Skeletal Maturity Indicators

International Journal of Science and Research (IJSR)

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Skeletal Maturity Indicators - Review Article

Dr. Swapnil J. Korde

, Dr. Pallavi Daigavane

, Dr. Sunita Shrivastav

PG, Student Department of Orthodontics, Sharad Pawar Dental College Sawangi (Meghe) Wardha

Reader, Department of Orthodontics, Sharad Pawar Dental College Sawangi (Meghe) Wardha

Professor and Head, Department of Orthodontics, Sharad Pawar Dental College Sawangi (Meghe) Wardha

Abstract: Growth biologically and histologically is a composite of morphogenetic and histogenetic changes occurring continuously

over a period in response to genetic coding and environmental influence. It is one of the most myriad variations and plays an important

role in the etiology of malocclusion and also in the evaluation of diagnosis, treatment planning retention and stability of any case. In

this review, various methods currently used as skeletal maturity indicators have been discussed.

Keywords: Cervical vertebrae maturation indicators, hand and wrist radiographs, middle phalanx of third finger, skeletal maturity

indicators, canine calcification

1. Introduction

Every individual matures according to his or her own

biological clock. Different authors had reported different

methods in an attempt to determine the best indicator of

maturity. These include height

1,2,3

weight

chronological

age;

4,5,6

sexual maturation

frontal sinus

biological age or

physiological age; hand-wrist maturity;

2,08,09,10,11-13

cervical

vertebrae

14,15,16,17

dental eruption; dental calcification

stages

18,19,20,21

and recently introduced biomarkers.

22-29

An understanding of growth events is of primary importance

in the practice of clinical orthodontics. Maturational status

can have considerable influence on diagnosis, treatment

goals, treatment planning, and the eventual outcome of

orthodontic treatment. Clinical decisions regarding the use

of extra oral traction forces, functional appliances, extraction

versus nonextraction treatment, or orthognathic surgeries

are, at least partially, based on growth considerations.

Prediction of both the times and the amount of active

growth, especially in the craniofacial complex, would be

useful to the orthodontist.

Growth modulation procedures,

which bring about changes in the skeletal base such as the

use of extra oral orthopedic forces or functional appliances,

are suggested to be initiated during active growth periods.

These active growth periods have to be objectively assessed

for both the timing and the amount of active growth vector

or direction of growth. Maturational status of an individual

can be best evaluated relative to different stages of

physiologic maturity rather than evaluating it with

chronologic age because the latter is not a reliable indicator.

Physiologic maturity is best- estimated by the maturation of

one or more tissue systems, such as somatic, sexual, skeletal,

and dental maturity. Amongst the given indicators,

chronological age is considered to be an easy parameter to

assess expected amount of growth and development.

Chronological age

Birth date by calendar determines chronological age. Wide

individual variation lies in timing of pubertal growth spurt

with respect to chronological age. Therefore, thus,

chronological age cannot be considered as a reliable

indicator for the evaluation of maturity status of a

child.

02,31,32

This has led to the concept of Biological age or

physiological age.

Biological age or physiological age

The physiological age of a person is determined by the

degree of maturation of the different tissue systems.

Physiological age can be estimated by maturational status of

somatic, sexual, skeletal, and dental system.

Somatic maturity

An annual growth increment in height or weight determines

the somatic maturity.

Measurement of height represents

general growth of the skeleton. Average age of onset of

stature growth for females and males of approximately 10

and 12 years, respectively, with the peak coming later in

both sexes.

Height, therefore, might represent a skeletal

measure that can be used to predict the timing of the facial

growth spurt and needs further exploration.

Sexual maturation

Sexual maturation involves using secondary sex

characteristics to predict the individual maturational status.

