physical growth maturity indicators

5/25/2018 Physical Growth Maturity Indicators

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PHYSICAL GROWTH

MATURITY INDICATORS

PUNEET JAINJR-1


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CONTENTS

INTRODUCTION

VARIOUS MATURITY INDICATORS

THEIR CLINICAL IMPLICATION CONCLUSION


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INTRODUCTION:

One of the objective for treating skeletal discrepancies, isto take advantage of the patients growth spurt, which helpto achieve optimal results,within the short period of time.

Evaluation of individual biologic time table and identification ofperiod of accelerated growth is essential for clinical decisions,regarding growth modulation procedures for skeletaldiscrepancies, extraction versus non extraction options,use of

extra oral orthopaedic forces and planning for orthognathicsurgery for skeletal malocclusions.


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As a results many investigators have attempted , to predict theduration ,magnitude, direction and timing of the adolescentgrowth changes.

The developmental status of a child is usually assessed inrelation 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 biologicalindicators that have been used to identify stages of growth.

INTRODUCTION:


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Chronological age is often not sufficient for assessing thedevelopmental stage and somatic maturity of the patient,so thatthe biological age has to be determined.

The biological age is determined from the skeletal, dental andmorphologic age and onset of puberty.

Patient chronological age is defined as the time period from thebirth 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 agegroups to determine where he stands in relation to others.Height is useful as a maturity indicator from late infancy to

early adulthood.

INTRODUCTION:


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Dental age has been based on two different methods ofassessment. 1. Tooth eruption age.

2. Tooth mineralization stage.

Sexual age refers to development of secondary sexualcharacteristics. This type of indicator is useful only foradolescent growth.

Skeletal age Assessment is often made with the help of hand -

wrist radiograph which can be considered the Biologicalclock.

INTRODUCTION:


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INTRODUCTION

In orthodontics the assessment of skeletal ageand pubertal growth spurt (in particular)are ofprime importance in

1. Diagnosis

2. treatment planning

3. Retention.


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INDICATIONS FOR GROWTH

STATUS1. 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 dentaland chronological age

3. Patients requiring orthognatnic surgery if undertakenbetween 16-20 years of age

4. Prior to rapid maxillary expansion(Transverse Plane)


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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


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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 ofepiphyses is termed as Adolescence- wherein most ofindividuals growth & development occurs.


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VARIOUS SKELETAL MATURITY

INDICATORS

Hand wrist radiograph

Cervical vertebrae

Canine calcification

Frontal sinus

Third molar level

Mid palatal suture

Antigonial notch


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HAND WRIST RADIOGRPH EVALUVATION

Ranke is considered to have been the first to study skeletaldevelopmental progress by means of wrist roentgenograms.

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

Hellman used the total length of the digits and the width andlength of the phalanges to supplement his inspection ofroentgenograms of skeletal Maturation.Hellman published hisobservations on the ossification of epiphysial cartilages of the

hand in 1928.


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In 1936 Flory indicated that beginning of calcification of thecarpal sesamoid was a good guide to determine the periodimmediately before puberty

The appearance of the adductor sesamoid has been highlycorrelated to peak height velocity and start of adolescentgrowth spurt.

Fishman developed a system of hand wrist skeletal maturationindicators using four stages of bone maturation at sixanatomic sites on the hand and the wrist.

Hagg and Taranger created a method using the hand wristradiograph to correlate certain maturity indicators to thepubertal growth spurt.


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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)


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Anatomy of hand wrist radiograph


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First stage of maturation:

( PP2= stage)

The epiphysis of the proximalphalanx of the index finger has thesame width as the diaphysis.

This stage occurs approximately 3

years before the peak of thepubertal growth spurt.

Second stage :(MP3=stage)

Epiphysis of the middle phalanx ofthe 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


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Third stage :( Pisi-, H1-, and R=stage)

This stage of development canbe identified by three distinctossification areas. These showindividual variations but appearat the same time during theprocess of the maturation.

