Tooth mineralization and sesamoid

The Relationship Between
Tooth Mineralization and Early
Radiographic Evidence of the
Ulnar Sesamoid
www.indiandentalacademy.com

This study investigates the relationship
b/w the stages of mineralization of
various teeth and early radiographic
evidence of calcification of sesamoid
among South African white boys and
girls.
Sample size – 140 (93 girls, 47 boys)
OPG of jaws and teeth and left hand
wrist X-rays were examined.
The criterion for selection was based on
the appearance of a calcified sesamoid
of atleast one mm diameter.

Skeletal age was given to each
individual using T.W.2 method (Tanner,
Whitehouse, Marshall, Healy and
Goldstein, 1975.)
The OPGs were examined and tooth
mineralization on the left side rated
according to the method described by
Demerjian et al, 1973.
The range of the stages ascribed to the
state of development of the teeth used
in the study varied from C to H.

The maxillary posterior teeth were omitted
from the study because superimposition of
calcified structures in this area rendered
accurate assessment of the state of
development of these teeth virtually
impossible.
Incisors and first molar teeth were not rated
because apical closure had already taken
place in all the subjects selected.
Third molars were also excluded from the
study.
The teeth examined were thus the maxillary
and mandibular canines, mandibular first and
second premolars and mandibular second
molars.

Discussion, Result and Summary
The role of the sesamoid as a maturity indicator was
described by many authors.
Ossification usually commences during the year prior
to, or at the time of, commencement of the pubertal
growth spurt.
The radiographic of mineralization is easily
recognised.
The findings of the present study suggests that
ossification of the sesamoid commences two years
earlier in SA girls when compared with boys, at a
mean age of 11.3 years.
The relationship b/w early commencement of
calcification of the sesamoid and the state of
mineralization of individual teeth studied varied from
tooth to tooth. www.indiandentalacademy.com

No close relationship could be shown b/w SM and
mineralisation of lower premolar and second molar
teeth. These findings were in accordance with the
other studies (Lewis and Garn, 1960)
The maturation patterns of these teeth varied
widely within the sample with a distinct tendency
towards an acceleration in the rate of tooth
calcification in boys.
However, the stages of calcification related to
maxillary and mandibular canine teeth were far
narrower.
The state of the development of the mandibular
canine in particular was closely related to the early
ossification of sesamoid in boys as well as girls
having reached stage G (prior to apical closure).

Significant sex differences in the distribution of
the stages of the tooth mineralisation were
evident in all teeth studied with the exception of
mandibular canine.
Tooth development in boys tended to be
accelerated in relation to skeletal maturity when
compared with girls.
The close relationship b/w calcification stage G
of the mandibular canine and calcification of the
sesamoid raises the possibility of use of this
tooth as a maturity indicator for the
commencement of pubertal growth spurt in
South African Caucasian children.

Completion of mineralisation of mandibular canine
root prior to apical closure may thus herald the onset
of adolescent Peak Growth Velocity in height as well
as commencement of calcification of adductor
sesamoid.
However, the relationship b/w skeletal maturation
and dental mineralization may vary in different
population groups.
It is a well documented fact that dental development
is accelerated among black races of South Africa
compared with Caucasian whites.
The above was confirmed by Chertkow in 1980 in a
study in which he included Black South Africans.
For this reason these findings should be applied to
other population groups with caution.

Relationship between
mandibular canine
calcification stages & skeletal
maturity
AJO 1993, 104: 262-8
Sandra Coutinho – Guam
Peter H. Buschang – Bylor, Dallas
Tx
Francis Miranda – Bylor, Dallas Tx

Knowledge of the stage of maturation that a child has
attained helps in evaluating his or her progression through
expected developmental events. Such information is
clinically important in:
1) Helps interdisciplinary health teams assessing patients
with various types of short stature, endocrine disorders,
and/or metabolic diseases.
Its utility is well established in syndrome identification and
forensics.
2) A child’s maturity status helps better identify optimal time
for certain types of orthopedic treatments.
Variations exist between individual children in the ages at
which they attain similar developmental events.
In addition, there are diseases, systemic disorders and
environmental factors that may affect child’s physiologic
maturity.

Relationship between the stages of tooth mineralization of
mandibular canine appear to co relate better with ossification
stages than the other teeth (studies by Chertkow 1979, 80 and
Alicia M. Sierra in 1987)
Interrelationship between skeletal, somatic and sexual maturity
have shown to be consistently strong.(Demirjian 1985AJO)
Given the well established relation between skeletal and
somatic maturity, stages of calcification of the mandibular
canine might be used as a first level diagnostic tool to estimate
timing of pubertal growth spurt.
Ease of recognizing dental developmental stages, together with
the availability of intra oral or panoramic radiographs in most
orthodontic or paediatric practice are practical reasons for
attempting to assess a person’s physiologic maturity without
resorting to multiple hand wrist radiographs.
The purpose of this study was to verify relationships between
canine calcifications and skeletal maturity.

Materials and Methods
Pre treatment dental OPG – 200 boys,
215 girls between 7 – 165 years.
Skeletal age determined from hand
wrist radiographs and assessed
according to Pyle and Greulich.

