MATURITY INDICATORS
PRESENTED BY
Dr. JASMINA.T
FIRST YEAR PG
DEPARTMENT OFORTHODONTICS &
DENTOFACIAL ORTHOPEDICS
CONTENTS
• INTRODUCTION
• CLASSIFICATION OF MATURITY INDICATORS
CHRONOLOGICAL AGE
BIOLOGICAL AGE
• BIOLOGICAL AGE INDICATORS
MORPHOLOGICAL AGE INDICATORS
DENTAL AGE INDICATORS
SEXUAL AGE INDICATORS
SKELETAL AGE INDICATORS
• SKELETAL AGE INDICATORS
HAND AND WRIST RADIOGRAPH
CERVICAL VERTEBRAE
. ADVANCED METHOD(BIOLOGICAL MARKER)
. CONCLUSION
INTRODUTION
• The level of maturity attained and the amount of growth potential
remaining
• The maturational status of patients has a strong bearing in
orthodontic diagnosis , treatment planning, outcome of the treatment
and post treatment stability.
• Very important to assess the level of maturity attained by a child
during postnatal growth .
CLASSIFICATION OF MATURITY
INDICATORS.
1. Morphological
age.
2. Dental age.
Maturity 3. Circumpuberta
indicators l age.
4. Skeletal age
Chronologi
cal age Biological
age
TEXTBOOK OF orthodontics by SAMIRE.BISHARA
IDEAL REQUIREMENT OF A MATURITY INDICATORS.
safe , noninvasive, simple , accurate
and cost effective..
radiation exposure minimal .
Stages well defined and easily
identifiable.
valid in both genders and in different
population groups
TEXTBOOK OF orthodontics by SAMIRE.BISHARA
ROLE OF GROWTH SPURT
• Before birth
• Infantile growth spurt: 1year after birth(3yr)
• Juvenile spurt(mixed dentition):
7-9year (females)
8-11years(males)
• pubertal spurt:
11-13years(females)
14-16years(males)
• Growth spurts : acceleration phase and
deceleration phase
Contemporary Orthodontics Fourth Edition William R. Proffit
INITIATION OF ADOLESCENTS
• Release of GnRH from
neurosecretory cells
• Acceleration in general body
growth
Contemporary Orthodontics Fourth Edition William R. Proffit
1-MORPHOLOGICAL AGE.
• Based on height.
• compared with same age group and other
age groups to determine where he stands
in relation to other.
• It useful as a MI from late infancy to early
childhood.
TEXTBOOK OF orthodontics by SAMIRE.BISHARA
DISTANCE CURVE VELOCITY CURVE
• Females are shorter on average than males .
• Growth in height stops at 18 years in females and 20years in males.
• Height may slightly increase up to 30 years of age because of growth of
vertebral column.
TEXTBOOK OF orthodontics by SAMIRE.BISHARA
SIX TYPES OF HEIGHT GROWTH IN
CHILDREN
1. AVERAGE GROWERS:
2. EARLY MATURING :
3. GENETICALLY TALL:
4. LATE MATURING :
5. GENETICALLY SHORT:
6. START PUBERTY EITHER EARLY OR LATE
TEXTBOOK OF orthodontics by SAMIRE.BISHARA
2-DENTAL AGE.
1. Tooth eruption age.
2. from crown calcification to root
completion using x-rays of the
unerupted and developing teeth
.: demirijian index.
TEXTBOOK OF orthodontics by SAMIRE.BISHARA
DEMIRJIAN INDEX
BY DEMIRJIAN A,GOLDSTEIN
H,TANNER JM.
• used mandibular left
quadrant and divided
into 8 stages.
• Seymour chertkow :based on the mineralization of the
lower canine.
Sandra Coutinho ,Buschang and miranda:Relationships between mandibular canine
calcification stages and skeletal maturity.Am JDO 1993;104:262-8
Most children having attained canine stage G showed the
presence of the adductor sesamoid (81%), capping of the
diaphysis of the third middle phalanx (77%), and capping of
the fifth proximal phalanx (87%). Growth reference data for
American children suggest that stage G occurred
approximately 0.4 years and 1.3 years before peak height
velocity for girls and boys, respectively. It is indicated that
canine calcification could serve as a useful tool for evaluating
childrens' skeletal maturation and, by association, somatic
maturity.
STAGES OF TOOTH CALCIFICATION-
NOLLA(1960)
3- SEXUAL/ CIRCUMPUBERTAL AGE
Refers to the development of secondary sex characteristic.