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

Pisi-stage: Visible ossification ofthe pisiforme.

R-stage : Same width ofepiphysis and diaphysis of the

radius.


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Fourth stage :

(S-and H2-stage)

S-stage: First mineralization ofthe ulnar sesamoid bone of themetacarpophalangeal joint ofthe thumb.

H2-stage: Progressiveossification of the hamularprocess of the hamate.

The fourth stage marks thebeginning of the pubertalgrowth spurt.


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Fifth stage :( MP3cap, PP1cap-, andRcap-stage)

During this stage, the diaphysis covered

by the cap shaped epiphysis.

MP3capstage: The process begins at themiddle phalanx of the third finger.

PP1cap-stage: At the proximal phalanxof the thumb.

Rcap-stage : At the radius.

This stage of ossification marks the peakof the pubertal growth stage


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Sixth stage :( DP3u-stage)

Visible union of the epiphysis anddiaphysis at the distal phalanx of themiddle finger.

This stage of development

constitutes the end of the pubertalgrowth.


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Seventh stage :( PP3u-stage)

Visible union of the epiphysisand diaphysis at the proximalphalanx of the middle finger.

1 yr after growth

Little growth potential isremaining


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Eighth stage :( MP3u-stage)

Visible union of the epiphysisand diaphysis at the middlephalanx of the middle fingeris clearly seen.

Ni h (R )


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Ninth stage :(Ru-stage)

Complete union of the

epiphysis and diaphysis of theradius.

The ossification of all the hand

bones is completed andskeletal growth is completed.

J li Si (1980) d ib d 6 f


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Stage 1 (Early):

1. Absence of Pisiform2. Absence of Hook of Hamate3. Epiphysis of proximal phalanx of

second digit (PP2) narrower than itsshaft.

Stage 2 (Prepubertal):

1. Proximal phalanx of second digit andits 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.

S 3 (P b l )


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Stage 3 (Pubertal onset):1. Beginning calcification of Ulnarsesamoid.

2. Increased width of epiphysis ofPP2.

3. Increased calcification of hamatehook and pisiform.

Stage 4 (Pubertal):1. Calcified ulnar sesamoid.

2. Capping of shaft of middlephalanx of third digit by its

epiphysis (MP3cap).

S 5 (P b l D l i )


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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 ulnanot fully calcified withrespective shafts.

Stage 6 (Growth completion):

No remaining growth sites.


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LEONARD S. FISHMAN 1982 (AO)

outlined four stages of bone

maturation found at sixanatomical sites located on

the thumb, third finger, fifth

finger and radius. Eleven skeletal maturity

indicators are found in thesesix anatomic sites.

Epiphysis as wide as diaphysis


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Epiphysis as wide as diaphysis

1. Third finger-proximal phalanx2. Third finger-middle phalanx3. Fifth finger-middle phalanx

Ossification

4. Adductor sesamoid of thumbCapping of epiphysis

5. Third finger distal- phalanx6. Third finger middlephalanx7. Fifth finger middle-phalanx

Fusion of epiphysis and diaphysis8. Third finger distal -phalanx9. Third finger proximal- phalanx10. Third finger middlephalanx

11. Radius


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Accelerating growth velocity period. SMI 14.

High growth velocity period. SMI 47.

Decelerating growth velocity period. SMI 711.

Girls generally reach point of peak growth velocity at SMI 5 and boys at SMI 7


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Hagg and Taranger skeletal maturity indicators: (AJO 82)

They described a method in which skeletal development is assessedby ossification of the ulnar sesamoid of the metacarpophalangeal joint of the first

finger (S) and certain specified stages of three epiphyseal bones; the middle anddistal phalanges of the third finger (MP3 and DP3) and the distal epiphysis ofthe radius R

In order to obtain maturation indicators of shorter duration, two newepiphyseal stages were defined. One stage in the middle phalanx of thethird finger, denoted MP3-FG, and one stage in the distal end of theradius, denoted R-IJ.

