The document discusses various methods used to assess skeletal maturity indicators including hand-wrist radiographs, cervical vertebrae morphology, and tooth development stages. It describes in detail the Greulich and Pyle atlas method of comparing radiographs to standardized images, the nine stages of the Bjork, Brown, Grave method, Singer's six stage system, and Fishman's 11 skeletal maturity indicators. Assessment of cervical vertebrae morphology uses the six stage Cervical Vertebral Maturation Index. Skeletal maturity assessment is useful for orthodontic treatment planning, predicting growth, and research studies.

1. Presented by- Dr. Smaraki Mahapatra
Guided by-Dr. Neetu Dabla

2. 1.Introduction
2.History
3.Hand-wrist Radiograph
4.Methods of Hand-wrist Radiograph as SMI
a. Greulich and Pyle Method
b. Bjork, Grave and Brown Method
c. Singer’s Method
d. Fishman’s SMI
e. Hagg and Taranger Method
f. Modification of Hagg and Taranger Method
5. Cervical vertebrae as SMI and its Modification
6. Tooth mineralization as SMI
7. Applications
8. Conclusion
9.References

3.  Since orthodontist works primarily with teeth and
bone, the skeletal age or bone age can provide reliable
information while helping in accurate growth prediction.
 The level of maturity attained and the amount of growth
potential remaining is an important consideration while
treating malocclusion.

4. A number of methods are available to assess the
skeletal maturity indicators. They include :-
a. Use of hand-wrist radiographs
b. Evaluation of skeletal maturation using cervical
vertebrae
c. Assessment of maturity by clinical and radiographic
examination of different stages of tooth development.

5. 1. 1896- Ranke is considered to have been the first to
study skeletal development progress by means of wrist
roentgenogram.
2. 1910-
i. Rotch recognized that weight, height, and tooth eruption
were at best only rough estimates of physical maturity in
terms of chronological age.
ii. Bayley found a correlation between maturation of the
knee as seen on the roentgenogram up to 13 years.
iii.Garn and Rohmann concluded that hand-wrist ossification
is useful in detecting growth abnormalities but it is not a
precise method of measuring developmental progress in
normal individuals.

6.  1931- Todd TW started a longitudinal study by taking
a series of periodic hand and wrist radiographs of
growing children in Cleveland, Ohio, USA.
Unfortunately , Professor Todd died in 1938 after
publishing the initial data of his study in 1937.
 1959- After his death , the study was continued and
William Greulich and Idell Pyle compiled the
Radiographic atlas of skeletal development of hand
and wrist , which was published in 1950 and revised.

7. THOMAS
WINGATE TODD
LEOPOLD VON
RANKE
THOMAS MORGAN
ROTCH
Dr. Urban Hagg
SM Garn
William Walter
Greulich
Leonardo S.
Fishman

8.  1965- Lampirski developed 6 stages of CVM.
 1976-Bjork, Brown, Grave discovered 9
developmental stages of skeletal maturation.
 1980-Julian Singer proposed 6 stages of Hand-wrist
development.
 1982- Leonardo S. Fishman’s 11 SMI
 1995-Hassel and Farman proposed CVMI 6 stages of
skeletal maturation.
2005-Bacietti et al modified Hagg and Taranger
method of Skeletal maturation

9. Indications-
 In patients who exhibit major discrepancy between dental
and chronological age.
 It is indicated in patients with skeletal malocclusion
needing orthognathic surgery, if undertaken between 16-
20 years so as to assess the growth status.
 To predict the pubertal growth spurt.
 It is valuable aid in research aimed at studying the role of
heredity ,environment, nutrition etc, on the skeletal
maturation pattern.

10.  Hand-wrist region is made up of 4 groups of bone ;-
1. Distal ends of long bones of forearm( Distal
epiphysis of Radius and Ulna)
2. Carpals(8 carpal bones)
3. Meta carpals(5 in no)
4. Phalanges(14 in no)

12. She
Looks
Too
Pretty
Try
To
Catch
Her

13. Most commonly used methods:
1. Atlas Method by Greulich and Pyle
2. Bjork, Grave and Brown Method
3. Singer’s method
4. Fishman’s Skeletal Maturity Indicators
5. Hagg and Taranger Method

14.  Greulich and Pyle published an atlas containing ideal
skeletal age pictures of the hand-wrist for different
chronological ages and for each sex.
 Each photograph in the atlas is representative of a
particular skeletal age. The patient’s radiograph is
matched on an overall basis with one of the photographs
in the atlas.

