Skeletal maturity indicator

Functional Matrix
Hypothesis
(Moss’ Hypothesis-1968
www.indiandentalacademy.com

Functional Matrix Hypothesis
(Moss’ Hypothesis-1968)
“The functional matrix is primary and the
presence, size, shape, spatial position, and
growth of any skeletal unit is secondary,
compensatory, and mechanically obligated to
changes in the size, shape, spatial position of
its related functional matrix”
PROFESSOR MEVLIN L MOSS

Functional Matrix Hypothesis
(Moss’ Hypothesis)
“The origin, development and maintenance of
all skeletal units are secondary, compensatory
and mechanically obligatory responses to
temporally and operationally prior demands of
related functional matrices.”www.indiandentalacademy.com

The functional cranial component is
divided into two:
• Functional Matrix
• Skeletal Unit.
•All the tissues, organs and spaces comprise the
functional matrix
•Skeletal matrix comprises the skeletal unit.

Skeletal unit:
 All skeletal tissues associated with a single
function are called “skeletal unit”. E.g. bone,
cartilage and tendinious tissue.
When a bone is comprised of several contiguous skeletal units,
they are termed as “micro- skeletal units”.
Maxilla and Mandible are comprised of number of such Micro-
Skeletal Units.
e.g. Mandible: alveolar,angular,condylar,gonial,mental,coronoid
and Basal skeletal units.
Maxilla: Orbit, Pneumatic,, palatal micro skeletal units.www.indiandentalacademy.com

Types of Functional Matrix
1. Periosteal matrix
(e.g., muscles, blood vessels,
nerves and glands)
Act directly on skeletal units
Deposition and resorption
Affect size and/or shape
2. Capsular matrix
(e.g., brain, oral cavity)
Passive growth
No deposition
No resorption
Affect location

Growth
Active growth (Periosteal)
+
Passive growth (Capsular)
=
Total growth
Craniofacial Growth
Active growth process
1) Sutural growth
2) Bone remodeling
3) Cephalic cartilage growth
Passive growth process
1) The growth of neural,
orbital, CSF, and other
masses and real substances
2) The expansion of oro- naso-
pharyngeal and other functioning
spaces

He theorizes that growth of face
occurs as response to functional needs
and neurotrophic influences, and is
mediated by the soft tissue in which
the jaws are embedded.
The soft tissues grow, and both bone and
cartilage react.

 The growth of cranium is a
direct response to the growth of
the brain.
 Pressure exerted by the growing
brain separates the bones at
sutures, and new bone passively
fills in at these sites .
e.g. Microcephaly &
Hydrocephaly are
explanatory.

 Enlarged eye or small eye causes a
corresponding change in the orbital cavity.
 Moss theorizes that major determinant of
growth of maxilla and mandible is enlargement
of nasal and oral cavities, which grow in
response to functional needs.
 Absence of normal function would have wide-
ranging effects.

 Resulting loss of condyle in condylar # does
not impede mandibular growth.
 Children in whom a growth deficit occurs,
may be due to interference with normal
function.
 Mandibular Ankylosis.
 Infection or trauma in the TMJ, leading to
scarring causes mechanical restriction, thus
impeding the growth .

Illizarow: 1950
 Demonstrated that bone can be induced to
grow at surgically created sites by a method
called Distraction osteogenesis.
“If cuts were made through
the cortex of any bone, they
could be lengthened by
applying graduated traction
(.5-1.5mm/day) after initial
callus formation (7 days).
Large amounts of new bone
can be formed in between the
cut segments”. www.indiandentalacademy.com

Distraction osteogenesis is now a days
widely used in lengthening Arms or
legs by several centimeters.
In 1992, McCarthy et al, reported the first
clinical cases of mandibular lengthening
by gradual distraction.
Molina et al, reported mandibular
elongation by distraction as a farewell to
major osteotomies.
Reconstruction of mandibular and
maxillary defects, treating patients
with “hemi facial microsomia” is
done now a days by distraction
osteogenesis. www.indiandentalacademy.com

Mouth breathing children tend to have
higher mandibular inclination and more
vertical growth. These findings support
the influence of the breathing mode in
craniofacial development.
V.71, n.2, 156-60, mar./apr. 2005
Fernanda Campos Rosetti Lessa,etal
Otorrinolaringol.

Obliterative osteogenesis occurred in the
inter nasal suture (synostosis) in the group of rats
with reduced masticatory function. Thus,
it seems that masticatory function may influence
suture closure.
The European Journal of Orthodontics 1986 8(4):271-279;
doi:10.1093/ejo/8.4.271
© 1986 by European Orthodontic Society
Christer Engström, Stavros Kiliaridis and etal

Skeletal Maturity Indicators

Teacher: " Where were U born?
Sardar : In Tiruvanantapuram.
Teacher: Spell it?
Sardar : (after thinking) I think I was born in GOA.
Thought for the Day!!!
If you call your mother as MUM..
What will you call Mother's younger
sis and elder sis?

