Brief description of Skeletal Maturity indicators and advancements in this aspect . Biochemical markers as new advancements in AGE assessment Realtionship between SMI and CVMI , MP3 AND CVMI

1. SKELETAL MATURITY
INDICATORS
BY – YASH SRIVASTAVA
BDS ( FINAL YEAR )
BATCH -VIII
Department Of Orthodontics And Dento – Facial
Orthopaedics
KING GEORGE’S MEDICAL UNIVERSITY , LUCKNOW ( UTTAR
PRADESH )

2. CONTENTS
1. INTRODUCTION
2. HAND WRIST RADIOGRAPHS
3. ANATOMY OF HAND WRIST RADIOGRAPHS
4. INDICATIONS OF HAND WRIST RADIOGRAPHS
5. FISHMAN’S SKELETAL MATURITY INDICATORS
6. MATURATION ASSESSMENT BY HAGG AND TARANGER
7. SKELETAL MATURATION EVALUATION USING CERVICAL VERTEBRAE
8. BIOCHEMICAL MARKERS AS SKELETAL MATURITY INDICATORS
9. REFERENCES

3. INTRODUCTION
• “ TO TAKE ADVANTAGE OF GROWTH WE MUST HAVE SOME IDEA ,FIRST ,OF ITS
AMOUNT ,AND SECOND OF TS DIRECTION”. - RICKETTS
• The Chronological Age Based On The Date Of Birth Offers Little Insight In Determining The
Developmental Stage Or Somatic Maturity Of A Person .Thus Maturity Indicators Provide
An Objective Diagnostic Evaluation Of Stage Of Maturity In An Individual.
• The Biological Age Is Determined From The Skeletal ,Dental And Morphologic Age And
Onset Of Puberty.
• Patient Chronological Age Is Defined As The Time Period From The Birth To Till Date.
• Morphological Age Is Based Upon On The Height .Height Is Useful As A Maturity Indicator
From Late Infancy To Early Adulthood.
• Dental Age Is Based Upon 2 Different Methods Of Assessment : 1. Tooth Eruption Age 2.
Tooth Mineralization Age
• Sexual Age Refers To Dev. Of Sec. Sexual Characteristics..

4. INTRODUCTION
• A NUMBER OF METHODS ARE AVAILABLE TO ACCESS THE SKELETAL MATURITY OF
AN INDIVIDUAL . THESE INCLUDE :–
• 1. USE OF HAND – WRIST RADIOGRAPHS
• 2. EVALUATION OF SKELETAL MATURATION USING CERVICAL
VERTEBRAE
• 3. ASSESSMENT OF MATURTY BY CLINICAL AND RADIOGRAPHIC
EXAMINATION OF DIFFERENT STAGES OF TOOTH DEVELOPMENT.
• 4. BIOCHEMICAL MARKERS AS SKELETAL MATURITY INDICATOR.
• THE USE OF HAND – WRIST RADIOGRAPHS HAS BEEN THE MOST WIDELY ACCEPTED
METHOD.

5. HAND –WRIST RADIOGRAPHS
• By Merely Comparing A Patient’s Hand – Wrist Radiographs With Standard Radiographs That Represent
Different Skeletal Ages , We Will Be Able To Determine The Skeletal Maturation Status Of That Individual.
• A NO. OF METHODS HAVE BEEN DESCRIBED TO ASSESS THE SKELETAL MATURITY USING HAND –
WRIST RADIOGRAPHS –
• 1. ATLAS METHOD BY GREULICH AND PYLE
• 2. BJORK ,GRAVE AND BROWN METHOD
• 3. FISHMAN’S SKELETAL MATURITY INDICATORS
• 4. HAGG AND TARANGER METHOD
• THE HAND – WRIST REGION IS MADE UP OF 4 GROUP OF BONES –
• 1.DISTAL ENDS OF LONG BONES
• 2.CARPALS
• 3.METACARPALS
• 4.PHALANGES

6. ANATOMY OF HAND – WRIST RADIOGRAPHS

7. BIOLOGICAL AGE AND HAND-WRIST
RADIOGRAPHS
• GROWTH STAGES OF THE FINGERS ARE ASSESSED ACCORDING TO THE RELATIONSHIP BETWEEN THE EPIPHYSIS AND
DIAPHYSIS.
• THERE ARE 3 STAGES OF OSSIFICATION OF THE PHALANGES :-
• First Stage : Epiphysis Shows The Same Width As The Diaphysis.
• Second Stage ( Capping Stage ) : The Epiphysis Surrounds The Diaphysis Like A Cap.
• Third Stage ( U – Stage ) : Bony Fusion Occurs Between Epiphysis And Diaphysis
First stage capping fusion

