SKELETAL MATURITY INDICATORS
SKELETAL MATURITY INDICATORSUnder the guidance of : Department
of orthodontia and Dentofacial orthopaedicsNBDCH
INTRODUCTIONChronologycal 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.
A number of methods are available to assess the skeletal
maturity of an individual.These include-Use of hand-wrist
radiographs.Evaluation of skeletal maturation using cervical
vertebrae.Assessment of maturity by clinical and radiological
examination of different stages of tooth development.
HAND-WRIST RADIOGRAPHSINDICATIONSIn patients who exhibit major
discrepancy between dental and chronologic ageDetermination of
skeletal maturity status prior to treatment of skeletal
malocclusion such as a skeletal class II or class III
malocclusionTo access the skeletal age in a patient whose growth is
affected by infection, neoplastic or traumatic condition
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 statusTo predict
pubertal growth spurtIt is a valuable aid in research aimed at
studying the role of heredity, environment, nutrition etc., on the
skeletal maturation patternIt is indicated in patients with
skeletal malocclusion needing orthognathic surgery, if undertaken
between 16-20 years so as to access the growth status
Hand wrist region is made of 4 groups of bones-1.Distal ends of
long bones of forearm2.Carpals3.Metacarpals4.Phalanges
A number of methods have been described to assess the skeletal
maturity using Hand- Wrist radiographs. The following are the most
commonly used methodsAtlas method by Greulich and PyleBjork,Grave
and Brown methodFishmans Skeletal Maturity IndicatorsHagg and
Taranger Method
BJORK , GRAVE AND BROWN METHODThey 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.
The hamular process of hamate exhibits ossificationOssification
of pisiformThe 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 :
Initial mineralization of the ulnar sesamoid of the
thumb.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
:
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;Middle phalanx of the third finger
Proximal phalanx of the thumb
Radius
It is characterized by the union between epiphysis and diaphysis
of the distal phalanx of the middle fingerThis stage signifies the
end of the pubertal growth spurt.STAGE 6[males 15y, females13y]
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]
This stage shows the fusion between the ephyphysis and diaphysis
of the middle phalanx of the middle finger
STAGE 8 [male15.9y,female13.9y]
It is characterized by the by the fusion of the diaphysis and
the epiphysis at the radiusit signifies the end of skeletal growth.
STAGE 9 [male18.5y, female16y]
FISHMANS SKELETAL MATURITY INDICATORSLeonard 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 fishmans system of interpretation uses four stages
of bone maturation:Epiphysis equal in width to diaphysis.Appearance
of adductor sesamoid of the thumb.Capping of epiphysis.Fusion of
epiphysis.
Eleven discrete adolescent skeletal maturity indicators covering
the entire period of adolescent development have been
described.Epiphysis as wdie as diaphysisSMI 1; Third finger
proximal phalanxSMI 2; Third finger middle phalanxSMI 3; Fifth
finger middle phalanxOssificationSMI 4; Appearance of adductor
sesamoid of thumbCapping of EpiphysisSMI 5; Third finger distal
phalanxSMI 6; Third finger middle phalanxSMI 7; Fifth finger middle
phalanx
Fussion of epiphysis and diaphysisSMI 8; Third finger distal
phalanx SMI 9; Third finger proximal phalanxSMI 10; third finger
middle phalanxSMI 11; Radius
SKELETAL MATURATION ASSESSMENTAccelerating growth velocity
period=SMI 1-4
High growth velocity period=SMI 4-7
Decelerating growth velocity period=SMI 7-11
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.
SKELATAL MATURATION EVALUATION USING CERVICAL VERTEBRAE The
following six stages were put forward in vertebral development.
STAGE 1This stage called initiation corresponds to beginning of
adolescents growth with 80% to 100% adolescents growth
expectedInferior borders of C2,C3 and C4 were flat at this stageThe
vertebrae were wedge shaped, and the superior vertebral borders
were tapered from posterior to anterior.
STAGE 2The second stage is called acceleration.Growth
acceleration begins at this stage with 65% to 85% of adolescents
growth expectedConcavities were developing in the inferior borders
of C2 and C3.The inferior border of C4 was flatThe bodies of C3 and
C4 were nearly rectangular in shape
STAGE 3This stage is called transition.It corresponds to
acceleration of growth towards peak height velocity with 25% to 65%
of adolescent growth expected.Distinct concavities were seen in the
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.
STAGE 4This stage called deceleration, corresponds to the
deceleration of adolescent growth spurt with 10% to 25% of
adolescents growth expected.Distinct concavities were seen in the
inferior borders of C2,C3 and C4.The vertebral bodies of C3 and C4
were becoming more squarer in shape.
STAGE 5The fifth stage is called maturation.Final maturation of
the vertebrae took place during this stage, with 5% to 10% of
adolescent growth expectedMore accentuated concavities were seen in
the inferior borders of C2,C3 and C4.The bodies of C3 and C4 were
nearly square in shape.
STAGE 6This stage is called completion corresponds to completion
of growth.Little or no adolescent growth expectedDeep concavities
were seen in the inferior borders of C2,C3 and C4.The bodies of C3
and C4 were square or were greater in vertical dimensions than in
horizontal dimension.
APPLICATION TO DENTOFACIAL ORTHOPEDICSClass 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)
TOOTH MINERALIZATION AS AN INDICATOR OF SKELETAL MATURITYThe
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.
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:
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:
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:
CONCLUSIONSSkeletal maturity indicators can be used as an
secondary diagnostic tool for orthodontic treatment.
THANK YOUREFERENCES:CONTEMPORARY ORTHODONTICS- W.R.
ProffitORTHODONTICS The art and science- S.L.Bhalajhi
