Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy
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Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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    Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy Presentation Transcript

    • SKELETAL AGE ASSESMENT INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    • INTRODUCTION VARIOUS METHODS OF SKELETAL AGE ASSESMENT HAND WRIST RADIOGRAPH CERVICAL VERTEBRA MIDPALATAL SUTURE FRONTAL SINUS www.indiandentalacademy.com
    • Sexual maturation characteristics, chronologic age, dental development, height, weight, and skeletal development are some of the more common means that have been used to identify stages of growth. HUNTER 1966, BROWN 1972, , FISHMAN 1979 AND HAGG 1982 demonstrated that chronologic age alone provides little insight or validity for identifying the stages of developmental progression through adolescence to adulthood Children of the same chronological age vary in their maturity Variation in growth arises because biological clock for same events during growth are set differently for different individuals www.indiandentalacademy.com
    • Some children grow rapidly and mature early completing their growth quickly,others grow and develop slowly and so appear to behind even though given they will catch up with and even surpass children who where larger once Because of timing and variablity chronological age is not agood indicator of maturity The pubertal growth spurt is considered to be an advantageous period for certain types of orthodontic treatment and should be taken into account in connection with orthodontic treatment planning. Because of the wide individual variation in the timing of the pubertal growth spurt, chronologic age cannot be used in the evaluation of pubertal growth. Many studies have shown a strong correlation between the peak of facial growth and peak height www.indiandentalacademy.com velocity.
    • Longitudinal records of height can therefore be used for evaluation of the facial growth rate during puberty. In the clinical context, longitudinal growth records of height are seldom available. Even with adequate records, it may be difficult to locate the pubertal growth spurt before it is passed, since the increase in growth rate is often too small, especially in many girls, to be clinically discernible Most of the time the clinician must base his judgment on a single examination and, therefore, determine the status of the individual by cross-sectional evaluation alone. Stature is not an indicator of maturity. Thus, additional information is necessary to estimate the maturation level of the individual. Such information can be obtained from the dental, skeletal, and pubertal development. www.indiandentalacademy.com
    • By comparing with standards for age and sex, it is possible to assess whether the development of the individual is average, accelerated, or retarded. In orthodontics it is more relevant to evaluate the individual's maturation in relation to his or her own pubertal growth spurt. This presupposes knowledge of relationships in time between maturation indicators and pubertal growth events. Suitable maturation indicators for clinical orthodontics have been devised and the associations between these indicators and the peak of growth have been reported. Growth prediction based on the appearance of secondary sexual characteristics(voice change,menarche,hair growth etc) requires a long observation period and frequent physical examinations. www.indiandentalacademy.com
    • Biologic age, skeletal age, bone age, and skeletal maturation are nearly synonymous terms used to describe the stages of maturation of a person Skeletal maturation refers to the degree of development of ossification in bone. Size and maturation can vary independently of each other. During growth, every bone goes through a series of changes that can be seen radiologically. The sequence of changes is relatively consistent for a given bone in every person. The timing of the changes varies because each person has his or her own biologic clock. www.indiandentalacademy.com
    • The use of skeletal age has been shown to be more reliable and precise in assessing the progress of an individual toward maturity.The technique for assessing skeletal age consists of visual inspection of bones— their initial appearance and their subsequent ossification changes in shape and size. Various areas of the skeleton have been used: the foot, the ankle, the hip, the elbow, the handwrist, and the cervical vertebrae. Hand wrist radiograph One important diagnostic tool currently used in determining whether the pubertal growth has started, is occurring, or has finished is the hand-wrist radiographic evaluation. www.indiandentalacademy.com
