skeletal maturity indicators in orthodontics /certified fixed orthodontic courses by Indian dental academy


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skeletal maturity indicators in orthodontics /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in Continuing Dental
  2. 2. Introduction: One of the objective for treating skeletal discrepancies, is to take advantage of the patients growth spurt, which help to achieve optimal results,within the short period of time. Evaluation of individual biologic time table and identification of period of accelerated growth is essential for clinical decisions, regarding growth modulation procedures for skeletal discrepancies, extraction versus non extraction options,use of extra oral orthopaedic forces and planning for orthognathic surgery for skeletal malocclusions.
  3. 3. Introduction: As a results many investigators have attempted , to predict the duration ,magnitude, direction and timing of the adolescent growth changes. The developmental status of a child is usually assessed in relation to events that take place during progress of growth. Thus chronological age, sexual maturational characteristics , dental development (dental age), height and weight measurements and skeletal age are some of the biological indicators that have been used to identify stages of growth.
  4. 4. Introduction: Chronological age is often not sufficient for assessing the developmental stage and somatic maturity of the patient,so that the biological age has to be determined. The biological age is determined from the skeletal, dental and morphologic age and onset of puberty. Patient chronological age is defined as the time period from the birth to till date. Morphologic age is based on the height . A child’s height can be compared with those of his same age group and other age groups to determine where he stands in relation to others. Height is useful as a maturity indicator from late infancy to early adulthood.
  5. 5. Introduction: Dental age has been based on two different methods of assessment. 1. Tooth eruption age. 2. Tooth mineralization stage. Sexual age refers to development of secondary sexual characteristics. This type of indicator is useful only for adolescent growth. Skeletal age Assessment is often made with the help of hand - wrist radiograph which can be considered the ‘Biological clock ’. Nine developmental stages are there according BJork(1972), Grave and Brown (1976).The ossification events are localized in the area of the phalanges, carpal bones and radius.
  6. 6. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH Orthodontic treatment progresses more quickly during growth spurts. Generally children experience a pattern of fast growth, followed by a slow growth in late childhood and then accelerated and peak growth in adolescence. Because children begin this sequence of growth at different ages, chronological age is a poor indicator of a child’s development. Hand-wrist radiograph is a useful tool for identifying a child’s skeletal development.
  7. 7. HAND-WRIST RADIO GRAPHIC EVALUATIONAfter Roentgen demonstrate his new radiographic discovery in 1895 Ronaldo, in 1896,introduced the idea of using the comparative size and shape of the radiographicshadows of growing bones as indicators of rate of growth and maturity.In early 1900s, Pryor, Rotch and Crampton began tabulating indicators of maturityon sequential radiographs of the growing hand and wrist.Hellman published his observations on the ossification of epiphysial cartilage of thehand in 1928.Todd compiled hand –wrist data that was further elaborated on by Greulich and Pylein atlas form. In 1936 Flory indicated that beginning of calcification of the carpalsesamoid was a good guide to determine the period immediately before puberty.The appearance of the adductor sesamoid has been highly correlated to peak heightvelocity and start of adolescent growth spurt.Fishman developed a system of hand wrist skeletal maturation indicators using fourstages 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 correlatecertain maturity indicators to the pubertal growth spurt.
  10. 10. TOPOGRAPHIC ANATOMY OF THE SKELETON OF THE HAND 1. Epiphysis of the thumb. 2. Epiphysis of the proximal phalanx of the thumb. 3. Sesamoid of the adductor brevis muscle at the metacarpophalangeal joint of the thumb. 4. Epiphysis of the distal phalanx of the index finger. 5. Epiphysis of the middle phalanx of the index finger. 6. Epiphysis of the proximal phalanx of the index finger. 7. Epiphysis of the distal phalanx of the middle finger. 8. Epiphysis of the middle phalanx of the middle finger. 9. Epiphysis of the proximal phalanx of the middle finger. 10. Epiphysis of the distal phalanx of the ring finger. 11. Epiphysis of the middle phalanx of the ring finger. 12. Epiphysis of the proximal phalanx of the ring finger. 13. Epiphysis of the distal phalanx of the little finger. 14. Epiphysis of the middle phalanx of the little finger. 15. Epiphysis of the proximal phalanx of the little finger. 16. Epiphysis of the metacarpal bone. 17. Epiphysis of the second metacarpal bone.
