Growth Assessment Parameters

GROWTH
ASSESSMENT
PARAMETERS
ANUNITHA .R
FIRST YEAR PG
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CONTENTS
■ Growth assessment
■ Growth assessment parameters
■ Types of age
■ Hand wrist radiograph
■ Anatomy of hand wrist radiograph
■ Indications of hand wrist radiograph
■ Methods to estimate maturity based on hand wrist radiograph
■ Cervical vertebrae maturation
■ Other methods
■ Clinical significance of skeletal maturity indicators
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GROWTH ASSESSMENT
■ Growth assessment is the process of assessing the maturational status of an

individual.
■ It is very critical for an orthodontist to know the pubertal growth spurt so
that he or she can time the treatment of skeletal discrepancy between the
maxilla and mandible
Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015

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GROWTH ASSESSMENT
PARAMETERS
■ The correct knowledge of facial age, developmental age, chronologic age, etc.
is very necessary for formulating treatment plan.
■ These anthropometric measurements are also useful in the interdisciplinary
evaluation of patients.
Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

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TYPES OF AGE
There are two types of age that denote the physical maturation of an individual:
■ Chronological age
■ Biological age
Biological age can in turn be divided into four types:
1. Dental age
2. Morphological age
3. Skeletal age
4. Sexual age or endocrinological

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SOMATOTYPI ■ In the overall assessment of child a
C AGE general somatotype may be
appreciated.
■ Sheldon defined somatotype by a
series of 17 anthropometric
measurements
■ Endomorph: Stocky abundant
subcutaneous fat, digestive viscera that
are highly developed.
Nikhil Marwah , Textbook Of

Pediatric Dentistry , Third Edition ,
6
Jaypee Publications
■ Mesomorph: Upright, sturdy, athletic, muscle bone and connective tissue
predominate

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Ectomorph: Tall, thin and fragile with minimal subcutaneous fat and muscle tissue.

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■ In terms of chronologic age ectomorph is a late maturer whereas endomorph is
an early maturer.
■ Although somatotype may give gestalt about child’s developmental pattern it is
not on accurate predictor of growth

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CHRONOLOGIC AGE
■ This is the most obvious and most easily determined developmental age
parameter, which is figured from child’s date of birth.
■ There might be difference in children of same chronologic age due to
difference in thing of maturation, diseases and various environmental factors.
■ Although it is easy to determine but, chronologic age is not an accurate
indicator of development nor is it a good predictor of growth.

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HEIGHT AND WEIGHT AGE
■ Height has been commonly employed as determinant of development age.

■ The standard growth curve commonly employed to characterize a child’s height
compared, to that of children of same chronologic age is used to assess
development age.
■ Growth of all children up to puberty follows nearly the same curves but the
difference in adolescent growth spurts change the growth curves during and
after puberty greatly.

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■ Because height of each child is related to genetic as well as environmental
factors itis clear that a single measurement is limited as a predictor of
development age.
■ If at all height age has to be considered then longitudinal height of a child
which expresses the child’s own growth curve is of more value.
■ Weight and height age are corelated well with each other
■ But weight age alone is a poor indicator if growth or developmental age owing
to a large number of variations.
■ Clinical implications of this age are that earlier the spurt occurs shorter it is
and therefore late matures are taller which also accounts for the difference in
males and females.

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SEXUAL AGE
■ At puberty differential hormones actions yield characteristic body charges.
■ These changes are classified into five stages according to Reynolds EL, Wines
JV and Tanner JM.
■ They outlined the stages of secondary sexual characteristics and their relation
to pubertal growth spurt in height and their relation with developmental age

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Stage Pubic hair ratings for Breast development Genitalia maturity
girls and boys ratings in girls rating in boys
Stage 1 No pubic hair Elevation of papilla only Testes, penis is same size
and proportion as in
Stage 2 Sparse growth, straight Enlargement of breast bud childhood
hair with increase in areolar Enlargement of testes and
diameter scrotum with change in
Stage 3 texture of skin
Dark, coarse, curled hair Further enlargement Enlargement of penis in
without separation of length with continued
contour of areola from growth of testes and
breast scrotum

