Growth Prediction and age estimation

Growth Prediction andGrowth Prediction and
Age EstimationAge Estimation

ContentsContents
 IntroductionIntroduction
 Growth spurtsGrowth spurts
 Skeletal Maturity IndicatorsSkeletal Maturity Indicators
1. Hand wrist Radiographs1. Hand wrist Radiographs
2. Cervical Vertebrae2. Cervical Vertebrae
3. Mid-palatal suture3. Mid-palatal suture
4. Densitometry Method4. Densitometry Method
5. Ante-gonial Notch5. Ante-gonial Notch
6. Symphysis Morphology6. Symphysis Morphology
 Dental IndicatorsDental Indicators
1. Tooth mineralization1. Tooth mineralization
2. 3rd molar development2. 3rd molar development
 Frontal sinus developmentFrontal sinus development
 Somatomedin levelsSomatomedin levels
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IntroductionIntroduction
 As stated byAs stated by Ricketts, to take the advantage of growth weRicketts, to take the advantage of growth we
must have an idea of –must have an idea of –
- its magnitude,- its magnitude,
- its direction, and- its direction, and
- its timing .- its timing .
 By using the element ofBy using the element of timing of maximum growthtiming of maximum growth inin
conjunction with ones knowledge of magnitude andconjunction with ones knowledge of magnitude and
direction, readily transforms orthodontics to a professiondirection, readily transforms orthodontics to a profession
of “face forming , as well as tooth positioning”.of “face forming , as well as tooth positioning”.
 A number of growth assessment methods likeA number of growth assessment methods like
chronological age, dental age, morphological age, skeletalchronological age, dental age, morphological age, skeletal
age & circumpubertal age are available.age & circumpubertal age are available.

 Chronological ageChronological age is often not sufficient for assessingis often not sufficient for assessing
the developmental stage and somatic maturity of thethe developmental stage and somatic maturity of the
patient.patient.
 TheThe biological agebiological age is determined from the skeletal, dentalis determined from the skeletal, dental
and morphologic age and the onset of puberty.and morphologic age and the onset of puberty.
 Due to individual variations in timing, duration andDue to individual variations in timing, duration and
velocity of growth,velocity of growth, skeletal ageskeletal age assessment is essentialassessment is essential
in formulating viable orthodontic treatment plans.in formulating viable orthodontic treatment plans.

Clinical Importance of MaturityClinical Importance of Maturity
IndicatorsIndicators
 To determine the potential vector of facialTo determine the potential vector of facial
development.development.
 To determine the amount of significant facial cranialTo determine the amount of significant facial cranial
growth potential left.growth potential left.
 To decide the onset of treatment timing and type ofTo decide the onset of treatment timing and type of
effective treatment.effective treatment.
 To evaluate the treatment prognosis.To evaluate the treatment prognosis.
 To understand the role of genetics and environment onTo understand the role of genetics and environment on
the skeletal maturation pattern.the skeletal maturation pattern.

Anatomical Region Suitable For SkeletalAnatomical Region Suitable For Skeletal
Maturational AssessmentMaturational Assessment
 Head and Neck : SkullHead and Neck : Skull
Cervical VertebraeCervical Vertebrae
 Upper Limb :Shoulder Joint-ScapulaUpper Limb :Shoulder Joint-Scapula
ElbowElbow
Hand Wrist and FingersHand Wrist and Fingers
 Lower Limb : Femur and HumerusLower Limb : Femur and Humerus
Hip jointHip joint
KneeKnee
AnkleAnkle
Foot tarsals and Meta tarsalsFoot tarsals and Meta tarsals
 Tooth mineralization as an indicator.Tooth mineralization as an indicator.
 Frontal sinusFrontal sinus

Growth spurtsGrowth spurts
 Periods of sudden acceleration of growth.Periods of sudden acceleration of growth.
 Due to physiological alteration in hormonal secretion.Due to physiological alteration in hormonal secretion.
 Timing-sex linked.Timing-sex linked.
Normal spurts areNormal spurts are
Infantile spurt :Infantile spurt : at 3 years ageat 3 years age
Juvenile spurt :Juvenile spurt : 7-8 years (females); 8-10 years (males)7-8 years (females); 8-10 years (males)
Pubertal spurt :Pubertal spurt : 10-14 years (females); 12-17years (males)10-14 years (females); 12-17years (males)

Periodic Variations in Growth RatePeriodic Variations in Growth Rate
 The typical growth patternThe typical growth pattern
of a child is characterizedof a child is characterized
by a growth rate thatby a growth rate that
decreases from birth with adecreases from birth with a
minor midgrowth spurt atminor midgrowth spurt at
approx. 6-8 years of age, aapprox. 6-8 years of age, a
prepubertal minimum and aprepubertal minimum and a
pubertal or adolescentpubertal or adolescent
growth spurt.growth spurt.

Pubertal growth spurt:Pubertal growth spurt:
 Important period for orthodontic treatment.Important period for orthodontic treatment.
 Initiated in the brain-secretion of releasing factors,Initiated in the brain-secretion of releasing factors,
pituitary gonadotropins.pituitary gonadotropins.
 Sex hormones released-physiological changes occur-Sex hormones released-physiological changes occur-
classic growth cure pattern.classic growth cure pattern.
 Affected by genetic and environmental factors.Affected by genetic and environmental factors.

AdolescenceAdolescence
 It can be defined as the period of life when sexualIt can be defined as the period of life when sexual
maturity is attained.maturity is attained.
 It is a transitional period between the juvenile stage andIt is a transitional period between the juvenile stage and
adulthood during which adolescent growth spurt takesadulthood during which adolescent growth spurt takes
place.place.
 This period is particularly important in orthodonticThis period is particularly important in orthodontic
treatment, because the physical changes at adolescencetreatment, because the physical changes at adolescence
significantly affect the face and dentition.significantly affect the face and dentition.
 Major events that occur during adolescence include-Major events that occur during adolescence include-
- Exchange from mixed to permanent dentition- Exchange from mixed to permanent dentition
- Acceleration in overall rate of facial growth &- Acceleration in overall rate of facial growth &
- Differential growth of jaws.- Differential growth of jaws.

GIRLSGIRLS
Total development of adolescent growth- 3½yrsTotal development of adolescent growth- 3½yrs
Stage 1Stage 1
Beginning of adolescent growthBeginning of adolescent growth Appearance of breast buds,Appearance of breast buds,
initial pubic hairinitial pubic hair
Stage 2Stage 2
(12 months later)(12 months later)
Peak velocity in height.Peak velocity in height.
Noticeable breast development,Noticeable breast development,
axillary hair, dark/moreaxillary hair, dark/more
abundant pubic hair.abundant pubic hair.
Stage 3Stage 3
(12-18 months later)(12-18 months later)
Growth spurt ending.Growth spurt ending.
Menses, broadening of hips withMenses, broadening of hips with
adult fat distribution, breastsadult fat distribution, breasts
completedcompleted
Contemporary Orthodontics – W.R.Proffit, 3Contemporary Orthodontics – W.R.Proffit, 3rdrd
eded

BOYSBOYS
Total development of adolescent growth- 5 yrsTotal development of adolescent growth- 5 yrs
Stage 1Stage 1
Beginning of adolescent growthBeginning of adolescent growth
Fat spurt, weight gain, feminine fatFat spurt, weight gain, feminine fat
distribution (“fat spurt”)distribution (“fat spurt”)
Stage 2Stage 2
(12 months later)(12 months later)
Height spurt beginningHeight spurt beginning
Redistribution or reduction in fat,Redistribution or reduction in fat,
pubic hair, growth of penispubic hair, growth of penis
Stage 3Stage 3
Peak velocity of height.Peak velocity of height.
Facial hair appears on upper lip only,Facial hair appears on upper lip only,
axillary hair, muscular growth with,axillary hair, muscular growth with,
harder/more angular body formharder/more angular body form
Stage 4Stage 4
Growth spurt endingGrowth spurt ending
Facial hair on chin and lip, adultFacial hair on chin and lip, adult
distribution/colour of pubic anddistribution/colour of pubic and
axillary hair, adult body form.axillary hair, adult body form.
eded

Timing of PubertyTiming of Puberty
 Velocity curves for growth atVelocity curves for growth at
adolescence shows difference inadolescence shows difference in
timing between boys and girls.timing between boys and girls.
 Pubertal growth spurt occurs onPubertal growth spurt occurs on
an average nearly 2 years earlieran average nearly 2 years earlier
in girls than boys.in girls than boys.
 Sex hormones are produced inSex hormones are produced in
adrenals by 6 years-‘adrenarche’.adrenals by 6 years-‘adrenarche’.
 More prominent in girls due toMore prominent in girls due to
greater adrenal component.greater adrenal component.
eded

 Growth of the jaws correlates with physiologic eventsGrowth of the jaws correlates with physiologic events
of puberty in about the same way as growth in height.of puberty in about the same way as growth in height.
 Important clinically - careful assessment of physiologicImportant clinically - careful assessment of physiologic
age - plan orthodontic treatment.age - plan orthodontic treatment.
ededwww.indiandentalacademy.com

Treatment must begin duringTreatment must begin during
 mixed dentition-formixed dentition-for girls.girls.
 Near completion of permanent dentition-forNear completion of permanent dentition-for boys-boys-
ProffitProffit..