    • The radiograph of the hand-wrist has been the most frequently used area of the skeleton. The reason for its use is that many centers are available in this area of the skeleton that undergo changes at different times and rates. The information from the hand-wrist radiograph has been used in a number of ways to evaluate the skeletal age or bone age of the child. Bone age can be obtained by either comparing the radiograph in question with a series of standards films representative of normal children at different chronologic ages and assigning to the film in question the age of the standard that matches it most closely, or by assigning a weighted score to the developmental stage of each of 20 bones in the hand and wrist, the bone age being the total score for the radiograph www.indiandentalacademy.com
    • Driezen and associatesfound no difference between skeletal age of the left and right hand-wrist; Garn and Rohman found a high correlation among assessments from the hand-wrist, the elbow, the shoulder, the hip, the knee, and the foot; Lamparski found no difference and a high correlation between vertebrae and hand-wrist skeletal age assessments. History of hand wrist radiograph Roland, in 1896, introduced the idea of using the comparative size and shape of the radiographic shadows of growing bones as indicators of rate of growth and maturity. Hellman published his observations on the ossification of epiphysial cartilages of the hand in 1928. www.indiandentalacademy.com
    • Todd compiled hand-wrist data that was further elaborated on by Greulich and Pyle in atlas form Flory in 1936, indicated that the beginning of calcification of the carpal sesamoid (adductor sesamoid) was a good guide to determining the period immediately before puberty. The appearance of the adductor sesamoid has been highly correlated to peak height velocity and the start of the adolescent growth spurt. Most authors agree that peak height velocity follows adductor sesamoid appearance by approximately 1 year. Hagg and Taranger created a method using the hand-wrist radiograph to correlate certain maturity indicators to the pubertal growth spurt. Fishman developed a system of hand-wrist skeletal maturation indicators (SMIs) using four stages of bone maturation at six anatomic sites on the hand and the wrist. Others who contributed are Tanner-white,maria.t.oreilly,shigemi www.indiandentalacademy.com Goto,Rajagopal, Bjork, Grave and Brown,schopf
    • Anatomy of hand wrist radiograph www.indiandentalacademy.com
    • Bjork, Grave and Brown Stage-1 males10.6y,female8.1y Epiphysis and diaphysis of proximal Phalanx index finger equal 3y before puberty Stage-2 Male12y,female8.1y Epiphysis and diaphysis middle phalanx middle finger equal www.indiandentalacademy.com
    • Stage-3(male 12.6y female 9.6y) Male12.6yfemale9.6y a) Hamular process of hamate Ossification b)ossification of pisiform www.indiandentalacademy.com c) Epiphysis and diaphysis of radius equal
    • Stage-4(male 13y,female 10.6y) Initial mineralization of ulnar sesamoid of thumb Increased ossification of hamular process of hamate bone www.indiandentalacademy.com
    • Stage-5(male 14.0y,female 11.0y) Capping of the diaphysis by epiphysis Middle phalanx of third finger Proximal phalanx of thumb radius www.indiandentalacademy.com
    • Stage-6(male 15y female13y) Characterized by the end of pubertal spurt Union of epiphysis and diaphysis of distal phalanx of middle finger Stage-7(male 15.9y,female13.3y) Union of epiphysis and diaphysis of proximal phalanx of litlle finger www.indiandentalacademy.com
    • Stage-8(male 15.9y,female 13.9y) Fusion of the epiphysis and diaphysis of middle phalanx of middle finger Stage-9(male 18.5y female 16.0y Last phase fusion of epiphysis and diaphysis www.indiandentalacademy.com
    • m Fishman(1982) Skeletal Maturity Indicators (SMI) Epiphysis as wide as diaphysis 1. Third finger-proximal phalanx 2. Third finger-middle phalanx 3. Fifth finger-middle phalanx Ossification 4. Adductor sesamoid of thumb Capping of epiphysis 5. Third finger-distal phalanx 6. Third finger-middle phalanx 7. Fifth finger-middle phalanx Fusion of epiphysis and diaphysis 8. Third finger-distal phalanx 9. Third finger-proximal phalanx 10. Third finger-middle phalanx www.indiandentalacademy.com 11. Radius
    • As seen above, SMI’s 1–3 and 5–7 are based on selected areas of the third and fifth fingers. SMI 4 is based on the ossification of the adductor sesamoid of the thumb, and 8–11 on fusion of selected areas of the third finger and the radiu www.indiandentalacademy.com
