INDIAN DENTAL ACADEMY Leader in Continuing Dental Education www. indiandentalacademy.com4 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 surgexdyafornsiaskskahndatocclusions.i Introduction: = As aresults 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 stagesvof. grawdbntalacademy.comi 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 asa maturity indicatayfrqnaiatadntancategaonadulthood.J 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, carpe) Panes aan saetfiemy comBIOLOGICAL AGE AND ub HAND WRIST RADIO GRAPH = Orthodontic treatment progresses more quickly during growth spurts. Generally children experience a pattern of fast growth, followed by a slow growth in late childhood and then accelerated and peak growth in adolescence. Because children begin this sequence of growth at different ages, chronological age is a_ poor indicator of a child’s development. Hand-wrist radiograph is a useful tool for identifying a child’s skeletal develop ent. wwwrindiandentalacademy.comHAND-WRIST RADIO GRAPHIC . EVALUATION After Roentgen demonstrate his new radiographic discovery in 1895 Ronaldo, 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. In early 1900s, Pryor, Rotch and Crampton began tabulating indicators of maturity on sequential radiographs of the growing hand and wrist. Hellman published his observations on the ossification of epiphysial cartilage of the hand in 1928. Todd compiled hand -wrist data that was further elaborated on by Greulich and Pyle in atlas form. 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. www. indiandentalacademy.comTOPOGRAPHIC ANATOMY OF THE SKELETON OF THE HAND www. indiandentalacademy.comTOPOGRAPHIC ANATOMY OF THE SKELETON OF THE HAND www.indiandentalacademy.comTOPOGRAPHIC ANATOMY OF THE en N@ARBNESCHONOOAD SKELETON OF THE HAND . Epiphysis of the thumb. . Epiphysis of the proximal phalanx of the thumb. . Sesamoid of the adductor brevis muscle at the metacarpophalangeal joint of the thumb. . Epiphysis of the distal phalanx of the index finger. . Epiphysis of the middle phalanx of the index finger. . Epiphysis of the proximal phalanx of the index finger. Epiphysis of the distal phalanx of the middle finger. . Epiphysis of the middle phalanx of the middle finger. . Epiphysis of the proximal phalanx of the middle finger. . Epiphysis of the distal phalanx of the ring finger. . Epiphysis of the middle phalanx of the ring finger. . Epiphysis of the proximal phalanx of the ring finger. . Epiphysis of the distal phalanx of the little finger. . Epiphysis of the middle phalanx of the little finger. . Epiphysis of the proximal phalanx of the little finger. |. Epiphysis of the m: tana bra bone. . Epiphysid\OW Welbedandl aisaburpsemanecomTOPOGRAPHIC ANATOMY OF THE SKELETON OF THE HAND |. Epiphysis of the third metacarpal bone. . Epiphysis of the fourth metacarpal bone. |. Epiphysis of the fifth metacarpal bone. . Trapezium. . Trapezoid bone. |. Capitate bone. . Hamate bone. . Hamular process of the hamate bone. |. Triquetral bone. . Pisiform bone. . Lunate bone. |. Scaphoid bone. }. Distal epiphysis of the radius. . Distal epiphysis of the ulna. www.indiandentalacademy.comob Hand-wrist radiographs = Atlas = Sesamoid bone(Flory,Bjork, Chapman) = Julian Singer (1980) = Fishman(1982) =" Hagg & Taranger(1982) = Leite &O’Reilly(1985) = Abdel Kader(1998) www. indiandentalacademy.comHand-wrist radiograph: www. indiandentalaca emy.comHand-wrist radiograph:Hand-wrist radiograph: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 Fusion of epiphysis and 1. Third finger-proximal phalanx diaphysis 2.Third finger-middle phalanx 8.Third finger distal -phalanx 3.Fifth finger-middle phalanx 9. Third finger proximal- phalanx Ossification 10. Third finger middle- phalanx 4.Adductor sesamoid of thumb 11.Radius Capping of epiphysis 5.Third finger distal- phalanx 6.Third finger middle -phalanx. 7.Fifth finger middle-phalanx www. indiandentalacademy.comFis! ; | ity indi EISHMAN’s SKELETAL MATURATION INDICATORS a ee we et og hd. Aaa WoTH OF eR =a AML WWW. IGA UC aa CaUenLy COLL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-lJ. = Sesamoid: sesamoid is usually attained during the acceleration period i thrlianbentalagnamih, seunt(onset of puW\Hagg and Taranger :TAL MATURATION ASSESSMENT By Haga & Taranger. _ TH BO a Men: ‘THE MIDDLE PHALANXBIOLOGICAL AGE anp 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 MAN Malacadem com.MP3 STAGESBIOLOGICAL AGE anp 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. R 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 =f middle finger is of the same width as the diaphysis. : www. indiandentalacademy.comBIOLOGICAL AGE anp HAND WRIST RADIO PH 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. r ; : ue E.. Titdlacademy .comBIOLOGICAL AGE AnD HAND WRIST RADIO GRAPH . 