Hand Wrist RadiographsHand Wrist Radiographs
 Assessment of the skeletal age is often made with the helpAssessment of the skeletal age is often made with the help
of a hand wrist radiograph which can be considered theof a hand wrist radiograph which can be considered the
“Biological clock.”“Biological clock.”
 Hand wrist region is made up of numerous small bones.Hand wrist region is made up of numerous small bones.
These bone show a predictable and scheduled pattern ofThese bone show a predictable and scheduled pattern of
appearance, ossification and union from birth to maturity.appearance, ossification and union from birth to maturity.
Hence, this region is one of the most suited to studyHence, this region is one of the most suited to study
growth.growth.
 For the analysis of skeletal maturityFor the analysis of skeletal maturity up to the age of 9up to the age of 9
years, the stage of mineralization of the carpel bonesyears, the stage of mineralization of the carpel bones mustmust
be determined;be determined; thereafter the development of metacarpalthereafter the development of metacarpal
bones & phalanxbones & phalanx should be evaluated.should be evaluated.

Indication Of Hand Wrist RadiographsIndication Of Hand Wrist Radiographs
 In patients who exhibit major discrepancy between dentalIn patients who exhibit major discrepancy between dental
and chronologic age.and chronologic age.
 Determination of skeletal maturity status prior toDetermination of skeletal maturity status prior to
treatment of skeletal malocclusion (class II & III).treatment of skeletal malocclusion (class II & III).
 To assess the skeletal age in a patient whose growth isTo assess the skeletal age in a patient whose growth is
affected by infections, neoplastic or traumatic conditions.affected by infections, neoplastic or traumatic conditions.
 Help to predict future skeletal maturation rate and status.Help to predict future skeletal maturation rate and status.
 To predict the pubertal growth spurt.To predict the pubertal growth spurt.
 It is a valuable aid in research aimed at studying the roleIt is a valuable aid in research aimed at studying the role
of heredity, environment, nutrition etc., on the skeletalof heredity, environment, nutrition etc., on the skeletal
maturation pattern.maturation pattern.

Anatomy of Hand-WristAnatomy of Hand-Wrist
The hand wrist region is
made of four groups of
bones
1) Distal ends of long
bones of forearm.
2) Carpals (8)
3) Metacarpals (5)
4) Phalanges (14)

Anatomy of skeleton of Hand

Methods Of Assessing Skeletal AgeMethods Of Assessing Skeletal Age
 Atlas method by Greulich and PyleAtlas method by Greulich and Pyle
 Bjork ,Grave and Brown methodBjork ,Grave and Brown method
 Julian singer’s methodJulian singer’s method
 Fishman’s skeletal maturity indicatorsFishman’s skeletal maturity indicators
 Hagg and Taranger methodHagg and Taranger method

Greulich and Pyle MethodGreulich and Pyle Method
 Greulich and Pyle (1959) published an atlas containingGreulich and Pyle (1959) published an atlas containing
ideal skeletal age pictures of the hand-wrist for differentideal skeletal age pictures of the hand-wrist for different
chronological ages and for each sex.chronological ages and for each sex.
 Each photograph in the atlas is representative of aEach photograph in the atlas is representative of a
particular skeletal age.particular skeletal age.
 The patient’s radiograph is matched on an overall basisThe patient’s radiograph is matched on an overall basis
with one of the photographs in the atlas.with one of the photographs in the atlas.

Bjork , Grave And Brown MethodBjork , Grave And Brown Method
 They have divided skeletal development into 9 stages.They have divided skeletal development into 9 stages.
 Each of these stages represents a level of skeletalEach of these stages represents a level of skeletal
maturity.maturity.
 Appropriate chronological age for each of the stagesAppropriate chronological age for each of the stages
was given bywas given by SchopfSchopf in 1978in 1978
 This method can differentiate maturation process ofThis method can differentiate maturation process of
hand bones between 9 to 17 years of age.hand bones between 9 to 17 years of age.
 The ossification events are localized in the area of theThe ossification events are localized in the area of the
phalanges, carpal bones, and radius (R)phalanges, carpal bones, and radius (R)
Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. GraberOrthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. Graber

There are 3 stages of ossificationThere are 3 stages of ossification
of the phalanges:of the phalanges:
 First stage: Epiphysis shows theFirst stage: Epiphysis shows the
same width as the diaphysissame width as the diaphysis (=)(=)
 Second stage:Second stage: CappingCapping stagestage
(=cap);(=cap); the epiphysis surroundsthe epiphysis surrounds
the diaphysis like a capthe diaphysis like a cap
 Third stage: U-stageThird stage: U-stage (=U);(=U); bonybony
fusionfusion of epiphysis andof epiphysis and
diaphysisdiaphysis

First stage: PP2= -stageFirst stage: PP2= -stage
 The epiphysis of theThe epiphysis of the
proximal phalanx of theproximal phalanx of the
index finger (PP2) has theindex finger (PP2) has the
same width as thesame width as the
diaphysis.diaphysis.
 This stage occursThis stage occurs
approximately 3 yearsapproximately 3 years
before the peak of thebefore the peak of the
puberal growth spurt.puberal growth spurt.

Second stage: MP3= -stageSecond stage: MP3= -stage
 Epiphysis of the middleEpiphysis of the middle
phalanx of the middlephalanx of the middle
finger (MP3) is of thefinger (MP3) is of the
same width as thesame width as the
diaphysisdiaphysis

Stage three: Pisi-, H1-, and R= - stageStage three: Pisi-, H1-, and R= - stage
 This stage of developmentThis stage of development
can be identified by threecan be identified by three
distinct ossification areas;distinct ossification areas;
these show individualthese show individual
variations but appear at thevariations but appear at the
same time during the processsame time during the process
of maturation.of maturation.
 Pisi-stage = visiblePisi-stage = visible
ossification of the pisiformeossification of the pisiforme

 H1-stage = ossification ofH1-stage = ossification of
the hamular process ofthe hamular process of
the hamatumthe hamatum
 R = -stage, same width ofR = -stage, same width of
epiphysis and diaphysis ofepiphysis and diaphysis of
the radiusthe radius

Fourth stage: S- and H2-stageFourth stage: S- and H2-stage
 S-stage=first mineralisationS-stage=first mineralisation
of the ulnar sesamoid boneof the ulnar sesamoid bone
of the metacarpophalangealof the metacarpophalangeal
joiant of the thumb.joiant of the thumb.
 H2-stage= progressiveH2-stage= progressive
ossification of the hamularossification of the hamular
process of the hamatumprocess of the hamatum
 The fourth stage is reachedThe fourth stage is reached
shortly before or at theshortly before or at the
beginning of the puberalbeginning of the puberal

Fifth stage: MP3Fifth stage: MP3capcap-, PP1-, PP1capcap- and R- and Rcapcap-stage-stage
 During this stage, theDuring this stage, the
diaphysis is covered by thediaphysis is covered by the
cap-shaped epiphysiscap-shaped epiphysis
 MP3MP3capcap-stage, the process-stage, the process
begins at the middle phalanxbegins at the middle phalanx
of the third fingerof the third finger

 PP1PP1capcap-stage, at the-stage, at the
thumbthumb
 RRcapcap-stage, at the radius-stage, at the radius
 This stage of ossificationThis stage of ossification
marks the peak of themarks the peak of the
puberal growth spurt.puberal growth spurt.

Sixth stage: DP3Sixth stage: DP3uu-stage-stage
 Visible union of epiphysisVisible union of epiphysis
and diaphysis at the distaland diaphysis at the distal
finger (DP3).finger (DP3).
 This stage ofThis stage of
development constitutesdevelopment constitutes
the end of puberalthe end of puberal
growthgrowth

Seventh stage: PP3Seventh stage: PP3uu-stage-stage
 Visible union of epiphysisVisible union of epiphysis
and diaphysis at theand diaphysis at the
little finger (PP3)little finger (PP3)

Eighth stage: MP3Eighth stage: MP3uu-stage-stage
 Union of epiphysis andUnion of epiphysis and
diaphysis at the middlediaphysis at the middle
finger is clearly visiblefinger is clearly visible
(MP3)(MP3)

Ninth stage: RNinth stage: Ruu-stage-stage
 Complete union ofComplete union of
epiphysis and diaphysis ofepiphysis and diaphysis of
the radius.the radius.
 The ossification of all theThe ossification of all the
hand bones is completehand bones is complete
and skeletal growth isand skeletal growth is
finished.finished.

