PHYSICAL GROWTH

MATURITY INDICATORS
PUNEET JAIN
JR-1
CONTENTS
INTRODUCTION
VARIOUS MATURITY INDICATORS
THEIR CLINICAL IMPLICATION
CONCLUSION


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.
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.
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 childs 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.
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.

INTRODUCTION:
INTRODUCTION

In orthodontics the assessment of skeletal age
and pubertal growth spurt (in particular)are of
prime importance in
1. Diagnosis
2. treatment planning
3. Retention.

INDICATIONS FOR GROWTH
STATUS

1. When maxillomandibular changes are indicated in the
treatment of
a) Skeletal Class III cases,
b) Skeletal Class II cases or
c) Skeletal open bites
2. In patients with marked discrepancy between dental
and chronological age
3. Patients requiring orthognatnic surgery if undertaken
between 16-20 years of age
4. Prior to rapid maxillary expansion(Transverse Plane)

AMOUNT AND TIMING OF GROWTH
There are four growth spurts :

On birth.

1 yr. after birth.

Pre pubertal growth spurt.

6-7 yrs. in females.
7-9 yrs. in males.

Adolescent growth spurt.

11-13 yrs. in females.
14-16 yrs. in males

SKELETAL MATURATION
Defined as the process of becoming fully developed.
Skeletal maturation begins with puberty & is complete
when the epiphyses are closed.
The intermediate phase between puberty & closure of
epiphyses is termed as Adolescence- wherein most of
individuals growth & development occurs.


VARIOUS SKELETAL MATURITY
INDICATORS

Hand wrist radiograph

Cervical vertebrae

Canine calcification

Frontal sinus

Third molar level

Mid palatal suture

Antigonial notch
HAND WRIST RADIOGRPH EVALUVATION
Ranke is considered to have been the first to study skeletal
developmental progress by means of wrist roentgenograms.

In the early 1900s, Pryor,Rotch,and Crampton began
tabulating indicators of maturity on sequential radiographs of
the growing hand and wrist.

Hellman used the total length of the digits and the width and
length of the phalanges to supplement his inspection of
roentgenograms of skeletal Maturation.Hellman published his
observations on the ossification of epiphysial cartilages of the
hand in 1928.
In 1936 Flory indicated that beginning of calcification of the
carpal sesamoid was a good guide to determine the period
immediately before puberty

The appearance of the adductor sesamoid has been highly
correlated to peak height velocity and start of adolescent
growth spurt.

Fishman developed a system of hand wrist skeletal maturation
indicators using four stages of bone maturation at six
anatomic sites on the hand and the wrist.

Hagg and Taranger created a method using the hand wrist
radiograph to correlate certain maturity indicators to the
pubertal growth spurt.
Different analysis of the hand wrist radiograph
Atlas method ( Greulich & Pyle)
Bjork, Grave and Brown
Julian Singer (1980)
Fishman(1982)
Hagg & Taranger (ajo 1982 oct)
Rajagopal&kansal(2002)

Anatomy of hand wrist radiograph
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.

Second stage :(MP3=stage)
Epiphysis of the middle phalanx of
the middle finger is of the same
width as the diaphysis.
Just before pubertal spurt

There are nine developmental stages according to Bjork (1972).
PP2
MP3
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.

H-stage: Ossification of the
hamular process of the hamate.

Pisi-stage: Visible ossification of
the pisiforme.

R-stage : Same width of
epiphysis and diaphysis of the
radius.


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 hamate.

The fourth stage marks the
beginning of the pubertal
growth spurt.


Fifth stage :( MP3cap, PP1cap-, and
Rcap-stage)

During this stage, the diaphysis covered
by the cap shaped epiphysis.

MP3capstage: 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 stage






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 pubertal
growth.


Seventh stage :( PP3u-stage)

Visible union of the epiphysis
and diaphysis at the proximal
phalanx of the middle finger.

1 yr after growth
Little growth potential is
remaining


Eighth stage :( MP3u-stage)

Visible union of the epiphysis
and diaphysis at the middle
phalanx of the middle finger
is clearly seen.




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.


Stage 1 (Early):

1. Absence of Pisiform
2. Absence of Hook of Hamate
3. Epiphysis of proximal phalanx of
second digit (PP2) narrower than its
shaft.