    • Hagg and taranger(1982) Skeletal development in the hand and wrist was by assessment of the ossification of the ulnar sesamoid of the metacarpophalangeal joint of the first finger (S) and certain specified stages of three epiphyseal bones (closure of epiphyseal plates): the middle and distal phalanges of the third finger (MP3 and DP3) and the distal epiphysis of the radius (R) Eight of the ten indicator have been defined been previously defined by previous author. In order to obtain maturation indicators of shorter duration, two new epiphyseal stages were defined in this study: one stage in the middle phalanx of the third finger, denoted MP3-FG, and one stage in the distal ed of the radius, denoted R-IJ. www.indiandentalacademy.com
    • The ulnar sesamoid (S) of the metacarpophalangeal joint of the first finger before and after ossifying. The distal phalanx of the third finger (DP3) before and after Stage l: fusion of the epiphysis and metaphysis is completed. The middle phalanx of the third finger (MP3): Stage F— the epiphysis is as wide as the metaphysis. Stage FG— the epiphysis is as wide as the metaphysis and there is distinct medial and/or lateral border of the epiphysis forming a line of demarcation at right angles to the distal border. Stage G— the sides of the epiphysis have thickened and also cap its metaphysis, forming a sharp edge distally at one or both sides. Stage H— fusion of the epiphysis and metaphysis has begun. Stage I— fusion of the epiphysis and metaphysis is completed. The distal epiphysis of the radius: Stage I— fusion of the epiphysis and metaphysis has begun. Stage IJ— fusion is almost completed but there is still a small gap at one or both margins. Stage J— fusion of the epiphysis and metaphysis is completed. www.indiandentalacademy.com
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    • The pubertal growth spurt. Onset of the spurt (ONSET) is the smallest annual increment from which there is a marked continuous increase in growth rate to PHV. ONSET is found by locating the smallest annual increment (A) from which there is a continuous increase in growth rate to PHV. The curve is then followed toward PHV until the growth rate has accelerated 10 mm. ONSET will be indicated by the annual increment which is next below or coincides with this growth rate. Peak height velocity (PHV) is the greatest annual increment during puberty. The end of the spurt (END) is the first annual increment after PHV below 20 mm. www.indiandentalacademy.com
    • Sesamoid S was usually period of the pubertal growth spurt (ONSET-PHV). Middle third phalanx MP3-F was attained before ONSET. MP3-FG was attained 1 year before or at PHV . MP3-G was attained at or 1 year after PHV MP3-H was attained after PHV but before END MP3-I was attained before or at END Distal third phalanx DP3-I was attained during the deceleration period of the pubertal growth spurt (PHV-END) by all subjects. Radius R-I was attained 1 year before or at END R-IJ and R-J were not attained before END by any subject. www.indiandentalacademy.com
    • Leite, O'Reilly, and Close (1987) Using first, second and third fingers The following maturity indicators and ossification events were evaluated 1. First appearance of the adductor sesamoid of the first metacarpophalangeal joint — No ossification — First appearance 2. Changes in the epiphysis and diaphysis of the proximal, medial, and distal phalanges of the first, second, and third fingers — E¾: The epiphysis reaches ¾ of the width of its diaphysis. — EQ: The epiphysis is as wide as its diaphysis. — EC: The epiphysis is as wide as its diaphysis and there is a distinct medial and/or lateral border of the epiphysis forming a line of demarcation at right angles to the distal border. — FB: Fusion between the epiphysis and its diaphysis has begun. — FC: Fusion between the epiphysis and its diaphysis www.indiandentalacademy.com is complete
    • The advantage of the three-fingers method is that it eliminates the need for an additional radiograph. This reduces the amount of radiation exposure to the patient and cost to the clinician, and can be obtained more readily during the treatment progress since it can be included in the lateral cephalometric radiograph. Radiographs of the head, hand, and wrist can taken on a single film instead of the usual two films. Their technique provides both records on one film; however, it still requires two exposures. www.indiandentalacademy.com