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Stage Pubic hair ratings for Breast development Genitalia maturity
girls and boys ratings in girls rating in boys
Stage 4 Adult type hair but cover Projection of areola to form Increase in breadth of
less area a secondary mound penis with glan
development and
continued enlargement of
testes
Stage 5 Adult quantity and type Further projection of

with spread to medial papilla Adult size and shape
surface of thigh

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FACIAL AGE
■ The ultimate goal of developmental growth assessment of children being
evaluated for craniofacial intervention is facial age.
■ The aim is to identify whether they are on their own facial growth curve and to
use this as a predictor of future growth.
■ Various methods used for measurement of facial age and prediction of
craniofacial growth are anthropometric measurement, facial growth velocity
curve and cephalometric radiography

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DENTAL AGE
■ Dental age is estimated according to the last tooth erupted in oral cavity in
normal sequence.
■ This is the simplest but, the least accurate method.
■ This involves recognizing the teeth clinically present in the oral cavity in
comparison to dental eruption charts.
■ The disadvantages of this technique are the wide variations in time of
eruption, influence of local and environmental factors and the fact that no or
several teeth may erupt during the same time interval.
■ Dental age is not well correlated with the developmental status of the child
but there are a few methods which give the development quotient to a fairly
accurate level thus signifying the close relation between dental and
chronologic age.
Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications 17

DENTAL AGE MEASUREMENT
APPROACHES
■ Atlas approach where we see the distinct stages of mineralization of tooth on
radiographs and identify the age, e.g. Massler’s method, Moorrees method,
Andersons method
■ Scoring approach where each development is divided into stages and each stage
given a score, e.g. Demirjian method, Nolla’s classification, Jhonson’s method

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GRON AND MOORREES METHOD
■ They helped formulate what is to date the most commonly used method of
determining dental age.
■ This method involved scoring of ten permanent teeth according to crown and
root formation using standard dental films
■ The teeth which were scored were maxillary and mandibular incisor,
mandibular canine, premolars and molars.
■ Scores are plotted on a chart composed of horizontal segment for each tooth
with demarcation for developmental stages and horizontal segment marked in
years of age.
■ For each tooth appropriate stage is checked and a vertical line drawn through
the corresponding checks, yielding a mean dental age.
■ This was later modified by Anderson who added 3rd molar also

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NOLLA STAGES

DEMIRJIAN METHOD
Stage Description
O No sign of calcification

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Stage Description
A Beginning of calcification seen at superior

level of crypt

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Stage Description
B Fusion of calcification points in the cuspal

area to form occlusal surface

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Stage Description
C • Enamel formation is complete with

convergence towards cervical region
• Beginning of dentinal deposit
• Outline of pulp chamber has a curved
shape at the occlusal border

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Stage Description
D • Crown formation is completed till CEJ

• Superior border of pulp chamber in
uniradicular teeth is curved and in molars is
in trapezoidal form
• Projection of pulp horn starts
• Beginning of root formation in form of a
spicule

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Stage Description
E • In uniradicular teeth pulp chamber forms

straight line whose continuity is broken by
pulp horns
• Initial formation of bifurcation is seen in
molars
• Root length is less than crown height

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Stage Description
F • Walls of pulp chamber form a triangle and

apex ends in funnel shape in uniradicular
teeth
• Calcified region of bifurcation in molars is
more developed thus giving roots of the
teeth a more distinctive outline
• The root length is equal to or greater than
crown height

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Stage Description
G • Walls of root canal are parallel and apical

end is still open in molars

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Stage Description
H • Apical end of distal root in molars is closed

• Periodontal membrane has uniform width
around the root and apex

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SKELETAL AGE
■ This is a very important aspect of assessing the developmental age of child as
skeletal age was found to more highly correlate with the developmental age
than any other growth parameter.
■ Each endochondral bone begins with a primary center of ossification which
then changes shape, size and contour till its fusion.
■ Any of the skeletal growth centers can be used for skeletal age assessment but
hand and wrist have been most commonly used for assessment of pubertal
maturation.
■ Advantages of using skeletal age are readily recognizable stage of
ossification; regular sequence of developmental changes occurring from birth
to adulthood; characteristic pattern of progression of ossification of epiphyseal
centers can be identified.