The ulnar sesamoid (S) of the metacarpophalangeal jointusuallyattained

Pubertal development Assesed from 10-18 years

Menarche in girls

Voice change in boys


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The middle phalanx of the third finger

(MP3):

Stage Fthe epiphysis is as wide as themetaphysis.

Stage FGthe epiphysis is as wide asthe metaphysis and there is distinctmedial and/or lateral border of the

epiphysis forming a line of demarcationat right angles to the distal border.

Stage Gthe sides of the epiphysishave thickened and also cap itsmetaphysis, forming a sharp edge distally

at one or both sides.

Stage H fusion of the epiphysis and


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Stage Hfusion of the epiphysis andmetaphysis has begun

Stage Ifusion of the epiphysis andmetaphysis is completed.

The distal epiphysis of the radius:

Stage Ifusion of the epiphysis andmetaphysis has begun.

Stage IJfusion is almost completed butthere is still a small gap at one or bothmargins.

Stage Jfusion of the epiphysis andmetaphysis is completed.

Distal Phalanx (DP3-I)-fusion of the epiphysisand metaphysis complete


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SignificanceSesamoid 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.


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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.Rajagopal and Dr. Kansal were to be evaluated and compared with sixstages of cervical vertebrae which were described by HASSEL &FARMAN(1995).


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Lateral cephalograms for recording the CVMI stages were taken innatural head position following standard procedure, with patientsstanding 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 weretaken using the following procedure

1. The subject was instructed to place the right hand with the palmdownward on a flat table.

2. The middle finger was centered on a 31mm 41mm periapicaldental x-ray film, parallel with the long axis of the film.

3. The cone of the dental x-ray machine was positioned in slightcontact with the middle phalanx, perpendicular to the film.


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COMPARISON BETWEEN MP3-F & INITIATION STAGE

MP3-F stage: Start of the curve of pubertalgrowth 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 andmetaphysis 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 fromposterior to anterior (wedge shape).

3. 80-100% of pubertal growth remains

COMPARISION BETWEEN MP3 FG & ACCELERATION STAGE


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MP3-FG stage: Acceleration of the curvepubertal 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 demarcationat 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


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COMPARISION BETWEEN MP3-G & TRANSION STAGE

MP3-G stage: Maximum point of pubertalgrowth spurt

Features observed by Hagg and Taranger:

1. Sides of epiphysis have thickened andcap metaphysis, forming sharp distaledge on one both sides.

Additional features observed in this study:

2. Marked undulations in metaphysisgive Cupids bow appearance.

3. Radiolucent gap is moderate betweenepiphysis 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 lowerborder C4

3. C3 and C4 are rectangular in shape-

COMPARISION BETWEEN MP3-H & DECELERATION STAGE


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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 ofmetaphysis.

5. Typical Cupids bow appearance of metaphysis isabsent, but slight undulation is distinctly present.

6. Radiolucent gap between epiphysis and metaphysis isnarrower

CVMI-4: Deceleration stage of cervical vertebrae

1. Distinct concavities are seen in lowerborders of C2, C3, and C4.

2. C3 and C4 are nearly square in shape


COMPARISION BETWEEN MP3 HI & MATURATION STAGE


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COMPARISION BETWEEN MP3-HI & MATURATION STAGE

MP3-HI stage: Maturation of the curve of pubertalgrowth spurt

Features of this new stage observed in this study:

1. Superior surface of epiphysis shows smoothconcavity.

2. Metaphysis shows smooth, convex surface,almost fitting into reciprocal concavity ofepiphysis.

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 bordersare observed

2. C3 and C4 are square in shape


COMPARISION BETWEEN MP3 I & COMPLETION STAGE


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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 betweenmetaphysis and epiphysis

3. Dense, radiopaque epiphyseal line forms

integral part of proximal portion of middlephalanx

CVMI-6: Completion stage of cervicalvertebrae

1. Deep concavities are present in C2,C3, and C4 inferior vertebral bodyborders.

2. C3 and C4 are greater in height thanin width

3. Pubertal growth is complete


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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 thirdthrough the seventh have great similarity.