Growth periodGrowth period
Schopf, 1978Schopf, 1978 MaleMale FemaleFemale
Stage1Stage1 PP2 =PP2 = 10.6yr10.6yr 8.18.1
Stage2Stage2 MP3 =MP3 = 12.012.0 8.18.1
Stage3Stage3 Pisi, H1,R=Pisi, H1,R= 12.612.6 9.69.6
Stage4Stage4 S & H2S & H2 13.013.0 10.610.6
Stage5Stage5 MP3,R,PP1MP3,R,PP1
capcap
14.014.0 11.011.0
Stage6Stage6 DP3UDP3U 15.015.0 13.013.0
Stage7Stage7 PP3UPP3U 15.915.9 13.313.3
Stage8Stage8 MP3UMP3U 15.915.9 13.913.9
Stage9Stage9 RURU 18.518.5 16.016.0
As a rule, girls reach the various developmental stages 2 years earlier than boys.
Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. GraberOrthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. Graberwww.indiandentalacademy.com

Singer’s method of assessmentSinger’s method of assessment
 Julian singerJulian singer inin 19801980 proposed a system of hand-wristproposed a system of hand-wrist
radiograph assessmentradiograph assessment that would enable the clinician tothat would enable the clinician to
rapidly and with some reliability help determine the maturationalrapidly and with some reliability help determine the maturational
status of the patient.status of the patient.
 To establish baseline for simple clinical reference, sixTo establish baseline for simple clinical reference, six
stages of hand-wrist development are described. Thestages of hand-wrist development are described. The
stages and characteristics are:stages and characteristics are:
Julian Singer: Physiologic timing of orthodontic treatment. Angle Orthod 1980,Julian Singer: Physiologic timing of orthodontic treatment. Angle Orthod 1980,
pg-322-333pg-322-333

Stage 1 (Early)Stage 1 (Early)
1.1. Absence of the pisiform,Absence of the pisiform,
2.2. Absence of the hook ofAbsence of the hook of
Hamate andHamate and
3.3. Epiphysis of proximalEpiphysis of proximal
phalanx of second digitphalanx of second digit
(pp2) narrower than its(pp2) narrower than its
shaft.shaft.

Stage 2 (Prepuberal)Stage 2 (Prepuberal)
1.1. Proximal phalanx of secondProximal phalanx of second
digit and its epiphysis aredigit and its epiphysis are
equal in width (pp2=),equal in width (pp2=),
2.2. Initial ossification of hookInitial ossification of hook
of Hamate andof Hamate and
3.3. Initial ossification of theInitial ossification of the
pisiformpisiform

Stage 3 (Puberal onset)Stage 3 (Puberal onset)
1.1. Beginning calcification ofBeginning calcification of
ulnar sesamoid,ulnar sesamoid,
2.2. Increased width ofIncreased width of
epiphysis of pp2 andepiphysis of pp2 and
3.3. Increased calcification ofIncreased calcification of
Hamate hook andHamate hook and
pisiformpisiform

Stage 4 (Puberal)Stage 4 (Puberal)
1.1. Calcified ulnar sesamoidCalcified ulnar sesamoid
andand
2.2. Capping of shaft of theCapping of shaft of the
middle phalanx of thirdmiddle phalanx of third
digit by its epiphysisdigit by its epiphysis
(MP3cap)(MP3cap)

Stage 5 (Puberal deceleration)Stage 5 (Puberal deceleration)
1.1. Ulnar sesamoid fullyUlnar sesamoid fully
calcified andcalcified and
2.2. Calcification of epiphysis ofCalcification of epiphysis of
distal phalanx of third digitdistal phalanx of third digit
with its shaft (DP3u)with its shaft (DP3u)
3.3. All phananges and carpalsAll phananges and carpals
fully calcified andfully calcified and
4.4. Epiphysis of radius and ulnaEpiphysis of radius and ulna
not fully calcified withnot fully calcified with
respective shafts.respective shafts.

Stage 6 (Growth completion)Stage 6 (Growth completion)
1.1. No remaining growthNo remaining growth
sites.sites.

Clinical implicationClinical implication
 Stage 2Stage 2 represents that period prior to the adolescentrepresents that period prior to the adolescent
growth spurt during which significant amounts ofgrowth spurt during which significant amounts of
mandibular growth are possible.mandibular growth are possible.
Maxillary orthodontic therapy in conjuction withMaxillary orthodontic therapy in conjuction with
mandibular growth might aid correction of a class IImandibular growth might aid correction of a class II
relationship with considerable speed and ease.relationship with considerable speed and ease.
 Stage 5Stage 5 represents that period of growth whenrepresents that period of growth when
orthodontic treatment might be completed and theorthodontic treatment might be completed and the
patient is in retention therapy.patient is in retention therapy.

Fishman’s Skeletal Maturity IndicatorsFishman’s Skeletal Maturity Indicators
(SMI)(SMI)
 Proposed byProposed by Leonard SLeonard S
FishmanFishman in 1982.in 1982.
 Make use of anatomicalMake use of anatomical
sites located onsites located on thumb,thumb,
third finger, fifth fingerthird finger, fifth finger
and Radius .and Radius .
Leonard S. Fishman :Radiographic Evaluation of Skeletal Maturation. AngleLeonard S. Fishman :Radiographic Evaluation of Skeletal Maturation. Angle
orthod vol.52, No.2 april 1982.orthod vol.52, No.2 april 1982.www.indiandentalacademy.com

The Fishman’s system ofThe Fishman’s system of interpretationinterpretation
Uses fourUses four
stages of bone maturationstages of bone maturation
1. Epiphysis equal in width to diaphysis1. Epiphysis equal in width to diaphysis
2. Appearence of adductor sesamoid of thumb2. Appearence of adductor sesamoid of thumb
3. Capping of epiphysis.3. Capping of epiphysis.
4. Fusion of epiphysis4. Fusion of epiphysis

Fishman method –Eleven SMIsFishman method –Eleven SMIs
Width of Epiphysis equal to Diaphysis
SMI-1 Third finger-Proximal Phalanx
SMI-2 Third finger-Middle Phalanx
SMI-3 Fifth finger-Middle Phalanx
SMI-4 Appearance of adductor sesamoid of the
thumb
Capping of Epiphysis
SMI-5 Third finger –Distal Phalanx
SMI-7 Fifth finger-Middle Phalanx
Fusion of Epiphysis and Diaphysis
SMI-8 Third finger-Distal Phalanx
SMI-9 Third finger-Proximal Phalanx
SMI-11 Seen in Radius

SignificanceSignificance
 SMI 1,2,3SMI 1,2,3 :- Occur approximately 3 years before the:- Occur approximately 3 years before the
pubertal growth spurt.pubertal growth spurt.
 SMI 4SMI 4 :- This stage occurs shortly before or at the:- This stage occurs shortly before or at the
beginning of pubertal growth spurt.beginning of pubertal growth spurt.
 SMI 5,6,7SMI 5,6,7 :- This stage occurs at the peak of the:- This stage occurs at the peak of the
 SMI 8,9,10,11SMI 8,9,10,11 :- The ossification of all hand bones is:- The ossification of all hand bones is
completed and skeletal growth is finished.completed and skeletal growth is finished.

Maturation Assessment by Hagg andMaturation Assessment by Hagg and
TarangerTaranger
 Hagg and Taranger in 1980 described 5 stages of MP3Hagg and Taranger in 1980 described 5 stages of MP3
growth , based primarily on epiphyseal changes.growth , based primarily on epiphyseal changes.
 Skeletal development in the hand-wrist is analyzed fromSkeletal development in the hand-wrist is analyzed from
annual radiographs, taken between the ages of 6 and 18annual radiographs, taken between the ages of 6 and 18
years, by assessment of the ossification of the ulnaryears, by assessment of the ossification of the ulnar
sesamoid of the metacarpophalangeal joint of firstsesamoid of the metacarpophalangeal joint of first
finger (S) and Certain specified stages of 3 epiphysealfinger (S) and Certain specified stages of 3 epiphyseal
bones:bones:
- Middle and distal phalanges of third finger (MP3 and DP3)- Middle and distal phalanges of third finger (MP3 and DP3)
- distal epiphysis of Radius (R).- distal epiphysis of Radius (R).

SesamoidSesamoid
 Sesamoid is usually attainedSesamoid is usually attained
during theduring the
acceleration period of theacceleration period of the
pubertal growthpubertal growth
spurt (onset of peak heightspurt (onset of peak height
velocity)velocity)

Third Finger Middle PhalanxThird Finger Middle Phalanx
MP3-F StageMP3-F Stage
 Start of the curve of pubertalStart of the curve of pubertal
growthgrowth spurt .spurt .
 Epiphysis is as wide asEpiphysis is as wide as
metaphysismetaphysis

MP3-FG StageMP3-FG Stage
 Acceleration of the curve ofAcceleration of the curve of
 Epiphysis is as wide asEpiphysis is as wide as
metaphysis.metaphysis.
 Distinct medial and lateral borderDistinct medial and lateral border
of epiphysis forms line ofof epiphysis forms line of
demarcation at right angle todemarcation at right angle to
distal border.distal border.

