Skeletal Age Assessment and Maturity Indicators

SKELETAL AGE ASSESSMENT
Bikash Chaurasia
JR,Pedodontics
AIIMS
Webinar
04/16/2020

The importance of knowing age: as a forensic expert
Knowing your age is a basic human right and having it documented is what gives identity to
the individual (UNICEF, 1989)
In the society we live in, one’s date of birth is the epitome of one’s entity.
It also plays a role in unfortunate events pertaining to justice and dealing with offenders
rightfully according to their age, and protecting them and the people around them by
knowing their appropriate age group.
In other words it drives the journey of life from birth to death.
Introduction
Adams C, Carabott R, Evans S. Forensic Odontology an essential guide.1st edition. Wiley Blackwell.2014

 Due to individual variations in timing, duration and velocity of growth, skeletal age
assessment is essential in formulating viable orthodontic treatment plans.
 In orthodontics and pedodontics maturation status can have considerable influence on:
The importance of knowing age: to us

Importance of Maturity Indicators and Age assessment:
The chronological age offers little insight
in determining the developmental stage
or somatic maturity of a person.
Thus the maturity indicators provide an
objective diagnostic evaluation of stage
of maturity in an individual.
The basis for skeletal age assessment by
radiographs is that the different
ossification centers appear and mature
at different times.
The order , rate , time of appearance
and progress of ossification in the
various ossification centers occurs in a
predictable sequence.
Hagg U, Taranger J. Maturation indicators and the pubertal growth spurt. Am J Orthod Dentofacial Orthop 1982;82: 299-309

Various methods are available to access the skeletal maturity of an individual.

WHY?
Bones of hand-wrist
radiograph show a
predictable and
scheduled pattern of
appearance,
ossification and union
from birth to maturity.
Hence, this region is
one of the most suited
to study growth.
Greulich WW, Pyle SI. In: ed. 2. Radiographic atlas of skeletal development of the hand and wrist. Stanford, Calif: Stanford University Press; 1959

1.When palatine suture expansion is planned.
2.In interdisciplinary treatment – orthodontic-surgical cases in which the surgical procedure is
planned between 16 and 20 years of age.
3.When there is a need to take advantage of growth during orthodontic treatment.
4.In the case of risk of adverse effects due to growth during or after orthodontic treatment
(the assessment of residual growth).
5.In the case of a discrepancy between chronological and dental age.
Indications of Hand-wrist radiograph: according to Nötzel and Schultz
F. Nötzel, Ch. Schultz, Kompendium diagnostyki ortodontycznej, Czelej Sp z o.o., Lublin, 2004

Atlas Method by Greulich and Pyle
Bjork, Grave and Brown Method
Julian Singer’s Method
Fishman’s Skeletal Maturity Indicators
Hagg and Taranger method
Hand-wrist Radiograph: Assessment of Skeletal age

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.
Greulich and Pyle Method (1959)
Greulich WW, Pyle SI. Radiographic atlas of skeletal development of the hand-wrist. Stanford: Stanford University Press, 1959

Bjork, Grave and Brown Method (1976)
Stage 1.(M:10.6 yr. , F:8.1 yr.)
Epiphysis and diaphysis of the proximal
phalanx of index finger are equal.
Stage 2.(M:12.0 yr., F: 8.1 yr.)
Epiphysis and diaphysis of the middle
phalanx of the middle finger are equal.
Brown T, Barrett MJ, Grave KC. Facial growth and skeletal maturation at adolescence. Dan Dent J1971;75:1121-2

Stage 3.(M:12.6 yr., F:9.6 yr.)
Characterised by presence of 3
areas of ossification:
a.Hamular process
b.Pisiform
c.Epiphysis and diaphysis of radius
are equal.
Visible ossification of the Pisiform
Same width of epiphysis and
diaphysis of the radius

Stage 4.(M:12.6 yr., F:10.6 yr.)
Characterized by:
a. Initial mineralization of the ulnar sesamoid of the thumb.
b. Increased ossification of the hamular process.