Tanner had given separate sexual maturity ratings for boys

and girls which consists of five stages of sexual maturity

with stage 1 being the least mature (preadolescent) and stage

5 being the most mature (adult). In boys, Tanner Sexual

Maturity Ratings assesses pubic hair (amount, coarseness,

color and location), penile length and breadth, scrotal

development and testicular size. In girls, tanner sexual

maturation rating assesses breast development (size and

morphology) and pubic hair (location, color, morphology,

quantity). Prediction of sexual maturity requires a physical

examination, and hence use of sexual maturity as maturation

marker is limited in the orthodontic set up. Serial recording

of voice change in boys can be used as a measurement of

maturity but as mentioned above it requires a serial

recording, not practical in orthodontic clinics.

Menarche is

an important predictor of maturation in females.

Once

menstruation begins, the growth spurt is usually near

completion

Skeletal maturation

Certain bones in the body demonstrate an organized event of

ossification. Degree of ossification in these bones

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determines skeletal maturation. These changes can be seen

radiologically. The hand, foot, knee, elbow, shoulder, and

hip, cervical vertebrae can be used to assess skeletal age of

an individual. Skeletal maturity assessment involves visual

inspection of the developing bone and their initial

appearance, sequential ossification, and related changes in

shape and size. Thus, the skeletal maturity indicators provide

an objective diagnostic evaluation of stage of maturity in an

individual.

2. Pubertal/Adolescent Growth Spurt

The timing of recognition of the last and important growth

spurt that is, the pubertal growth spurt is important in

percept of orthodontics. It is during this growth phase, the

somatic growth rate is at its maximum. Every growth spurt

has definite onset, accelerating phase, peak of the growth

spurt, decelerating phase, end of the growth spurt. The

duration of this growth spurt is short in females around 3-4

years compared to males in which it extends 4-5 years. The

girls have an earlier onset of puberty whereas in the boys,

late onset is seen. The accelerating phase may last for 2

years on average. After 3 4 years of the end of this growth

spurt, the active growth ceases.

33-36

3. Assessment of Timing of Adolescent Growth

Spurt

The timing of the growth spurt can be assessed by

chronological age, skeletal age, physiologic age, and dental

age. The chronological age is not reliable as variability is the

rule of growth pattern. In most of the conditions, skeletal age

is assessed to pinpoint identify the different phases of the

growth spurt. A number of methods are available to assess

the skeletal maturity of an individual in orthodontic practice

which are broadly classified as follows:

A. Radiological

1. Special radiographs:

Use of hand-wrist radiographs: This is the most common

method and widely accepted method.

16,37,38-40

2. Lateral cephalograms:

Use of cervical vertebrae on a lateral cephalogram.

14,16

Use of frontal sinus using lateral cephalogram.

3. Orthopantomogram (OPG)/intraoral periapical:

Use of different stages of tooth development

14,18,19,42-44

B. Biochemical

Recent biochemical method in saliva and serum are the

23,45-

A. Insulin-like growth factor (IGF) growth hormone (GH),

B. Creatinine,

C. Alkaline phosphatase (ALP).

The review of the literature shows a vast ore on this topic.

These studies or reviews are related to methods of

assessment, correlation between different methods,

correlation between skeletal age and dental age and

chronological, etc.

Radiological

Hand wrist radiographs

The hand wrist radiograph is considered to be the most

standardized method of skeletal assessment. Assessment of

skeletal maturation using hand wrist radiograph as an index

based upon time and sequence of appearance of carpal bones

and certain ossification events has been reported by many

investigators. A number of methods have been described to

assess the skeletal maturity using hand-wrist

radiographs.

37,16,38-40

The following are the most commonly

used methods:

A. Atlas Method by Greulich and Pyle.

B. Biork, Grave and Brown Method modified by Schopf in

1978.

C. Fishman‟s skeletal maturity indicators.

D. Hägg and Taranger Method.

E. Singers Method.

Amongst all, Atlas Method by Greulich and Pyle is a

comparative method whereas all the other methods are

individualized methods. All of these methods rely on the

stage of the development of the epiphysis over the diaphysis.

