Journal of Advanced Clinical & Research Insights (2015), 2, 100103

REVIEW ARTICLE

Assessment of maturity in orthodontics: Areview

Sushma Dhiman, Sandhya Maheshwari, Sanjeev K. Verma
Department of Orthodontics and Dental Anatomy, Aligarh Muslim University, Aligarh, Uttar Pradesh, India

Keywords
Biomarkers, cervical vertebral maturational
index, dental maturation, hand-wrist
radiographs, skeletal maturation
Correspondence
Dr.Dhiman S, Department of Orthodontics
and Dental Anatomy, Aligarh Muslim
University, Aligarh, Uttar Pradesh,
India. Phone: +91-8527214151,
Email:drsushma.mdsortho@gmail.com
Abstract
Precise evaluation of maturational stage should be an integral part of both diagnosis and
treatment. Different authors had reported different methods in an attempt to determine
the best indicator of maturity. These include body height, body weight; sexual maturation;
frontal sinus, chronological age, biological age or physiological age; hand-wrist maturity
cervical vertebrae; dental eruption; dental calcification stages and biomarkers. Ever the
method has its own advantages, disadvantages and over the other method. However, still
researches are being done to explore best method to assess the maturity of an individual.
This article reviews the methods of assessment of skeletal maturation.

Received 05 November 2014;

Accepted 20 December 2014

doi: 10.15713/ins.jcri.54

Introduction Somatic maturity

Every individual matures according to his or her own biological
clock. Different authors had reported different methods in an
attempt to determine the best indicator of maturity. These
include height;[1-3] weight;[4] chronological age;[4-6] sexual
maturation;[6] Frontal sinus;[7] biological age or physiological
age; Hand-wrist maturity;[2,8-13] Cervical vertebrae;[14-17]
dental eruption; dental calcification stages;[18-21] and recently
biomarkers.[22-29]
Chronological age
Birth date by calendar determines chronological age. Wide
individual variation lies in timing of pubertal growth spurt with
respect to chronological age. Therefore, thus, chronological age
cannot be considered as a reliable indicator for the evaluation of
maturity status of a child.[2,30,31] This has led to the concept of
Biological age or physiological age.
Biological age or physiological age
The physiological age of a person is determined by the degree
of maturation of the different tissue systems.[18] Physiological
age can be estimated by maturational status of somatic, sexual,
skeletal, and dental system.
Annual growth increments in height or weight determines the
somatic maturity.[2] Measurement of height represents general
growth of the skeleton. Average age of onset of stature growth for
females and males of approximately 10 and 12years, respectively,
with the peak coming later in both sexes.[6] Height, therefore,
might represent a skeletal measure that can be used to predict the
timing of the facial growth spurt and needs further exploration.
Sexual maturation
Sexual maturation involves using secondary sex characteristics
to predict the individual maturational status. Tanner had
given separate sexual maturity ratings for boys and girls which
consists of five stages of sexual maturity with stage 1 being the
least mature (preadolescent) and stage 5 being the most mature
(adult). In boys, Tanner Sexual Maturity Ratings assesses pubic
hair (amount, coarseness, color and location), penile length and
breadth, scrotal development and testicular size. In girls, tanner
sexual maturation rating assesses breast development (size and
morphology) and pubic hair (location, color, morphology,
quantity). Prediction of sexual maturity requires a physical
examination, and hence use of sexual maturity as maturation
marker is limited in the orthodontic set up. Serial recording of
voice change in boys can be used as a measurement of maturity