The phalangeal
maturity stages and
appearance of
adductor sesamoid
were defined by
using the Tanner
Whitehouse method.

• The development of the mandibular canines
were assessed according to Demirjian stages
of dental calification.

Results
Mean skeletal age for the presence of
the adductor sesamoid in girls 12.2
years and boys 13.2 years.
The middle phalanx of the third finger
shows the highest relationship with
canine maturity for both sexes, followed
by PP5, DP3.
The PP3 and adductor sesamoid show
similar patterns of association with
canine maturation.

Most subjects having attained mandibular canine
stage F show no presence of adductor sesamoid.
Stage F – epiphysis of MP3 and MP5 equal to
diaphysis. This stage indicates initiation of growth
spurt.
Stage G – Eruption of the canine into the oral
cavity.
Shows adductor sesamoid.
Capping of MP3, DP3, PP5.
1 year before PHV in boys.
5 months before PHV in girls.
Stage H – Stage of apical closure. Fusion of
epiphysis to diaphysis.

Conclusion
Close association exists between mandibular canine
calcification stages and skeletal maturity indicators.
The intermediate stage between stages F and G should be
used to identify early stages of pubertal growth spurt.
While there is a close relationship between canine
calcification and skeletal maturation, canine calcification
cannot and should not be used as a sole criterion to predict
developmental landmarks (I.e., onset of puberty, PHV etc.)
Dental calcification stages of mandibular canine are readily
available and easily recognized indicators of maturity status
of a person. They are simple, first level diagnostic test to
determine whether additional, more sensitive measures of
maturity are needed.

Relationships Between
Dental Calcification Stages
and Skeletal Maturity
Indicators in Thai
Individuals
Suleekorn Krailassiri, DDS;
Niwat Anuwongnukroh, DDS, MSD;
Surachai Dechkunakorn, DDS, D Ortho
Angle Orthodontics, 2002.

INTRODUCTION
It is important to know the stage of maturation of a
patient.
Assessing maturational status, whether the pubertal
growth spurt of that patient has been reached or
completed, can have a considerable influence on
diagnosis, treatment goals, treatment planning, and
the eventual outcome of orthodontic treatment.
This is especially true when clinical considerations
are based strongly on the increased or decreased
rates of craniofacial growth, such as the timing and
use of extraoral traction, the use of functional
appliances, extraction vs non extraction, the
selection and execution of orthodontic retention,
and the timing of orthognathic surgery.www.indiandentalacademy.com

Physiological age can be estimated by somatic,
sexual, skeletal, and dental maturity.
Somatic maturity is recognized by the annual growth
increments in height or weight.
The changes of secondary sex characteristics, voice
changes in boys and menarche in girls, are
characterized as sexual maturity.
The usefulness of the 2 maturity indicators has
limited value for the immediate clinical judgment of a
patient’s maturity stage because these indicators
can be applied only after the serial recording of
height or the inception of puberty.
The technique for assessing skeletal maturity
consists of visual inspection of the developing bones
— their initial appearance and their subsequent
ossification-related changes in shape and size.www.indiandentalacademy.com

Various areas of the skeleton have been used: the
foot, the ankle, the hip, the elbow, the hand-wrist,
and the cervical vertebrae.
The hand-wrist radiograph is commonly used for
skeletal developmental assessment.
Most investigators have found significant correlation
among maturation stages derived from hand-wrist
radiographs, changes in height during pubertal
growth period, and facial growth.
The last physiologic measure is dental maturity,
which can be determined by the stage of tooth
eruption or the stage of tooth formation.
The latter is proposed as a more reliable criterion for
determining dental maturation.

If a strong association exists between skeletal
maturity and dental calcification stages, the stages
of dental calcification might be used as a first-level
diagnostic tool to estimate the timing of the
pubertal growth spurt.
The ease of recognizing dental developmental
stages, together with the availability of intraoral or
panoramic radiographs in most orthodontic or
pediatric dental practices, are practical reasons for
attempting to assess physiologic maturity without
resorting to hand-wrist radiographs.

Relationships between the calcification
stages of individual teeth and skeletal
maturity have been previously reported.
Racial variations in the relationships
have also been suggested.
Unfortunately, little is known of this
relationship in Thai children and
adolescents.

AIM
The purpose of this study was to investigate
the relationship between the stages of
calcification of various teeth and skeletal
maturity stages among Thai individuals.
The objective of this study was to investigate
the relationships between the stages of
maturity stages among Thai individuals.
The findings from this study will establish a
valid clinical tool for indicators of the pubertal
growth period in Thai children, adolescents,
and young adults without the necessity of
resorting to hand-wrist radiographs.

Assessment of dental calcification
stage
From several investigators (Demerjian and
others) the tooth calcification of homologous
teeth was found to be symmetrical; therefore,
only left mandibular teeth in panoramic
radiographs were examined.
In the case of any missing left mandibular
teeth, the right teeth corresponding to the
missing teeth were substituted.
The maxillary posterior teeth were omitted
from the study because superimposition of
calcified structures in this area resulted in
inaccurate assessment of the stage of
development of these teeth.www.indiandentalacademy.com

Mandibular incisors as well as first molars
were not rated because apical closure had
already taken place.
The teeth examined were thus the mandibular
canines, the first and second premolars, and
the second and third molars.
Tooth calcification was rated according to the
method described by Demirjian et al in which
one of 8 stages of calcification, A to H, was
assigned for each tooth.