• breast development.
• menarche in females.
• penis and testis growth in males.
• axillary and pubic hair development in both sexes.
TEXTBOOK OF orthodontics by SAMIRE.BISHARA
• Growth of the ovaries Earliest sign of male
precedes growth of puberty is the growth of
the rest of the sex the testicle.
apparatus. In response to hormone
Menarche occurs production of the testes ,
after the peak the other parts of sex
velocity in height apparatus begin their
growth. adolescent development.
ASSESSMENT OF TIMING OF
ADOLESCENT GROWTH SPURT
• Sex hormones stimulate cartilage to grow faster.
• Sex hormones increase’s rate of skeletal maturation.
• At end of adolescence last of the cartilage is transformed into bone, and
the epiphyseal plates close.
Contemporary Orthodontics Fourth Edition William R. Proffit
GROWTH TIMING BOYS
• More growth in the lower jaw than
in the upper.
• Differential jaw growth.
• Affected by both genetic and
environmental influences.
• Puberty begins later and extends
over a longer period- about 5 years
compared with 3 & ½years for girls.
Contemporary Orthodontics Fourth Edition William R. Proffit
Stage 1 Stage 2 Stage 3 Stage 4
4 stages in development can be correlated with the curve of general body growth
• Initial
at sign : fat spurt
adolescence. • About 1year • 8-12 month after stage • 15-24 months after
• Gain weight and become after stage 1 2 and coincide with the stage 3
almost chubby, with a • Redistribution PHV • Sex hormones
somewhat feminine fat and relative • Axillary hair appear stimulate the cartilage
distribution &obese. decrease in and facial hair appear to grow faster
• Estrogen production by subcutaneous on the upper lip only • Major factor
Leydig cells in the testes is fat ,pubic hair • Muscle growth, • Cartilage is
stimulated before the more begins to decrease in transformed to bone
abundant Sertoli cells begin appear and subcutaneous fat • Acceleration in
to produce significant growth of the • More angular body maturation greater
amounts of testosterone penis begins form , pubic hair than in growth . thus
• At this time scrotum begins to distribution appear during the rapid
increase in size and may show more adult ¬ yet growth at adolescence,
some increase or change in spread to medial areas the cartilage is used up
pigmentation of thigh faster than it is
• The penis and scrotum replaced
are near adult size
GROWTH TIMING GIRLS
STAGE 1 STAGE 2 STAGE 3
• Beginning of physical • Noticeable breast • 1-1½ year after stage 2
growth spurt , development. • Marked by onset of
appearance of breast bud • Pubic hair is darker menstruation
and starting and widespread and • Growth spurt is complete
development of pubic hair appears in the • Noticeable broadening of
hair. armpit(axillary hair) the hips with more adult fat
• PHV of physical growth distribution and
occur about 1year after development of the breast
is complete.
4-SKELETAL MATURITY
INDICATORS.
Use of hand wrist Evaluation using
radiograph cervical vertebra
SKELETAL
MATURITY
INDICATORS
Assessment by clinical and radiographic examination of
different stages of tooth development.
I. HAND WRIST RADIOGRAPH
• made up of 27 small bones + distal end of long bones radius and ulna.
• total of 51 separate growth centers
phalanges 28(14 primary,14 secondary)
metacarpals 10
carpals 8
ulna 2
radius 2
sesamoid 1
anatomy
ANATOMY
DISTAL ENDS OF BONES OF FOREARM
ORTHODONTIC principles and practice- phulari
CARPAL BONES
1:Trepezium 5:scaphoid
2:trapezoid DISTAL PROXIMAL
6:lunate
1 2 4
3 8
5 7
6
3:capitate
7:triquetral
4:hamate.
Hamular process :
hook of hamate 8:pissiform
METACARPAL BONES
ORTHODONTIC principles and practice- phulari
PHALANGES
ORTHODONTIC principles and practice- phulari
Ossify in 3 stages.
• Stage 1:the epiphysis and the diaphysis are
equal.
• Stage2:the epiphysis caps the diaphysis by
covering it like a cap.
• Stage3:fusion occur between the epiphysis
and the diaphysis.
ULNAR SESAMOID BONE
• Small nodular bone.
• Found embedded within the
tendons in the region of thumb.
ORTHODONTIC principles and practice- phulari
INDICATION OF HAND WRIST RADIOGRAPH
• Pt with major discrepancy between dental and chronological age.
