skeletal maturity indicators

1. SKELETAL
MATURATION
Bhaskar.k
PG

2. CONTENTS
• Introduction
• Growth spurts
• Various methods to determine the skeletal age
- Hand and wrist radiographs
- Tooth mineralisation
- Cervical vertebrae
- Mid palatal suture
- Frontal sinus
- Harmones related to skeletal maturation

3. • Conclusion
• References

4. INTRODUCTION
• Growth factor is critical variable in orthodontic treatment
• Ricketts said that to take advantage of growth, we must have
some idea of its amount and direction.
• Julian mentions it also need to know when the major growth
increments are likely to occur.

5. Developmental status of the child judged by:
• Sexual maturation characterstics
• Chronological age
• Biologic age- Dental development
- Skeletal development
- morphologic age
- onset of puberty

6. • Skeletal maturation - degree of development of ossification
in bone. It is more closely related to sexual maturity than to
stature.

7. GROWTH SPURTS
• It is period where sudden acceleration of growth occurs. It
occurs at different times in different individual.
Normal growth spurts is given by Woodside
• First peak – 3years in both male and female.
• Second peak – 6 -7years in females,
7- 9 years in males.
• Third peak – 11-12 years in females,
14-15 years in males.

8. • WOODSIDE - pubertal growth spurt is important period for the
orthodontics
• PROFFIT - juvenile growth spurt is more prominent in girls
than pubertal growth spurt

9. VARIOUS METHODS TO
DETERMINE THE SKELETAL
AGE
Hand and wrist radiographs
• Standard method for the evaluation of the skeletal age.
• Easily identifiable maturity indicators.
• Reliable source of maturation process.
• Serves as a useful diagnostic aid.

10. Anatomy of skeleton of the hand
• Phalanges – 14 in no.
• Metacarpals – 5
• Carpals - 8

11. GRAVE & BROWN , AJO
1976

12. FIRST STAGE
• PP2 = -Stage

13. SECOND STAGE
• MP3 = -Stage

14. THIRD STAGE
• H1, pisi, and R

15. FOURTH STAGE
• S
• H2

16. FIFTH STAGE
• Diaphysis is covered by cap shaped epiphysis
• MP3 cap
• PP1 cap
• R cap

17. SIXTH STAGE
• DP3u
• End of pubertal growth

18. SEVENTH STAGE
• PP3u

19. EIGHTH STAGE
• MP3u

20. NINTH STAGE
• Ru
• Skeletal growth finished

22. CLINICAL IMPORTANCE
• Treatment involving the application of extraoral traction
should be commenced prior to ossification of the hamate-2 or
sesamoid.
• Complete band placement should take place at the time of
peak growth velocity
• retention phase of treatment.

23. JULIAN SINGER AO 1980
• 1. To enable the clinician to rapidly and with some degree of
reliability utilize the hand and wrist film to determine the
maturation status.
• 2. Examine several other stages of the growth which could be
significance in treatment, exclusive puberal growth spurt.

24. EARLY

25. PREPUBERTAL

26. PUBERTAL ONSET

27. PUBERTAL

28. PUBERTAL
DECELERATION

29. GROWTH COMPLETION• No remaining growth sites

30. Mainly concerned with stage 2 & 5.
• Stage 2 represents that period prior to the adolescent growth
spurt during which significant amounts of mandibular growth
are possible.
• Stage 5 represents that period of growth when orthodontic
treatment might be completed and the pt is in retention
therapy.

31. STAGE 2 CASE

32. STAGE 5 CASE

35. • Prepubertal period - during which Cl.II correction could be
effectively achieved
• Pubertal spurt may be short in female.
• Stage 5-period of residual growth during which post
treatment changes could occur

36. • Hunter- stated that dimension Ar- Po increased at a rate of
2.73mm per yr in females and 3.58mm per yr in males during
the puberal growth period.

37. FISHMAN AO 1982

41. HAGG & TARANGER
1982
• A longitudinal study- 212 children- from birth to childhood.
• Examinations include- standing height
- tooth emergence
- pubertal development
- radiograph of right hand and wrist

42. • Skeletal deveolpment
• Two new epiphyseal stages:
- MP3-FG
- R-IJ
Hagg & Taranger, AJODO

43. • The ossification of the ulnar sesamoid (S)- not a reliable
indicator of the beginning of the pubertal growth in either sex.
• In clinical context - if S is not attained, neither is PHV.
• If S is just attained, most individuals are in the acceleration
period of the pubertal growth spurt.
• According to Bjork, the pubertal growth spurt ends with the
complete fusion of the third distal phalanx (DP3-I).