  11. 11. TOPOGRAPHIC ANATOMY OF THE SKELETON OF THE HAND 18. Epiphysis of the third metacarpal bone. 19. Epiphysis of the fourth metacarpal bone. 20. Epiphysis of the fifth metacarpal bone. 21. Trapezium. 22. Trapezoid bone. 23. Capitate bone. 24. Hamate bone. 25. Hamular process of the hamate bone. 26. Triquetral bone. 27. Pisiform bone. 28. Lunate bone. 29. Scaphoid bone. 30. Distal epiphysis of the radius. 31. Distal epiphysis of the ulna.
  12. 12. Hand-wrist radiographs Atlas Sesamoid bone(Flory,Bjork,Chapman) Julian Singer (1980) Fishman(1982) Hagg & Taranger(1982) Leite &O’Reilly(1985) Abdel Kader(1998)
  13. 13. Hand-wrist radiograph:
  14. 14. Hand-wrist radiograph:
  15. 15. Hand-wrist radiograph:
  16. 16. SKELETAL MATURATIONASSESSMENT. LEONARD S.FISHMAN 1982 outlined four stages of bone maturation foundat six anatomical sites located on the thumb, third finger, fifth finger andradius. Eleven skeletal maturity indicators are found in these six anatomic sites. Epiphysis as wide as diaphysis Fusion of epiphysis and 1.Third finger-proximal phalanx diaphysis 2.Third finger-middle phalanx 8.Third finger distal -phalanx 3.Fifth finger-middle phalanx 9.Third finger proximal- phalanx Ossification 10.Third finger middle- phalanx 4.Adductor sesamoid of thumb 11.Radius Capping of epiphysis 5.Third finger distal- phalanx 6.Third finger middle -phalanx 7.Fifth finger middle-phalanx
  17. 17. Fishman’s skeletal maturity indicators
  18. 18. Hagg and Taranger skeletal maturity indicators They described a method in which skeletal development is assessed by ossification of the ulnar sesamoid of the metacarpophalangeal joint of the first finger (S) and certain specified stages of three epiphyseal bones; the middle and distal phalanges of the third finger (MP3 and DP3) and the distal epiphysis of the radius (R ). All the four bones to be used as indicators of the skeletal development were choosen according to Bjork. Eight of the ten indicators were already defined by others. In order to obtain maturation indicators of shorter duration, two new epiphyseal stages were defined. One stage in the middle phalanx of the third finger,denoted MP3-FG,and one stage in the distal end of the radius,denoted R-IJ. Sesamoid: sesamoid is usually attained during the acceleration period of the pubertal growth spurt(onset of
  19. 19. Hagg and
  20. 20. BIOLOGICAL AGE HAND WRIST RADIO AND GRAPH Growth stages of the fingers are assessed according to the relationship between the epiphysis and diaphysis. There are three stages of ossification of the phalanges. FIRST STAGE: Epiphysis shows the same width as the diaphysis. SECOND STAGE :(CAPPING STAGE) The epiphysis surrounds the diaphysis like a cap. THIRD STAGE:(U-STAGE)
  21. 21. MP3 STAGES
  22. 22. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH There are nine developmental stages.1.First stage of maturation :(PP2= stage) The epiphysis of the proximal phalanx of the index finger has the same width as the diaphysis. This stage occurs approximately 3 years before the peak of the pubertal growth spurt.2.second stage :(MP3=stage) Epiphysis of the middle phalanx of the middle finger is of the same width as the diaphysis.
  23. 23. BIOLOGICAL AGE AND HAND WRIST RADIOGRAPH 4. Fourth stage :(S-and H2-stage) S-stage: First mineralization of the ulnar sesamoid bone of the metacarpophalangeal joint of the thumb. H2-stage: Progressive ossification of the hamular process of the hamatum. The fourth stage is reached shortly before or at the beginning of the pubertal growth spurt.
  24. 24. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH3. Third stage:(Pisi-,H1-,and R= stage) This stage of development can be identified by three distinct ossification areas. These show individual variations but appear at the same time during the process of the maturation. Pisi-stage: Visible ossification of the pisiforme. H1-stage : Ossification of the hamular process of the hamatum. R-stage : Same width of epiphysis and diaphysis of the radius.
  25. 25. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH5. Fifth stage:( MP3cap–,PP1cap-,and Rcap-stage) During this stage ,the diaphysis covered by the cap shaped epiphysis. MP3cap–stage: The process begins at the middle phalanx of the third finger. PP1cap-stage : At the proximal phalanx of the thumb. Rcap-stage : At the radius. This stage of ossification marks the peak of the pubertal growth spurt.
