Skeletal Maturity Indicators Guide

THE SKELETAL
MATURITY
INDICATORS
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

1

INTRODUCTION……...


2

The identification of skeletal maturation
levels provides a very useful means of
identifying specific points along the
progressive path of adolescent growth.
It is analogous to mileage signs posted
along a highway between two cities.
This provides a new dimension for
evaluating general and individual growth,
including facial growth

3

Sexual maturation characteristics, chronological
age, dental development, height, weight, and
skeletal development are some of the common
means that have been used to identify stages of
growth.
Determination of maturation and subsequent
evaluation of growth potential during
preadolescence or adolescence is extremely
important. With many orthodontic patients,
pubertal growth needs to be factored into the
diagnostic equation.

4

The chronological age offers little insight in
determining the developmental stage or somatic
maturity of a person. Thus the maturity
indicators provide an objective diagnostic
evaluation of stage of maturity in an individual.
The basis for skeletal age assessment by
radiographs is that the different ossification
centers appear and mature at different times.
The order , rate , time of appearance and
progress of ossification in the various
ossification centers occurs in a predictable
sequence.

5

HISTORY/BACKGROUND…..


6

After Roentgen demonstrated his radiographic
discovery in 1895, Roland, in 1896, introduced
the idea of using the comparative size and shape
of the radiographic shadows of growing bones
as indicators of rate of growth and maturity.
In the early 1900s, Pryor, Rotch, and
Crampton began tabulating indicators of
maturity on sequential radiographs of the
growing hand and wrist.
In 1928.Hellman published his observations on
the ossification of epiphysial cartilages of the
hand

7

In 1935 Todd compiled hand-wrist data that
was further elaborated on by Greulich and
Pyle in atlas form
In 1936 Flory, indicated that the beginning
of calcification of the carpal sesamoid
(adductor sesamoid) was a good guide to
determining the period immediately before
puberty.
The appearance of the adductor sesamoid
has been highly correlated to peak height
velocity and the start of the adolescent
growth spurt.

8

Most authors agree that peak height velocity
follows adductor sesamoid appearance by
approximately 1 year.
Fishman developed a system of hand-wrist
skeletal maturation indicators (SMIs) using
four stages of bone maturation at six
anatomic sites on the hand and the wrist.
Hagg and Taranger created a method using
the hand-wrist radiograph to correlate
certain maturity indicators to the pubertal
growth spurt.

9

Hassel and Farman developed a system
of skeletal maturation determination using
the cervical vertebrae.
The shapes of the cervical vertebrae were
seen to differ at each level of skeletal
development, which provided a means to
determine the skeletal maturity of a person
and thereby determine whether the
possibility of potential growth existed

10

FISHMAN’S SKELETAL
MATURITY INDICATORS….


11

A system of skeletal maturation was
proposed by Leonord S .Fishman in
1982. This system of evaluating hand wrist
radiographs uses only four stages of bone
maturation, all found at six anatomical
sites located on the thumb, third finger and
radius.
Eleven discrete adolescent skeletal
maturational indicators, covering the entire
period of adolescent development, are
found on these six sites.

12


13

The sequence of the four ossification
stages progresses through epiphyseal
widening on the selected phalanges,
the ossification of the adductor
sesamoid of the thumb, the capping of
the selected epiphyses over their
diaphyses.
The sequence of eruption of the eleven
indicators is exceptionally stable

14


15

Widening of the epiphyses relative to its
diaphyses is a progressive process.
The epiphyses first appears as a small
center of ossification centrally located in
the diaphyses.
When it has developed laterally to the
width of the diaphyses, it is considered
applicable as an SMI in this system

16

Capping occurs in the transition between
initial widening and fusion between
epiphyses and diaphyses.
It is the stage in which the rounded lateral
margins of the epiphyses begin to flatten
and point towards the diaphyses, with an
acute angle on the side facing the
diaphyses.
The time of first appearance of this
capping is applicable as SMI.