44. RELATIONSHIP OF ULNAR SESAMOID
BONE AND MAXIMUM MANDIBULAR
GROWTH VELOCITY
• Several studies were done and observed that-
sesamoid bone precedes peak mandibular velocity by
- 0.72 yrs in males
- 1.09 yrs in females
• Mean age of appearance of sesamoid bone in females
precedes mean age in males by 2.34yrs
Pileski et al..,April 1973

45. THE RELATIONSHIP BETWEEN TOOTH
MINERALIZATION AND EARLY
RADIOGRAPHIC EVIDENCE OF ULNAR
SESAMOID
• Demirjain, Goldstein and Tanner- gave description of each
stage of tooth clcification.

47. • Ossification of adductor sesamoid commences two yrs earlier
among girls when compared with boys at mean age of 11.3yrs
• Lewis and Garn – no close relationship
• Close relationship b/w calcification stage G of mandibular
canine and calcification of sesamoid

48. MANDIBULARCANINE
CALCIFICATION
Coutinho, AJODO 1

49. • They concluded that the initiation of pubertal growth spurt
relates with stage F of canine calcification.
• canine calcification stage G- relates to MP3cap,S,PP5cap.

50. • Stage G occurs approximately around 1 yrs before PHV in
boys but only 5 months before PHV in girls.(coincides with
MP3cap,PP5cap.S)
• The intermediate stage between stage F and stage G should
be used to identify the early stages of pubertal growth spurt.

51. MANDIBULAR THIRD
MOLAR
• Engstorm (1983) compared lower third molar development
stages with skeletal maturity indicators.

52. • PP2=
• MP3 cap
• DP3 u
• Ru:

53. CERVICAL VERTEBRAE
MATURATION
• Lamparski (1972)

54. HASSEL AND FARMAN,
AJODO 1995

55. NEW CVM
• Baccetti et al (AO 2002) came with new version of CVM.
• Lampraski method was modified because:
• Make it easier & applicable to majority
• To use minimal no. of vertebral bodies

56. • Five stages of new CVM

57. A COMPARISON OF MODIFIED MP3STAGES & THE
CERVICAL VERTEBRAE AS MATURITY
INDICATORS
RAJAGOPAL AND KANSAL, JCO
JULY 2002
• Aim: determine whether the 6 modified MP3 stages (Hagg &
Taranger) could be correlated with the 6 stages of CVMI’s
(Hassel & farman).
• Evaluate the feasibility of recording MP3 stages using the
standard dental x-ray.

58. • Chapman – first use the IOPA film to evaluate ossification of
the ulnar sesamoid.
• Abdel kadar applied this idea to recording MP3 stages.

59. • MP3-F stage & CVMI 1

60. • MP3 – FG stage & CVMI 2

61. • MP3 - G stage & CVMI 3

62. • MP3 – H stage &CVMI 4

63. • MP3 – HI stage & CVMI 5

64. • MP3 – I stage & CVMI - 6

65. Modified MP3 stages using periapical X-ray film can be an
accurate & simple growth indicator. Advantage of modified
MP3
• Lower radiation exposure
• High degree of clarity on radiograph
• Easily identifiable stages of development
• Close correlation to the six stages of CVMI
• Less equipment

66. MATURATIONAL EVALUATION
OF OSSIFICATION OF THE MID
PALATAL SUTURE
• positive correlation b/w adolescent maturation development
and the approximation of the mid palatal suture.

67. • H & W radiographs – Fishman’s method
• Occlusal radiographs - Approx. of mid palatal suture.

68. • Increase in sutural approx. as SMI stages progressed.
• SMI 1&2(PP3&MP3= less sutural approximation
• After SMI 9(PP5u)- significant increase in the sutural
approximation
• No significant difference b/w sexes.