  26. 26. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH6. Sixth stage :(DP3u-stage) Visible union of the epiphysis and diaphysis at the distal phalanx of the middle finger. This stage of development constitutes the end of the puberal growth.
  27. 27. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH7. Seventh stage:(PP3u-stage) Visible union of the epiphysis and diaphysis at the proximal phalanx of the little finger.
  28. 28. BIOLOGICAL AGE AND HAND WRIST RADIOGRAPH8. Eighth stage :(MP3u-stage)Visible union of the epiphysis and diaphysis at the middlephalanx of the middle finger is clearly seen.
  29. 29. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH9. Ninth stage:(Ru-stage) Complete union of the epiphysis and diaphysis of the radius. The ossification of all the hand bones is completed and skeletal growth is completed.
  30. 30. Growth period 1. 2. 3. 4. 5. 6. 7. 8. 9. PP2 MP3 Pisi S MP3 DP3 PP3 MP3 Ru u H1 H2 u u cap R= R cap PP1 capmales 10. 12. 12. 13. 14. 15. 15. 15. 18. 6 2 6 0 0 0 9 9 5females 8.1 8.1 9.6 10. 11. 13. 13. 13. 16. 6 0 0 3 9 0
  31. 31.
  32. 32. Cervical vertebrae maturation indicators The first seven vertebrae in the spinal column constitutethe cervical spine. The first two, the atlas and the axisare quite unique, the third through the seventh have great similarity. Maturational changes can be observed from birthto full maturity.Vertebral growth takes place from the cartilagenous layer onthe superior and inferior surface of each vertebrae.Secondary ossification nuclei on the tips of the bifid spinousprocesses and transverses appear during puberty. Secondaryossification nuclei unite with the spinous processes when vertebral growth is complete. After completion of endochondral ossification, growth ofthe vertebral body takes place by periosteal apposition. Itappears to take place only at the front and sides. Todd andPyle , Lanier and Taylor made measurements from lateralradiographs of the lower cervical vertebrae. Lamparski
  33. 33. Cervical vertebrae maturation indicators The standard method of evaluating skeletal maturity has been to use a hand- wrist x-ray to compare the bones of an individual’s hand with those in published atlases. To avoid taking an additional x-ray,some researchers sought to relate maturation with dental and skeletal features other than the bones in the hand and wrist. The use of cervical vertebrae to determine skeletal maturity is not new. In 1972, Lamparski concluded that the cervical vertebrae ,as seen on the routine lateral cephalograms , were as statistically and clinically reliable in assessing skeletal age as the hand-wrist technique. He found that the cervical vertebral indicators were the same for females and males, but that females developed the changes earlier.
  34. 34. Cervical vertebrae maturation indicatorsThe use of cervical vertebrae to determine skeletalmaturity was suggested by Lamparski in 1972.He concluded that the cervical vertebrae, as seenon routine lateral cephalograms,were as statisticallyand clinically reliable in assessing skeletal age asthe hand-wrist technique. He found that the cervicalvertebral indicators were the same for the femalesand males, but that females developed the changesearlier.
  35. 35. Cervical vertebrae maturation indicators -Lamparski Six stages of cervical vertebral maturation were described. 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 second vertebrae.the anterior vertical heights of the bodies have increased. Stage 3:A concavity has developed in the inferior border of the third vertebra. The other inferior borders are still flat. Stage 4: All bodies are now rectangular in shape. The concavity of the third vertebra has increased, and a distinct concavity has developed on the fourth vertebra. Concavities on 5 and 6 are just beginning to form . Stage 5: The bodies have become nearly square in shape and the space between the bodies are visibly smaller.concavities are well defined on all six bodies. Stage 6: All bodies have increased in vertical height and are
  36. 36. Cervical vertebrae maturation indicators Cvs1 cvs2 cvs3 cvs4 cvs6
  37. 37. Cervical vertebrae maturation indicators STAGES
  38. 38. Cervical vertebrae maturation indicators
  39. 39. Cervical vertebrae maturation indicators STAGES
  40. 40. Cervical vertebrae maturation indicators 1. Initiaton:• Inferior borders of 2nd 3rd and 4th cervical vertebrae are flat at this stage.• The third and fourth vertebrae are wedge shaped and the superior vertebral borders are tapered from posterior to anterior.• 100% of pubertal growth remains.• Very significant amount of adolescent growth expected.
