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MIDDLE PHALYNX OF THIRD FINGER (MP3) -A REVIEW

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 A Case Report - Oral Surgery

MIDDLE PHALYNX OF THIRD FINGER (MP3) - A REVIEW

1. Dr. Sarika Sharma, 2. Dr. Sukhdeep Singh, 3. Dr. Neha Awasthi and 4. Dr. Mandeep Kaur
1, 2 & 3 - Dept of Pediatric Dentistry, School of Dental Sciences, Sharda University, Greater Noida.
4 - Faculty of Dentistry, Jamia Millia Islamia, New Delhi.

ABSTRACT
Maturational status of an individual can be best evaluated relative to different stages of physiologic maturity rather than evaluating it
with chronologic age because latter is not a reliable indicator. Thus, additional information is necessary to estimate the maturation
level of the individual. Such information can be obtained from the dental, skeletal, and pubertal development. There are various
skeletal maturity indicators such as hand and wrist, cervical vertebrae, midpalatal suture, middle phalynx of third finger (MP3)
etc.to name a few. Through this paper we want to review the role of MP3 as skeletal maturity indicator and at the same time evaluate
the reliability of the same.

INTRODUCTION
Interceptive and preventive orthodontics is an integral part of
paediatric dentistry. There are many advantages to providing
treatment during early developmental stages in children.1 The
developmental status of a child is usually assessed in relation to
the physical events that take place during the progress of growth,
such as the skeletal ossification stages, the attainment of the peak
growth velocity, or the pubescent changes in the body. Although
growth events occur in a reasonably constant sequence the ages at
which they are reached vary considerably among children. The
indicators of the developmental age are, therefore, more
informative than the chronological age, particularly for clinical
application.2
Skeletal maturation refers to the degree of development of
ossification in bone.3 These changes can be seen radiologically in
the bone.Bones such as hand4, midpalatal suture5, middle phalynx
of third finger (MP3)6 and cervical vertebrae3 can be assessed to
determine skeletal age of an individual. The anatomic changes in
the MP3 region can be recorded conveniently by using dental x-
ray film and machine reducing the x ray exposure to minimum.7
Hence it is a simple, reliable cost effective and time saving
technique for the assessment of skeletal maturity.8
Therefore, we aim to discuss the reliability and efficacy of MP3 as
a skeletal maturity indicator through this paper. Based on the
research done in the past, we want to review the role of middle
MP3 as one of the skeletal maturity indicator.
DISCUSSION
Hagg and Tarangerin 1982 was the first person to note that the
stages of ossification of the middle phalynx of the third finger
(Mp3) follow the pubertal growth spurt.6They described the
stages of development of MP3 region namely MP3F, MP3FG,
MP3G, MP3H and MP3I .
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 and this period should be utilized for
modifying growth. Every growth spurt has definite onset,
accelerating phase, peak of the growth spurt, decelerating phase
and end of the growth spurt.9 The MP3 stages are five stages
representing the different stages of the pubertal growth spurt from
onset to end which are as follows (Fig 1):
Fig 1: Representation of the developmental stages of the MP3 region
1. MP3-F stage (onset or start of the curve of pubertal growth
spurt); In this stage epiphysis is as wide as metaphysis.
2. MP3-FG stage (acceleration part of the curve of pubertal
growth spurt); Epiphysis is as wide as the metaphysis and
there is a distinct medial and or lateral border of the epiphysis
forming a line of demarcation at right angle to the distal border.
3. MP3-G stage (peak-PTV, the point of maximum pubertal
growth spurt); Sides of the epiphysis becomes thick and caps
its metaphysis forming a sharp edge distally at one or both
sides.
4. MP3-H stage (deceleration part of the curve of pubertal
growth spurt); Fusion of the epiphysis and metaphysis begins.
5. MP3-I stage (end of pubertal growth spurt); Fusion of
epiphysis and metaphysis is completed Chapman in 1972 was
the first to use periapical x-ray film to evaluate ossification of
the ulnar sesamoidbone as a skeletal maturity indicator.10
Abdel - Kader in 1998 applied this idea to record MP3 stages. He
recorded middle phalynx of third finger (MP3) stages with the
dental periapical radiographs and the standard dental x-ray
machine which fulfilled the principle of ALARA, which states
that the patient should be subjected to only that amount of
radiation that is absolutely needed for the diagnostic