    • Shigemi goto and takamasa(1996) Ossification of distal phalanx of first digit ossification of the distal phalanx of the first digit used to estimate the stage of craniofacial maturation. ossification of the first digit begins at an early age and continues over a period of several years. development proced from no observable epiphysis to the complete epiphysial union of the digital phalanx of the first digit The peak growth velocity in body height in occurs at 10 years of age in girls and 12 years in boys. complete epiphysial union takes place between 12 and 13 years of age in girls and after 14 years in boys complete fusion of the distal phalanx of the first digit normally occurs after maximum pubertal growth . 90% of the total growth in length of the cranial base and maxillary and mandibular length had already been achieved at this stage www.indiandentalacademy.com
    • Ossification event of distal phalanx of first digit. Stage E0: No epiphysis; Stage E1: Narrower epiphysis than diaphysis; Stage E2: As wide epiphysis as diaphysis; Stage E3: Wider epiphysis than diaphysis; Stage E4: Wider epiphysis than diaphysis with threequarters of epiphysis union; Stage E5: Complete epiphyseal union. www.indiandentalacademy.com
    • As this maturation event is closely associated with a declining growth rate of the mandibular condyles, in particular in girls, it may be used as an indication for when to initiate orthodontic treatment in subjects with mild to moderate skeletal malocclusion III discrepancies. it is used to predict the extent of residual mandibular growth toward the end of the growth period at the stage of fusion of the distal phalanx of the first digit. www.indiandentalacademy.com
    • Tanner-white method third middle phalanx and radius www.indiandentalacademy.com
    • Rajagopal and kansal(2002) Hagg and taranger were based on five stages of MP3 growth based primarily epiphyseal change This method used changes observed in the metaphyseal region. Provided an additional bone stage between MP3-H (deceleration of the curve of the pubertal growth spurt) and MP3-I (end of the pubertal growth spurt), which we called the MP3-HI stage, resulting in a total of six stages of MP3 growth. www.indiandentalacademy.com
    • Lateral cephalograms for recording the CVMI stages were taken in natural head position following standard procedure, with patients standing erect and instructed to look straight into their own eyes in a mirror placed on the wall www.indiandentalacademy.com
    • Periapical radiographs was used for recording the MP3 stages3 were taken using the following procedure 1. The subject was instructed to place the right hand with the palm downward on a flat table. 2. The middle finger was centered on a 31mm ⋅ 41mm periapical dental x-ray film, parallel with the long axis of the film. 3. The cone of the dental x-ray machine was positioned in slight contact with the middle phalanx, perpendicular to the film. www.indiandentalacademy.com
    • MP3-F stage: Start of the curve of pubertal growth spurt Features observed by Hagg and Taranger1: 1. Epiphysis is as wide as metaphysis. Additional features observed in this study: 2. Ends of epiphysis are tapered and rounded. 3. Metaphysis shows no undulation. 4. Radiolucent gap (representing cartilageous epiphyseal growth plate) between epiphysis and metaphysis is wide. CVMI-1: Initiation stage of cervical vertebrae2 1. C2, C3, and C4 inferior vertebral body borders are flat . 2. Superior vertebral borders are tapered from posterior to anterior (wedge shape). 3. 80-100% of pubertal growth remains. www.indiandentalacademy.com
    • MP3-FG stage: Acceleration of the curve pubertal growth spurt Features observed by Hagg and Taranger: 1. Epiphysis is as wide as metaphysis. 2. Distinct medial and/or lateral border of epiphysis forms line of demarcation at right angle distal border . Additional features observed in this study : 3. Metaphysis begins to show slight undulation . 4. Radiolucent gap between metaphysis and epiphysis is wide. 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% of pubertal growth remains www.indiandentalacademy.com
    • MP3-G stage: Maximum point of pubertal growth spurt Features observed by Hagg and Taranger: 1. Sides of epiphysis have thickened and cap metaphysis, forming sharp distal edge on one both sides. Additional features observed in this study: 2. Marked undulations in metaphysis give “Cupid’s bow” appearance. 3. Radiolucent gap is moderate between epiphysis and metaphysis . CVMI-3: Transition stage of cervical vertebrae 1. Distinct concavities are seen in lower borders of C2 and C3 2. Concavity is developing in lower border C4 . 3. C3 and C4 are rectangular in shape 4. 25-65% of pubertal growth remains www.indiandentalacademy.com