Assessment of skeletal age
Each hand-wrist radiograph was
assigned a skeletal age by comparing it
with the standard plates in the
Radiographic Atlas of Skeletal
Development of the Hand and Wrist
(Greulich and Pyle, 1959).

Assessment of skeletal maturity stage
To evaluate the stage of skeletal maturation of
each hand-wrist radiograph according to the
method described by Fishman, the following
selected ossification events were determined:
MP3 : the middle phalanx of the third finger, the
epiphysis equals its diaphysis
S stage: the first mineralization of the ulnar
sesamoid bone
MP3cap : the middle phalanx of the third finger,
the epiphysis caps its diaphysis
DP3u : the distal phalanx of the third finger,
complete epiphyseal union
MP3u : the middle phalanx of the third finger,
complete epiphyseal unionwww.indiandentalacademy.com

Results
The mean ages for each stage of skeletal
maturity were consistently younger in female
subjects.
The mean chronological age of the female
group was approximately 1.5 years (range,
1.3 years through 1.8 years) younger than
that of the male group.
The tooth sequence in order of the highest to
the lowest correlation for male subjects was
the second premolar, the first premolar, the
second molar, the canine, and the third
molar; the corresponding sequence in female
subjects was the second premolar, the
second molar, the first premolar as well as
the canine, and the third molar.www.indiandentalacademy.com

The second premolar was the tooth showing the
highest correlation for male and female subjects.
The third molar showed the lowest correlation for
both sexes.
At the MP3 stage, the canine stage F and the
second premolar stage E in female subjects
showed the highest percent distribution.
For male subjects the canine stage F also
presented the highest distribution among all of
the teeth studied.
At the S stage, in female subjects, the second
premolar stage F and the second molar stage E
demonstrated highest distribution, whereas in
male subjects, no tooth calcification stages in
any teeth studied had a distribution greater than
50%. www.indiandentalacademy.com

At the MP3cap stage, wide distribution of tooth
calcification stages was clearly seen in all of the
teeth for female subjects, with less than 50% in
each stage.
For male subjects, root formation of the canine as
well as the first premolar was completed (stage
H) in the majority of the subjects, and the second
molar development was highly concentrated in
stage G.
At the DP3u stage, in female subjects, most of
the canine and first premolars were in stage H.

In male subjects, the root formation of most of
the teeth, with the exception of the second
molar, has attained stage H.
At the MP3u stage, in both sexes, most of the
tooth formation of all of the teeth, with the
exception of the second molar, showed stage
H calcification.
The second molar development was
approximately equally distributed between
stages G and H.

DISCUSSION
Dental maturity assessment
Panoramic radiographs were used to assess dental
maturity because they are routinely available in
orthodontic clinics, and the mandibular region is
clearly visible.
There are a number of standard scales for rating the
tooth calcification stage.
The method described by Demirjian et al was
chosen in the present study because its criteria
consist of distinct details based on shape criteria
and proportion of root length, using the relative
value to crown height rather than on absolute length.
Foreshortened or elongated projections of
developing teeth will not affect the reliability of
assessment. www.indiandentalacademy.com

DISCUSSION
Skeletal age assessment
The skeletal age for each hand-wrist
radiograph was assigned according to the
method outlined in the atlas of Greulich and
Pyle, which is quick and relatively easy to
learn and perform.
It is less time consuming and shows greater
reproducibility between observers.
The Greulich and Pyle method seems to be
highly practical for clinical use in skeletal age
assessment.
It is, however, essential to bear in mind the
differences between the local population and
the reference population used to define the
standards in the atlas.www.indiandentalacademy.com

By the time the skeletal age assessment was performed,
hand-wrist radiographs from male subjects clearly differed
from the standard plates more frequently than those of the
female subjects, particularly in the carpal bone area, which
always showed less maturity compared with the other
bones.
This observation corresponded with the findings of
Acheson et al and Carpenter and Lester, who found that
the maturity of the carpal bones varies greatly and
influences skeletal age assessment.
Carpenter and Lester suggested that when reading the
skeletal age by comparing the hand-wrist radiographs with
the Greulich and Pyle atlas, clinicians should be careful to
examine the entire radiograph and should place less
emphasis on the carpal bones.
As a result, during the skeletal age assessment in this
study, the examiners also paid more attention to the entire
radiograph. www.indiandentalacademy.com

DISCUSSION
Skeletal maturity assessment
In this study, the skeletal maturity assessment
was based on the system of Fishman.
This technique offers an organized and relatively
simple approach to determine the level of
maturation.
The system uses only 11 anatomical sites located
on the phalanges, the adductor sesamoid, and the
radius, all of which exhibit consistency in the time
of onset of ossification.
It is also an advantage to exclude the carpals
from the system since irregularity in the order of
onset of ossification occurs more frequently in the
carpals than in the metacarpal or phalangeal
epiphyses. www.indiandentalacademy.com

