Skeletal maturity index- Orthodontics

1. Under the guidance of :
Department of orthodontia and Dentofacial orthopaedics
NBDCH

2. INTRODUCTION
 Chronologycal age is often not sufficent for assessing
the development stage and somatic maturity of the
patient, so that the biological age has to be
determined.
 The biological age is determined from the skeletal,
dental,& morphologic age and onset of purberty.

3. A number of methods are available to assess the skeletal maturity
of an individual.
These include-
A. Use of hand-wrist radiographs.
B. Evaluation of skeletal maturation using cervical vertebrae.
C. Assessment of maturity by clinical and radiological
examination of different stages of tooth development.

4. HAND-WRIST RADIOGRAPHS
INDICATIONS
In patients who exhibit major discrepancy between
dental and chronologic age
Determination of skeletal maturity status prior to
treatment of skeletal malocclusion such as a skeletal
class II or class III malocclusion
To access the skeletal age in a patient whose growth
is affected by infection, neoplastic or traumatic
condition

5. INDICATIONS (continue)
Serial assesment of skeletal age using
hand-wrist radiographs helps not only in
accessing the growth of an individual, but
also help predict future skeletal
maturation rate and status
To predict pubertal growth spurt
It is a valuable aid in research aimed at
studying the role of heredity,
environment, nutrition etc., on the
skeletal maturation pattern
It is indicated in patients with skeletal
malocclusion needing orthognathic surgery,
if undertaken between 16-20 years so as
to access the growth status

6. Hand wrist region
is made of 4
groups of bones-
1.Distal ends of
long bones of
forearm
2.Carpals
3.Metacarpals
4.Phalanges

7.  A number of methods have been described to
assess the skeletal maturity using Hand-
Wrist radiographs. The following are the most
commonly used methods
a. Atlas method by Greulich and Pyle
b. Bjork,Grave and Brown method
c. Fishman’s Skeletal Maturity Indicators
d. Hagg and Taranger Method

8. BJORK , GRAVE AND BROWN METHOD
 They have divided skeletal development into 9 stages.
 Appropriate chronological age for each stage was given by
Schopf in 1978.
STAGE – 1 (males 10.6 y , females 8.1 y)
The epiphysis and diaphysis of the
proximal phalanx of index finger are equal
in width. It occurs approximately 3 years
before the peak of pubertal growth spurt.
STAGE – 2 (males 12 y , females 8.1 y)
the epiphysis and diaphysis of the middle
phalanx of the middle finger are equal in
width. This stage is noticed prior to the
beginning of the pubertal growth spurt.

9. a. The hamular
process of hamate
exhibits ossification
b. Ossification of
pisiform
c. The epiphysis and
diaphysis of radius
are equal.
STAGE – 3 (male 12.6 y , females 9.6 y)
This stage is characterized by the presence of
three areas of ossification :

10. a. Initial mineralization of
the ulnar sesamoid of
the thumb.
b. Increased ossification
of the hamular process
of the hamate bone.
STAGE – 4 (males 13 y , females 10.6 y)
This stage marks the beginning of the
pubertal growth spurt. It is characterized by :

11. STAGE – 5 (males 14 y, females 11y)
This stage heralds the peak of pubertal growth spurt.
Capping of diaphysis by the epiphysis is seen in;
a. Middle phalanx of
the third finger
b. Proximal phalanx
of the thumb
c. Radius

12.  It is characterized by
the union between
epiphysis and
diaphysis of the distal
phalanx of the middle
finger
 This stage signifies the
end of the pubertal
growth spurt.
STAGE – 6[males 15y, females13y]

13. visible Union of
epiphysis and
diaphysis of the
proximal phalanx
of the little finger.
It is Seen after a
year of the growth
spurt.
STAGE – 7[males 15.9y, females13.3y]

14. This stage shows the
fusion between the
ephyphysis and
diaphysis of the
middle phalanx of
the middle finger
STAGE – 8 [male15.9y,female13.9y]

15. It is characterized by
the by the fusion of
the diaphysis and the
epiphysis at the
radius
it signifies the end of
skeletal growth.
STAGE – 9 [male18.5y, female16y]

16. FISHMAN’S SKELETAL MATURITY
INDICATORS
Leonard S. Fishman in 1982 proposed a system for
evaluation of skeletal maturation.
It uses anatomical sites located on the thumb , third finger ,
fifth finger and radius.
The fishman’s system of interpretation uses four stages of
bone maturation:
a. Epiphysis equal in width to diaphysis.
b. Appearance of adductor sesamoid of the thumb.
c. Capping of epiphysis.
d. Fusion of epiphysis.

17. Eleven discrete adolescent skeletal maturity indicators
covering the entire period of adolescent development
have been described.
Epiphysis as wdie as diaphysis
SMI 1; Third finger –proximal phalanx
SMI 2; Third finger – middle phalanx
SMI 3; Fifth finger – middle phalanx
Ossification
SMI 4; Appearance of adductor sesamoid of thumb
Capping of Epiphysis
SMI 5; Third finger – distal phalanx
SMI 6; Third finger – middle phalanx
SMI 7; Fifth finger – middle phalanx

18. Fussion of epiphysis and diaphysis
SMI 8; Third finger –distal phalanx
SMI 9; Third finger – proximal phalanx
SMI 10; third finger – middle phalanx
SMI 11; Radius

21. SKELETAL MATURATION ASSESSMENT
 Accelerating growth velocity period=SMI 1-4
 High growth velocity period=SMI 4-7
 Decelerating growth velocity period=SMI 7-11

22. SKELATAL MATURATION EVALUATION
USING CERVICAL VERTEBRAE
Developed by Hassel and Farman.
The shapes of cervical vertebrae were seen to differ
at each level of skeletal development.
this provided a means to determine whether the
possibility of potential growth existed.

