Hand-wrist Radiographs Research Articles

Prediction of Fishman’s skeletal maturity indicators using artificial intelligence

The present study aimed to evaluate the performance of automated skeletal maturation assessment system for Fishman’s skeletal maturity indicators (SMI) for the use in dental fields. Skeletal maturity is particularly important in orthodontics for the determination of treatment timing and method. SMI is widely used for this purpose, as it is less time-consuming and practical in clinical use compared to other methods. Thus, the existing automated skeletal age assessment system based on Greulich and Pyle and Tanner-Whitehouse3 methods was further developed to include SMI using artificial intelligence. This hybrid SMI-modified system consists of three major steps: (1) automated detection of region of interest; (2) automated evaluation of skeletal maturity of each region; and (3) SMI stage mapping. The primary validation was carried out using a dataset of 2593 hand-wrist radiographs, and the SMI mapping algorithm was adjusted accordingly. The performance of the final system was evaluated on a test dataset of 711 hand-wrist radiographs from a different institution. The system achieved a prediction accuracy of 0.772 and mean absolute error and root mean square error of 0.27 and 0.604, respectively, indicating a clinically reliable performance. Thus, it can be used to improve clinical efficiency and reproducibility of SMI prediction.

A comparison of skeletal age of thalassemic patients of 9 – 15 years with chronological age by radiography.

Objective: To compare bone/skeletal age of thalassemic children with chronological age by hand-wrist radiography to assess possible growth retardation. Study Design: Descriptive Cross-sectional study. Setting: In collaboration of Radiology & Pathology Department of Sahiwal Teaching Hospital and Ali Zaib Foundation, Sahiwal. Period: January 2021 to June 2021. Material & Methods: Three hundred and fifty patients were purposively recruited for the study. Among them 250 were registered children of thalassemia at Ali Zaib Foundation, Sahiwal and 100 were non-thalassemic children taken as control group to make comparison of the findings from thalassemia patients. After approval from institutional review board (IRB) and taking written informed consent of the parents, the researchers get their hand-wrist radiographs done. Ossification centers were evaluated to assess bone age that was compared with chronological age. Data was analyzed using SPSS-24. Results: The statically significant difference was seen in bone age between the two groups as compared to their chronological age that remained statically non – significant. Conclusion: To evaluate possible growth retardation in thalassemia children, hand-wrist X-ray can be considered a standard modality.

Association between dental and skeletal maturation in Scandinavian children born between 2005 and 2010

Objective The aim of this cross-sectional study was to analyse the association between dental and skeletal maturation in children born between 2005 and 2010. Materials and methods Dental and skeletal maturation of 117 ethnic Scandinavian children born between 2005 and 2010 (70 girls, 47 boys, mean age 11.48 years) was analysed. Dental maturation (DM) was assessed on orthopantomographs (OPs) by using Demirjian’s and Haavikko’s methods while skeletal maturation was assessed on hand-wrist radiographs by use of Helm’s method. The correlation between skeletal and DM was analysed using Spearman’s rho (Rs). Additionally, the most frequent DM stage in relation to the skeletal maturation stage was analysed by logistic regression adjusted for age and sex. Results The correlation between dental and skeletal maturation was significant for all teeth (Rs = 0.071–0.562; p < .000–p = .035) except for the first incisor and the first molar. Logistic regression analysis showed that when the mandibular and maxillary canines are ¾ mineralized, this is significantly associated with the beginning of the adolescent period before peak height velocity (PHV) (PP2= p < .005–< .05). Likewise, when the mandibular second premolars are ¾ mineralized, this is significantly associated with the maturation stage PP2= or S (PP2= p < .05, S: p < .005–< .05), both of which are before PHV at the beginning of the adolescent period. Limitations Limited sample size and the X-rays were taken before orthodontic treatment, which may have introduced a selection bias. Conclusions When the root of the canines or second premolars is ¾ mineralized, it may indicate the beginning of the adolescent period with increased skeletal growth intensity.

