Assessment of Developmental Age ortho .pdf

Assessment of Developmental Age.pdf

1. Assessment of developmental age
I –Accurate maturation indicator methods:
1- Hand wrist radiograph (SMI) and MP3.
2- Cervical Vertebrae Maturation indicators
(CVMI)
3-Concentration of growth hormon (insulin like factor 1)
II–Questionable maturation indicator
methods (Individual variation) :
1 - Chronological Age is a poor indicator.
2 - Body height and weight 3 - Growth Velocity
4 - Dental Development (Nolla`s stages) .
5 – Ultrasonography of the hip bone.
6-Midpalatal suture stages. 7-Frontal sinus ratio.
8-Alkaline phosphatase concertration.

2. Developmental age assessment .

3. Methods of skeletal age assessment
Radiographic
methods
Non
Radiographic
methods
1.Hand wrist radiograph
2.MP3 method
3.Cervical vertebral maturation index
4.Frontal sinus
5. Midpalatal suture ossifiycation and density

4. 1-Hand wrist radiograph (SMI)
Identify certain ossification events in the
hand, wrist and fingers
for assessment of growth status using standard tables and the atlas of Greulich
and Pyle(1959).

5. Newborn
3 m 6m
9m
15m
2y 4y 10y 15y 19y

6. (SMI ) : 9 developmental stages are assessed by Bjork 1972
& modified by Grave & Brown ,1976 .
Ossification events are
localized in phalanges ,
carpal bones and
Radius. Growth stages
are assessed according
to the relation of
epiphysis to diaphysis.

7. 1st stage (PP2) :
Proximal Phalange of index showing
equal width of epiphysis and diaphysis.
3 years before peak (10.6 y in males &
8.1 y in females)
2nd stage (MP3) :
Epiphysis and diaphysis of middle Phalanx
of middle finger show equal width ( 12 y in
males & 8.1 y in females).

8. 3
rd
stage (Pisi , H1 and R 3rd stage) :
Three distinct ossification areas ( Pisiforme , Hamular process and Radius
epiphysis equals diaphysis) . They show individual variations .
(12.6 in males & 9.6 in females)
The Hamular
process of Hammate
exhibits calcification
Pisiform
Ossification

9. 4th stage (S and H2 stage) :
S: Sesamoid bone mineralization
H2: Progressive ossification of
the hamular process reached
shortly before or at the beginning
of the pubertal growth spurt ( 13 y
in males and 10.6 y in females).
5th stage (Mp3cap, Pp1cap and R cap ) :
This stage marks the peak of pubertal
growth spurt ( 14 y in males & 11 y in
females).
.

10. sixth stage (Dp3 union) :
Union of epiphysis and diaphysis at Dp3.
It indicates the end pubertal growth.
(15 y in males & 13 y in females).
Seventh stage (Pp3 union):
union of epiphysis and diaphysis at Pp3.
( 15.9 y in males & 13.3 y in females).

11. Eight stage (Mp3 union) :
Union of epiphysis and diaphysis at Mp3.
(15.9 y in males &13.9 y in females).
Ninth stage (R union) :
Complete union of epiphysis and
diaphysis of the radius.
Skeletal growth is finished.
(18.5 y in males & 16 y in females).

12. ChnracteristicStage
absence of pisiform &hook of the hamate
and epiphysis of proximal phalanx of 2
nd
finger narrower than its
diaphysis
One (early):
initial ossification of hook of the hamate & pisiform
and proximal phalanx of 2
nd
finger being equal to its epiphysis.
Two
(prepubertal)
beginning of calcification of ulnar sesamoid,
increased width of epiphysis of proximal phalanx of the 2
nd
finger
and increased calcification of hook of hamate and pisiform.
Three
(pubertal
onset)
calcified ulnar sesamoid and
capping of the diaphysis of middle phalanx of 3
rd
finger by its
epiphysis.
Four
(pubertal)
calcified ulnar sesamoid,
fusion of epiphysis of distal phalanx of 3
rd
finger with its shafts,
and epiphysis of radius and ulna not fully fused with respective
shafts
Five (pubertal
deceleration):
No remaining sites seenSix (growth
completion)
Singer’s Method 1980

13. First, look at the adductor sessamoid of the thumb in the patient`s hand –wrist radiograph .If it is
not ossified look at the width of the epiphysis of the middle phalanx of the third finger (MP3) , if
it is equal or less than the diaphysis width , the patient has not yet reached puberty . If the
sesamoid is ossified and capping of the MP3 is seen (epiphysis is wider than diaphysis), the
patient has just reached puberty .After this stage and within 2years ,fusion of MP3 will occur
indicating little growth remaining . Finally if fusion of radius is seen , growth of this pt is
complete .

14. Fishman,s 11 adolescent
skeletal maturity (SMI,s)
,82.

15. 2.MP3 method

16. 3-Cervical Vertebrae Maturation
indicators (CVMI)as described by Lamparski and
modified by Hassel and Farman.
It is simple ,
reliable and
economical.

17. 1- Initiation (CS1) :
The lower borders of 2
nd
,3
rd
& 4
th
cervical vertebrae are
flat.
The 3
rd
&4
th
vertebrae are wedge-shaped (tapered from
back to front).
100% of pubertal growth remains .

18. 2-Acceleration (CS 2) :
The lower borders of the 2
nd
& 3
rd
vertebrae begin to be
concave while of the 4
th
still flat.
3
rd
&4
th
vertebral bodies are nearly rectangular .
65-85% of pubertal growth remains.

19. 3- Transition (CS 3) :
Distinct concavities of the 2
nd
& 3
rd
lower borders while
that of the 4
th
begin to be concave.
3
rd
&4
th
vertebral bodies are rectangular .
25-65% of pubertal growth remains.

