Skeletal maturity indicators

orthodontic diagnostic aids

1. Skeletal Maturity indicators

2. Skeletal maturity indicators Hand and wrist radiographs, Cervical vertebrae Mid palatal suture Corpus index Tooth mineralization

3. Hand & wrist radiograph

4. Indications for hand & wrist radiographs Prior to rapid maxillary expansion When maxillomandibular changes are indicated Marked discrepancy b/w chronologic and dental age Orthodontic patients requiring orthognathic surgery between 16 &20 yrs of age.

5. Most commonly used, comprising of 28 – 30 separate centers of bone growth and maturation

6. Anatomy of skeleton of the hand Distal ends of long bones Carpals Metacarpals Phalanges Carpel bones: Trapezium Trapezoid Capitate Hamate Hamular processof the hamate Triquetral Pisiform Lunate Scaphoid

7. Introduction: One of the objective for treating skeletal discrepancies, is to take advantage of the patients growth spurt, which help to achieve optimal results,within the short period of time. Evaluation of individual biologic time table and identification of period of accelerated growth is essential for clinical decisions, regarding growth modulation procedures for skeletal discrepancies, extraction versus non extraction options,use of extra oral orthopaedic forces and planning for orthognathic surgery for skeletal malocclusions.

8. TOPOGRAPHIC ANATOMY OF THE SKELETON OF THE HAND 1. Epiphysis of the thumb. 2. Epiphysis of the proximal phalanx of the thumb. 3. Sesamoid of the adductor brevis muscle at the metacarpophalangeal joint of the thumb. 4. Epiphysis of the distal phalanx of the index finger. 5. Epiphysis of the middle phalanx of the index finger. 6. Epiphysis of the proximal phalanx of the index finger. 7. Epiphysis of the distal phalanx of the middle finger. 8. Epiphysis of the middle phalanx of the middle finger. 9. Epiphysis of the proximal phalanx of the middle finger. 10. Epiphysis of the distal phalanx of the ring finger. 11. Epiphysis of the middle phalanx of the ring finger. 12. Epiphysis of the proximal phalanx of the ring finger. 13. Epiphysis of the distal phalanx of the little finger. 14. Epiphysis of the middle phalanx of the little finger. 15. Epiphysis of the proximal phalanx of the little finger. 16. Epiphysis of the metacarpal bone. 17. Epiphysis of the second metacarpal bone.

9. TOPOGRAPHIC ANATOMY OF THE SKELETON OF THE HAND 18. Epiphysis of the third metacarpal bone. 19. Epiphysis of the fourth metacarpal bone. 20. Epiphysis of the fifth metacarpal bone. 21. Trapezium. 22. Trapezoid bone. 23. Capitate bone. 24. Hamate bone. 25. Hamular process of the hamate bone. 26. Triquetral bone. 27. Pisiform bone. 28. Lunate bone. 29. Scaphoid bone. 30. Distal epiphysis of the radius. 31. Distal epiphysis of the ulna.

10. Hand-wrist radiograph:

11. SKELETAL MATURATION ASSESSMENT . LEONARD S.FISHMAN 1982 outlined four stages of bone maturation found at six anatomical sites located on the thumb, third finger, fifth finger and radius. Eleven skeletal maturity indicators are found in these six anatomic sites. Epiphysis as wide as diaphysis 1.Third finger-proximal phalanx 2.Third finger-middle phalanx 3.Fifth finger-middle phalanx Ossification 4.Adductor sesamoid of thumb Capping of epiphysis 5.Third finger distal- phalanx 6.Third finger middle -phalanx 7.Fifth finger middle-phalanx Fusion of epiphysis and diaphysis 8.Third finger distal -phalanx 9.Third finger proximal- phalanx 10.Third finger middle- phalanx 11.Radius