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.BI ICAL A AND HAND WRIST RADI 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 : Atthe proximal phalanx of the thumb. Reap-stage : Atthe radius. This stage of ossification marks the peak of the pubertal growth spurt. f = Ao \ 5 ‘ E.GBIOLOGICAL AGE anp 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. www. indiandentalacademy.comBIOLOGICAL AGE anp HAND WRIST RADIO. I RAPH 7. Seventh stage:(PP3u-stage) Visible union of the epiphysis and diaphysis at the proximal phalanx of the little finger. ' www. indiandentalacademy.com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. Me 5 www. indiandentalacademy.comBIOLOGICAL AGE anD HAND WRIST RADIO RAPH 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. I | |\4 meen Se www. indiandentalacademy.commales females Growth period 1. 2. 3. 4. 5. 6. 7. 8. PP2 MP3 Pisi S MP3 DP3 PP3 MP3 H1 H2 u u . cap R= R cap PP14 10. 12. 12. 13. 74. 15. 15. 15. 6 2 6 0 0 0 9 9 81 81 96 10. 11. 13. 13. 13. 9 www iSdiand dtatacHemy. om 18. 16.www. indiandentalacademy.com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 Were aden HEM PIBY COM parc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. www.indiandentalacademy.com7 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. www.indiandentalacademy.comCervical vertebrae maturation indicators -Lamparski 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 www. indiandentalacademy.com7 Cervical vertebrae maturation indicators eas Lie) Cy Gt) aS) 9000 O° < & Pope e soo00 2 VSS 2 s4 cvs6 www.indiandentalacademy.comrvi | vertebrae maturation in STAGES www. indiandentalacademy.comoe vertebrae maturation indicators CERVICAL VERTIBRAE ASSESSMENT USING C3 AS GUIDE i-= = ia — ie INITIATION ACCELERATION TRANSITION m+ www. indiandentalacademy.comrvi | vertebrae maturation in STAGES www. indiandentalacademy.comCervical vertebrae maturation indicators 1. Initiaton: Inferior borders of 2"4 3 and 4" 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. eA Very significant amount of adolescent growth expected. www. indiandentalacademy.com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. www. indiandentalacademy.com7 Cervical vertebrae maturation indicators 3. Transition : inferior borders of second and third vertebrae. * A concavity begins to develop on the inferior border of fourth vertebrae. ova: «Vertebral bodies of third and fourth are rectangular in shape. * 25-65% of pubertal growth remains. www. indiandentalacademy.com * Distinct concavities are shown on the i ) ™ess vertebrae maturation indicators 4. Deceleration stage: * Distinct concavities can observed on i the inferior borders of second third @® and fourth cervical vertebrae. @ * Vertebral bodies of third and fourth begin to be more square in shape. ES * 10-25% of pubertal growth remains. www. indiandentalacademy.comCervical vertebrae maturation indicators 5. Maturation stage: * Marked concavities are observed dX 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. www. indiandentalacademy.coma vertebrae maturation indicators 6. Completion: « Deep concavities are observed on the second, third and fourth cervical K vertebrae. * Vertebral bodies are greater vertically ® than horizontally. * Pubertal growth has been completed. cvs www. indiandentalacademy.comAssessment of skeletal maturation The 5 distinct stages of MP3 as described by HAGG & TARANGER (1980), and 6" 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).COMPARISON BETWEEN MP3-F & INITIATION STAGE MP3-F STAGE INITIATION STAGE It represents the onset or the start 1.C2, C3 and Cs inferior vertebral of the curve of pubertal growth body borders are flat. Spurt. 2.Superior vertebral borders are FEATURES: tapered from posterior to Epiphysis is as wide as anterior. (Wedge shape). metaphysis. 3.100% of pubertal growth remains.COMPARISON BETWEEN MP3-FG & ACCELERATION STAGE MP3-FG STAGE ACCELERATION STAGE It represents the acceleration part of 1.Concavities developing in lower the curve of pubertal growth bordres of C2&C3. ceary RES: 2.Lower border of Ca vertebral body 1.Epiphysis is as wide as isifiat. metaphysis 3.C3 & C4 are more rectangular in 2.There is a distinct medial and or shape. lateral border of the epiphysis 4.65-85 % of pubertal growth forming tion at remaiaee right an ler.COMPARISON BETWEEN MP3-G & TRANSITION STAGE MP3-G 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. TRANSITION STAGE 1.Distinct concavities in lower borders of C2 and Cs are seen. 2.Developing concavity in lower border of body of C4 is seen. 3.C3 and Ca are rectangular in shape. 4.25-65% of pubertal growth remains. (SI seCOMPARISON BETWEEN MP3-H & DECELERATION STAGE MP3-H STAGE DECELERATION STAGE It represents the deceleration part of 1.Distinct concavities in the lower the Curve of pubertal growth bordrs of C2z,C3 and C4 are seen. spurt. FEATURES: 2.C3 and C4 are nearly square in Fusion of epiphysis and metaphysis shape. has begun. 