Growth prediction (2) /certified fixed orthodontic courses by Indian dental academy

GROWTH ASSESSMENTGROWTH ASSESSMENT
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IntroductionIntroduction
• An understanding of growth events is of primaryAn understanding of growth events is of primary
importance in the practice of clinicalimportance in the practice of clinical
orthodonticsorthodontics
• Biological , skeletal age or bone age andBiological , skeletal age or bone age and
skeletal maturation are nearly synonymousskeletal maturation are nearly synonymous
terms used to described the maturational stageterms used to described the maturational stage
of a personof a person
• Due to individual variation in growth timing ,Due to individual variation in growth timing ,
duration and velocity of growth, skeletal ageduration and velocity of growth, skeletal age
assessment is essential in formulatingassessment is essential in formulating
orthodontic treatment plans.orthodontic treatment plans.

• Maturational status can have considerable influence onMaturational status can have considerable influence on
diagnosis, treatment goals, treatment planning anddiagnosis, treatment goals, treatment planning and
eventual outcome of orthodontic treatment.eventual outcome of orthodontic treatment.
• Clinical decisions regarding use of extra oral tractionClinical decisions regarding use of extra oral traction
forces, functional appliances, extraction versus nonforces, functional appliances, extraction versus non
extraction treatment or Orthognethic surgery all are atextraction treatment or Orthognethic surgery all are at
least partially based on growth considerations.least partially based on growth considerations.
• Prediction of both the time and amount of active growthPrediction of both the time and amount of active growth
especially in the craniofacial complex would be useful toespecially in the craniofacial complex would be useful to
the orthodontist.the orthodontist.

Prediction/Assessment/MaturityPrediction/Assessment/Maturity
IndicatorIndicator
Predict – to say in advance.Predict – to say in advance.
AssessmentAssessment
• Analysis of the nature and amount ofAnalysis of the nature and amount of
growth that has taken place.growth that has taken place.
PredictionPrediction
• To make a statement about the furtherTo make a statement about the further
development of anatomical entitydevelopment of anatomical entity

Clinical ImportanceClinical Importance
• To determine potential vector of facial developmentTo determine potential vector of facial development
• To determine the amount of significant cranial growthTo determine the amount of significant cranial growth
potential leftpotential left
• To evaluate the rate of growthTo evaluate the rate of growth
• To decide the onset of treatment timingTo decide the onset of treatment timing
• To decide the type of effective treatment:To decide the type of effective treatment:
• a) Orthopedic (removable or fixed )a) Orthopedic (removable or fixed )
• b) Orthodonticb) Orthodontic
• c) Orthognethic surgical procedurec) Orthognethic surgical procedure
• d) Combination of aboved) Combination of above
• To evaluate the treatment prognosisTo evaluate the treatment prognosis
• To understood the role of genetics and environment onTo understood the role of genetics and environment on
the skeletal maturation pattern.the skeletal maturation pattern.

Ideal requirement of maturityIdeal requirement of maturity
indicatorindicator
• Should be safeShould be safe
• Non invasiveNon invasive
• Require minimum radiationRequire minimum radiation
• Should be accurateShould be accurate
• Stages of maturity should be well defined and easilyStages of maturity should be well defined and easily
identifiableidentifiable
• Cost effectiveCost effective
• Minimum armamentarium and personal requirementMinimum armamentarium and personal requirement
• Method should be simple to conductMethod should be simple to conduct
• Should be valid over time and across age groups.Should be valid over time and across age groups.

LATE AND EARLYLATE AND EARLY
DEVELOPMENTDEVELOPMENT
• Six type of skeletal developmentSix type of skeletal development
11stst
groupgroup Average childrenAverage children
22ndnd
groupgroup children who are tall in childhood only b/cchildren who are tall in childhood only b/c
matured faster than average, not particularlymatured faster than average, not particularly
tall adultstall adults
33rdrd
groupgroup not only early matures but are genetically tallnot only early matures but are genetically tall
also and will be tall adults.also and will be tall adults.
4rh group4rh group who are small b/c they mature late but willwho are small b/c they mature late but will
eventually be of average stature.eventually be of average stature.
55thth
groupgroup children who are both late developing andchildren who are both late developing and
genetically short in stature.genetically short in stature.
66thth
groupgroup indefinite group who start puberty muchindefinite group who start puberty much
earlier or much late than usual.earlier or much late than usual.www.indiandentalacademy.comwww.indiandentalacademy.com

Indices of maturityIndices of maturity
• Neural ageNeural age
• Mental ageMental age
• Physiological and biochemical agePhysiological and biochemical age
• Chronological ageChronological age
• Sexual/pubertal ageSexual/pubertal age
• Dental ageDental age
• Age determination using growth chartsAge determination using growth charts
• Skeletal/anatomic/radiological ageSkeletal/anatomic/radiological age

Neural ageNeural age
• Gesell and his colleaguesGesell and his colleagues in Americain America
have done great deal of work on thehave done great deal of work on the
neural development in humans.neural development in humans.
• Certain landmarks of development wereCertain landmarks of development were
accounted.accounted.
• Help us to understand that the patient isHelp us to understand that the patient is
mentally developed to understand thementally developed to understand the
need for treatment .need for treatment .

Neural AgeNeural Age
• Developmental landmarksDevelopmental landmarks
• Years Age (months)Years Age (months)
• 22 follows moving object with eyesfollows moving object with eyes
44 can sit propped up for a short time, movescan sit propped up for a short time, moves
head to inspect surroundingshead to inspect surroundings
6 grasps objects, begin to bang and shake them6 grasps objects, begin to bang and shake them
88 may sit unaidedmay sit unaided
10 creeps, picks up small objects between10 creeps, picks up small objects between
fingersfingers and thumb, one/two words,and thumb, one/two words,
tries to help withtries to help with
feedingfeeding
11 cruises holding on to rail of cot, walks withcruises holding on to rail of cot, walks with
oneone
hand held, throws objects on floor, cooperateshand held, throws objects on floor, cooperates
in dressing, waves good-byein dressing, waves good-bye
1.51.5 walks, runs awkwardly and stiffy, can trunwalks, runs awkwardly and stiffy, can trun
pagespages of book, abt 30 words, builds towersof book, abt 30 words, builds towers
of 3-4 blockof 3-4 block

yrsyrs
22 Runs without falling, uses three word sentences ,Runs without falling, uses three word sentences ,
can turn doorknob, obeys simple instructions, buildscan turn doorknob, obeys simple instructions, builds
towers of 6-7 blocks, bowel and bladder controltowers of 6-7 blocks, bowel and bladder control
some times good.some times good.
33 walks erect. Stand on foot, climbs, can put on shoeswalks erect. Stand on foot, climbs, can put on shoes
and unbutton some buttons, bowel and bladderand unbutton some buttons, bowel and bladder
control is established.control is established.
44 Cleans teeth , washes and dried face and hands.Cleans teeth , washes and dried face and hands.
55 can tie shoe lasses and is beginning to use tools,can tie shoe lasses and is beginning to use tools,
some are reading quite well, questions abt meaningsome are reading quite well, questions abt meaning
of wardsof wards
66 reads, balls are bounced and sometimes caught.reads, balls are bounced and sometimes caught.

MENTAL AGEMENTAL AGE
• Attempt to device performance tests, measuresAttempt to device performance tests, measures
intelligence by stanford binet test /or Wechslerintelligence by stanford binet test /or Wechsler
scalescale
• Help in determining the outlook of the patientHelp in determining the outlook of the patient
towards treatment.towards treatment.
• Also help In determining the expected level ofAlso help In determining the expected level of
cooperation that can be expected from patient.cooperation that can be expected from patient.
• Mental age:Mental age:
““index of maturation of mind”index of maturation of mind”
increase at a rate that depends on manyincrease at a rate that depends on many
intrinsicintrinsic and environmental factors.”and environmental factors.”

A) IQ which is the mental age expressed as a percentage of theA) IQ which is the mental age expressed as a percentage of the
chronological age.chronological age.
thus a child with a mental age of 12 yrs and a chronologicalthus a child with a mental age of 12 yrs and a chronological
age of 10 would have an IQ of 120.age of 10 would have an IQ of 120.
B) Ability to draw a human figure is often used to assessB) Ability to draw a human figure is often used to assess
development and the items the child includes can be scoreddevelopment and the items the child includes can be scored
and rated in terms of mental age. This is good correlationand rated in terms of mental age. This is good correlation
between assessments made between 5 and 11 years of age.between assessments made between 5 and 11 years of age.
C) Use as the standard capacity of the child to read.C) Use as the standard capacity of the child to read.

PHYSIOLOGICAL AND BIOCHEMICALPHYSIOLOGICAL AND BIOCHEMICAL
AGEAGE
A)A) Girls show a spurt in systolic blood pressure which occursGirls show a spurt in systolic blood pressure which occurs
earlier than the corresponding spurt in the maleearlier than the corresponding spurt in the male
Resting mouth temperature which falls by 0.5 to 1 *c fromResting mouth temperature which falls by 0.5 to 1 *c from
infancy to maturity and reaches its adult value earlier ininfancy to maturity and reaches its adult value earlier in
girls.girls.
B)B) In the plasma, inorganic phosphate shows a steady fallIn the plasma, inorganic phosphate shows a steady fall
from the high levels of childhood to reach adult by the agefrom the high levels of childhood to reach adult by the age
15 in girls and 17 in boys.15 in girls and 17 in boys.
c)c) Alkaline phosphate rises significantly in parallel withAlkaline phosphate rises significantly in parallel with
growth between the ages of 8-12 yrs in girls and 10-14yrsgrowth between the ages of 8-12 yrs in girls and 10-14yrs
in boys.in boys.
D)D) Ratio of creatinine in the urineRatio of creatinine in the urine
fall progressively with age after abt 14.5 yrs probablyfall progressively with age after abt 14.5 yrs probably
under hormonal influences.under hormonal influences.

CHRONOLOGICAL AGECHRONOLOGICAL AGE
• Poor indicator of maturityPoor indicator of maturity
• Little identifying stages of development fromLittle identifying stages of development from
adolescence to adulthood.adolescence to adulthood.
• Help to categorize individual asHelp to categorize individual as
• ““ early , average, late maturer.”early , average, late maturer.”
• Enable an orthodontist toEnable an orthodontist to determine and predict thedetermine and predict the
rate and magnitude of facial growthrate and magnitude of facial growth
• Help to decide time, duration and method ofHelp to decide time, duration and method of
treatment.treatment.