Usually, all the methods depend on the assessment of the

following stages in ossification of phalanges:

Stage 1: The epiphysis and diaphysis are equal (Sign

convention „=‟).

Stage 2: The epiphysis caps the diaphysis by surrounding it

like a cap (cap).

Stage 3: Fusion occurs between the epiphysis and diaphysis

(U-Union).

Greulich and Pyle Method [1959]

Greulich and Pyle published an atlas containing the pictures

of standard hand wrist radiographs.In that they had given

ideal pictures of hand wrist radiograph for different

chronological age, and for each sex.Each photograph in atlas

representative of particular skeletal age.Patient radiograph is

matched with photographs in atlas.It involves comparing a

hand wrist film with standard of same sex and nearest

chronological age.The film then compared with adjacent

standards.Both older and younger than the one which is of

the nearest chronological age. Close one are chosen.

Bjork Grave and Brown [1976]

 They divide maturation process of bone of hand between

ages 9 to 17 years into 9 stages,

 Each stage represent level of skeletal maturity.

 Total 14 ossification points were used

 Development stage assessed according to relation between

epiphyses and diaphysis.

Stages-

First stage: ( Males 10.6 y , Females 8.1 y ) (Fig 2)

PP2- stageThe epiphysis and diaphysis are equal .Occurs

approximately 3 yrs before the peak of pubertal growth

spurts

Second stage:( Males 12 y , Females 8.1 y ) (Fig 3)

MP3 –stageThe epiphysis and diaphysis are equal.Just

before beginning of pubertal growth spurts

Third stage: ( Males 12.6 y , Females 9.6 y ) (Fig 4)

Pisi- stage = visible ossification of the pisiforme

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H1- stage = ossification of the hamular process of the

hamatum

R- stage = The epiphysis and diaphysis are equal.

Stageoccure 6 month b4

Fourth stage: ( Males 13 y , Females 10.6 y ) (Fig 5)

S = First mineralization of the ulnar sesamoid bone

H2- Progressive ossification of the hamular process of the

hamatum marks the beginning of growth spurt

Fifth stage: ( Males 14 y , Females 11 y )MP3 CAP (Fig 6)

The diaphysis is covered by cap shaped epiphysisThis stage

marks the peak of pubertal growth spurt

Sixth stage: ( Males 15 y , Females13 y ) (Fig 7)

DP3u : Visible union of epiphysis and diaphysis. Indicates

the end of pubertal growth spurt

Seventh stage: ( Males 15.9 y , Females13.3 y ) (Fig 8)

PP3u : Visible union of epiphysis and diaphysis.Occurs One

year after growth spurt. Little growth potential is remaining

Eighth stage:( Males 15.9 y , Females13.9 y ) (Fig 9)

MP3u : Visible union of epiphysis and diaphysis

Ninth stage: ( Males 18.5 y , Females 16y ) (Fig 10)

R u : Visible union of epiphysis and diaphysis of radius. End

of Active growth

FISHMAN SKELETAL MATURITY INDICATOR

[1982]

He made use of anatomical site on thumb, third finger, fifth

finger, and radius.The system uses 11 anatomical sites, all of

which exhibit consistency in time of onset of ossification

covering entire period of adolescent growth period.

Stages (Fig 11)

