Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy

SKELETAL AGE ASSESMENT
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION
VARIOUS METHODS OF SKELETAL AGE
ASSESMENT
HAND WRIST RADIOGRAPH
CERVICAL VERTEBRA
MIDPALATAL SUTURE
FRONTAL SINUS


Sexual maturation characteristics, chronologic age, dental
development, height, weight, and skeletal development are some
of the more common means that have been used to identify stages
of growth.
HUNTER 1966, BROWN 1972, ,
FISHMAN 1979 AND
HAGG
1982
demonstrated that chronologic age alone

provides little insight or
validity for identifying the stages of developmental progression through
adolescence to adulthood

Children of the same chronological age vary in their maturity
Variation in growth arises because biological clock for same events
during growth are set differently for different individuals

Some children grow rapidly and mature early completing their
growth quickly,others grow and develop slowly and so appear to
behind even though given they will catch up with and even surpass
children who where larger once
Because of timing and variablity chronological age is not agood
indicator of maturity
The pubertal growth spurt is considered to be an advantageous
period for certain types of orthodontic treatment and should be
taken into account in connection with orthodontic treatment
planning.
Because of the wide individual variation in the timing of the
pubertal growth spurt, chronologic age cannot be used in the
evaluation of pubertal growth. Many studies have shown a strong
correlation between the peak of facial growth and peak height
velocity.

Longitudinal records of height can therefore be used for evaluation of
the facial growth rate during puberty. In the clinical context,
longitudinal growth records of height are seldom available. Even with
adequate records, it may be difficult to locate the pubertal growth
spurt before it is passed, since the increase in growth rate is often too
small, especially in many girls, to be clinically discernible
Most of the time the clinician must base his judgment on a single
examination and, therefore, determine the status of the individual by
cross-sectional evaluation alone.
Stature is not an indicator of maturity. Thus, additional information
is necessary to estimate the maturation level of the individual. Such
information can be obtained from the dental, skeletal, and pubertal
development.

By comparing with standards for age and sex, it is possible to assess
whether the development of the individual is average, accelerated, or
retarded. In orthodontics it is more relevant to evaluate the
individual's maturation in relation to his or her own pubertal growth
spurt. This presupposes knowledge of relationships in time between
maturation indicators and pubertal growth events. Suitable maturation
indicators for clinical orthodontics have been devised and the
associations between these indicators and the peak of growth have
been reported.
Growth prediction based on the
appearance of secondary sexual characteristics(voice
change,menarche,hair growth etc)
requires a long observation period and frequent
physical examinations.

Biologic age, skeletal age, bone age, and skeletal maturation are
nearly synonymous terms used to describe the stages of maturation of
a person
Skeletal maturation refers to the degree of development of
ossification in bone. Size and maturation can vary independently of
each other.
During growth, every bone goes through a series of changes that can
be seen radiologically. The sequence of changes is relatively
consistent for a given bone in every person. The timing of the
changes varies because each person has his or her own biologic
clock.


The use of skeletal age has been shown to be more reliable and
precise in assessing the progress of an individual toward
maturity.The technique for assessing skeletal age consists of visual
inspection of bones— their initial appearance and their subsequent
ossification changes in shape and size. Various areas of the skeleton
have been used: the foot, the ankle, the hip, the elbow, the handwrist, and the cervical vertebrae.

Hand wrist radiograph
One important diagnostic tool currently used in determining whether
the pubertal growth has started, is occurring, or has finished is the
hand-wrist radiographic evaluation.

The radiograph of the hand-wrist has been the most frequently used
area of the skeleton. The reason for its use is that many centers are
available in this area of the skeleton that undergo changes at different
times and rates.
The information from the hand-wrist radiograph has been used in a
number of ways to evaluate the skeletal age or bone age of the child.
Bone age can be obtained by either comparing the radiograph in
question with a series of standards films representative of normal
children at different chronologic ages and assigning to the film in
question the age of the standard that matches it most closely, or by
assigning a weighted score to the developmental stage of each of 20
bones in the hand and wrist, the bone age being the total score for the
radiograph


Driezen and associatesfound no difference between skeletal age of the
left and right hand-wrist; Garn and Rohman found a high correlation
among assessments from the hand-wrist, the elbow, the shoulder, the
hip, the knee, and the foot; Lamparski found no difference and a high
correlation between vertebrae and hand-wrist skeletal age
assessments.