Relationship between skeletal maturity indicators and dental calcification stages in a sample pediatric population.

Human growth shows considerable variation. In addition to constitutional differences in the timing of maturation, there are diseases, systemic disorders and environmental factors that may affect a child's physiologic maturity. Interrelationships among skeletal, somatic and sexual maturity have been shown to be consistently strong. The study was conducted to evaluate the relationship between dental calcification stages and skeletal maturity indicators. The hand wrist radiographs, the lateral cephalogram and the orthopantomogram (OPG) of 120 patients (60 males and 60 females, age group 8-14 years) were taken. The hand wrist radiographs were analyzed using Fishman's skeletal maturity index (SMI), and the cephalograms analyzed by cervical vertebrae maturation (CVM) by Baccetti. OPG was analyzed according to the Demirjian's system. On assessment, cervical vertebrae maturation indicator (CVMI) staging showed significant results with a correlation coefficient of 0.716 being the highest in canines in males while assessment of dental calcification stages and its comparison with skeletal maturity indicator showed insignificant results. The correlation coefficient values were 0.11, 0.09, 0.09 and 0.13 for canine, first premolar, second premolar and second molar respectively. There is a strong correlation between the maturation stage of cervical vertebrae and calcification stages of canine, first premolar, second premolar and second molar as determined by Demirjian's method.

Prediction of Stature from Index Finger Length in South Karnataka Population: A First Radiographic Study

Context: The “big four” components of biological profile are age, sex, race, and stature. Stature estimation is considered as one of the most important biological profiles for identification of an individual. Aims: We aimed to estimate stature from index finger length (IFL) clinically and also radiographically in South Indian population. Subjects and Methods: A cross-sectional sample of 100 patients was randomly selected from patients who visited the Department of Oral Medicine and Radiology in our institution. Stature of the participants was measured using a height chart ruler. IFL was measured clinically using digital calipers. Handwrist radiographs of the left hand were obtained using the KODAK 8000C Panoramic and Cephalometric System. Radiographic measurements were taken from the line joining the metacarpophalangeal joint to the distal point on the distal phalange of the index finger done using Windows Trophy DICOM software. Statistical Analysis Used: Data were subjected to logistic regression analysis. Results: Significant correlation was found between IFL and stature both clinically and radiographically. Conclusions: The use of IFL can be recommended to predict stature. Even if the soft tissues undergo putrefaction, the radiographs can help in assessing the stature of the individual and can provide an advantage of time in comparison to estimation of stature clinically.

Comparison of Cervical Vertebral Maturation with Fishman’s Skeletal Maturity Index Method in Assessment of Growth Status

Assessment of skeletal maturity is paramount for orthodontists since optimal use and effectiveness of orthodontic and orthopedic appliances depends on it. Objective: To compare the cervical vertebral maturation (CVM) with Fishman’s hand wrist radiograph (HWR) method in assessment of growth status. Methods: This comparative cross sectional study was conducted at the Orthodontics department at the Khyber College of dentistry, Peshawar on 100 participants. The patients with 9 to 15 years of age, relatively well aligned arches, both genders, mild to moderate skeletal discrepancy, minimal dental compensations, vertical normal angle, and without temporomandibular joint disorders were included. Along with age and gender, stages of HWR and CVM were recorded. HWRs were acquired by standardized method and lateral cephalograms were taken in natural head position. The staging of HWR was done by using Fishman method while CVM staging. Comparison of CVM stages and Fishmann’s HWR stages were done using chi-square test. Results: The mean age was 11.79 ± 1.62 years. The females were 53(53%) and males were 47(47%). Most common stage of CVM was III (n=33, 33%) followed by IV (n=27, 27%). Similarly, common stage of hand wrist radiograph was III (n=32, 32%) followed by IV (n=28, 28%).There was no statistically significant different between two methods for assessing skeletal growth status (p=0.697). Conclusions: Cervical vertebral maturation can have used as an alternative to hand wrist radiograph for growth assessment without an extra radiation