Stage 2 (Prepubertal):

1. Proximal phalanx of second digit and
its epiphysis are equal in width (PP2).
2. Initial ossification of hook of hamate.
3. Initial ossification of pisiform.
Julian Singer (1980) described 6 stages of
development on the hand wrist radiograph.
Stage 3 (Pubertal onset):
1. Beginning calcification of Ulnar
sesamoid.
2. Increased width of epiphysis of
PP2.
3. Increased calcification of hamate
hook and pisiform.
Stage 4 (Pubertal):
1. Calcified ulnar sesamoid.
2. Capping of shaft of middle
phalanx of third digit by its
epiphysis (MP3cap).
Stage 5 (Pubertal Deceleration):
1. Ulnar sesamoid fully calcified
2. Calcification of the shaft of
middle phalanx of third digit
by its epiphysis (DP3u).
3. All phalanges and carpals
fully calcified.
4. Epiphysis of radius and ulna
not fully calcified with
respective shafts.

Stage 6 (Growth completion):
No remaining growth sites.
LEONARD S. FISHMAN 1982 (AO)
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


Accelerating growth velocity period. SMI 1 4.

High growth velocity period. SMI 4 7.

Decelerating growth velocity period. SMI 7 11.

Girls generally reach point of peak growth velocity at SMI 5 and boys at SMI 7
Hagg and Taranger skeletal maturity indicators: (AJO 82)

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

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.

The ulnar sesamoid (S) of the metacarpophalangeal joint usually
attained
Pubertal development
Assesed from 10-18 years
Menarche in girls
Voice change in boys


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.

Distal Phalanx (DP3-I)-fusion of the epiphysis
and metaphysis complete
Significance

Sesamoid is usually attained during the acceleration period of the pubertal growth spurt
(onset of P.H.V.)

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.
RAJAGOPAL & KANSAL ( JCO 2002 )
The 5 distinct stages of MP3 as described by HAGG &
TARANGER (1980), and 6th stage (between MP3-H and MP3-I which
is called as MP3-HI stage) which was introduced by 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).
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.
COMPARISON BETWEEN MP3-F & INITIATION STAGE
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
bordersare flat
2. Superior vertebral borders are tapered from
posterior to anterior (wedge shape).
3. 80-100% of pubertal growth remains
COMPARISION BETWEEN MP3 FG & ACCELERATION STAGE
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
COMPARISION BETWEEN MP3-G & TRANSION STAGE
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 Cupids 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
COMPARISION BETWEEN MP3-H & DECELERATION STAGE
MP3-H stage: Deceleration of the curve of pubertal growth spurt
Features observed by Hagg and Taranger
1. Fusion of epiphysis and metaphysis begins
Additional features observed in this study
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 Cupids 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

COMPARISION BETWEEN MP3-HI & MATURATION STAGE
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

COMPARISION BETWEEN MP3-I & COMPLETION STAGE
MP3-I stage: End of pubertal growth spurt
1. Fusion of epiphysis and metaphysis
complete
Additional features observed in this study
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.

The use of cervical vertebrae to determine skeletal maturity was
suggested by Lamparski in 1972.

Lamparski studied changes and shape of cervical vertebrae sides. Todd
and Pyle, Lanier and Taylor made measurements from lateral
radiographs of the lower cervical vertebrae. Lamparski studied changes
and shape of cervical vertebra .

The standard method of evaluating skeletal maturity has been to use a
hand- wrist x-ray to compare the bones of an individuals 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.
Six stages of cervical vertebral maturation were described(Hassel & Farman,1995
AJO)
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.
Cervical vertebrae maturation indicators
HASSEL & FARMAN AJO 1995

1. Initiaton:
Inferior borders of 2nd 3rd and
4th 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.
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

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.
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.

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
6. Completion:

Deep concavities are
observed on the second,
third and fourth cervical
vertebrae.

Vertebral bodies are
greater in dimension
vertically than horizontally.

Pubertal growth has been
completed.

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

Advantage
The orthodontist could obtain additional information about
the growth potential in the adolescent patient by observing the
anatomical changes of the cervical vertebrae, thereby
formulation of a treatment could be made.

Apart from this any anomalies in the Cervical spine of
children & adolescents like fractures, infections, polyarthritis,
ankylosis & ankylosing spondylitis etc can be identified.
Franchi, Bacetti & McNamara (2002 AJO )Presented an
improved version of the CVM method to test its validity for
the appraisal of mandibular skeletal maturity in the individual
patient.

The morphology of the bodies of the second (odontoid process,
C2), third (C3), and fourth (C4) cervical vertebrae were
analyzed in the six consecutive observations (T1 through T6).