History of hand wrist radiograph
Roland, in 1896, introduced the idea of using the comparative size
and shape of the radiographic shadows of growing bones as
indicators of rate of growth and maturity.
Hellman published his observations on the ossification of epiphysial
cartilages of the hand in 1928.


Todd compiled hand-wrist data that was further elaborated on by
Greulich and Pyle in atlas form Flory in 1936, indicated that the
beginning of calcification of the carpal sesamoid (adductor sesamoid)
was a good guide to determining the period immediately before
puberty. The appearance of the adductor sesamoid has been highly
correlated to peak height velocity and the start of the adolescent
growth spurt. Most authors agree that peak height velocity follows
adductor sesamoid appearance by approximately 1 year.
Hagg and Taranger created a method using the hand-wrist
radiograph to correlate certain maturity indicators to the pubertal
growth spurt.
Fishman developed a system of hand-wrist skeletal maturation
indicators (SMIs) using four stages of bone maturation at six
anatomic sites on the hand and the wrist.
Others who contributed are Tanner-white,maria.t.oreilly,shigemi
Goto,Rajagopal, Bjork, Grave and Brown,schopf

Anatomy of hand wrist radiograph


Bjork, Grave and Brown
Stage-1
males10.6y,female8.1y
Epiphysis and diaphysis of
proximal
Phalanx index finger equal
3y before puberty
Stage-2
Male12y,female8.1y
Epiphysis and diaphysis middle phalanx middle finger equal


Stage-3(male 12.6y female 9.6y)
Male12.6yfemale9.6y
a) Hamular process of hamate
Ossification
b)ossification of pisiform
c) Epiphysis and diaphysis of radius equal

Stage-4(male 13y,female 10.6y)
Initial mineralization of ulnar sesamoid of thumb
Increased ossification of hamular process of hamate bone


Stage-5(male 14.0y,female 11.0y)
Capping of the diaphysis by epiphysis
Middle phalanx of third finger
Proximal phalanx of thumb
radius


Stage-6(male 15y female13y)
Characterized by the end of pubertal spurt
Union of epiphysis and diaphysis of distal phalanx of middle finger
Stage-7(male 15.9y,female13.3y)
Union of epiphysis and diaphysis of proximal phalanx of litlle
finger


Stage-8(male 15.9y,female 13.9y)
Fusion of the epiphysis and diaphysis of middle phalanx of
middle finger
Stage-9(male 18.5y female 16.0y
Last phase fusion of epiphysis and diaphysis

m

Fishman(1982)

Skeletal Maturity Indicators (SMI)
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.
7.
Fifth finger-middle phalanx
Fusion of epiphysis and diaphysis
8.
Third finger-distal phalanx
9.
Third finger-proximal phalanx
10.
11.
Radius

As seen above, SMI’s 1–3 and 5–7 are based on selected areas of
the third and fifth fingers. SMI 4 is based on the ossification of the
adductor sesamoid of the thumb, and 8–11 on fusion of selected
areas of the third finger and the radiu


Hagg and taranger(1982)
Skeletal development in the hand and wrist was by assessment of
the ossification of the ulnar sesamoid of the metacarpophalangeal
joint of the first finger (S) and certain specified stages of three
epiphyseal bones (closure of epiphyseal plates): the middle and
distal phalanges of the third finger (MP3 and DP3) and the distal
epiphysis of the radius (R)
Eight of the ten indicator have been defined been previously
defined by previous author. In order to obtain maturation indicators
of shorter duration, two new epiphyseal stages were defined in this
study: one stage in the middle phalanx of the third finger, denoted
MP3-FG, and one stage in the distal ed of the radius, denoted R-IJ.


