Skeletal Age

Assessment

Presented by:

Dr. Gaurav Acharya

2nd year PG Resident

Department of Orthodontics and Dentofacial Orthopedics

Peoples Dental College and Hospital, Kathmandu

Growth Prediction

Chronological Age

Dental Development

Growth Charts

Secondary Sexual

Characteristics

Skeletal Development

Skeletal Age

Assessment

Hand wrist radiograph

Cervical vertebra

Frontal Sinus

Midpalatalsuture

Hand wrist Radiograph

Most standardized method

Shows predictable and scheduled pattern of appearance, ossification & union.

Hand wrist Radiograph

Sequence of Ossification

First to Ossify→

Capitate

Last to Ossify→

Sesamoid

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: Birth to 10 months

Males: Birth to 14 months

Hamate Capitate

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 10 months to 2 years

Males: 14 months to 3 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 10 months to 2 years

Males: 14 months to 3 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 10 months to 2 years

Males: 14 months to 3 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 10 months to 2 years

Males: 14 months to 3 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 2 years to 7 years

Males: 3 years to 9 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 7 years to 13 years

Males: 9 years to 14 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 13 years to 15 years

Males: 14 years to 16 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 13 years to 15 years

Males: 14 years to 16 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 13 years to 15 years

Males: 14 years to 16 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 13 years to 15 years

Males: 14 years to 16 years

Hand wrist Radiograph

Infancy

Toddlers

Pre-puberty

Puberty

Late Puberty

Post-puberty

Females: 15 years to 17 years

Males: 17 years to 19 years

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)

Hand wrist Radiograph

Atlas of Greulich and Pyle (1959)

Hand wrist Radiograph

Atlas of Greulich and Pyle (1959)

Hand wrist Radiograph

Atlas of Greulich and Pyle (1959)

Hand wrist Radiograph

Atlas of Greulich and Pyle (1959)

Hand wrist Radiograph

Fishman Method (1982)

Cervical Vertebra

Suggested by Lamparski in 1972.

Possible with routinely taken lateral cephalograms

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

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

Cervical Vetebra

Init

iati

on

Acc

eler

atio

n

Tra

nsi

tion

Dec

cele

rati

on

Mat

ura

tion

Com

ple

tion

C2

C3

C4

Cervical Vertebrae

Co- relation of Hand wrist & Cervical Vertebra maturation Stages1

1- Garcia fernandez. The cervical vertebrae as maturational indicators, JCO APRIL 1998

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

Frontal Sinus

Radiographs taken at yearly intervals.

Average yearly growth velocity (millimeters per year) of the frontal sinus was calculated

Frontal Sinus

From longitudinal growth data of the subjects, the average yearly body height growth velocity (millimeters per year) was calculated

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

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

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

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

Midpalatine SutureResults

Increase in sutural approximation as SMI stages progressed.

SMI 1&2- decreased suturalapprox.

After SMI 9- significant increase in the sutural approx.

No significant difference b/n sexes.

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.

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

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

Thank You…