17

Fusion between the epiphyses and
diaphyses follows capping it also
begins centrally and progresses
laterally, until the two formerly
separate bones become one.
The time of completion of this fusion,
with a smooth continuity of the surface
at the junction area, is applicable as an
SMI..

18

Ossification of the adductor sesamoid of the
thumb first appears as small, relatively round
center of ossification medial to the junction
of the epiphyses and diaphyses of the
proximal phalanx.
It then becomes progressively larger and
more dense. It is the first observation of the
existence of this bone that is considered
applicable as an SMI. This occurs after the
SMI’S based on epiphyseal widening, but
before those based on capping

19

The eleven skeletal maturity indicators are as
follows:-Epiphysis as wide as diaphysis
1. Third finger-proximal phalanx
2.

Third finger-middle phalanx

3.

Fifth finger-middle phalanx Ossification

4.

Adductor sesamoid of thumb

20

Capping of epiphysis
5. Third finger-distal phalanx
6. Third finger-middle phalanx
7. Fifth finger-middle phalanx
Fusion of epiphysis and diaphysis
8. Third finger-distal phalanx
9. Third finger-proximal phalanx
10. Third finger-middle phalanx
11. Radius

21


22


23

A longitudinal study was carried out
and an average age standards for eleven
SMI’s were established and the values
for each skeletal maturational age were
tabulated. Earlier age of maturational
development for females was seen


24


25


26


27


28


29

Both maxilla and mandible achieved their
maximum growth rate later than the statural
height.
Statural height demonstrated a greater percentage
of completed growth than the facial
measurements in the middle and the late periods
of adolescent growth.
Very close similarities were found between
maxillry and mandibular patterns of relative
growth rate, but the maxilla showed more growth
completed than the mandible until the final stage,
30
when the mandible tended to catch up.

Maturation assesment by
Hagg and Taranger…..

(AJO-1982)

31

Every skeletal and muscular dimension seems
to be involved in the pubertal growth spurt.
The pubertal growth spurt is considered to be
an advantageous period for certain types of
orthodontic treatment and should be taken
into account in connection with orthodontic
treatment planning.
Because of the wide individual variation in
the timing of the pubertal growth spurt,
chronologic age cannot be used in the
evaluation of pubertal growth.

32

THE PUBERTAL GROWTH SPURT


33

ONSET is found by locating the smallest annual
increment (A) from which there is a continuous
increase in growth rate to PHV.
The curve is then followed toward PHV until the
growth rate has accelerated.
ONSET will be indicated by the annual
increment which is next below or coincides with
this growth rate.
Peak height velocity (PHV) is the greatest
annual increment during puberty.
The end of the spurt (END) is the first annual
increment after PHV
34

Skeletal development in the hand and wrist is
analyzed from annual radiographs, taken
between the ages of 6 and 18 years, by
assessment of the ossification of the ulnar
sesamoid of the metacarpophalangeal joint of the
first finger (S) and
certain specified stages of three epiphyseal
bones (closure of epiphyseal plates): the middle
and distal phalanges of the third finger (MP3 and
DP3) and the distal epiphysis of the radius (R).

35


36

The ulnar sesamoid (S) of the
metacarpophalangeal joint of the first
finger before and after ossifying.
.

S was usually attained during the
acceleration period of the pubertal growth
spurt (ONSET-PHV).


37

The distal phalanx of the third finger
(DP3) before and after
Stage l:
This stage signifies the fusion of
epiphysis and metaphysis and is
attained during the deceleration period
of the pubertal growth spurt (PHVEND) by all subjects..

38

The middle phalanx of the third finger
(MP3):
Stage F— the epiphysis is as wide as the
metaphysis.
This stage is attained before ONSET by about
40 percent of the subjects and at PHV by many
others


39

Stage FG— the epiphysis is as wide as
the metaphysis and there is distinct
medial and/or lateral border of the
epiphysis forming a line of demarcation
at right angles to the distal border.
This stage is attained 1 year before or at
PHV by about 90 percent of the subjects.


