Skeletal Maturity Indicators

Dr CHETAN S
 Timing of growth spurts:-
1. Just before birth

2. One year after birth.
3. Mixed dentition growth spurts.
- Boys 8-11 yrs
- Girls7- 9 yrs.
4. ADOLOSCENT GROWTH SPURTS
- Boys 14- 16 yrs
- Girls 11- 13 years.
Scammon’s Growth Curve:
Cephalo-caudal gradient of growth
Biological Maturity Indicators
Chronological age.
Dental age.
Morphological age.
Sexual age.
Skeletal age.
Biological Maturity indicators.
Chronological Age:-
 common and easy method
“ Age measured by year living since birth.’’
Since each child has his own characteristic growth

clock , i.e., there are early , middle and late
maturation chronological age is not a accurate
method
Dental Age:
Dental Age:- has 2 different methods of assessment
1. Tooth Eruption Age
2. Rating of tooth development from crown

calcification to root completion using x-ray of the
unerrupted and developing teeth.
Dental Age:- has 2 different methods of assessment
1. Tooth Eruption Age : Observation of the age of

eruption of the primary and permanent teeth.
Disadvantage:-
-wide variation in times of eruption
-Influence of local and environmental factors
TOOTH CALCIFICATION.
Demerjian, Goldstein and Tanner gave a new method for
estimating dental maturity or dental age by refrence to the
radiographic appearance of the 7 teeth on the left side of mandible.
 Each tooth was rated according to development criteria ( amount of

dentinal deposit and shape change of the chamber) rather than
change in size.
 Eight stages, A- H were defined for each tooth mineralization stage.
 The summed score of all seven teeth gave dental maturity.

Dental age determination according to the stage of mineralization
Demirjian et al., in 1973 divided tooth mineralization into nine stages.
 o. Tooth germ without signs of

calcification.
 A. Calcificaion of single occlusal points
without
 fusion of different calcification.
 B. Fusion of mineralization points. The
contour
 of the occlusal surface is recognizable.  Single rooted
 C. Calcification of the crown is tooth
complete;
 beginning of dentin deposits.
 D. Crown formation is complete up to the
 cemento enamel junction.  Multi rooted
tooth
 E. Root length shorter than crown height.
 F. Root length larger than crown height.
 G. Root formation finished. Apical foramen
 still open.
 H. Apical foramen is closed.
Scores of different dental formation stages
Morphological Age(Somatic maturity)
Morphological age is based upon height of the
individual.
Onset of the spurt (ONSET) - the smallest annual

increment from which there is a marked continuous
increase in growth rate to PHV.
Peak height velocity (PHV) is the greatest annual

increment during puberty.
Sexual maturation
Secondary sex characteristics - Tanner
Five stages of sexual maturity with stage 1 being the
least mature (preadolescent) and stage 5 being the most
mature (adult)
Pubic hair (amount, coarseness, color and location), penile

length and breadth, scrotal development and testicular size.
Serial recording of voice change in boys can be used as a
measurement of maturity
SEXUAL AGE :-
 Stage of development of secondary sexual

characteristics.
Menarche in girls
 Change to adult voice is seen soon after peak
has passed
Peak height velocity
Secondary sexual charecters – beard, mustache
Body fat distribution
HAGG and TARANGER (1980)

`
Best indicator for the
pubertal growth spurt
is the attainment of the
peak height velocity
The clinician prefers to
start the treatment
during the acceleration
phase
Earlier in girls
SKELETAL AGE:-
 Skeletal maturity , perhaps the most commonly
used index in routine clinical work is closely related
to sexual and somatic maturity
Different Methods
1. CVMI
2. Hand and wrist Radiographs.
3. Mid palatal suture
4. Corpus index
5. Tooth mineralization
CERVICAL VERTEBRA MATURITY
INDEX (CVMI)
HASSEL AND FARMAN :AM J ORTHOD1995.
Hassel and Ferman developed a system of

skeletal maturation determination using the
cervical vertebrae
Skeletal maturation evaluation using cervical
vertebrae
CATEGORY 1(INITIATION)
Corresponds to SMI 1&2.