8. INDICATIONS OF HAND – WRIST RADIOGRAPHS
• With Major Discrepancy B/W Dental And Chronological Age .
• Prior To Rapid Maxillary Expansion.
• Ortho Pts. Requiring Orthognathic Surgery Between 16 To 20 Years Age.
• To Predict The Pubertal Growth Spurt.
• To Assess The Growth Of An Individual And Predict Future Skeletal
Maturation Rate And Status.
• To Assess The Skeletal Age In A Pt. Whose Growth Is Affected By
Infections ,Neoplastic Or Traumatic Conditions.
• To Assess The Skeletal Malocclusion Such As Class 2 And Class 3.

9. FISHMAN’S SKELETAL MATURITY INDICATORS
• PROPOSED BY LEONARD FISHMAN IN 1982 .
• The System Of Evaluating Hand-wrist Radiographs Makes Use Of Anatomical Sites Located On The Thumb , Third
Finger , Fifth Finger And Radius. Eleven Discrete Adolescent S.M.I. Are Found In These 6 Anatomic Sites.
EPIPHYSIS AS WIDE AS DIAPHYSIS FUSION OF EPIPHYSIS AND DIAPHYSIS
 1. 3RD FINGER – PROXIMAL PHALANX 8.3RD FINGER – DISTAL PHALANX
 2. 3RD FINGER – MIDDLE PHALANX 9. 3RD FINGER – PROXIMAL PHALANX
 3. 5TH FINGER – MIDDLE PHALANX 10. 3RD FINGER – MIDDLE PHALANX
11. RADIUS
OSSIFICATION
 4. ADDUCTOR SESAMOID OF THUMB ** ACCELERATING GROWTH ( SMI 1 TO 3 )
PEAK VELOCITY OF GROWTH ( SMI 4 TO 7 )
CAPPING OF EPIPHYSIS DECELERATING GROWTH ( SMI 8 TO 11 )
 5. 3RD FINGER – DISTAL PHALANX
 6. 3RD FINGER – MIDDLE PHALANX
 7. 5TH FINGER – MIDDLE PHALANX

10. FISHMAN’S SKELETAL MATURITY INDICATORS

11. MATURATION ASSESSMENT BY HAGG AND
TARANGER
• Skeletal Dev. In The Hand And Wrist Is Analysed From Annual Radiographs , Taken B/W The Ages Of 6 And 18 Yrs , By
Assessment Of The Ossification Of The Ulnar Sesamoid Of The Metacarpophalangeal Joint Of The First Finger ( S) And
Certain Stages Of Three Epiphyseal Bones : The Middle And Distal Phalanges Of The 3rd Finger ( Mp3 And Dp3 ) And
The Distal Epiphysis Of The Radius ( R ).
• All The 4 Bones To Be Used As Indicators Of The Skeletal Dev. Were Chosen According To Bjork.
1. Sesamoid – Attained During The Acceleration Period Of Pubertal Growth Spurt ( Onset Of
Peak High Velocity ).
2. 3RD FINGER MIDDLE PHALANX
 MP3 – F : EPIPHYSIS AS WIDE AS METAPHYSIS .
ATTAINED BEFORE ONSET OF P.H.V BY ABOUT 40% OF THE SUBJECTS.
 MP3 – FG : EPIPHYSIS AS WIDE AS METAPHYSIS.
DISTINCT MEDIAL AND LATERAL BORDER OF TH EEPIPHYSIS FORMING A
LINE OF DEMARCATION AT ANGLES TO DISTAL
BORDER .
ATTAINED 1 YR BEFORE OR AT P.H.V.

12. MATURATION ASSESSMENT BY HAGG AND
TARANGER
 MP3 – G : CAPPING OF METAPHYSIS .
ATTAINED AT OR 1 YR AFTER P.H.V.
 MP3 – H : FUSION OF EPIPHYSIS AND METAPHYSIS STARTS.
ATTAINED AFTER P.H.V. BUT BEFORE THE END OF GROWTH SPURT BY
PRACTICALLY ALL BOYS AND ABOUT 90% OF GIRLS.
 MP3 – I : IS ATTAINED BEFORE OR AT END OF GROWTH SPURT IN ALL SUBJECTS EXCEPT A
FEW GIRLS .