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

Lamparski studied changes and shape of cervical vertebrae sides. Toddand Pyle, Lanier and Taylor made measurements from lateralradiographs of the lower cervical vertebrae. Lamparski studied changesand shape of cervical vertebra .

The standard method of evaluating skeletal maturity has been to use ahand- wrist x-ray to compare the bones of an individuals hand withthose in published atlases.


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To avoid taking an additional x-ray, some researchers sought to relatematuration with dental and skeletal features other than the bones in the handand wrist.

The use of cervical vertebrae to determine skeletal maturity is not new.

In 1972, Lamparski concluded that the cervical vertebrae ,as seen on theroutine 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 femalesand males, but that females developed the changes earlier.


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Six stages of cervical vertebral maturation were described(Hassel & Farman,1995AJO)

Stage 1: All inferior borders of the bodies are flat. The superior borders arestrongly tapered from posterior to anterior.

Stage 2: A concavity has developed in the inferior border of the secondvertebrae.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 thirdvertebra has increased, and a distinct concavity has developed on the fourthvertebra. Concavities on 5 and 6 are just beginning to form .

Stage 5: The bodies have become nearly square in shape and the spacebetween the bodies are visibly smaller.concavities are well defined on all sixbodies.

Stage 6: All bodies have increased in vertical height and are higher thanthey are wide.All concavities have deepened.


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Cervical vertebrae maturation indicators


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HASSEL & FARMAN AJO 1995

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

4th cervical vertebrae are flat atthis stage.

The third and fourth vertebrae arewedge shaped and the superiorvertebral borders are tapered fromposterior to anterior.

100% of pubertal growth remains.

Very significant amount ofadolescent growth expected.


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2. Acceleration:

Concavities on the inferior

borders of second and thirdvertebrae begin to develop.

Inferior border of fourth

vertebrae remains flat.

Vertebral bodies of third andfourth are nearly rectangular in

shape.

65-85% of pubertal growthremains


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3. Transition :

Distinct concavities are shownon the inferior borders ofsecond and third vertebrae.

A concavity begins to develop on

the inferior border of fourthvertebrae.

Vertebral bodies of third and

fourth are rectangular in shape.

25-65% of pubertal growthremains.


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4. Deceleration stage:

Distinct concavities canobserved on the inferiorborders of second third andfourth cervical vertebrae.

Vertebral bodies of thirdand fourth begin to be moresquare in shape.

10-25% of pubertal growthremains.

5 M i


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5. Maturation stage:

Marked concavities areobserved on the inferiorborders of second, thirdand fourth cervical

vertebrae.

Vertebral bodies of thirdand fourth are almost

square in shape.

5-10% of pubertalgrowth remains

6 C l i


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6. Completion:

Deep concavities areobserved on the second,third and fourth cervical

vertebrae.

Vertebral bodies aregreater in dimension

vertically than horizontally.

Pubertal growth has beencompleted.


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Stages 1 through 3 were generally observed prior to peakvelocity 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 inthe other ten subjects stages 4 through 6 occurred after peak

velocity


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Advantage

The orthodontist could obtain additional information aboutthe growth potential in the adolescent patient by observing theanatomical changes of the cervical vertebrae, thereby

formulation of a treatment could be made.

Apart from this any anomalies in the Cervical spine ofchildren & adolescents like fractures, infections, polyarthritis,ankylosis & ankylosing spondylitis etc can be identified.

F hi B tti & M N (2002 AJO )P t d


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Franchi, Bacetti & McNamara (2002 AJO)Presented animproved version of the CVM method to test its validity forthe 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 wereanalyzed in the six consecutive observations (T1 through T6).

The analysis consisted of both visual and cephalometricappraisals of morphological characteristics of the cervical

vertebrae.