HAND–WRIST RADIOGRAPH
Principle of Bone Age Assessment
■ In growing human, the most common measure for biological maturation is
skeletal or bone age and is derived from the assessment of successive stages of
skeletal development, e.g. hand–wrist radiographs.
■ Currently this is the only available indicator that spans the entire growth period
(birth to maturity) and is used to study human growth by orthodontists,
pediatricians, orthopedic surgeons and anthropologists.
■ The degree of skeletal maturity depends on two features namely the growth of
the ossification area and calcium deposition in that area

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■ The bones ossified from the primary and
secondary center are called diaphysis and
epiphysis, respectively.
■ Metaphysis represents growing end of the
bone and is the diaphysis part abutted on
the epiphysis.
■ As the secondary center is progressively
ossified, bone replaces the cartilage until a
thin layer called epiphyseal plate separates
diaphyseal bone from epiphyseal bone.
■ As long as the epiphyseal cartilage plate
persists, both the diaphysis and epiphysis
continue to grow,
■ But eventually, the osteoblasts cease to
multiply and the epiphyseal plate is
ossified
Sridhar Premkumar , Textbook Of
Orthodontics , Elseiver
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Publications 2015
ANATOMY OF HAND–WRIST
REGION
■ There are numerous small bones in the hand–wrist region.
■ They follow a pattern in ossification and union of epiphysis with diaphysis.
■ Carpal bones were first named by Lyser in 1683.
■ The left hand–wrist is used by convention and a posteroanterior view is taken
to register the hand–wrist region

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■ Each hand–wrist area has 8 carpals, 5
metacarpals, and 14 phalanges, which
make a total of 27 bones
■ Distal ends of the radius and ulna also
appear in the hand–wrist radiograph.
■ Radius and ulna are the long bones of the
forearm.
■ Ulna lies in the medial aspect and radius
in the distal aspect when the palm is
facing front.

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Publications 2015
■ The carpal bones are arranged in two
rows:
■ Distal row— trapezium, trapezoid,
capitate, and hamate; proximal row—
scaphoid, lunate, triquetral, and pisiform.
■ These small irregular bones lie in
between the long bones of the forearm
and the metacarpals

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Publications 2015
■ Metacarpals are small long bones.
■ Each of the five metacarpals has a base,
shaft and head.
■ They lie between the carpals and
phalanges forming the skeletal
framework of the palm

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Publications 2015
■ Each finger has a proximal phalanx,
middle phalanx and distal phalanx.
■ The middle phalanx is absent in the
thumb.
■ The small round bone located in the
thumb embedded in the tendons is
called the sesamoid bone.

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Publications 2015
■ The phalanges and carpal bones have a
pattern of ossification that can be divided
into the following stages
■ Epiphysis width less than that of
diaphysis
■ Epiphysis width equal with that of
diaphysis
■ Epiphysis caps the diaphysis
■ Epiphysis starts fusing with the diaphysis

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Publications 2015
Indications of hand wrist radiograph
■ In patients who exhibit a marked discrepancy between chronological age and
dental age
■ To apply modulation procedures to interrupt developing skeletal class II or
class III malocclusion
■ To assess skeletal age in a patient whose normal growth is affected by general
factors
■ To predict the timing of variation of pubertal growth
Si Bhalajhi , Orthodontics The Art And Science , Fifth Edition , Arya Medical Publications Pvt Ltd
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METHODS OF SKELETAL
MATURITY ESTIMATION BASED ON
HAND WRIST RADIOGRAPH
■ Atlas method by Greulich and Pyle
■ Björk, Grave and Brown Method
■ Singers method of assessment
■ Fishmans skeletal maturity indicators
■ Hagg and Taranger method

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ATLAS METHOD BY GREULICH AND PYLE
■ Published an atlas containing pictures of standard handwrist radiographs of
different skeletal ages
■ Given ideal picture of hand and wrist radiograph for different chronological age
and both sexes
■ Each photograph in the atlas is representative of a particular skeletal age
■ Patients radiograph is matched on an overall basis with one of the photographs
in the atlas
Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015 43