Dental Buzz 1
Journal of ida North-West Delhi Branch - Feb. 2015 • Volume 2 • Issue 1
Dr. Sarika Sharma, Dr. Sukhdeep Singh, Dr. Neha Awasthi and Dr. Mandeep Kaur
MIDDLE PHALYNX OF THIRD FINGER (MP3) -
A REVIEW
purpose.7Hence MP3 can be a boon if compared to other skeletal
indicators.
In 1999Abdel - Kader further used digital dental radiography for
recording the adductor sesamoid and MP3 stageswhich gave a
more precise detection of the different stages of pubertal growth
spurt period and the late mandibular growth stage.11(Fig 2)
Fig 2: Digitalradiographic images of the various MP3 stages
Fig 2: Digital radiographic images of the various MP3 stages
There was much faster and easier orthodontist-patient-parent
communication and the time of X-ray exposure was five times
lower than usual MP3 method.
Modified MP3 stages (Fig 3): R. Rajgopal & Sudhanshu Kansal
in 2002 added an additional bone stage between MP3 - H and
MP3 - I which they called as MP3 - HI.12 In this new stage
superior surface of epiphysis showed smooth concavity and the
radiolucent gap between epiphysis and metaphysis was
insignificant. Moreover, metaphysis showed smooth, convex
surface, almost fitting into reciprocal concavity of epiphysis.
Further, they compared the modified MP3 stages and CVMI
(cervical vertebrae maturation index) given by Hassel and
Farmanin 1995 as growth indicator 3 and found a high correlation
with an overall similarity of 94.7%.
Fig 3: Six modified stages of MP3 development
Dental Buzz
Journal of ida North-West Delhi Branch - Feb. 2015 • Volume 2 • Issue 1
A Case Report - Oral Surgery
Kucukkles et al. categorized CVMI stages into prepeak
represented by CVMI 1 and 2, peak by CVMI 3 and 4 and
postpeak by CVMI 5 and 6 respectively.13
In 2003 S.Madhu et al. assessed the reliability of MP3 method
with the CVMA method and categorized the MP3 stages into the
clinically relevant categories of prepeak, peak and postpeak
stages. They found that the prepeak period coincided with MP3F
and MP3FG and is the ideal time to start a growth initiation
procedure. The peak period of growth coincided with the MP3G
stage, and treatment initiated during this period does not have a
favorable prognosis. The post-peak stage was represented by the
MP3H and MP3I stages and initiation of growth modification
procedures are contraindicated in this stage.14
Another interesting observation was noted by them on comparing
the corresponding chronological age in males and females
according to MP3 stages. Correlation in both males and females
was very highly significant. The initiation of pre-peak stage of
growth was achieved at 12.18 + 1.25 years in boys and 10.36+
0.92 years in girls and the peak stage that is MP3G, at 13.50 + 0.72
for boys and 12.13+0.35 for girls respectively. The active growth
phase was found essentially complete at 17 years for boys and
14.60 + 0.55 years for girls.
Bala M, Pathak A, Jain R15 conducted a study to assess skeletal age
using MP3 and hand – wrist radiographs and to find the
correlation amongst the skeletal, dental and chronological ages.
Skeletal age from MP3 and hand – wrist radiographs showed high
correlation in all the age groups for both sexes. The dental age was
assessed from IOPA radiographs of right permanent maxillary
canine based on Nolla’s calcification stages. Skeletal age showed
high correlation with dental age in 12-14 years age group.
One another study was undertaken by Deepa Hegde, Sudhindra
Baliga, Ramakrishna Yeluri, AK Munshi8 with the main aim of
determining the reliability of the digital radiograph of the MP3
region as compared to the CVMI in the evaluation of skeletal
maturity and to further categorize them peak-wise into prepeak,
peak, and postpeak stages. According to their observations, the
digital MP3 radiographic method of skeletal maturity assessment
was reliable, with results comparable to the standard CVMI
method. Their peak- wise distribution was similar as Madhu et.al.
Mandava Prasad, Venkata Suresh Kumar Ganji, Suja Ani George,
and Sharath Kumar Shetty16observed that there was a good
concordance between 6 stages of CVMI and the 6 stages of MP3
given by Rajagopal and Kansal. Physiological maturity was
earlier in females than in males when compared to the individuals
of opposite sex of same chronological age. Chronological age was
not a valid predictor of assessing the skeletal maturity because of
significant variations in the distribution of CVMI and MP3 stages
with respect to individual chronological age distribution.
Gautham Hegde, Nanditha Hegde, Anil Kumar, Keshavraj17
compared the developmental stages of the mandibular canine
with that the stages of modified MP3 and to find if any correlation
exists between the two. He concluded that the correlation between
canine calcification stages and MP3 stages was of high statistical
significance.
A study was conducted by Suchita M. Tarvade (Daokar), Sheetal
Rama krishna and Sanjay Sarode18 to evaluate the salivary
1
Dr. Sarika Sharma, Dr. Sukhdeep Singh, Dr. Neha Awasthi and Dr. Mandeep Kaur
MIDDLE PHALYNX OF THIRD FINGER (MP3) -
A REVIEW
alkaline phosphatase (ALP) activity in growing subjects in
relation to the stages of individual skeletal maturation using
middle phalynx of third finger (MP3). Salivary ALP were
estimated by the enzymatic method using p-nitro phenyl
phosphate as substrate and MP3 stages were assessed using Hagg
and Taranger method. ALP is a marker for osteoblastic activity
therefore growing children have higher levels than fully grown.
Highest levels of ALP are detected during the rapid growth phases
of the childhood such as infancy and puberty.
According to the authors study was done to evaluate salivary ALP
levels at MP3 stages since MP3 stages are more relevant. FG stage
indicates acceleration of the curve of pubertal growth spurt and G
stage with maximum point of pubertal spurt. It was found that
peak levels of salivary ALP levels in girls as well as in boys
correlated with G stage of MP3. Thus a strong correlation of
salivary ALP levels with growth spurt was established and clinical
relevance of MP3 was proved.
By examining the MP3 digital radiograph the clinician can now
evaluate the skeletal maturity of the patient at that point in time
and have a reasonable idea as to how much growth should be
factored into the proposed treatment.8
CONCLUSION
1. MP3 stages using periapical x-ray film can be accurate,
simple, practical and economical growth indicator for
making decisions on treatment timing.
2. Use of digitized radiographic image of the MP3 reduces
the exposure five times less than the conventional approach
and give more precise detection of the different
stages of pubertal growth spurt period.
3. The peak period of growth coincided with the MP3G stage
and females achieve the peak growth period almost 2 years
before males.
REFERENCES
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Dental Buzz
Journal of ida North-West Delhi Branch - Feb. 2015 • Volume 2 • Issue 1
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A Case Report - Oral Surgery
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Address for correspondence :
Dr. Sukhdeep Singh, MDS
Dept. of Pediatric Dentistry,
School of Dental Sciences,
Sharda University, Greater Noida.
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