To facilitate clear discrimination between the stages
and to provide a good description relative to growth
status, only 5 out of 11 skeletal maturity indicators
used in the system were selected in the present
study.
As illustrated by Fishman, meaningful interpretation
of growth status was represented by these skeletal
maturity stages.
The MP3 stage appears during the onset of
accelerating growth velocity.
The S and the MP3cap stages become visible
during a period of very rapid growth velocity.
The DP3u and MP3u stages coincide with the
time interval of decelerating growth rate.
Female subjects mature earlier than male subjects by
an average of 1.5 years.www.indiandentalacademy.com

The first 3 stages, MP3 , S, and MP3cap ,
demonstrated smaller deviations between
skeletal and chronological ages than did the
DP3u and the MP3u stages.
Cole and coworkers explained that there are
3 sources for the discrepancy between
skeletal age and chronological age:
1.natural variations between individuals in their
rates of skeletal maturation,
2.systematic error inherent in the method used
to assess skeletal age, and
3.variation between different observers.

DISCUSSION
Dental and skeletal maturity
Maturation patterns of tooth development have shown
that male individuals tend to be more advanced as
compared with female individuals in relation to skeletal
maturity stages.
At the same skeletal maturity stage, male subjects had
a higher distribution toward late dental developmental
stages, whereas the opposite pattern was present in
female subjects.
This result was similar to that obtained by Chertkow,
who studied the relationship between early presence
of ulnar sesamoid and tooth mineralization in 66 white
and 22 black boys and 93 white and 16 black girls in
South Africa and reported that a markedly more
advanced trend in tooth calcification was evident
among the boys.

It is suggested that tooth mineralization
relative to stages of skeletal maturation be
considered individually for male and female
individuals.
The correlation coefficients between skeletal
maturity and calcification stages of the teeth,
with the exception of the third molar, were
quite high.
For both sexes, a weak correlation was found
between the lower third molar development
and skeletal maturity.
This finding agreed with those of Garn et al,
and Demerjian et al, who reported a poor
relationship between third molar formation
and skeletal maturity.www.indiandentalacademy.com

However, in contrast to the finding in the
present study, Engstrom and coworkers
found a strong correlation.
The strong relationship reported may have
resulted from the use of fewer differentiated
stages of mandibular molar development in
their study.
This tooth offers an advantage over other
teeth because its development tends to
continue over a longer period and until a later
age; however, in light of the weak correlation
found in this study, we do not recommend
use of the stage of third molar formation for
comparison with skeletal maturity.

Chertkow; Chertkow and Fatti; Sierra; and
Coutinho et al, have suggested a high relationship
between calcification of mandibular canine and
skeletal maturity indicators.
The present study found a similar trend.
Chertkow and Fatti and Chertkow also reported
that mandibular canine stage G coincided with the
early appearance of the sesamoid in 77% of their
sample and in boys as well as in girls.
In this study, no uniformity in canine development
was found relative to the S stage.
This is in accordance with the study by So (1997),
who found no close relation between early
ossification of the sesamoid and complete root
formation with open apex of the mandibular
canine calcification stage.www.indiandentalacademy.com

It is interesting to note that in the present study,
strong correlations were found in the premolars
and the second molars.
At the MP3 stage, the majority of the canine in
both sexes attained root formation in stage F.
For female subjects, the second premolar stage F
and the second molar stage E showed a high
percentage distribution at the S stage.
For male subjects, the second molar stage G
markedly commenced at the MP3cap stage.

A large number of the canines and first
premolars had already attained apical closure
since the MP3cap stage for male subjects
and the DP3u stage onward for female
subjects.
Therefore, the interpretation of the
relationship between the stage of dental and
skeletal development from these teeth and
the late stages of skeletal maturity was not
meaningful.

Clinical implications
Many investigators have studied the optimal time
for treating patients with orthopedic appliances.
McNamara et al reported that in children treated
with the Frankel appliance, a larger increase of
mandibular length was evidenced at ages
estimated to be closer to puberty than at younger
ages.
Pancherz and Hagg (AJO, 1985), and Hagg and
Pancherz (EJO, 1988) related the effect of
treatment with the Herbst appliance to longitudinal
records of standing height and concluded that the
skeletal effect of the appliance was more
pronounced during the peak height velocity period
than during the prepeak period.

A similar appropriate treatment time was also
suggested by Malmgren et al, who
investigated the skeletal effect of a modified
activator combined with high-pull headgear.
Kopecky et al showed that the skeletal
correction with cervical-pull headgear could
be initiated during the accelerating growth
period and continued through the peak
velocity period, depending on the severity of
skeletal malrelationship.

According to the skeletal maturity stages
assessed from hand-wrist radiographs that
can represent pubertal growth indicators,
orthodontists who expect more orthopedic
effect should consider starting treatment
during the MP3 stage, the S stage (in female
patients), and the MP3cap stage (in male
patients).
Treatment rendered after these stages may
result in more dental rather than skeletal
effects.