69. Significant correlation b/w maturational development
&beginning of ossification.
• At SMI 3(MP5)-
• AT SMI 4-7 -
• At SMI 9 (PP3u) –
• At SMI 11 (Ru) -

70. • If orthopedic expansion forces are applied to physically open
an approx. suture – best to accomplish this before SMI 9.
• Ideal time to initiate orthopedic expansion is during the SMI 1-
4 / early maturational stage.
• Mid palatal approx. occurs more posterior.

71. The frontal sinus- indicator for somatic maturity
at puberty
Sabine Ruf AJODO 1991
Sh
Si

72. 72

73. FRONTAL SINUS GROWTH VELOCITY
(SV)
THRESHOLD VALUE T (1.3 MM/YR.)
Sinus data Prediction
Sv > T. Bp passed by approximately 1.4 yrs
Sv < T and Age <I5.1 yrs Bp not yet reached or reached less than 1.4
yrs. before the end of the observation
interval
Sv < T and Age >15.1 yrs Bp passed by more than 1.4 yrs. with respect
to the beginning of the observation interval

74. INSULIN LIKE GROWTH FACTOR -1
ISHAQ ET AL 2012
• Salmon and Daughaday - first to discover IGF-I
Insulin-like growth factor I (IGF-I) :
• Polypeptide hormone synthesized mainly by the liver.
• Mediator of growth-hormone function.
• Major role in postnatal growth
• Process of longitudinal bone growth.

75. •Peak IGF-I concentrations reaches 1 year before
puberty.
•Earlier in girls than boys,
•Peak IGF-I concentrations declines after puberty.

76. SERUM PTHRP
ZAHID HUSSAIN ET AL AJODO 2013
PTHrP is produced by cells at the periarticular ends of
bones and acts on nearby chondrocytes bearing PTH/PTHrP
receptors to keep them proliferating and delay their
differentiation.
Inference :
• Peak serum PTHrP – late pubertal growth spurt

77. SERUM DHEAS
• Stimulation of pitutary and hypothalamus
• Stimulate growth and proliferation of epiphyseal cartilage and
potentiates the action of GH.
• Enhance bone deposition
Inference
First peak – 6-8yrs
Second peak – 11yrs in females
- 13yrs in males

78. CONCLUSION
• With reference to the studies related to the each of the
maturity indicators, we can conclude that tooth calcification
alone cannot be used for assessing maturity and the
remaining growth potential.
• Hence correlation of the various indicators are necessary to
plan treatment accordingly for any individual patient, whether
to treat orthodontically, orthopaedically (or) surgically.

79. REFERENCES
• 1. Hassel B, Farman A G.”Skeletal maturation evaluation
using cervical vertebrae” Am J Orthod, 1995; 107:58-61
• 2. Julian Singer “ Physiologic timing of orthondic treatment”.
Angle Orthod, 1980; 50:320-333.
• 3.Hagg U,Taranger J “ Maturational indicators and the
pubertal growth spurt”. Am J Orthod, 1982; 88:299-309.
• 4.Revelo B,Fishman LS,” Maturational evaluation of
ossification of midpalatal suture”. Am J Orthod, 1994;105:288-
292

80. • 5. Fishman L S,” Radiographic evaluation of skeletal
maturation”. Angle Orthod ; 1982; 52:89-111
• 6. A comparison of modified MP3stages & the cervical
vertebrae as maturity indicators - Rajgopal and kansal ,Jco
2002
• 7. Tooth mineralization as an indicator of the pubertal growth
spurt. Am J Orthod, Jan 1980, Chertkow.
• 8. Sabine Ruf. Frontal sinus development as maturity indicator at
puberty? Am J Orthod Dentofac Orthop 1996 110 476-82

81. • 9. Mohammed Zahid Hussain,a Ashok Kumar Talapaneni,b
Mandava Prasad,c and Ramalingam Krishnand ;Serum PTHrP level
as a biomarker in assessing skeletal maturation during
circumpubertal development. Am J Orthod Dentofacial
Orthop2013;143:515-21
• 10. Ramy Abdul Rahman Ishaq,a Sanaa Abou Zeid Soliman,b
Manal Yehya Foda,b and Mona Mohamed Salah Fayed;Insulin-like
growth factor I: A biologic maturation indicator; Am J Orthod
Dentofacial Orthop 2012;142:654-61

82. • 11. Relationship between mandibular canine calcification
stages and skeletal maturity – Am J Ortho Dentofac Orthop
1993; 104: 262-8.