    • MP3-H stage: Deceleration of the curve of pubertal growth spurt Features observed by Hagg and Taranger : 1. Fusion of epiphysis and metaphysis begins . Additional features observed in this study : 2. One or both sides of epiphysis form obtuse angle to distal border . 3. Epiphysis is beginning to narrow . 4. Slight convexity is seen under central part of metaphysis. 5. Typical “Cupid’s bow” appearance of metaphysis is absent, but slight undulation is distinctly present. 6. Radiolucent gap between epiphysis and metaphysis is narrower . www.indiandentalacademy.com
    • CVMI-4: Deceleration stage of cervical vertebrae 1. Distinct concavities are seen in lower borders of C2, C3, and C4. 2. C3 and C4 are nearly square in shape . 3. 10-25% of pubertal growth remains. www.indiandentalacademy.com
    • MP3-HI stage: Maturation of the curve of pubertal growth spurt Features of this “new” stage observed in this study: 1. Superior surface of epiphysis shows smooth concavity. 2. Metaphysis shows smooth, convex surface, almost fitting into reciprocal concavity of epiphysis. 3. No undulation is present in metaphysis. 4. Radiolucent gap between epiphysis and metaphysis is insignificant. CVMI-5: Maturation stage of cervical vertebrae 1. Accentuated concavities of C2, C3, and C4 inferior vertebral body borders are observed . 2. C3 and C4 are square in shape . 3. 5-10% of pubertal growth remains www.indiandentalacademy.com
    • MP3-I stage: End of pubertal growth spurt 1. Fusion of epiphysis and metaphysis complete . Additional features observed in this study : 2. No radiolucent gap exists between metaphysis and epiphysis . 3. Dense, radiopaque epiphyseal line forms integral part of proximal portion of middle phalanx . CVMI-6: Completion stage of cervical vertebrae 1. Deep concavities are present in C2, C3, and C4 inferior vertebral body borders. 2. C3 and C4 are greater in height than in width 3. Pubertal growth is complete www.indiandentalacademy.com
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    • Cervical vertebra The first seven vertebrae in the spinal column constitute the cervical spine. The first two, the atlas and the axis, are quite unique, the third through the seventh have great similarity Vertebral growth takes place from the cartilagenous layer on the superior and inferior surfaces of each vertebrae.Secondary ossification nuclei on the tips of the bifid spinous processes and transverse processes appear during puberty.Secondary ossification nuclei unite with the spinous processes when vertebral growth is complete. After completion of endochondral ossification, growth of the vertebral body takes place by periosteal apposition. It appears to take place only at the front and sides www.indiandentalacademy.com
    • Category 2 was called ACCELERATION. This corresponded to a combination of SMI 3 and 4. Growth acceleration was beginning at this stage, with 65% to 85% of adolescent growth expected. Concavities were developing in the inferior borders of C2 and C3. The inferior border of C4 was flat. The bodies of C3 and C4 were nearly rectangular in shape Category 3 was called TRANSITION. This corresponded to a combination of SMI 5 and 6. Adolescent growth was still accelerating at this stage toward peak height velocity, with 25% to 65% of adolescent growth expected. Distinct concavities were seen in the inferior borders of C2 and C3. A concavity was beginning to develop in the inferior border of C4. The bodies of C3 and C4 were rectangular in shape www.indiandentalacademy.com
    • CVMI readings were then evaluated against the previously determined SMI readings Category 1 was called INITIATION. This corresponded to a combination of SMI 1 and 2. At this stage, adolescent growth was just beginning and 80% to 100% of adolescent growth was expected.36 Inferior borders of C2, C3, and C4 were flat at this stage. The vertebrae were wedge shaped, and the superior vertebral borders were tapered from posterior to anterior www.indiandentalacademy.com
    • Category 4 was called DECELERATION. This corresponded to a combination of SMI 7 and 8. Adolescent growth began to decelerate dramatically at this stage, with 10% to 25% of adolescent growth expected.36 Distinct concavities were seen in the inferior borders of C2, C3, and C4. The vertebral bodies of C3 and C4 were becoming more square in shape www.indiandentalacademy.com
    • Category 5 was called MATURATION. This corresponded to a combination of SMI 9 and 10. Final maturation of the vertebrae took place during this stage, with 5% to 10% of adolescent growth expected.36 More accentuated concavities were seen in the inferior borders of C2, C3, and C4. The bodies of C3 and C4 were nearly square to square in sh Category 6 was called COMPLETION. This corresponded to SMI 11. Growth was considered to be complete at this stage. Little or no adolescent growth was expected.36 Deep concavities were seen in the inferior borders of C2, C3, and C4. The bodies of C3 and C4 were square or were greater in vertical dimension than in horizontal dimension www.indiandentalacademy.com