20. 4- Deceleration (CS 4) :
Distinct concavities of the lower borders of the 2
nd
,3
rd
&
4
th
vertebrae.
Vertebral bodies of the 3
rd
& 4
th
begin to be square .
10- 25% of pubertal growth remains .

21. 5- Maturation (CS5) :
Marked concavities of the lower borders of the 2
nd
,3
rd
&
4
th
vertebrae.
Vertebral bodies of the 3
rd
& 4
th
are almost square .
5 - 10% of pubertal growth remains .

22. 6 – Completion (CS 6) :
Deep concavities of the lower borders of the 2
nd
,3
rd
& 4
th

vertebrae.
Vertebral bodies of the 3
rd
& 4
th
are longer vertically
than horizontally.
Pubertal growth has been completed .

23. SMI CVMS
% Pub Growth Remaining
1-2 Initiation 85-100
3-4 Acceleration 65-85
5-6 Transition 25-65
7-8 Deceleration 10-25
9-10 Maturation 5-10
11 Completion 0
Correlation of SMI & CVMS

24. Maxillary expansion and protraction is effective in the
maxilla only when it is performed before the peak
(CS1 or CS2), while if pubertal or post pubertal ,it
entails more dento alveolar effects.
Orthopedic treatment of increased anterior facial
height(maxillary posterior impaction) and maxillary
retraction is performed at the peak of mandibular
growth (CS3).
Restraining and stimulation of the mandibular growth
are effective during both pre pubertal and pubertal
stages.

25. Modified Median Phalanx Index (MP3) Rajagobal
and Kansal (2002)
correlated with Cervical Vertebrae Index (CVMI)
Hassel and Farman

26. MP3-F stage ( Initiation , CS1):
* Epiphysis is as wide as metaphysis.
* Ends of epiphysis are tapered.
* Metaphysis shows no undulation.
•Wide Radiolucent gap.
* 100% of pubertal growth
remains .
* ( 12.o1Y) – ( Y)

27. MP3-FG stage (Acceleration (CS 2) :
* Epiphysis is as wide as metaphysis.
* Distinct medial and/or lateral border
of epiphysis.
* Metaphysis shows slight undulation.
* Wide Radiolucent gap.
* 65-85% of pubertal growth remains.
* ( 12.85 Y) – ( Y)

28. MP3-G stage (Transition (CS 3) :
*Sides of epiphysis have thickened
and cap its metaphysis.
*Marked undulation in metaphysis
(Cuspid Bow apperance).
•Radiolucent gap is moderate.
* 25-65% of pubertal growth
remains.
•( 13.57 Y) – ( Y)

29. MP3-H stage (Deceleration (CS4):
•Fusion of epiphysis and
metaphysis begins.
* Epiphysis is beginning to narrow.
* Slight convexity is seen under
central part of metaphysis.
•Radiolucent gap is narrower.
•10- 25% of pubertal growth
remains .
• ( 14.61 Y) – ( Y)

30. MP3-HI stage (Maturation,CS5):
* Epiphysis shows smooth concavity.
* Metaphysis shows smooth convexity
•No undulation in metaphysis.
•Radiolucent gap is insignificant.
•5 - 10% of pubertal growth
remains.
* ( 15.03 Y) – ( Y)

31. MP3- I stage (Completion,CS6):
•Fusion of epiphysis and
metaphysis is complete.
* No radiolucent gap between
metaphysis and epiphysis.
*Pubertal growth is completed .
(15.38 y - )

32. Sp coincided with
MP3 G stage
Frontal sinus as a
developmental indicator

33. Growth continued up to
the age of 16 in girls and
18 in boys

34. 2010

35. 2013
Stage A.
Straight high
density
sutural line
along maxilla
and palate
without
interdigitation

36. A B C
D
E

37. The hip boneassessment (Rissersign)
Is used to grade skeletal maturity based
on the level of ossification and fusion of
the iliac crest apophasis.

38. Grade 1:Apophysisis under 25%of the iliac crest
it corresponds toprepubertyor earlypuberty
Grade 2 :Apophysisis 25% -50%of the iliac crest
it corresponds to the stage growth spurt.
Grade 3 : Apophysisis 50%-75%of the iliac crest
it corresponds to the slowing of growth.
Grade 4 : Apophysisis over 75%of the iliac crest
it corresponds to an almost cessation of growth.
Grade 5 : complete ossification and fusion of the iliac apophysis

39. MPSD ratio = GD s – G D sp / GD ppm – G D sp = 0 - 1
GD s :Grey density of 6mm width & distance from distal to incisive papilla to 1
st
molars length.
GD ppm : Grey density of palatal process 4 x 4 mm
G D sp : Grey density of soft palate 4 x 4 mm
Lower Values: near soft palate density
Higher Values: near
palatal process density
Midpalatal suture density ratio: A novel predictor of
skeletal response to rapid maxillary expansion.
Larson CE , 2017.

40. Pattern of IGF-I in relation to the stages of the cervical
vertebral maturation index
Insulin - like growth factor 1 as maturity indicator

42. GCF ALP is a good
indicator for skeletal
maturation unlike
GCF proteins

43. 54
49
58
51
49
44
88
74
46
50
CS1 CS2 CS3 CS4 CS5 CS6
Max Mand
Alkaline
phosphatase
Protein
content

44. Serial height and weight
records using standard
growth chart:
A child who is between 3rd
and 97
th
percentiles is
considered normal ,while
outside that range,
abnormality must be
suspected. It is useful also
for determining whether
the subject is likely to
experience mandibular
growth.
Morphologic Age

45. Nolla `s 10 stages of
tooth movement,1952.
Dental Age