Stage 5.(M:14 yr., F: 10 yr.)
Capping of diaphysis by the epiphysis
is seen in:
a. Middle phalanx of the third finger
b. Proximal phalanx of the thumb
c. Radius
Stage 6.(M:15 yr., F: 13 yr.)
Signifies the end of Pubertal growth
spurt. Characterized by union between
epiphysis and diaphysis of distal
phalanx of middle finger.

Stage 7.(M:15.9 yr., F: 13.3 yr.)
Union of epiphysis and diaphysis
of the proximal phalanx of the third
finger occurs.
Stage 8.(M:15.9 yr., F: 13.9 yr.)
Fusion between epiphysis and
diaphysis of middle phalanx of the
middle finger.

Stage 9.(M:18.5 yr., F:16 yr.)
Last stage
Signifies the end of skeletal growth
fusion of epiphysis and diaphysis
of the radius.

Julian Singer’s Method (1980)
Stage one (early)
Absence of Pisiform, absence of
Hook of hamate and epiphysis
of proximal phalanx of second
finger being narrower than its
diaphysis.
Stage two (prepubertal)
Characterised by the initial
ossification of hook of the hamate,
pisiform and proximal phalanx of
second finger being equal to its
diaphysis.
Stage three (pubertal onset)
Beginning of calcification of ulnar
sesamoid, increased width of
epiphysis of proximal phalanx of the
second finger and increased
calcification of hook of hamate and
pisiform.

Stage four (pubertal)
Characterised by calcified
ulnar sesamoid and capping
of the diaphysis of the middle
phalanx of third finger by its
epiphysis.
Stage five (pubertal deceleration)
Fully calcified ulnar sesamoid,
Fusion of epiphysis of distal phalanx of third
finger with its shaft and epiphysis of radius and
ulna not fully fused with respective shafts.
Represents that period of growth when
orthodontic treatment might be completed and
the patient is in retention therapy.
Stage six (growth completion)
No remaining growth sites seen.
Signifies completion of growth.

• Third finger-
distal
phalanx
• Fifth finger-
middle
phalanx
• Third finger-
middle
phalanx
• Third finger-
proximal
phalanx
Epiphysis
equal in
width to
diaphysis
Appearance
of adductor
sesamoid of
the thumb
Capping of
epiphysis
Fusion of
Epiphysis
Fishman’s Skeletal Maturity Indicators (1982)
• Radius • Adductor
sesamoid of
thumb
Fishman LS. Radiographic evaluation of skeletal maturation; a clinically oriented method based on hand wrist films. Angle Orthod 1982;52:88-112.

A . Epiphysis equal width of diaphysis:
1.Third finger-proximal phalanx
2.Third finger-middle phalanx
3.Fifth finger-middle phalanx
4 . Appearance of Adductor sesamoid of thumb
C. Capping of epiphysis:
5.Third finger-distal phalanx
7.Fifth finger-middle phalanx
D. Fusion of epiphysis and diaphysis:
8.Third finger-distal phalanx
9.Third finger-proximal phalanx
11.Radius

Note: A Longitudinal study was carried out
and an average age standards for eleven SMI’s
were established and the values for each
skeletal maturational age were tabulated.
Earlier age of maturational development for
females was seen.

Clinical significance:
Occur approximately 3 years before the pubertal growth spurt.
This stage occurs shortly before or at the beginning of pubertal growth spurt.
This stage occurs at the peak of the pubertal growth spurt.
The ossification of all hand bones is completed and skeletal growth is completed
SMI 1,2,3
SMI 4
SMI 5,6,7
SMI
8,9,10,11

 Assessment of the ossification of the ulnar Sesamoid
of the metacarpophalangeal joint of the first finger
(S),
 And certain specified stages of three epiphyseal
bones (closure of epiphyseal plates): the middle and
distal phalanges of the third finger (MP3 and DP3),
 And the distal epiphysis of the radius (R).
Hagg and Taranger method (1982)
Hagg U, Taranger J. Maturation indicators and the pubertal growth spurt. AM J ORTHOD 1982;82:299-308.