The analysis consisted of both visual and cephalometric
appraisals of morphological characteristics of the cervical
vertebrae.
On the lateral cephalograms, the following
points for the description of the morphologic
characteristics of the cervical vertebral bodies
were traced and digitized.

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 most anterior points on the
lower border of the body 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 most anterior points on the
lower border of the body of C4

With the aid of these landmarks, the following measurements were performed

C2 conc :a measure of the concavity depth at the lower border of c2(distance from
the line connecting c2p and c2a to the deepest point on the vertebra ,c2m)

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 C3ua- C3la) 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 C4ua- C4la) 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 discrimination
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 not later than
one year before this stage.

CVMS V: The concavities at the lower borders of C2, C3,and
C4 still are evident. At least one of the bodies of C3 and C4 is
rectangular vertical in shape. If not rectangular vertical, the
body of the other cervical vertebra is squared. The peak in
mandibular growth has occurred not later than two years
before this stage.
The authors conclude that:

The new CVM method is comprised of five maturational
stages (CVMS I through CVMS V, instead of Cvs 1 through
Cvs 6 in the former CVM method), with the peak in
mandibular growth occurring between CVMS II and CVMS
III.

The pubertal peak has not been reached without the
attainment of both CVMS I and CVMS II.

The new method is particularly useful when skeletal maturity
has to be appraised on a single cephalogram and only the
second through fourth cervical vertebrae are visible.
MID PALATAL SUTURE:(AJO 1994)
REVELO & FISHMAN
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).
Standardized occlusal radiographs are taken

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 maturation, the
following key landmarks and planes were identified:

1. Point A, most anterior point of the premaxilla;
2. Point B, most posterior point on the posterior wall of the incisive
foramen; and
3. 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 4).
25% -SMI 8-9
Approx 50% till SMI 11
CLINICAL IMPLICATIONS

Maturational development related to the mid-palatal fusion can provide
information about the treatment timing for maxillary expansion.

This study reveals that for the expansion forces to physically open an
approximated suture the best time would be before SMI 9 as the % of
approximation is less.

The ideal time to initiate orthopedic expansion is during the early
maturational stage corresponding to SMI 1 to 4. During this period less
orthopedic force values might be required.

This study has also verified the fact that mid-palatal approximation
occurs more posterior during the entire adolescent period. Therefore
Orthodontic mechanics could probably be more efficiently designed if
more force value is expressed more posterior to the suture.
Frontal sinus development (AJO 1996)
SABINE RUF & HANS PACHERZ

TWO head films were taken(1-2 yr interval basis)
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
In a 2-year observation interval, a peak growth velocity in the frontal sinus of at
least 1.2 mm/yr
ADVANTAGES

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.
If only prediction of whether pubertal growth peak has passed,this method
has high precision(>90%)

DISADVANTAGES

For incidence of body height peak-low precision(~50%)
will not be able to replace hand-wrist radiographs in routine orthodontic
diagnostics.
CANINE CALCIFICATION
Tooth mineralisation as an indicator of pubertal growth spurt
(1980 AJO Jan)

Seymour, Chertkow (1980 AJO Jan) performed a study to evaluate whether
tooth could be used as a maturational indicator to predict growth.

He found that the Mandibular canine calcification stage G, (stage of root
formation prior to closure of the apices), corresponded with the
maturational stage characterized by, ( correlation in other teeth was low)

1) Adductor sesamoid ossification,
2) Ossification of the Hook of the Hamate,
3) Capping of the Epiphyses of the Middle Phalanx of the 3rd finger,

These stages characterize the onset of Pubertal Growth spurt.
Disadvantage : Racial Variation
DENTAL FORMATI ON STAGES
D-H OF MANDI BULAR CANI NE
Demirjian et al, 1973
Antegonial notch as indicator of growth potential (AJO 1987 Feb )

Singer, Mamandras, and Hunter (AJO 1987 Feb) performed a study to evaluate the
effectiveness of Antegonial Notch in predicting Mandibular growth.

They stated that,

Deep notch cases had more retrusive mandibles with a shorter corpus, smaller ramus
height, and a greater gonial angle than did shallow notch cases.

The lower facial height in the subjects with a deep mandibular notch was found to be
longer, and both the mandibular plane angle and facial axis were more vertically
directed.