From the present study, the relationship
between the tooth calcification stages and the
skeletal maturity indicators probably allows the
clinician to more easily identify the stages of the
pubertal growth period from the panoramic
radiographs.
We found that the canine stage F may represent
the MP3 stage and could serve as a simple tool
for evaluating the onset of the accelerating
growth period.
The second molar stage E for female subjects,
coinciding with the S stage, and the second
molar stage G for male subjects, coinciding with
the MP3cap stage, were indicative of a very
high rate of growth acceleration.

CONCLUSION
The relationship between the stages of
maturity stages was evaluated from dental
panoramic and hand-wrist radiographs of 139
male subjects and 222 female subjects
ranging in age from 7 years to 19 years.
From the correlation coefficients and the
percent distribution of stages, there was a
relationship between dental and skeletal
development; however, the relationship
differed for individual teeth.

At the same skeletal maturity stage, the dental
maturational patterns of male subjects were ahead of
those of female subjects.
The canine stage F for both sexes coincided with the
MP3 stage and indicated the onset of a period of
accelerating growth.
The second molar stage E for female subjects and
stage G for male subjects were related to the S stage
and MP3cap stage, respectively, and were indicative
of the period of very rapid growth velocity.
The findings of this study indicate that tooth
calcification stages might be clinically used as a
maturity indicator of the pubertal growth period.
However, further study is recommended in a larger
sample size, and future studies should address
development of the canines and second molars.www.indiandentalacademy.com

Lower Third Molar
Development in Relation to
Skeletal Maturity and
Chronological Age

Most of the studies correlating dental
maturation to skeletal maturation have
not included the lower third molar.
Engstrom in 1983 conducted a study to
analyse development of the lower third
molar and whether it could be co-
related to skeletal maturity.

A probable reason for the greater variability
seen in the previous studies regarding third
molar development might be because its
development was related to chronological
rather than skeletal age.
This study was conducted on 221 subjects
(123 girls and 88 boys).
The stages of development of lower third
molars were assessed from OPGs.

The developmental stages of the lower
third molar were as follows:
A – Tooth germ visible as a rounded
radiolucency
B – Cusp mineralisation complete
C – Crown formation complete
D – Root half formed
E – Root formation complete but apex
not closed

Hand X-rays of the subjects were taken and
their skeletal development classified as
follows:
PP2 – Proximal phalanx of second finger,
epiphysis as wide as diaphysis
MP3cap – Middle phalanx of third finger,
epiphysis caps its diaphysis
DP3U – Distal phalanx of third finger,
complete epiphyseal union
RU – Distal epiphysis of radius, complete
epiphyseal union

RESULTS
Development of the lower third molar
appeared slightly earlier in boys than
in girls.
Strong correlation was found b/w
chronological age and third molar
development.
Strong correlation was found b/w third
molar development and skeletal
maturity.

At stage PP2 – The third molar showed signs of
completed crown mineralization in most subjects.
At stage MP3cap lower third molar crown
formation was complete in most subjects and root
development had begun in some.
At stage DP3U lower third molar crown was still
incomplete in some subjects but full root length
was attained in others.
At stage RU only the crown was complete in one
third of the subjects, half the root had developed
in one third and full length was seen in another
one third.
The results seem to show that lower third molar
development on the whole seems to be correlated
with skeletal maturation.www.indiandentalacademy.com

Cervical Vertebrae Maturation
Indices
Lamparski, 1972, Univ. of
Pittsburgh
(Masters Thesis)
Hassel and Farman
AJO, 1995.

The Cervical Vertebrae as
Maturational Indicators
PATRICIA GARCÍA-FERNANDEZ
et al, Mexico
JCO 1998

INTRODUCTION
Because of individual variation,
physiological and anatomical maturity
cannot be accurately assessed by age alone.
Other parameters, such as growth velocity,
secondary sex changes, dental development,
and skeletal ossification, have proven of
more value.

The early hope of those who championed the
idea of accurately determining the skeletal age
of patients was to coordinate this information
with orthodontic treatment so as to maximize
the therapeutic effect.
Unfortunately, a low correlation has been
found between general skeletal maturity and
facial growth as measured by common
parameters.

Since the presence, magnitude, and timing of
facial growth have proven so unpredictable,
clinicians have generally lost interest in trying
to coordinate the pubertal growth spurt with
orthodontic therapy.
Orthodontic appliances such as the
Mandibular Protraction Appliance, Herbst,
Fränkel, bionator, and twin block, as well as
cervical and high-pull headgears and
protraction facemasks, will only have the
desired effect in patients who have growth
capability.

Orthodontists do not necessarily need to know
the exact skeletal age of a patient, or how much
individual facial bones may grow during
treatment, or even when that growth is likely to
occur.
They simply need to know whether the patient
will grow at all during a one- or two-year
treatment period and what percentage of growth
can reasonably be expected during that time.

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,
however, some researchers have 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 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.
Other researchers have confirmed the validity of
Lamparski's method of evaluating the skeletal
maturity of orthodontic patients.

AIM
The purpose of the present study was to
determine whether the maturation of
cervical vertebrae would correlate with the
maturation indicated by hand-wrist x-rays
in a Mexican population.