MP3-G StageMP3-G Stage
 Maximum point of pubertalMaximum point of pubertal
 Sides of epiphysis haveSides of epiphysis have
thickened and cap itsthickened and cap its
metaphysis, forming sharp distalmetaphysis, forming sharp distal
edge on one or both the sides.edge on one or both the sides.

MP3-H StageMP3-H Stage
 Deceleration of the curve ofDeceleration of the curve of
 Fusion of epiphysis and metaphysisFusion of epiphysis and metaphysis
begins.begins.

MP3-I StageMP3-I Stage
 End of pubertal growth spurtEnd of pubertal growth spurt
complete.complete.

Third finger distal phalanxThird finger distal phalanx
 DP3-1:DP3-1:Fusion of Epiphysis and Metaphysis isFusion of Epiphysis and Metaphysis is
completed.completed.
-This is attained during the deceleration period-This is attained during the deceleration period
of pubertal growth spurt ( end of PHV) .of pubertal growth spurt ( end of PHV) .

RadiusRadius
 R-I:R-I: Fusion of the epiphysis and Metaphysis hasFusion of the epiphysis and Metaphysis has
began.began.
-This stage is attained 1 year before or at the end of-This stage is attained 1 year before or at the end of
 R-IJ:R-IJ: Fusion is almost completed but there is still aFusion is almost completed but there is still a
small cap at one or both margin.small cap at one or both margin.
 R-J:R-J: Characterized by fusion of the epiphysis andCharacterized by fusion of the epiphysis and
These stages were not attained before end of PHV.These stages were not attained before end of PHV.

Cervical Vertebrae Maturity IndicatorsCervical Vertebrae Maturity Indicators
(CVMI)(CVMI)
 The development of the cervical vertebrae showedThe development of the cervical vertebrae showed
similarities with skeletal maturity indicators found in thesimilarities with skeletal maturity indicators found in the
hand wrist area and could as such offer an alternativehand wrist area and could as such offer an alternative
method of assessing maturity without the need for amethod of assessing maturity without the need for a
hand-wrist radiograph.hand-wrist radiograph.
 LAMPARSKILAMPARSKI in 1972 was the first person to studyin 1972 was the first person to study
cervical vertebrae and he developed a series of standardscervical vertebrae and he developed a series of standards
for assessing skeletal age in both males and female basedfor assessing skeletal age in both males and female based
on cervical vertebrae.on cervical vertebrae.

 HasselHassel andand FarmanFarman developed a system of skeletaldeveloped a system of skeletal
maturation determination using cervical vertebrae.maturation determination using cervical vertebrae.
 The shapes of the cervical vertebrae were found to beThe shapes of the cervical vertebrae were found to be
different at different levels of skeletal development.different at different levels of skeletal development.
 The shapes of the cervical bodies of C3 & C4 changedThe shapes of the cervical bodies of C3 & C4 changed
from somewhat wedge shaped, to rectangular, followedfrom somewhat wedge shaped, to rectangular, followed
by square shape.by square shape.
 The inferior vertebral borders were flat when immature,The inferior vertebral borders were flat when immature,
& they were concave when mature.& they were concave when mature.
 Hassel and Farman put forward 6 stages in vertebralHassel and Farman put forward 6 stages in vertebral
development using C2,C3, & C4 cervical vertebrae.development using C2,C3, & C4 cervical vertebrae.
Hassel, Farman : Skeletal maturation evaluation using cervical vertebrae.Hassel, Farman : Skeletal maturation evaluation using cervical vertebrae.
AJODO 1995; 107:58-66.AJODO 1995; 107:58-66.

Kansal and Rajagopal modified MP3Kansal and Rajagopal modified MP3
MethodMethod
 Kansal and Rajagopal modified the MP3 indicatorsKansal and Rajagopal modified the MP3 indicators
further and compared it to the cervical vertebraefurther and compared it to the cervical vertebrae
maturation indicators (CVMI) as described by Hasselmaturation indicators (CVMI) as described by Hassel
and Farman.and Farman.
 Periapical radiographs were used for recording MP3Periapical radiographs were used for recording MP3
stages.stages.
Rajagopal.R, Kansal.S : A Comparision of modified MP3 stages and the cervicalRajagopal.R, Kansal.S : A Comparision of modified MP3 stages and the cervical
vertrbrae as growth indicators. JCO/JULY 2002vertrbrae as growth indicators. JCO/JULY 2002

Modified MP3 Cervical VertebraeModified MP3 Cervical Vertebrae
MP3-F StageMP3-F Stage
Start of the curve of pubertal growthStart of the curve of pubertal growth
spurtspurt
 Epiphysis is as wide as metaphysisEpiphysis is as wide as metaphysis
 End of epiphysis are tapered andEnd of epiphysis are tapered and
rounded.rounded.
 Radiolucent gap [representingRadiolucent gap [representing
cartilageous epiphyseal growth plate]cartilageous epiphyseal growth plate]
between epiphysis and metaphysis isbetween epiphysis and metaphysis is
wide.wide.
Initiation stage of cervical vertebrae
 C2,C3 and C4 inferior vertebral
body borders are flat.
 Superior vertebral borders are
tapered from posterior to anterior
[wedge shape]
 80-100% of pubertal growth
remains.
CVMI-1

Acceleration of the curve of pubertalAcceleration of the curve of pubertal
 Epiphysis is as wide as metaphysis.Epiphysis is as wide as metaphysis.
 Distinct medial and/or lateral borderDistinct medial and/or lateral border
of epiphysis forms line of demarcationof epiphysis forms line of demarcation
at right angle to distal border.at right angle to distal border.
 Metaphysis begins to show slightMetaphysis begins to show slight
undulation.undulation.
 Radiolucent gap between metaphysisRadiolucent gap between metaphysis
and epiphysis is wide.and epiphysis is wide.
Acceleration stage of cervical vertebrae.
Concavities are developing in lower
borders of C2 and C3.
 Lower border of C4 vertebral body
is flat.
 C3 and C4 are more rectangular in
shape.
remains.
MP3-FG Stage CVMI-2

MP3-G Stage CVMI-3MP3-G Stage CVMI-3
Maximum point of pubertal growthMaximum point of pubertal growth
spurt.spurt.
 Sides of epiphysis have thickenedSides of epiphysis have thickened
and cap its metaphysis, formingand cap its metaphysis, forming
sharp distal edge on one or bothsharp distal edge on one or both
sides.sides.
 Marked undulations in metaphysisMarked undulations in metaphysis
give it “Cupid’s bow’’ appearance.give it “Cupid’s bow’’ appearance.
 Radiolucent gap is moderate.Radiolucent gap is moderate.
Transition stage of cervical vertebrae
 Distinct concavities are seen in lower
borders of C2 and C3.
 Concavity is developing in lower
border of C4.
 C3 and C4 are rectangular in shape.
 25-65% of pubertal growth remains.

MP3-H Stage CVMI-4MP3-H Stage CVMI-4
Deceleration of the curve of pubertal growthDeceleration of the curve of pubertal growth
spurt.spurt.
 Fusion of epiphysis and metaphysis begins.Fusion of epiphysis and metaphysis begins.
 Side of epiphysis form obtuse angle toSide of epiphysis form obtuse angle to
distal border.distal border.
 Epiphysis is beginning to narrow.Epiphysis is beginning to narrow.
 Slight convexity under central part ofSlight convexity under central part of
 Typical Cupid’s bow appearance is absentTypical Cupid’s bow appearance is absent
 Radiolucent gap is narrow.Radiolucent gap is narrow.
Deceleration stage of cervical
vertebrae.
 Distinct concavities are seen in
lower borders of C2, C3 and C4.
 C3 and C4 are nearly square in
shape.
remains.

MP3-HI Stage CVMI-5MP3-HI Stage CVMI-5
Maturation of the curve of pubertalMaturation of the curve of pubertal
growth spurtgrowth spurt
 Superior surface of epiphysis showsSuperior surface of epiphysis shows
smooth concavity.smooth concavity.
 Metaphysis shows smooth, convexMetaphysis shows smooth, convex
surface, almost fitting into reciprocalsurface, almost fitting into reciprocal
concavity of epiphysis.concavity of epiphysis.
 No undulation present in metaphysis.No undulation present in metaphysis.
 Radiolucent gap is insignificant.Radiolucent gap is insignificant.
Maturation stage of cervical vertebrae.
Accentuated concavities of C2, C3
and C4 inferior vertebral body
borders are observed.
 C3 and C4 are square in shape.
remains.

