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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
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Skeletal maturity indicators /certified fixed orthodontic courses by Indian dental academy Presentation Transcript

  • 1. THE SKELETAL MATURITY INDICATORS INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com 1
  • 2. INTRODUCTION……... www.indiandentalacademy.com 2
  • 3. The identification of skeletal maturation levels provides a very useful means of identifying specific points along the progressive path of adolescent growth. It is analogous to mileage signs posted along a highway between two cities. This provides a new dimension for evaluating general and individual growth, including facial growth www.indiandentalacademy.com 3
  • 4. Sexual maturation characteristics, chronological age, dental development, height, weight, and skeletal development are some of the common means that have been used to identify stages of growth. Determination of maturation and subsequent evaluation of growth potential during preadolescence or adolescence is extremely important. With many orthodontic patients, pubertal growth needs to be factored into the diagnostic equation. www.indiandentalacademy.com 4
  • 5. The chronological age offers little insight in determining the developmental stage or somatic maturity of a person. Thus the maturity indicators provide an objective diagnostic evaluation of stage of maturity in an individual. The basis for skeletal age assessment by radiographs is that the different ossification centers appear and mature at different times. The order , rate , time of appearance and progress of ossification in the various ossification centers occurs in a predictable sequence. www.indiandentalacademy.com 5
  • 6. HISTORY/BACKGROUND….. www.indiandentalacademy.com 6
  • 7. After Roentgen demonstrated his radiographic discovery in 1895, 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. In the early 1900s, Pryor, Rotch, and Crampton began tabulating indicators of maturity on sequential radiographs of the growing hand and wrist. In 1928.Hellman published his observations on the ossification of epiphysial cartilages of the hand www.indiandentalacademy.com 7
  • 8. In 1935 Todd compiled hand-wrist data that was further elaborated on by Greulich and Pyle in atlas form In 1936 Flory, 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. www.indiandentalacademy.com 8
  • 9. Most authors agree that peak height velocity follows adductor sesamoid appearance by approximately 1 year. 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. Hagg and Taranger created a method using the hand-wrist radiograph to correlate certain maturity indicators to the pubertal growth spurt. www.indiandentalacademy.com 9
  • 10. Hassel and Farman developed a system of skeletal maturation determination using the cervical vertebrae. The shapes of the cervical vertebrae were seen to differ at each level of skeletal development, which provided a means to determine the skeletal maturity of a person and thereby determine whether the possibility of potential growth existed www.indiandentalacademy.com 10
  • 11. FISHMAN’S SKELETAL MATURITY INDICATORS…. www.indiandentalacademy.com 11
  • 12. A system of skeletal maturation was proposed by Leonord S .Fishman in 1982. This system of evaluating hand wrist radiographs uses only four stages of bone maturation, all found at six anatomical sites located on the thumb, third finger and radius. Eleven discrete adolescent skeletal maturational indicators, covering the entire period of adolescent development, are found on these six sites. www.indiandentalacademy.com 12
  • 13. www.indiandentalacademy.com 13
  • 14. The sequence of the four ossification stages progresses through epiphyseal widening on the selected phalanges, the ossification of the adductor sesamoid of the thumb, the capping of the selected epiphyses over their diaphyses. The sequence of eruption of the eleven indicators is exceptionally stable www.indiandentalacademy.com 14
  • 15. www.indiandentalacademy.com 15
  • 16. Widening of the epiphyses relative to its diaphyses is a progressive process. The epiphyses first appears as a small center of ossification centrally located in the diaphyses. When it has developed laterally to the width of the diaphyses, it is considered applicable as an SMI in this system www.indiandentalacademy.com 16