THE GROWTH SPURT ONSET is found by locating the smallest annual
increment (A) from which there is a continuous
increase in growth rate to PHV(Peak Height
Velocity).
 The curve is then followed toward PHV until the
growth rate has accelerated.
 ONSET will be indicated by the annual increment
which is next below or coincides with this
growth rate.
 PHV is the greatest annual increment during
puberty.
 The end of the spurt (END) is the first annual
increment after PHV

The ulnar sesamoid (S):
Is usually attained during the acceleration period of the pubertal growth spurt (ONSET-PHV).
Third finger middle phalanx (MP3):
MP3-F
•The epiphysis is as wide as the metaphysis. This stage is attained before onset of P.H.V. by about 40% of the
subjects and at P.H.V. by many others.
MP3-FG
•The epiphysis is as wide as the metaphysis and there is distinct medial and/or lateral border of the epiphysis
forming a line of demarcation at right angles to the distal border. This stage is attained 1 yr. before or at P.H.V
by about 90 percent of the subjects.
MP3-G
•The sides of the epiphysis have thickened and also cap its metaphysis, forming a sharp edge distally at one or
both sides. This stage is attained at 1 or 1 yr. after P.H.V.
MP3-H
•Fusion of the epiphysis and metaphysis has begun and is attained after PHV but before END by practically all
boys and about 90 percent of the girls..
MP3-I
•fusion of the epiphysis and metaphysis is completed and Is attained before or at END of growth spurt in all
subjects expect a few girls.
ONSET ACCELERATION
PEAK
DECELERATION END

Third finger distal phalanx (DP3-I):
The fusion of the epiphysis and metaphysis is completed.
This stage signifies the fusion of epiphysis and metaphysis and is attained during the deceleration period of the
pubertal growth spurt (PHV-END) by all subjects.
The distal epiphysis of the radius:
R-I :
The fusion of the epiphysis and metaphysis has begun. This stage is attained 1 year before or at END by about 80
percent of the girls and about 90 percent of the boys.
R-IJ :
The fusion is almost completed but there is still a gap at one or both margins.
R-J :
Is characterized by fusion of the epiphysis and metaphysis .

 Hassel and Farman carried out a study; the sample of 11 groups of 10 males and 10 females (220
subjects) aged from 8 to 18 years was taken from the Bolton-Brush Growth Center.
 The radiographs used included the left hand-wrist and the lateral cephalogram.
 Three parts of the cervical vertebrae were traced.
 These entities were:
The dens (odontoid process),
The body of the third cervical vertebra (C3), and the body of the fourth cervical vertebra (C4).
 These areas were selected because C3 and C4 could be visualized even when a thyroid protective
collar was worn during radiation exposure.
Skeletal maturation evaluation using Cervical vertebrae (1995)
Lamparski DG. Skeletal Age Assessment Utilizing Cervical Vertebrae [master’s thesis]. Pittsburgh, Pa: University of Pittsburgh; 1972

 The cervical vertebrae tracings were paired with their respective hand-wrist radiographs that
had been grouped by SMI categories(1-6). These tracings were photocopied.
 The photocopies of the vertebral tracings were evaluated to see whether changes in shape
and dimension of the vertebrae could be observed between SMI groupings.
 Specific entities looked at were the presence or absence of curvature in the inferior borders
of the dens, C3, and C4.
 General shapes of the bodies of C3 and C4 were evaluated.
 Intervertebral spacing was visualized.

Cervical vertebrae maturation indicators using C3 as guide.

• This corresponded to a combination of SMI 1 and 2.
• At this stage, adolescent growth is just beginning and 80% to 100%
of adolescent growth is expected.
• Inferior borders of C2, C3, and C4 are flat at this stage.
• The vertebrae are wedge shaped, and the superior vertebral
borders are tapered from posterior to anterior.
Category 1
INITIATION
• This corresponded to a combination of SMI 3 and 4
• Growth acceleration is beginning at this stage, with 65% to 85% of
adolescent growth expected. Concavities are developing in the
inferior borders of C2 and C3.
• The inferior border of C4 is flat. The bodies of C3 and C4 are nearly
rectangular in shape.
Category 2
ACCELERATION
• Adolescent growth is still accelerating at this stage toward peak
height velocity, with 25% to 65% of adolescent growth expected.
• Distinct concavities are seen in the inferior borders of C2 and C3.
• A concavity is beginning to develop in the inferior border of C4.
The bodies of C3 and C4 are rectangular in shape
Category 3
TRANSITION

CVMI 1: A. Typical hand-wrist
radiograph. B. Typical cervical
vertebrae appearance using
lateral cephalogram.
vertebrae appearance using lateral
cephalogram.
CVMI 3: A. Typical
hand-wrist radiograph.
B. Typical cervical
vertebrae appearance
using lateral
cephalogram.

