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Skeletal age assessment
1. Skeletal Age
Assessment
Presented by:
Dr. Gaurav Acharya
2nd year PG Resident
Department of Orthodontics and Dentofacial Orthopedics
Peoples Dental College and Hospital, Kathmandu
6. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
7. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: Birth to 10 months
Males: Birth to 14 months
Hamate Capitate
8. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 10 months to 2 years
Males: 14 months to 3 years
9. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 10 months to 2 years
Males: 14 months to 3 years
10. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 10 months to 2 years
Males: 14 months to 3 years
11. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 10 months to 2 years
Males: 14 months to 3 years
12. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 2 years to 7 years
Males: 3 years to 9 years
13. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 7 years to 13 years
Males: 9 years to 14 years
14. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 13 years to 15 years
Males: 14 years to 16 years
15. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 13 years to 15 years
Males: 14 years to 16 years
16. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 13 years to 15 years
Males: 14 years to 16 years
17. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 13 years to 15 years
Males: 14 years to 16 years
18. Hand wrist Radiograph
Infancy
Toddlers
Pre-puberty
Puberty
Late Puberty
Post-puberty
Females: 15 years to 17 years
Males: 17 years to 19 years
19. Hand wrist Radiograph
Different methods of assessing
1. Atlas of Greulich and Pyle (1959)
2. Bjork Method (1972)
3. Fishman Method (1982)
4. Hagg and Taranger (1982)
26. Cervical Vertebra
Variables analyzed:
1. Concavity at lower border of C2, C3 & C4
2. Shape of the body of C3 and C4
Trapezoid : least mature
Rectangular horizontal
Squared
Rectangular vertical : in adult life
27. Cervical Vertebra
Hassel & Farman1 suggested 6 stages of
cervical vertebral maturation
1- Brent Hassel and Allan Farman. Skeletal maturation evaluation using cervical
vertebrae, AJODO 1995:107:58-66
1. Initiation
2. Acceleration
3. Transition
4. Decceleration
5. Maturation
6. Completion
29. Cervical Vertebrae
Co- relation of Hand wrist & Cervical Vertebra
maturation Stages1
1- Garcia fernandez. The cervical vertebrae as maturational indicators, JCO APRIL 1998
30. Frontal Sinus
Study done by Ruf and Pancherz in 19961
1- Sabine Ruf, Hans Pancherz. Frontal Sinus Development as an indicator for somatic
maturity at puberty?, AJODO 1996;110:476-82
31. Frontal Sinus
Radiographs taken at yearly intervals.
Average yearly growth velocity (millimeters per year) of
the frontal sinus was calculated
32. Frontal Sinus
From longitudinal growth data of the subjects, the
average yearly body height growth velocity
(millimeters per year) was calculated
33. Frontal Sinus
Frontal sinus growth
velocity at puberty is
closely related to body
height growth velocity.
Frontal sinus growth
shows a well-defined
pubertal peak (Sp) which
on the average occurs 1.5
yr after body ht. peak
34. Midpalatine Suture1
Amount of approximation of the midpalatal suture
compared with stages of ossification of the hand-
wrist according to the Fishman’s system
1- Bernal Revalo, Fishman. Maturational evaluation of ossification of the
mid palatal suture, AJO MARCH 1994
35. Midpalatine Suture
Key landmarks -
Point A→ most anterior point of premaxilla
Point B→ most posterior point on the posterior wall of
the incisive foramen
Point P→ Point on the line tangent to the posterior walls
of the greater palatine foramen
36. Midpalatine Suture
• A-P (total dimension of the suture)
• A-B (anterior dimension of the suture)
• B-P (posterior dimension of the suture)
• Percentage of osseous development were
recorded
37. Midpalatine Suture
Results
Increase in sutural approximation
as SMI stages progressed.
SMI 1&2- decreased sutural
approx.
After SMI 9- significant increase
in the sutural approx.
No significant difference b/n
sexes.
38. Midpalatine Suture
Conclusion:
Best to accomplish ME-before SMI 9.
Ideal time- SMI 1- 4
Less orthopedic force required.
Mid palatal approx. occurs more posteriorly.
39. Conclusion
Chronological age of an individual is often not
sufficient to assess the development age and somatic
maturity of the patient
Skeletal age derived from Hand-wrist radiograph
and cervical vertebra radiograph provide a reliable
and efficient means of assessment.