40

Stage G— the sides of the epiphysis have thickened
and also cap its metaphysis, forming a sharp edge
distally at one or both sides. This stage is attained at
or 1 year after PHV
Stage H— fusion of the epiphysis and metaphysis
has begun. and is attained after PHV but before
END by practically all boys and about 90 percent of
the girls.

41

Stage I— fusion of the epiphysis and
metaphysis is completed. is attained before or at
END in all subjects except a few girls.
(Rajagopal and Sudhanshu added an additional
bone stage between MP3H(deceleration of the
curve of the pubertal growth spurt) and MP3I(end of the pubertal growth spurt) which they
called it as MP3-HI stage, resulting in a total of
six stages of MP3 growth)

42


43

The distal epiphysis of the radius:
R-I the fusion of the epiphysis and metaphysis
has begun. This stage is attained 1 year before or
at END by about 80 percent of the girls and
about 90 percent of the boys
R-IJ - the fusion is almost completed but there is
still a gap at one or both margins.
R-J - is characterized by fusion of the
epiphysis and metaphysis . These stages are not
attained before END by any subject.

44

Distal third phalanx
DP3-I the fusion of the epiphysis and metaphyis
is completed.
This stage signifies the fusion of epiphysis and
metaphysis and is attained during the
deceleration period of the pubertal growth spurt
(PHV-END) by all subjects..

45

Cervical vertebrae as the
maturity indicators …….


46

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.
Vertebral growth takes place from the cartilagenous
layer on the superior and inferior surfaces of each
vertebrae.


47

Secondary ossification nuclei on the tips of
the bifid spinous processes and transverse
processes appear during puberty.
Secondary ossification nuclei unite with the
spinous processes when vertebral growth is
complete.
After completion of endochondral
ossification, growth of the vertebral body
takes place by periosteal apposition. It
appears to take place only at the front and
sides

48

Hassel and Farman carried out a study
The sample of 11 groups of 10 males and
10 females (220 subjects) aged from 8 to
18 years was taken from the BoltonBrush Growth Center
The radiographs used included the left
hand-wrist and the lateral cephalogram.


AJO-1995

49

The system developed by Fishman
was used to determine skeletal
maturation by hand-wrist evaluation
on each subject.
Once skeletal maturation was
assessed from the hand-wrist
radiograph, the lateral cephalogram
taken on the same date was taken from
the record.

50

Three parts of the cervical vertebrae were traced .
These entities were
the dens (odontoid process),
the body of the third cervical vertebra (C3), and
the body of the fourth cervical vertebra (C4).
These areas were selected because C3 and C4
could be visualized even when a thyroid
protective collar was worn during radiation
exposure.

51

The cervical vertebrae tracings were paired
with their respective hand-wrist radiographs
that had been grouped by SMI categories.
These tracings were photocopied.
The photocopies of the vertebral tracings were
evaluated to see whether changes in shape and
dimension of the vertebrae could be observed
between SMI groupings.


52

Specific entities looked at were the
presence or absence of curvature in
the inferior borders of the dens, C3,
and C4.
General shapes of the bodies of C3
and C4 were evaluated
Intervertebral spacing was visualized.

53

RESULTS
Six categories of cervical vertebrae skeletal maturation could
be defined….

Cervical vertebrae maturation indicators using C3 as guide.

54

Category 1 was called INITIATION. This
corresponded to a combination of SMI 1 and 2.
At this stage, adolescent growth was just
beginning and 80% to 100% of adolescent
growth was expected.36 Inferior borders of C2,
C3, and C4 were flat at this stage.
The vertebrae were wedge shaped, and the
superior vertebral borders were tapered from
posterior to anterior

55

CVMI 1: A. Typical hand-wrist radiograph. B. Typical cervical
56
vertebrae appearance using lateral cephalograph.

Category 2 was called ACCELERATION. This
corresponded to a combination of SMI 3 and 4
Growth acceleration was beginning at this stage,
with 65% to 85% of adolescent growth expected.
Concavities were developing in the inferior
borders of C2 and C3.
The inferior border of C4 was flat. The bodies of
C3 and C4 were nearly rectangular in shape.