• Adolescent growth begin to decelerate dramatically at this stage,
with 10% to 25% of adolescent growth expected.
• Distinct concavities are seen in the inferior borders of C2, C3, and
C4. The vertebral bodies of C3 and C4 are becoming more square
in shape
Category 4
DECELERATION
• Final maturation of the vertebrae take place during this stage, with
5% to 10% of adolescent growth expected.
• More accentuated concavities are seen in the inferior borders of
C2, C3, and C4.
• The bodies of C3 and C4 are nearly square to square in shape.
Category 5
MATURATION
• This corresponded to SMI 11.
• Growth is considered to be complete at this stage. Little or no
adolescent growth is expected.
• Deep concavities are seen in the inferior borders of C2, C3, and C4.
• The bodies of C3 and C4 are square or are greater in vertical
dimension than in horizontal dimension.
Category 6
COMPLETION

radiograph.
B. Typical cervical vertebrae
appearance using lateral
cephalogram.
vertebrae appearance using
lateral cephalogram.
CVMI 6: A. Typical
hand-wrist radiograph.
B. Typical cervical
vertebrae appearance
using lateral
cephalogram.

 The shapes of the cervical vertebrae were seen to differ at each level of skeletal development.
 This provided a means with which 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 changed from somewhat wedge shaped, to
rectangular, to square, to greater in dimension vertically than horizontally as skeletal maturity
progressed.
 The inferior vertebral borders were flat when most immature, and they were concave when
mature. The curvatures of the inferior vertebral borders were seen to appear sequentially
from C2 to C3 to C4 as the skeleton matured.
 The concavities became more distinct as the person matured.

 This serves the purpose of an Orthodontists to help determine growth potential by using
anatomic changes of the cervical vertebrae observed on the lateral cephalometric radiograph
and develop a reliable diagnostic tool to aid in formulating treatment options.
 When two successive SMI-CVMI groups were combined, it was observed that distinct cervical
vertebrae anatomic characteristics were unique to each of these groupings.
 Eleven SMI (skeletal maturation index) groupings were condensed into six CVMI (cervical
vertebrae maturation index) categories.
 The SMI groupings 1 and 2, 3 and 4, 5 and 6, 7 and 8, 9 and 10, and SMI 11 were given CVMI
categories 1 through 6, respectively.

 Additional radiation exposure.
 Lack of changes that signal the ONSET of the pubertal growth spurt. Only stages related to the PEAK or the END
of the pubertal growth spurt can be depicted.
 Polymorphism and sexual dimorphism often limits in the interpretation of the results.
Limitations of HWM(Hand Wrist Method):
The Advantages of CVM over HWM are: Franchi et al.
1. In nearly 95% of the subjects the interval from vertebral stage 3–4 coincides with the pubertal spurt ONSET
in mandibular growth and the peak in body height.
2. The reproducibility is as high as 98.6%.
3. The usefulness of the method for the anticipation of ONSET spurt in mandibular growth(peak was not reached if
stage 1 or 2 was observed in the patient).
L. Franchi, T. Baccetti, J. McNamara Jr., Mandibular growth as related to cervical vertebral maturation and body height, Am. J. Orthod. Dentofacial Orthop. 118 (2000) 335–340

Skeletal age assessment using Frontal sinus :

