalanx of fifth finger. SMI 4: Appearance of adductor sesmoid of the thumb. SMI 5: Capping of epiphysis seen in distal phalanx of third finger. SMI 6: Capping of epiphysis seen in middle phalanx of third finger. SMI 7: Capping of epiphysis seen in middle phalanx of fifth finger. SMI 8: Fusion of epiphysis & diaphysis in the distal phalanx of third finger. SMI 9: Fusion of epiphysis and diaphysis in proximal phalanx of third finger. SMI 10: Fusion of epiphysis and diaphysis in the midde phalanx of third finger. SMI 11: Fusion of epiphysis and diaphysis seen in the radius.
- 31. 1. PP3 2. MP3 Epiphisys = Diaphysis 3. MP5 4. Sessamoid Ossification 5. DP3 6. MP3 Capping 7. MP5 8. DP3 9. PP3 Fusion 10. MP3 11. RADIUS Fishman’s Skeletal Maturity Indicators
- 32. • Stages of Ossification of the sesamoid, middle and distal phalanx of third finger and the epiphyses of the radius are considered. • Sesamoid is usually attained during acceleration period/ onset of peck height velocity. • Five stages of development of MP3 region 1. MP3F stage 4. MP3-H stage 2. MP3-FG stage 5. MP3-I stage 3. MP3-G stage Hagg &Taranger’s Method
- 33. • Epiphyses = Diaphyses • Epiphyses –tapered and rounded • No undulations of metaphyses • Radiolucent gap • Start of pubertal growth spurt MP3 F - Stage MP3 FG - Stage • Epiphyses =Diaphyses • Distinct medial & lateral borders • Metaphyses begins to show undulations • Radiolucent gap • Acceleration of pubertal growth spurt
- 34. • Capping of the metaphysis by epiphyses • Cupid bow appearance of metaphysis • Radiolucent gap – moderate • Peak of pubertal growth spurt MP3 G - Stage MP3 H - Stage • Fusion of epiphyses and metaphysis begins • Narrowing of epiphyses • Cupid bow appearance disappears • Radiolucent gap becomes narrower • Deceleration of pubertal growth spurt
- 35. • Fusion of epiphyses and metaphysis completed • No radiolucent gap between epiphyses and metaphyses • End of pubertal growth spurt MP3 I - Stage Third finger distal phalanx DP3-I – Fusion of epipysis and metaphysis is completed - Decelaration period of pubertal growth spurts Radius R-I : fusion of epipysis and diaphysis has begun. -1 year before / at the end of growth spurts R-IJ: Fusion is almost competed but still gap at the margin. R-J: Fusion of epiphysis and metaphysis.
- 36. Skeletal Maturation Evaluation Using Cervical Vertebrae.
- 37. • Hassel & Farman (1995) gave 6 stages of Cervical Maturation. • Shapes of the cervical vertebrae differ at each level of skeletal development. • C3 & C4 changes from wedge shaped to rectangular followed by square shape & became taller. • Inferior vertebral border were flat when immature & were concave when mature.
- 38. Six Stages – in the development of cervical vertebrae. Stage 1 Initiation Stage 2 Acceleration Stage 3 Transition Stage 4 Deceleration Stage 5 Maturation Stage 6 Completion
- 39. CATEGORY 1(initiation) • Corresponds to SMI 1&2. • 80-100% of growth expected • Inferior borders of C2,C3 & C4 flat • Vertebrae wedge shaped • Tapered from post. to Ant. CVMI 1
- 40. CATEGORY 2(Acceleration) • Corresponds to SMI 3&4 • 65-85% of growth expected • Inferior borders of C2,C3- concavities developing • Inf. Border C4 flat • C3 & C4 bodies nearly rectangular CVMI 2 SMI 3 EP=DP PP3 & MP3 & SMI 4 Sisamoid Ossification
- 41. CATEGORY 3(Transition) • Corresponds to SMI 5& 6 • 25-65% growth expected • Distinct concavities-C3&C4 • Concavity begins to develop-C4 • C3 &C4 rectangular CVMI 3 SMI 5 & 6 Capping DP3 & MP3
- 42. CATEGORY 4(Deceleration) • Corresponds to SMI 7&8. • 10-25% growth expected • Distinct concavities- C2, C3&C4. • C3&C4-becoming square in shape. CVMI 4 SMI 7 Capping PP5 & SMI 8 Fusion DP3
- 43. CATEGORY 5(Maturation) CVMI 5 SMI 9 & 10 Fusion PP3 & MP3 • Corresponds to SMI 9 & 10 • 5-10% growth expected. • Accentuated concavities-C2,C3 &C4. • C3 &C4 almost square in shape
- 44. CATEGORY 6 (Completion) CVMI 6 SMI 11 Fusion Radius • Corresponds to SMI 11 • Adolescent growth complete • Deep concavities-C2, C3 &C4. • Vertebral bodies greater • vertically than horizontally
- 45. Tooth mineralization as an indicator of skeletal maturity
- 46. The examination of panoramic radiograph offers several advantages over conventional hand -wrist radiograph method: - Dentists are more familiar with the stages of dental development than indicator in hand- wrist radiograph. - No additional exposure to radiation.
- 47. A. Calcification of single occlusal points without fusion of different calcification. B. Fusion of mineralization points; the contour of the occlusal surface is recognizable. C. Enamel formation has been competed at the occlusal surface, and dentine formation has commenced. The pulp chamber is curved, and no pulp horns are visible. D. Crown formation has been completed to the level of the cemento-enamel junction. root formation has commenced. The pulp horn are beginning to differentiate, but the walls of pulp chamber remain curved. E. The root length remains shorter than the crown height . The walls of the pulp chamber are straight, & pulp horns have become more differentiated than in the previous stage. In molars the radicular bifurcation has commenced to calcify. 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 form. 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. The root apex is completely closed (distal root in molars) The periodontal member surrounding the root and apex is uniform in width throughout.
- 48. Conclusion • Growth modification therapy needs evaluation of each patient’s maturational profile individually. • Skeletal maturity Indicators can improve the diagnostic expertise of the orthodontist, and helps to excerpt between the Orthopedic & Orthodontic Therapy.
- 49. Thank you