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    • The shapes of the vertebral bodies of C3 and C4 changed from somewhat wedge shaped, to rectangular, to square, to greater in dimension vertically than horizontally as skeletal maturity progressed. The inferior vertebral borders were flat when most immature, and they were concave when mature. The curvatures of the inferior vertebral borders were seen to appear sequentially from C2 to C3 to C4 as the skeleton matured. The concavities became more distinct as the person matured. www.indiandentalacademy.com
    • Stage 1: All inferior borders of the bodies are flat. The superior borders are strongly tapered from posterior to anterior. Stage 2: A concavity has developed in the inferior border of the 2nd vertebra. The anterior vertical heights of the bodies have increased. Stage 3: A concavity has developed in the inferior border of the 3rd vertebra. The other inferior borders are still flat. Stage 4: All bodies are now rectangular in shape. The concavity of the 3rd vertebra has increased, and a distinct concavity has developed on the 4th vertebra. Concavities on 5 and 6 are just beginning to form. Stage 5: The bodies have become nearly square in shape, and the spaces between the bodies are visibly smaller. Concavities are well defined on all 6 bodies. Stage 6: All bodies have increased in vertical height and are higher than they are wide. All concavities www.indiandentalacademy.com have deepened
    • Stages 1 through 3 were generally observed prior to peak velocity for all the mandibular dimensions, with stages 2 and 3 occurring in the year immediately preceeding peak. Stages 2 and 3 were observed in the year immediately preceeding the maximum increment for corpus length stage 3. Stage 4 also occurred prior to peak in three subjects, and in the other ten subjects stages 4 through 6 occurred after peak velocity. www.indiandentalacademy.com
    • Cervical maturation and age www.indiandentalacademy.com
    • Lorenzo franchi and tiziano bacceti(2002) Inorder to make the method easier and applicable to the vast majority of patients: (1) To use a more limited number of vertebral bodies to perform the staging (as suggested by Hassel and Farman30). In particular, the method should include only those cervical vertebrae (C2, C3, and C4) that can be visualized when the patient wears a protective radiation collar. (2) To avoid definitions of stages based on a comparative assessment of between-stage changes, so that stages can be identified easily in a single cephalogram . The analysis consisted of both visual and cephalometric appraisals of morphological characteristics of the cervical vertebrae. www.indiandentalacademy.com
    • 1) presence of a concavity at the lower border of the body of C2, C3, and C4; and (2) shape of the body of C3 and C4: trapezoid (the superior border is tapered from posterior to anterior); rectangular horizontal (the heights of the posterior and anterior borders are equal; the superior and inferior borders are longer than the anterior and posterior borders); squared (the posterior, superior, anterior and inferior borders are equal); www.indiandentalacademy.com
    • C2p, C2m, C2a: the most posterior, the deepest and the most anterior points on the lower border of the body of C2. C3up, C3ua: the most superior points of the posterior and anterior borders of the body of C3. C3lp, C3m, C3la: the most posterior, the deepest and the most anterior points on the lower border of the body of C3. C4up, C4ua: the most superior points of the posterior and anterior borders of the body of C4. C4lp, C4m, C4la: the most posterior, the deepest and the most anterior points on the lower border of the body of C4. www.indiandentalacademy.com
    • C3Conc: a measure of the concavity depth at the lower border of C3 (distance from the line connecting C3lp and C3la to the deepest point on the lower border of the vertebra, C3m). C4Conc: a measure of the concavity depth at the lower border of C4 (distance from the line connecting C4lp and C4la to the deepest point on the lower border of the vertebra, C4m). C3BAR: ratio between the length of the base (distance C3lp-C3la) and the anterior height (distance C3uaC3la) of the body of C3. C3PAR: ratio between the posterior (distance C3up-C3lp) and anterior (distance C3ua-C3la) heights of the body of C3. C4BAR: ratio between the length of the base (distance C4lp-C4la) and the anterior height (distance C4uaC4la) of the body of C4. C4PAR: ratio between the posterior (distance C4up-C4lp) and anterior (distance C4ua-C4la) heights of the body www.indiandentalacademy.com of C4.