Trends and Application of Artificial Intelligence Technology in Orthodontic Diagnosis and Treatment Planning—A Review

Artificial intelligence (AI) is a new breakthrough in technological advancements based on the concept of simulating human intelligence. These emerging technologies highly influence the diagnostic process in the field of medical sciences, with enhanced accuracy in diagnosis. This review article intends to report on the trends and application of AI models designed for diagnosis and treatment planning in orthodontics. A data search for the original research articles that were published over the last 22 years (from 1 January 2000 until 31 August 2022) was carried out in the most renowned electronic databases, which mainly included PubMed, Google Scholar, Web of Science, Scopus, and Saudi Digital Library. A total of 56 articles that met the eligibility criteria were included. The research trend shows a rapid increase in articles over the last two years. In total: 17 articles have reported on AI models designed for the automated identification of cephalometric landmarks; 12 articles on the estimation of bone age and maturity using cervical vertebra and hand-wrist radiographs; two articles on palatal shape analysis; seven articles for determining the need for orthodontic tooth extractions; two articles for automated skeletal classification; and 16 articles for the diagnosis and planning of orthognathic surgeries. AI is a significant development that has been successfully implemented in a wide range of image-based applications. These applications can facilitate clinicians in diagnosing, treatment planning, and decision-making. AI applications are beneficial as they are reliable, with enhanced speed, and have the potential to automatically complete the task with an efficiency equivalent to experienced clinicians. These models can prove as an excellent guide for less experienced orthodontists.

Evaluation of effects of Forsus Fatigue Resistance device in correction of class II division 1 malocclusion in adolescent patient: A case report

Introduction: Class II malocclusion is one of the most prevalent malocclusions. The Class II malocclusions are caused due to forwardly placed maxilla, the backward position of the mandible, or a combination of both these factors. This disparity in skeletal base growth and position can be corrected during growth spurts using functional and fixed functional appliances. Description: An adolescent boy with Class II division 1 malocclusion, retrusive mandible, and increased overjet was treated with a pre-adjusted edgewise appliance (0.022-slot Gemini 3M -MBT prescription) along with a fixed functional appliance, Forsus TM Fatigue Resistant Device. The Skeletal age of the patient assessment using Hand wrist radiograph and CVM showed a major part of the adolescent growth spurt to be completed. Pre-treatment and post-functional cephalograms were traced and superimposed to compare changes in the skeletal base and dental structures. Result: The Class II molar and canine relationships were corrected to class I and the mandible showed forward positioning leading to correction for the skeletal base to class I. The facial profile showed marked improvement to an orthognathic pleasing profile. Conclusion: The purpose of this case report is to emphasize on use of fixed functional appliances in the treatment of adolescents with skeletal base discrepancies like Class II division 1 malocclusion. Intervention with fixed functional appliances at the appropriate skeletal age can prevent the need for extractions or other surgical procedures that may be needed to correct the malocclusion.

Examining the Deciduous Tooth Eruption and Carpal Osteogenesis in Relation to Forensic age Estimation

Objective: To compare the accuracy of deciduous teeth eruption and ossification of carpel bone of hand for estimation of forensic age. Study Design: Randomized controlled trial Place and Duration: Department of Forensic, Bacha Khan Medical college Mardan from January 2022 to June 2022. Methodology: Total 140 children of both genders with ages 5 to 15 years were enrolled in this study. All the patients were equally divided into two groups, each group consist of 70 patients. In group A dental age estimates were made using radioscopic (RVG) pictures of the left quadrant mandibular teeth by Demirjian method and the right hand wrist radiograph by Greulich and Pyle method was used for the estimation of the age of the skeleton in Group B. Statistical analysis on differences between chronological age and approximate skeletal and dental age was carried out. Results: There were 40 (57.14%) male and 30 (42.86%) females in group A and in group B 38 (54.29%) male and 32 (45.71%) females. The difference between chronological age and dental age in children with ages 5 to 10 years was 0.64±1.24 years and children with ages 11 to 15 years the difference was 0.67±0.18 years in group A and in group B difference between chronological age and skeletal age among children with age group 5 to 10 years was 0.72±1.18 years and among children with ages 11 to 15 years the difference was 0.66±1.18 years. No significant difference was observed between both groups with p-value &gt;0.05. Conclusion: It is concluded that both procedures dental age estimation and skeletal age estimation are effective for forensic age estimation. No significant difference was observed between both methods. Keywords: Age Estimation, Forensic, Dental Age (Demirjian’s), Bone Age (Greulich and Pyle)