BJÖRK, GRAVE AND BROWN
METHOD
■ Björk, Grave and Brown outlined nine developmental stages with the ossification
events localized in the area of the phalanges, carpal bones and radius.
■ The developmental stages are assessed according to the relation between the
epiphyses and the diaphysis.
■ There are three stages of ossification of the phalanges

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First stage of maturation (PP2 stage)
■ The epiphysis of the proximal phalanx of
the index finger (PP2) has the same
width as the diaphysis.
■ Stage approximately occurs 3 years
before the peak of the pubertal growth
spurt

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Publications 2015
Second Stage (MP3 Stage)
■ Epiphysis of the middle phalanx of the
third finger (MP3) is of the same width
of the epiphysis

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Publications 2015
Third Stage (Pisi, H1 and R Stage)
■ This stage of development can be
identified by three distinct ossification
areas;
■ These show individual variations but
appear at the same time during the
process of maturation.
■ Pisi stage = visible ossification of the
pisiform.
■ H1 stage = ossification of the hamular
process of the hamatum.
■ R stage = same width of the epiphysis
and the diaphysis.

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Publications 2015
Fourth Stage (S and H2 Stage)
■ S stage = first mineralization of the
ulnar sesamoid bone of the
metacarpophalangeal joint of the thumb
■ H2 stage = progressive ossification of
the hamular process of the hamatum
■ The fourth stage is reached shortly
before or at the beginning of the pubertal
growth spurt

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Publications 2015
Fifth stage (MP3 cap, PP1 cap and R cap
stage)
■ During this stage, the diaphysis is
covered by the cap shaped epiphysis.
■ In the mp3 cap stage, the process of
ossification begins at the middle phalanx
of the third finger;
■ In the pp1 cap stage, at the proximal
phalanx of the thumb and in the r cap
stage at the radius.
■ This stage of ossification marks the peak
of the pubertal growth spurt.

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Publications 2015
Sixth Stage (DP3u Stage)
■ There is visible union of epiphysis and
diaphysis at the distal phalanx of the
middle finger (DP3).
■ This stage of development constitutes the
end of pubertal growth
Sridhar Premkumar , Textbook Of 50

Seventh Stage (PP3u Stage)
■ Visible union of the epiphysis and
diaphysis at the proximal phalanx of the
little finger (PP3) is seen.

Eighth Stage (MP3u Stage)
■ Union of epiphysis and diaphysis at the
middle phalanx of the middle finger is
clearly visible (MP3).

■ Ninth Stage (Ru Stage)
■ There is complete union of the
epiphysis and diaphysis of the radius.
■ Grave has demonstrated that the
developmental status of a child is
better measured in relationship to
specified stages of maturation—in
other words, against a scale of events
rather than chronologically.

■ Grave assessed the relations between timing of maturation events, maximum
growth in body height and maximum facial growth during the circumpubertal
period.
■ Results showed that the initial ossification of the pisiform and the hook of the
hamate preceded peak growth in most boys and girls.
■ While initial ossification of the sesamoid of the thumb and advanced
ossification of the hook of the hamate coincided with peak growth in most
boys, this was true in only about half the girls (fourth stage).

HAGG AND TARANGER METHOD
■ In this method, the emphasis was on identifying PHV of the child, so
maturation of certain specific phalanges and not all is considered.
■ The assessment was done by taking into consideration the ossification of the
ulnar sesamoid of the metacarpophalangeal joint of the first finger (s), and
certain specified stages of three epiphyseal bones
■ The middle and distal phalanges and third finger (MP3 and DP3) and the
distal epiphysis of the radius (R). Hand–wrist radiographs used to develop
this method were taken from 6 to 18 years of age.

Sesamoid
■ Appearance of the ulnar sesamoid is seen
during the acceleration period of pubertal
growth spurt (onset of PHV) in 86% of
girls and 92% of boys

Middle Third Phalanx
■ MP3 F: The epiphysis is as wide as the
metaphysis.
■ MP3 F was attained before pubertal
onset by about 40% of the subjects and
at PHV by the rest of the subjects.