Age Determination Using Growth chartsAge Determination Using Growth charts
• Involves height, weight and chronological age of childInvolves height, weight and chronological age of child..
• Variation seen in boys and girlsVariation seen in boys and girls
• Uses :Uses :
Use to understand growth patterns in terms of deviationsUse to understand growth patterns in terms of deviations
from the usual pattern to express variability quantitatively.from the usual pattern to express variability quantitatively.
 can be done by compare the child with standardcan be done by compare the child with standard
growth charts. And determine growth isgrowth charts. And determine growth is
normal/abnormal and child is early/late maturer.normal/abnormal and child is early/late maturer.
 growth charts can be followed from birth togrowth charts can be followed from birth to
adulthood to determineadulthood to determine pattern, variability andpattern, variability and
timing and predictability of growth.timing and predictability of growth.

3.3. Determine peak height velocity which is circum pubertalDetermine peak height velocity which is circum pubertal
maximum.maximum.
height and weight measurement are compare withheight and weight measurement are compare with
pubertal and skeletal age for growth assessment.pubertal and skeletal age for growth assessment.

Sexual/pubertal AgeSexual/pubertal Age
• 2 yrs earlier in girls than boys.2 yrs earlier in girls than boys.
• Begins later and extends over a longer periodBegins later and extends over a longer period
of abt 5yrs in boys and 3.5yrs in girls.of abt 5yrs in boys and 3.5yrs in girls.
• According toAccording to HAGG & TARANGERHAGG & TARANGER (1980)(1980)
• Pubertal development was assessed fromPubertal development was assessed from
menarche in girls and the voicemenarche in girls and the voice
change in boys.change in boys.

Sexual AgeSexual Age
• IN Girls :IN Girls :
• if menarche has occurred, peak height velocityif menarche has occurred, peak height velocity
(PHV) has been attained and growth rate is(PHV) has been attained and growth rate is
decelerating.decelerating.
• In Boys,In Boys,
33 stages of voice changes were used:stages of voice changes were used:
• PPV –PPV – prepubertal voiceprepubertal voice ; the pitch of the voice; the pitch of the voice
had not changed noticeably.had not changed noticeably.
• PV –PV – pubertal voicepubertal voice; the pitch of the voice had; the pitch of the voice had
changed noticeably but the voice had not yetchanged noticeably but the voice had not yet
acquired adult characteristics.acquired adult characteristics.
• MV –MV – male voicemale voice; the pitch of the voice had; the pitch of the voice had
acquired adult characteristics.acquired adult characteristics.www.indiandentalacademy.comwww.indiandentalacademy.com

Growth spurts - GraberGrowth spurts - Graber
• Childhood growth spurt (3 yrs)Childhood growth spurt (3 yrs)
• Juvenile growth spurtJuvenile growth spurt
girls – 6 to 7 yrsgirls – 6 to 7 yrs
boys – 7 to 9 yrsboys – 7 to 9 yrs
• Pubertal growth spurtPubertal growth spurt
girls – 10½ to 13 yrsgirls – 10½ to 13 yrs
boys – 12½ to 16 yrsboys – 12½ to 16 yrs

Pubertal growth spurt-girlsPubertal growth spurt-girls
• Stage-I : beginning of growth spurtStage-I : beginning of growth spurt
10½ to 11½yrs10½ to 11½yrs
• Stage-II : peak velocityStage-II : peak velocity
lasts for 1 to 2yrslasts for 1 to 2yrs
• Stage-III : menarcheStage-III : menarche
deceleration and end of growthdeceleration and end of growth
spurt.spurt.

Pubertal growth spurt-boysPubertal growth spurt-boys
• Stage-I : beginning of growth spurtStage-I : beginning of growth spurt
lasts for 1 yr (fat spurt)lasts for 1 yr (fat spurt)
• Stage-II : fat redistribution, pubic hairsStage-II : fat redistribution, pubic hairs
• Stage-III : peak velocityStage-III : peak velocity
• Stage-IV : height stagnatesStage-IV : height stagnates
deceleration and end of growth spurt.deceleration and end of growth spurt.

• Anatomic RegionAnatomic Region
• Region should be small to restrictRegion should be small to restrict
radiation exposure and expense.radiation exposure and expense.
• Should have many ossificationShould have many ossification
centers which ossify at separatecenters which ossify at separate
times and which can be standardized.times and which can be standardized.
• Region should be easily accessible.Region should be easily accessible.
Skeletal Age

Regions for Age AssessmentRegions for Age Assessment
• Head and neck:Head and neck: SkullSkull
Cervical vertebraeCervical vertebrae
• Upper limb :Upper limb : Shoulder joint- ScapulaShoulder joint- Scapula
ElbowElbow
Hand wrist and fingerHand wrist and finger
• Lower limb :Lower limb : Femur and humerusFemur and humerus
Hip jointHip joint
Knee jointKnee joint
AnkleAnkle
Foot tarsalsFoot tarsals
MetatarsalsMetatarsals
PhalangesPhalanges

Skeletal maturity indicatorsSkeletal maturity indicators
• Handwrist radiographsHandwrist radiographs
• Cervical vertebraeCervical vertebrae
• Mid-palatal sutureMid-palatal suture
• Frontal sinusFrontal sinus
• Mandibular canine calcificationMandibular canine calcification
• Tooth mineralizationTooth mineralization
• Symphysis as an predictor of direction of mandibularSymphysis as an predictor of direction of mandibular
growthgrowth
• Antegonial notch as an predictor of direction ofAntegonial notch as an predictor of direction of
mandibular growthmandibular growth
• Craniocervical posture as an predictor of craniofacialCraniocervical posture as an predictor of craniofacial
growthgrowth
• Björk’s structural signs of growth predictionBjörk’s structural signs of growth prediction
• Mesh diagram for growth predictionMesh diagram for growth predictionwww.indiandentalacademy.comwww.indiandentalacademy.com

Hand and Wrist RadiographHand and Wrist Radiograph
X ray discovery
in 1895 by
Roentgen.

Review of literatureReview of literature
• 11stst
hand wrist film was published byhand wrist film was published by SydneySydney
Rowland in EnglandRowland in England in april 1890 (4in april 1890 (4
months after discovery of x-rays).months after discovery of x-rays).
• 1926 –1926 – CarterCarter reported a study of carpalreported a study of carpal
bones of children.bones of children.
• 1929 – 2 comprehensive growth studies by1929 – 2 comprehensive growth studies by
Weingate Todd and Harold StuartWeingate Todd and Harold Stuart
respectively.respectively.

Review of literatureReview of literature
• HunterHunter reported that carpal bones hadreported that carpal bones had
proved to be the best site for determiningproved to be the best site for determining
skeletal maturation.skeletal maturation.
• Björk and HelmBjörk and Helm stated that appearance ofstated that appearance of
ulnar sesamoid on hand wrist film wasulnar sesamoid on hand wrist film was
related to the onset of maximum pubertalrelated to the onset of maximum pubertal
growth in height.growth in height.
• HelmHelm elaborated on other structures in theelaborated on other structures in the
hand wrist film to pubertal growth spurt.hand wrist film to pubertal growth spurt.

• HellmanHellman published his observations on the ossification ofpublished his observations on the ossification of
epiphyseal cartilages of the hand in 1928epiphyseal cartilages of the hand in 1928
• Todd compiled hand-wrist data that was furtherTodd compiled hand-wrist data that was further
elaborated on byelaborated on by Greulich and PyleGreulich and Pyle in atlas form 6 Floryin atlas form 6 Flory
in 1936, indicated that the beginning of calcification ofin 1936, indicated that the beginning of calcification of
the carpal sesamoid (adductor sesamoid) was a goodthe carpal sesamoid (adductor sesamoid) was a good
guide to determining the period immediately beforeguide to determining the period immediately before
pubertypuberty
• FishmanFishman developed a system of hand-wrist skeletaldeveloped a system of hand-wrist skeletal
maturation indicators (SMIs) using four stages of bonematuration indicators (SMIs) using four stages of bone
maturation at six anatomic sitesmaturation at six anatomic sites
• Hagg and TarangerHagg and Taranger created a method using the hand-created a method using the hand-
wrist radiograph to correlate certain maturity indicators towrist radiograph to correlate certain maturity indicators to
the pubertal growth spurt .the pubertal growth spurt .

Indications of handwristIndications of handwrist
radiographradiograph
• Prior to rapid maxillary expansion.Prior to rapid maxillary expansion.
• Marked discrepancy between dental or skeletalMarked discrepancy between dental or skeletal
and chronological age.and chronological age.
• Where maxillomandibular changes are indicatedWhere maxillomandibular changes are indicated
e.g. skeletal class II or III or skeletal openbite.e.g. skeletal class II or III or skeletal openbite.
• Orthognathic surgery if undertaken between theOrthognathic surgery if undertaken between the
ages of 16-20 years.ages of 16-20 years.
• To asses the skeletal growth in a patient whoseTo asses the skeletal growth in a patient whose
growth is affected by infection, neoplastic orgrowth is affected by infection, neoplastic or
traumatic conditions.traumatic conditions.
• To predict future skeletal maturation rate andTo predict future skeletal maturation rate and
status.status.
• To predict pubertal growth spurt.To predict pubertal growth spurt.www.indiandentalacademy.comwww.indiandentalacademy.com

ANATOMYANATOMY

PA view

Oblique view

Hand and Wrist RadiographHand and Wrist Radiograph
• Made up of numerous small bones.Made up of numerous small bones.
• These bones have predictable and scheduledThese bones have predictable and scheduled
pattern of appearance and ossification andpattern of appearance and ossification and
union from birth to maturity.union from birth to maturity.
• One of the most suited region to study growthOne of the most suited region to study growth
• Disadvantage:Disadvantage:
• Away from the sight ( i.e. oral cavity)Away from the sight ( i.e. oral cavity)

ANATOMYANATOMY
• Made up of four groups of bones.Made up of four groups of bones.
1.1. Distal ends of long bones of forearmDistal ends of long bones of forearm
2.2. CarpalsCarpals
3.3. MetacarpalsMetacarpals
4.4. PhalangesPhalanges

Distal ends of long bones of forearmDistal ends of long bones of forearm
• Distal ends ofDistal ends of
radius and ulnarradius and ulnar
• Give rise to aGive rise to a
distal projectiondistal projection
on their respectiveon their respective
sides. c/d Ulnasides. c/d Ulna
styloid and radialstyloid and radial
styloid.styloid.