The ulnar sesamoid (S) of the metacarpophalangeal
joint of the first finger before and after ossifying.
The distal phalanx of the third finger (DP3) before
and after Stage l: fusion of the epiphysis and
metaphysis is completed.
The middle phalanx of the third finger (MP3): Stage
F— the epiphysis is as wide as the metaphysis.
Stage FG— the epiphysis is as wide as the
metaphysis and there is distinct medial and/or lateral
border of the epiphysis forming a line of
demarcation at right angles to the distal border.
Stage G— the sides of the epiphysis have thickened
and also cap its metaphysis, forming a sharp edge
distally at one or both sides.
Stage H— fusion of the epiphysis and metaphysis
has begun.
Stage I— fusion of the epiphysis and metaphysis is
completed.
The distal epiphysis of the radius: 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.

The pubertal growth spurt. Onset of the spurt (ONSET) is the
smallest annual increment from which there is a marked continuous
increase in growth rate to PHV. ONSET is found by locating the
smallest annual increment (A) from which there is a continuous
increase in growth rate to PHV. The curve is then followed toward
PHV until the growth rate has accelerated 10 mm. ONSET will be
indicated by the annual increment which is next below or coincides
with this growth rate. Peak height velocity (PHV) is the greatest
annual increment during puberty. The end of the spurt (END) is the
first annual increment after PHV below 20 mm.


Sesamoid
S was usually period of the pubertal growth spurt (ONSET-PHV).
Middle third phalanx
MP3-F was attained before ONSET.
MP3-FG was attained 1 year before or at PHV .
MP3-G was attained at or 1 year after PHV
MP3-H was attained after PHV but before END
MP3-I was attained before or at END
Distal third phalanx
DP3-I was attained during the deceleration period of the pubertal
growth spurt (PHV-END) by all subjects.
Radius
R-I was attained 1 year before or at END
R-IJ and R-J were not attained before END by any subject.

Leite, O'Reilly, and
Close (1987) Using first, second and third fingers
The following maturity indicators and ossification
events were evaluated
1. First appearance of the adductor sesamoid of the
first metacarpophalangeal joint
— No ossification
— First appearance
2. Changes in the epiphysis and diaphysis of the
proximal, medial, and distal phalanges of the first,
second, and third fingers
— E¾: The epiphysis reaches ¾ of the width of its
diaphysis.
— EQ: The epiphysis is as wide as its diaphysis.
— EC: The epiphysis is as wide as its diaphysis and
there is a distinct medial and/or lateral border of the
epiphysis forming a line of demarcation at right
angles to the distal border.
— FB: Fusion between the epiphysis and its diaphysis
has begun.
— FC: Fusion between the epiphysis and its diaphysis
is complete

The advantage of the three-fingers method is that it eliminates the
need for an additional radiograph. This reduces the amount of
radiation exposure to the patient and cost to the clinician, and can
be obtained more readily during the treatment progress since it can
be included in the lateral cephalometric radiograph. Radiographs
of the head, hand, and wrist can taken on a single film instead of
the usual two films. Their technique provides both records on one
film; however, it still requires two exposures.


Shigemi goto and takamasa(1996)
Ossification of distal phalanx of first digit
ossification of the distal phalanx of the first digit used to
estimate the stage of craniofacial maturation.
ossification of the first digit begins at an early age and
continues over a period of several years.
development proced from no observable epiphysis to the
complete epiphysial union of the digital phalanx of the first
digit
The peak growth velocity in body height in occurs at 10
years of age in girls and 12 years in boys.
complete epiphysial union takes place between 12 and 13
years of age in girls and after 14 years in boys
complete fusion of the distal phalanx of the first digit
normally occurs after maximum pubertal growth .
90% of the total growth in length of the cranial base and
maxillary and mandibular length had already been achieved
at this stage

Ossification event of distal phalanx of first digit. Stage E0: No
epiphysis; Stage E1: Narrower epiphysis than diaphysis; Stage E2:
As wide epiphysis as diaphysis; Stage E3: Wider epiphysis than
diaphysis; Stage E4: Wider epiphysis than diaphysis with threequarters of epiphysis union; Stage E5: Complete epiphyseal union.