■ MP3 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.

■ MP3 G: The sides of the epiphysis have
thickened and also cap its metaphysis,
forming an edge distally at one or both
sides. This stage is attained at or 1 year
after the PHV

■ MP3 H: Fusion of the epiphysis and
metaphysis has begun and is attained
after PHV but before the end of growth
spurt by practically all boys and about
90% of girls

■ MP3 I: Fusion of the epiphysis and
metaphysis is completed. MP3 I was
attained before or at the end of pubertal
growth spurt in all subjects except a few
girls

Distal Third Phalanx
■ DP3 I: The fusion of epiphysis and
diaphysis is completed. This stage was
attained during the deceleration period of
the pubertal growth spurt (PHV-END) by
all subjects. The distal epiphysis of the
radius (R):
■ Stage I: Fusion of the epiphysis and
metaphysis has begun
■ Stage IJ: Fusion is almost complete but
there is still a small gap at one or both
margins
■ Stage J: Fusion of the epiphysis and
metaphysis is complete.

■ R-I is attained 1 year before or at the end of
the pubertal growth spurt by about 80% of
the girls and about 90% of the boys.
■ R-IJ and R-J are not attained before the end
of the pubertal growth spurt by any subject

SINGERS METHOD OF
■ ASSESSMENT
Julian singer 1980 proposed a system of hand wrist radiograph assessment
■ It helps the clinician to rapidly determine the maturational status of the
adolescent
■ He described six stages of hand wrist radiographs
He utilised
■ Middle phalanx of third finger – epiphysis equal to diaphysis
■ First mineralization of ulnar sesamoid bone
■ Middle phalanx of third finger – epiphysis cap its diaphysis

STAGE CHARACTERISTIC RELATION OF INFERENCE
FEATURE EPHYSIS/DIAPHYSIS
I Absence of pisiform hook Epiphysis is narrow than 1 year before
( EARLY) and hamate diaphysis in PP2 beginning of peak
pubertal growth
Initial ossification of hook Epiphysis is equal to Beginning of pubertal

II of hamate and pisiform diaphysis in PP2 growth spurt
(PREPUB
ERTAL )
Beginning of calcification Increased width of epiphysis

III of ulnar, sesamoid Onset of pubertal
(PUBERT increased calcification of growth spurt
AL hook of hamate and
ONSET ) pisiform

STAGE CHARACTERISTIC RELATION OF INFERENCE
FEATURE EPHYSIS/DIAPHYSIS
IV Calcified ulnar and Capping of diaphysis by Accelerating phase of
(PUBERT sesamoid epiphysis in MP3 pubertal growth spurt
AL)
Fusion of epiphysis of DP3 Period of growth in
V Fully calcified ulnar and Epiphysis of radius and which dental
(PUBERT sesamoid ulnar not fully fused with treatment should be
AL respective shafts completed and patient
DECELER be in retention
ATION ) No remaining growth sites Fusion of epiphysis of Growth completion
seen radius and ulna with their
VI shafts

FISHMANS SKELETAL MATURITY INDICATORS
■ Given by Leonard S Fishman 1982

■ Six anatomical sites – third finger, MP3,PP3,DP3
■ Fifth finger – MP5 , thumb –S, radius R
■ Uses four maturational stages for 11 discrete adolescent skeletal maturity
indicators
■ Exhibit consistency in the time of onset of ossification covering the entire
period of adolescent growth
Si Bhalajhi , Orthodontics The Art And Science , Fifth Edition , Arya Medical Publications Pvt Ltd
67
■ Stage I (PP3) equal width of epiphysis
and diaphysis in the proximal phalanx of
middle finger
■ Stage II (MP3) equal width of epiphysis
and diaphysis in the middle phalanx of
middle finger
■ Stage III (MP5) equal width of epiphysis
and diaphysis in the middle phalanx of
fifth finger
■ Stage IV (S) appearance of adductor
sesamoid of the thumb
Si Bhalajhi , Orthodontics The Art