 The development of the frontal sinus in relation to somatic and skeletal maturity was analyzed in 26
male subjects aged 9-22 years by means of longitudinal data obtained from lateral head films, hand
wrist radiographs and body height growth curves.
 These were grouped together and analyzed in a cross-sectional manner.
 The results revealed that the final size of the frontal sinus varied considerably.
 Analogous to body height growth at puberty, the enlargement of the frontal sinus exhibited a similar
pattern with a well-defined peak, which on average occurred 1.4 years after the body height peak.
 In comparison with skeletal maturity, 65 per cent of the subjects reached the sinus peak(Sp) during the
hand radiographic stages MP3-G or MP3-H, while the body height peak(Bp) coincided with an earlier
maturity stage (MP3-FG).
Ruf S, Pancherz H. Development of the frontal sinus in relation to somatic and skeletal maturity. A cephalometric roentgenographic study at puberty. Eur J
Orthod. 1996; 18(5): 491–497

NOTE: The pubertal sinus peak
(Sp) took place at a mean age of
15.1 years. (12.5-17.5 years)
following body height peak (Bp) by
an average of 1.4 years.

Aim To evaluate the association between frontal sinus morphology and cervical vertebral maturation for the
assessment of skeletal maturity and to determine its validity in assessing the different stages of the
adolescent growth spurt.
Authors/Journ
al/Year
Mahmood HT, Shaikh A, and Fida M ;AJODO ;2016
Material and
Method
 A cross-sectional study was performed on the pretreatment lateral cephalograms of 252 subjects aged 8 to
21 years.
 The sample was divided into 6 groups based on the cervical vertebral maturation stages.
 The frontal sinus index was calculated by dividing the frontal sinus height and width, and the cervical stages
were evaluated on the same radiograph.
 The Kruskal-Wallis test was applied to compare frontal sinus index values at different cervical stages, and the
post hoc Dunnett T3 test was applied to compare frontal sinus index values between adjacent cervical stages
for each sex.
 A P-value of <0.05 was considered statistically significant.
Result  The height and width of the frontal sinus were significantly larger in the male subjects than in the females.
 A significant association was found between the frontal sinus height and width and cervical stages (P <0.001)
in both sexes. However, the changes in the frontal sinus index across the different cervical stages were found
to be significant (P <0.001) in male subjects only.
 Similarly, a weak negative correlation was found between the sinus index and the cervical stages in male
subjects, whereas no correlation was found in female subjects.
 However, the post hoc analysis showed that the values of the sinus index were comparable between any 2
adjacent cervical stages.
Conclusion The frontal sinus index cannot be used to identify the prepubertal, pubertal, and post pubertal stages of the adolescent
growth spurt. Therefore, it cannot be used as a reliable maturity indicator.

Skeletal age assessment using Midpalatal suture:
Angelieri et al. Midpalatal suture maturation: Classification method for individual assessment before rapid maxillary expansion. AJODO. November 2013 Vol 144 Issue 5

 The start and the advance of fusion of the Midpalatal suture vary greatly with age and sex.
 Persson and Thilander observed fusion of the midpalatal suture in subjects ranging from 15 to 19 years old.
 On the other hand, patients at ages 27, 32,54,and even 71years have been reported to have no signs of fusion of this suture.
 Such findings indicate that variability in the developmental stages of fusion of the midpalatal suture is not related directly to
chronologic age, particularly in young adults.
 For this reason, Revelo and Fishman proposed individual assessment of the midpalatal suture morphology with occlusal
radiographs before RME therapy.
 However, occlusal radiographs are not reliable for analyzing midpalatal suture morphology because the vomer and the
structures of the external nose overlay the midpalatal area and thus might lead to false radiographic interpretations of
midpalatal suture fusion.

Straight high-density sutural line, with no or little interdigitation
Scalloped appearance of the high-density sutural line
Two parallel, scalloped, high-density lines that were close to each other, separated in some
areas by small low-density spaces
Fusion completed in the palatine bone, with no evidence of a suture
Fusion anteriorly in the maxilla
Stage A
Stage B
Stage C
Stage D
Stage E

 Stages A and B typically were observed up to 13 years of age,
 whereas stage C was noted primarily from 11 to 17 years but occasionally in younger and older age
groups.
 Fusion of the palatine (stage D) and maxillary (stage E) regions of the midpalatal suture was completed
after 11 years only in girls.
 From 14 to 17 years, boys showed fusion only in the palatine bone (stage D).
 Thus, this new classification method has the potential to avoid the side effects of rapid maxillary
expansion failure or unnecessary surgically assisted rapid maxillary expansion for late adolescents and
young adults.
Decision making