23. SKELATAL MATURATION EVALUATION USING CERVICAL VERTEBRAE
The following six stages were put forward in
vertebral development.
STAGE 1
a. This stage called initiation
corresponds to beginning
of adolescents growth
with 80% to 100%
adolescents growth
expected
b. Inferior borders of C2,C3
and C4 were flat at this
stage
c. The vertebrae were wedge
shaped, and the superior
vertebral borders were
tapered from posterior to
anterior.

24. STAGE 2
a. The second stage is called
acceleration.
b. Growth acceleration begins
at this stage with 65% to
85% of adolescents growth
expected
c. Concavities were developing
in the inferior borders of
C2 and C3.
d. The inferior border of C4
was flat
e. The bodies of C3 and C4
were nearly rectangular in
shape

25. STAGE 3
a. This stage is called
transition.
b. It corresponds to
acceleration of growth
towards peak height
velocity with 25% to 65%
of adolescent growth
expected.
c. Distinct concavities were
seen in the inferior borders
of C2 and C3.
d. A concavity was beginning
to develop in the inferior
border of C4.
e. The bodies of C3 and C4
were rectangular in shape.

26. STAGE 4
a. This stage called
deceleration,
corresponds to the
deceleration of
adolescent growth
spurt with 10% to
25% of adolescents
growth expected.
b. Distinct concavities
were seen in the
inferior borders of
C2,C3 and C4.
c. The vertebral bodies
of C3 and C4 were
becoming more
squarer in shape.

27. STAGE 5
a. The fifth stage is
called maturation.
b. Final maturation of
the vertebrae took
place during this stage,
with 5% to 10% of
adolescent growth
expected
c. More accentuated
concavities were seen in
the inferior borders of
C2,C3 and C4.
d. The bodies of C3 and
C4 were nearly square
in shape.

28. STAGE 6
a. This stage is called
completion corresponds
to completion of growth.
b. Little or no adolescent
growth expected
c. Deep concavities were
seen in the inferior
borders of C2,C3 and
C4.
d. The bodies of C3 and C4
were square or were
greater in vertical
dimensions than in
horizontal dimension.

29. APPLICATION TO DENTOFACIAL ORTHOPEDICS
 Class II treatment is most effective when it includes the peak in
mandibular growth(stage 3)
 Class III treatment with maxillary expansion and protraction is
effective when performed before the peak(stage 1 & 2)
 Class III treatment is effective in mandible during both pubertal and
prepubertal stage.
 Skeletal effects of rapid maxillary expansion for the correction of
transverse maxillary deficiencies are greater at prepubertal stages
(stage 1 -3)
 Deficiency in ramus height : the peak in mandibular growth (stage 3)

30. TOOTH MINERALIZATION AS AN
INDICATOR OF SKELETAL MATURITY
The calcification patterns and stage of
mineralization of the teeth is believed to have a
close relationship with the skeletal maturation of
an individual.
Dental development can be assessed by either the
phase of tooth eruption or the stage of tooth
calcification, with the latter being more reliable.
To assess developmental stage of dentition
through examination of panoramic radiograph
offers several advantages over conventional hand-
wrist radiograph method.

31. DENTAL CALCIFICATION STAGES
USING DEMIRJIAN INDEX (DI)
STAGE A: calcification of single
occlusal points without fusion
of different calcifications.
STAGE B: fusion of mineralization
points: the contour of the
occlusal surface is recognizable.
STAGE C: enamel formation has
been completed at the occlusal
surface , and dentine
formation has commenced. the
pulp chamber is curved , and
no pulp horns are visible.
Fig:

32. DEMIRJIAN INDEX (DI)
STAGE D: Crown formation has
been completed to the level
of the cemento-enamel
junction. Root formation has
commenced. The pulp horns
are beginning to differentiate,
but the walls of the pulp
chamber remain curved.
STAGE E: The root length remains
shorter than the crown
height. The walls of the pulp
chamber are straight, and the
pulp horns have bocome more
differentiated than in the
previous stage. In molars the
radicular bifurcation has
commenced to calcify. Fig:

33. DEMIRJIAN INDEX (DI)
STAGE F: the walls of the pulp
chamber now form an isosceles
triangle, and the root length is
equal to or greater than the
crown height. In molars the
bifurcation has developed
sufficiently to give the roots a
distinct form.
STAGE G: the walls of the root canal
are now parallel, but the apical
end is partially open.in molars
only the distal root is rated.
STAGE H: the root apex is completely
closed (distal root in molars).
The periodontal membrane
surrounding the root and apex is
uniform in width throughout.
Fig:

34. CONCLUSIONS
Skeletal maturity indicators can be used as an
secondary diagnostic tool for orthodontic
treatment.

35. THANK YOU
REFERENCES:
CONTEMPORARY ORTHODONTICS- W.R. Proffit
ORTHODONTICS The art and science- S.L.Bhalajhi