Material and Methods
A total of 113 patients (50 males and 63 females),
age 9 to 18, had cephalometric and hand-wrist
radiographs taken on the same day.
The hand-wrist radiographs were evaluated with a
system developed by Fishman, which uses four
stages of bone maturation found at six sites
located on the thumb, third finger, fifth finger, and
radius.
Eleven adolescent skeletal maturation indicators
(SMI) are found on these six sites.

The sequence of four
ossification stages
includes epiphyseal
widening, ossification
of the sesamoid of the
thumb, capping of
selected epiphyses
over their diaphyses,
and fusion of selected
epiphyses and
diaphyses.
Skeletal maturation
indicators
Stages of ossification
Sites of bone maturation

The percentage of adolescent growth
completed provides a basis for interpreting
the amount of skeletal growth that has
occurred and for predicting future growth.

completed
Female SMI Male
0.00 1 0.00
12.15 2 15.02
22.54 3 21.60
32.73 4 28.92
39.75 5 34.00
51.70 6 52.62
73.58 7 74.29
86.58 8 87.32
91.87 9 91.98
96.14 10 95.34
100.00 11 100.00www.indiandentalacademy.com

Although statural and facial growth show
wide individual variations and do not
proceed equally or simultaneously, there
remains a direct association between the
two, so that SMI have significant clinical
relevance.

Cervical vertebral development of the sample was evaluated by
the Hassel and Farman modification of Lamparski's criteria,
which assesses maturational changes on the second, third, and
fourth cervical vertebrae.
Hand-Wrist
SMI
Cervical
Vertebral
Stages
Percentage of
pubertal
growth
remaining
1 – 2 1. Initiation 85 – 100%
3 – 4 2. Acceleration 65 – 85%
5 – 6 3. Transition 25 – 65%
7 – 8 4. Deceleration 10 – 25%
9 – 10 5. Maturation 5 – 10%

Six distinct stages of growth can be related to
the SMI developed by Fishman :
Initiation (SMI 1 and
2). The vertebrae are
wedge-shaped, with
the superior vertebral
borders tapering from
posterior to anterior.
Eighty to 100 percent
of adolescent growth
can be anticipated at
this stage.

Acceleration (SMI 3 and
4). Growth acceleration
begins at this stage, when
65-85% of adolescent
growth can be
anticipated.
Concavities develop on
the inferior borders of C2
and C3.
The bodies of C3 and C4
are nearly rectangular,
and the inferior border of
C4 is flat.

Transition (SMI 5 and 6).
Adolescent growth
accelerates toward peak
velocity, with 25-65% of
adolescent growth
anticipated.
Distinct concavities
develop on the inferior
borders of C2 and C3.
A concavity begins to
develop on the inferior
border of C4, and the
bodies of C3 and C4 are
rectangular.

Deceleration (SMI 7
and 8). Only 10-25%
of adolescent growth
remains.
Clear concavities are
seen on the inferior
borders of C2, C3, and
C4 with the bodies of
C3 and C4 nearly
square.

Maturation (SMI 9 and
10). Final maturation takes
place at this stage, when
only 5-10% of adolescent
growth can be anticipated.
Accentuated cavities are
seen on the inferior borders
of C2, C3, and C4, and the
bodies of C3 and C4 are
nearly square.

Completion (SMI 11).
Little to no adolescent
growth is expected at this
point.
Deep concavities are
seen on the inferior
borders of C2, C3, and
C4, and the vertebral
bodies are more vertical
than horizontal.

Results
92% of females patients and 96% of the
male patients in this study showed
cervical vertebral maturation matching
that found with hand – wrist technique.

Conclusion
The hypothesis that there is no significant difference
between the two techniques of assessing skeletal
maturation in a Mexican population can be accepted as
valid at the 95% level, for both males and females.
This agrees with findings in other population groups,
suggesting that the cervical vertebrae technique is race
-neutral.
The ability to accurately appraise skeletal maturity from
the cervical vertebrae, without the need for additional
radiographs, has the potential to improve orthodontic
diagnostic and therapeutic decisions.
The technique's simplicity and ease of use should
encourage more orthodontists to use this method to
assess skeletal maturation.www.indiandentalacademy.com

A Comparison of Modified MP3
Stages and the Cervical
Vertebrae
as Growth Indicators
R. RAJAGOPAL, DDS, MDS
SUDHANSHU KANSAL, DDS, MDS
(Saveetha Dental College, Chennai)
JCO, July, 2002.

Introduction
The developmental status of a child can be
assessed with various growth indicators,
including chronological age, dental
development, height and weight, secondary
sexual characteristics, and skeletal age.
The key issue with any of these growth
assessment methods is reliability.
Orthodontists need an accurate method,
based on a cross-sectional study, that does
not require a long observation period.

Because skeletal age has been considered the
most reliable method developed to date, the
current study was devised to determine the
feasibility of using radiographs of the MP3 (the
middle phalanx of the middle finger) as an
indicator of skeletal maturity.
Hagg and Taranger (1980), have described five
stages of MP3 growth, based primarily on
epiphyseal changes, although distinct changes
were also observed in the metaphyseal region.
They have added an additional bone stage
between MP3-H (deceleration of the curve
of the pubertal growth spurt) and MP3-I
(end of the pubertal growth spurt), which
they called the MP3-HI stage, resulting in
a total of six stages of MP3 growth.www.indiandentalacademy.com

Aims and Objectives
Determine whether the six modified
MP3 stages could be correlated with
the six stages of cervical vertebrae
maturation indices (CVMI), as described
by Hassel and Farman.
Evaluate the feasibility of recording
MP3stages using standard dental x-ray
film.