Answer : MINIMUM &
MAXIMUM

Introduction
 Chronological age is often not sufficient for
assessing the developmental stage and
somatic maturity of the patient.
 The biological age is determined from the
skeletal, dental and morphologic age and
the onset of puberty.
 Due to individual variations in timing, duration
and velocity of growth, skeletal age
assessment is essential in formulating viable
orthodontic treatment plans.

Skeletal maturation refers to the degree of
development of ossification in bone. Size and
maturation can vary independently of each
other.
During growth, every bone goes through a
series of changes that can be seen
radiologically. The sequence of changes is
relatively consistent for a given bone in every
person. The timing of the changes varies
because each person has his or her own
biologic clock.

SKELETAL MATURITY
INDICATORS PROVIDE
AN OBJECTIVE
DIAGNOSTIC
EVALUATION OF
STAGE OF MATURITY
IN AN INDIVIDUAL

Biologic age, skeletal age, bone age, and skeletal maturation
are nearly synonymous terms used to describe the stages of
maturation of a person
The technique for assessing skeletal age
consists of visual inspection of bones— their
initial appearance and their subsequent
ossification changes in shape and size.
Various areas of the skeleton have been used:
the foot, the ankle, the hip, the elbow, the
hand-wrist, and the cervical vertebrae

METHODS AVAILABLE TO ASSESS THE
SKELETALMATURITY
OF AN INDIVIDUAL--
1.USE OF HAND WRIST X-RAYS
2.EVALUATION OF SKELETAL MATURATION
USING CERVICAL VERTEBRAE
3.ASSESMENT OF MATURITY BY CLINICAL AND
RADIOGRAPHIC EXAMINATION OF DIFFERENT STAGES
OF TOOTH DEVELOPMENT.

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

Anatomical Region Suitable For Skeletal
Maturational Assessment
 Head and Neck : Skull
Cervical Vertebrae
 Upper Limb :Shoulder Joint-Scapula
Elbow
Hand Wrist and Fingers
 Lower Limb : Femur and Humerus
Hip joint
Knee
Ankle
Foot tarsals and Meta tarsals
 Tooth mineralization as an indicator.
 Frontal sinus

Hand wrist radiograph
One important diagnostic
tool currently used in
determining whether the
pubertal growth has
started, is occurring, or
has finished is the hand-
wrist radiographic
evaluation.

Roland, in 1896, introduced the
idea of using the comparative
size and shape of the
radiographic shadows of growing
bones as indicators of rate of
growth and maturity.
Hellman published his
observations on the ossification
of epiphysial cartilages of the
hand in 1928.

Flory in 1936, indicated that the
beginning of calcification of the carpal
sesamoid (adductor sesamoid) was a
good guide to determining the period
immediately before puberty.
The appearance of the adductor
sesamoid has been highly correlated
to peak height velocity and the start of
the adolescent growth spurt. Most
authors agree that peak height
velocity follows adductor sesamoid
appearance by approximately 1 year.

Fishman developed a system of hand-wrist skeletal
maturation indicators (SMIs) using four stages of
bone maturation at six anatomic sites on the hand
and the wrist.
Others who contributed are Tanner-
white,maria.t.oreilly,shigemi
Goto,Rajagopal, Bjork, Grave and
Brown,schopf

Hand Wrist Radiographs
 Assessment of the skeletal age is often made
with the help of a hand radiograph which can
be considered the Biological clock.
 Hand wrist region is made up of numerous
small bones. These bone show a predictable
and scheduled pattern of appearance,
ossification and union from birth to maturity.
Hence, this region is one of the most suited
to study growth.

Anatomy of Hand-Wrist
The hand wrist
region is made of
four groups of bones
1.Distal ends of long
bones of forearm.
2.Carpal
3.Metacarpals
4.Phalanges

Anatomy of skeleton of Hand

Indication Of Hand Wrist Radiographs
 In patients who exhibit major discrepancy between
dental and chronologic age.
 Determination of skeletal maturity status prior to
treatment of skeletal malocclusion.
 To assess the skeletal age in a patient whose
growth is affected by infections, neoplastic or
traumatic conditions.
 Help to predict future skeletal maturation rate and
status.
 To predict the pubertal growth spurt.

ANATOMY OF
HAND AND WRIST

Methods Of Assessing Skeletal Age
 Bjork ,Grave and Brown method
 Fishman’s skeletal maturity indicators
 Hagg and Taranger method
 Atlas method by Greulich and Pyle

SHE
LOOK’S
TOO
PRETTY
TRY TO
CATCH
HER
CARPEL’S INDEX

SCAPHOID
LUNATE
TRIQUETRAL
PISIFORM
TRAPEZIUM
TRAPEZOID
CAPITATE
HAMMATE
PROXIMAL ROWS
DISTAL ROW
CARPELS INDEX
CONSISTS OF EIGHT SMALL IRREGULARLY SHAPED BONES ARRANGED
IN 2 ROWS- - PROXIMAL ROW AND DISYAL ROW

Fishman Skeletal Maturity Indicators
 Proposed by Leonard S
Fishman in 1982.
 Make use of anatomical
sites located on thumb,
third finger, fifth finger
and Radius .

