This document discusses various methods for assessing skeletal maturity and dental age from radiographs, including: - Greulich & Pyle atlas method for dental age - Bjork, Grave & Brown method and Fishman's index for skeletal maturity assessment from hand-wrist radiographs - Hagg & Taranger's method focuses on the middle phalanx of the middle finger - Cervical vertebrae maturation indicators divide maturation into six stages based on vertebral morphology - Eight stages of tooth development are also described from initiation of calcification to root completion. Assessing skeletal and dental maturity from radiographs has several clinical indications and helps predict growth and timing of pubertal growth spurt.

1. Dr. Rakesh Kumar
Reader, Dept Of Orthodontics
Navodaya Dental College, Raichur

2.  Hand wrist radiographs
 Dental age
 Cervical vertebrae maturation

3.  Atlas method by Greulich & Pyle
 Bjork, Grave & Brown
 Fishman’s index
 Hogg & Taranger method
 Singer’s method

4. Indications of hand wrist radiographs
1. Discrepancy between dental & chronologic age
2. Determination of skeletal maturity status prior
treatment
3. To assess skeletal age in patients whose growth is
affected by infections, neoplastic or traumatic
conditions
4. Serial assessment of skeletal age which helps in
predicting future skeletal maturation status
5. To predict pubertal growth spurt
6. In cases of orthognathic surgery to asses growth
7. Valuable aid in research to study role of hereditary,
environment, nutrition etc on skeletal maturation

5. Description of Hand Wrist X-ray
Ulna
Radius
Capitate Bone Lunate Bone
Tricuetral Bone
Pisi Form Bone
Hamate Process
Hamate Bone
Trapezium Bone
Trapezoid Bone
Scaphoid Bone
Sesamoid Bone
M
M
M
M
M
P
P
P
P
P
P
P
P
P
P
P
P
P
P

6. Development of the ring finger, row by row. The image top-left is from a baby; the
image at the lower right is from a nineteen year old. In the fifth image, the
epiphysis appears, which becomes wider and in the final images fuses with the
metaphysis. These images are taken from the Greulich and Pyle atlas.

7. Bjork – (1972), Grave & Brown (1976)

8. 1.The epiphysis of the proximal
phalanx of the index finger
(PP2)has the same width as the
diaphysis
2.Epiphysis of the middle
phalanx of the middle
finger (MP3) is of the same
width as the diaphysis
3. Pisi stage=Visible
ossification of the pisiforme
H1 stage=Ossification of the
hamular process of the
hamatrum
R= stage.same width of
epiphysis and diaphysis of thr
radius

9. 4.S-stage=first
mineralisation of the
metacarpophalangeal
joint of the thumb
H2-stage=ossification
of the hamular process
of the hamate
5.The diaphysis is
covered by the cap-
shaped epiphysis
In the MP3 cap stage,the
processs begins at the
middle phalanx of the
third finger;
In the PP1 cap stage ,at
the proximal phalanx of
the thumb;and in the
Rcap stage, at the radius

10. 6.Visible union of epiphysis and
diaphysis at the distal phalanx of the
middle finger(DP3)
7.Visible union of epiphysis at the
proximal phalanx of the little
finger(PP3)
8.Union of epiphysis and diaphysis
at the middle phalanx of the middle
finger is clearly visible(MP3)
9.Complete union of epiphysis and
diaphysis of the radius.
The ossification of all the hand bones
is completed and skeletal growth is
finished

11. Fishman’s Maturation Index

12.  Stage I (early )
absence of ossification of pisiform & hook of
hamate
epiphysis of proximal phalanx of 2nd finger
short of diaphysis

13.  Stage II ( prepubertal )
initial calcification of pisiform & hook of
hamate process
epiphysis of proximal phalanx of 2nd finger
similar to diaphysis

14.  Stage III ( pubertal onset )
initial calcification of ulnar sesamoid
increased width of epiphysis of proximal
phalanx of 2nd finger
calcified pisiform & hamate process

15.  Stage IV ( pubertal )
calcified ulnar sesamoid
epiphysis covering of diphysis of middle
phalanx of middle finger

16.  Stage V ( pubertal deceleration )
fully calcified ulnar sesamoid
union between epiphysis & diaphysis of distal
phalanx of middle finger

17.  Stage VI ( growth completion )
 No remaining growth sites seen.

18. Hagg &
Taranger’s
- MP3

19. Cervical Vertebrate maturation indicators

20. 1. Initiation (SMI 1&2)
• Very significant amount of the adolescent growth expected
• C2, C3 and C4 inferior vertebral body borders are flat
• Superior vertebral borders are tapered posterior to anterior
2. Acceleration (SMI 3&4)
• Significant amount of adolescent growth expected
• Concavities developing in lower borders of C2 and C3
• Lower borders of C4 vertebral body is flat
• C3 and C4 are more rectangular in shape

21. 3. Transition (SMI 5&6)
• Moderate amount of adolescent growth is expected
• Distinct concavities of the lower borders of C2 and C3
• C4 developing concavity in lower border of body
• C3 and C4 are rectangular in shape
4. Deceleration (SMI 7&8)
• Small amount of adolescent growth is expected
• Distinct concavities in lower borders of C2,C3 and C4
• C3 and C4 are nearly square in shape

22. 5. Maturation (SMI 9&10)
• Insignificant amount of adolescent growth expected
• Accentuated concavities in lower borders of C2,C3,C4
• C3 and C4 are square in shape
6. Completion (SMI 11)
• Adolescent growth is completed
• Deep concavities are present for inferior vertebral body
borders of C2,C3 and C4
• C3 and C4 heights are greater than widths

23. C2
C3
C4
C5
C6
Cvs 1 Cvs 2 Cvs 3 Cvs 4 Cvs 5 Cvs 6
Development stage of Cervical Vertebrae

24. Development stage of tooth

25. Eight relevant stages of dental development
A – Calcification if single occlusal points
without fusion of different calcifications
B – Fusion of the materialization points the
contour of the occlusal surface is recognizable

26. C – Calcification of the crown is
complete: beginning of dentin deposits.
The pulp chamber is curved, and no
pulp horns are visible.
D - Crown formation is complete up to the cement enamel
junction. Root formation has commenced. The pulp horns are
beginning to differentiate, but the wall of the pulp remain
curved.
E – Root length shorter than crown height .The walls of the
pulp chamber are straight, and the pulp horn have become
more differentiated than in the previous stage .In molars the
radicular bifurcation has commenced to calcify.

27. F – Root length larger than crown
height the walls of the pulp chamber
now form an isosceles triangle. In
molars the bifurcation has developed sufficiently to give the
root a distinct form.
G – Root formation finished. Apical foramen still open, the
walls of the root canal are now parallel. In molars only the
distal root is rated.
H – Apical foramen is closed the periodontal membrane
surrounding the root and apex is uniform in width throughout.