3.10-25% of pubertal growth remains.COMPARISON BETWEEN MP3-HI & MATURATION STAGE MP3-HI STAGE MATURATION STAGE It represents the maturation part of 1. Accentuated concavities of the curve of pubertal growth spurt. inferior vertebral body borders FEATURES: £0203 and G4 1.Superior surface of the epiphysis or G2,43,an are seen. shows a smooth concavity. 2. C3 and C4 are square in shape. 2.Metaphysis shows a smooth convex 3. 5-10% of pubertal growth surface almost fitting into the remains. reciprocal concavity of epiphysis. 3.Radiolucent gap between epiphysis and met aw ment.COMPARISON BETWEEN MP3-! & COMPLETION STAGE MP3-I| STAGE COMPLETION STAGE It represents the end of pubertal 1.Deep concavities present on growth Spurt. FEATURES: inferior vertebral body borders of 1.Fusion of epiphysis and C2,C3 and Ca. metaphysis is completed. 2.Cs and Ca heights are greater than widths. 3. PubertalComparison of a MP3 and CVMI © I-F STAGE MP3-FOSTAGE MP3 STAGE vic ~ iy | W STAGE raw stace www, /indiandental lacademy.com. i BES igs igss iseCorrelation of hand-wrist and 7 cervical vertebral maturation stages mparative evaluation of hand-wrist and cervical vertebrae was done in our department by Prof.Dr.shyamala and Dr.Akshay gupta to find out the validity of the cervical vertebrae as maturation marker. 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. Www. in iandentalacademy. comCorrelation of hand-wrist cervical vertebral maturation stages Hand -wrist Cervical Pubertal growth vertebral stages remaining SMI 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 www. indiandentalacademy.comHWVGE 0 G0 ato Men 000 Se08 2S 628 qaece 2000 oOo00 Saha esha — Bags BeBe 2298 eeee @2e0eG QBeCe2e Q000 Doo0o 10.Root apex completed. 9 Root almost completed,open apex. 8.Two thirds of root completed. 7.One third of root completed. 6.Crown completed. 5.Crown almost completed. 4.Two thirds of crown completed. 3.One third of root completed. 2.Initial calcification. lL cept present. | __ ceensenitertereeDental age determination according to the stage of mineralization Demirjian et al., in 1973 divided tooth mineralization into nine stages. o. Tooth germ without signs of calcification. A. Calcificaion of single occlusal points without ==> fusion of different calcification. 4 a @ q q B. Fusion of mineralization points. The contour of the occlusal surface is recognizable. * C. Calcification of the crown is complete; Single rooted tooth beginning of dentin deposits. D. Crown formation is complete up to the “mea cemento enamel junction. E. Root length shorter than crown height. F. Root length larger than crown height. G. Root formation finished. Apical foramen still open. H. Apical foramen is closed. Multi rooted tooth www.indiandentalacademy.comScores of different dental formation stages The table was made for the left mandibular quadrant. www. indiandentalacademy.comiccording to the score-system of dental formation The overall figure for assessm aan of den) ea age is obtained by adding together the separal¥ Wi ft quadraiDENTAL FORMATION STAGES D-H OF MANDIBULAR CANINETooth mineralization as an indicator of the pubertal a growth spurt Diagrammatic appearance of stages C to H of tooth development for uni and multi radicular teeth. www. indiandentalacademy.comMandibular growth changes & Maturation of cervical vertebrae Maria T o’Reilly & Gary J Yanniello conducted a study on relationship of cervical vertebral maturation and mandibular growth changes using lateral cephalometric radiographs in females age group of 9-15 years. They found that cervical vertebral stages of maturation are telated to mandibular growth changes during puberty. An analysis of variance for repeated measurements and Scheffee’s tests reveal significant increase between stages 1 and 2, 2 and 3 and 3 and 4 for mandibular length; between land 2 and 2 and 3 for corpus length; and between 1 and 2 for ramus height.On the average, stages1 through 3 occurred prior to peak velocity, with 2 and 3 in the year preceeding peak growth velgoity.indiandentalacademy.comClinical significance: 1. Treatment involving modification of skeletal growth seems to demand as much as information as possible about patient’s growth potential. 2. Orthodontic appliances such as the mandibular protraction appliance, Herbst appliance, Frankel, Bionator, Twin block and activator. 3. In cases where patient require orthopedic changes using head gears and protraction masks. 4. Prior to rapid maxillary expansion. 5. Inpatients with marked discrepancy between dental and chronological age. 6. Orthodontic patients requiring orthognathic surgery if under taken during growth period. 7. When maxillo mandibular changes are indicated in the treatment of class Ill cases, skeletal class Il cases or skeletal open bites. www. indiandentalacademy.comSe THANK YOU INDIAN DENTAL ACADEMY www. indiandentalacademy.com