12. Fishman’s skeletal maturity indicators

13. Hagg and Taranger skeletal maturity indicators They described a method in which skeletal development is assessed by ossification of the ulnar sesamoid of the metacarpophalangeal joint of the first finger (S) and certain specified stages of three epiphyseal bones; the middle and distal phalanges of the third finger (MP3 and DP3) and the distal epiphysis of the radius (R ). All the four bones to be used as indicators of the skeletal development were choosen according to Bjork. Eight of the ten indicators were already defined by others. In order to obtain maturation indicators of shorter duration, two new epiphyseal stages were defined. One stage in the middle phalanx of the third finger,denoted MP3-FG,and one stage in the distal end of the radius,denoted R-IJ. Sesamoid: sesamoid is usually attained during the acceleration period of the pubertal growth spurt(onset of P.H.V.)

14. Hagg and Taranger

15. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH Growth stages of the fingers are assessed according to the relationship between the epiphysis and diaphysis. There are three 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.

16. MP3 STAGES

17. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH There are nine developmental stages. 1. First stage of maturation :(PP2= stage) The epiphysis of the proximal phalanx of the index finger has the same width as the diaphysis. This stage occurs approximately 3 years before the peak of the pubertal growth spurt. 2. second stage :(MP3=stage) Epiphysis of the middle phalanx of the middle finger is of the same width as the diaphysis.

18. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH 4. Fourth stage :(S-and H2-stage) S-stage: First mineralization of the ulnar sesamoid bone of the metacarpophalangeal joint of the thumb. 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.

19. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH 3. Third stage :(Pisi-,H1-,and R= stage) This stage of development can be identified by three distinct ossification areas. These show individual variations but appear at the same time during the process of the maturation. Pisi-stage: Visible ossification of the pisiforme. H1-stage : Ossification of the hamular process of the hamatum. R-stage : Same width of epiphysis and diaphysis of the radius.

20. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH 5. Fifth stage :( MP3cap–,PP1cap-,and Rcap-stage) During this stage ,the diaphysis covered by the cap shaped epiphysis. MP3cap–stage: The process begins at the middle phalanx of the third finger. PP1cap-stage : At the proximal phalanx of the thumb. Rcap-stage : At the radius. This stage of ossification marks the peak of the pubertal growth spurt.

21. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH 6. Sixth stage :(DP3u-stage) Visible union of the epiphysis and diaphysis at the distal phalanx of the middle finger. This stage of development constitutes the end of the puberal growth.

22. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH 7. Seventh stage :(PP3u-stage) Visible union of the epiphysis and diaphysis at the proximal phalanx of the little finger.

23. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH 8. Eighth stage :(MP3u-stage) Visible union of the epiphysis and diaphysis at the middle phalanx of the middle finger is clearly seen .

24. BIOLOGICAL AGE AND HAND WRIST RADIO GRAPH 9. Ninth stage :(Ru-stage) Complete union of the epiphysis and diaphysis of the radius. The ossification of all the hand bones is completed and skeletal growth is completed.

25. Cervical vertebrae maturation indicators The first seven vertebrae in the spinal column constitute the cervical spine. The first two, the atlas and the axis are quite unique, the third through the seventh have great similarity. Maturational changes can be observed from birth to full maturity. Vertebral growth takes place from the cartilagenous layer on the superior and inferior surface of each vertebrae. Secondary ossification nuclei on the tips of the bifid spinous processes and transverses appear during puberty. Secondary ossification nuclei unite with the spinous processes when vertebral growth is complete. After completion of endochondral ossification, growth of the vertebral body takes place by periosteal apposition. It appears to take place only at the front and sides. Todd and Pyle , Lanier and Taylor made measurements from lateral radiographs of the lower cervical vertebrae. Lamparski studied changes in size and shape of cervical vertebrae .

26. Cervical vertebrae maturation indicators The standard method of evaluating skeletal maturity has been to use a hand- wrist x-ray to compare the bones of an individual’s hand with those in published atlases. To avoid taking an additional x-ray,some researchers sought to relate maturation with dental and skeletal features other than the bones in the hand and wrist. The use of cervical vertebrae to determine skeletal maturity is not new. In 1972, Lamparski concluded that the cervical vertebrae ,as seen on the routine lateral cephalograms , were as statistically and clinically reliable in assessing skeletal age as the hand-wrist technique. He found that the cervical vertebral indicators were the same for females and males, but that females developed the changes earlier.