Materials and Methods
The sample consisted of 75 females and 75 males
age 9 to 17, with an equal distribution of males and
females in each age group.
The subjects were selected randomly from patients
visiting the Departments of Orthodontics, Pediatric
Dentistry, and Oral Medicine and Radiology at
Saveetha Dental College and Hospital.
These patients included some with normal
occlusions, some with malocclusions, and some
already undergoing orthodontic treatment.
Lateral cephalograms for recording the CVMI
stages were taken in natural head position
following standard procedure, with patients
standing erect and instructed to look straight into
their own eyes in a mirror placed on the wall.www.indiandentalacademy.com

Periapical radiographs for recording the MP3
stages 3 were taken using the following
procedure:
1. The subject was instructed to place the right
hand with the palm downward on a flat table.
2. The middle finger was centered on a 31mm X
41mm periapical dental x-ray film, parallel with the
long axis of the film.
3. The cone of the dental x-ray machine was
positioned in slight contact with the middle
phalanx, perpendicular to the film.
All radiographs were carefully examined by the
radiologist, and any patients who presented with
congenital or acquired abnormalities of the
cervical vertebrae or phalanges were eliminated
from the study. www.indiandentalacademy.com

Evaluation
Comparative evaluation of the modified MP3
stages and CVMI produced the following
findings.
MP3-F stage: Start of the curve of pubertal
growth spurt.
Features observed by Hagg and Taranger :
1. Epiphysis is as wide as metaphysis.
Additional features observed in this study:
2. Ends of epiphysis are tapered and rounded.
3. Metaphysis shows no undulation.
4. Radiolucent gap (representing cartilageous
epiphyseal growth plate) between epiphysis
and metaphysis is wide.www.indiandentalacademy.com

CVMI-1: Initiation stage of cervical
vertebrae.
1. C2,C3, and C4 inferior vertebral body
borders are flat.
2. Superior vertebral borders are tapered
from posterior to anterior (wedge shape).
3. 80-100% of pubertal growth remains.

MP3-FG stage: Acceleration of the curve of
Features observed by Hagg and Taranger:
1. Epiphysis is as wide as metaphysis.
2. Distinct medial and/or lateral border of
epiphysis forms line of demarcation at right
angle to distal border.
3. Metaphysis begins to show slight
undulation.
4. Radiolucent gap between metaphysis and
epiphysis is wide.

CVMI-2: Acceleration stage of cervical
vertebrae.
1. Concavities are developing in lower borders of
C2 and C3.
2. Lower border of C4 vertebral body is flat.
3. C3 and C4 are more rectangular in shape.

MP3-G stage: Maximum point of pubertal
growth spurt.
1. Sides of epiphysis have thickened and cap
its metaphysis, forming sharp distal edge on
one or both sides.
2. Marked undulations in metaphysis give it
“Cupid’s bow” appearance.
3. Radiolucent gap between epiphysis and
metaphysis is moderate.

CVMI-3: Transition stage of cervical vertebrae.
1. Distinct concavities are seen in lower
borders of C2 and C3.
2. Concavity is developing in lower border of
C4.
3. C3 and C4 are rectangular in shape.

MP3-H stage: Deceleration of the curve of pubertal
growth spurt.
1. Fusion of epiphysis and metaphysis begins.
2. One or both sides of epiphysis form obtuse angle
to distal border.
3. Epiphysis is beginning to narrow.
4. Slight convexity is seen under central part of
metaphysis.
5. Typical “Cupid’s bow” appearance of metaphysis
is absent, but slight undulation is distinctly present.
metaphysis is narrower.

CVMI-4: Deceleration stage of cervical
vertebrae.
1. Distinct concavities are seen in lower
borders of C2,C3, and C4.
2. C3 and C4 are nearly square in shape.

MP3-HI stage: Maturation of the curve of
Features of this “new” stage observed in this
study:
1. Superior surface of epiphysis shows
smooth concavity.
2. Metaphysis shows smooth, convex
surface, almost fitting into reciprocal
concavity of epiphysis.
3. No undulation is present in metaphysis.
metaphysis is insignificant.

CVMI-5: Maturation stage of cervical vertebrae.
1. Accentuated concavities of C2,C3, and C4
inferior vertebral body borders are observed.
2. C3 and C4 are square in shape.

MP3-I stage: End of pubertal growth spurt.
1. Fusion of epiphysis and metaphysis
complete.
2. No radiolucent gap exists between
metaphysis and epiphysis.
3. Dense, radiopaque epiphyseal line forms
integral part of proximal portion of middle
phalanx.

CVMI-6: Completion stage of cervical vertebrae.
1. Deep concavities are present in C2,C3, and C4
inferior vertebral body borders.
2. C3 and C4 are greater in height than in width.
3. Pubertal growth is complete.