During the average 4-year period, they found the deep notch sample experienced less
mandibular growth as evidenced by

1) a smaller increase in total mandibular length,
2) corpus length, and
3) less displacement of the chin in a horizontal direction than did the shallow notch
sample.
Measuring Antegonial Notch
The results of this study suggest that the clinical presence of a deep
mandibular antegonial notch is indicative of a diminished mandibular
growth potential and a vertically directed mandibular growth pattern.
Ronald, Thomas E. Southard, Karin A. Southard (AJO 2002 Apr)
Performed the investigation to test the hypothesis that the antegonial
notch depth is a useful predictor of facial growth in a longitudinal
sample of untreated growing patients selected at random.

Conclusion
1. As notch depth decreased, more horizontal jaw growth was observed.
2. Conversely, as notch depth increased, less horizontal jaw growth was
observed.
Disadvantage : the strength of this relationship was weak & antegonial
notch depth fails to sufficiently indicate future facial growth to warrant
its application as a growth predictor
Mandibular third Molar development and Skeletal
maturity(Engstorm ,1983 AO)

Engstorm (1983) compared lower third molar development stages with
skeletal maturity indicators.
Third molar stages were (seen on OPG)
A: Tooth germ visible as rounded radiolucency
B: cusp mineralization complete.
C: Crown formation complete.
D: Root half formed.
E: Root formation complete but apex not closed.

Skeletal indicators used were
PP2: proximal phalanx of second finger, epiphysis as wide as diaphysis
MP3 cap: middle phalanx third finger, epiphysis caps the diaphysis
DP3 u: distal phalanx of third finger, complete epiphyseal union.
Ru: Distal epiphysis of radius, complete epiphyseal union.


At stage PP2 third molar crown completion took place in majority of
subjects.
At stage MP3 cap crown completion in all and root development had
begun in few subjects.
At DP3u Root length was completed in some subjects.
At Ru one third subjects crown was complete, half the root was
complete in other one third, and in the remaining third root had reached
full length.
CORRELATION OF SKELETAL MATURATION STAGES
DETERMINED BY CERVICAL VERTEBRAE &HAND-WRIST
EVALUATION
(AO 2006) CARLOS FLORES -MIR



The aim of this study was to assess the correlation
between the Fishman maturation prediction method (FMP) and
the cervical vertebral maturation (CVM) method for skeletal
maturation stage determination.
Hand wrist and lateral cephalograms from 79 subjects
(52 females and 27 males ) were used.
Hand wrist radiographs were analysed using the FMP to
determine the skeletal maturation level (advanced, average or
delayed ) and stage (relative position of the individual in the
pubertal growth curve).
Cervical vertebrae ( C2, C3 and C4) outlines obtained from
lateral cephalograms were analysed using the CVM to determine
skeletal maturation stage.


The sample was sub grouped according to skeletal maturation
level, the following correlation values were found :
1. For early mature adolescents 0.73
2. For average mature adolescents 0.70
3. For late mature adolescents 0.87

Correlation values between both skeletal maturation methods are
moderately high. This maybe high enough to use either of the
methods indistinctly for research purposes but not for the
assessment of individual patients.
The following conclusions were drawn:

1. Wide variation in chronological age for different maturity levels
suggests that chronological age is a poor indicator of maturity.
Skeletal maturity indicators provide a more valid basis than
chronological age for grouping of individuals.
2. Females are ahead of males at all levels of skeletal maturity.,
indicating early age of maturation for female group.
3. Females tend to achieve a higher percentage of their total growth
than male especially during mid-adolescence. Early and late
adolescence show less variation in percentage of growth completed .
4. cervical vertebrae can be used as an alternative method for
evaluation of skeletal maturity, with the same confidence as hand
wrist radiographs.
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%
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 associated in any accurate manner with a specific
indiviual of either sex.
References
Hassel B, Farman A G.Skeletal maturation evaluation using cervical
vertebrae Am J Orthod,1995; 107:58-61
Julian Singer . Angle Orthod, 1980;50:320-333.
Hagg U,Taranger J Maturational indicators and the pubertal growth
spurt. Am J Orthod, 1982; 88:299-309
Revelo B,Fishman LS, Maturational evaluation of ossification of
midpalatal suture. Am J Orthod,1994;105:288-292
Ruf S,Pancherz, Frontal sinus development as an indicator for somatic
maturity at puberty. Am J Orthod ;1996; 110: 476-82
Fishman L S, Radiographic evaluation of skeletal maturation. Angle
Orthod ; 1982; 52:89-111