• Determine maturity status prior to treatment of skeletal
malocclusion such as a skeletal class 2 and class 3.
• To assess the skeletal age in patient whose growth is affected by
infections , neoplastic or traumatic condition.
• predict future skeletal maturation rate and status.
• To predict pubertal growth spurt.
• in research aimed at studying the role of heredity , environment,
nutrition etc
• I patient with skeletal mal occlusion needing orthognathic surgery
DIFFERENT METHODS
2.Bjork,grave
and brown 4.singer’s
method method
1.Greulich 3.fishman’s 5.Hog and
and Pyle indicators taranger
method method
1.GREULICH AND
PYLE METHOD
• published an atlas
• Each photograph in the atlas is the
representative of a particular skeletal age.
Textbook of craniofacial growth- sridhar premkumar
2.BJORK,GRAVE AND BROWN METHOD
• by Bjork 1972 and later modified by grave and brown(1976)
• maturational process of the bones of hand between ages 9
and 17 into 9stages.
• Total of 14 ossification point were utilized.
• The 9 stages with appropriate chronological age for each of
these stages was given by schopf in 1978.
Textbook of craniofacial growth- sridhar premkumar
3.FISHMAN’S INDICATORS.
• by Leonard's fishman in 1982.
• the thumb(adductor sesamoid),3rd finger ,5th finger and radius.
• 11 anatomical site .
• Technique is an organized and relatively simple approach to
determine the level of maturation.
• Interpretation: use 4 stages of bone maturation.
1. Epiphysis is equal in width to diaphysis
2. Appearance of adductor sesamoid of the thumb.
3. Capping of epiphysis.
4. Fusion of epiphysis
Textbook of craniofacial growth- sridhar premkumar
SMI 1 epiphysis and the diaphysis are
SMI 2 equal.
SMI 3
SMI 4 APPEARANCE OF SESAMOID
SMI 5 the epiphysis caps the diaphysis by
SMI 6 covering it like a cap.
SMI 7
SMI 8 fusion occur between the epiphysis
SMI 9 and the diaphysis.
SMI 10
SMI 11 SEEN IN RADIUS
Textbook of craniofacial growth- sridhar premkumar
S.M.I INFERENCE
2 Appear during onset of prepubertal growthvelocity
4,6 Visible during a period of very rapid growth velocity
5,7 Peak height velocity
8,10 Time interval of decelerating growth rate
11 Growth completed
4.SINGER’S METHOD
• Proposed by julian singer in 1980.
• Help to rapidly determine the maturational status of
the adolescent patient.
• 6 stages described.
Textbook of craniofacial growth- sridhar premkumar
5.HAGG AND TARANGER METHOD
• Skeletal development from hand wrist radiographs of
individual taken annually between the ages of 6 and 18
years and studied the ossification of the following
bones
Ulnar sesamoid(s)
Middle and distal phalanges of the third
finger(mp3 and DP3)
The distal epiphysis of the radius.
MIDDLE PHALYNX OF THIRD FINGER (MP3) journal of ida North-west Delhi
branch-feb 2015.volume 2
sesamoid
• Sesamoid usually attained during the acceleration period of the
pubertal growth spurt.
• At the onset of peak height velocity(PHV)
MIDDLE PHALYNX OF THIRD FINGER (MP3) journal of ida North-west Delhi branch-feb 2015.volume 2
3rd finger-middle phalanx
Mp3-f Mp3-fg Mp3-g Mp3-h Mp3-i
• Epiphysis is as • Epiphysis wide • Side of the • Fusion of • Attained
wide as the as the epiphysis have epiphysis and before or
metaphysis. metaphysis, thickened and metaphysis at the end
• Attained • There is distinct also cap its has begun. of growth
before onset medial or lateral metaphysis , • Attained after spurt in all
of PHV in border of the forming a sharp PHV , but subject
about 40% of epiphysis edge distally at before end of except in
the subject forming a line of one or both growth spurt few girls.
and at PHV in demarcation at sides by practically
many others right angle to the • Attained 1year all boys and
distal border. after PHV about 90% of
• Attained 1year the girls.
before or at PHV.
3RD FINGER-DISTAL RADIUS
PHALANX DP3-1
R-I R-IJ R-J
• Fusion of Fusion is Characteriz
• Fusion of epiphysis and epiphysis and almost ed by the
metaphysis is metaphysis has complete fusion of
completed in distal begun. except for epiphysis
phalanx of 3 finger.
rd
• Attained 1year a small gap and
• Attained during before or at the still metaphysis
deceleration period of end of growth remaining .
the pubertal growth spurts in about at one or
spurt(end of PHV) by 80% of females both the
all subjects. and in90% of margins.
males.