S.M.I. 1 PP3=

Third finger shows equal width of epiphysis with diaphysis

S.M.I.2 MP3=

Width of epiphysis equal to that of diaphysis in middle

phalanx of third finger

Appears during onset of prepubertal growth velocity

S.M.I.3 MP5=

Width of epiphysis equal to that of diaphysis in middle

phalanx of fifth finger

S.M.I. 4 S

Appearance of adductor sesamoid of thumb.Become visible

during period of very rapid growth velocity

S.M.I.5 DP3cap

Capping of epiphysis over diaphysis is seen in distal phalanx

of third finger.Peak height velocity

S.M.I. 6 MP3cap

Capping of epiphysis over diaphysis is seen in middle

phalanx of third finger.Become visible during period of very

rapid growth

Stage 7 MP5cap

Capping of epiphysis over diaphysis is seen in middle

phalanx of fifth finger.Peak height velocity

Stage 8 DP3U

Fusion of epiphysis over the diaphysis is seen in distal

phalanx of third finger.Time interval of decelerating growth

rate

Stage 9 PP3

Fusion of epiphysis over the diaphysis is seen in distal

phalanx of third finger

Stage 10 MP3u

Fusion of epiphysis and diaphysis is seen in middle phalanx

of third finger.Time interval of decelerating growth rate

Stage 11 R U

Fusion of epiphysis and diaphysis is seen in radius.Growth

completed

Hagg and Taranger Method

In 1982 they carried out longitudinal study on 212 Swedish

children. Skeletal development from hand wrist radiographs

is analyzed by taking annual radiographs between age of 6

and 18 years. The assessment is done for Ulnar Sesamoid of

metacarpophylangeal (S) joint of first finger and certain

specified stages of the three epiphyseal bones: middle

phalanges and distal phalanges of third finger (MP3 and

DP3) and distal epiphysis of radius (R).HAGG and

TARANGER 1982 made following findings concerning the

relationship in time between the various pubertal events:-

 Girls: if menarche has occurred PHV has been attain and

growth rate is decelerating. If menarche has not occurred

growth rate may be decreasing but has not yet reached the

level of the end of pubertal growth spurts

 Boys:-if a boy has prepubertal voice most probably the

PHV has not yet been reached

 If the voice change has begun the boys is in pubertal

growth spurts

 If the boy has a male voice the growth rate has begun to

decelerate.

 No boy will reach the end of pubertal spurt without having

male voice.

Middle phalanx-

MP3-F: (Fig 12)

The epiphysis is as wide as metaphysis.

Stage attained before onset of PHV

Stage indicate more than 80%of pubertal growth remaining.

MP3-FG: (Fig.13)

The epiphysis is as wide as metaphysis

Distinct medial and /or lateral border of epiphysis forming a

line of demarcation at right angle to distal border

Stage indicates the accelerating slop of pubertal growth spurt

MP3-G: (Fig.14)

Sides of epiphysis thickened and cap its metaphysis forming

sharp edge at one or both sides

Stage is attaining at about peak height of pubertal growth

spurts.

MP3-H: (Fig 15)

Stage is characterized by beginning of fusion epiphysis and

metaphysis. This stage indicated by decelerating slope of

PHV but before end of growth spurt.

MP3-I(Fig. 16)

This stage is characterized by completion of fusion of

epiphysis and metaphysis.This is attained at end of growth

spurt,

Third finger distal phalanx

DP3-I (Fig. 17)

Fusion of epiphysis and metaphysis completed. Indicates the

decelerating period of pubertal growth spurts. Means end of

peak height velocity.

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Distal Epiphysis of Radius (R)

R-I:

Fusion of epiphysis and metaphysis on radius has begun.

Stage R-i is attained one year before or at end of pubertal

growth spurt.

R-IJ:

Fusion almost completed

R-J: complete fusion of epiphysis and metaphysis

R-IJ, R-J:( Fig. 18) are not attained before the end of

pubertal growth spurts

Rajgopal and Kansal in 2005

modified the stages of MP3

MP3-F stage: (Fig. 19)Start of the curve of pubertal growth

spurt.

Epiphysis is as wide as metaphysis.

Ends of epiphysis are tapered and rounded.

Metaphysis shows no undulation.

Radiolucent gap (representing cartilageous epiphyseal

growth plate) between epiphysis and metaphysis is wide.

MP3-FG stage: (Fig 20)Acceleration of the curve of

pubertal growth spurt.

Epiphysis is as wide as metaphysis.

Distinct medial and/or lateral border of epiphysis forms line

of demarcation at right angle to distal border.

Metaphysis begins to show slight undulation.