27. Cervical vertebrae maturation indicators The use of cervical vertebrae to determine skeletal maturity was suggested by Lamparski in 1972. He concluded that the cervical vertebrae, as seen on routine lateral cephalograms,were as statistically and clinically reliable in assessing skeletal age as the hand-wrist technique. He found that the cervical vertebral indicators were the same for the females and males, but that females developed the changes earlier.

28. Cervical vertebrae maturation indicators Six stages of cervical vertebral maturation were described. Stage 1 : All inferior borders of the bodies are flat. The superior borders are strongly tapered from posterior to anterior. Stage 2 : A concavity has developed in the inferior border of the second vertebrae.the anterior vertical heights of the bodies have increased. Stage 3 :A concavity has developed in the inferior border of the third vertebra. The other inferior borders are still flat. Stage 4 : All bodies are now rectangular in shape. The concavity of the third vertebra has increased, and a distinct concavity has developed on the fourth vertebra. Concavities on 5 and 6 are just beginning to form . Stage 5 : The bodies have become nearly square in shape and the space between the bodies are visibly smaller.concavities are well defined on all six bodies. Stage 6 : All bodies have increased in vertical height and are higher than they are wide.All concavities have deepened. - Lamparski

29. Cervical vertebrae maturation indicators Cvs1 cvs2 cvs3 cvs4 cvs6

30. Cervical vertebrae maturation indicators STAGES

31. Cervical vertebrae maturation indicators 1. Initiaton: Inferior borders of 2 nd 3 rd and 4 th cervical vertebrae are flat at this stage. The third and fourth vertebrae are wedge shaped and the superior vertebral borders are tapered from posterior to anterior. 100% of pubertal growth remains. Very significant amount of adolescent growth expected.

32. Cervical vertebrae maturation indicators 2. Acceleration: Concavities on the inferior borders of second and third vertebrae begin to develop. Inferior border of fourth vertebrae remains flat. Vertebral bodies of third and fourth are nearly rectangular in shape. 65-85% of pubertal growth remains.

33. Cervical vertebrae maturation indicators 3. Transition : Distinct concavities are shown on the inferior borders of second and third vertebrae. A concavity begins to develop on the inferior border of fourth vertebrae. Vertebral bodies of third and fourth are rectangular in shape. 25-65% of pubertal growth remains.

34. Cervical vertebrae maturation indicators 4. Deceleration stage: Distinct concavities can observed on the inferior borders of second third and fourth cervical vertebrae. Vertebral bodies of third and fourth begin to be more square in shape. 10-25% of pubertal growth remains.

35. Cervical vertebrae maturation indicators 5. Maturation stage: Marked concavities are observed on the inferior borders of second, third and fourth cervical vertebrae. Vertebral bodies of third and fourth are almost square in shape. 5-10% of pubertal growth remains.

36. Cervical vertebrae maturation indicators 6. Completion: Deep concavities are observed on the second, third and fourth cervical vertebrae. Vertebral bodies are greater vertically than horizontally. Pubertal growth has been completed.

37. Assessment of skeletal maturation The 5 distinct stages of MP3 as described by HAGG & TARANGER (1980), and 6 th stage (between MP3-H and MP3-I which is called as MP3-HI stage) which was introduced by our prof. Dr.Raja gopal and Dr. Kansal were to be evaluated and compared with six stages of cervical vertebrae which were described by HASSEL & FARMAN(1995).

38. COMPARISON BETWEEN MP3-F & INITIATION STAGE MP3-F STAGE INITIATION STAGE It represents the onset or the start of the curve of pubertal growth spurt. FEATURES: Epiphysis is as wide as metaphysis. 1.C 2 , C 3 and C 4 inferior vertebral body borders are flat. 2.Superior vertebral borders are tapered from posterior to anterior. (Wedge shape). 3.100% of pubertal growth remains.