Age Estimation by Dental Calcification Stages and Hand-Wrist Radiograph.

Introduction: An essential part of pediatric dentistry in recent times is age estimation for various purposes such as orthodontics, forensic dentistry, human anthropology, and bioarchaeology. Assessment of calcification of dental tissue is another physiologic method for skeletal growth assessment.Aims: This study aims to evaluate the correlation between dental calcification stages and skeletal maturity indicators and their application in age estimation purposes.Methods: Tooth calcification was assessed by Demirjian's method and hand-wrist assessment was done by Fishman’s method. Spearman's rank-order correlation coefficient was applied to measure the association between skeletal maturational indicators and dental calcification stages of individual teeth, and the statistical significance of the correlation was tested.Results: Spearman's significant coefficients for canine, first premolar, second premolar, and molar are 0.11, 0.09, 0.09, and 0.13, respectively, which are not significant.Conclusion: Fishman's method of hand-wrist radiograph assessment is quite accurate as a maturity indicator but its association with dental calcification stages cannot be established.

Generational perspectives of orthodontists in the U.S. and Canada: A survey study

The objectives of this study were to identify differences between generations of orthodontists in the United States and to evaluate the perspective of each generation on widely debated topics in orthodontics. A 22-item Institutional Review Board-approved survey was randomly distributed to orthodontists in the United States and Canada. Participants were asked questions about the use of technology, the future of clear aligner therapy, orthodontic education, student debt, marketing, and corporate orthodontics, among other topics. Significant increase in female orthodontists over generations and a decrease in orthodontic educators were found (P<0.001). Among generations, differences were found regarding the amount of student debt, use of specific diagnostic tools, marketing preferences, and their opinion on the future of clear aligner therapy. Most of the silent generation did not have student debt, whereas millennials reported paying off their debt in 1 year to>20 years and being most heavily burdened by student debt. Younger generations appeared more likely to use cone-beam computed tomography and intraoral imaging, whereas older generations preferred traditional diagnostic tools such as hand-wrist radiographs and alginate impressions. Most of the silent generation indicated not marketing their practices, whereas millennials rely heavily on social media and e-mails for marketing. Clear distinctions exist between different generations of orthodontists. Issues such as increasing student debt load and a decrease in orthodontic educators over generations should be addressed to preserve the future of the orthodontic specialty.

Deep focus approach for accurate bone age estimation from lateral cephalogram

Background/purposeBone age is a useful indicator of children's growth and development. Recently, the rapid development of deep-learning technique has shown promising results in estimating bone age. This study aimed to devise a deep-learning approach for accurate bone-age estimation by focusing on the cervical vertebrae on lateral cephalograms of growing children using image segmentation. Materials and methodsWe included 900 participants, aged 4–18 years, who underwent lateral cephalogram and hand-wrist radiograph on the same day. First, cervical vertebrae segmentation was performed from the lateral cephalogram using DeepLabv3+ architecture. Second, after extracting the region of interest from the segmented image for preprocessing, bone age was estimated through transfer learning using a regression model based on Inception-ResNet-v2 architecture. The dataset was divided into train:test sets in a ratio of 4:1; five-fold cross-validation was performed at each step. ResultsThe segmentation model possessed average accuracy, intersection over union, and mean boundary F1 scores of 0.956, 0.913, and 0.895, respectively, for the segmentation of cervical vertebrae from lateral cephalogram. The regression model for estimating bone age from segmented cervical vertebrae images yielded average mean absolute error and root mean squared error values of 0.300 and 0.390 years, respectively. The coefficient of determination of the proposed method for the actual and estimated bone age was 0.983. Our method visualized important regions on cervical vertebral images to make a prediction using the gradient-weighted regression activation map technique. ConclusionResults showed that our proposed method can estimate bone age by lateral cephalogram with sufficiently high accuracy.