57

58

Category 3 was called TRANSITION. This
Adolescent growth was still accelerating at this
stage toward peak height velocity, with 25% to
65% of adolescent growth expected.
Distinct concavities were seen in the inferior
A concavity was beginning to develop in the
inferior border of C4. The bodies of C3 and C4
were rectangular in shape

59

60

Category 4 was called DECELERATION. This
Adolescent growth began to decelerate
dramatically at this stage, with 10% to 25% of
adolescent growth expected.
Distinct concavities were seen in the inferior
borders of C2, C3, and C4. The vertebral
bodies of C3 and C4 were becoming more
square in shape

61

vertebrae appearance using Iateral cephalograph.
62

Category 5 was called MATURATION.
This corresponded to a combination of SMI 9
and 10.
Final maturation of the vertebrae took place
during this stage, with 5% to 10% of adolescent
growth expected.
More accentuated concavities were seen in the
inferior borders of C2, C3, and C4.
The bodies of C3 and C4 were nearly square to
square in shape .

63

64

Category 6 was called COMPLETION.
This corresponded to SMI 11.
Growth was considered to be complete at
this stage. Little or no adolescent growth
was expected.
Deep concavities were seen in the inferior
borders of C2, C3, and C4.
The bodies of C3 and C4 were square or
were greater in vertical dimension than in
horizontal dimension.

65

66

The purpose of this investigation was to
provide the orthodontist with an additional tool
to help determine growth potential in the
adolescent patient.
This was to be accomplished by using
anatomic changes of the cervical vertebrae
observed on the lateral cephalometric
radiograph to determine skeletal maturity.
By using a routinely taken diagnostic
radiograph, the orthodontist would have a
reliable diagnostic tool to aid in formulating
treatment options.

67

This study combined the observations of the
changes in the hand-wrist and the changes in
the cervical vertebrae during skeletal
maturation.
The shapes of the cervical vertebrae were
seen to differ at each level of skeletal
development.
This provided a means with which to
determine the skeletal maturity of a person
and thereby determine whether the possibility
of potential growth existed.

68

The shapes of the vertebral bodies of C3 and C4
changed from somewhat wedge shaped, to
rectangular, to square, to greater in dimension
vertically than horizontally as skeletal maturity
progressed.
The inferior vertebral borders were flat when
most immature, and they were concave when
mature. The curvatures of the inferior vertebral
borders were seen to appear sequentially from C2
to C3 to C4 as the skeleton matured. The
concavities became more distinct as the person
matured.

69

When two successive SMI-CVMI groups were
combined, it was observed that distinct cervical
vertebrae anatomic characteristics were unique
to each of these groupings.
Eleven SMI (skeletal maturation index)
groupings were condensed into six CVMI
(cervical vertebrae maturation index) categories.
The SMI groupings 1 and 2, 3 and 4, 5 and 6, 7
and 8, 9 and 10, and SMI 11 were given CVMI
categories 1 through 6, respectively

70

A comparison of the modified MP3 stages and
the cervical vertebrae was carried out by
Rajagopal and Kansal (2002) in order to
determine whether the six modified MP3 stages
could be correlated with the six stages of
cervical vertebrae maturation indices(CVMI) as
described by Hassel and Farman


71


72

MP3-F stage: Start of the curve of pubertal
growth spurt
Features observed by Hagg and Taranger:
1. Epiphysis is as wide as metaphysis.
Additional features observed in this study:
2. Ends of epiphysis are tapered and rounded.
3. Metaphysis shows no undulation.
4. Radiolucent gap (representing cartilageous
epiphyseal growth plate) between epiphysis and
metaphysis is wide.


73

CVMI-1:
Initiation stage of cervical vertebrae
1. C2, C3, and C4 inferior vertebral body
borders are flat.
2. Superior vertebral borders are tapered
from posterior to anterior (wedge shape).
3. 80-100% of pubertal growth remains.


74


75

MP3-FG stage: Acceleration of the curve of
pubertal growth spurt
1. Epiphysis is as wide as metaphysis.
2. Distinct medial and/or lateral border of
epiphysis forms line of demarcation at right angle
to distal border.
3. Metaphysis begins to show slight undulation.
4. Radiolucent gap between metaphysis and
epiphysis is wide.

