Assessment of developmental age
I –Accurate maturation indicator methods:
1- Hand wrist radiograph (SMI) and MP3.
2- Cervical Vertebrae Maturation indicators
(CVMI)
3-Concentration of growth hormon (insulin like factor 1)
II–Questionable maturation indicator
methods (Individual variation) :
1 - Chronological Age is a poor indicator.
2 - Body height and weight 3 - Growth Velocity
4 - Dental Development (Nolla`s stages) .
5 – Ultrasonography of the hip bone.
6-Midpalatal suture stages. 7-Frontal sinus ratio.
8-Alkaline phosphatase concertration.
Developmental age assessment .
Methods of skeletal age assessment
Radiographic Non
methods Radiographic
methods
1.Hand wrist radiograph
2.MP3 method
3.Cervical vertebral maturation index
4.Frontal sinus
5. Midpalatal suture ossifiycation and density
1- Hand wrist radiograph (SMI)
Identify certain ossification events in the
hand, wrist and fingers
for assessment of growth status using standard tables and the atlas of Greulich
and Pyle(1959).
Newborn
3m 6m 9m 15m
2y 4y 10y 15y 19y
(SMI ) : 9 developmental stages are assessed by Bjork 1972
& modified by Grave & Brown ,1976 .
Ossification events are
localized in phalanges ,
carpal bones and
Radius. Growth stages
are assessed according
to the relation of
epiphysis to diaphysis.
1st stage (PP2) :
Proximal Phalange of index showing
equal width of epiphysis and diaphysis.
3 years before peak (10.6 y in males &
8.1 y in females)
2nd stage (MP3) :
Epiphysis and diaphysis of middle Phalanx
of middle finger show equal width ( 12 y in
males & 8.1 y in females).
3rd stage (Pisi , H1 and R 3rd stage) :
Three distinct ossification areas ( Pisiforme , Hamular process and Radius
epiphysis equals diaphysis) . They show individual variations .
(12.6 in males & 9.6 in females)
The Hamular
process of Hammate
exhibits calcification
Pisiform
Ossification
4th stage (S and H2 stage) :
S: Sesamoid bone mineralization
H2: Progressive ossification of
the hamular process reached
shortly before or at the beginning
of the pubertal growth spurt ( 13 y
in males and 10.6 y in females).
5th stage (Mp3cap, Pp1cap and R cap ) :
This stage marks the peak of pubertal
growth spurt ( 14 y in males & 11 y in
females).
.
sixth stage (Dp3 union) :
Union of epiphysis and diaphysis at Dp3.
It indicates the end pubertal growth.
(15 y in males & 13 y in females).
Seventh stage (Pp3 union):
union of epiphysis and diaphysis at Pp3.
( 15.9 y in males & 13.3 y in females).
Eight stage (Mp3 union) :
Union of epiphysis and diaphysis at Mp3.
(15.9 y in males &13.9 y in females).
Ninth stage (R union) :
Complete union of epiphysis and
diaphysis of the radius.
Skeletal growth is finished.
(18.5 y in males & 16 y in females).
Singer’s Method 1980
Stage Chnracteristic
One (early): absence of pisiform &hook of the hamate
and epiphysis of proximal phalanx of 2nd finger narrower than its
diaphysis
Two initial ossification of hook of the hamate & pisiform
(prepubertal) and proximal phalanx of 2 finger being equal to its epiphysis.
nd
Three beginning of calcification of ulnar sesamoid,
(pubertal increased width of epiphysis of proximal phalanx of the 2nd finger
onset) and increased calcification of hook of hamate and pisiform.
Four calcified ulnar sesamoid and
(pubertal) capping of the diaphysis of middle phalanx of 3rd finger by its
epiphysis.
Five (pubertal calcified ulnar sesamoid,
deceleration): fusion of epiphysis of distal phalanx of 3rd finger with its shafts,
and epiphysis of radius and ulna not fully fused with respective
shafts
Six (growth No remaining sites seen
completion)
First, look at the adductor sessamoid of the thumb in the patient`s hand –wrist radiograph .If it is
not ossified look at the width of the epiphysis of the middle phalanx of the third finger (MP3) , if
it is equal or less than the diaphysis width , the patient has not yet reached puberty . If the
sesamoid is ossified and capping of the MP3 is seen (epiphysis is wider than diaphysis), the
patient has just reached puberty .After this stage and within 2years ,fusion of MP3 will occur
indicating little growth remaining . Finally if fusion of radius is seen , growth of this pt is
complete .
Fishman,s 11 adolescent
skeletal maturity (SMI,s)
,82.
2.MP3 method
3- Cervical Vertebrae Maturation
indicators (CVMI) as described by Lamparski and
modified by Hassel and Farman.
It is simple ,
reliable and
economical.
1- Initiation (CS1) :
The lower borders of nd
2 ,3 rd
& 4 th
cervical vertebrae are
flat.
rd th
The 3 &4 vertebrae are wedge-shaped (tapered from
back to front).
100% of pubertal growth remains .
2-Acceleration (CS 2) :
The lower borders of the2 nd
& 3 rdvertebrae begin to be
th
concave while of the 4 still flat.
rd th
3 &4 vertebral bodies are nearly rectangular .
65-85% of pubertal growth remains.
3- Transition (CS 3) :
Distinct concavities of the
2 nd& 3 rd
lower borders while
th
that of the 4 begin to be concave.
rd th
3 &4 vertebral bodies are rectangular .
