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1. Skeletal Maturity Indicators
INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
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2. Introduction
 Chronological age is often not sufficient for
assessing the developmental stage and
somatic maturity of the patient.
 The biological age is determined from the
skeletal, dental and morphologic age and
the onset of puberty.
 Due to individual variations in timing, duration
and velocity of growth, skeletal age
assessment is essential in formulating viable
orthodontic treatment plans.
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3. SKELETAL MATURITY
INDICATORS PROVIDE
AN OBJECTIVE
DIAGNOSTIC
EVALUATION OF
STAGE OF MATURITY
IN AN INDIVIDUAL
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4. METHODS AVAILABLE TO ASSESS THE SKELETALMATURITY
OF AN INDIVIDUAL--
1.USE OF HAND WRIST X-RAYS
2.EVALUATION OF SKELETAL MATURATION
USING CERVICAL VERTEBRAE
3.ASSESMENT OF MATURITY BY CLINICAL AND
RADIOGRAPHIC EXAMINATION OF DIFFERENT STAGES
OF TOOTH DEVELOPMENT.
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5. Clinical Importance
 To determine the amount of significant facial
cranial growth potential left and potential
vector of facial development.
 To decide the onset of treatment timing and
type of effective treatment.
 To evaluate the treatment prognosis.
 To understand the role of genetics and
environment on the skeletal maturation
pattern.
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6. Anatomical Region Suitable For Skeletal
Maturational Assessment
 Head and Neck : Skull
Cervical Vertebrae
 Upper Limb :Shoulder Joint-Scapula
Elbow
Hand Wrist and Fingers
 Lower Limb : Femur and Humerus
Hip joint
Knee
Ankle
Foot tarsals and Meta tarsals
 Tooth mineralization as an indicator.
 Frontal sinus
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7. Hand Wrist Radiographs
 Assessment of the skeletal age is often made
with the help of a hand radiograph which can
be considered the Biological clock.
 Hand wrist region is made up of numerous
small bones. These bone 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.
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8. Anatomy of Hand-Wrist
The hand wrist
region is made of
four groups of bones
1.Distal ends of long
bones of forearm.
2.Carpal
3.Metacarpals
4.Phalanges
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9. Anatomy of skeleton of Hand
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10. Indication Of Hand Wrist Radiographs
 In patients who exhibit major discrepancy between
dental and chronologic age.
 Determination of skeletal maturity status prior to
treatment of skeletal malocclusion.
 To assess the skeletal age in a patient whose
growth is affected by infections, neoplastic or
traumatic conditions.
 Help to predict future skeletal maturation rate and
status.
 To predict the pubertal growth spurt.
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11. Methods Of Assessing Skeletal Age
 Bjork ,Grave and Brown method
 Fishman’s skeletal maturity indicators
 Hagg and Taranger method
 Atlas method by Greulich and Pyle
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13. CARPELS INDEX
CONSISTS OF EIGHT SMALL IRREGULARLY SHAPED BONES ARRANGED
IN 2 ROWS- - PROXIMAL ROW AND DISYAL ROW
SCAPHOID
LUNATE PROXIMAL ROWS
TRIQUETRAL
PISIFORM
TRAPEZIUM
TRAPEZOID DISTAL ROW
CAPITATE
HAMMATE
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14. Fishman Skeletal Maturity Indicators
 Proposed by Leonard S
Fishman in 1982.
 Make use of anatomical
sites located on thumb,
third finger, fifth finger
and Radius .
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16. The Fishman’s system of interpretation
Uses four stages
of bone maturation
 1.Epiphysis equal in width to diaphysis
 2.Appearence of adductor sesamoid of thumb
 3.Capping of epiphysis.
 4.Fusion of epiphysis
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17. Fishman method –Eleven SMIs
Width of Epiphysis equal to Diaphysis
SMI-1 Third finger-Proximal Phalanx
SMI-2 Third finger-Middle Phalanx
SMI-3 Fifth finger-Middle Phalanx
SMI-4 Appearance of adductor sesamoid of
the thumb
Capping of Epiphysis
SMI-5 Third finger –Distal Phalanx
SMI-6 Third finger-Middle Phalanx
SMI-7 Fifth finger-Middle Phalanx
Fusion of Epiphysis and Diaphysis
SMI-8 Third finger-Distal Phalanx
SMI-9 Third finger-Proximal Phalanx
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SMI-10 Third finger-Middle Phalanx
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SMI-11 Seen in Radius

18. Maturation Assessment by Hagg and
Taranger
 Analyzed from radiograph taken between the
ages of 6 and 18 years, by assessing of the
ossification of the ulnar sesamoid of the
metacarpophalangeal joint of first finger.