39. COMPARISON BETWEEN MP3-FG & ACCELERATION STAGE MP3-FG STAGE ACCELERATION STAGE It represents the acceleration part of the curve of pubertal growth spurt. FEATURES: 1.Epiphysis is as wide as metaphysis 2.There is a distinct medial and or lateral border of the epiphysis forming a line of demarcation at right angle to the distal border. 1.Concavities developing in lower bordres of C 2 & C 3 . 2.Lower border of c 4 vertebral body is flat. 3. c 3 & c 4 are more rectangular in shape. 4.65-85 % of pubertal growth remains.

40. COMPARISON BETWEEN MP3-G & TRANSITION STAGE MP3-G STAGE TRANSITION STAGE It represents the point of maximum pubertal growth spurt. FEATURES: Sides of epiphysis have thickened and cap its metaphysis forming a sharp edge distally at one or both sides. 1.Distinct concavities in lower borders of c 2 and c 3 are seen. 2.Developing concavity in lower border of body of c 4 is seen. 3. c 3 and c 4 are rectangular in shape. 4.25-65% of pubertal growth remains.

41. COMPARISON BETWEEN MP3-H & DECELERATION STAGE MP3-H STAGE DECELERATION STAGE It represents the deceleration part of the Curve of pubertal growth spurt. FEATURES: Fusion of epiphysis and metaphysis has begun. 1.Distinct concavities in the lower bordrs of c 2 , c 3 and c 4 are seen. 2. c 3 and c 4 are nearly square in shape. 3.10-25% of pubertal growth remains.

42. COMPARISON BETWEEN MP3-HI & MATURATION STAGE MP3-HI STAGE MATURATION STAGE It represents the maturation part of the curve of pubertal growth spurt. FEATURES: 1.Superior surface of the epiphysis shows a smooth concavity. 2.Metaphysis shows a smooth convex surface almost fitting into the reciprocal concavity of epiphysis. 3.Radiolucent gap between epiphysis and metaphysis is insignificant. 1. Accentuated concavities of inferior vertebral body borders of c 2, c 3 ,and c 4 are seen. 2. c 3 and c 4 are square in shape. 3. 5-10% of pubertal growth remains.

43. COMPARISON BETWEEN MP3-I & COMPLETION STAGE MP3-I STAGE COMPLETION STAGE It represents the end of pubertal growth Spurt. FEATURES: 1.Fusion of epiphysis and metaphysis is completed. 1. Deep concavities present on inferior vertebral body borders of c 2 , c 3 and c 4. 2. c 3 and c 4 heights are greater than widths. 3. Pubertal growth has been completed.

44. Correlation of hand-wrist and cervical vertebral maturation stages Hand –wrist SMI Cervical vertebral stages Pubertal 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%

45. Introduction: As a results many investigators have attempted , to predict the duration ,magnitude, direction and timing of the adolescent growth changes. The developmental status of a child is usually assessed in relation to events that take place during progress of growth. Thus chronological age, sexual maturational characteristics , dental development (dental age), height and weight measurements and skeletal age are some of the biological indicators that have been used to identify stages of growth.

46. Introduction: Chronological age is often not sufficient for assessing the developmental 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 and morphologic age and onset of puberty. Patient chronological age is defined as the time period from the birth to till date. Morphologic age is based on the height . A child’s height can be compared with those of his same age group and other age groups to determine where he stands in relation to others. Height is useful as a maturity indicator from late infancy to early adulthood.

47. Introduction: Dental age has been based on two different methods of assessment. 1. Tooth eruption age. 2. Tooth mineralization stage. Sexual age refers to development of secondary sexual characteristics. This type of indicator is useful only for adolescent growth. Skeletal age Assessment is often made with the help of hand - wrist radiograph which can be considered the ‘ Biological clock ’ . Nine developmental stages are there according BJork (1972), Grave and Brown (1976).The ossification events are localized in the area of the phalanges, carpal bones and radius.