Radiolucent gap

MP3-G stage: (Fig. 21)Maximum point of pubertal growth

spurt.

Sides of epiphysis have thickened and cap its metaphysis,

forming sharp distal edge on one or both sides.

Marked undulations in metaphysis give it “Cupid‟s bow”

appearance.

Radiolucent gap between epiphysis and metaphysis is

moderate.

MP3-H stage: (Fig. 22)Deceleration of the curve of pubertal

growth spurt.

Fusion of epiphysis and metaphysis begins.

One or both sides of epiphysis form 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 undulation is distinctly present.

Radiolucent gap between epiphysis and metaphysis is

narrower.

MP3-HI stage: (Fig. 23)Maturation of the curve of pubertal

growth spurt.

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.

MP3 I Stage(Fig.24)

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.

Singers Methode [1980]

Julian Singer in 1980 proposed system of hand wrist

radiographic assessment. It helps the clinician to rapidly

determine maturational status of adolescent patient. This

system has six stages.

Stage

Characteristic feature

Relation of epiphysis and diaphysis

Inference

Stage 1 (early)

1.Absence of pisiform 2.absence of hook of

hamate

Epiphysis of proximal phalanx of

second finger being narrower than

its diaphysis

1year before beginning of peak

pubertal growth

Stage 2

(prepubertal)

1.Initial ossification of hook of hamate

2.Initial ossification of pisiform

PP2=

Just beginning of pubertal

growth spurt.

Mandibular growth potential is

possible

Stage 3

(pubertal onset)

1.Begining of calcification of ulnar sesamoid

2.Increased calcification of hook of hamate and

pisiform

Increased width of epiphysis of

proximal phalanx of second finger

Onset of pubertal growth spurt.

Stage 4

(pubertal)

calcified ulnar sesamoid

MP3 cap

Accelerating phase of pubertal

growth spurt

Stage 5

(pubertal

deceleration)

Fully calcified ulnar sesamoid

1.DP3-U

2.Radius and ulna not fully fused

with respect to shaft

This stage represent that period

of growth when orthodontic

treatment might be completed

and patient is on retention

therapy

Stage 6

No remaining growth sites

R-U

Growth completed

4. Lateral Cephalograms

Skeletal Maturation Evaluation Using Cervical Vertebrae

Cervical Vertebrae maturational indicator(CVMI) given by

Lamparski

in 1965.

The primary objective of the author was to create a method

of evaluating the skeletal maturation of the orthodontic

patient with the cephalometric radiograph that is routinely

taken with pretreatment records. Correlations were made

between cervical vertebrae maturation and the skeletal

maturation of the hand-Wrist.

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Lamparski studied changes in size and shape of cervical

vertebrae to create maturational standards for the cervical

vertebrae. Six categories of cervical vertebrae skeletal

maturation could be defined, and the following observations

were made for each category.

5. Stages of Cervical Vertebrae Maturation

Indicator

Stage 1 / Category 1

 All inferior borders of the bodies of C2, C3 and C4 are

flat.

 The Superior borders are strongly tapered posterior to

anterior region.

 Very significant amount of adolescent growth expected.

Stage 2 / Category 2

 A concavity has developed in the inferior borders of C2

and C3.

 The anterior vertical height of the bodies has increased.

 C3 and C4 are more rectangular in shape.

 Significant amount of adolescent growth expected.

Stage 3 / Category 3

 Distinct concavities have developed in the inferior border

of the C2 and C3.

 C4 starts developing concavity in lower border of body.

 Moderate amount of growth expected.

Stage 4/Category 4

 C3 and C4 are nearly square in shape.

 Distinct concavities in lower borders of C2, C3 and C4.

 Small amount of growth expected.

Stage 5 / Category 5

 C3 and C4 are square in shape.

 Accentuated concavities are formed in C2, C3 and C4

 Insignificant amount of growth expected.

Stage 6 / Category 6

 C3 and C4 are increased in Vertical height and are higher

than they are wide.