25-65% of pubertal growth remains.
4- Deceleration (CS 4) :
2 nd
Distinct concavities of the lower borders of the ,3 rd &
th
4 vertebrae.
rd th
Vertebral bodies of the 3 & 4 begin to be square .
10- 25% of pubertal growth remains .
5- Maturation (CS5) :
Marked concavities of the lower borders of the
2 nd ,3 rd &
th
4 vertebrae.
rd th
Vertebral bodies of the 3 & 4 are almost square .
5 - 10% of pubertal growth remains .
6 – Completion (CS 6) :
Deep concavities of the lower borders of the
2 nd ,3
& rd 4 th
vertebrae.
rd th
Vertebral bodies of the 3 & 4 are longer vertically
than horizontally.
Pubertal growth has been completed .
Correlation of SMI & CVMS
SMI CVMS % Pub 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
Maxillary expansion and protraction is effective in the
maxilla only when it is performed before the peak
(CS1 or CS2), while if pubertal or post pubertal ,it
entails more dento alveolar effects.
Orthopedic treatment of increased anterior facial
height(maxillary posterior impaction) and maxillary
retraction is performed at the peak of mandibular
growth (CS3).
Restraining and stimulation of the mandibular growth
are effective during both pre pubertal and pubertal
stages.
Modified Median Phalanx Index (MP3) Rajagobal
and Kansal (2002)
correlated with Cervical Vertebrae Index (CVMI)
Hassel and Farman
MP3-F stage ( Initiation , CS1):
* Epiphysis is as wide as metaphysis.
* Ends of epiphysis are tapered.
* Metaphysis shows no undulation.
•Wide Radiolucent gap.
* 100% of pubertal growth
remains .
* ( 12.o1Y) – ( Y)
MP3-FG stage (Acceleration (CS 2) :
* Epiphysis is as wide as metaphysis.
* Distinct medial and/or lateral border
of epiphysis.
* Metaphysis shows slight undulation.
* Wide Radiolucent gap.
* 65-85% of pubertal growth remains.
*( 12.85 Y) – ( Y)
MP3-G stage (Transition (CS 3) :
*Sides of epiphysis have thickened
and cap its metaphysis.
*Marked undulation in metaphysis
(Cuspid Bow apperance).
•Radiolucent gap is moderate.
* 25-65% of pubertal growth
remains.
•( 13.57 Y) – ( Y)
MP3-H stage (Deceleration (CS4):
•Fusion of epiphysis and
metaphysis begins.
* Epiphysis is beginning to narrow.
* Slight convexity is seen under
central part of metaphysis.
•Radiolucent gap is narrower.
•10- 25% of pubertal growth
remains .
•( 14.61 Y) – ( Y)
MP3-HI stage (Maturation,CS5):
* Epiphysis shows smooth concavity.
* Metaphysis shows smooth convexity
•No undulation in metaphysis.
•Radiolucent gap is insignificant.
•5 - 10% of pubertal growth
remains.
*( 15.03 Y) – ( Y)
MP3- I stage (Completion,CS6):
•Fusion of epiphysis and
metaphysis is complete.
* No radiolucent gap between
metaphysis and epiphysis.
*Pubertal growth is completed .
(15.38 y - )
Frontal sinus as a
developmental indicator
Sp coincided with
MP3 G stage
Growth continued up to
the age of 16 in girls and
18 in boys
2010
Stage A.
Straight high
density
2013
sutural line
along maxilla
and palate
without
interdigitation
A B C
D E
The hip bone assessment (Risser sign)
Is used to grade skeletal maturity based
on the level of ossification and fusion of
the iliac crest apophasis.
Grade 1: Apophysis is under 25% of the iliac crest
it corresponds to prepuberty or early puberty
Grade 2 : Apophysis is 25% - 50% of the iliac crest
it corresponds to the stage growth spurt.
Grade 3 : Apophysis is 50% - 75% of the iliac crest
it corresponds to the slowing of growth.
Grade 4 : Apophysis is over 75% of the iliac crest
it corresponds to an almost cessation of growth.
Grade 5 : complete ossification and fusion of the iliac apophysis
Midpalatal suture density ratio: A novel predictor of
skeletal response to rapid maxillary expansion.
Larson CE , 2017.
MPSD ratio = GD s – G D sp / GD ppm – G D sp = 0 - 1
GD s :Grey density of 6mm width & distance from distal to incisive papilla to 1st molars length.
GD ppm : Grey density of palatal process 4 x 4 mm
G D sp : Grey density of soft palate 4 x 4 mm
Lower Values: near soft palate density
Higher Values: near
palatal process density
Insulin - like growth factor 1 as maturity indicator
Pattern of IGF-I in relation to the stages of the cervical
vertebral maturation index
GCF ALP is a good
indicator for skeletal
maturation unlike
GCF proteins
88
74
Alkaline
58 phosphatase
51
50
49
46
44
Protein
content
1 CS2 CS3 CS4 CS5 CS6
Max Mand
Serial height and weight
records using standard Morphologic Age
growth chart:
A child who is between 3rd
th
and 97 percentiles is
considered normal ,while
outside that range,
abnormality must be
suspected. It is useful also
for determining whether
the subject is likely to
experience mandibular
growth.
Dental Age
Nolla `s 10 stages of
tooth movement,1952.