15. STAGE-I (PP2) (Males 10.6 yrs ,
Females 8.1 yrs)
The epiphysis and diaphysis of proximal
phalanx of Index finger are equal.
It occurs approximately 3 years before the
peak of pubertal growth spurt.
They divided skeletal development in to 9 stages. Each
of these represents a skeletal maturity. Appropriate
chronological age for each of the stages was given by
Schopf in 1976.

16. STAGE II-(MP3)-
(males 12.0 yr, females 8.1yr):-
The epiphysis and diaphysis of the middle phalanx of the
middle finger are equal.
This stage is noticed prior to the beginning of the
pubertal growth spurt.

17. STAGE III:-(Pisi-stage)(males 12.6 yr, females 9.6
yr)-
 This stage is characterized by presence of 3 areas of
ossification:
 The hamular process of the hamate exhibits ossification.
 Ossification of psiform
 The epiphysis and diaphysis of radius are equal.

19. Stage-IV:-(S, H2 Stage)(males 13.0 yr, females
10.6 yr)-
 This stage marks the beginning of the pubertal growth
spurt. It is characterized by:
 Initial mineralization of the ulnar sesamoid of the
thumb.
 Increased ossification of the hamular process of the
hamate bone.

21.  Stage V;-(MP3 CAP)(males 14.0 yr, females
10yr)-
 This stage heralds the peak of the pubertal growth
spurt. Capping of diaphysis by the epiphysis is seen in:
 Middle phalanx of third finger
 Proximal phalanx of the thumb
 Radius

23.  Stage VI;- (DP3u)(males 15.0 yr, females 13.0
yr):
 This stage signifies the end of pubertal growth spurt.
 It is characterized by union between epiphysis and
diaphysis of the distal phalanx of the middle finger.

25.  Stage VII;-(PP3u)(males 15.9 yr, females 13.3
yr)-
 Union of epiphysis and diaphysis of the proximal
phalanx of the third finger occurs.
 It is seen a year after the growth spurt.

27. It shows fusion between the epiphysis and diaphysis of
the middle phalanx of the middle finger.

28.  Stage IX;-(Ru)(males 18.5 yr, females 16.0 yr)-
 This is the last stage and it signifies the end of skeletal
growth.
 It is characterized by fusion of epiphysis and diaphysis
of the radius.

30.  Julian Singer in 1980 proposed system of hand wrist
radiographic assessment. It helps the clinician to
rapidly determine maturational status of the
adoloscent patient. This system has 6 stages. The
stages and their characteristics are:
 Stage 1(early)-
It is characterized by absence of hook of the hamate
and epiphysis of proximal phalanx of second finger
being narrower than its diaphysis.

32.  Stage 2(pre-pubertal)
• It characterized by initial ossification of hook of the
hamate , initial ossification of pisiform and proximal
phalanx of second finger being equal to its epiphysis.
• It represents that period prior to the adolescent growth
spurt during which significant amounts of mandibular
growth are possible.
• Maxillary orthodontic therapy in conjuction with
mandibular growth might aid correction of a Class II
relationship with considerable speed and ease.

34.  Stage III(pubertal onset)-
This stage is characterised by beginning of
calcification of ulnar sesamoid, increased width of
epiphysis of proximal phalanx of the 2nd finger and
increased calcification of hook of hamate and pisiform
.
Signifies the onset of pubertal growth spurt.

36.  Stage IV(Pubertal)
It is characterized by calcified ulnar sesamoid and
capping of the diaphysis of the middle phalanx of the
third finger by its epiphysis .
This stage signifies the accelerating phase of pubertal
growth spurt.

38.  Stage V(Pubertal deceleration)-
1. This stage is characterized by fully calcified ulnar
sesamoid , fusion of epiphysis of distal phalanx of
third finger with its shaft, and epiphyses of radius and
ulna not fully fused with respective shafts.
2. Stage 5 represents that period of growth when
orthodontic treatment might be completed and the
patient is in retention therapy.

