Assessment of skeletal age in Orthodontics

This presentation outlines various methods of Skeletal Age Assessment in Orthodontics

1. ASSESSMENT OF SKELETAL AGE Dr. SAIF ALAM JR-I

2. CONTENTS

3. METHODS OF SKELETAL AGE ASSESSMENT

4. HAND WRIST RADIOGRAPH CARPAL BONES

5. Bjork, Grave and Brown Method (1976)

6. Maturation Stages First stage: PP2 Stage The epiphysis of the proximal phalanx of the index finger (PP2) has the same width as the diaphysis Occurs approximately 3 years before the peak of the pubertal spurt 

7. Second stage (MP3 Stage) Epiphysis of the middle phalanx of the middle finger (MP3) is of the same width as the diaphysis

8. Third Stage This stage of development can be identified by three distinctive ossification areas; Pisi stage = visible ossification of the pisiformae H1 stage = ossification of the hamular process of the hamatum R stage = same width of the epiphysis and diaphysis of the radius

9. Fourth stage (S and H2 stage) S stage : first mineralisation of the ulnar sesamoid bone H2 stage : progressive ossification of the hamular process of the hamatum The fourth stage is reached shortly before or at the beginning of the pubertal growth spurt

10. Fifth Stage (MP3 cap, PP1 cap , R cap ) During this stage the diaphysis is covered by the cap-shaped epiphysis MP3 cap Stage : the process begins at the middle phalanx of the third finger   PP1 cap stage : at the proximal phalanx of thumb R cap stage : at the radius This stage marks the peak of the pubertal growth spurt

11. Sixth Stage (DP3 u ) Visible union of the epiphysis and diaphysis at the distal phalanx of the middle finger This stage of development constitutes the end of the pubertal growth 

12. Seventh Stage (PP3 u stage) Visible union of the epiphysis and diaphysis at the proximal phalanx of the middle finger

13. Eighth stage (MP3 u ) Union of the epiphysis and diaphysis of the middle phalanx of the middle finger

14. Ninth stage (R u ) Complete union of the epiphysis and diaphysis of the radius The ossification of all the hand bones is completed and skeletal growth is finished

15. FISHMAN SKELETAL MATURITY INDICATOR Leonard S Fishman, 1982. It makes use of anatomical sites located on thumb, third finger, fifth finger and radius. The Fishman's 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.

16. The Eleven Skeletal Maturity Indicators

17. Tanner And Whitehouse Method Tanner and Whitehouse suggested three methods of scoring maturity of individual bones to determine skeletal age.  Radius, ulna, short bones score ,i.e., RUS score, rates the radius, ulna, metacarpals of digits as 1, 3, and 5, middle and distal phalanges of digits as 3 and 5. In this method, twenty regions of interest (ROI's) located in the main bones are considered for the bone age evaluation. The development of each ROI is divided into discrete stages and each stage is given a letter (A, B, C, D... H)   A numerical score is associated with each stage for each bone. By adding the scores of all ROIs, an overall maturity score is obtained.

18. Singer’s Method of Skeletal Maturity Assessment Given by Julius Singer in 1980 Six stages of hand wrist development are described: Stage one : absence of pisiform and hook of hamate. The epiphysis of proximal phalanx of second finger being narrower than its diaphysis. Stage two (pre pubertal): initial ossification of hook of the hamate, pisiform. Stage two represents that period prior to the adolescent growth spurt during which significant amounts of mandibular growth are possible. Stage three (pubertal onset): beginning of calcification of ulnar sesamoid, increased width of epiphysis of proximal phalanx of the second finger and increased calcification of hook of hamate and pisiform.

19. Stage four (pubertal): presence of calcified ulnar sesamoid and capping of the diaphysis of the middle phalanx of the third finger by its epiphysis. Stage five (pubertal deceleration): fully calcified ulnar sesamoid, fusion of epiphysis of distal phalanx of third finger with its shaft, and epiphyses of radius and ulna not fully fused with respective shafts. Stage 5 represents that period of growth when orthodontic treatment might be completed and the patient is in retention therapy. Stage six (Growth completion): No remaining growth sites are seen

20. Skeletal Maturity Indication Method Developed by Hagg and Taranger The assessment was done by taking into consideration the ossification of the ulnar sesamoid of metacarpo -phalangeal joint of the first finger (S) and certain specified stages of three epiphyseal bones: the middle and distal phalanges and third finger (MP3 and DP3) and the distal epiphysis of the radius (R). Hand wrist radiographs used to develop this method were taken from 6 to 18 years of age. Sesamoid: Appearance of the ulnar sesamoid is seen during the acceleration period of pubertal growth spurt

21. Middle Third Phalanx MP3 F : The epiphysis is as wide as the metaphysis MP3 FG : The epiphysis is as wide as the metaphysis. This stage is attained one year before or at PHV. MP3 G : The sides of the epiphysis have thickened and also cap its metaphysis, forming an edge distally at one or both sides. This stage is attained at or one year after the PHV MP3 H : Fusion of the epiphysis and metaphysis has begun and is attained after PHV but before the end of growth spurt. MP3 I : Fusion of the epiphysis and metaphysis is completed.

22. Distal Third Phalanx DP31 : the fusion of epiphysis and diaphysis is completed. The distal epiphysis of the radius (R): Stage I -fusion of the epiphysis and metaphysis has begun Stage IJ -fusion is almost completed but there is still a small gap at one or both margins. Stage J -fusion of the epiphysis and metaphysis is completed

23. Modified Hagg and Taranger Given by Rajagopal et al in 2002 Additional bone stage between MP3-H (deceleration of the curve of the pubertal growth spurt), which is called the MP3-HI stage has been introduced MP3-F Stage : Corresponds to the start of the curve of the pubertal growth spurt Features observed by Hagg and Taranger : Epiphysis is as wide as the metaphysis Ends of the epiphysis are tapered and rounded Metaphysis shows no undulation Radiolucent gap (representing cartilaginous epiphyseal growth plate) between epiphysis and metaphysis is wide

24. MP3-FG Stage : Acceleration of the curve of the pubertal growth spurt Features observed: Epiphysis is as wide as the metaphysis Distinct medial and/or lateral border of epiphysis forms line of demarcation at right angles to distal border Metaphysis begins to show slight undulation Radiolucent gap between epiphysis and metaphysis is wide

25. MP3-G Stage : Maximum point of pubertal growth spurt Sides of epiphysis have thickened and cap its metaphysis, forming sharp distal edge on one or both sides Marked undulations in metaphysis give it a “Cupid’s bow” appearance Radiolucent gap between epiphysis and metaphysis is moderate

26. MP3-H Stage : Deceleration of the curve of pubertal growth spurt Fusion of epiphysis and metaphysis begins One or both sides of epiphysis form obtuse angle to distal border Epiphysis is beginning to narrow Slight convexity is seen under central part of metaphysis Typical “Cupid’s bow” appearance of metaphysis is absent, but slight angulation is distinctly present Radiolucent gap between epiphysis and metaphysis is narrower

27. MP3-HI Stage : Maturation of the curve of pubertal growth spurt Superior surface of epiphysis shows smooth concavity Metaphysis shows smooth, convex surface, almost fitting into reciprocal concavity of epiphysis No undulation is present in metaphysis Radiolucent gap between epiphysis and metaphysis is insignificant

28. Indications of Hand Wrist Radiograph

29. To be continued…………. Thank You