 All concavities have deepened.

 Adolescent growth is completed.

 Later, Hassel and Farman in 1995

used the cervical

vertebrae and developed a system of skeletal maturation

determination. Later, this was modified by Baccettiet al.

2005

. The shapes of the cervical vertebrae were seen to

differ to teach level of skeletal development. This

provided a means to determine the skeletal maturity of a

person and thereby determine whether the possibility of

potential growth existed. The shapes of the vertebral

bodies of C3 and C4 changes from wedge shape to

rectangle followed by square shape. In addition, they

became taller as skeletal maturity progressed. The inferior

vertebral borders were flat when immature and became

concave with maturity. The curvatures of the inferior

vertebral borders seem to appear sequentially from C2 to

C3 to C4 as the skeleton matures. The concavities become

more distinct as the person matures.

14,16

 Hassel and Farman in 1995

found the correlation

between skeletal maturity indicators seen in hand wrist

radiograph and cervical maturity indicators in lateral

cephalogram.

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. 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.

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.

Category 3 was called TRANSITION.This corresponded to

a combination of SMI 5 and 6. 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 borders of C2 and C3.

A concavity was beginning to develop in the inferior border

of C4. The bodies of C3 and C4 were rectangular in shape.

Category 4 was called DECELERATION.This

corresponded to a combination of SMI 7 and 8. 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

squarer in shape.

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.

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. Bacetti et al

in 2005

modified the stages given by Hassel and

Farman

(Fig. 25)

Cervical stage 1- The lower borders of all the three

vertebrae (C2-C4) are flat. 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 on average 2 years after this

stage.

Cervical stage 2- A concavity is present at the lower border

of C2 (in four of five cases, with the remaining subjects still

showing a cervical stage 1). The bodies of both C3 and C4

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are still trapezoid in shape. The peak in mandibular growth

will occur on average 1 year after this stage.

Cervical stage 3- 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 during the year after this

stage.

Cervical stage 4- 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 1 or 2 years before this stage.

Cervical stage 5 -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. The

peak in mandibular growth has ended at least 1 year before

this stage.

Cervical stage 6 -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.

The peak in mandibular growth has ended at least 2 years

before this stage.

6. Intraoral Radiographs/OPG

Tooth Mineralization - An Indicator of Skeletal Maturity

Dental maturity can be determined by the stage of tooth

eruption or the stage of tooth formation. Tooth formation is

proposed as more reliable criteria for determining dental

maturation. The ease of recognition of dental development

stages, together with the availability of periapical or

panoramic radiographs in most orthodontic and dental

practices are practical reasons for attempting to assess the

physiologic maturity without resorting to hand wrist

radiographs. Various researchers have carried out extensive

work to correlate the dental age and skeletal age. It is

believed that stages of root formation and mineralization

have a close relationship with the skeletal maturation of an

individual. Relationships between the stages of tooth

mineralization of the mandibular canine appear to correlate

better with ossification stages than do the other teeth. Some

of the dental indicators for skeletal maturity were put

forward by Chertkow and Fatti

based on the mineralization

of the lower canine. Nolla‟s

stage of calcification was

utilized by some workers to correlate with skeletal maturity.

Goldstein and Tanner have described a similar method based

on third molar. If a strong association exists between skeletal

maturity and dental calcification stages, the stages of the

dental calcification might be used as a first level diagnostic

tool to estimate the timing of the pubertal growth spurt.

Relationships between the stages of tooth mineralization of

the mandibular canine appear to correlate better with

ossification stages than do the other teeth.

Demirjlan’s Stages of Dental Calcification (1973)

Demirjian developed a method for estimating dental

maturity or dental age using radiological appearances of the

mandibular teeth i.e. from incisors to molars. Each tooth was

rated according to the developmental criteria. (Amount of

dentinal deposit, shape changes of pulpal chamber, etc)

Rather than changes in size. Eight stages i.e. from A to H

were defined from first appearance of calcified points to the

closure of apex.