And Science , Fifth Edition , Arya
68
Medical Publications Pvt Ltd
■ Stage V (DP3 cap ) capping of epiphysis
over diaphysis in distal phalanx of
middle finger
■ Stage VI (MP3 cap) ) capping of
epiphysis over diaphysis in middle
phalanx of middle finger
■ Stage VII (MP5 cap) capping of
epiphysis over diaphysis in middle
phalanx of fifth finger
■ Stage VIII (DP3 u ) fusion of epiphysis
and diaphysis in distal phalanx of
middle finger
■ Stage IX (PP3 u ) fusion of epiphysis
and diaphysis in proximal phalanx of
middle finger
69
Medical Publications Pvt Ltd
■ Stage X (MP3 u ) fusion of epiphysis
and diaphysis in middle phalanx of third
finger
■ Stage XI (R u ) fusion of epiphysis and
diaphysis in radius

Medical Publications Pvt Ltd 70
CERVICAL VERTEBRAE
MATURATION AS SKELETAL
MATURITY INDICATOR
■ Hassel and Farman9 (1995) found that the shapes of the cervical vertebrae were
found to differ with different levels of skeletal development
■ The stages of cervical vertebrae maturation are as follows

■ Initiation: Inferior borders of the second,
third and fourth cervical vertebrae are
flat at this stage.
■ The third vertebrae are wedge-shaped
and the superior vertebral borders are
tapered from posterior to anterior; 100%
of pubertal growth remains.

■ Acceleration: Concavities on the inferior
borders of the second and third vertebrae
begin to develop.
■ Inferior borders of the fourth vertebrae
remain flat.
■ Vertebral bodies of the third and fourth
vertebrae are nearly rectangular in shape.
About 65–85% of pubertal growth
remains

■ Transition: Distinct concavities are
shown on the inferior borders of the
second and third vertebrae.
■ A concavity begins to develop on the
inferior border of the fourth. Vertebral
bodies of the third and fourth vertebrae
are rectangular in shape. About 25–65%
of pubertal growth remains

■ Deceleration: Distinct concavities can
be observed on the inferior borders of
the second, third and fourth cervical
vertebrae. Vertebral bodies of the third
and fourth vertebrae begin to be
squarer in shape. About 10– 25% of
pubertal growth remains

■ Maturation: Marked concavities are
observed on the inferior border to the
second, third and fourth cervical
vertebrae.
■ Vertebral bodies of the third and fourth
vertebrae are almost square in shape.
About 5–10% of pubertal growth
remains.

■ Completion: Deep concavities are
observed on the second, third, and
fourth cervical vertebrae.
■ Vertebral bodies size are more vertical
than horizontal. Pubertal growth has
been completed.

OTHER METHODS
MODIFIED HAGG AND TARANGER METHOD
■ Hägg and Taranger used the medial phalanges of the third finger (MP3) to
determine the pubertal growth spurt.
■ They primarily used the developmental changes in the epiphyseal region of the
third finger.
■ Rajagopal and Kansal added an additional bone stage to the method of Hägg and
Taranger
■ The MP3-HI, which occurs between MP3-H and MP3-I and reflects changes in
the metaphyseal region of the third finger
Ozer T, Kama JD, Ozer SY. A practical method for determining pubertal growth spurt. Am J Orthod
Dentofacial Orthop. 2006 Aug;130(2):131.e1-6 78
MP3-F stage: start of the pubertal growth
spurt
These features were observed by Hägg and
Taranger. : Epiphysis is as wide as metaphysis
■ These additional features were observed in
this study as described by Rajagopal and
Kansal.
■ Ends of epiphysis are tapered and rounded.
■ Metaphysis shows no undulation.
■ Radiolucent gap (representing cartilageous
epiphyseal growth plate) between
epiphysis and metaphysis is wide.
Ozer T, Kama JD, Ozer SY. A