76

CVMI-2: Acceleration stage of cervical
vertebrae
1. Concavities are developing in lower
2. Lower border of C4 vertebral body is
flat.
3. C3 and C4 are more rectangular in
shape.

77


78

MP3-G stage: Maximum point of pubertal
growth spurt
1. Sides of epiphysis have thickened and cap its
metaphysis, forming sharp distal edge on one or
both sides.
2. Marked undulations in metaphysis give it
“Cupid’s bow” appearance.
3. Radiolucent gap between epiphysis and
metaphysis is moderate.

79

CVMI-3: Transition stage of cervical
vertebrae
1. Distinct concavities are seen in lower
2. Concavity is developing in lower
border of C4.
3. C3 and C4 are rectangular in shape.


80


81

MP3-H stage: Deceleration of the curve of pubertal
growth spurt
1. Fusion of epiphysis and metaphysis begins.
2. One or both sides of epiphysis form obtuse angle
to distal border.
3. Epiphysis is beginning to narrow.
4. Slight convexity is seen under central part of
metaphysis.


82

5. Typical “Cupid’s bow” appearance of
metaphysis is absent, but slight undulation is
distinctly present.
metaphysis is narrower.

CVMI-4: Deceleration stage of cervical
vertebrae
1. Distinct concavities are seen in lower
borders of C2, C3, and C4.
2. C3 and C4 are nearly square in shape.

83


84

MP3-HI stage: Maturation of the curve of
pubertal growth spurt
Features of this “new” stage observed in this
study:
1. Superior surface of epiphysis shows smooth
concavity.
2. Metaphysis shows smooth, convex surface,
almost fitting into reciprocal concavity of
epiphysis.
3. No undulation is present in metaphysis.
metaphysis

85

CVMI-5: Maturation stage of cervical
vertebrae
1. Accentuated concavities of C2, C3, and C4
inferior vertebral body borders are observed.
2. C3 and C4 are square in shape.


86


87

MP3-I stage: End of pubertal growth spurt
1. Fusion of epiphysis and metaphysis
complete.
2. No radiolucent gap exists between
metaphysis and epiphysis.
3. Dense, radiopaque epiphyseal line forms
integral part of proximal portion of middle
phalanx.

88

CVMI-6: Completion stage of cervical
vertebrae
1. Deep concavities are present in C2, C3,
and C4 inferior vertebral body borders.
2. C3 and C4 are greater in height than in
width.
3. Pubertal growth is complete.


89


90

Advantages of the modified MP3
stages include:
1. Significantly lower radiation exposure
compared to lateral cephalograms or handwrist xrays.
2. High degree of clarity on the
radiographs, with no superimposition of
bones or variations in posture as in
evaluation of the cervical vertebrae.

91

3. Discrete, easily identifiable stages of
development, unlike the more subtle
changes in CVMI stages.
4. Close correlation to the six stages of
CVMI.
5. No need to obtain equipment beyond the
standard periapical x-ray film and dental xray machine.

92

CONCLUSION…..


93

Dental, maturational and chronological ages
are not nessesarily interrelated on a simple
one to one basis.
All these variations make maturational age a
more valid means of judging physiological
development than chronological age, which
can be a most misleading piece of
information.

94

Growth magnitude, direction and timing are
intimately dependent on each other.
A vertically growing mandible will display a
greater magnitude of vertical growth during a
time of accelerated growth velocity
Every person matures on a very individual
schedule, and it is here that the value of hand
wrist films becomes apparent


95

The skeletal maturity of the bones of the hand
and wrist and the cervical vertebrae, on the
other hand, is closely related to that of the
craniofacial region, and skeletal maturity
indices are reliable predictors of sexual and
somatic maturity as well.
Radiologic skeletal maturation indicators
should be used to augment other observations
by the orthodontist. One diagnostic test
should not be relied on too heavily.

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Skeletal Maturity Indicators Guide

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