    • The findings of both the inspective and cephalometric analyses revealed that no statistically significant discrimi nation can be made between Cvs 1 and Cvs 2 as defined in the former CVM method. two former stages (Cvs 1 and Cvs 2) merge into one single stage. This newly described Cervical Vertebral Maturation Stage is referred to as CVMS The appearance of a visible concavity at the lower border of the third cervical vertebra is the anatomic characteristic that mostly accounts for the identification of the stage immediately preceding the peak in mandibular growth (former Cvs 3, actual CVMS II) www.indiandentalacademy.com
    • CVMS I: the lower borders of all the three vertebrae are flat, with the possible exception of a concavity at the lower border of C2 in almost half of the cases. The bodies of both C3 and C4 are trapezoid in shape (the superior border of the vertebral body is tapered from posterior to anterior). The peak in mandibular growth will occur not earlier than one year after this stage. CVMS II: Concavities at the lower borders of both C2 and C3 are present. The bodies of C3 and C4 may be either trapezoid or rectangular horizontal in shape. The peak in mandibular growth will occur within one year after this stage. CVMS III: Concavities at the lower borders of C2, C3, and C4 now are present. The bodies of both C3 and C4 are rectangular horizontal in shape. The peak in mandibular growth has occurred within one or two years before this stage. CVMS IV: The concavities at the lower borders of C2, C3, and C4 still are present. At least one of the bodies of C3 and C4 is squared in shape. If not squared, the body of the other cervical vertebra still is rectangular horizontal. The peak in mandibular growth has occurred www.indiandentalacademy.com
    • Mitani and mitotsato(2002) On lateral cephalometric radiographs in the following cervical vertebrae were traced by pencil and measured with micrometer calipers: anterior vertebral body height (AH), vertebral body height (H), posterior vertebral body height (PH), and anteroposterior vertebral body length (AP) on the third and fourth cervical vertebrae (Fig 2). The ratios of these parameters were calculated (AH/AP, H/AP, PH/AP, AH/H, H/PH, and AH/PH). A formula for obtaining cervical vertebral bone age was determined from the ratios and the chronological age using a stepwise multiple regression analysis. www.indiandentalacademy.com
    • Lower lines are tangent to the front and back of the lower part of the Cervical vertebral bodies AH3,4-distance from top of front part to tangent of lower part H3,4 distance from top of middle part to tangent of lower part PH3,4-distance from top of back part to tangentof lower part AP3,4-ant post distance middle of cervical vertbral body www.indiandentalacademy.com
    • AH3,4, H3,4, and PH3,4 increased in an accelerated manner from 10 to 13 years of age. The ratios of these parameters were calculated. The formula for calculating cervical vertebral bone age was determined by stepwise multiple regression analysis with chronological age as a dependent variable and the ratios of these parameters as independent variables AH3/AP3 and AH4/AP4 increased in an accelerated manner at about 12 years of age, and AH4/PH4 continued to increase until about 14 years of age Cervical bone age =-0.20+6.20x AH3AP3+5.90xAH4AP4+4.74xAH4PH4 www.indiandentalacademy.com
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    • Almost all previous evaluations in puberty with cervical vertebrae on cephalometric radiographs either used or referred to the atlas reported by Lamparski The use of an atlas is convenient because changes in cervical vertebral bodies can be evaluated with regard to growth in the atlas. However, an atlas cannot be used to evaluate growth in an objective and detailed manner because the results can differ from operator to operator, and an atlas also cannot be used to calculate age as the TW2 method can. Thus, the method used in this study is more objective than those used in most previous studies. www.indiandentalacademy.com
    • ratios were used to calculate cervical vertebral bone age because this considers only the shape of cervical vertebrae and discounts their size. When deriving the formula for cervical vertebral bone age, chronological age instead of bone age determined from hand-wrist radiographs. There were 2 reasons for this: (1) generally, average chronological age corresponded with average bone age when there was no great deviation within groups, and (2) chronological age had little operator error compared with bone age. www.indiandentalacademy.com
    • Koshitsato,mitani and mito(2001) Introduced the CASMAS(computer aided skeletal maturity assessment) The CASMAS can be performed with a standard Windows 95/98/Me/NT/2000-based PC and an image scanner with a transparent film unit. Measurements of the epiphyseal, metaphyseal, and overlapping width were made automatically on the distal, middle, and proximal phalanges of the third digit. By programming an algorithm, we were able to extract the digital image (300 dpi, 8 bit, gray scale) of the distal, middle, and proximal phalanges of the third digit from the computerized scan of the hand-wrist radiograph www.indiandentalacademy.com