On the lateral cephalograms the following


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On the lateral cephalograms, the followingpoints for the description of the morphologiccharacteristics of the cervical vertebral bodieswere traced and digitized.

C2p, C2m, C2a: the most posterior, thedeepest and the most anterior points on thelower border of the body of C2.

C3up, C3ua: the most superior points of theposterior and anterior borders of the body ofC3.

C3lp, C3m, C3la: the most posterior, thedeepest and the most anterior points on thelower border of the body of C3.

C4up, C4ua: the most superior points of theposterior and anterior borders of the body ofC4.

C4lp, C4m, C4la: the most posterior, the

deepest and the most anterior points on thelower border of the body of C4

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


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C2 conc :a measure of the concavity depth at the lower border of c2(distance fromthe 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 theline 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 theline 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.

Th fi di f b h h i i d h l i


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The findings of both the inspective and cephalometricanalyses revealed that no statistically significant discriminationcan 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 MaturationStage is referred to as CVMS.

The appearance of a visible concavity at the lower border ofthe third cervical vertebra is the anatomic characteristic thatmostly accounts for the identification of the stage immediatelypreceding the peak in mandibular growth (former Cvs 3,

actual CVMS II).


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CVMS I: the lower borders of all the three vertebrae are flat,with the possible exception of a concavity at the lowerborder of C2 in almost half of the cases. The bodies of both

C3 and C4 are trapezoid in shape (the superior border of thevertebral body is tapered from posterior to anterior). Thepeak in mandibular growth will occur not earlier than oneyear after this stage.


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CVMS II: Concavities at the lower borders of both C2 and C3are present. The bodies of C3 and C4 may be either trapezoidor rectangular horizontal in shape. The peak in mandibulargrowth will occur within one year after this stage.

CVMS III: Concavities at the lower borders of C2, C3, and C4now are present. The bodies of both C3 and C4 are

rectangular horizontal in shape. The peak in mandibulargrowth 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 issquared in shape. If not squared, the body of the othercervical vertebra still is rectangular horizontal.


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The peak in mandibular growth has occurred not later thanone year before this stage.

CVMS V: The concavities at the lower borders of C2, C3,andC4 still are evident. At least one of the bodies of C3 and C4 isrectangular vertical in shape. If not rectangular vertical, thebody of the other cervical vertebra is squared. The peak in

mandibular growth has occurred not later than two yearsbefore this stage.


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The authors conclude that:

The new CVM method is comprised of five maturationalstages (CVMS I through CVMS V, instead of Cvs 1 throughCvs 6 in the former CVM method), with the peak inmandibular growth occurring between CVMS II and CVMSIII.

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

The new method is particularly useful when skeletal maturityhas to be appraised on a single cephalogram and only thesecond through fourth cervical vertebrae are visible.

D A ATA S T (A O 1994)


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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'ssystem 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 to11), allowing for comparison of the differences of maturationaldevelopment between delayed, average, and accelerated maturation, thefollowing 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; and3. Point P, point tangent to a line connecting the posterior walls of the

greater palatine foramens

M f l h d i d


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Measurements of length and associatedpercentage of osseous development wererecorded 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 ofsutural approximation (fusion) as the SMIstages 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


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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 anapproximated suturethe best time would be before SMI 9 as the % ofapproximation is less.

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

This study has also verified the fact that mid-palatal approximationoccurs more posterior during the entire adolescent period. ThereforeOrthodontic mechanics could probably be more efficiently designed ifmore force value is expressed more posterior to the suture.

Frontal sinus development (AJO 1996)


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SABINE RUF & HANS PACHERZ

TWO head films were taken(1-2 yr interval basis)

Lateral radiographs were oriented with the nasion sella line horizontally. Theperipheral border of the frontal sinus was traced, and the highest (Sh) andlowest (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). .


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From longitudinal growth data of the subjects, the average yearly body height

growth velocity (millimeters per year) was calculated. The maximum bodygrowth 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 ofpubertal stage as assessed from frontal sinus development.