II -CERVICAL VERTEBRAE
MATURATION INDEX
• 1972 lamparski : C2 TO C6
• 1995 HASSEL AND FARMAN : based on 3 vertebrae(C2,C3 and C4 )
• 2002 san -roman et al : high correlation between CVMI and handwrist.
STAGE1 :INITIA
TION
• 80-90%of pubertal growth is remaining
• Beginning of adolescent growth.
• Cervical vertebral bodies,c2,c3 and c4
are wedge shaped with their superior
borders tapering posteroanteriorly.
• Their inferior borders are flat.
STAGE 2: ACCELARATION
• 65-85% of pubertal growth remaining.
• Acceleration of growth occur.
• Concavities are developing on the lower
borders of c2 and c3.
• Lower border of c4 vertebral body is
flat.
• C3 and c4 assume rectangular shape
STAGE 3:TRANSITION
• 25-65% pubertal growth remaining.
• Growth is accelerated to reach peak
height velocity.
• Distinct concavity seen in lower borders
of c2 and c3.
• concavity is developing in the lower
borders of c4.
• C3 and c4 are more rectangular in shape.
STAGE 4:DECELARATION
• 10-25% of pubertal growth is
remaining.
• Deceleration of adolescent
growth spurt begins.
• Distinct concavities seen in
lower border of all 3
vertebrae(c2,c3 and c4)
• C3 and c4 are nearly square in
shape.
STAGE 5:MATURATION
• 5-10%pubertal growth
remaining.
• Cervical vertebrae attain
maturity.
• concavities at lower border
of c2 ,c3 and c4 become more
accentuated.
• c3 and c4 are more square in
shape.
STAGE 6:COMPLETION
• Pubertal growth is complete with
no more growth potential
remaining.
• Adolescent growth is nearly
complete.
• More accentuated concavities are
seen at lower borders of c2,c3 and
c4.
• Shape of c3 and c4 is square with
greater vertical dimension than
width.
IOSR Journal of Dental and Medical Sciences (IOSR-JDMS) e-ISSN:
2279-0853, p-ISSN: 2279-0861. Volume 6, Issue 4 (May.- Jun. 2013), PP
06-12 www.iosrjournals.org www.iosrjournals.org 6 | Page Dental &
Skeletal maturity indicators of Chronological age: Radiographic
evaluation amongst children in Gujarat, India Dr. Sheron Bhanat1 , Dr.
Dolly Patel 2 1 Senior Lecturer; Department of Orthodontia; AMC
Dental College and Hospital, Ahmedabad, G
Special Article The cervical vertebral
maturation method: A user’s guide James A.
McNamara, Jra; Lorenzo Franchib
CLINICAL IMPLICATION
Class3 treatment .It is ideal stage
with maxillary
expansion and to begin
protraction is functional jaw
CVMI effective in maxilla
only when it is
orthopedics and
is also the
2. performed before
the peak.it is appropriate age
effective in for treatment of
mandible at vertical
prepubertal malocclusion
&pubertal age
III - MID PALATAL SUTURE
STAGE A:
• Suture straight
• High density sutural line
with no or little
interdigitation
• At 5- almost 11 years
Midpalate suture maturation: classification method for individual assessment before rapid
maxillary expansion , Fernanda angelieri (Am j orthod dentofacial orthop 2013;144:759-69
STAGE B:
• Suture is irregular shape
and appear scalloped high
density line
• Up to age of 13
Midpalate suture maturation: classification method for individual assessment before rapid
maxillary expansion , Fernanda angelieri (Am j orthod dentofacial orthop 2013;144:759-69
STAGE C:
• Suture is parallel ,
scalloped high density lines
separated by small low
density spaces.
• Seen at 11-18 years (11-
24years in girls)
Midpalate suture maturation: classification method for individual assessment before rapid maxillary
expansion , Fernanda angelieri (Am j orthod dentofacial orthop 2013;144:759-69
STAGE D:
• Suture is not visualized and
the Para sutural bone
density is increased
• 11-14 yeas of age
Midpalate suture maturation: classification method for individual assessment before rapid maxillary
expansion , Fernanda angelieri (Am j orthod dentofacial orthop 2013;144:759-69
STAGE E:
• Fussed of the mid palatal
suture
• Actual suture is not
visible
• 14-18years
Clinical implication:
• an ideal time to initiate orthopedic expansion 11years
• Theoretically less orthopedic force values would be required if treatment is
initiated early
Midpalate suture maturation: classification method for individual assessment before rapid maxillary
expansion , Fernanda angelieri (Am j orthod dentofacial orthop 2013;144:759-69
IV - FRONTAL SINUS AS A SKELETAL
MATURITY INDICATOR
• Max body growth velocity at puberty was assigned a term
body height peak.