MP3-I Stage CVMI-6MP3-I Stage CVMI-6
End of pubertal growth spurtEnd of pubertal growth spurt
complete.complete.
 No radiolucent gap.No radiolucent gap.
 Dense, radiopaque epiphyseal lineDense, radiopaque epiphyseal line
forms integral part of proximalforms integral part of proximal
portion of middle phalanx.portion of middle phalanx.
Completion stage of cervical vertebrae.
 Deep concavities are present in C2,
C3 and C4 inferior vertebral body
borders.
 C3 and C4 are greater in height than
in width.
 Pubertal growth is completed.

Advantages of modified MP3 methodAdvantages of modified MP3 method
 Significantly low radiation exposure.Significantly low radiation exposure.
 High degree of clarity on the radiographs.High degree of clarity on the radiographs.
 Close correlation to the six stages of CVMI.Close correlation to the six stages of CVMI.
 No need to obtain equipment beyond the standardNo need to obtain equipment beyond the standard
periapical x-ray film and dental x-ray machine.periapical x-ray film and dental x-ray machine.

Mid Palatal Suture as an Indicator ofMid Palatal Suture as an Indicator of
MaturityMaturity
 In 1982, Fishman developed the system of skeletalIn 1982, Fishman developed the system of skeletal
maturation assessment (SMA) which involves thematuration assessment (SMA) which involves the
identification of 11 skeletal maturity indicators on H/Widentification of 11 skeletal maturity indicators on H/W
radiographs that occur serially from the onset toradiographs that occur serially from the onset to
termination of adolescence.termination of adolescence.
 All measurements associated with the growth of theAll measurements associated with the growth of the
mandible correlate in intensity and timing with growth inmandible correlate in intensity and timing with growth in
stature. The maxilla demonstrates less conformity.stature. The maxilla demonstrates less conformity.
Revelo.B, Fishman.L.S : Maturational evaluation of ossification of the midpalatalRevelo.B, Fishman.L.S : Maturational evaluation of ossification of the midpalatal
suture. AJODO 1994; 105;288-92suture. AJODO 1994; 105;288-92

 Therefore knowing more about the development of theTherefore knowing more about the development of the
maxilla can help a clinician to better time proceduresmaxilla can help a clinician to better time procedures
like maxillary expansion.like maxillary expansion.
 Fishman in 1994 conducted a study to evaluate theFishman in 1994 conducted a study to evaluate the
ossification pattern of the mid-palatal suture andossification pattern of the mid-palatal suture and
whether this could be used as a maturity indicator.whether this could be used as a maturity indicator.

 Stages of ossification of mid-Stages of ossification of mid-
palatal suture were comparedpalatal suture were compared
with Fishman’s SMI stages.with Fishman’s SMI stages.
 Certain landmarks wereCertain landmarks were
identified on the occlusal filmsidentified on the occlusal films
which formed the basis ofwhich formed the basis of
comparision.comparision.
 Point A - Most anterior point on premaxillaPoint A - Most anterior point on premaxilla
 Point B – Most posterior point on the posterior wall ofPoint B – Most posterior point on the posterior wall of
the incisive foramen.the incisive foramen.
 Point P – point tangent to a line connecting the posteriorPoint P – point tangent to a line connecting the posterior
walls of greater palatine foramen.walls of greater palatine foramen.

 All measurements were made for –All measurements were made for –
a. Lengtha. Length
b. Percentage of development.b. Percentage of development.
 These were recorded for the following dimensions :These were recorded for the following dimensions :
A-P - total dimension of the sutureA-P - total dimension of the suture
A-B - anterior dimension of the sutureA-B - anterior dimension of the suture
B-P - posterior dimension of the sutureB-P - posterior dimension of the suture
 The results reveled that there is significant correlationThe results reveled that there is significant correlation
b/n maturational development and the beginning ofb/n maturational development and the beginning of
ossification of the mid-palatal suture.ossification of the mid-palatal suture.

SMISMI MPSMPS CORRELATIONCORRELATION
SMI 3SMI 3 Only about 8% fusedOnly about 8% fused
Before SMI 4Before SMI 4 Very little or no midpalatalVery little or no midpalatal
approximation existsapproximation exists
Before beginningBefore beginning
of pubertyof puberty
b/w SMI 4 - 7b/w SMI 4 - 7 An osseous interdigitation isAn osseous interdigitation is
very evident with approximationvery evident with approximation
in some areasin some areas
Occurs duringOccurs during
spurtspurt
SMI 9SMI 9 Increase in rate ofIncrease in rate of
approximation (25%)approximation (25%)
Deceleration ofDeceleration of
spurtspurt
SMI 11SMI 11 Only 50% approximatedOnly 50% approximated
(higher %age occurs posteriorly)(higher %age occurs posteriorly)
End of adolescenceEnd of adolescence

 No differences were seen in the pattern ofNo differences were seen in the pattern of
approximation b/w males and females.approximation b/w males and females.
 This study has also verified the fact that midpalatalThis study has also verified the fact that midpalatal
approximation occurs more posteriorly during theapproximation occurs more posteriorly during the
entire adolescent period.entire adolescent period.
Clinical implication :Clinical implication :
 An ideal time to initiate orthopedic expansion is duringAn ideal time to initiate orthopedic expansion is during
the early maturational stage, SMI 1 to 4.the early maturational stage, SMI 1 to 4.
 Theoretically less orthopedic force values would beTheoretically less orthopedic force values would be
required if treatment is initiated early.required if treatment is initiated early.

Symphysis morphology as a predictor ofSymphysis morphology as a predictor of
the direction of mandibular growththe direction of mandibular growth
 Nanda et al determined in their study that SymphysisNanda et al determined in their study that Symphysis
morphology could be used as a predictor of the directionmorphology could be used as a predictor of the direction
of mandibular growth.of mandibular growth.
 The direction of mandibular growth was evaluated withThe direction of mandibular growth was evaluated with
seven cephalometric measurements that included –seven cephalometric measurements that included –
1. y – axis (FH to S-Gn)1. y – axis (FH to S-Gn)
2. SN to mandibular plane2. SN to mandibular plane
3. Palatal plane to mandibular plane3. Palatal plane to mandibular plane
4. Gonial angle4. Gonial angle
5. Sum of saddle, articular and gonial angle (Bjork sum)5. Sum of saddle, articular and gonial angle (Bjork sum)
6. Percentage lower facial height6. Percentage lower facial height
7. Posterior/Anterior face height (Jaraback ratio)7. Posterior/Anterior face height (Jaraback ratio)

 The mandibular symphyseal dimensions studied wereThe mandibular symphyseal dimensions studied were
height, depth, ratio (height/depth), and angle.height, depth, ratio (height/depth), and angle.
 TheThe Symphysis heightSymphysis height was defined as the distancewas defined as the distance
from the superior to the inferior limit on the grid.from the superior to the inferior limit on the grid.
 TheThe Symphysis depthSymphysis depth was defined as the distance fromwas defined as the distance from
the anterior to the posterior limit on the gridthe anterior to the posterior limit on the grid

 Symphysis ratioSymphysis ratio was calculated by dividing Symphysiswas calculated by dividing Symphysis
height by depth.height by depth.
 TheThe Symphysis angleSymphysis angle was determined by the posterior-was determined by the posterior-
superior angle formed by the line through menton andsuperior angle formed by the line through menton and
point B and the mandibular plane.point B and the mandibular plane.

 Large Symphysis ratioLarge Symphysis ratio – receding chin,– receding chin,
high mandibular plane,high mandibular plane,
high angle SN-MP,high angle SN-MP,
large saddle, articulare & gonial angles,large saddle, articulare & gonial angles,
large anterior facial height,large anterior facial height,
large percentage lower facial heightlarge percentage lower facial height
 Small Symphysis ratioSmall Symphysis ratio – large chin– large chin
low mandibular planelow mandibular plane
low angle SN-MPlow angle SN-MP
low saddle, articular & gonial angleslow saddle, articular & gonial angles
Small anterior facial heightSmall anterior facial height
Small percentage lower facial heightSmall percentage lower facial heightwww.indiandentalacademy.com

 The axiom about the chin is thatThe axiom about the chin is that those children whothose children who
have, will get more with growth, whereas those who dohave, will get more with growth, whereas those who do
not will not get much growth at the chin.not will not get much growth at the chin.
 Symphysis ratio was strongly related to the direction ofSymphysis ratio was strongly related to the direction of
mandibular growth in men.mandibular growth in men.
 Symphysis with anSymphysis with an anterior growth directionanterior growth direction of theof the
mandible had a short height, large depth, small ratio,mandible had a short height, large depth, small ratio,
and large angle.and large angle.
 In contrast, a Symphysis with a large height, smallIn contrast, a Symphysis with a large height, small
depth, large ratio, and small angle demonstrated adepth, large ratio, and small angle demonstrated a
posterior growth direction.posterior growth direction.