CarpalsCarpals
• Eight small irregularly shapedEight small irregularly shaped
bones arranged in two raws,bones arranged in two raws,
proximal and distal rawproximal and distal raw
• Proximal raw:Proximal raw:
scaphoid, lunate, triquetralscaphoid, lunate, triquetral
and pisiformand pisiform
• Distal raw:Distal raw:
trapezium, trapezoid,trapezium, trapezoid,
capitate and hamatecapitate and hamate
• All bones osssifies from oneAll bones osssifies from one
primary center.primary center.

MetacarpalsMetacarpals
• Five miniature long bonesFive miniature long bones
forming the skeletalforming the skeletal
framwork of the palm offramwork of the palm of
the hand from thumb tothe hand from thumb to
little fingerlittle finger
• Ossify from one primaryOssify from one primary
center ( in shaft ) andcenter ( in shaft ) and
secondary center on distalsecondary center on distal
end (except for first)end (except for first)

PhalangesPhalanges
• Small bones forming theSmall bones forming the
fingersfingers
• Three in numbers in eachThree in numbers in each
fingersfingers
• In thumb only twoIn thumb only two
phalangesphalanges
• Ossify in 3 stagesOssify in 3 stages
1.1. epiphysis = diaphysisepiphysis = diaphysis
2.2. Epiphysis caps diaphysisEpiphysis caps diaphysis
3.3. Fusion b/w epiphysis andFusion b/w epiphysis and
diaphysisdiaphysis

Sesmoid boneSesmoid bone
• Small nodular boneSmall nodular bone
most often presentmost often present
embedded inembedded in
tendons in the regiontendons in the region
of the thumb.of the thumb.

MethodsMethods
• Atlas Method by Greulich and PyleAtlas Method by Greulich and Pyle
• Bjork, Grave and Brown MethodBjork, Grave and Brown Method
• Fishman’s Skeletal Maturity indicatorsFishman’s Skeletal Maturity indicators
• Hagg and Taranger MethodHagg and Taranger Method
• Julian Singer’s methodJulian Singer’s method

Björk, Grave and Brown’sBjörk, Grave and Brown’s
methodmethod
• Bjork, 1972Bjork, 1972,, divided the maturation processdivided the maturation process
of hand bones into developmental stagesof hand bones into developmental stages..
• Brown, 1976Brown, 1976,, included six further ossificationincluded six further ossification
centres in the hand radiograph.centres in the hand radiograph.
• According to Grave and BrownAccording to Grave and Brown ,,
growth stages of the fingers are assessedgrowth stages of the fingers are assessed
according to the relationship between theaccording to the relationship between the
epiphysis and diaphysisepiphysis and diaphysis..
• Appropriate chronological age for each of theAppropriate chronological age for each of the
stages was givenstages was given by Schopf in 1978by Schopf in 1978

• There are three stages of ossification of theThere are three stages of ossification of the
phalanges.phalanges.
• First Stage:First Stage:
• Epiphysis shows the same width as theEpiphysis shows the same width as the
diaphysis (=)diaphysis (=)
• Second Stage:Second Stage:
• Capping stage (=cap); the epiphysis surroundsCapping stage (=cap); the epiphysis surrounds
the diaphysis like a cap.the diaphysis like a cap.
• Third Stage:Third Stage:
• U-stage (=u); bony fusion of epiphysis andU-stage (=u); bony fusion of epiphysis and
diaphysis.diaphysis.

methodmethod
9 stages:9 stages:
Stage 1(males-10.6 yrs, femalesStage 1(males-10.6 yrs, females
8.1yrs):8.1yrs):
• epiphysis and diaphysis ofepiphysis and diaphysis of
proximal phalanx of indexproximal phalanx of index
finger are equal.finger are equal.
• 3 yrs before peak of pubertal3 yrs before peak of pubertal
growth spurt.growth spurt.
AJO 1976
pp2

methodmethod
Stage 2(males-12.0 yrs,Stage 2(males-12.0 yrs,
females 8.1yrs):females 8.1yrs):
• epiphysis and diaphysis ofepiphysis and diaphysis of
middle phalanx of middlemiddle phalanx of middle
finger are equal.finger are equal.
MP3

methodmethod
Stage 3(males-12.6 yrs, females 9.6yrs):Stage 3(males-12.6 yrs, females 9.6yrs):
3 stages3 stages
• Ossification of hamular process of hamate.Ossification of hamular process of hamate.
• Ossification of pisiform.Ossification of pisiform.
• Epiphysis and diaphysis of radius has sameEpiphysis and diaphysis of radius has same
width.width.
H PiSi R

methodmethod
Stage 4(males-13.0yrs, femalesStage 4(males-13.0yrs, females
10.6yrs):10.6yrs):
• Initial mineralization of ulnarInitial mineralization of ulnar
sesamoid of thumb.sesamoid of thumb.
• Increased ossification of theIncreased ossification of the
hamular process of hamate.hamular process of hamate.
• Shortly before or at theShortly before or at the
beginning of the pubertalbeginning of the pubertal
US
H2

methodmethod
Stage 5(males-14 yrs, females 11yrs):Stage 5(males-14 yrs, females 11yrs):
Capping of diaphysis is seen inCapping of diaphysis is seen in
• Middle phalanx of 3Middle phalanx of 3rdrd
finger.finger.
• Proximal phalanx of thumb.Proximal phalanx of thumb.
• Radius.Radius.
marks themarks the peak of pubertal growthpeak of pubertal growth ..
Cap-MP3 PP1
R

methodmethod
Stage 6(males-15 yrs, femalesStage 6(males-15 yrs, females
13.3yrs):13.3yrs):
• Visible union of diaphysis andVisible union of diaphysis and
epiphysis at the distal phalanx ofepiphysis at the distal phalanx of
the middle finger.the middle finger.
• SignifiesSignifies end of pubertalend of pubertal
DP3-U

methodmethod
13.3 yrs):13.3 yrs):
• Visible union of the epiphysisVisible union of the epiphysis
and diaphysis at theand diaphysis at the proximalproximal
phalanx of little finger.phalanx of little finger.
PP5-U

methodmethod
Stage 8(males-15.9 yrs, females 13.9yrs):Stage 8(males-15.9 yrs, females 13.9yrs):
• Union of epiphysis and diaphysis atUnion of epiphysis and diaphysis at
middle phalanx of middle finger.middle phalanx of middle finger.
MP3-U

methodmethod
16 yrs):16 yrs):
• Complete union of epiphysis andComplete union of epiphysis and
diaphysis of radius.diaphysis of radius.
• Ossification of all bones isOssification of all bones is
complete and skeletal growth iscomplete and skeletal growth is
complete.complete.
R-U

Julian Singer methodJulian Singer method
• In 1980In 1980, proposed a system of hand wrist, proposed a system of hand wrist
radiograph assessment that would enableradiograph assessment that would enable
the clinician to rapidly and with somethe clinician to rapidly and with some
degree of reliabilitydegree of reliability help to determinehelp to determine
the maturational status of thethe maturational status of the
patientpatient
• Six stagesSix stages of hand and wristof hand and wrist
development are described.development are described.
AO: 1980,oct-322-333

Six stages are described:Six stages are described:
• Stage 1 (early) :Stage 1 (early) :
Pisiform is absent.Pisiform is absent.
Hook of hamate absent.Hook of hamate absent.
Epiphysis of proximal phalanx of 2Epiphysis of proximal phalanx of 2ndnd
finger being narrow than diaphysis.finger being narrow than diaphysis.
AO: 1980,oct-322-333

Julien Singer methodJulien Singer method
• Stage 2 (prepubertal) :Stage 2 (prepubertal) : ( pisi, H , PP2 )( pisi, H , PP2 )
• Proximal phalanx of 2Proximal phalanx of 2ndnd
finger is equal to itsfinger is equal to its
epiphysis.epiphysis.
• Initial ossification of hook of hamate.Initial ossification of hook of hamate.
• Initial ossification of pisiform.Initial ossification of pisiform.
• Stage prier to adolescent growth spurt duringStage prier to adolescent growth spurt during
whichwhich significant amount of mandibular growth aresignificant amount of mandibular growth are
possible.possible.
• Maxillary orthodontic therapy in conjunction withMaxillary orthodontic therapy in conjunction with
mandibular growth might aidmandibular growth might aid correction of a cl IIcorrection of a cl II
relationship with considerable speed and ease.relationship with considerable speed and ease.

• Stage 3 (pubertal onset):Stage 3 (pubertal onset): (US and(US and
stage2)stage2)
• Calcification of ulnar sesamoid.Calcification of ulnar sesamoid.
• Increased width of proximal phalanx ofIncreased width of proximal phalanx of
22ndnd
finger.finger.
• Increased calcification of hook ofIncreased calcification of hook of
hamate.hamate.
• Increased calcification of pisiform.Increased calcification of pisiform.

• Stage 4 (pubertal stage)Stage 4 (pubertal stage):: (US , C-mp3)(US , C-mp3)
• Calcification of ulnar sesamoid.Calcification of ulnar sesamoid.
• Capping of diaphysis of middle phalanxCapping of diaphysis of middle phalanx
of 3of 3rdrd
finger by its epiphysis.(MP3-C)finger by its epiphysis.(MP3-C)

• Stage 5 (pubertal deceleration):Stage 5 (pubertal deceleration):
• Full calcification of ulnar sesamoid.Full calcification of ulnar sesamoid.
• Fusion of epiphysis of distal phalanx of 3Fusion of epiphysis of distal phalanx of 3rdrd
finger with its diaphysis. (DP3-F)finger with its diaphysis. (DP3-F)
• Epiphysis of radius and ulnar not fusedEpiphysis of radius and ulnar not fused
completely with diaphysis.completely with diaphysis.
• Phalanges and carpals are fully calcified.Phalanges and carpals are fully calcified.
• Period of growth when orthodonticPeriod of growth when orthodontic
treatment might be completed and thetreatment might be completed and the
patient is in retention therapy.patient is in retention therapy.