13. MATURATION ASSESSMENT BY HAGG AND
TARANGER
4. 3RD FINGER DISTAL PHALANX
 DP3 – I : FUSION OF EPIPHYSIS AND METAPHYSIS IS COMPLETED.
ATTAINED DURING THE DECELERATION PERIOD OF PUBERTAL GROWTH
SPURT (END OF P.H.V) BY ALL SUBJECTS.
5. RADIUS
 R – I : FUSION OF EPIPHYSIS AND METAPHYSISHAS BEGUN.
ATTAINED 1 YR BEFORE OR AT THE END OF GROWTH SPURT BY ABOUT 80%
OF THE GIRLS AND 90% O FTHE BOYS.
 R – IJ : FUSION IS ALMOST COMPLETED BUT THERE IS STILL A SMALL GAP AT ONE OR BOTH
THE MARGINS .

14. SKELETAL MATURATION EVALUATION USING
CERVICAL VERTEBRAE
• HASSEL AND Farman Developed A System Of Skeletal Maturation Determination Using Cervical
Vertebrae. The Shapes Of Cervical Vertebrae Were Seen To Differ At Each Level Of Skeletal Development.
This Provides A Means To Determine The Maturity Of A Person.
• The Shapes Of Vertebral Bodies Of C3 And C4 Changes From
Wedge Rectangular Square
• The Inferior Vertebral Borders Are Flat When Immature , And They Are Concave When Mature.
• The Curvatures Of The Inferior Borders Are Seen To Appear Sequentially From C2 To C3 To C4 As The
Skeleton Matures . The Concavities Becomes More Distinct As The Person Matures.
• Lamparski Was A First Person To Utilize The Cervical Vertebrae Radiographically And Found Them To Be
As Reliable And Valid As The Hand – Wrist Radiography For Assessing Skeletal Age.
• Hassel And Farman Have Put Forward The Following 6 Stages In Vertebral Dev. :-

15. SKELETAL MATURATION EVALUATION USING
CERVICAL VERTEBRAE
ASSESSMENT OF SKELETAL MATURATION USING
THE VERTEBRAL COLUMN C3
 The Above Comparison Of Modified Mp3 Stages And The
Cervical Vertebrae As Skeletal Maturity Growth Indicator
Was Brought About By R . Rajagopal And Sudhanshu
Kansal (2002).
 Similar Correlation Was Found Between CVMI And SMI By
Sachan Kiran , V.P. Sharma And Dr. Pradeep Tondon Sir
(2012) , Which Suggests That CVMI Can Also Be Used As
SMI And Also Has The Advantage Of Using The Lateral
Cephalogram As Orthodontic Diagnosis Which Thereby
Eliminate The Need For An Additional Radiograph , Hence
Being Cost – Effective And Reducing The Radiation

16. SKELETAL MATURATION EVALUATION USING
CERVICAL VERTEBRAE
 STAGE 1 : INITIATION – BEGINNING OF GROWTH WITH 80 – 100 % OF ADOLESCENT GROWTH LEFT .
 INFERIOR BORDERS OF C2 ,C3 AND C4 WERE FLAT .
 THE VERTEBRAE WERE WEDGE SHAPED , AND THE SUPERIOR VERTEBRAL BORDERS WERE TAPERED FROM
POSTERIOR TO ANTERIOR.
 STAGE 2 : ACCELERATION - GROWTH ACCELERATES , WITH 65 – 85% GROWTH EXPECTED.
 CONCAVITIES WERE DEVELOPING IN THE INFERIOR BORDERS OF C2 AND C3.
 THE INFERIOR BORDER OF C4 WAS FLAT.
 THE BODIES OF C3 AND C4 WERE NEARLY RECTANGULAR IN SHAPE.
 STAGE 3 : TRANSITION – ACCELERATION OF GROWTH TOWARDS P.H.V. WITH 25 – 65% OF ADOLESCENT GROWTH
EXPECTED.
 DISTINCT CONCAVITIES WERE SEEN IN INFERIOR BORDERS OF C2 AND C3.
 A CONCAVITY WAS BEGINNING TO DEVELOP IN THE INFERIOR BORDER OF C4.THE BODIES OF C3 AND C4 WERE
RECTANGULAR IN SHAPE.