As this maturation event is closely associated with a declining growth
rate of the mandibular condyles, in particular in girls, it may be used
as an indication for when to initiate orthodontic treatment in subjects
with mild to moderate skeletal malocclusion III discrepancies.
it is used to predict the extent of residual mandibular growth toward
the end of the growth period at the stage of fusion of the distal
phalanx of the first digit.


Tanner-white method third middle phalanx
and radius


Rajagopal and kansal(2002)
Hagg and taranger were based on five stages of MP3 growth
based primarily epiphyseal change
This method used changes observed in the metaphyseal
region.
Provided an additional bone stage
between MP3-H (deceleration of the curve of the
pubertal growth spurt) and MP3-I (end of the
pubertal growth spurt), which we called the
MP3-HI stage, resulting in a total of six stages of
MP3 growth.

Lateral cephalograms for recording
the
CVMI stages were taken in natural
head position
following standard procedure, with
patients
standing erect and instructed to
look straight into
their own eyes in a mirror placed
on the wall


Periapical radiographs was used
for recording the
MP3 stages3 were taken using the
following procedure
1. The subject was instructed to
place the right hand with the
palm downward on a flat table.
2. The middle finger was centered
on a 31mm ⋅ 41mm periapical
dental x-ray film, parallel with
the long axis of the film.
3. The cone of the dental x-ray
machine was positioned in slight
contact with the middle phalanx,
perpendicular to the film.

MP3-F stage: Start of the curve of pubertal
growth spurt
Features observed by Hagg and Taranger1:
1. Epiphysis is as wide as metaphysis.
Additional features observed in this study:
2. Ends of epiphysis are tapered and rounded.
3. Metaphysis shows no undulation.
4. Radiolucent gap (representing cartilageous
epiphyseal growth plate) between epiphysis
and
metaphysis is wide.
CVMI-1: Initiation stage of cervical vertebrae2
1. C2, C3, and C4 inferior vertebral body
borders
are flat
. 2. Superior vertebral borders are tapered from
posterior to anterior (wedge shape).
3. 80-100% of pubertal growth remains.

MP3-FG stage: Acceleration of the curve
pubertal growth spurt
Features observed by Hagg and Taranger:
1. Epiphysis is as wide as metaphysis.
2. Distinct medial and/or lateral border of epiphysis
forms line of demarcation at right angle distal border
. Additional features observed in this study
: 3. Metaphysis begins to show slight undulation
. 4. Radiolucent gap between metaphysis and epiphysis
is wide.
CVMI-2: Acceleration stage of cervical vertebrae
1. Concavities are developing in lower borders
of C2 and C3
. 2. Lower border of C4 vertebral body is flat
. 3. C3 and C4 are more rectangular in shape
. 4. 65-85% of pubertal growth remains

MP3-G stage: Maximum point of pubertal
growth spurt
Features observed by Hagg and Taranger:
1. Sides of epiphysis have thickened and cap
metaphysis, forming sharp distal edge on one
both sides.
Additional features observed in this study:
2. Marked undulations in metaphysis give
“Cupid’s bow” appearance.
3. Radiolucent gap is moderate between epiphysis and metaphysis
. CVMI-3: Transition stage of cervical vertebrae
1. Distinct concavities are seen in lower borders
of C2 and C3
2. Concavity is developing in lower border C4
. 3. C3 and C4 are rectangular in shape
4. 25-65% of pubertal growth remains

MP3-H stage: Deceleration of the curve of
pubertal growth spurt
Features observed by Hagg and Taranger
: 1. Fusion of epiphysis and metaphysis begins
: 2. One or both sides of epiphysis form obtuse
angle to distal border
. 3. Epiphysis is beginning to narrow
. 4. Slight convexity is seen under central part of
metaphysis.
5. Typical “Cupid’s bow” appearance of metaphysis
is absent, but slight undulation is distinctly
present.
6. Radiolucent gap between epiphysis and metaphysis
is narrower
.