Frontal sinus & midpalatine sutute evaluation are the
new approaches for the skeletal maturity assessment
40. References
Vicente Gilsanz, Osman Ratib. Bone Age : A Digital Atlas of
Skeletal Maturity, Springer publication 2005
Greulich-Pyle Hand &Wrist Atlas
Brent Hassel and Allan Farman. Skeletal maturation evaluation
using cervical vertebrae, AJODO 1995:107:58-66
Sabine Ruf, Hans Pancherz. Frontal Sinus Development as an
indicator for somatic maturity at puberty?, AJODO
1996;110:476-82
Heinrich Wehrbein and Faruk Yildizhan. Mid-palatal suture in
young adults. European Journal of Orthodontics 23 (2001) 105—
114
Garcia fernandez. The cervical vertebrae as maturational
indicators, JCO APRIL 1998
GP is ofen required in O becauze
Rate of facial growth n % of facial growth remaining plays imp role in making decisions regarding growth modification or orthognathic surgery
Skeletal age- Most reliable age for assessment of growth for orthodontic purposes
Most commonly used skeleton- Hand-wrist and cervical vertebra
Idea introduced by Roland in 1896
Idea introduced by Roland in 1896
In the majority of healthy children, there is an established sequence of ossification for the carpal, metacarpal and phalangeal bones, which is constant and the same for both sexes.
First ossification center to appear in hand and wrist radiographs is the capitate, and the last is, most often, the sesamoid of the adductor pollicis of the thumb
In different categories of human development, the specific ossification centers can be considered as a best predictors of skeletal maturity.
The ossification centers of the capitate and hamate become apparent at about 3 months of age and remain the only useful observable features for the next six months.
ossification centers for the epiphyses of all phalanges and metacarpals become recognizable
usually in the middle finger first, and the fifth finger last
ossification centers for the epiphyses of all phalanges and metacarpals become recognizable
usually in the middle finger first, and the fifth finger last
ossification centers for the epiphyses of all phalanges and metacarpals become recognizable
usually in the middle finger first, and the fifth finger last
ossification centers for the epiphyses of all phalanges and metacarpals become recognizable
usually in the middle finger first, and the fifth finger last
Assessment of Skeletal maturity is based on the epiphyseal size of the phalanges
Epiphyses increase in width and thickness and becomes as wide as the metaphyses.
Mainly emphasis is given in the distal phalanges than to the middle phalanges, and even less in the proximal phalanges.
Epiphyses at this stage continue to grow and their widths become greater than the metaphyis
Contours of the epiphyses begin to overlap, or cap, the metaphyses.
Sesamoid in the tendon of the abductor pollicis, just medial to the head of the first metacarpal, become recognizable during puberty.
Assessments of skeletal maturity in this stage are primarily based on the degree of epiphyseal fusion of the distal phalanges
Since all carpal bones have now attained their early adult shape, they are of less value for determination of bone age.
Assessments of skeletal maturity in this stage are primarily based on the degree of epiphyseal fusion of the distal phalanges
Since all carpal bones have now attained their early adult shape, they are of less value for determination of bone age.
Assessments of skeletal maturity in this stage are primarily based on the degree of epiphyseal fusion of the distal phalanges
Since all carpal bones have now attained their early adult shape, they are of less value for determination of bone age.
Assessments of skeletal maturity in this stage are primarily based on the degree of epiphyseal fusion of the distal phalanges
Since all carpal bones have now attained their early adult shape, they are of less value for determination of bone age.
all carpals, metacarpals and phalanges are completely developed,
assessments of skeletal maturity are based on the degree of epiphyseal fusion of the ulna and radius.
Contains pictures of the handwrist for different chronological ages and for each sex
Patients radiograoph is matched with the photographs of atlas
use of cervical vertebrae to determine skeletal
maturity was suggested by Lamparski ¡n 1972.
. Presence or absence of a concavity at the lower border of the body of C2, C3, and C4
Skeletal parameters, such as hand wrist bones ossification, have been considered to cause an additional radiation exposure. To avoid such situation, new approaches as the cervical vertebrae maturation have been proposed.
Lateral ceph orientated with Nasion- Sella line horizontally
Peripheral border of sinus traced.
Highest (Sh) & lowest (S1) point of sinus extension is marked
Skeletal parameters, such as hand wrist bones ossification, have been considered to cause an additional radiation exposure. To avoid such situation, new approaches as the cervical vertebrae maturation have been proposed.
Skeletal parameters, such as hand wrist bones ossification, have been considered to cause an additional radiation exposure. To avoid such situation, new approaches as the cervical vertebrae maturation have been proposed.
The key landmarks and
planes were identified: Point A, most anterior point
of the premaxilla, Point B, most posterior point on
the posterior wall of the incisive foramen; and Point P,
point on the line tangent to the posterior walls of the
greater palatine foramen
The key landmarks and
planes were identified: Point A, most anterior point
of the premaxilla, Point B, most posterior point on
the posterior wall of the incisive foramen; and Point P,
point on the line tangent to the posterior walls of the
greater palatine foramen
Very large increases in approximation are evident during the late maturation period, from SMI 8 to 11. There is no significant difference between the amount of midpalatal sutural approximation between the male and female groups, although the male values were slightly higher in numerical value.
The key landmarks and
planes were identified: Point A, most anterior point
of the premaxilla, Point B, most posterior point on
the posterior wall of the incisive foramen; and Point P,
point on the line tangent to the posterior walls of the
greater palatine foramen