  • 17. Capping occurs in the transition between initial widening and fusion between epiphyses and diaphyses. It is the stage in which the rounded lateral margins of the epiphyses begin to flatten and point towards the diaphyses, with an acute angle on the side facing the diaphyses. The time of first appearance of this capping is applicable as SMI. www.indiandentalacademy.com 17
  • 18. Fusion between the epiphyses and diaphyses follows capping it also begins centrally and progresses laterally, until the two formerly separate bones become one. The time of completion of this fusion, with a smooth continuity of the surface at the junction area, is applicable as an SMI.. www.indiandentalacademy.com 18
  • 19. Ossification of the adductor sesamoid of the thumb first appears as small, relatively round center of ossification medial to the junction of the epiphyses and diaphyses of the proximal phalanx. It then becomes progressively larger and more dense. It is the first observation of the existence of this bone that is considered applicable as an SMI. This occurs after the SMI’S based on epiphyseal widening, but before those based on capping www.indiandentalacademy.com 19
  • 20. The eleven skeletal maturity indicators are as follows:-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 www.indiandentalacademy.com 20
  • 21. 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 11. Radius www.indiandentalacademy.com 21
  • 22. www.indiandentalacademy.com 22
  • 23. www.indiandentalacademy.com 23
  • 24. A longitudinal study was carried out and an average age standards for eleven SMI’s were established and the values for each skeletal maturational age were tabulated. Earlier age of maturational development for females was seen www.indiandentalacademy.com 24
  • 25. www.indiandentalacademy.com 25
  • 26. www.indiandentalacademy.com 26
  • 27. www.indiandentalacademy.com 27
  • 28. www.indiandentalacademy.com 28
  • 29. www.indiandentalacademy.com 29
  • 30. Both maxilla and mandible achieved their maximum growth rate later than the statural height. Statural height demonstrated a greater percentage of completed growth than the facial measurements in the middle and the late periods of adolescent growth. Very close similarities were found between maxillry and mandibular patterns of relative growth rate, but the maxilla showed more growth completed than the mandible until the final stage, www.indiandentalacademy.com 30 when the mandible tended to catch up.
  • 31. Maturation assesment by Hagg and Taranger….. (AJO-1982) www.indiandentalacademy.com 31
  • 32. Every skeletal and muscular dimension seems to be involved in the pubertal growth spurt. 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. www.indiandentalacademy.com 32
  • 33. THE PUBERTAL GROWTH SPURT www.indiandentalacademy.com 33
  • 34. 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. 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 www.indiandentalacademy.com 34
  • 35. Skeletal development in the hand and wrist is analyzed from annual radiographs, taken between the ages of 6 and 18 years, 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). www.indiandentalacademy.com 35
  • 36. www.indiandentalacademy.com 36
  • 37. The ulnar sesamoid (S) of the metacarpophalangeal joint of the first finger before and after ossifying. . S was usually attained during the acceleration period of the pubertal growth spurt (ONSET-PHV). www.indiandentalacademy.com 37
  • 38. The distal phalanx of the third finger (DP3) before and after Stage l: This stage signifies the fusion of epiphysis and metaphysis and is attained during the deceleration period of the pubertal growth spurt (PHVEND) by all subjects.. www.indiandentalacademy.com 38
  • 39. The middle phalanx of the third finger (MP3): Stage F— the epiphysis is as wide as the metaphysis. This stage is attained before ONSET by about 40 percent of the subjects and at PHV by many others www.indiandentalacademy.com 39
  • 40. 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. This stage is attained 1 year before or at PHV by about 90 percent of the subjects. www.indiandentalacademy.com 40
  • 41. Stage G— the sides of the epiphysis have thickened and also cap its metaphysis, forming a sharp edge distally at one or both sides. This stage is attained at or 1 year after PHV Stage H— fusion of the epiphysis and metaphysis has begun. and is attained after PHV but before END by practically all boys and about 90 percent of the girls. www.indiandentalacademy.com 41
  • 42. Stage I— fusion of the epiphysis and metaphysis is completed. is attained before or at END in all subjects except a few girls. (Rajagopal and Sudhanshu added an additional bone stage between MP3H(deceleration of the curve of the pubertal growth spurt) and MP3I(end of the pubertal growth spurt) which they called it as MP3-HI stage, resulting in a total of six stages of MP3 growth) www.indiandentalacademy.com 42