CVMI-4: Deceleration stage of cervical vertebrae
1. Distinct concavities are seen in lower borders
of C2, C3, and C4.
2. C3 and C4 are nearly square in shape
. 3. 10-25% of pubertal growth remains.


MP3-HI stage: Maturation of the curve of pubertal
growth spurt
Features of this “new” stage observed in this
study:
1. Superior surface of epiphysis shows smooth
concavity.
2. Metaphysis shows smooth, convex surface,
almost fitting into reciprocal concavity of epiphysis.
3. No undulation is present in metaphysis.
4. Radiolucent gap between epiphysis and metaphysis
is insignificant.
CVMI-5: Maturation stage of cervical vertebrae
1. Accentuated concavities of C2, C3, and C4
inferior vertebral body borders are observed
. 2. C3 and C4 are square in shape
. 3. 5-10% of pubertal growth remains

MP3-I stage: End of pubertal growth spurt
1. Fusion of epiphysis and metaphysis complete
: 2. No radiolucent gap exists between metaphysis
and epiphysis
. 3. Dense, radiopaque epiphyseal line forms integral
part of proximal portion of middle phalanx
. CVMI-6: Completion stage of cervical vertebrae
1. Deep concavities are present in C2, C3, and C4
inferior vertebral body borders.
2. C3 and C4 are greater in height than in width
3. Pubertal growth is complete


Cervical vertebra
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
Vertebral growth takes place from the cartilagenous layer on the
superior and inferior surfaces of each vertebrae.Secondary
ossification nuclei on the tips of the bifid spinous processes and
transverse processes 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

Category 2 was called ACCELERATION. This corresponded to a
combination of SMI 3 and 4. Growth acceleration was beginning at this
stage, with 65% to 85% of adolescent 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

Category 3 was called TRANSITION. This corresponded to a
combination of SMI 5 and 6. Adolescent growth was still accelerating at
this stage toward 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

CVMI readings were then evaluated against the previously determined
SMI readings
Category 1 was called INITIATION. This corresponded to a
combination of SMI 1 and 2. At this stage, adolescent growth was just
beginning and 80% to 100% of adolescent growth was expected.36
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


Category 4 was called DECELERATION. This corresponded to a
combination of SMI 7 and 8. Adolescent growth began to decelerate
dramatically at this stage, with 10% to 25% of adolescent growth
expected.36 Distinct concavities were seen in the inferior borders of C2,
C3, and C4. The vertebral bodies of C3 and C4 were becoming more
square in shape


Category 5 was called MATURATION. This corresponded to a
combination of SMI 9 and 10. Final maturation of the vertebrae took
place during this stage, with 5% to 10% of adolescent growth
expected.36 More accentuated concavities were seen in the inferior
borders of C2, C3, and C4. The bodies of C3 and C4 were nearly square
to square in sh

Category 6 was called COMPLETION. This corresponded to SMI 11.
Growth was considered to be complete at this stage. Little or no
adolescent growth was expected.36 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 dimension than in horizontal dimension

The shapes of the vertebral bodies of C3 and C4 changed from somewhat
wedge shaped, to rectangular, to square, to greater in dimension
vertically than horizontally as skeletal maturity progressed. The inferior
vertebral borders were flat when most immature, and they were concave
when mature. The curvatures of the inferior vertebral borders were seen
to appear sequentially from C2 to C3 to C4 as the skeleton matured. The
concavities became more distinct as the person matured.