18,19,42,43,45

Panoramic radiographs were used because they are easier to

make than intra oral radiographs in young and nervous

children and they give less radiation for full mouth

radiograph and picture of the mandible region produced is

little distorted. Though there is 3% to 10% enlargement of

the mandible (Sapoka and Demirjian 1971) this is not a

serious drawback, because the rating system is based on

shape criteria rather than on absolute lengths.

Canine calcification stages starts from stage D to H

Stage D (Fig. 26)

 The crown formation is completed down to the cemento-

enamel junction.

 The superior border of the pulp chamber has a definite

curved form, being concave towards the cervical region.

 The projection of the pulp horn, if present, gives an

outline shaped like an umbrella top.

 Beginning of root formation is seen in the form of a

Spicule.

Stage E (Fig. 27)

 The walls of pulp chamber now form straight lines, whose

continuity is broken by the presence of the pulp horn,

which is larger in the previous stage.

 The root length is less than the crown height.

Stage F (Fig. 28)

 The walls of the pulp chamber now form a more or less

isosceles triangle. The apex ends is funnel shape.

 The root length is equal to or greater than the crown

height.

Stage G (Fig. 29)

 The walls of the root canal are now parallel.

 Its apical end is still partially open.

Stage H (Fig. 30)

 The apical end of root canal is completely closed.

 The periodontal membrane has a uniform width around

the root and the apex.

7. Conclusion

Growth maturation stages are important for proper timing

and treatment management. Various methods are present of

which skeletal and physiologic/biochemical methods are

reliable for the clinical references. The review also suggests

that more simplified noninvasive methods can be considered

as additional diagnostic tool to avoid exposure to radiation.

Paper ID: ART20163727

366

International Journal of Science and Research (IJSR)

ISSN (Online): 2319-7064

Index Copernicus Value (2015): 78.96 | Impact Factor (2015): 6.391

Volume 6 Issue 3, March 2017

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Licensed Under Creative Commons Attribution CC BY

Figure 1: Stages in ossification of phalanges

Figure 2: First stage: ( Males 10.6 y , Females 8.1 y )

Figure 3: Second stage (Males 12y, Females 8.1 y)

Figure 4: Third stage: (Males 12.6y, Females 9.6y)

Figure 5: Fourth stage: (Males 13y, Females 10.6 y)

Figure 6: Fifth stage: (Males 14y, Females 11y)MP3 cap

Figure 7: Sixth stage (Males 15y, Females13y)

Figure 8: Seventh stage (Males 15.9y, Females13.3y)

Figure 9: Eighth stage (Males 15.9 y, Females13.9 y)

Figure 10: Ninth stage: (Males 18.5y, Females 16y)

Figure 11: Stages

Figure 12: MP3 F stage by Hagg and Taranger

Figure 13: MP3 FG stage by Hagg and Taranger

Figure 14: MP3 G stage by Hagg and Taranger

Figure 15: MP3 H stage by Hagg and Taranger

Figure 16: MP3 I stage by Hagg and Taranger

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Figure 17: DP-3 I stage by Hagg and Taranger

Figure 18: R-J stage by Hagg and Taranger

Figure 19: MP3-F stage modification by

Figure 20: MP3-FG stage modification by

Figure 21: MP3-G stage modification by Rajgopal and

Kansal

Figure 22: MP3-H stage modification by Rajgopal and

Kansal

Figure 23: MP3-HI stage modification by Rajgopal and

Kansal

Figure 24: MP3-I stage modification by Rajgopal and

Kansal

Figure 25: CVMI Stages

Figure 26: Mandibular Canine calcification stages stage D

Figure 27: Mandibular Canine calcification stages stage E

Figure 28: Mandibular Canine calcification stages stage F

Figure 29: Mandibular Canine calcification stages stage G

Figure 30: Mandibular Canine calcification stages stage H

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