 Certain specified stages of 3 epiphyseal bone
-Middle and distal phalanges of third finger
[MP3 and DP3] and distal epiphysis of
Radius.
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19. Sesamoid
 Sesamoid is usually attained during the
acceleration period of the pubertal growth
spurt [onset of peak height velocity]
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20. Anatomy of skeleton of Hand
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21. Modified MP3 Cervical Vertebrae
MP3-F Stage CVMI-1
 Start of the curve of pubertal growth spurt . Initiation stage of cervical vertebrae
C2,C3 and C4 inferior vertebral body
 Epiphysis is as wide as metaphysis borders are flat.
 End of epiphysis are tapered and rounded. Superior vertebral borders are tapered
 Radiolucent gap [cartilageous epiphyseal growth from posterior to anterior [wedge shape]
plate] between epiphysis and metaphysis is wide. 80-100% of pubertal growth remains.
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22. MP3-FG Stage CVMI-2
 Acceleration of the curve of pubertal growth spurt. Acceleration stage of cervical vertebrae.
 Epiphysis is as wide as metaphysis. Concavities are developing in lower
 Distinct medial and lateral border of epiphysis forms borders of C2 and C3.
line of demarcation at right angle to distal border. Lower border of C4 vertebral body is flat.
 Metaphysis begins to show slight undulation.
C3 and C4 are more rectangular in shape.
 Radiolucent gap between metaphysis and epiphysis
is wide. 65-85% of pubertal growth remains.
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23. • MP3-G Stage CVMI-3
 Maximum point of pubertal growth spurt. Transition stage of cervical vertebrae
 Sides of epiphysis have thickened and cap Distinct concavities are seen in lower borders
its metaphysis, forming sharp distal edge of C2 and C3.
on one or both the sides.
Concavity is developing in lower border of C4.
 Marked undulations in metaphysis give it
“Cupid’s bow’’ appearance. C3 and C4 are rectangular in shape.
 Radiolucent gap is moderate. 25-65% of pubertal growth remains.
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24. MP3-HI Stage CVMI-5
 Maturation of the curve of pubertal growth spurt Maturation stage of cervical vertebrae.
 Superior surface of epiphysis shows smooth Accentuated concavities of C2, C3 and C4
concavity.
inferior vertebral body borders are obser
 Metaphysis shows smooth, convex surface,
fitting into reciprocal concavity of epiphysis. C3 and C4 are square in shape.
 No undulation present in metaphysis. 5-10% of pubertal growth remains.
 Radiolucent gap is insignificant.
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25. MP3-I Stage CVMI-6
 End of pubertal growth spurt Completion stage of cervical vertebrae.
 Fusion of epiphysis and metaphysis complete. Deep concavities are present in C2, C3
 No radiolucent gap.
 Dense, radiopaque epiphyseal line forms and C4 inferior vertebral body borders.
integral part of proximal portion of middle C3 and C4 are greater in height than in width.
phalanx.
Pubertal growth is completed.
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26. Third finger distal phalanx
 DP3-1:Fusion of Epiphysis and Metaphysis is
completed.
-This is attained during the deceleration period
of pubertal growth spurt [ end of PHV] .
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27. Radius
 R-1:Fusion of the epiphysis and Metaphysis has
began.
-This stage is attained 1 year before or at the end of
growth spurt.
 R-1J:Fusion is almost completed but there is still a
small cap at one or both margin.
 R-J:Characterised by fusion of the epiphysis and
metaphysis.
These stages were not attained before end of PHV.
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28. Bjork , Grave And Brown Method
Male Female
Stage1 PP2 = 10.6yr 8.1
Stage2 MP3 = 12.2 8.1
Stage3 Pisi, 12.6 9.6
H1,R=
Stage4 S & H2 13.0 10.6
Stage5 MP3,R 14.0 11.0
PP1cap
Stage6 DP3U 15.0 13.0
Stage7 PP3U 15.9 13.3
Stage8 MP3U 15.9 13.9
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