40.  Stage-VI(Growth completion)-
No remaining growth sites seen. Signifies
completion of growth.

42.  Leonard S. Fishman in 1982 proposed a system for
evaluation of skeletal maturation.
 It uses anatomical sites located on the thumb, third
finger ,fifth finger and radius.
 Fishman’s system for interpretation uses 4 stages for
bone maturation.
1. Epiphysis equal in width to diaphysis.
2. Apperance of Adductor Sesamoid of Thumb
3. Capping of epiphysis
4. Fusion of epiphysis

43. Eleven discrete adolescent SMI covering the entire period of
adolescent development have been described .
Epiphysis as width as diaphysis;-
SMI I;- Third finger – Proximal phalanx(PP3)
SMI II;- Third finger – Middle Phalanx(MP3)
SMI III;- Fifth finger - Middle Phalanx(MP5)

44. Ossification;-
SMI IV;- Appearance of Adductor Sesamoid of
Thumb(4S)
Capping of Epiphysis ;-
SMI V ;- Third finger – distal phalanx(DP3 CAP)
SMI VI;- Third Finger– middle phalanx(MP3 CAP)
SMI VII;- Fifth Finger-middle phalanx (MP5 CAP)

46.  Fusion of epiphysis and diaphysis ;-
SMI VIII- Third finger- distal phalanx(DP3U)
SMI IX- Third finger- proximal phalanx(PP3)
SMI X- Third finger- middle phalanx(MP3u)
SMI XI- Radius(Ru)

47.  Skeletal development in the hand and wrist is analysed
from annual radiogrphs, taken between ages of 6
and 18 years.
1. By assessment of ossification of ulnar sesamoid of the
metacarpophalangeal joint of the first finger (S)
2. By certain specified stages of 3 epiphyseal bones:
a. the middle and distal phalanges of the third
finger(MP3 and DP3)
b. the distal epiphysis of the radius (R).

48.  Sesamoid is attained during the acceleration period of
the pubertal growth spurt.

50.  MP3-F;-The epiphysis is as wide as the metaphysis.
 MP3-FG;-The epiphysis is as wide as metaphysis and
there is distinct medial or lateral border of the
epiphysis forming a line of demarcation at right angles
to the distal border.
 MP3-G;- The sides of the epiphysis have thickened
and also cap its metaphysis, forming a sharp edge
distally at one or both sides.
 MP3-H;-Fusion of epiphysis and metaphysis has
begun .
 MP3-I:-Fusion of epiphysis and metaphysis is
completed.

51.  Fusion of the epiphysis and metaphysis is
completed.
 This stage signifies the fusion of the epiphysis and
metaphysis and is attained during the deceleration
period of the pubertal growth spurt by all subjects.

53.  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 are not attained before the end of pubertal
growth spurts.

55.  MP3-HI stage:-
Features of this “new” stage observed in this study :
1. Superior suface of epiphysis shows smooth concavity.
2. Metaphysis shows smooth, convex surface, almost
fitting in to reciprocal concavity of epiphysis.
3. Radiolucent gap between epiphysis and metaphysis
is insignificant.

57.  CVMI was given by Lamparski in 1965.Later it was
modified by Hassel and Farman in 1995 and Baccetti et al
in 2005.
The following six stages were put forward in vertebral
development.

58. 1.This stage is called initiation
corresponds to beginning of
adolescent growth with 80-
100 percent growth expected.
2. Inferior border of C2, C3
and C4 were flat at this stage.
3.The vertebrae were wedge
shaped, the superior
vertebrae borders were
tapered from posterior to
anterior.

59. 1. The second stage is called
acceleration .
2. Growth acceleration begins at
this stage with 65-75 percent
adolescent growth expected.
3. Concavities were developing in
the inferior border of C2 and C3.
4. The inferior border of C4 was
flat.
5. The bodies of C3 and C4 were
nearly rectangular in shape.

60. 1.This stage is called transition .
2.It corresponds to acceleration of
growth towards peak height
velocity with 25-65 percent of
adolescent growth expected.
3.Distinct concavities were
developing in the inferior border of
C2 and C3 .
4.A concavity was beginning to
develop in the inferior border of
C4.
5.The bodies of C3 and C4 are
rectangular in shape.

61. 1.The stage is called Deceleration,
corresponds to deceleration of
adolescent growth spurt with 10-25
percent of growth expected.
2. Discint concavities were seen
in the inferior border of C2, C3 and
C4.
3. The vertebral bodies of C3 and
C4 were more squarer in shape.