Julien Singer methodJulien Singer method
• Stage 6 (growth completion):Stage 6 (growth completion):
No remaining growth site is seen.No remaining growth site is seen.

Fishman’s skeletal maturityFishman’s skeletal maturity
indicatorindicator
• In 1982In 1982 –– Leonard FishmanLeonard Fishman gavegave
system of skeletal maturationsystem of skeletal maturation
assessment (SMA).assessment (SMA).
• 11 skeletal maturity indicators (SMI’s)11 skeletal maturity indicators (SMI’s)
were described.were described.
Angle Orthodontia:No. 3: 1987Angle Orthodontia:No. 3: 1987

11 SMI were divided into 411 SMI were divided into 4
stagesstages
• Epiphysis as wide as diaphysis.Epiphysis as wide as diaphysis.
• Ossification of ulnar sesamoid of thumb.Ossification of ulnar sesamoid of thumb.
• Capping of epiphysis.Capping of epiphysis.
• Fusion of epiphysis and diaphysis.Fusion of epiphysis and diaphysis.

pp3
mp3
mp5
Us
C-dp3
C-mp3
C-mp5
F-dp3
F-pp3
F-mp3
R

Epiphysis as wide asEpiphysis as wide as
diaphysisdiaphysis
1.1. Third finger-proximal phalanxThird finger-proximal phalanx
2.2. Third finger-middle phalanxThird finger-middle phalanx
3.3. Fifth finger-middle phalanxFifth finger-middle phalanx

OssificationOssification
4. Adductor sesamoid of thumb.4. Adductor sesamoid of thumb.

Capping of epiphysisCapping of epiphysis
5. Third finger – distal phalanx.5. Third finger – distal phalanx.
6. Third finger – middle phalanx.6. Third finger – middle phalanx.
7. Fifth finger – middle phalanx.7. Fifth finger – middle phalanx.

Fusion of epiphysis andFusion of epiphysis and
diaphysisdiaphysis
8. Third finger – distal phalanx.8. Third finger – distal phalanx.
9. Third finger – proximal phalanx.9. Third finger – proximal phalanx.
10. Third finger – middle phalanx.10. Third finger – middle phalanx.
11. Radius.11. Radius.

• Accelerating growth velocity period (1–4)Accelerating growth velocity period (1–4)
• High growth velocity period (4–7)High growth velocity period (4–7)
• Decelerating velocity period (7–11)Decelerating velocity period (7–11)

ConclusionConclusion
• SMI occurs at earlier chronological agesSMI occurs at earlier chronological ages
for girls.for girls.
• SMI make it possible to judge an individualSMI make it possible to judge an individual
relative timing of maturation – whether it isrelative timing of maturation – whether it is
early, average or late.early, average or late.
• Comparison of boys and girls onComparison of boys and girls on
maturational time scale shows no sexualmaturational time scale shows no sexual
differences in the percentages ofdifferences in the percentages of
completion of incremental growth at samecompletion of incremental growth at same
SMI levels, regardless of chronologicalSMI levels, regardless of chronological
age.age.

• Early maturer of both sexes exhibitedEarly maturer of both sexes exhibited
almostalmost identical SMI duration values foridentical SMI duration values for
SMI’s 1-5 & 7-11SMI’s 1-5 & 7-11. The only significant. The only significant
difference in SMI duration for early groupdifference in SMI duration for early group
is between SMI 5 & 6. Girls in generalis between SMI 5 & 6. Girls in general
reach the point of peak velocity of growthreach the point of peak velocity of growth
at SMI 5, and boys at SMI 6.at SMI 5, and boys at SMI 6.

• In late maturation groups, considerablyIn late maturation groups, considerably
less correlation is foundless correlation is found between malebetween male
and female groups, although duration ofand female groups, although duration of
time between SMI’s 1-2 and 10-11, attime between SMI’s 1-2 and 10-11, at
beginning and end of adolescent period,beginning and end of adolescent period,
are very similar.are very similar.

• In regard to the comparisons of lateIn regard to the comparisons of late
periods with early periods, the female lateperiods with early periods, the female late
group exhibits significantly longer timegroup exhibits significantly longer time
between SMI periods 4–5, 6–9, and 10–between SMI periods 4–5, 6–9, and 10–
11. The male late group exhibited longer11. The male late group exhibited longer
time periods between SMI 2–4, 9–10, andtime periods between SMI 2–4, 9–10, and
10–11.10–11.

Levels of maturation - FEMALELevels of maturation - FEMALE
Maturation stages : A: early, B and C :Average , D: latewww.indiandentalacademy.comwww.indiandentalacademy.com

Levels of maturation - MALELevels of maturation - MALE
Mean value for total sample
Maturation stages : A: early, B and C :Average , D: latewww.indiandentalacademy.comwww.indiandentalacademy.com

For both sexes, the earlyFor both sexes, the early (level A)(level A) curves remainedcurves remained
within their boundaries or close to the border of level Bwithin their boundaries or close to the border of level B
untiluntil SMI stage 8, at which time the A curve enteredSMI stage 8, at which time the A curve entered
well within the B rangewell within the B range (within one SD of average),(within one SD of average),
approaching the mean values for their respective totalapproaching the mean values for their respective total
samples.samples.
• Those with late maturation (Those with late maturation (level Dlevel D) also exhibited) also exhibited
similarities between the male and female sample, insimilarities between the male and female sample, in
that the curvesthat the curves did not regress toward the total sampledid not regress toward the total sample
mean values until SMI 10mean values until SMI 10,, late in the adolescent periodlate in the adolescent period
for both sexes.for both sexes.
• Those with near-average maturation (Those with near-average maturation (B and CB and C))
maintained a consistency in their maturationalmaintained a consistency in their maturational
progress, not departing outside their respectiveprogress, not departing outside their respective
boundaries.boundaries. Toward the end of the maturation periodToward the end of the maturation period
these two curves regressed even closer to the meanthese two curves regressed even closer to the mean
values.values.

Maturation indications andMaturation indications and
pubertal growth spurtpubertal growth spurt
• Urban Hägg and John TarangerUrban Hägg and John Taranger
did a study in 1982 to investigatedid a study in 1982 to investigate
pubertal growth spurt and dental,pubertal growth spurt and dental,
skeletal and pubertal development.skeletal and pubertal development.
• Sample:212Sample:212
• Examination: birth to adulthoodExamination: birth to adulthood
• Once a yearOnce a year
Am J Orthod: 82: oct 1982Am J Orthod: 82: oct 1982

Method of analysisMethod of analysis
• Adolescent growth:Adolescent growth:
was studied by graphic analysis of thewas studied by graphic analysis of the
unsmoothed incremental curves ofunsmoothed incremental curves of
standing height.standing height.
These curves were based on theThese curves were based on the
annual increments from 3 to 20 years.annual increments from 3 to 20 years.

• Dental development was assessed by dental emergence stagesDental development was assessed by dental emergence stages
(DES). (devised by Bjork and asso.)(DES). (devised by Bjork and asso.)
• Emergence stages:Emergence stages:
• TTeeth anterior to molareeth anterior to molar
Des 1: 1to 7 incisorsDes 1: 1to 7 incisors
Des 2: all incisorsDes 2: all incisors
Des 3: 1 to 11 canine &/or premolarDes 3: 1 to 11 canine &/or premolar
des 4: all canine and premolarsdes 4: all canine and premolars
• Molar teethMolar teeth
Des m1: 1 to 3 1Des m1: 1 to 3 1stst
molarsmolars
Des m2: all 1Des m2: all 1stst
molarsmolars
Des m3:1-3 2Des m3:1-3 2ndnd
molarsmolars
Des m4: all 2Des m4: all 2ndnd
molarsmolars
Des m5: 1-3 3Des m5: 1-3 3rdrd
molarsmolars
Des m6: all 3Des m6: all 3rdrd
molarsmolars

Skeletal developmentSkeletal development
• In the hand and wrist was analyzed from annualIn the hand and wrist was analyzed from annual
radiographs, taken between the ages ofradiographs, taken between the ages of 6 and 186 and 18
yearsyears,,
Assessment of,Assessment of,
• ossification of the ulnar sesamoidossification of the ulnar sesamoid of theof the
metacarpophalangeal joint of the first finger (S)metacarpophalangeal joint of the first finger (S)
• certaincertain specified stages of three epiphysealspecified stages of three epiphyseal
bonesbones (closure of epiphyseal plates):(closure of epiphyseal plates):
1) middle and distal phalanges of the third finger1) middle and distal phalanges of the third finger
(MP3 and DP3)(MP3 and DP3)
2) distal epiphysis of the radius (R).2) distal epiphysis of the radius (R).

• Pubertal development was assessedPubertal development was assessed
from 10 to 18 years by determining thefrom 10 to 18 years by determining the
occurrence ofoccurrence of menarche in girlsmenarche in girls
and the voice change in boys.and the voice change in boys.

3 stages of voice changes were used:3 stages of voice changes were used:
• PPV – prepubertal voice; the pitch of thePPV – prepubertal voice; the pitch of the
voice had not changed noticeably.voice had not changed noticeably.
• PV – pubertal voice; the pitch of the voicePV – pubertal voice; the pitch of the voice
had changed noticeably but the voicehad changed noticeably but the voice
had not yet acquired adulthad not yet acquired adult
characteristics.characteristics.
• MV – male voice; the pitch of the voiceMV – male voice; the pitch of the voice
had acquired adult characteristics.had acquired adult characteristics.