 Growth changes in Symphysis continued up toGrowth changes in Symphysis continued up to
adulthood in both female and male subjects, with theadulthood in both female and male subjects, with the
female subjects having a smaller and earlier occurringfemale subjects having a smaller and earlier occurring
change compared with the male subjects.change compared with the male subjects.
 Symphysis height, depth, and ratio increased whileSymphysis height, depth, and ratio increased while
Symphysis angle decreased with age.Symphysis angle decreased with age.
Todd Aki, RS Nanda, Frans Currier : Assessment of Symphysis morphology as aTodd Aki, RS Nanda, Frans Currier : Assessment of Symphysis morphology as a
predictor of the direction of mandibular growth. AJODO 1994; 106; 60-9.predictor of the direction of mandibular growth. AJODO 1994; 106; 60-9.

Ante gonial Notch – As an indicator ofAnte gonial Notch – As an indicator of
mandibular growth potentialmandibular growth potential
 The presence of a prominent mandibular ante gonialThe presence of a prominent mandibular ante gonial
notch is a commonly reported finding in subjects withnotch is a commonly reported finding in subjects with
disturbed or arrested growth of the mandibulardisturbed or arrested growth of the mandibular
condyles.condyles.
 In unilateral condylar hypoplasia, marked mandibularIn unilateral condylar hypoplasia, marked mandibular
notching develops only on the affected side.notching develops only on the affected side.
 Bjork’s implant studies have showed that in forwardBjork’s implant studies have showed that in forward
rotating mandibles apposition occurs below therotating mandibles apposition occurs below the
Symphysis and resorption takes place under the angle.Symphysis and resorption takes place under the angle.
Conversely, in backward mandibular rotationConversely, in backward mandibular rotation
apposition beneath the angle is common and resorptionapposition beneath the angle is common and resorption
underneath the Symphysis is possible.underneath the Symphysis is possible.

 The direction of mandibular growth rotation is reflectedThe direction of mandibular growth rotation is reflected
in the location and degree of remodeling on the inferiorin the location and degree of remodeling on the inferior
surface of the mandible and most pronounced area ofsurface of the mandible and most pronounced area of
remodeling is below the angular region.remodeling is below the angular region.
 Singer and HunterSinger and Hunter did a study to compare thedid a study to compare the
craniofacial characteristics and growth potential ofcraniofacial characteristics and growth potential of
orthodontically treated patients with deep mandibularorthodontically treated patients with deep mandibular
ante gonial notch; with those of a similar group ofante gonial notch; with those of a similar group of
shallow notch subjects by use of lateral cephalometricshallow notch subjects by use of lateral cephalometric
radiographs.radiographs.
CP Singer, AH Mamandras, WS Hunter : The Depth of the mandibularCP Singer, AH Mamandras, WS Hunter : The Depth of the mandibular
antegonial notch as an indicator of mandibular growth potential. AJODOantegonial notch as an indicator of mandibular growth potential. AJODO
1987; 91; 117-24.1987; 91; 117-24.

 > 3 mm - Very deep mandibular ante gonial notch> 3 mm - Very deep mandibular ante gonial notch
 < 3 mm - Very shallow mandibular ante gonial notch< 3 mm - Very shallow mandibular ante gonial notch
 These extremes were examined by them with the hopeThese extremes were examined by them with the hope
that any biologic relationship might be more readilythat any biologic relationship might be more readily
apparent in extremes of population.apparent in extremes of population.

Concluding remarks were:Concluding remarks were:
Deep notch subjects –Deep notch subjects –
 more retrusive mandible with short corpus, less ramusmore retrusive mandible with short corpus, less ramus
height, and a greater gonial angle than did shallowheight, and a greater gonial angle than did shallow
notch subjects.notch subjects.
 Mandibular growth direction was more verticallyMandibular growth direction was more vertically
directeddirected
 Longer total facial height and longer lower facial heightLonger total facial height and longer lower facial height
 Smaller saddle angleSmaller saddle angle
 Required a longer duration of orthodontic treatmentRequired a longer duration of orthodontic treatment
(extractions 3 times the frequency, high-pull and(extractions 3 times the frequency, high-pull and
straight-pull head gear, shallow notch subjects – worestraight-pull head gear, shallow notch subjects – wore
low pull head gear exclusively)low pull head gear exclusively)

 During the average 4-year period examined, the deepDuring the average 4-year period examined, the deep
notch subjects experienced less mandibular growth asnotch subjects experienced less mandibular growth as
evidenced by-evidenced by-
1. a smaller increase in total mandibular length.1. a smaller increase in total mandibular length.
2. corpus length, and2. corpus length, and
3. less displacement of the chin in a horizontal direction3. less displacement of the chin in a horizontal direction
than did the shallow notch subjects.than did the shallow notch subjects.

Clinical implicationClinical implication
 The results of this study suggest that the clinicalThe results of this study suggest that the clinical
presence of a deep mandibular ante gonial notch ispresence of a deep mandibular ante gonial notch is
indicative of a diminished mandibular growth potentialindicative of a diminished mandibular growth potential
and a vertically directed mandibular growth pattern.and a vertically directed mandibular growth pattern.
 An explanation for this could be when the growth ofAn explanation for this could be when the growth of
the mandibular condyle fails to contribute to thethe mandibular condyle fails to contribute to the
lowering of the mandible,lowering of the mandible, the masseter and medial pterygoidthe masseter and medial pterygoid
by their continued growth, cause the bone in the regionby their continued growth, cause the bone in the region
of the angle to grow downward, producing notching.of the angle to grow downward, producing notching.

Dental ageDental age
 Chronological and dental age are synchronous in theChronological and dental age are synchronous in the
normal patient.normal patient.
 A child is labeled as anA child is labeled as an early or lateearly or late developerdeveloper if thereif there
is a difference of +/- 2 years from the average value.is a difference of +/- 2 years from the average value.
 If the chronologic age of the patient is younger thanIf the chronologic age of the patient is younger than
the dental age, one can rely on increased growth to athe dental age, one can rely on increased growth to a
greater degree than when dental age is retarded ingreater degree than when dental age is retarded in
relation to the chronologic age ( and possibly biologicrelation to the chronologic age ( and possibly biologic
age).age).
 Dental age can be determined two methods:Dental age can be determined two methods:
- Stage of eruption- Stage of eruption
- stage of tooth mineralization on radiograph- stage of tooth mineralization on radiograph

Stage of EruptionStage of Eruption
 Determination of dental age from observation ofDetermination of dental age from observation of
eruption has been the only method available for aeruption has been the only method available for a
long timelong time
 In certain cases however, the accuracy of theIn certain cases however, the accuracy of the
method is limited.method is limited.
 During the quiescent period in eruption, thisDuring the quiescent period in eruption, this
appoach is inadequate.appoach is inadequate.

Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. GraberOrthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. Graberwww.indiandentalacademy.com

Stage of tooth mineralization onStage of tooth mineralization on
radiograph (Demirjian et al 1973)radiograph (Demirjian et al 1973)
 When determining dental age radiographicallyWhen determining dental age radiographically
according to the stages of germination, the degree ofaccording to the stages of germination, the degree of
the development of individual teeth is compared to athe development of individual teeth is compared to a
fixed scale.fixed scale.
 For age determination one does not rely on the lastFor age determination one does not rely on the last
stage of tooth formation but on the entire process ofstage of tooth formation but on the entire process of
dental mineralization.dental mineralization.
 The procedure can be used for the entire deciduousThe procedure can be used for the entire deciduous
and mixed dentition period, and is not influnced byand mixed dentition period, and is not influnced by
early loss of deciduous teeth.early loss of deciduous teeth.

 The calculation is made using a point evaluationThe calculation is made using a point evaluation
system.system.
 Each tooth is given a point value according to itsEach tooth is given a point value according to its
state of development.state of development.
 The sum of individual points gives the developmentThe sum of individual points gives the development
value, which can be transferred into the dental agevalue, which can be transferred into the dental age
with the aid of standard tables.with the aid of standard tables.

 The smaller the sum of points, the younger theThe smaller the sum of points, the younger the
dental age; the higher the sum, the older the dentaldental age; the higher the sum, the older the dental
age.age.
 Experience shows that the method is sufficientlyExperience shows that the method is sufficiently
accurate if the stage of mineralization of teeth 1-7 inaccurate if the stage of mineralization of teeth 1-7 in
thethe left lower quadrant is examinedleft lower quadrant is examined..
 The procedure is not valid for patients with severalThe procedure is not valid for patients with several
congenitally absent teeth.congenitally absent teeth.

Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M.Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M.
Graber

Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. GraberOrthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. Graber

Lower third molar development inLower third molar development in
relation to Skeletal Maturity andrelation to Skeletal Maturity and
Chronological AgeChronological Age
 Most of the studies correlating dental maturation toMost of the studies correlating dental maturation to
skeletal maturation have not included the lower 3skeletal maturation have not included the lower 3rdrd
molars.molars.
 Engstrom in 1983 conducted a study to analyzeEngstrom in 1983 conducted a study to analyze
development of the lower 3development of the lower 3rdrd
molar and whether itmolar and whether it
could be correlated to skeletal maturity.could be correlated to skeletal maturity.
 A probable reason for the great variability seen inA probable reason for the great variability seen in
previous studies regarding 3previous studies regarding 3rdrd
molar development mightmolar development might
be because its development was related tobe because its development was related to chronologicalchronological
ageage rather thanrather than skeletal age.skeletal age.
Engstrom.C Engstrom.H, Sagne.s : Lower third molar development in relation toEngstrom.C Engstrom.H, Sagne.s : Lower third molar development in relation to
skeletal maturity and chronological age. Angle orthodontist; vol.53, no.2, april 1983.skeletal maturity and chronological age. Angle orthodontist; vol.53, no.2, april 1983.

Developmental stages of the lower 3rd molarDevelopmental stages of the lower 3rd molar
 The stages of development of the lower 3The stages of development of the lower 3rdrd
molar weremolar were
determined from OPGs.determined from OPGs.
 The developmental stages were categorized into-The developmental stages were categorized into-

Hand wrist x-rays were taken and their skeletalHand wrist x-rays were taken and their skeletal
development classified as -development classified as -
 PP2= : proximal phalanx of secondPP2= : proximal phalanx of second
finger, the epiphysis as widefinger, the epiphysis as wide
as diaphysis.as diaphysis.
 MP3cap : Middle phalanx of thirdMP3cap : Middle phalanx of third
finger, the epiphysis cap itsfinger, the epiphysis cap its
diaphysis.diaphysis.
 DP3u : Distal phalanx of thirdDP3u : Distal phalanx of third
finger, complete epiphysealfinger, complete epiphyseal
union.union.
 Ru : Distal epiphysis of radius,Ru : Distal epiphysis of radius,www.indiandentalacademy.com

ConclusionsConclusions
 Development of lower third molar appeared slightlyDevelopment of lower third molar appeared slightly
earlier in boys than in girls.earlier in boys than in girls.
 Strong correlation was found between chronologicalStrong correlation was found between chronological
age and third molar development.age and third molar development.
 A strong correlation was also found between thirdA strong correlation was also found between third
molar development and skeletal maturity.molar development and skeletal maturity.
 At stage PP2-At stage PP2- The 3The 3rdrd
molar showed signs of completedmolar showed signs of completed
crown molar mineralization in most subjects. (B)crown molar mineralization in most subjects. (B)
 At stage MP3cap-At stage MP3cap- Lower third molar crown formationLower third molar crown formation
was complete in most subjects and root developmentwas complete in most subjects and root development
has begun in some. (C)has begun in some. (C)

 At stage DP3u-At stage DP3u- Lower third molar crown was stillLower third molar crown was still
incomplete in some subjects but full root length wasincomplete in some subjects but full root length was
attained in others. (E)attained in others. (E)
 At stage Ru-At stage Ru- Only the crown was completed in 1/3Only the crown was completed in 1/3rdrd
ofof
subjects. Half the root had developed in 1/3subjects. Half the root had developed in 1/3rdrd
and fulland full
length was seen in another 1/3length was seen in another 1/3rdrd
. (E). (E)
 The results seem to show that lower third molarThe results seem to show that lower third molar
development on the whole seems to be correlated withdevelopment on the whole seems to be correlated with
skeletal maturation.skeletal maturation.

Frontal Sinus Development as anFrontal Sinus Development as an
Indicator for Somatic Maturity at PubertyIndicator for Somatic Maturity at Puberty
 The possibility of predicting the stage of somaticThe possibility of predicting the stage of somatic
maturity by analyzing frontal sinus growth was evaluated.maturity by analyzing frontal sinus growth was evaluated.
 The development of the frontal sinus as seen in lateralThe development of the frontal sinus as seen in lateral
cephalograms was assessed at various ages.cephalograms was assessed at various ages.
 The material composed of 53 boys. Lateral head filmsThe material composed of 53 boys. Lateral head films
existed for each individual over a 2 year period along withexisted for each individual over a 2 year period along with
body height data for 7 years including the pubertal period.body height data for 7 years including the pubertal period.
The head films were taken at yearly intervals and bodyThe head films were taken at yearly intervals and body
height readings were taken every 3-6 months.height readings were taken every 3-6 months.
Sabin Ruf, Hans Pancherz : Frontal sinus development as an indicator for somaticSabin Ruf, Hans Pancherz : Frontal sinus development as an indicator for somatic
maturity at puberty? AJO-DO 1996;110;476-82maturity at puberty? AJO-DO 1996;110;476-82..

 Two lateral head films of each subject were analysed atTwo lateral head films of each subject were analysed at
1year and 2 year intervals. Two prediction intervals1year and 2 year intervals. Two prediction intervals T1T1
and T2and T2 (1yr & 2yr) were formed.(1yr & 2yr) were formed.
 The peripheral borders of theThe peripheral borders of the
frontal sinus were traced. Thefrontal sinus were traced. The
highest pointhighest point ShSh &the lowest&the lowest
pointpoint SlSl were marked. A line waswere marked. A line was
drawn connecting Sh & Sl. Adrawn connecting Sh & Sl. A
perpendicular to this line wasperpendicular to this line was
drawn at the widest pt and thedrawn at the widest pt and the
max. width of the sinus wasmax. width of the sinus was
assessd.assessd.

 The average yearly growth velocity (mm/yr) of frontalThe average yearly growth velocity (mm/yr) of frontal
sinus was calculated seperatedly for each of predictionsinus was calculated seperatedly for each of prediction
intervalsintervals T1 or T2.T1 or T2.
 The average yearly body height increase in mm wasThe average yearly body height increase in mm was
calculated. The max body growth velocity at puberty wascalculated. The max body growth velocity at puberty was
assigned a termassigned a term body height peakbody height peak oror Bp.Bp.
 Frontal sinus growth velocity isFrontal sinus growth velocity is
closely related to body heightclosely related to body height
growth velocity during puberty.growth velocity during puberty.
 Frontal sinusFrontal sinus growth shows agrowth shows a
well definedwell defined pubertal peakpubertal peak (Sp).(Sp).
This occurs approx. 1.4 yrs afterThis occurs approx. 1.4 yrs after
Bp or body height peak.Bp or body height peak.

 In males the average age at frontal sinus peak is 15.1 yrs.In males the average age at frontal sinus peak is 15.1 yrs.
 In a 1 yr period, growth of 1.3 mm/yr is seen in frontalIn a 1 yr period, growth of 1.3 mm/yr is seen in frontal
sinus in 84% of subjects.sinus in 84% of subjects. (T1)(T1)
 In a 2 yr period, growth of 1.2 mm/yr is seen in 70% ofIn a 2 yr period, growth of 1.2 mm/yr is seen in 70% of
subjects in frontal sinus region.subjects in frontal sinus region. (T2)(T2)
Prediction procedure:Prediction procedure:
 The frontal sinus growth velocityThe frontal sinus growth velocity SvSv was compared withwas compared with
T1 & T2 values.T1 & T2 values.
 If Sv value was as high as or higher than T values, it canIf Sv value was as high as or higher than T values, it can
be assumed that the frontal sinus peak was reached duringbe assumed that the frontal sinus peak was reached during
the prediction interval. Therefore Bp has been reachedthe prediction interval. Therefore Bp has been reached
approx. 1.4 yes before the midpoint of the observationapprox. 1.4 yes before the midpoint of the observation
interval.interval.

 If Sv value was lower than T values, it cannot be saidIf Sv value was lower than T values, it cannot be said
whether the subject is prepeak or post peak in frontalwhether the subject is prepeak or post peak in frontal
sinus growth. The age of the subject is also needed.sinus growth. The age of the subject is also needed.
 As the frontal sinus peak is reached at 15.1 yrs, a lowAs the frontal sinus peak is reached at 15.1 yrs, a low
subject age means that the frontal sinus peak has notsubject age means that the frontal sinus peak has not
yet been reached. Therefore Bp (body ht peak) has notyet been reached. Therefore Bp (body ht peak) has not
been reached.been reached.
 If subjects age is more than 15.1 yrs with a Sv valueIf subjects age is more than 15.1 yrs with a Sv value
lower than T value, it can be assumed that the frontallower than T value, it can be assumed that the frontal
sinus growth peak has passed and also that the Bp hassinus growth peak has passed and also that the Bp has
passed more than 1.4 yrs before the beginning of thepassed more than 1.4 yrs before the beginning of the
observation interval. (T1 or T2).observation interval. (T1 or T2).