• Pubertal peak is at age males 12-16years,females 10-14years.
• Frontal sinus growth shows well defined pubertal peak at 1.4
years after the pubertal peak
• In males peak is 15.1years.
• In females 11.5years
• In a 1year interval, growth of T1/yr is seen in frontal sinus
• In a 2year interval , growth of T2/yr is seen in frontal sinus
region
Thomas Rakoski , I Jonas and T M Graber,Textbook of orthodontic
diagnosis
Prediction procedure:
• The frontal sinus growth velocity SV was compared
with T values
• SV was higher than T values, it can be assumed that
the frontal sinus peak was reached during the
prediction interval
• Age more than 15.1 years with a sinus velocity value
lower than T value, shows sinus growth peak passed
and the body peak has passed more than 1.4years
ago.
BIOLOGICAL MARKERS
1- INSULIN LIKE GROWTH FACTOR 1
• Insulin like growth factor 1 is measurable in serum (first
detected) as well as in urine and saliva
• Salivary IGF-1 its level in plasma are extremely low: less than
1% of serum level.IGF-1 rapidly activate bone turn over and
insulin like growth factor- binding protein-3 (IGFBP-3)
• IGF-1 levels were low at prepubertal levels(CS 1, CS 2,CS 3) it
increased gradually
• Peaking during puberty showing maximum values (CS4, CS5)
which later dropped to reach prepubertal values(CS6)
Insulin-like Growth Factor I as a Skeletal Maturity Indicator -BK
Sharmada, :journal of Indian orthodontic society ,October December
2013;48(4):370-374
Biomarkers in Body Fluids as Indicators of Skeletal Maturity: A Systematic Review and Meta-
analysis
A significant
Priyanka Kapoor difference
, Rajiv
1,2 in, IGF-1
Balachandran
3 levels was
Aman Chowdhry seen between
, Giuseppe
1,4 stages
Perinetti , Om
5 ofKharbanda
Prakash peak
pubertal growth spurt (CS3 and CS4) and decelerating pubertal growth (CS5)
6,7,*
compared with growth initiation stage (CS2).
2-ALP,BALP,DHEAS,DBP,PYHRP,OSTEOCALCIN,
METALLOPROTEINS AND SEROTRANSFERRIN.
Biomarkers in Body Fluids as Indicators of Skeletal Maturity: A Systematic Review
and Meta-analysis
Priyanka Kapoor 1,2, Rajiv Balachandran 3, Aman Chowdhry , Giuseppe Perinetti 5,
1,4
Om Prakash Kharbanda 6,7,*
• At puberty : a rise was seen in IGF-1,
DBP, ALP, osteocalcin, TF, and BALP.
• pre-pubertal to post-pubertal stages :
serum DHEAS and PTHrP increased
Growth hormone (GH): is a hormone that stimulates
growth, cell reproduction, cell regeneration, and Igf1
(6).The amount of this hormone changes under the
influence of various factors. Therefore, it is
considerablychallenging to measure it accurately
Testosterone (T) and estradiol (E2): are the major sex hormones; they have effect on male bone tissue (11). Estrogen
determines the acceleration of bone elongation at puberty, epiphyseal closure, harmonic skeletal proportions, peak bone
mass achievement, and bone mass maintenance (12). These markers are low in accuracy and reproducibility (12).
Alkaline phosphatase (ALP): it is vital in development within the skeleton (13); its amount increases along with the growth
rate; also, it is suggested that ALP activity in GCF reflects the biological activity in the periodontium during orthodontic
movement (14). Tarvade et al. reported a significant correlation of salivary ALP with median phalanx index skeletal
maturation stages. Moreover, the collection of saliva for analysis is not complex, does not require invasive procedures, and
does not require very complex equipment (15,16).
CLINICAL IMPLICATION OF SMI
• Determine potential of facial development.
• Determine facial cranial growth potential left.
• Evaluate the velocity of growth.
• Decide the onset of treatment timing.
THANK YOU