  41. 41. Cervical vertebrae maturation indicators 2. Acceleration:• Concavities on the inferior borders of second and third vertebrae begin to develop.• Inferior border of fourth vertebrae remains flat.• Vertebral bodies of third and fourth are nearly rectangular in shape.• 65-85% of pubertal growth remains.
  42. 42. Cervical vertebrae maturation indicators 3. Transition :• Distinct concavities are shown on the inferior borders of second and third vertebrae.• A concavity begins to develop on the inferior border of fourth vertebrae.• Vertebral bodies of third and fourth are rectangular in shape.• 25-65% of pubertal growth remains.
  43. 43. Cervical vertebrae maturation indicators 4. Deceleration stage:• Distinct concavities can observed on the inferior borders of second third and fourth cervical vertebrae.• Vertebral bodies of third and fourth begin to be more square in shape.• 10-25% of pubertal growth remains.
  44. 44. Cervical vertebrae maturation indicators 5. Maturation stage:• Marked concavities are observed on the inferior borders of second, third and fourth cervical vertebrae.• Vertebral bodies of third and fourth are almost square in shape.• 5-10% of pubertal growth remains.
  45. 45. Cervical vertebrae maturation indicators 6. Completion:• Deep concavities are observed on the second, third and fourth cervical vertebrae.• Vertebral bodies are greater vertically than horizontally.• Pubertal growth has been completed.
  46. 46. Assessment of skeletal maturationThe 5 distinct stages of MP3 asdescribed by HAGG & TARANGER (1980),and 6 th stage (between MP3-H and MP3-Iwhich is called as MP3-HI stage) which wasintroduced by ourprof. Dr.Raja gopal and Dr. Kansal were tobe evaluated and compared with sixstages of cervical vertebrae which weredescribed by HASSEL & FARMAN(1995).
  47. 47. COMPARISON BETWEEN MP3-F & INITIATION STAGE MP3-F STAGE INITIATION STAGEIt represents the onset or the start 1.C2, C3 and C4 inferior vertebralof the curve of pubertal growth body borders are flat.spurt. 2.Superior vertebral borders areFEATURES: tapered from posterior toEpiphysis is as wide as anterior. (Wedge shape).metaphysis. 3.100% of pubertal growth remains.
  48. 48. COMPARISON BETWEEN MP3-FG & ACCELERATION STAGE MP3-FG STAGE ACCELERATION STAGEIt represents the acceleration part of 1.Concavities developing in lower the curve of pubertal growth bordres of C 2 & C 3 .spurt. 2.Lower border of c4 vertebral bodyFEATURES: is flat.1.Epiphysis is as wide asmetaphysis 3.c3 & c4 are more rectangular in2.There is a distinct medial and or shape. lateral border of the epiphysis 4.65-85 % of pubertal growth forming a line of demarcation at remains. right angle to the distal border.
  49. 49. COMPARISON BETWEEN MP3-G & TRANSITION STAGE MP3-G STAGE TRANSITION STAGEIt represents the point of maximum 1.Distinct concavities in lower borderspubertal growth spurt. of c2 and c3 are seen.FEATURES: 2.Developing concavity in lower borderSides of epiphysis have thickened of body of c4 is seen.and cap its metaphysis forming asharp edge distally at one or both 3.c3 and c4 are rectangular in shape.sides. 4.25-65% of pubertal growth remains.
  50. 50. COMPARISON BETWEEN MP3-H & DECELERATION STAGE MP3-H STAGE DECELERATION STAGEIt represents the deceleration part of 1.Distinct concavities in the lower the Curve of pubertal growth bordrs of c2,c3 and c4 are seen.spurt.FEATURES: 2.c3 and c4 are nearly square inFusion of epiphysis and metaphysis shape.has begun. 3.10-25% of pubertal growth remains.
  51. 51. COMPARISON BETWEEN MP3-HI & MATURATION STAGE MP3-HI STAGE MATURATION STAGEIt represents the maturation part of 1. Accentuated concavities ofthe curve of pubertal growth spurt. inferior vertebral body bordersFEATURES: of c2,c3,and c4 are seen.1.Superior surface of the epiphysis shows a smooth concavity. 2. c3 and c4 are square in shape.2.Metaphysis shows a smooth convex 3. 5-10% of pubertal growth surface almost fitting into the remains. reciprocal concavity of epiphysis.3.Radiolucent gap between epiphysis and metaphysis is insignificant.