Evaluation of the compatibility of C2, C3, and C4 fractal dimension values with hand-wrist and cervical vertebra maturation methods in determining skeletal maturation.

To examine the correlation between the fractal dimension (FD) values of cervical vertebrae (C2, C3, and C4) and hand-wrist maturation (HWM) and cervical vertebra maturation (CVM) methods. In addition, the correlation between the pubertal growth spurt (PGS) and FD values was examined. The lateral cephalometric and hand-wrist radiographs of 120 subjects (61 females and 59 males) aged 8-18 years with a mean age of 13 years, were evaluated retrospectively. The CVM stages were determined in accordance with Hassel-Farman's modification of Lamparski criteria. The HWM stages were determined in accordance with Björk and Grave-Brown criteria. Both HWM and CVM stages were divided into two according to PGS. Fractal analysis of cervical vertebrae was performed according to the White-Rudolph method. The relationships between HWM stages, CVM stages and other variables were evaluated by Spearman's rank-order correlation coefficient. The relationships between FD values, chronological age, and divided stages were evaluated by the Pearson correlation coefficient. The Mann-Whitney U test was used to compare the FD values of two divided stages. There were positive and statistically significant positive correlations between chronological age and both HWM and CVM stages. There was a positive and statistically significant correlation between CVM and HWM stages. In females and total, there were negative and statistically significant correlations between C4 FD values and divided HWM stages, and the differences between C4 FD values of divided HWM stages were also statistically significant. In total, there was a negative and statistically significant correlation between C4 FD values and divided CVM stages, and the difference between C4 FD values of divided CVM stages was also statistically significant. The negative correlations found between C4 FD values and divided HWM and CVM stages suggest the fractal analysis of cervical vertebrae, especially of C4, may be used as an objective tool for evaluating the PGS.

The Effect of Clinical Experience on Cervical Vertebral Maturation Assessment: Is a Hand-wrist Radiograph Necessary?

The Effect of Clinical Experience on Cervical Vertebral Maturation Assessment: Is a Hand-wrist Radiograph Necessary?

Estimating Skeletal Maturity Using Wrist Radiographs During Preadolescence: The Epiphyseal:Metaphyseal Ratio.

Although skeletal maturity is most relevant during adolescence, it has utility in treatment of younger patients in some circumstances, such as scoliosis, limb length discrepancy, or endocrinopathies. Currently, a quick, accurate, and reproducible method of estimating skeletal maturity in preadolescents using wrist radiographs is lacking. Serial anteroposterior wrist radiographs taken at historical growth study visits leading up to the chronological age (CA) associated with 90% of the final height (an enhanced skeletal maturity standard as compared with peak height velocity) were analyzed in 102 children. Epiphyseal and metaphyseal widths of 5 physes were evaluated: distal radius, distal ulna, first metacarpal, third metacarpal, and fifth metacarpal. Ulnar styloid height and radial styloid height were also measured, for a total of 7 epiphyseal:metaphyseal radiographic parameters. Greulich and Pyle (GP) bone age was also measured. A combination of stepwise linear regression and generalized estimating equation analyses was used to produce a skeletal maturity estimation model incorporating demographics (CA and sex) and the epiphyseal:metaphyseal ratios significantly correlated with skeletal maturity. A total of 273 left anteroposterior hand-wrist radiographs from 56 girls (163 radiographs, range 4 to 13 y) and 46 boys (112 radiographs, range 3.8 to 15 y) were included. The demographics+ratios model had better prediction accuracy than GP only and GP with demographics (0.44, 0.87, and 0.47 y mean discrepancy from actual skeletal age, P <0.05 for both comparisons). There was no significant difference in the rate of outlier skeletal age estimates, defined as an estimate >1 year off from the true skeletal age, between the demographics+ratios model and the demographics+GP model (5.9% vs. 8.4%, P =0.12). When combined with CA and sex data, measurement of the epiphyseal:metaphyseal ratios of the left first and third metacarpals allows for improved skeletal maturity estimation compared with the GP technique. Our modified wrist skeletal maturity system offers a relatively quick and reproducible method for estimating skeletal maturity extending into the juvenile age range. This study is a level III retrospective study of longitudinal human growth data obtained from the Bolton Brush Collection in Cleveland, Ohio.