62. 1. The fifth stage is called
maturation.
2.Final maturation of vertebrae
took place during this stage
with 5-10 percent adolescent
growth expected.
3. More accentuated concavities
were seen in the inferior
borders of C2, C3 and C4.
4. The bodies of C3 and C4
were nearly square in shape

63. 1. The stage is called completion
of growth.
2. Little or no adolescent growth
expected.
3. Deep concavities were seen in
the inferior borders of C2 , C3
and C4.
4. The bodies of C3 and C4 were
square or were greater in
vertical dimension than the
horizontal dimension.

64. 1. Class II treatment is most effective when it includes
the peak in Mandibular growth.(Stage III)
2. Class III treatment with maxillary expansion and
protraction is effective
When performed before the peak ( Stage I and II ).
3. Class III treatment is effective in mandible during both
pubertal and pre-pubertal stage.

67.  The shapes of the cervical vertebral bodies of C3 and C4
changes from wedge shape to rectangle followed by
square shape.
 In addition, they become taller as skeletal maturity
progressed .The inferior vertebral borders were flat when
immature and became concave with maturity.

68.  CS1;- The lower borders of all the three vertebrae
(c2-c4) are flat . The bodies of both C3 and C4 are
trapezoid in shape. The peak mandibular growth will
occur on average 2 years after this stage.
 CS2;- A concavity is present at the lower border of
C2.The bodies of both C3 and C4 are still trapezoid in
shape. The peak in mandibular growth will occur on
average 1 year after this stage.

69.  CS3;- 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.
 CS4;- 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.

70.  CS5;-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 squred in shape . If not squared , the body of the
other cervical vertebrae still is rectangular horizontal .The
peak in mandibular growth has ended at least 1 year
before this stage.
 CS6;-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.

71. The calcification patterns and stage of mineralization
of the teeth is believed to have a close relationship
with the skeletal maturation of the individual.
Dental development can be assessed by either the
tooth eruption or the stage of tooth calcification ,with
the latter being more reliable.
 To assess the developmental stage of dentition
through examination of panoromic radiograph offers
a several advantages.

73.  STAGE A;- Calcification of single occlusal points with
out fusion of different calcifications.
 STAGE B;-. Fusion of mineralization points ; the
contour of occlusal surface is recognizable.
 STAGE C;- Enamel formation has been completed at
the occlusal surface , the dentine formation has
commenced, the pulp chamber is curved and no pulp
horns are visible.

74.  STAGE D;-Crown formation has completed to the level
of CEJ. Root formation has commenced. The pulp
horns are beginning to differentiate, but the walls of
the pulp chamber remain curved.

 STAGE E;- The root length remains shorter than the
crown height. The walls of pulp chamber are straight
and the pulp horns become more differentiated than
the previous stage.
 STAGE F:- The walls of the pulp chamber now form an
isoscleles triangle , and the root length is equal to or
greater than the crown height. In molars the
bifurcation has developed sufficiently to give the roots
a distinct form.

75.  STAGE G;- The walls of root canals are now parallel
but apical end is partially open in molars only the
distal root is rated.
 STAGE H:-The root apex is completely closed (
distal roots in molars). The periodontal membrane
surrounding the root and apex is uniform in width
through out.

77. APPLICATIONS

78.  Engstrom et al in 1983 did a study correlating the
developmental stages of mandibular 3rd molar with skeletal
age assessed by hand wrist radiographs.
 The development stages of 3rd molar were categorized in
to one of the following classes.
A. Tooth germ visible as a rounded radiolucency.
B. Cusp mineralization complete.
C. Crown formation is complete.
D. Root half formed.
E. Root formation complete, but apex not closed.

80.  After comparing the stages of formation of lower 3rd
molar with hand-wrist radiographs , the following
points were concluded.
 PP2- Lower 3rd molar showed complete crown
mineralization.
 MP3 CAP- The lower 3rd molar crown formation was
complete in majority of subjects.
 DP3 U- The lower 3rd molar crown was completed
with full root length in others and some cases it was
not completed.
 RU- The crown was completed in one-third of subjects
and root had reached full length in rest.

81. Correlation between Chronological Age, Cervical
Vertebrae Maturation and Fishman’s Skeletal
Maturity Indicators in Southern Chinese. Alkhal et
al. Angle Orthodontist. 2008; 78(4):591-6.
OBJECTIVE:-
To investigate the correlation between chronological
age, cervical vertebral maturation(CVM), and Fishman’s
hand-wrist skeletal maturity indicators in southern
chinese.