practical method for determining
pubertal growth spurt. Am J Orthod
79
Dentofacial Orthop. 2006
MP3-FG stage: acceleration of the pubertal
growth spurt
■ These features were observed by Hägg and
Taranger : Epiphysis is as wide as
metaphysis
■ Distinct medial or lateral border of
epiphysis forms line of demarcation at
right angle to distal border
■ These additional features were observed in
this study as described by Rajagopal and
Kansal.
■ Metaphysis begins to show slight
undulation.
■ Radiolucent gap between metaphysis and
epiphysis is wide
80
■ MP3-G stage: maximum point of
pubertal growth spurt
■ These features were observed by Hägg
and Taranger :Sides of epiphysis have
thickened and cap its metaphysis,
forming sharp distal edge on at least 1
side.
■ These additional features were observed
in this study as described by Rajagopal
and Kansal.
■ Marked undulations in metaphysis give it
“Cupid’s bow” appearance.
■ Radiolucent gap between epiphysis and
metaphysis is moderate.
Dentofacial Orthop. 2006 81
■ MP3-H stage: deceleration of the
pubertal growth spurt
■ These features were observed by Hägg
and Taranger : Fusion of epiphysis and
metaphysis begins.
and Kansal.
■ At least 1 side of epiphysis forms obtuse
angle to distal border.
■ Epiphysis is beginning to narrow.
■ Slight convexity is seen under central
part of metaphysis.
■ Typical “Cupid’s bow” appearance of
metaphysis is absent, but slight
pubertal growth spurt. Am J Orthod undulation is distinctly present. 82
■ MP3-HI stage: maturation of the pubertal
growth spurt
■ These features of this new stage were
observed in this study as described by
Rajagopal and Kansal.
■ Superior surface of epiphysis shows
smooth concavity.
■ Metaphysis shows smooth, convex
surface, almost fitting into reciprocal
concavity of epiphysis.
■ No undulation is present in metaphysis.
■ Radiolucent gap between epiphysis and
metaphysis is insignificant

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■ MP3-I stage: end of pubertal growth
spurt These features were observed by
Hägg and Taranger : Fusion of epiphysis
and metaphysis are complete.
and Kansal.
■ No radiolucent gap exists between
metaphysis and epiphysis.
■ Dense, radiopaque epiphyseal line forms
integral part of proximal portion of
middle phalanges

84
MODIFIED STAGES
CVMS I
OF CERVICAL ■ The lower borders of all the three
VERTEBRAL vertebrae are flat, with the possible
MATURATION exception of a concavity at the lower
border of c2 in almost half of the cases.
■ The bodies of both c3 and c4 are
trapezoid in shape (the superior border of
the vertebral body is tapered from
posterior to anterior).
■ The peak in mandibular growth will
occur not earlier than one year after this
stage
Angle Orthod. 2002

Aug;72(4):316-23 85
CVMS II
■ Concavities at the lower borders of both
C2 and C3 are present.
■ The bodies of C3 and C4 may be either
trapezoid or rectangular horizontal in
shape.
■ The peak in mandibular growth will
occur within one year after this stage.
Angle Orthod. 2002

Aug;72(4):316-23 86
CVMS III
■ Concavities at the lower borders of C2,
C3, and C4 now are present.
■ The bodies of both C3 and C4 are
rectangular horizontal in shape
■ The peak in mandibular growth has
occurred within one or two years before
this stage
Angle Orthod. 2002

Aug;72(4):316-23 87
CVMS IV
■ The concavities at the lower borders of
C2, C3, and C4 still are present.
■ At least one of the bodies of C3 and C4
is squared in shape. If not squared, the
body of the other cervical vertebra still is
rectangular horizontal.
occurred not later than one year before
this stage
Angle Orthod. 2002

Aug;72(4):316-23 88
CVMS V
■ The concavities at the lower borders of
C2, C3, and C4 still are evident.
■ At least one of the bodies of C3 and C4
is rectangular vertical in shape.
■ If not rectangular vertical, the body of
the other cervical vertebra is squared.
occurred not later than two years before
this
Angle Orthod. 2002

Aug;72(4):316-23 89
■ The new CVM method is comprised of five maturational stages (CVMS I
through CVMS V, instead of cvs 1 through cvs 6 in the former CVM method)
■ 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
Angle Orthod. 2002 Aug;72(4):316-23