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 2nd vertebra. The anterior vertical
heights of the bodies have increased.
Stage 3: A concavity has developed in the inferior border of the 3rd vertebra. The other inferior borders
are still flat.
Stage 4: All bodies are now rectangular in shape. The concavity of the 3rd vertebra has increased, and a
distinct concavity has developed on the 4th vertebra. Concavities on 5 and 6 are just beginning to form.
Stage 5: The bodies have become nearly square in shape, and the spaces between the bodies are visibly
smaller. Concavities are well defined on all 6 bodies.
Stage 6: All bodies have increased in vertical height and are higher than they are wide. All concavities
have deepened

Stages 1 through 3 were generally observed prior to peak velocity for
all the mandibular dimensions, with stages 2 and 3 occurring in the
year immediately preceeding peak.
Stages 2 and 3 were observed in the year immediately preceeding the
maximum increment for corpus length stage 3. Stage 4 also occurred
prior to peak in three subjects, and in the other ten subjects stages 4
through 6 occurred after peak velocity.


Cervical maturation and age


Lorenzo franchi and tiziano bacceti(2002)
Inorder to make the method easier and applicable
to the vast majority of patients: (1) To use a more
limited number of vertebral bodies to perform the staging
(as suggested by Hassel and Farman30). In particular, the
method should include only those cervical vertebrae (C2,
C3, and C4) that can be visualized when the patient wears
a protective radiation collar. (2) To avoid definitions of stages
based on a comparative assessment of between-stage
changes, so that stages can be identified easily in a single
cephalogram
.

The analysis consisted of both visual and cephalometric
appraisals of morphological characteristics of the
cervical vertebrae.

1) presence of a concavity at
the lower border of the body of C2, C3, and C4; and (2)
shape of the body of C3 and C4:
trapezoid (the superior border is tapered from posterior to
anterior);
rectangular horizontal (the heights of the posterior and anterior
borders are equal; the superior and inferior borders
are longer than the anterior and posterior borders);
squared (the posterior, superior, anterior and inferior borders
are equal);


C2p, C2m, C2a: the most posterior, the deepest and the
most anterior points on the lower border of the body
of C2.
C3up, C3ua: the most superior points of the posterior and
anterior borders of the body of C3.
C3lp, C3m, C3la: the most posterior, the deepest and the
of C3.
C4up, C4ua: the most superior points of the posterior and
anterior borders of the body of C4.
C4lp, C4m, C4la: the most posterior, the deepest and the
of C4.


C3Conc: a measure of the concavity depth at the lower
border of C3 (distance from the line connecting C3lp
and C3la to the deepest point on the lower border of
the vertebra, C3m).
C4Conc: a measure of the concavity depth at the lower
border of C4 (distance from the line connecting C4lp
and C4la to the deepest point on the lower border of
the vertebra, C4m).
C3BAR: ratio between the length of the base (distance
C3lp-C3la) and the anterior height (distance C3uaC3la) of the body of C3.
C3PAR: ratio between the posterior (distance C3up-C3lp)
and anterior (distance C3ua-C3la) heights of the body
of C3.
C4BAR: ratio between the length of the base (distance
C4lp-C4la) and the anterior height (distance C4uaC4la) of the body of C4.
C4PAR: ratio between the posterior (distance C4up-C4lp)
and anterior (distance C4ua-C4la) heights of the body
of C4.

The findings of both the inspective and cephalometric
analyses revealed that no statistically significant discrimi
nation can be made between Cvs 1 and Cvs 2 as defined
in the former CVM method.
two former stages (Cvs 1 and Cvs 2) merge into one single
stage. This newly described Cervical Vertebral Maturation
Stage is referred to as CVMS
The appearance of a visible concavity at the lower border
of the third cervical vertebra is the anatomic characteristic
that mostly accounts for the identification of the stage immediately
preceding the peak in mandibular growth (former
Cvs 3, actual CVMS II)