Evaluation of the Effects of Distal Malocclusion Activators on the Craniofacial Complex

Introduction: Class II malocclusions are the most commonly seen, and therefore, the most commonly treated type of anomalies. Dental and skeletal factors are involved in the development of Class II malocclusions. The purpose of this study was to investigate whether or not there were any changes in the increased cranial base angle and cranial base dimensions, which have been reported to be among the morphological characteristics of Class II malocclusions, with functional orthopedic treatment and to evaluate effects of these changes on facial structures. Materials and Methods: The study was conducted on hand-wrist radiographs and lateral cephalometric radiographs of 50 patients taken at the beginning and at the end of treatment. The control group comprised 17 patients and the treatment group comprised 17 patients who were treated with a Class II division 1 activator and 16 patients who were treated with a combination of Class II division 1 activator and an Occipital Headgear (Hg). Results: Among the measurements for cranial base dimensions, only the increase in S-N in the treatment group was smaller than that in the control group. No significant differences were found among groups regarding the values of NSBa and NSAr angles, which are known to be cranial base angles. Conclusion: The increase in the S-N dimension being smaller in the treatment group brings about the idea that the activator treatment may influence maxillary development and consequently the nasomaxillary complex.

Correlation between Salivary Levels of IGF-1, IGFBP-3, IGF-1/IGFBP3 Ratio with Skeletal Maturity Using Hand-Wrist Radiographs.

Objective: The relevance of growth determination in orthodontics is driving the search for the most precise and least invasive way of tracking the pubertal growth spurt. Our aim was to explore whether minimally invasive salivary estimation of biomarkers Insulin-like growth factor (IGF-1) and Insulin-like growth factor binding protein-3 (IGFBP-3) could be used to estimate skeletal maturity for clinical convenience, especially in children and adolescent age groups. Materials and Method: The cross-sectional study was conducted on 90 participants (56 girls and 34 males) with ages ranging from 6 to 25 years. Each subject’s hand-wrist radiograph was categorized based on skeletal maturity, and saliva samples were estimated for IGF-1 and IGFBP-3 using the respective ELISA kits. Kruskal–Wallis nonparametric ANOVA was applied to compare different skeletal stages. Results: The study demonstrated low salivary IGF-1 levels at the prepubertal stage, with increase during pubertal onset and peak pubertal stage followed by a decline during pubertal deceleration to growth completion. Spearman’s correlation coefficient demonstrated a strong positive association (r = 0.98 p < 0.01) between salivary IGF/IGFBP-3 ratio and different stages of skeletal maturity. Conclusion: Salivary IGF-1, IGFBP-3, and IGF/IGFBP-3 ratio could serve as a potential biochemical marker for predicting the completion of skeletal maturity.