90
DEVELOPMENT OF MANDIBULAR THIRD
MOLAR AS AN INDICATOR OF SKELETAL
MATURATION
■ For clinicians contemplating the initiation of orthopedic treatment, continual
monitoring of skeletal maturity through hand-wrist films may not be necessary
to estimate peak pubertal growth velocity
■ Instead, they can monitor the root development of the mandibular canine with
periapical or panoramic radiographs, which are more readily available and
easily interpreted
■ Orthodontists should use the demonstrated relationships between canine root
development and skeletal maturity
Sandra Coutinho, Peter H. Buschang, Francis Miranda,Relationships between mandibular canine

calcification stages and skeletal maturity, American Journal of Orthodontics and Dentofacial
Orthopedics,Volume 104, Issue 3,1993,Pages 262-268
91
■ Skeletal age was determined from hand-wrist radiographs
■ according to methods described by Greulich and Pyle.
■ The phalangeal maturity stages and the appearance of the adductor sesamoid
were defined by using the Tanner and Whitehouse method.
■ The development of the mandibular canine was assessed according to
Demirjian's 19 stages of dental calcification

Orthopedics,Volume 104, Issue 3,1993,Pages 262-268 92
■ Canine stage F indicates the initiation of puberty.
■ The timing of stage G coincides with the capping of the third middle and the
fifth proximal phalanges and the presence of the adductor sesamoid. It is
indicative of PHV.
■ The intermediate stage between stages F and G should be used to identify the
early stages of the pubertal growth spurt.

■ While the findings clearly indicate relationships, canine development can not
and should not be used as the sole criterion to predict developmental landmarks
(i.e., onset of puberty, PHV).
■ Dental calcification stages of the mandibular canine provide readily available
and easily recognized indications of the maturity status of a person; they are
simple first-level, diagnostic tests to determine whether additional, more
sensitive, measures of maturity are warranted.

CLINICAL SIGNIFICANCE
■ Class II treatment is most effective when performed in the circumpubertal
period (include the peak of pubertal growth).
■ Skeletal Class III malocclusion due to retrognathic maxilla requires early
treatment, during the prepubertal period
■ Rapid maxillary expansion yields skeletal expansion when performed at the
prepubertal stages; at later stages it shows only dentoalveolar expansion
■ Long face syndrome is best treated at the circumpubertal period

REFERENCES
■ Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015
■ Si Bhalajhi , Orthodontics The Art And Science , Fifth Edition , Arya Medical
Publications Pvt Ltd
■ Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee
Publications
■ Sandra Coutinho, Peter H. Buschang, Francis Miranda, Relationships between
mandibular canine calcification stages and skeletal maturity, American Journal
of Orthodontics and Dentofacial Orthopedics, Volume 104, Issue 3,1993,Pages
262-268
■ Angle Orthod. 2002 Aug;72(4):316-23
96
■ Ozer T, Kama JD, Ozer SY. A practical method for determining pubertal growth
spurt. Am J Orthod Dentofacial Orthop. 2006 Aug;130(2):131.e1-6
97

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GROWTH

■ Growth assessment is the process of assessing the maturational status of an

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015

Nikhil Marwah , Textbook Of

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

■ Height has been commonly employed as determinant of development age.

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Stage 5 Adult quantity and type Further projection of

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications 17

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications 22

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

A Beginning of calcification seen at superior

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

B Fusion of calcification points in the cuspal

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

C • Enamel formation is complete with

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

D • Crown formation is completed till CEJ

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

E • In uniradicular teeth pulp chamber forms

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

F • Walls of pulp chamber form a triangle and

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

G • Walls of root canal are parallel and apical

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

H • Apical end of distal root in molars is closed

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications

Nikhil Marwah , Textbook Of Pediatric Dentistry , Third Edition , Jaypee Publications 32

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015 43

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of

Sridhar Premkumar , Textbook Of 50

Sridhar Premkumar , Textbook Of 51

Sridhar Premkumar , Textbook Of 52

Sridhar Premkumar , Textbook Of 53

Sridhar Premkumar , Textbook Of Orthodontics , Elseiver Publications 2015 54