    • an algorithm was designed to extract each phalanx, to set measurements of the parameters for evaluating epiphyses and metaphyses of the phalanges, and to calculate bone age automatically www.indiandentalacademy.com
    • Frontal sinus development lateral radiographs were oriented with the nasion sella line horizontally. The peripheral border of the frontal sinus was traced, and the highest (Sh) and lowest (S1) points of sinus extension relative to the nasion sella line were marked. Perpendicular to the interconnecting line (Sh-S1), the maximum width of the frontal sinus was assessed The average yearly growth velocity (millimeters per year) of the frontal sinus was calculated separately for each of the prediction intervals (Tl or T2). . www.indiandentalacademy.com
    • From longitudinal growth data of the subjects, the average yearly body height growth velocity (millimeters per year) was calculated. The maximum body growth velocity at puberty was assigned as body height peak (Bp). The body height growth data were used only to test the accuracy of the prediction of pubertal stage as assessed from frontal sinus development. • 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 1.4 years after the pubertal body height peak (Bp). • In male subjects, the average age at frontal sinus peak is 15.1 years. • In a l-year observation interval, a peak growth velocity in the frontal sinus of at least 1.3 mm/yr. is attained by 84% of the subjects • In a 2-year observation interval, a peak growth velocity in the frontal sinus of at least 1.2 mm/yr. is attained by 70% of the subjects www.indiandentalacademy.com
    • the presented prediction procedure for somatic maturity stage will not be able to replace hand-wrist radiographs in routine orthodontic diagnostics, it may deliver important information with respect to the person's stage of somatic development when two lateral head films are available spaced approximately 1 to 2 years apart www.indiandentalacademy.com
    • Midpalatal suture Maturational evaluation of the approximation of the midpalatal suture was accomplished by examining hand-wrist radiographs with Fishman's system of skeletal maturation assessment (SMA).2 Standardized occlusal radiographs www.indiandentalacademy.com
    • Stages of ossification of the midpalatal suture were compared with Fishman's standards of skeletal maturation indicators (SMI stages 1 to 11), allowing for comparison of the differences of maturational development between delayed, average, and accelerated matu, the following key landmarks and planes were identified: Point A, most anterior point of the premaxilla; Point B, most posterior point on the posterior wall of the incisive foramen; and Point P, point tangent to a line connecting the posterior walls of the greater palatine foramens Measurements of length and associated percentage of osseous development were recorded for the following dimensions: A-P (total dimension of the suture), A-B (anterior dimension of the suture), and B-P (posterior dimension of the suture). www.indiandentalacademy.com
    • Both the male and female subjects demonstrated an increase in the amount of sutural approximation (fusion) as the SMI stages progressed through adolescence. Very little midpalatal approximation existed during the early maturational stages (SMI 1 to 2). An important finding is that at SMI 11, when general skeletal and facial growth is completed, the midpalatal suture is only approximately half the suture distance. Very large increases in approximation are evident during the late maturation period, from SMI 8 to 11. There is no significant difference between the amount of midpalatal sutural approximation between the male and female groups, although the male values were slightly higher in www.indiandentalacademy.com numerical value.
    • Maturational development is related to midpalatal fusion in ways that can provide the clinician with information to better time orthodontic maxillary expansion. This study has revealed that it is probably best to accomplish this before SMI 9 as the percentage of approximation is significantly less. An ideal time to initiate orthopedic expansion is during the early maturational stage, SMI 1 to 4. Theoretically less orthopedic force values would be required if treatment is initiated early. www.indiandentalacademy.com
    • conclusion If utilized properly hand-wrist radiograph and cervical vertebra radiograph provide a reliable and efficient means of development assessment. Simple reference on the assumption that skeletal age or rather normal skeletal age for a specific chronologic age as a reasonable indicator of maturity is not justified Studies have shown that healthy children of any age do not demonstrate any chronological specificity regarding particular stages of maturation All the maturity indices are sequence of maturational stages Representing the general poulation and cannot be directly associatedIn any accurate manner with a specific indiviual of either sex No dignostic tool should be heavily relied over sound clinical judgement www.indiandentalacademy.com
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