  • 43. www.indiandentalacademy.com 43
  • 44. The distal epiphysis of the radius: R-I the fusion of the epiphysis and metaphysis has begun. This stage is attained 1 year before or at END by about 80 percent of the girls and about 90 percent of the boys R-IJ - the fusion is almost completed but there is still a gap at one or both margins. R-J - is characterized by fusion of the epiphysis and metaphysis . These stages are not attained before END by any subject. www.indiandentalacademy.com 44
  • 45. Distal third phalanx DP3-I the fusion of the epiphysis and metaphyis is completed. This stage signifies the fusion of epiphysis and metaphysis and is attained during the deceleration period of the pubertal growth spurt (PHV-END) by all subjects.. www.indiandentalacademy.com 45
  • 46. Cervical vertebrae as the maturity indicators ……. www.indiandentalacademy.com 46
  • 47. 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. Maturational changes can be observed from birth to full maturity. Vertebral growth takes place from the cartilagenous layer on the superior and inferior surfaces of each vertebrae. www.indiandentalacademy.com 47
  • 48. 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 48
  • 49. Hassel and Farman carried out a study The sample of 11 groups of 10 males and 10 females (220 subjects) aged from 8 to 18 years was taken from the BoltonBrush Growth Center The radiographs used included the left hand-wrist and the lateral cephalogram. www.indiandentalacademy.com AJO-1995 49
  • 50. The system developed by Fishman was used to determine skeletal maturation by hand-wrist evaluation on each subject. Once skeletal maturation was assessed from the hand-wrist radiograph, the lateral cephalogram taken on the same date was taken from the record. www.indiandentalacademy.com 50
  • 51. Three parts of the cervical vertebrae were traced . These entities were the dens (odontoid process), the body of the third cervical vertebra (C3), and the body of the fourth cervical vertebra (C4). These areas were selected because C3 and C4 could be visualized even when a thyroid protective collar was worn during radiation exposure. www.indiandentalacademy.com 51
  • 52. The cervical vertebrae tracings were paired with their respective hand-wrist radiographs that had been grouped by SMI categories. These tracings were photocopied. The photocopies of the vertebral tracings were evaluated to see whether changes in shape and dimension of the vertebrae could be observed between SMI groupings. www.indiandentalacademy.com 52
  • 53. Specific entities looked at were the presence or absence of curvature in the inferior borders of the dens, C3, and C4. General shapes of the bodies of C3 and C4 were evaluated Intervertebral spacing was visualized. www.indiandentalacademy.com 53
  • 54. RESULTS Six categories of cervical vertebrae skeletal maturation could be defined…. Cervical vertebrae maturation indicators using C3 as guide. www.indiandentalacademy.com 54
  • 55. 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 55
  • 56. CVMI 1: A. Typical hand-wrist radiograph. B. Typical cervical www.indiandentalacademy.com 56 vertebrae appearance using lateral cephalograph.
  • 57. 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. www.indiandentalacademy.com 57
  • 58. CVMI 2: A. Typical hand-wrist radiograph. B. Typical cervical www.indiandentalacademy.com 58 vertebrae appearance using lateral cephalograph.
  • 59. 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 59
  • 60. CVMI 3: A. Typical hand-wrist radiograph. B. Typical cervical vertebrae appearance using lateral cephalograph. www.indiandentalacademy.com 60
  • 61. 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. 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 61
  • 62. CVMI 4: A. Typical hand-wrist radiograph. B. Typical cervical vertebrae appearance using Iateral cephalograph. www.indiandentalacademy.com 62
  • 63. 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. 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 shape . www.indiandentalacademy.com 63
  • 64. CVMI 5: A. Typical hand-wrist radiograph. B. Typical cervical www.indiandentalacademy.com 64 vertebrae appearance using lateral cephalograph.
  • 65. 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. 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 65
  • 66. CVMI 6: A. Typical hand-wrist radiograph. B. Typical cervical www.indiandentalacademy.com 66 vertebrae appearance using lateral cephalograph.