  52. 52. COMPARISON BETWEEN MP3-I & COMPLETION STAGE MP3-I STAGE COMPLETION STAGEIt represents the end of pubertal 1. Deep concavities present ongrowth Spurt.FEATURES: inferior vertebral body borders of1.Fusion of epiphysis and c2,c3 and c4. metaphysis is completed. 2. c3 and c4 heights are greater than widths. 3. Pubertal growth has been completed.
  53. 53. Comparison ofMP3 and
  54. 54. Correlation of hand-wrist and cervical vertebral maturation stagesA comparative evaluation of hand-wrist and cervical vertebrae wasdone in our department by Prof.Dr.shyamala and Dr.Akshay guptato find out the validity of the cervical vertebrae as maturation marker.The following conclusions were drawn:1. Wide variation in chronological age for different maturity levels suggests that chronological age is a poor indicator of maturity. Skeletal maturity indicators provide a more valid basis than chronological age for grouping of individuals.2. Females are ahead of males at all levels of skeletal maturity., indicating early age of maturation for female group.3. Females tend to achieve a higher percentage of their total growth than male especially during mid-adolescence. Early and late adolescence show less variation in percentage of growth completed .4. cervical vertebrae can be used as an alternative method for evaluation of skeletal maturity, with the same confidence as hand wrist radiographs.
  55. 55. Correlation of hand-wrist andcervical vertebral maturation stages Hand –wrist Cervical Pubertal growth vertebral stages remaining SMI 1-2 Initiation 85-100% 3-4 Acceleration 65-85% 5-6 Transition 25-65% 7-8 Deceleration 10-25% 9-10 Maturation 5-10% 11 completion 0%
  56. 56. STAGES OF TOOTH CALCIFICATION-NOLLA(1960) 10.Root apex completed. 9.Root almost completed,open apex. 8.Two thirds of root completed. 7.One third of root completed. 6.Crown completed. 5.Crown almost completed. 4.Two thirds of crown completed. 3.One third of root completed. 2.Initial calcification. 1.Crypt present. 0.Crypt absent.
  57. 57. Dental age determination according to the stage of mineralization Demirjian et al., in 1973 divided tooth mineralization into nine stages. o. Tooth germ without signs of calcification. A. Calcificaion of single occlusal points without fusion of different calcification. B. Fusion of mineralization points. The contour of the occlusal surface is recognizable. C. Calcification of the crown is complete; Single rooted tooth beginning of dentin deposits. D. Crown formation is complete up to the cemento enamel junction. E. Root length shorter than crown height. F. Root length larger than crown height. Multi rooted tooth G. Root formation finished. Apical foramen still open. H. Apical foramen is closed.
  58. 58. Scores of different dental formation stagesThe table was made for the left mandibular quadrant.
  59. 59. Conversion chart for dental age determination,calculated according to the score-system of dental formation The overall figure for assessment of dental age is obtained by adding together the separate values for 7 teeth in the lower left quadrant.
  61. 61. Tooth mineralization as an indicator of the pubertal growth spurt Diagrammatic appearance of stages C to H of tooth development for uni and multi radicular teeth.
  62. 62. Mandibular growth changes & Maturation of cervical vertebraeMaria T o’Reilly & Gary J Yanniello conducted a study onrelationship of cervical vertebral maturation and mandibulargrowth changes using lateral cephalometric radiographs infemales age group of 9-15 years.They found that cervical vertebral stages of maturation arerelated to mandibular growth changes during puberty. Ananalysis of variance for repeated measurements andScheffee’s tests reveal significant increase between stages1 and 2, 2 and 3 and 3 and 4 for mandibular length; between1 and 2 and 2 and 3 for corpus length; and between 1 and 2for ramus height.On the average, stages1 through 3 occurredprior to peak velocity, with 2 and 3 in the year preceedingpeak growth velocity.
  63. 63. Clinical significance: 1. Treatment involving modification of skeletal growth seems to demand as much as information as possible about patient’s growth potential. 2. Orthodontic appliances such as the mandibular protraction appliance, Herbst appliance, Frankel, Bionator, Twin block and activator. 3. In cases where patient require orthopedic changes using head gears and protraction masks. 4. Prior to rapid maxillary expansion. 5. In patients with marked discrepancy between dental and chronological age. 6. Orthodontic patients requiring orthognathic surgery if under taken during growth period. 7. When maxillo mandibular changes are indicated in the treatment of class III cases, skeletal class II cases or skeletal open bites.