Aim The aim of the study was to assess the usefulness of the CVM method and to verify the assumption, according
to which the CVM method modified by Baccetti et al. may replace the method for the assessment of skeletal
maturation based on a hand-wrist X-ray, which is known as the hand-wrist maturation (HWM) method.
Authors/Journ
al/Year
Szemraj A, Slominska AW, Pilszak BR; European Journal of Radiology ;2018
Material and
Method
 The present study reviewed the literature between 2006 and 2016. In the first stage of selection 905 articles
were obtained.
 The PubMed database was used and the following keywords were used: CVM Hand Wrist (21 results), CVM
method (725 results), Baccetti method (159 results)
 The articles which appeared more than once when the keywords were used were excluded from the study.
 Based on exclusion criteria’s and careful analysis of the content of the articles, finally, 10 articles were
enrolled for the review.
Result  All of the studies presented a high level of correlation between the examined methods.
 In eight articles the researchers admitted that the CVM classification could replace the HWM method,
known as the “gold standard”.
 In two studies, the researchers suggested considering the CVM method an additional method despite its
compatibility and usefulness.
 The lowest correlation coefficient was 0.616 and the highest 0.937.
Conclusion The CVM method shows a high level of correlation with the HWM method.

 Dental maturity can be determined by the stage of tooth eruption or the stage of tooth formation.
 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.

An Insight into Tooth mineralization: An Indicator of Skeletal Maturity

Ojha A et al. J Forensic Dental Sci.2018
Materials and Methods:
A cross-sectional pilot study was performed using
orthopantomograph (OPG) and hand–wrist radiographs
of fifty children (25 males and 25 females) with age
ranging from 8 to 14 years.
The hand–wrist radiographs and OPG were analyzed
using Fishman’s Skeletal Maturity Index and the
Demirjian’s system, respectively.
SPSS software version 19 (IBM) was used in the
calculation of all statistical analyses.
Results:
• MP3 stage:
The canine stage F had shown the highest percentage distribution in males (92%)
as well as females (80%) in the MP3 stage, whereas all the remaining teeth had
scattered distribution, which indicated the onset of a period of accelerating
growth.
• MP3 cap stage:
In this stage, root completion of canine as well as the 1st and 2nd Premolars had
been taken place in a majority of participants. The second molar development
was highly concentrated in stage G (50%)
• MP3 ustage:
In this stage, all males showed calcification stage G, whereas in females, G and H
calcification stages were shown.
• S stage:
The second molar stage G was related to the S stage and is indicative of the
period of very rapid growth velocity.

 To determine the innate direction and facial growth potential of the patient in orthodontic
treatment that allows the proper selection of therapeutic methods.
 To determine the optimal time for orthopedic and retention treatment.
 To recognize deviations from the normal growth pattern.
 It is also necessary for arranging the time of surgical-orthognathic surgery, since performing
such procedures may be planned after completion of the facial skeletal growth.
Why ? Skeletal age assessment is important
S. Krailassiri, N. Anuwongnukroh, S. Dechkunakorn, Relationship between dental calcification stages and skeletal maturity indicators in Thai individuals, Angle Orthod. 72 (2002) 155–166

 Growth magnitude, direction and timing are intimately dependent on each other.
 A vertically growing mandible will display a greater magnitude of vertical growth during a time of accelerated growth
velocity.
 Every person matures on a very individual schedule, and it is here that the value of hand wrist films becomes
apparent.
 Dental, Skeletal and chronological ages are not necessarily interrelated on a simple one to one basis.
 All these variations make skeletal age a more valid means of judging physiological development than chronological
age, which can be a most misleading piece of information.
 Thus, radiologic skeletal maturation indicators should be used to augment other observations by the orthodontist
and Pedodontist. One diagnostic test should not be relied upon too strictly.
Conclusion:

Skeletal Age Assessment and Maturity Indicators

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