  • 67. The purpose of this investigation was to provide the orthodontist with an additional tool to help determine growth potential in the adolescent patient. This was to be accomplished by using anatomic changes of the cervical vertebrae observed on the lateral cephalometric radiograph to determine skeletal maturity. By using a routinely taken diagnostic radiograph, the orthodontist would have a reliable diagnostic tool to aid in formulating treatment options. www.indiandentalacademy.com 67
  • 68. This study combined the observations of the changes in the hand-wrist and the changes in the cervical vertebrae during skeletal maturation. The shapes of the cervical vertebrae were seen to differ at each level of skeletal development. This provided a means with which to determine the skeletal maturity of a person and thereby determine whether the possibility of potential growth existed. www.indiandentalacademy.com 68
  • 69. 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 69
  • 70. When two successive SMI-CVMI groups were combined, it was observed that distinct cervical vertebrae anatomic characteristics were unique to each of these groupings. Eleven SMI (skeletal maturation index) groupings were condensed into six CVMI (cervical vertebrae maturation index) categories. The SMI groupings 1 and 2, 3 and 4, 5 and 6, 7 and 8, 9 and 10, and SMI 11 were given CVMI categories 1 through 6, respectively www.indiandentalacademy.com 70
  • 71. A comparison of the modified MP3 stages and the cervical vertebrae was carried out by Rajagopal and Kansal (2002) in order to determine whether the six modified MP3 stages could be correlated with the six stages of cervical vertebrae maturation indices(CVMI) as described by Hassel and Farman www.indiandentalacademy.com 71
  • 72. www.indiandentalacademy.com 72
  • 73. MP3-F stage: Start of the curve of pubertal growth spurt Features observed by Hagg and Taranger: 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. www.indiandentalacademy.com 73
  • 74. CVMI-1: Initiation stage of cervical vertebrae 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 74
  • 75. www.indiandentalacademy.com 75
  • 76. MP3-FG stage: Acceleration of the curve of 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 to distal border. Additional features observed in this study: 3. Metaphysis begins to show slight undulation. 4. Radiolucent gap between metaphysis and epiphysis is wide. www.indiandentalacademy.com 76
  • 77. 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 77
  • 78. www.indiandentalacademy.com 78
  • 79. MP3-G stage: Maximum point of pubertal growth spurt Features observed by Hagg and Taranger: 1. Sides of epiphysis have thickened and cap its metaphysis, forming sharp distal edge on one or both sides. Additional features observed in this study: 2. Marked undulations in metaphysis give it “Cupid’s bow” appearance. 3. Radiolucent gap between epiphysis and metaphysis is moderate. www.indiandentalacademy.com 79
  • 80. 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 of C4. 3. C3 and C4 are rectangular in shape. 4. 25-65% of pubertal growth remains. www.indiandentalacademy.com 80
  • 81. www.indiandentalacademy.com 81
  • 82. 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. www.indiandentalacademy.com 82
  • 83. 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. 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 83
  • 84. www.indiandentalacademy.com 84
  • 85. 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 www.indiandentalacademy.com 85
  • 86. 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 86
  • 87. www.indiandentalacademy.com 87
  • 88. MP3-I stage: End of pubertal growth spurt Features observed by Hagg and Taranger: 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. www.indiandentalacademy.com 88
  • 89. 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 89
  • 90. www.indiandentalacademy.com 90
  • 91. Advantages of the modified MP3 stages include: 1. Significantly lower radiation exposure compared to lateral cephalograms or handwrist xrays. 2. High degree of clarity on the radiographs, with no superimposition of bones or variations in posture as in evaluation of the cervical vertebrae. www.indiandentalacademy.com 91
  • 92. 3. Discrete, easily identifiable stages of development, unlike the more subtle changes in CVMI stages. 4. Close correlation to the six stages of CVMI. 5. No need to obtain equipment beyond the standard periapical x-ray film and dental xray machine. www.indiandentalacademy.com 92
  • 93. CONCLUSION….. www.indiandentalacademy.com 93
  • 94. Dental, maturational and chronological ages are not nessesarily interrelated on a simple one to one basis. All these variations make maturational age a more valid means of judging physiological development than chronological age, which can be a most misleading piece of information. www.indiandentalacademy.com 94
  • 95. Growth magnitude, direction and timing are intimately dependent on each other. A vertically growing mandible will display a greater magnitude of vertical growth during a time of accelerated growth velocity Every person matures on a very individual schedule, and it is here that the value of hand wrist films becomes apparent www.indiandentalacademy.com 95
  • 96. The skeletal maturity of the bones of the hand and wrist and the cervical vertebrae, on the other hand, is closely related to that of the craniofacial region, and skeletal maturity indices are reliable predictors of sexual and somatic maturity as well. Radiologic skeletal maturation indicators should be used to augment other observations by the orthodontist. One diagnostic test should not be relied on too heavily. www.indiandentalacademy.com 96
  • 97. www.indiandentalacademy.com 97