Pubertal growth spurtPubertal growth spurt
The individual unsmoothed incremental curves of height were based on annualThe individual unsmoothed incremental curves of height were based on annual
increments calculated between specified target ages. It should be pointed out thatincrements calculated between specified target ages. It should be pointed out that
height was recorded in millimeters, usually in the morning, by a trained examinerheight was recorded in millimeters, usually in the morning, by a trained examiner
using the stretching-up techniqueusing the stretching-up technique

ResultsResults
• The pubertal growth spurt –The pubertal growth spurt –
ONSET is found by locating the smallest annual incrementONSET is found by locating the smallest annual increment
(A) from which there is continuous increase in growth rate to(A) from which there is continuous increase in growth rate to
PHV.PHV.
• Onset :Onset : 10yr in girls10yr in girls
12.1yr in boys12.1yr in boys
PHV :PHV : 12 yr in girls12 yr in girls
14.1 yr in boys ( 2 yr after ONSET)14.1 yr in boys ( 2 yr after ONSET)
End :End : 14.8 yr in girls14.8 yr in girls
17.1 yr in boys17.1 yr in boys

ResultsResults
• Dental development and pubertalDental development and pubertal
growth spurt - The dental developmentgrowth spurt - The dental development
was more advanced in boys than inwas more advanced in boys than in
girls at all three pubertal growthgirls at all three pubertal growth
events.events.
• The dental emergence stages were notThe dental emergence stages were not
useful as indicators of the pubertaluseful as indicators of the pubertal

ResultsResults
• Skeletal development and the pubertalSkeletal development and the pubertal
growth spurt –growth spurt –
• Skeletal development at ONSET andSkeletal development at ONSET and
PHV was more advanced in girls than inPHV was more advanced in girls than in
boys, whereas at END the skeletalboys, whereas at END the skeletal
development was more advanced indevelopment was more advanced in
boys.boys.

The skeletal stages were useful asThe skeletal stages were useful as
indicators of the pubertal growth spurt.indicators of the pubertal growth spurt.
Skeletal stages:Skeletal stages:
• Sesamoid – it appeared during theSesamoid – it appeared during the
acceleration period of pubertal growthacceleration period of pubertal growth
spurt (ONSET of PHV).spurt (ONSET of PHV).

• Middle third phalanx:Middle third phalanx:
• MP3-FMP3-F - was attained before- was attained before
ONSET by about 40 percent of theONSET by about 40 percent of the
subjects and at PHV by the others.subjects and at PHV by the others.
TheThe epiphysis is as wide asepiphysis is as wide as
metaphysis.metaphysis.
• MP3-FGMP3-FG – epiphysis is as wide as– epiphysis is as wide as
metaphysis and there is distinctmetaphysis and there is distinct
medial and/or lateral border of themedial and/or lateral border of the
epiphysis forming a line ofepiphysis forming a line of
demarcation at right angle to distaldemarcation at right angle to distal
border. This stage is attained by 1yrborder. This stage is attained by 1yr
before or at PHV.before or at PHV.

• MP3-GMP3-G – the sides of the epiphysis– the sides of the epiphysis
have thickened and also caps itshave thickened and also caps its
metaphysis forming a sharp edgemetaphysis forming a sharp edge
distally at one or both sides. Thisdistally at one or both sides. This
stage isstage is attained at or 1 yr after PHV.attained at or 1 yr after PHV.
• MP3-HMP3-H – fusion of epiphysis and– fusion of epiphysis and
metaphysis has begun. It is attainedmetaphysis has begun. It is attained
after PHV but before the END.after PHV but before the END.
• MP3-IMP3-I - fusion of epiphysis andfusion of epiphysis and
metaphysis is complete. It wasmetaphysis is complete. It was
attained before or at END in allattained before or at END in all
subjects.subjects.

Distal third phalanx:Distal third phalanx:
• DP3-IDP3-I – it is attained during the– it is attained during the
deceleration period of the pubertaldeceleration period of the pubertal
growth spurt. The fusion of epiphysis andgrowth spurt. The fusion of epiphysis and
metaphysis is complete.metaphysis is complete.

Radius:Radius:
R-IR-I – it is– it is attained 1 yr before or at theattained 1 yr before or at the
ENDEND. Fusion of the epiphysis. Fusion of the epiphysis
andand metaphysis has begun.metaphysis has begun.
R-IJR-IJ- Fusion almost complete.- Fusion almost complete.
R-JR-J - Fusion of the epiphysis and- Fusion of the epiphysis and
metaphysis is complete.metaphysis is complete.

Pubertal development andPubertal development and
pubertal growth spurtpubertal growth spurt
• Pubertal development (menarche andPubertal development (menarche and
voice change) and pubertal growth eventsvoice change) and pubertal growth events
has a close relationship in both sexes.has a close relationship in both sexes.
• Menarche occurred 1.1yr after peak heightMenarche occurred 1.1yr after peak height
velocity.velocity.
• The pubertal voice was attained 0.2 yrsThe pubertal voice was attained 0.2 yrs
before PHV .before PHV .
• male voice 0.9yrs after PHV.male voice 0.9yrs after PHV.

DiscussionDiscussion
• Reliable indications taken from skeletalReliable indications taken from skeletal
development were found for PHV and END butdevelopment were found for PHV and END but
not for beginning (ONSET) of pubertal growthnot for beginning (ONSET) of pubertal growth
spurt.spurt.
• During theDuring the endend of the prepubertal period theof the prepubertal period the
radiographic changes in the form of bones ofradiographic changes in the form of bones of
hand wrist are smallhand wrist are small. Therefore there is a lack of. Therefore there is a lack of
indications during this period.indications during this period.

According to Björk,According to Björk,
pubertal growth spurt ends with the completepubertal growth spurt ends with the complete
fusion of the third distal phalanx (DP3-I).fusion of the third distal phalanx (DP3-I).
Schouboe reported,Schouboe reported,
DP3-I in some girls coincided with PHV, whichDP3-I in some girls coincided with PHV, which
was also found in this study.was also found in this study.
In girls DP3-I is therefore not anIn girls DP3-I is therefore not an
absolute indicator that PHV has beenabsolute indicator that PHV has been
passed.passed.

conclusionconclusion
• There was a 2-year sex difference in age at the beginning, peak,There was a 2-year sex difference in age at the beginning, peak,
and end of the pubertal growth spurt. The individual variationand end of the pubertal growth spurt. The individual variation
was about 6 years at each growth event in both sexes.was about 6 years at each growth event in both sexes.
• Dental development, assessed by means of dental emergenceDental development, assessed by means of dental emergence
stages, was not useful as an indicator of the pubertal growthstages, was not useful as an indicator of the pubertal growth
spurt.spurt.
• Dental development in relation to the pubertal growth spurt wasDental development in relation to the pubertal growth spurt was
more advanced in boys than in girls, but the individual variationmore advanced in boys than in girls, but the individual variation
was great in both sexes.was great in both sexes.
• The peak and end, but not the beginning, of the pubertal growthThe peak and end, but not the beginning, of the pubertal growth
spurt could be determined by means of indicators taken fromspurt could be determined by means of indicators taken from
the skeletal development of the hand and wrist and the pubertalthe skeletal development of the hand and wrist and the pubertal
development (menarche and voice change), which are suitabledevelopment (menarche and voice change), which are suitable
for use in clinical orthodontics.for use in clinical orthodontics.www.indiandentalacademy.comwww.indiandentalacademy.com

THANK YOUTHANK YOU

• SEM -2SEM -2
• Includes,Includes,
1.1. Cervical VertebraeCervical Vertebrae
2.2. Frontal sinus developmentFrontal sinus development
3.3. Maxillary mid palatal sutureMaxillary mid palatal suture
approximationapproximation
4.4. Canine calcification stagesCanine calcification stages

CERVICAL VERTEBRAECERVICAL VERTEBRAE
– 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.

CERVICALCERVICAL
VERTEBRAEVERTEBRAE
• Vertrebral growth takes place from the cartilagenous layer on theVertrebral growth takes place from the cartilagenous layer on the
superior and inferior surfaces of the vertrebra.superior and inferior surfaces of the vertrebra.
• Secondary ossification on the tips of bifid spinousSecondary ossification on the tips of bifid spinous
processes and transverse processes appear duringprocesses and transverse processes appear during
pubertypuberty ..
• After completion of endochondral ossification, growth of vertrebralAfter completion of endochondral ossification, growth of vertrebral
body takes place by periosteal apposition.body takes place by periosteal apposition.
• Todd and Pyle, Lanier, and Taylor made measurements fromTodd and Pyle, Lanier, and Taylor made measurements from
lateral radiographs of the lower cervical vertrebralateral radiographs of the lower cervical vertrebra..
• Lamparski studied changes in size and shape ofLamparski studied changes in size and shape of
cervical vertrebra to create maturational standards forcervical vertrebra to create maturational standards for
the cervical vertrebrathe cervical vertrebrawww.indiandentalacademy.comwww.indiandentalacademy.com

• 1972 – Lamparski1972 – Lamparski was the 1was the 1stst
person to study cervical vertebrae andperson to study cervical vertebrae and
he found them to be as reliable as handhe found them to be as reliable as hand
wrist film.wrist film.
• He found that cervical vertebraeHe found that cervical vertebrae
indicators were same for males andindicators were same for males and
females, but the females developed thefemales, but the females developed the
changes earlier.changes earlier.

• 1n 1995 – Hassel and Farman modified1n 1995 – Hassel and Farman modified
the Lamparski criteria by using C2, C3,the Lamparski criteria by using C2, C3,
and C4 cervical vertebrae.and C4 cervical vertebrae.

Lamparski methodLamparski method
• Stage 1 –Stage 1 –
The inferior bordersThe inferior borders of the bodies of allof the bodies of all
cervical vertebrae are flat.cervical vertebrae are flat.
The superior bordersThe superior borders are tapered fromare tapered from
posterior to anterior.posterior to anterior.
• Stage 2 – a concavity develops in theStage 2 – a concavity develops in the
inferior border of the second cervicalinferior border of the second cervical
vertebrae. The anterior vertical height ofvertebrae. The anterior vertical height of
body is increase.body is increase.

• Stage 3 – a concavity develops in theStage 3 – a concavity develops in the
inferior border of the 3inferior border of the 3rdrd
vertebrae.vertebrae.
• Stage 4 – a concavity develops in inferiorStage 4 – a concavity develops in inferior
border of 4border of 4thth
vertebrae. Concavities invertebrae. Concavities in
lower border of 5lower border of 5thth
and 6and 6thth
vertebrae arevertebrae are
beginning to form. The bodies of allbeginning to form. The bodies of all
cervical vertebrae arecervical vertebrae are rectangular inrectangular in
shapeshape..

• Stage 5 – concavities are well defined inStage 5 – concavities are well defined in
the lower border of the bodies of all 6the lower border of the bodies of all 6
cervical vertebrae. The bodies are nearlycervical vertebrae. The bodies are nearly
square in shape.square in shape.
• Stage 6 – all concavities have deepened.Stage 6 – all concavities have deepened.
The vertebral bodies are now higher thanThe vertebral bodies are now higher than
they are wide.they are wide.