Results:Results:
 If the only prediction was whether the pubertal growthIf the only prediction was whether the pubertal growth
peak in height has been passed, the precision of thepeak in height has been passed, the precision of the
method was rather high.(90%)method was rather high.(90%)
 However, if the age of body height peak was to beHowever, if the age of body height peak was to be
predicted, the method accuracy was lower.(55%)predicted, the method accuracy was lower.(55%)
 The study suggests that theThe study suggests that the somatic maturity stagesomatic maturity stage may bemay be
predicted rather accurately by analyzing frontal sinuspredicted rather accurately by analyzing frontal sinus
developmental on pre-existing lateral head films.developmental on pre-existing lateral head films.

Assessment of Physical Maturation byAssessment of Physical Maturation by
Somatomedin Levels During PubertySomatomedin Levels During Puberty
 This study was undertaken by leonard Rothenburg inThis study was undertaken by leonard Rothenburg in
1977. it was performed on 27 caucasian subjects, all1977. it was performed on 27 caucasian subjects, all
females.females.
 Growth hormone has long been known to play anGrowth hormone has long been known to play an
important role in linear growth. However, growthimportant role in linear growth. However, growth
hormone determination is not of any value becausehormone determination is not of any value because
growth hormone does not act directly on linear growthgrowth hormone does not act directly on linear growth
but acts through an intermediary calledbut acts through an intermediary called Somatomedin.Somatomedin.
Somatomedin is stimulated by growth hormone and hasSomatomedin is stimulated by growth hormone and has
a direct effect on cartilage.a direct effect on cartilage.

 This study determines whether Somatomedin levelsThis study determines whether Somatomedin levels
could serve as markers for assessing maturation levels.could serve as markers for assessing maturation levels.
 3 developmental categories were established based on a3 developmental categories were established based on a
physical examination by a pediatrician –physical examination by a pediatrician –
Category A Prepubertal stage 1Category A Prepubertal stage 1
Category B Circumpubertal stage 2,3Category B Circumpubertal stage 2,3
Category C Postpubertal stage 4,5Category C Postpubertal stage 4,5
 Blood samples were taken and the somatomedin levelsBlood samples were taken and the somatomedin levels
assessed.assessed.

Results:Results:
 There was a significant difference between theThere was a significant difference between the
somatomedin levels in plasma of circumpubertal andsomatomedin levels in plasma of circumpubertal and
post-pubertal females.post-pubertal females.
 No significant difference was seen in the levels ofNo significant difference was seen in the levels of
prepubertal and circumpubertal females.prepubertal and circumpubertal females.

Evaluation of skeletal maturation by using aEvaluation of skeletal maturation by using a
computed X-ray Densitometry methodcomputed X-ray Densitometry method
 This study was conducted in japan in the year 1995.This study was conducted in japan in the year 1995.
 The aim of this study was to obtain data about boneThe aim of this study was to obtain data about bone
density in normal children.density in normal children.
 It examined relationships between bone density,It examined relationships between bone density,
chronological age, bone age and cephalometricchronological age, bone age and cephalometric
measurements. The subjects consisted of 462 girls andmeasurements. The subjects consisted of 462 girls and
298 boys from 6-20 years.298 boys from 6-20 years.
 Hand wrist pictures were taken of all the subjects andHand wrist pictures were taken of all the subjects and
the densitometric pattern of the 2the densitometric pattern of the 2ndnd
metacarpal bone wasmetacarpal bone was
measured by computed x-ray densitometry methodmeasured by computed x-ray densitometry method

Results:Results:
 Bone density increased significantly until the age of 14Bone density increased significantly until the age of 14
years in girls and 16 years in boys.years in girls and 16 years in boys.
 There were differences between the sexes at each age.There were differences between the sexes at each age.
Bone density showed a strong co-relation with bone ageBone density showed a strong co-relation with bone age
rather than chronological age. Therefore Bone Densityrather than chronological age. Therefore Bone Density
may be an efficient indicator for estimating bonemay be an efficient indicator for estimating bone
maturation in a person.maturation in a person.

ConclusionConclusion
 Maturational development embodies the biologicMaturational development embodies the biologic
progression through life. In the growing years,progression through life. In the growing years,
indicators of the level of maturational development ofindicators of the level of maturational development of
the individual provide the best means for evaluatingthe individual provide the best means for evaluating
biologic age.biologic age.
 Maturational development can be assed with the helpMaturational development can be assed with the help
of all the indicators previously described.of all the indicators previously described.
 However, it must be kept in mind that every childHowever, it must be kept in mind that every child
demonstrates a unique sequential pattern of events.demonstrates a unique sequential pattern of events.
No child is the same as the other.No child is the same as the other.

 Skeletal indicators of maturation have been proved toSkeletal indicators of maturation have been proved to
be the most reliable. A combination of skeletal andbe the most reliable. A combination of skeletal and
dental indicators tend to give a very accurate picturedental indicators tend to give a very accurate picture
of each child’s developmental status.of each child’s developmental status.
 Finally it must be kept in mind that in orthodonticFinally it must be kept in mind that in orthodontic
practice it may be more relevant to evaluate thepractice it may be more relevant to evaluate the
development of the patient in relation to his owndevelopment of the patient in relation to his own
growth potential in order to assess whether peakgrowth potential in order to assess whether peak
velocity growth is imminent, present or completed.velocity growth is imminent, present or completed.
The choice of indicators to be used finallyThe choice of indicators to be used finally
depends upon an orthodontist’s preference.depends upon an orthodontist’s preference.

BibliographyBibliography
 Hand book of orthodontics – R.E.Moyers, 4Hand book of orthodontics – R.E.Moyers, 4thth
eded
 Orthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. GraberOrthodontic Diagnosis - Thomas Rakosi, I Jonas and T M. Graber
 Contemporary Orthodontics – W.R.Proffit, 3Contemporary Orthodontics – W.R.Proffit, 3rdrd
eded
 Facial Growth – D.H.Enlow, 3Facial Growth – D.H.Enlow, 3rdrd
eded
 Orthodontics – current principles and techniques – T.M.Graber,Orthodontics – current principles and techniques – T.M.Graber,
R.L.Vanarsdall 3R.L.Vanarsdall 3rdrd
eded
 Leonard S. Fishman :Radiographic Evaluation of SkeletalLeonard S. Fishman :Radiographic Evaluation of Skeletal
Maturation. Angle orthod vol.52, No.2 april 1982.Maturation. Angle orthod vol.52, No.2 april 1982.
 Julian Singer: Physiologic timing of orthodontic treatment. AngleJulian Singer: Physiologic timing of orthodontic treatment. Angle
Orthod 1980, pg-322-333Orthod 1980, pg-322-333
 Hassel, Farman : Skeletal maturation evaluation using cervicalHassel, Farman : Skeletal maturation evaluation using cervical
vertebrae. AJODO 1995; 107:58-66.vertebrae. AJODO 1995; 107:58-66.

 Rajagopal.R, Kansal.S : A Comparision of modified MP3 stages andRajagopal.R, Kansal.S : A Comparision of modified MP3 stages and
the cervical vertrbrae as growth indicators. JCO/JULY 2002the cervical vertrbrae as growth indicators. JCO/JULY 2002
 Revelo.B, Fishman.L.S : Maturational evaluation of ossification ofRevelo.B, Fishman.L.S : Maturational evaluation of ossification of
the midpalatal suture. AJODO 1994; 105;288-92the midpalatal suture. AJODO 1994; 105;288-92
 CP Singer, AH Mamandras, WS Hunter : The Depth of theCP Singer, AH Mamandras, WS Hunter : The Depth of the
mandibular antegonial notch as an indicator of mandibular growthmandibular antegonial notch as an indicator of mandibular growth
potential. AJODO 1987; 91; 117-24.potential. AJODO 1987; 91; 117-24.
 Todd Aki, RS Nanda, Frans Currier : Assessment of SymphysisTodd Aki, RS Nanda, Frans Currier : Assessment of Symphysis
morphology as a predictor of the direction of mandibular growth.morphology as a predictor of the direction of mandibular growth.
AJODO 1994; 106; 60-9.AJODO 1994; 106; 60-9.
 Engstrom.C Engstrom.H, Sagne.s : Lower third molar developmentEngstrom.C Engstrom.H, Sagne.s : Lower third molar development
in relation to skeletal maturity and chronological age. Anglein relation to skeletal maturity and chronological age. Angle
orthodontist; vol.53, no.2, april 1983.orthodontist; vol.53, no.2, april 1983.
 Sabin Ruf, Hans Pancherz : Frontal sinus development as anSabin Ruf, Hans Pancherz : Frontal sinus development as an
indicator for somatic maturity at puberty? AJO-DO 1996;110;476-indicator for somatic maturity at puberty? AJO-DO 1996;110;476-
82.82. www.indiandentalacademy.com

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