Skeletal maturity index

Skeletal maturity index- Orthodontics

1. SKELETAL MATURITY INDICATORS 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- 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 .

4. HAND-WRIST RADIOGRAPHS I NDICATIONS 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. I NDICATIONS (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 Atlas method by Greulich and Pyle Bjork,Grave and Brown method Fishman’s Skeletal Maturity Indicators 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. The hamular process of hamate exhibits ossification Ossification of pisiform 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. 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 :

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; Middle phalanx of the third finger Proximal phalanx of the thumb 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: Epiphysis equal in width to diaphysis . Appearance of adductor sesamoid of the thumb. Capping of epiphysis. 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

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

20. 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.

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

22. STAGE 2 The second stage is called acceleration. Growth acceleration begins at this stage with 65% to 85% of adolescents 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

23. STAGE 3 This 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.

24. STAGE 4 This 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.

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

26. STAGE 6 This stage is called completion corresponds to completion of growth. Little or no adolescent growth expected Deep 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.

27. 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)

28. 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.

29. 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:

30. 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:

31. 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:

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

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