Brent Hassel, Allan FarmanBrent Hassel, Allan Farman
• Objective of the studyObjective of the study
• ““ create a method ofcreate a method of evaluating biologicalevaluating biological
skeletal maturationskeletal maturation of orthodontic patient withof orthodontic patient with
cephalogram.”cephalogram.”
• Correlation made between vertebrae maturation andCorrelation made between vertebrae maturation and
skeletal maturation of hand and wrist radiographskeletal maturation of hand and wrist radiograph
• Skeletal maturation :Skeletal maturation :
““degree of development of ossification indegree of development of ossification in
bone”.bone”.
• AJODO: Jan 1995AJODO: Jan 1995www.indiandentalacademy.comwww.indiandentalacademy.com

Material and methodMaterial and method
• Sample of 10 group of 10 male and 10 femaleSample of 10 group of 10 male and 10 female
(220 subject)(220 subject)
from 8 to 18 yrsfrom 8 to 18 yrs

RadiographRadiograph
1.1. hand and wristhand and wrist
2.2. lateral cephalogramlateral cephalogram

Cervical vertebrae maturationCervical vertebrae maturation
indicators using C3 as guide.indicators using C3 as guide.

Six distinct stages of CVM can beSix distinct stages of CVM can be
related to the SMI developed byrelated to the SMI developed by
FishmanFishman
1.1. Initiation (SMI 1 and 2)Initiation (SMI 1 and 2)
2.2. Acceleration (SMI 3 and 4)Acceleration (SMI 3 and 4)
3.3. Transition (SMI 5 and 6)Transition (SMI 5 and 6)
4.4. Deceleration (SMI 7 and 8)Deceleration (SMI 7 and 8)
5.5. Maturation (SMI 9 and 10)Maturation (SMI 9 and 10)
6.6. Completion (SMI 11).Completion (SMI 11).

• Category 1 (Category 1 (InitiationInitiation) –) –
• At this stage adolescent growth was justAt this stage adolescent growth was just
beginning and 80% to 100% of the growth wasbeginning and 80% to 100% of the growth was
expected.expected.
• Inferior borders of C2, C3 and C4 were flat atInferior borders of C2, C3 and C4 were flat at
this stage.this stage.
• Vertebrae are wedge shaped,Vertebrae are wedge shaped,
• Superior vertebral border were tapered fromSuperior vertebral border were tapered from
posterior to anterior.posterior to anterior.
Six stages in vertebralSix stages in vertebral
developmentdevelopment

CVMI 1CVMI 1

• Category 2 (Category 2 (AccelerationAcceleration) –) –
• growth acceleration was beginning at thisgrowth acceleration was beginning at this
stage with 65% to 85% of adolescent growthstage with 65% to 85% of adolescent growth
expected.expected.
• Concavities were developing in the inferiorConcavities were developing in the inferior
border of C2, C3.border of C2, C3.
• The inferior border of C4 was flat.The inferior border of C4 was flat.
• The bodies of C3 and C4 were nearlyThe bodies of C3 and C4 were nearlywww.indiandentalacademy.comwww.indiandentalacademy.com

CVMI 2CVMI 2

• Category 3 (Category 3 (TransitionTransition) –) –
• Adolescent growth was still accelerating at thisAdolescent growth was still accelerating at this
stage towards peak height velocitystage towards peak height velocity with 25% towith 25% to
65% of adolescent growth expected.65% of adolescent growth expected.
• Distinct concavities were seen in theDistinct concavities were seen in the
inferior borders of C2 and C3inferior borders of C2 and C3 ..
• Concavity was beginning to develop in theConcavity was beginning to develop in the
inferior border of C4.inferior border of C4.
• The bodies of C3 and C4 were rectangular inThe bodies of C3 and C4 were rectangular in
shape.shape.

CVMI 3CVMI 3

• Category 4 (Category 4 (DecelerationDeceleration) –) –
• adolescent growth began to decelerateadolescent growth began to decelerate
dramatically at this stage with 10% todramatically at this stage with 10% to
25% of adolescent growth expected.25% of adolescent growth expected.
• Distinct concavities were seen in theDistinct concavities were seen in the
inferior borders of C2, C3 andC4.inferior borders of C2, C3 andC4.
• The vertebral bodies of C3 and C4 wereThe vertebral bodies of C3 and C4 were
becoming morebecoming more square in shapesquare in shape..

CVMI 4CVMI 4
C3,c4 (square)

• Category 5 (Category 5 (MaturationMaturation) –) –
• Final maturation of the vertebrae tookFinal maturation of the vertebrae took
place during this stage, with 5% to 10%place during this stage, with 5% to 10%
of adolescent growth expected.of adolescent growth expected.
• More accentuated concavities werewere
seen in the inferior borders of C2, C3seen in the inferior borders of C2, C3
and C4.and C4.
• The bodies of C3 and C4 were nearlyThe bodies of C3 and C4 were nearly
square to square in shape.square to square in shape.

CVMI 5CVMI 5

• Category 6 (Category 6 (CompletionCompletion) –) –
• growth was considered to be completegrowth was considered to be complete
at this stage.at this stage.
• Deep concavities were seen in theDeep concavities were seen in the
inferior borders of C2, C3 and C4.inferior borders of C2, C3 and C4.
• The bodies of C3 and C4 were squareThe bodies of C3 and C4 were square
or wereor were greater in vertical dimensiongreater in vertical dimension
than in horizontal dimension.than in horizontal dimension.www.indiandentalacademy.comwww.indiandentalacademy.com

CVMI 6CVMI 6
Square c3 and c4 vertebrae

• 1998 - PATRICIA1998 - PATRICIA GARCÍA-GARCÍA-
FERNANDEZ,FERNANDEZ,
• HILDA TORRE,HILDA TORRE,
• LUIS FLORES,LUIS FLORES,
• JESUS REAJESUS REA..
• To determine whether the maturationTo determine whether the maturation
of cervical vertebrae would correlateof cervical vertebrae would correlate
with the maturation indicated by hand-with the maturation indicated by hand-
wrist x-rays in a Mexican population.wrist x-rays in a Mexican population.
JCO:35:4:1998JCO:35:4:1998

Six distinct stages of growth canSix distinct stages of growth can
be related to the SMI developedbe related to the SMI developed
by Fishmanby Fishman
1.1. Initiation (SMI 1 and 2)Initiation (SMI 1 and 2)
2.2. Acceleration (SMI 3 and 4)Acceleration (SMI 3 and 4)
3.3. Transition (SMI 5 and 6)Transition (SMI 5 and 6)
4.4. Deceleration (SMI 7 and 8)Deceleration (SMI 7 and 8)
5.5. Maturation (SMI 9 and 10)Maturation (SMI 9 and 10)
6.6. Completion (SMI 11).Completion (SMI 11).

• PalomaPaloma San RomanSan Roman, Juan Carlos, Juan Carlos
Palma, M DoloresPalma, M Dolores OteoOteo andand EstherEsther
NevadoNevado::
• AIM :AIM :
• study to determine morphologicalstudy to determine morphological
changes seen in cervical vertebrae arechanges seen in cervical vertebrae are
as useful to determine growth stagesas useful to determine growth stages
as maturation stages assessed onas maturation stages assessed on
hand and wrist radiograph.hand and wrist radiograph.
EJO (24) June2002EJO (24) June2002

• Study consisting ofStudy consisting of 958 caucasian958 caucasian
subjectssubjects who attended orthodonticwho attended orthodontic
department betweendepartment between 1980 and 1996.1980 and 1996.
• 3 parameters to Assess Skeletal3 parameters to Assess Skeletal
MaturationMaturation..
• Anatomical changes observed in,Anatomical changes observed in,
1.1. concavity of lower borderconcavity of lower border
2.2. heightheight
3.3. shape of vertebral bodiesshape of vertebral bodies

Concavity of lower border –Concavity of lower border –
6 stages6 stages
1.1. All vertebrae have flat lower border.All vertebrae have flat lower border.
2.2. Concavity – C2 lower border.Concavity – C2 lower border.
3.3. Concavity – C3 lower border.Concavity – C3 lower border.
4.4. C2 and C3 concavity increases andC2 and C3 concavity increases and
concavity present in C4, C5 and C6.concavity present in C4, C5 and C6.
5.5. Concavity increases in all vertebrae.Concavity increases in all vertebrae.
6.6. Deep concavity in all vertebrae andDeep concavity in all vertebrae and
inferior angles are rounded.inferior angles are rounded.

Vertebral body heightVertebral body height
Calculated at middle of C3Calculated at middle of C3
and C4 body. Width alsoand C4 body. Width also
calculated at the middle.calculated at the middle.
4 stages-4 stages-
• Height < 80% width.Height < 80% width.
• Height between 80% andHeight between 80% and
99% of width.99% of width.
• Height = width.Height = width.
• Height > width.Height > width.

Shape of vertebral bodiesShape of vertebral bodies
Calculated at C3 and C4.Calculated at C3 and C4.
6 stages-6 stages-
1.1. Upper border tapered from posterior to anteriorUpper border tapered from posterior to anterior
((wedge shapedwedge shaped).).
2.2. Wedge shaped C3, nearlyWedge shaped C3, nearly rectangularrectangular C4,C4,
absence of superio-anterior angles.absence of superio-anterior angles.
3.3. Rectangular shaped bodies.Rectangular shaped bodies.
4.4. NearlyNearly squared bodies.squared bodies.
5.5. Squared bodies.Squared bodies.
6.6. Rectangular bodies with height greater thanRectangular bodies with height greater than
width.width. www.indiandentalacademy.comwww.indiandentalacademy.com

Cervical Vertebral MaturationCervical Vertebral Maturation
(CVM) Method for the Assessment(CVM) Method for the Assessment
of Mandibular Growthof Mandibular Growth
• Greatest effects of functional appliancesGreatest effects of functional appliances
take place when the peak in mandibulartake place when the peak in mandibular
growth is included in treatment period.growth is included in treatment period.
• Tiziano Baccetti, LorenzoTiziano Baccetti, Lorenzo Franchi,Franchi,
James A.James A. McNamara Jr.McNamara Jr.
Angle OrthodAngle Orthod 2002;72:316–323.2002;72:316–323.