100 Journal of Advanced Clinical & Research Insights Vol. 2:2 Mar-Apr 2015
Dhiman, et al.
but as mentioned above it requires a serial recording, not practical
in orthodontic clinics.[6] Menarche is an important predictor of
maturation in females.[9] Once menstruation begins, the growth
spurt is usually near completion.
Skeletal maturation
Certain bones in the body demonstrate an organized event of
ossification. Degree of ossification in these bones determines
skeletal maturation. These changes can be seen radiologically.
The hand, foot, knee, elbow, shoulder, and hip, cervical
vertebrae can be used to assess skeletal age of an individual. Out
of the above-mentioned bones, hand-wrist and cervical vertebrae
methods has been explored extensively as indicators of maturity.
Hand-wrist method
Hand and wrist region contains many bones that ossify at
different times and with different rates. Two general approaches
can be used to describe to assess hand-wrist radiograph. The first
is Atlas approach as used by Todd,[10] describe the progressive
maturation of the bones of the hand and wrist. Greulich and
Pyle[11] method utilizes an atlas of the hand and wrist as a
standard of comparison. Tanner et al. (1962; 1975; 1983;
2001)[13] improved the previous work of Pyle, Waterhouse, and
Greulich by individual bones, not the overall maturational status
of the hand and wrist. They gave a scoring method to determine
skeletal maturity from Hand wrist radiographs named it as TW1
method (1962). It assesses the maturity of twenty bones: Radius,
ulna, carpals (with the exception of the pisiform and metacarpals
and phalanges of the first, third, and fifth ray. Individual bones
of the subjects radiograph are matched with those given in the
atlas along with written criteria each bone of the hand and wrist is
assigned any of the eight or nine stages on its way to full maturity.
These stages then converted into the scores. These scores then
summed to obtain skeletal age of the subject. The sum of these
scores is termed the skeletal maturity score. However, there
were many difficulties in using TW1 method and also there was
a single set of scores for both the sexes that was not justifiable.
They revised TW1 and named it as TW2(1975). Basics of the
TW1 method were not changed only the scores of each stage
the bone were reassigned, and some bones that posed difficulties
in rating were excluded. Authors revised TW2 method (1983)
and scores were separately for males and females. This TW2
method provides standards for British Children which are age
and sex specific Tanner et al again revised the TW2 method and
named it as TW3 method (2001). Fishman developed a system
consisting of eleven adolescent skeletal maturation indicators
which identify four stages of the hand-wrist bone ossification
at six anatomical sites located on the thumb, third finger, fifth
finger and radius. SMI can be arbitrarily divided into periods of
accelerating velocity (SMI 1-3), high velocity (SMI 4-7), and
(SMI 8-11).[12] Main disadvantage of hand wrist X-rays is the
additional radiograph in addition to the routine radiographic
records such as lateral cephalogram and Orthopantomogram.
Journal of Advanced Clinical & Research Insights Vol. 2:2 Mar-Apr 2015101
Maturity assessment in orthodontics
Cervical vertebral maturation (CVM) methods
Skeletal maturation has been assessed using the shapes of the
first 4 or 5 vertebrae, excluding the atlas, and distinguishing 5 or
6 maturational stages based on the change ratio of the vertebral
bodies and the depth of the inferior concavity. These changes
have been used to estimate skeletal age. Several workers have
indicated this to be a superior alternative to the hand and wrist
method.[15,17,18,32-36] Lamparski first used cervical vertebrae to
determine skeletal maturity by analyzing size and shape changes
in the bodies of second to sixth cervical vertebrae. Initiation
and development of concavities on the lower border of the
vertebral body, and the increase in height of the vertebral body,
from tapered to rectangular, to square, can be used as skeletal
maturity indicators (SMIs).[14] Hassel and Farman developed
a cervical vertebral maturational index (CVMI) by using the
lateral profiles of the second, third and fourth cervical vertebrae
from lateral cephalogram radiographs. They also correlated their
CVMI with the Fishman SMI system method.[15] The Index
included six stages of vertebral maturation namely initiation,
acceleration, transition, deceleration, maturation, completion.
Authors condensed Fishmans 11 SMIs into six cervical
vertebrae maturation categories. Baccetti et al. modified earlier
six staged CVM method. They merged two former stages (Cvs1
and Cvs 2) single stage and presented a new CVM method with
five maturational stages from (CVMs) I through (CVMs) V.[17]
Latter on expanded back back to six stages from previously
condensed version of five maturation stages.[18] Main advantage
with CVM method lies in the fact that it eliminates radiation
exposure for orthodontic patients as lateral cephalogram
is routinely used for diagnosis and treatment planning in
orthodontic clinics. However, cervical vertebrae maturation
method required longitudinal follow-up for accuracy.
Dental maturation
Dental maturity can be estimated by the number of erupted
and unerupted teeth, stages of dentition (deciduous, mixed
or permanent);tooth calcification, degree of tooth structure,
stages of crown formation of developing teeth and stages of
root formation of all erupted teeth. Dental eruption may be
influenced by local factors: Ankylosis, early or extraction of the
deciduous tooth, impaction and crowding of the permanent
teeth. Moreover, the method can only be used during relatively
short periods because between the ages of 2.5-6, 8-10 and
13-18years, no teeth will emerge. Tooth mineralization is a
constant; mineralization was established as an alternative method
to determine dental maturation. There are basically two types of
techniques for evaluation of dental maturation and correlating it
to skeletal maturation-one uses Atlas approach while the other
uses Scoring systems. Altas approach requires comparison of
radiographs of jaws where morphologically different stages of
tooth mineralization are compared with standard tables, figures,
charts or radiographs provided by the respective authors in the
form of atlas.[37-42] Method using Atlas approach are Schour and
Massler, Nolla, Andersen et al. and Moorreees et al.[43,44]
Maturity assessment in orthodontics
Technique using Scoring systems include Demirjian[18,19]
and Haavikko methods.[45] These techniques also require jaw
radiographs but they restrict the number of teeth included
in the analysis. The teeth are assessed for crown and root
formation, and the results are interpreted into the dental age by
reference tables. Out of all above methods Demirjian method is
easy and accurate so, most widely accepted method for dental
maturation.
Biomarkers
Bone growth and remodeling is not only under the control
of local factors but systemic factors also play a crucial role.
Biomarkers represent agents that are involved directly in bone
growth and remodeling. Biomarkers avoid radiographic exposure
also. Research is being done to explore the role of biomarkers
for determination of skeletal maturation. Alkaline phosphates
in serum[22] and gingival crevicular and proteins in gingival
crevicular fluid[24] Serum Insulin-like growth factor-1.[25,26]
Serum PTHrP,[27] DHEAS[28] had been used to explore their role
in assessment maturation of an individual. Recently biomarkers
have been correlated with the dentition phase also.[29]
Conclusion
Precise evaluation of maturational stage should be an integral part
of both diagnosis and treatment. Different authors had reported
different methods in an attempt to determine the best indicator
of maturity. These include body height, body weight; sexual
maturation; Frontal sinus, chronological age, biological age or
physiological age; Hand-wrist maturity; Cervical vertebrae;
dental eruption; dental calcification stages and biomarkers. Every
method has its own advantages, disadvantages and limitation
over the other method. But still researches are being done to
explore best method to assess the maturity of an individual.
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How to cite this article: Dhiman S, Maheshwari S, Verma SK.
Assessment of maturity in orthodontics: A review. J Adv Clin
Res Insights 2015;2:100-103.