17. Skeletal Maturation Evaluation Using
Cervical
Vertebrae
STAGE 4 : DECELERATION – DECELERATION OF GROWTH SPURT WITH 10 – 25 % OF GROWTH
EXPECTED.
 DISTINCT CONCAVITIES IN INFERIOR BORDERS OF C2 ,C3 AND C4.
THE BODIES OF C3 , C4 WERE BECOMING MORE SQUARER.
STAGE 5 : MATURATION – FINAL MATURATION OF THE VERTEBRAE TOOK PLACE ,WITH 5 – 10% OF
GROWTH EXPECTED.
MORE ACCENTUATED CONCAVITIES IN INFERIOR BORDERS OF C2,C3 AND C4. THE BODIES OF C3, C4
WERE HZ.
MORE RECTANGULAR IN SHAPE.
STAGE 6 : COMPLETION –CORRESPONDS TO COMPLETION OF GROWTH.
DEEP CONCAVITIES IN INFERIOR BORDERS OF C2 , C3 AND C4.
THE BODIES C3 , C4 WERE SQUARE OR MORE GREATER IN VERTICAL DIMENSION THAN IN HZ.
DIMENSION.

18. BIOCHEMICAL MARKERS AS SKELETAL MATURITY
INDICATORS
• Precise Estimation Of Stage Of Skeletal Growth Is Essential For The Formulation Of
The Accurate Treatment Planning And Employing Orthodontics Intervention Through
Functional Orthopaedic Appliances.
• Along With Clinical Radiological Techniques, Biochemical Markers Play Important
Role In Growth Assessment For Differential Treatment Application .
• Isolation Of Various Systemic And Local Factors Having Significant Role In The
Process Provides Us The Side To Tap Their Potential To Be Used As SMI.
• Differentt Methods For Assessment Of Biomarkers In Use Are Enzyme Linked
Immunosorbent assay , Radioimmuno assay And Immunoradiometric assay. These
Methods Of Assessment Of Markers Are Non Invasive.
•

19. Biochemical Markers As Skeletal Maturity
Indicators
• A Biomarker Is Defined As “Any Substance ,Structure Or Process That Can Be Measured
In The Body Or Its Product And Predict The Incidence Of Outcome Or Disease.
• Skeletal Growth And Maturation Is The Outcome Of Complex Interaction Of Many
Genes , Hormones , growth Factors , Environment.
• Some Of The Markers Are : Growth Hormone, Insulin Like Growth Factor -1,
PTH –Related Protein, Dehydroepiandrosterone (DHEA) ,Testosterone ,
Androgens, Oestrogens, Cortisol, Osteocalcin (Bone Gamma –
Carboxyglutamic Acid Protein).
• Radiographic Growth Indicators Show Polymorphism Sexual Dimorphism Which Limit
Their Clinical Use. Ethical Issues Concerning Additional Radiographic Exposure Have
Resulted In Use Of Biochemical Markers To Assess Growth Status Of Of An Individual .

20. CONCLUSION
• ORTHODONTIC GREATMENT OF MOST DENTOFACIAL PROBLEMS WILL BE AFFECTED
BY CONCURRENT GROWTH REGARDLESS OF APPLIANCE MECHANICS.
• WITH REFERNCE TO THE STUDIES RELATED TO EACH OF THE MATURITY INDICATORS ,
WECAN CONCLUDE THAT ANY OF TH EMATURITY INDICATORS CAN’T BE USED
ALONE 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.

21. REFERENCES
• W.R. PROFITT : CONTEMPORARY ORTHODONTICS
S.L.BHALAJHI : ORTHODONTICS – THE ART AND SCIENCE
INTERNATIONAL JOURNAL OF ORTHODONTIC REHABILATATION
EUROPEAN JOURNAL OF GENERAL DENTISTRY
 S. GOWRI SHANKAR : TEXTBOOK OF ORTHODONTICS
 RAJAGOPAL AND S. KANSAL : COMPARISON OF MODIFIED MP3 STAGES AND THE
CERVICAL VERTEBRAE AS GROWTH INDICATORS .
SACHAN KIRAN , V.P. SHARMA AND PRADEEP TONDON : A CORRELATIVE STUDY BETWEEN
FISHMAN’S SMI WITH CVMI AND CHRONOLOGICAL AGE IN LUCKNOW POPULATION
T. TRIPATHI , P. GUPTA AND P. RAI : BIOCHEMICAL MARKERS AS SKELETAL MATURITY
INDICATORS

22. Thank You
• Presented By : Yash Srivastava
: BDS 2016 ( Final Year )
: Batch - VIII