CVMS I: the lower borders of all the three vertebrae are
flat, with the possible exception of a concavity at the
lower border of C2 in almost half of the cases. The
bodies of both C3 and C4 are trapezoid in shape (the
superior border of the vertebral body is tapered from
posterior to anterior). The peak in mandibular growth
will occur not earlier than one year after this stage.
CVMS II: Concavities at the lower borders of both C2 and
C3 are present. The bodies of C3 and C4 may be either
trapezoid or rectangular horizontal in shape. The peak
in mandibular growth will occur within one year after
this stage.
CVMS III: Concavities at the lower borders of C2, C3, and
C4 now are present. The bodies of both C3 and C4 are
rectangular horizontal in shape. The peak in mandibular
growth has occurred within one or two years before
this stage.
CVMS IV: The concavities at the lower borders of C2, C3,
and C4 still are present. At least one of the bodies of
C3 and C4 is squared in shape. If not squared, the body
of the other cervical vertebra still is rectangular horizontal.
The peak in mandibular growth has occurred

Mitani and mitotsato(2002)
On lateral cephalometric radiographs in
the following cervical vertebrae were traced by pencil
and measured with micrometer calipers: anterior vertebral body height (AH), vertebral body height (H),
posterior vertebral body height (PH), and anteroposterior
vertebral body length (AP) on the third and fourth
cervical vertebrae (Fig 2). The ratios of these parameters
were calculated (AH/AP, H/AP, PH/AP, AH/H,
H/PH, and AH/PH). A formula for obtaining cervical
vertebral bone age was determined from the ratios and
the chronological age using a stepwise multiple regression
analysis.


Lower lines are tangent to the front and back of the lower part of the
Cervical vertebral bodies
AH3,4-distance from top of front part to tangent of lower part
H3,4 distance from top of middle part to tangent of lower part
PH3,4-distance from top of back part to tangentof lower part
AP3,4-ant post distance middle of cervical vertbral body

AH3,4, H3,4, and PH3,4
increased in an accelerated manner from 10 to 13 years
of age. The ratios of these parameters were calculated.
The formula for calculating cervical vertebral bone age
was determined by stepwise multiple regression analysis
with chronological age as a dependent variable and
the ratios of these parameters as independent variables
AH3/AP3 and AH4/AP4 increased in an accelerated
manner at about 12 years of age, and AH4/PH4 continued
to increase until about 14 years of age
Cervical bone age =-0.20+6.20x
AH3AP3+5.90xAH4AP4+4.74xAH4PH4


Almost all previous evaluations in puberty with
cervical vertebrae on cephalometric radiographs either
used or referred to the atlas reported by Lamparski
The use of an atlas is convenient because changes in
cervical vertebral bodies can be evaluated with regard
to growth in the atlas. However, an atlas cannot be used
to evaluate growth in an objective and detailed manner
because the results can differ from operator to operator,
and an atlas also cannot be used to calculate age as the
TW2 method can. Thus, the method used in this study
is more objective than those used in most previous
studies.


ratios were used to calculate cervical vertebral bone age because
this considers only the shape of cervical vertebrae and
discounts their size. When deriving the formula for
cervical vertebral bone age, chronological age
instead of bone age determined from hand-wrist radiographs.
There were 2 reasons for this: (1) generally,
average chronological age corresponded with average
bone age when there was no great deviation within
groups, and (2) chronological age had little operator
error compared with bone age.


Koshitsato,mitani and mito(2001)
Introduced the CASMAS(computer aided skeletal maturity assessment)
The CASMAS can be performed
with a standard Windows 95/98/Me/NT/2000-based PC
and an image scanner with a transparent film unit.
Measurements
of the epiphyseal, metaphyseal, and overlapping
width were made automatically on the distal, middle,
and proximal phalanges of the third digit. By
programming an algorithm, we were able to extract the
digital image (300 dpi, 8 bit, gray scale) of the distal,
middle, and proximal phalanges of the third digit from
the computerized scan of the hand-wrist radiograph

an algorithm was designed to extract each
phalanx, to set measurements of the parameters
for evaluating epiphyses and metaphyses of the
phalanges, and to calculate bone age
automatically


Frontal sinus development
lateral radiographs were oriented with the nasion sella line
horizontally. The peripheral border of the frontal sinus was traced,
and the highest (Sh) and lowest (S1) points of sinus extension
relative to the nasion sella line were marked. Perpendicular to the
interconnecting line (Sh-S1), the maximum width of the frontal
sinus was assessed The average yearly growth velocity
(millimeters per year) of the frontal sinus was calculated
separately for each of the prediction intervals (Tl or T2). .