Frontal sinus growth velocity at puberty is closely related to body heightgrowth velocity.

Frontal sinus growth shows a well-defined pubertal peak (Sp), which on theaverage, 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 atleast 1.3 mm/yr

In a 2-year observation interval, a peak growth velocity in the frontal sinus of atleast 1.2 mm/yr


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ADVANTAGES


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ADVANTAGES

It may deliver important information with respect to the person's stage of

somatic development when two lateral head films are available spacedapproximately 1 to 2 years apart.

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

DISADVANTAGES

For incidence of body height peak-low precision(~50%)

will not be able to replace hand-wrist radiographs in routine orthodonticdiagnostics.

CANINE CALCIFICATION


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Tooth mineralisation as an indicator of pubertal growth spurt

(1980 AJO Jan)

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

He found that the Mandibular canine calcification stage G, (stage of rootformation prior to closure of the apices), corresponded with thematurational 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 FORMATION STAGES


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DENTAL FORMATION STAGES

D-H OF MANDIBULAR CANINE

Demirjian et al, 1973

Antegonial notch as indicator of growth potential (AJO 1987 Feb )


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

They stated that,

Deep notch cases had more retrusive mandibles with a shorter corpus, smaller ramusheight, 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 belonger, and both the mandibular plane angle and facial axis were more verticallydirected.

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

1) a smaller increase in total mandibular length,2) corpus length, and3) less displacement of the chin in a horizontal direction than did the shallow notchsample.


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Measuring Antegonial Notch


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The results of this study suggest that the clinical presence of a deepmandibular 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 antegonialnotch 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 wasobserved.

Disadvantage: the strength of this relationship was weak & antegonialnotch depth fails to sufficiently indicate future facial growth to warrantits application as a growth predictor

Mandibular third Molar development and Skeletal


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maturity(Engstorm,1983 AO)

Engstorm(1983) compared lower third molar development stages withskeletal 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.


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At stage PP2 third molar crown completion took place in majority of

subjects. At stage MP3 cap crown completion in all and root development hadbegun 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 reachedfull length.

CORRELATION OF SKELETAL MATURATION STAGESDETERMINED BY CERVICAL VERTEBRAE &HAND-WRIST

EVALUATION


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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 thepubertal growth curve).

Cervical vertebrae ( C2, C3 and C4) outlines obtained fromlateral cephalograms were analysed using the CVM to determine

skeletal maturation stage.


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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 aremoderately high. This maybe high enough to use either of themethods indistinctly for research purposes but not for theassessment of individual patients.


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The following conclusions were drawn:

1. Wide variation in chronological age for different maturity levelssuggests 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 forevaluation of skeletal maturity, with the same confidence as hand

wrist radiographs.

CORRELATION OF HAND-WRISTAND


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AND

CERVICAL VERTEBRAL MATURATION STAGES

Handwrist

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


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CONCLUSION

If utilized properly hand-wrist radiograph and cervicalvertebra radiograph provide a reliable and efficient means ofdevelopment assessment. Simple reference on the assumptionthat skeletal age or rather normal skeletal age for a specificchronologic age as a reasonable indicator of maturity is notjustified. Studies have shown that healthy children of any agedo not demonstrate any chronological specificity regardingparticular stages of maturation.

All the maturity indices are sequence of maturationalstages representing the general poulation and cannot bedirectly associated in any accurate manner with a specificindiviual of either sex.

R f


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References Hassel B, Farman A G.Skeletalmaturation evaluation using cervical

vertebrae Am J Orthod,1995; 107:58-61 Julian Singer . Angle Orthod, 1980;50:320-333.

Hagg U,TarangerJ Maturational indicators and the pubertal growthspurt. 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. AngleOrthod ; 1982; 52:89-111

physical growth maturity indicators

Documents

progress of growth

growth spurts

foradolescent growth

stages of growth

skeletal age assessment

sexual age

age group

patients growth spurt