80-100% of growth expected
Inferior borders of C2,C3 & C4 flat
Vertebrae wedge shaped
Tapered from post. to Ant.
vertebrae
CATEGORY 2
(ACCELERATION)
Corresponds to SMI 3&4
65-85% of growth expected
Inferior borders of C2,C3-
concavities developing
Inf. Border C4 flat
C3 & C4 bodies nearly rectangular
Skeletal maturation evaluation using cervical vertebrae
CATEGORY 3 (TRANSITION)
Corresponds to SMI 5& 6
25-65% growth expected
Distinct concavities-C3&C4
Concavity begins to develop-C4
C3 &C4 rectangular.
vertebrae
CATEGORY 4 (DECELERATION)
Corresponds to SMI 7&8.
10-25% growth expected
Distinct concavities- C2, C3&C4.
C3&C4-becoming square in shape.
vertebrae
CATEGORY 5 (MATURATION)
Corresponds to SMI 9 & 10
5-10% growth expected.
Accentuated concavities-C2,C3 &C4.
C3 &C4 almost square in shape.
vertebrae
Stage 6 (COMPLETION)
Corresponds to SMI 11
Adolescent growth complete
Deep concavities-C2, C3 &C4.
Vertebral bodies greater vertically
than horizontally.
Assessment Of Cervical Vertebrae HASSEL & FARMAN(1995).
INITIATION TRANSITION MATURATION
80-100% 25-65% 5-10%
ACCELERATION DECELERATION COMPLETION
65-85% 10-25% 0%
C2 C2
C2 C2 C2
C2
C3 C3 C3 C3

C3
C C4 C4 C4 C3

4
C4
C4
stage Growth shape Inferior
status border
Initiation 80-100% WEDGE FLAT
acceleration 65-85% RECTANGUAR SLIGHT
CONCAVE
transition 25-65% RECTANGULAR SLIGHT
CONCAVE
deceleration 10-25% SQUARE DISTINCT
CONCAVE
maturation 5-10% SQUARE ACCENTU
ATED
completion 0-LITTLE V.DIMENSION DEEP
Hand wrist radiographs
Anatomy of Hand-Wrist
The hand-wrist region is made up

of the following four groups
of bones.
1. Distal ends of long bones of

forearm.
2. Carpals
3. Metacarpals
4. Phalanges
Hand wrist radiographs
Anatomy
Methods Of Assessing Skeletal Age
 Atlas method by Greulich and Pyle
 Bjork ,Grave and Brown method
 Julian singer’s method
 Fishman’s skeletal maturity indicators
 Hagg and Taranger method

Atlas method of Greulich &
Pyle
Radiograph is compared with a standard series of
films, representative of normal children at different
chronological ages and for each sex.
FISHMAN’S SKELETAL MATURITY INDICATORS
Keonord S. Fishman proposed a system for evaluation for

skeleton maturation in 1982.
Fishman made use of four anatomical sites located on the
thumb, third finger, fifth finger and radius.
. The Fishman’s system of interpretation uses four stages of

bone maturation, which include:
Sequence of ossification stages
1. Widening of epiphysis.
2. Ossification of adductor sesamoid.
3. Capping of epiphysis over the diaphysis.
4. Fusion of epiphysis with diaphysis.
Widening of epiphysis Adductor sesamoid
Capping of epiphysis Fusion of epiphysis

SKELETAL MATURATION ASSESSMENT
.
 LEONARD S.FISHMAN 1982 outlined four stages of bone
maturation found at six anatomical sites located on the thumb,
third finger, fifth finger and radius. Eleven skeletal maturity
indicators are found in these six anatomic sites.

 Epiphysis as wide as diaphysis Fusion of epiphysis and
diaphysis
 1.Third finger-proximal phalanx
8.Third finger distal
 2.Third finger-middle phalanx
-phalanx
 3.Fifth finger-middle phalanx 
9.Third finger proximal-
 Ossification phalanx
 4.Adductor sesamoid of thumb 10.Third finger middle-
 Capping of epiphysis phalanx
 5.Third finger distal- phalanx 11.Radius
 6.Third finger middle -phalanx
 7.Fifth finger middle-phalanx
Fishmans method
Other methods.
Antegonial notch as indicator of growth maturity.

 Frontal sinus as indicator of growth maturation.

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Dr CHETAN S

 Timing of growth spurts:-

1. Just before birth

 common and easy method

“ Age measured by year living since birth.’’

Since each child has his own characteristic growth

1. Tooth Eruption Age

2. Rating of tooth development from crown

1. Tooth Eruption Age : Observation of the age of

 Each tooth was rated according to development criteria ( amount of

 Eight stages, A- H were defined for each tooth mineralization stage.

 The summed score of all seven teeth gave dental maturity.

Demirjian et al., in 1973 divided tooth mineralization into nine stages.

 o. Tooth germ without signs of

Onset of the spurt (ONSET) - the smallest annual

Peak height velocity (PHV) is the greatest annual

Pubic hair (amount, coarseness, color and location), penile

 Stage of development of secondary sexual

HAGG and TARANGER (1980)

Hassel and Ferman developed a system of

Corresponds to SMI 1&2.

C3 C3 C3 C3

C C4 C4 C4 C3

The hand-wrist region is made up

1. Distal ends of long bones of

 Bjork ,Grave and Brown method

 Julian singer’s method

 Fishman’s skeletal maturity indicators

 Hagg and Taranger method

Keonord S. Fishman proposed a system for evaluation for

. The Fishman’s system of interpretation uses four stages of

Capping of epiphysis Fusion of epiphysis

Antegonial notch as indicator of growth maturity.

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