From longitudinal growth data of the subjects, the average yearly
body height growth velocity (millimeters per year) was calculated.
The maximum body growth velocity at puberty was assigned as
body height peak (Bp). The body height growth data were used only
to test the accuracy of the prediction of pubertal stage as assessed
from frontal sinus development.
• Frontal sinus growth velocity at puberty is closely related to body height growth
velocity.
• Frontal sinus growth shows a well-defined pubertal peak (Sp), which on the
average, occurs 1.4 years after the pubertal body height peak (Bp).
• In male subjects, the average age at frontal sinus peak is 15.1 years.
• In a l-year observation interval, a peak growth velocity in the frontal sinus of at
least 1.3 mm/yr. is attained by 84% of the subjects
• In a 2-year observation interval, a peak growth velocity in the frontal sinus of at
least 1.2 mm/yr. is attained by 70% of the subjects


the presented prediction procedure for somatic maturity stage will
not be able to replace hand-wrist radiographs in routine orthodontic
diagnostics, it may deliver important information with respect to the
person's stage of somatic development when two lateral head films
are available spaced approximately 1 to 2 years apart


Midpalatal suture

Maturational evaluation of the approximation of the midpalatal
suture was accomplished by examining hand-wrist radiographs
with Fishman's system of skeletal maturation assessment (SMA).2
Standardized occlusal radiographs


Stages of ossification of the midpalatal suture were compared with
Fishman's standards of skeletal maturation indicators (SMI stages 1
to 11), allowing for comparison of the differences of maturational
development between delayed, average, and accelerated matu, the
following key landmarks and planes were identified: Point A, most
anterior point of the premaxilla; Point B, most posterior point on the
posterior wall of the incisive foramen; and Point P, point tangent to
a line connecting the posterior walls of the greater palatine
foramens Measurements of length and associated percentage of
osseous development were recorded for the following dimensions:
A-P (total dimension of the suture), A-B (anterior dimension of the
suture), and B-P (posterior dimension of the suture).


Both the male and female subjects demonstrated an increase in the
amount of sutural approximation (fusion) as the SMI stages progressed
through adolescence. Very little midpalatal approximation existed during
the early maturational stages (SMI 1 to 2). An important finding is that at
SMI 11, when general skeletal and facial growth is completed, the
midpalatal suture is only approximately half the suture distance. Very
large increases in approximation are evident during the late maturation
period, from SMI 8 to 11. There is no significant difference between the
amount of midpalatal sutural approximation between the male and
female groups, although the male values were slightly higher in
numerical value.

Maturational development is related to midpalatal fusion in ways that
can provide the clinician with information to better time orthodontic
maxillary expansion. This study has revealed that it is probably best
to accomplish this before SMI 9 as the percentage of approximation
is significantly less. An ideal time to initiate orthopedic expansion is
during the early maturational stage, SMI 1 to 4. Theoretically less
orthopedic force values would be required if treatment is initiated
early.


conclusion
If utilized properly hand-wrist radiograph and cervical
vertebra radiograph provide a reliable and efficient means
of development assessment.
Simple reference on the assumption that skeletal age or
rather normal skeletal age for a specific chronologic age as
a reasonable indicator of maturity is not justified
Studies have shown that healthy children of any age do not
demonstrate any chronological specificity regarding
particular stages of maturation
All the maturity indices are sequence of maturational stages
Representing the general poulation and cannot be directly
associatedIn any accurate manner with a specific indiviual of
either sex
No dignostic tool should be heavily relied over sound clinical
judgement

Thank you
For more details please visit


Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

En vedette

En vedette (20)

Similaire à Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy

Similaire à Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy (20)

Plus de Indian dental academy

Plus de Indian dental academy (20)

Dernier

Dernier (20)

Skeletal age assesment /certified fixed orthodontic courses by Indian dental academy