82. MATERIALS AND METHODS;-
1.400 Contemporary hand-wrist and lateral cephalometric
radiographs of Southern Chienese subjects were
randomly selected and analysed.
2.The female subjects were between 10-15 years of age,
and the male subjects were between 12-17 years of
age; all subjects were in circumpubertal period .
3.The CVM was assessed using the method developed by
Baccetti and coworkers, but the hand-wrist maturation
was assessed using the method developed by Fishman.

83.  RESULTS;-
1. The CVM was significantly correlated with the hand-
wrist skeletal age.
2. All patients in the cervical maturation stage (CS3) of
CVM were discovered to be skeletal maturation
indicator(SMI 2 and SMI 3 ) stages of hand-wrist
maturation, which was around peak of growth spurt.
3.Low correlations were found between the CVM and
chronological age and between the HWM and
chronological age.

84.  CONCLUSION:-
1. CVM is a valid indicator of skeletal growth during the
circumpubertal and has a high correlation with the
HWM for the Southern Chienese population .
2. However, the low correlations found between the
chronological age and both CVM and HWM showed that
the chronological age was not suitable to measure
skeletal maturity.

85. Association between frontal sinus morphology and
cervical vertebral maturation for the assessment
of skeletal maturity. Mahmood et al. AJODO .
2016;150:637-42.
 INTRODUCTION;-
The aim of the study to evaluate the association
between frontal sinus morphology and cervical maturation
for the assessment of skeletal maturity and to determine
its validity in assessing the different stages of the
adoloscent growth spurts.

86.  METHODS;-
1. A cross sectional study was performed on the
pretreatment lateral cephalograms of 252 subjects
aged 8-21 years.
2. The sample was divided in to 6 groups based on the
cervical vertebral maturation stages.
3. The frontal sinus index was calculated by dividing the
frontal sinus height and width and the cervical stages
were evaluated on the same radiograph.

87. Fig. Assessment of frontal sinus morphology on a lateral cephalometric
radiograph. SH-Highest point of the frontal sinus ; SL-Lowest point of
the frontal sinus; SPP-Posterior point on the frontal sinus; SAP-Anterior
point on the frontal sinus; B-Line joining SPP and SAP denoting the
maximum frontal sinus width perpendicular to line A.

88.  RESULTS:-
The height and width of the frontal sinus were
significantly larger in the male subjects than in the
females.
A significant association between frontal sinus
height and width and cervical stages in both sexes.

89.  CONCLUSION:-
Frontal sinus height and width are significantly
associated with the cervical vertebral maturation stages
in both sexes.
However, the frontal sinus index failed to
differentiate between the pre-pubertal, pubertal and
postpubertal growth periods.
Hence, the cervical vertebral maturation method
remains the standard to evaluate the skeletal maturity
of patients undergoing orthodontic treatment.

92. The percentage of osseous development were
recorded.

93. RESULT;-

95. Skeletal maturity indicators can be used as an
secondary diagnostic tool for orthodontic
treatment.

96. 1.Orthodontics principles and practice 2nd edition by
Phulari .
2.Color atlas of Dental Medicine by Thomas Rakosi.
3.Text book of Craniofacial Growth. Sridhar Premkumar.
4.Correlation between Chronological age , Cervical
vertebrae Maturation and Fishman’s Skeletal Maturity
Indicators in Southern Chinese. Alkhal et al. Angle
Orthodontist. 2008; 78(4):591-6.

97. 5.Association between frontal sinus morphology and
cervical vertebral maturation for the assessment of
skeletal maturity. Mahmood et al. AJODO.
2016:150:637-42.
6. Skeletal maturation evaluation using mandibular third
molar development in adoloscents. Cho SM, Hwang CJ.
KJO. 2009; 39(2):120-9.
7. Assessing skeletal Maturity by using blood spot
insulin-like growth factor I (IGF-I) testing. Am J Orthod
Dentofacial Orthop . 2008; 134:209-16.

98. 8.Insulin like growth factor 1:A biologic maturation
Indicator. Ishaq et al. AJODO.2012; 142:654-61.
9. Relationship between Dental and Skeletal Maturity in
Turkish Subjects. UT et al. Angle Orthod . 2004;
74:657-664.
10.Hassel and Farman : Skeletal maturation evaluation
.AJODO. 1995; vol:58-66.
11. Julian Singer : Physiologic timing of Orthodontic
treatment.Angle Orthod.1980; vol: 322-333.
12. Grave and Brown: Skeletal ossification and
adoloscent growth spurt.AJODO. 1976; vol:69-80.