• To provide a new version of the Cervical
Vertebral Maturation (CVM) method for the
detection of the peak in mandibular growth
based on the analysis of the second through
fourth cervical vertebrae in a single
cephalogram. (c2-c4)
• The morphology of the bodies of the second
(odontoid process, C2), third (C3), and fourth
(C4) cervical vertebrae were analyzed in six
consecutive cephalometric observations.
AIM OF THE STUDY

Components of studyComponents of study
• C2, C3 andC4.C2, C3 andC4.
• 706 subjects.706 subjects.
• Co-Gn = total mandibular length.Co-Gn = total mandibular length.
• Maximum increment between twoMaximum increment between two
consecutive cephalograms definesconsecutive cephalograms defines peak inpeak in
mandibular growth at puberty.mandibular growth at puberty.
• Six consecutive cephalograms.Six consecutive cephalograms.

• Observations for each subject consisted of
two consecutive cephalograms comprising
the interval of maximum mandibular
growth (as assessed by means of the
maximum increment in total mandibular
length, Co-Gn), together with two earlier
consecutive cephalogram and two later
consecutive cephalograms

• Lambarski’s CVM I and CVM II areLambarski’s CVM I and CVM II are
merged (CVMS I) because there is nomerged (CVMS I) because there is no
distinct demarcation is present betweendistinct demarcation is present between
stage I and II.stage I and II. And form CVMS IAnd form CVMS I
• CVMS = cervical vertebrae maturationCVMS = cervical vertebrae maturation
stage.stage.
• 5 maturational stages.5 maturational stages.

CVMS ICVMS I
• Lower border of C2, C3 and C4 isLower border of C2, C3 and C4 is
flat.flat.
• C2 may present slight concavity.C2 may present slight concavity.
• Bodies of C3 and C4 rBodies of C3 and C4 r
trapezoidal.trapezoidal.
• Peak mandibular growth willPeak mandibular growth will
occur not earlier than 1yr afteroccur not earlier than 1yr after
this stage.this stage.

CVMS IICVMS II
• Concavities present at the lowerConcavities present at the lower
border of C2 and C3.border of C2 and C3.
• Bodies of C3 and C4 – eitherBodies of C3 and C4 – either
trapezoid ortrapezoid or rectangular horizontal inrectangular horizontal in
shape.shape.
• Peak in mandibular growth will occurPeak in mandibular growth will occur
within 1yr after this stage.within 1yr after this stage.
• The appearance of a visible concavity
at the lower border of the third cervical
vertebra is accounts for the
identification of the stage immediately
preceding the peak in mandibular
growth.

CVMS IIICVMS III
• Concavities at the lowerConcavities at the lower
border of C2, C3 and C4border of C2, C3 and C4
are present.are present.
• Bodies of C3 and C4 –Bodies of C3 and C4 –
rectangular horizontal inin
shape.shape.
• Peak in mandibular growthPeak in mandibular growth
has occurred within twohas occurred within two
years before this stage.years before this stage.

CVMS IVCVMS IV
• Concavities at the lowerConcavities at the lower
border of C2, C3 and C4 areborder of C2, C3 and C4 are
present.present.
• At least one of the bodies of C3At least one of the bodies of C3
and C4 isand C4 is squared in shape.in shape.
• The peak in mandibular growthThe peak in mandibular growth
has occurred not later than onehas occurred not later than one
year before this stage.year before this stage.

CVMS VCVMS V
• The concavities at the lower bordersThe concavities at the lower borders
of C2, C3, and C4 still are evident.of C2, C3, and C4 still are evident.
• At least one of the bodies of C3 andAt least one of the bodies of C3 and
C4 isC4 is rectangular verticalrectangular vertical in shape.in shape.
• The peak in mandibular growth hasThe peak in mandibular growth has
occurred not later than two yearsoccurred not later than two years
before this stage.before this stage. (means two years(means two years
after peak )after peak )

discussiondiscussion
• Cervical Vertebral Maturation can be useful as
a maturational index to detect the optimal time
to start treatment of mandibular deficiencies by
means of functional jaw orthopedics.
• It has been demonstrated that the effectiveness
of functional treatment of Class II skeletal
disharmony strongly depends on the biological
responsiveness of the condylar cartilage, which
in turn is related to the growth rate of the
mandible

DiscussionDiscussion
• CVMS I – wait for 1 yr.CVMS I – wait for 1 yr.
• CVMS II – ideal time to begin treatment,CVMS II – ideal time to begin treatment,
because peak in mandibular growth occur withinbecause peak in mandibular growth occur within
1 yr after this stage1 yr after this stage..
• Total mandibular length exhibited an average
increase of 5.4 mm in the year following CVMS II, a
significantly greater increment when compared both
to the growth interval from CVMS I to CVMS II (about
2.4 mm) and to following between-stage intervals
(1.6 mm and 2.1 mm for the intervals from CVMS III
to CVMS IV and from CVMS IV to CVMS V,
respectively)

• The new CVM method is comprised of five
maturational stages with the peak in mandibular
growth occurring between CVMS II and CVMS
III.
• The pubertal peak has not been reached without
the attainment of both CVMS I and CVMS II.
• The new method is particularly useful when
skeletal maturity has to be appraised on a single
cephalogram and only the second through fourth
cervical vertebrae are visible.

Mid palatal suture region as anMid palatal suture region as an
indicator of maturityindicator of maturity
• Revelo and FishmanRevelo and Fishman inin 19941994
evaluated the ossification pattern of theevaluated the ossification pattern of the
mid palatal suture.mid palatal suture.
• purpose of this study was to determinepurpose of this study was to determine
whether a positive correlation existswhether a positive correlation exists
between adolescent maturationalbetween adolescent maturational
development and the approximation ofdevelopment and the approximation of
the midpalatal suturethe midpalatal suture
Revelo, Fishman AJO: 105:mar 1994.Revelo, Fishman AJO: 105:mar 1994.

Methods and MaterialsMethods and Materials
• sample of 84 patientssample of 84 patients
• 8 to 18 years of age8 to 18 years of age
• X-RAY:X-RAY:
1.1. Standardized Occlusal radiographsStandardized Occlusal radiographs
2.2. hand-wrist radiographshand-wrist radiographs
• Stages of ossification of the midpalatal
suture were compared with Fishman's
standards of skeletal maturation
indicators.

Key landmarks and planesKey landmarks and planes
Point APoint A – most anterior– most anterior
point on premaxilla.point on premaxilla.
Point BPoint B – most posterior– most posterior
point on the posterior wall ofpoint on the posterior wall of
the incisive foramen.the incisive foramen.
Point PPoint P – point tangent to a– point tangent to a
line connecting the posteriorline connecting the posterior
walls of the greater palatinewalls of the greater palatine
foramen.foramen.

Key landmarks and planesKey landmarks and planes
A-P – total dimension ofA-P – total dimension of
the suture.the suture.
A-B – anteriorA-B – anterior
dimension of the suture.dimension of the suture.
B-P – posteriorB-P – posterior
dimension of the suture.dimension of the suture.

ResultsResults
• Significant. correlation between maturationalSignificant. correlation between maturational
development and beginning of ossification ofdevelopment and beginning of ossification of
mid palatal suturemid palatal suture
• Before SMI 4Before SMI 4 (( i.e. before ossification ofi.e. before ossification of
adductor sesamoid)adductor sesamoid)
VeryVery little or no midpalatal approximationlittle or no midpalatal approximation
exists.exists.
Suture is onlySuture is only 8% fused at SMI 3.8% fused at SMI 3.
Anterior portion of suture is wide open.Anterior portion of suture is wide open.

ResultsResults
• SMI 4-7SMI 4-7 (i.e.(i.e. ossification of adductorossification of adductor
sesamoid, capping with distal and middlesesamoid, capping with distal and middle
phalanx of 3phalanx of 3rdrd
finger & fifth finger )finger & fifth finger )
osseous interdigitationosseous interdigitation is evidentis evident
with approximation in some areas.with approximation in some areas.
This period occurs during theThis period occurs during the pubertalpubertal

ResultsResults
• After SMI 8After SMI 8 (i.e. fusion of distal phalanx of 3(i.e. fusion of distal phalanx of 3rdrd
finger)finger)
The suture demonstrates a marked increase inThe suture demonstrates a marked increase in
rate of approximation.rate of approximation.
Increments to approximately 25%Increments to approximately 25%
approximation at maturational age SMIapproximation at maturational age SMI
9.9.
• AtAt SMI 11SMI 11 (i.e. fusion of radius )(i.e. fusion of radius )
 50% of total midpalatal suture is50% of total midpalatal suture is
approximatedapproximated..
 High percentage of approximation occursHigh percentage of approximation occurs
posteriorly.posteriorly.

• No difference in patterns of approximationNo difference in patterns of approximation
between males and females.between males and females.
• Thus, best time to use orthopedic force forThus, best time to use orthopedic force for
expansion isexpansion is before SMI 9 as percentagebefore SMI 9 as percentage
of approximation is less.of approximation is less.
• Ideal time isIdeal time is SMI 1 to 4 as less orthopedicSMI 1 to 4 as less orthopedic
force is required.force is required.

Frontal sinus development as anFrontal sinus development as an
indicator for somatic maturation atindicator for somatic maturation at
pubertypuberty
• Sabine RufSabine Ruf andand Hans Pancherz-Hans Pancherz-
19961996..
• 2 lateral head2 lateral head films from each subjectfilms from each subject
were analyzed onwere analyzed on 1 or 2 yrs interval basis1 or 2 yrs interval basis..
• Lateral radiographs were traced with theLateral radiographs were traced with the
SN line.SN line.
AJO 110: Nov 1996.AJO 110: Nov 1996.

