Skeletal maturity indicators

By samreen Tabassum .
MRIDS 2K14
 INTRODUCTION
•Chronological age is often not sufficient for
assessing the developmental stage and somatic
maturity of the patient.
•'The biological age is determined from the
skeletal, dental and morphologic age and the
onset of puberty.
• Due to individual variations in timing, duration
and velocity of growth, skeletal age assessment
is essential in formulating viable orthodontic
treatment plans.
• maturational status can have considerable
The anatomical site for the determination of
skeletal status should have ideally
. 1. Should be easily accessible
2. Should contain the bones or skeletal units that
mature at different time and the timing can be
standardized .

The following methods are followed

1. Use of hand-wrist radiographs.
2. Evaluation of skeletal maturation using cervical
vertebrae. vertebrae
3. Assessment of maturity by clinical and
radiographic examination of different stages of
• The hand-wrist region is made
Hand-wrist Radiographs up of
numerous small bones.

• The appearance, ossification and union of

these bones from birth to maturity show an
orderly sequence of the events in predictable
schedule pattern

• According to FISHMAN the osseous

changes seen in the hand-wrist are
indicators of more general skeletal changes.
 Indications of Hand-wrist
radiographs.
• In patients who exhibit a major discrepancy between
chronological age and dental or skeletal age.
• Determination of skeletal maturity status prior to
treatment of developing skeletal Class II or Class III
malocclusion.
• To assess the skeletal age in a patient.
• To predict the timing and variation of pubertal
growth spurt.
• It helps the clinician to know whether active growth
process is terminated so as to treat the skeletal
 Relative anatomy of hand-wrist

• The hand-wrist region is made up of the

following four groups of bones :

• 1. Distal ends of long bones of forearm

• 2. Carpals
• 3. Metacarpals
• 4. Phalanges
The sesamoid bone
It is a small nodular bone most often present
embedded in tendons in the region of the
thumb.
 Greulich and Pyle method
¢ Greulich and Pyle after a growth study published
an atlas containing the pictures of standard hand-
wrist radiographs of different skeletal ages.
¢They have given ideal pictures of hand and wrist
radiographs for different chronological ages and
for each sex.
¢Each photograph in the atIas is representative of
a particular skeletal age.
.:. The patient’s radiograph is matched on an
overall basis with one of the photographs in the
 Bjork,Grave and Brown analysis

• This was given by Bjork (1972) and later

modified by Grave and Brown (1976).
• They have divided the entire maturational
process of the bones of hand between ages 9
and 17 into 9 stages.
• Each of these stages represents a level of
skeletal maturity.
• A total of 14 ossification points were utilized.
 STAGE -l

» (10.6 YRS in males , 8.yrs in females).

» Epiphysis and metaphysis of the
proximal phalanx of index finger are
equal.
» 3 years before the peak of pubertal
growth spurt
SINGERS METHOD of ASSESSMENT

Julian Singer in 1980 proposed a system of

hand wrist radio-graph assessment.

This helps the clinician to rapidly determine

the maturational status of the adolescent
patient.
 HAGG AND TARANGER METHOD

• They described a in which skeletal

development is assessed by ossification of the
ulnar sesamoid of the meta carpo pharyngeal
joint of the first finger and certain specified
stages of three epiphyseal bones; the middle
and distal phalanges of the third finger(MP3 &
DP3) and the distal epiphysis of the radius
Fishman's skeletal maturity index
Leonard S. Fashman in 1982 proposed a system for
evaluation of skeletal maturation.
It uses anatomical sites located on the thumb ,
third Finger , fifth finger and radius.
•The fishman's system of interpretation uses four
stages of bone maturation:
a.Epiphysis equal in width to diaphysis.
b.Appearance of adductor sesamoid of the thumb.
c. Capping of epiphysis.
d.Fusion of epiphysis.
 • .
1.The proximal phalanx of the third finger shows equal
width of the epiphysis and diaphysis

2.The middle phalanx of the third hnger shows equal

width of the epiphysis and diaphysis

3.The middle phalanx of the fifth finger shows equal

width of the epiphysis and diaphysis

4.Appearance of adductor sesamoid of thumb

5.Capping of the epiphysis of distal phalanx on the third
hnger
6.Capping of the epiphysis on the middle phalanx of the
third finger
7.Capping of epiphyses of the middle phalanx on flfth
hnger
8.Fusion between the epiphysis and diaphysis of the
distal phalanx on the third finger
9.Fusion between the epiphysis and diaphysis of the
proximal phalanx of the third finger
10.Fusion between the epiphysis and diaphysis of the
CERVICAL VERTEBRAE MATURATION INDICATORS

The use of cervical vertebrae to determine skeletal

maturity was suggested by Lamparski in 1972
.
The first seven vertebrae in the spinal column
constitutes the cervical spine.
The first two, the atlas and the axis are quite unique,
the third through the seventh have great similarity.
Vertebral growth takes place from the cartilaginous
layer on the superior and inferior surface of each
vertebrae.
Lamparski concluded that the cervical
vertebrae as seen on routine cephalogram,
were as statistically and
clinically reliable in assessing skeletal age as
the hand wrist technique.

He found out that the cervical vertebral

indicators were the same for the females and
males, but that females developed the changes
earlier.
 CONCLUSION
• 1.Treatment involving modification of skeletal growth seems
to demand as much as information as possible about patient’s
growth potential. potential
• 2. Orthodontic appliances such as the mandibular protraction
appliance, Herbstappliance, 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. In patients 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