The Fishman’s system of interpretation
Uses four stages
of bone maturation 1.Epiphysis equal in width to diaphysis
 2.Appearence of adductor sesamoid of thumb
 3.Capping of epiphysis.
 4.Fusion of epiphysis

FISHMAN’S ELEVEN
SMI’S

Fishman method –Eleven SMIsWidth 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 Radiuswww.indiandentalacademy.com

Maturation Assessment by Hagg and
Taranger
 Analyzed from radiograph taken between the
ages of 6 and 18 years, by assessing of the
ossification of the ulnar sesamoid of the
metacarpophalangeal joint of first finger.
 Certain specified stages of 3 epiphyseal bone
-Middle and distal phalanges of third finger
[MP3 and DP3] and distal epiphysis of
Radius.

Sesamoid
 Sesamoid is usually attained during the
acceleration period of the pubertal growth
spurt [onset of peak height velocity]
The appearance of the adductor
sesamoid has been highly correlated
to peak height velocity and the start
of the adolescent growth spurt. Most
authors agree that peak height
velocity follows adductor sesamoid
appearance by approximately 1
year. www.indiandentalacademy.com

Modified MP3 Cervical Vertebrae
MP3-F Stage
 Start of the curve of pubertal growth spurt .
 Epiphysis is as wide as metaphysis
 End of epiphysis are tapered and rounded.
 Radiolucent gap [cartilageous epiphyseal growth
plate] between epiphysis and metaphysis is 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

Cervical vertebra
The first seven vertebrae in the spinal column constitute the
cervical spine. The first two, the atlas and the axis, are quite
unique, the third through the seventh have great similarity
Vertebral growth takes place from the cartilagenous layer on the
superior and inferior surfaces of each vertebrae.Secondary
ossification nuclei on the tips of the bifid spinous processes and
transverse processes appear during puberty.Secondary ossification
nuclei unite with the spinous processes when vertebral growth is
complete.

Cervical maturation and age

DON’T EVER TRY THIS!!!!!!!!!!!!BOY’Swww.indiandentalacademy.com

 Acceleration of the curve of pubertal growth spurt.
 Epiphysis is as wide as metaphysis.
 Distinct medial and lateral border of epiphysis forms
line of demarcation at right angle to distal border.
 Metaphysis begins to show slight undulation.
 Radiolucent gap between metaphysis 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.
MP3-FG Stage CVMI-2

• MP3-G Stage CVMI-3
 Maximum point of pubertal growth spurt.
 Sides of epiphysis have thickened and cap
its metaphysis, forming sharp distal edge
on one or both the sides.
 Marked undulations in metaphysis give it
“Cupid’s bow’’ appearance.
 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.

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

MP3-I Stage CVMI-6
 End of pubertal growth spurt
 Fusion of epiphysis and metaphysis complete.
 No radiolucent gap.
 Dense, radiopaque epiphyseal line forms
integral part of proximal 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.

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

Radius
 R-1:Fusion of the epiphysis and Metaphysis has
began.
-This stage is attained 1 year before or at the end of
growth spurt.
 R-1J:Fusion is almost completed but there is still a
small cap at one or both margin.
 R-J:Characterised by fusion of the epiphysis and
metaphysis.
These stages were not attained before end of PHV.

Bjork , Grave And Brown Method
Male Female
Stage1 PP2 = 10.6yr 8.1
Stage2 MP3 = 12.2 8.1
Stage3 Pisi,
H1,R=
12.6 9.6
Stage4 S & H2 13.0 10.6
Stage5 MP3,R
PP1cap
14.0 11.0
Stage6 DP3U 15.0 13.0
Stage7 PP3U 15.9 13.3
Stage8 MP3U 15.9 13.9
Stage9 RU 18.5 16.0www.indiandentalacademy.com

MOTHER-IN-LAW:
When you rearrange the letters:
WOMAN HITLER

THE EYES:
When you rearrange the letters:
THEY SEE

If utilized properly hand-wrist radiograph and cervical
vertebra radiograph provide a reliable and efficient means
of development assessment.
Simple reference on the assumption that skeletal age or
rather normal skeletal age for a specific chronologic age as
a reasonable indicator of maturity is not justified
Studies have shown that healthy children of any age do not
demonstrate any chronological specificity regarding
particular stages of maturation
conclusion

THANK YOU

Skeletal maturity indicator

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Viewers also liked

Viewers also liked (7)

Similar to Skeletal maturity indicator

Similar to Skeletal maturity indicator (20)

More from Indian dental academy

More from Indian dental academy (20)

Recently uploaded

Recently uploaded (20)

Skeletal maturity indicator

Editor's Notes