In these 150 subjects, the six modified
MP3 stages showed a high correlation
with the six stages of cervical vertebrae,
with an overall similarity of 94.7%.
Radiographs of only 5.3% of the
subjects were dissimilar in at least one
bone stage.

Discussion
Chronological age is an inaccurate indicator of
the stages of dental development through
adolescence to adulthood.
In fact, dental age has a significantly low
correlation with biological age.
Growth prediction based on the appearance of
secondary sexual characteristics requires a long
observation period and frequent physical
examinations.
The skeletal maturity of the bones of the hand
and wrist and the cervical vertebrae, on the
other hand, is closely related to that of the
craniofacial region, and skeletal maturity indices
are reliable predictors of sexual and somatic
maturity as well.www.indiandentalacademy.com

Hagg and Taranger recommended using five
distinct stages of MP3 development (adapted
from Tanner’s classification) as a reliable
biological indicator.
Chapman was the first to use periapical x-ray
film to evaluate ossification of the ulnar
sesamoid bone as a skeletal maturity marker.
Abdel-Kader applied this idea to recording MP3
stages.
As the present study confirms, assessment of
remaining pubertal growth can be reliably
performed throughout treatment using the
modified MP3 stages by taking simple
periapical x-rays, without the need for extra
lateral cephalograms or hand-wrist x-rays.

Conclusion
This study has shown that recording
modified MP3 stages using periapical x-
ray film can be an accurate, simple,
practical, and economical growth
indicator for making decisions on
treatment timing.

Advantages of the modified MP3 stages include:
1. Significantly lower radiation exposure compared
to lateral cephalograms or hand-wrist x-rays.
2. High degree of clarity on the radiographs, with no
superimposition of bones or variations in posture as
in evaluation of the cervical vertebrae.
3. Discrete, easily identifiable stages of
development, unlike the more subtle changes in
CVMI stages.
4. Close correlation to the six stages of CVMI.
5. No need to obtain equipment beyond the
standard periapical x-ray film and dental x-ray
machine.

Further longitudinal studies are needed
to establish the changes observed in
the metaphysis in all stages of MP3 and
to prove the validity of the new MP3-HI
stage.

The reliability of dental X-ray
film in assessment of MP3
stages of pubertal growth
Hussam M. Abdel-Kader, Cairo,
Egypt
AJO, 1998

Introduction
In orthodontics and dentofacial orthopedics,
the assessment of skeletal age and pubertal
growth spurt in particular are of prime
importance in diagnosis, treatment planning,
and retention.
Orthodontists currently use a number of
growth indicators that have been described in
the literature.
The hand-wrist radiograph has been the most
commonly used method.

Hägg and Taranger noted that the
stages of ossification of the middle
phalanx of the third finger of the hand
(MP3 stages) follow the pubertal growth
spurt.
The MP3 stages are five stages
representing the different stages of the
pubertal growth spurt from onset to end.

The first stage,
MP3-F, onset or
start of the
pubertal growth
spurt, corresponds
to the stage in which
“the epiphysis is
as wide as the
metaphysis.”

The second stage,
MP3-FG,
acceleration period of
pubertal growth
spurt, corresponds to
the stage in which “the
epiphysis is as wide
as the metaphysis,
and there is a
distinct medial
and/or lateral
border of the
epiphysis forming a
line of demarcation
at right angle to the
distal border.”

The third stage,
MP3-G, peak-PTV,
the point of maximum
pubertal growth
spurt, corresponds to
the stage in which “the
sides of epiphysis
have thickened and
also cap its
metaphysis forming
a sharp edge
distally at one or
both sides.”

The fourth stage,
MP3-H,
deceleration
period of pubertal
growth spurt,
corresponds to the
stage in which
“fusion of epiphysis
and metaphysis has
begun.”

The fifth stage,
MP3-I, end of
pubertal growth
spurt, corresponds
to the stage in which
“fusion of
epiphysis and
metaphysis is
completed.”

Dental radiographs were first used by
Chapman to record the ossification of
the adductor sesamoid.

Aim
The aim of the present study was to
evaluate the use of standard dental
periapical radiographs and standard
dental x-ray machine in recording the
MP3 stages.

MATERIAL AND METHODS
The study included radiographs of the middle pha-
lanx of the right hand, third finger, of 55 randomly
selected orthodontic patients of both sexes.
The ages ranged from 10 to 15 years.
The radiographs were interpreted for MP3 stages.
The following standard method was used.
The patient was instructed to place his or her hand
with the palm downward on a flat table, with the third
finger straight with the long axis of standard size
periapical dental x-ray film, in such a way that the
middle phalanx was located in the center of the film.
The cone of the dental X-ray machine was
positioned in a light contact with the middle phalanx
perpendicular to the X-ray film.

Results
The high degree of clarity of the radiographs,
the ease with which we can interpret the MP3
stages, the simplicity of the method, and the
significantly low patient radiation exposure
highly recommends it as a practical and
sensitive technique that meets the
requirements of the clinicians in our field.
The equipment required is available in most
clinics: the standard size periapical dental x-
ray films and the standard dental x-ray
machine.

Developmental stages of the
middle phalanx of the third
finger (MP3)

Tooth mineralization and sesamoid

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