AIM OF STUDYAIM OF STUDY
• predicting the stage of somatic maturitypredicting the stage of somatic maturity
by analyzing frontal sinus growth wasby analyzing frontal sinus growth was
evaluated.evaluated.
• The study was performed onThe study was performed on 53 adolescent53 adolescent
boysboys, and the frontal sinus size development, and the frontal sinus size development
was assessed onwas assessed on lateral head films.lateral head films.
• The accuracy of the prediction procedure wasThe accuracy of the prediction procedure was
tested by comparing the prediction stage withtested by comparing the prediction stage with
the longitudinal growth data for body height ofthe longitudinal growth data for body height of
the subjectsthe subjects

LandmarksLandmarks
• ShSh – highest point on– highest point on
peripheral border of frontalperipheral border of frontal
sinus.sinus.
• SlSl – lowest point on– lowest point on
peripheral border of frontalperipheral border of frontal
sinus.sinus.
• Perpendicular to thePerpendicular to the
interconnecting line (interconnecting line (Sh-Sh-
SlSl), the), the maximum widthmaximum width
of the frontal sinus wasof the frontal sinus was
assessed.assessed.
Sh
Sl

• Average yearly body height growthAverage yearly body height growth
velocity (mm/yr) was calculated.velocity (mm/yr) was calculated.
• BpBp (body height peak) = maximum body(body height peak) = maximum body
growth velocity at pubertygrowth velocity at puberty
• The body height growth data were usedThe body height growth data were used
onlyonly to test the accuracy of the predictionto test the accuracy of the prediction
of pubertal stageof pubertal stage as assessed fromas assessed from
frontal sinus development.frontal sinus development.
Body height VelocityBody height Velocity

Somatic maturity predictionSomatic maturity prediction
• Frontal sinus growth velocity at puberty isFrontal sinus growth velocity at puberty is
closely related to body height growthclosely related to body height growth
velocity.velocity.
• Well defined pubertal peak (Sp), onWell defined pubertal peak (Sp), on
average, occurs 1.4 years after theaverage, occurs 1.4 years after the
pubertal body height peak (Bp).pubertal body height peak (Bp).
• Males – average age at frontalMales – average age at frontal
sinus peak is 15.1 years.sinus peak is 15.1 years.

(Difference is 1.4 yrs)(Difference is 1.4 yrs)

Somatic maturity predictionSomatic maturity prediction
• Peak growth velocity in the frontal sinus ofPeak growth velocity in the frontal sinus of
atleast 1.3mm/yr is attained in 1 yr observation.atleast 1.3mm/yr is attained in 1 yr observation.
• In 2 yr observation interval, a peak velocity inIn 2 yr observation interval, a peak velocity in
the frontal sinus of atleast 1.2mm/yr is attained.the frontal sinus of atleast 1.2mm/yr is attained.
• These specific frontal sinus growth velocitiesThese specific frontal sinus growth velocities
(1.3 mm/yr. for the 1-year interval and 1.2(1.3 mm/yr. for the 1-year interval and 1.2
mm/yr. for the 2-year interval) were assigned asmm/yr. for the 2-year interval) were assigned as
threshold values T1 and T2, respectively.threshold values T1 and T2, respectively.

Prediction procedurePrediction procedure
• Frontal sinus growth velocity (Frontal sinus growth velocity (SvSv) in each) in each
person was compared with T1 andperson was compared with T1 and
T2(threshold) values.T2(threshold) values.
• IfIf SvSv is as high as or higher than T valueis as high as or higher than T value
(T1 or T2), it may be expected that the(T1 or T2), it may be expected that the
frontal sinus peak was reached duringfrontal sinus peak was reached during
prediction interval.prediction interval.

Prediction procedurePrediction procedure
• If theIf the SvSv is lower than the T-value, itis lower than the T-value, it
cannot be said whether the subject is precannot be said whether the subject is pre
peak or post peak in frontal sinus growth.peak or post peak in frontal sinus growth.
• May be related to chronologic age (frontalMay be related to chronologic age (frontal
sinus peak at 15.1 years).sinus peak at 15.1 years).

DISCUSSIONDISCUSSION
• disadvantagedisadvantage
1.1. it requiresit requires two lateral head films taken at leasttwo lateral head films taken at least
at a 1-year intervalat a 1-year interval. Two radiographs are, however,. Two radiographs are, however,
seldom available at the beginning of orthodonticseldom available at the beginning of orthodontic
treatment .treatment .
2.2. If the only prediction was whether the pubertal growthIf the only prediction was whether the pubertal growth
peak in height has been passed ,the precision of thepeak in height has been passed ,the precision of the
method was rather highmethod was rather high (approximately 90%).(approximately 90%).
However, if the age of body height peak was to beHowever, if the age of body height peak was to be
predicted, the method accuracy was lowerpredicted, the method accuracy was lower
(approximately 55%)(approximately 55%)

Canine calcificationCanine calcification
• Relationship between mandibularRelationship between mandibular
canine calcification stages and skeletalcanine calcification stages and skeletal
maturity.maturity.
Sandra Cortinho, Peter H.Sandra Cortinho, Peter H.
BuschangBuschang..
AJODO:104:sept 1993.AJODO:104:sept 1993.www.indiandentalacademy.comwww.indiandentalacademy.com

• Sample:Sample:
200 boys and 215 girls200 boys and 215 girls
• development of the mandibular canine wasdevelopment of the mandibular canine was
assessed according toassessed according to Demirjian's 9Demirjian's 9
stages of dental calcification.stages of dental calcification.
• Skeletal ageSkeletal age was determined from hand-was determined from hand-
wrist radiographs according to methodswrist radiographs according to methods
described bydescribed by
1.1. Greulich and PyleGreulich and Pyle ..
2.2. Tanner and Whitehouse method.Tanner and Whitehouse method.

Canine development stageCanine development stage
• Stage D:Stage D:

Canine development stageCanine development stage
Stage D:Stage D:
• Crown formation is complete down toCrown formation is complete down to
C.E. junction.C.E. junction.
• Superior border of the pulp chamber inSuperior border of the pulp chamber in
the uniradicular teeth has a definitethe uniradicular teeth has a definite
curved form being concave towardscurved form being concave towards
cervical region.cervical region.
• The projection of pulp horns, if presentThe projection of pulp horns, if present
gives outline shaped like an umbrellagives outline shaped like an umbrella
top.top.
• Beginning of root formation is seen inBeginning of root formation is seen in
the form of a spicule.the form of a spicule.
CE
JunctioJunctio
nn

Stage EStage E

Stage E:Stage E:
• The walls of the pulpThe walls of the pulp
chamber now form straightchamber now form straight
lines whose continuity islines whose continuity is
broken by the presence ofbroken by the presence of
the pulp horn, which isthe pulp horn, which is
larger than in the previouslarger than in the previous
stage.stage.
• The root length is less thanThe root length is less than
the crown height.the crown height.
Pulp horn

Stage FStage F

Stage F:Stage F:
• The walls of the pulpThe walls of the pulp
chamber now form a more orchamber now form a more or
less anless an isoscelesisosceles
triangletriangle. The apex ends in. The apex ends in
a funnel shape.a funnel shape.
• The root length is equal to orThe root length is equal to or
greater than the crowngreater than the crown
height.height.
IsoscelesIsosceles
triangletriangle

Stage GStage G

Stage G:Stage G:
• The walls of the root canalThe walls of the root canal
are now parallel and itsare now parallel and its
apical end is still partiallyapical end is still partially
open.open.
Parallel wallsParallel walls

Stage HStage H

Stage H:Stage H:
• The periodontal apical end ofThe periodontal apical end of
the root canal is completelythe root canal is completely
closed.closed.
• membrane has a uniform widthmembrane has a uniform width
around the root and the apex.around the root and the apex.

ResultsResults
• TheThe initiation of spurt is indicated by canineinitiation of spurt is indicated by canine
stagestage FF (i.e. the epiphysis of the 3(i.e. the epiphysis of the 3rdrd
and 5and 5thth
middlemiddle
phalanges are equal in length to their diaphysis.)phalanges are equal in length to their diaphysis.)
• No appearance of adductor sesamoid.No appearance of adductor sesamoid.
• The mean skeletal age for the presence of the adductorThe mean skeletal age for the presence of the adductor
sesamoid in the girls and the boys are 12.2 years andsesamoid in the girls and the boys are 12.2 years and
13.2 years, respectively.13.2 years, respectively.

• In stage G,In stage G, most show the adductor sesamoid.most show the adductor sesamoid.
• Capping of the diaphysis of the middle and distalCapping of the diaphysis of the middle and distal
phalanges of the third finger, and capping of the proximalphalanges of the third finger, and capping of the proximal
phalanx of the fifth finger.phalanx of the fifth finger.
• Stage GStage G coincides with the eruption of the canine intocoincides with the eruption of the canine into
the oral cavity, occurs approximatelythe oral cavity, occurs approximately 1 year before the1 year before the
PHV in boys, but only 5 months before the PHVPHV in boys, but only 5 months before the PHV
in girls.in girls.
• This may reflect hormonal changes which accompanyThis may reflect hormonal changes which accompany
puberty.puberty. www.indiandentalacademy.comwww.indiandentalacademy.com

• stage Hstage H, indicating apical closure, is, indicating apical closure, is
generally associated with fusion of thegenerally associated with fusion of the
epiphyses to their respective diaphysis.epiphyses to their respective diaphysis.

• stage F indicates ONSET of puberty.stage F indicates ONSET of puberty.
• Stage G indicates peak height velocityStage G indicates peak height velocity
(PHV).(PHV).
• The intermediate stage between stage F andThe intermediate stage between stage F and
G should be used to identify the early stagesG should be used to identify the early stages
of the pubertal growth spurt.of the pubertal growth spurt.
• Canine development cannot or should not beCanine development cannot or should not be
used as a sole criteria to predict developmentused as a sole criteria to predict development
landmarks.landmarks.

Symphysis morphology as a predictor ofSymphysis morphology as a predictor of
direction of mandibular growthdirection of mandibular growth
• AJODOAJODO
• Volume 1994 Jul (60 - 69): SymphysisVolume 1994 Jul (60 - 69): Symphysis
morphology as a predictor of direction ofmorphology as a predictor of direction of
mandibular growth –mandibular growth –
• Aki, Currier, and NandaAki, Currier, and Nanda

Determination of Height and DepthDetermination of Height and Depth
• A line tangent to point B was used as the long
axis of the symphysis, and a grid was formed
with the lines of the grid parallel and
perpendicular to the constructed tangent line.
• The superior limit of the symphysis was taken at
point B with the inferior, anterior, and posterior
limits taken at the most inferior, anterior, and
posterior borders of the symphysis outline,
respectively

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