Statistical validation of the computerized method for calculating vertebral bone age

For planned orthodontic therapy to be effective, it is important to define a treatment time based on the estimation of the child’s growth stage, skeletal maturation and therefore bone age. In a single irradiation via profile teleradiography, it is possible to obtain sufficient information to place the patient on his growth curve since the vertebral stages are good indicators of physiological maturity. The objective was to statistically validate the vertebral computerized method (MIV) on a large sample in order to reliably and reproducibly locate the stage of vertebral maturation. Hand-wrist radiographs and profile teleradiographs of 30 patients were included to set up the MIV. To validate the MIV, panoramic and telecranial radiographs of 192 children were included in the study. Spearman correlation tests were then performed to assess correlations and Lin’s concordance coefficient calculations were used to analyze concordances. The correlations and concordances obtained were statistically significant, positive and moderate. The vertebral computerized method is a method that seems reliable and usable in orthodontic practices.

Is there any relationship between pubertal growth spurt and dental or bone age estimation methods?

ABSTRACT The aim of this study was to compare the accuracy of the Willems method, Nolla method, Cameriere dental age estimation method(CDM), Greulich-Pyle Atlas(GPA) method, and Cameriere bone age estimation method(CBM) for age estimation in healthy children aged between ten and 14.9 years, according to the pubertal growth stage(PGS). The accuracy was determined as the difference between estimated age(EA) and chronological age(CA) was assessed by analysing orthopantomograms and hand-wrist radiographs. At the onset of the PGS, the Willems method showed the closest value to the CA for both sexes(girls = 0.17 ± 0.78, boys = 0.006 ± 0.96 years). At the peak, the Willems method showed the closest value to the CA for girls(0.005 ± 1.09 years), and the GPA method for boys(0.05 ± 0.68 years). At the end of the PGS, the Willems method showed the closest value to the CA for girls(0.09 ± 1.23 years), and the CBM for boys(0.24 ± 0.74 years). It was observed that all methods concluded with the closest result to the CA at the onset period of the PGS. Our study demonstrates that sex and PGS are effective in over- or under- estimations that are obtained according to the CA.

Systematic Isolation of Key Parameters for Estimating Skeletal Maturity on Anteroposterior Wrist Radiographs.

The ability to make a continuous skeletal maturity estimate from a wrist radiograph would be useful in the treatment of adolescent forearm fractures, scoliosis, and other conditions. We attempted to create a reliable, rapid, and accurate method to do this. Many anteroposterior wrist radiographic parameters from 3 skeletal maturity systems were simplified to 23 based on relevance to the peripubertal age range, univariate correlation with skeletal maturity, and reliability. These 23 parameters were evaluated on serial peripubertal anteroposterior hand-wrist radiographs. We determined the Greulich and Pyle (GP) skeletal age and Sanders hand system (SHS) stage. We used stepwise linear regression and generalized estimating equation (GEE) procedures to identify important radiographic and demographic parameters for estimating skeletal maturity, creating the "Modified Fels wrist skeletal maturity system." Its accuracy predicting skeletal maturity was evaluated and compared with that of 4 other systems: (1) GP system, (2) SHS, (3) GP parameters along with age and sex, and (4) SHS parameters along with age and sex. Three hundred and seventy-two radiographs of 42 girls (age range, 7 to 15 years) and 38 boys (age range, 9 to 16 years) were included. Fifteen radiographic parameters were excluded from the Modified Fels wrist system by stepwise regression and GEE analyses, leaving age, sex, and 8 radiographic parameters in the final model. Use of the Modified Fels wrist system resulted in more accurate skeletal maturity estimations (0.34-year mean discrepancy with actual skeletal maturity) than all other systems (p < 0.001 for all). The Modified Fels wrist system had a similar rate of outlier skeletal maturity estimations as the age, sex, and SHS model (1.9% versus 3.5%, p = 0.11) and fewer outliers than all other systems (p < 0.05 for all). A system that included demographic factors and 8 anteroposterior wrist radiographic parameters estimates skeletal maturity more accurately than the 2 most-used skeletal maturity systems in the United States. The Modified Fels wrist skeletal maturity system may allow for more accurate, reliable, and rapid skeletal maturity estimation than current systems, and also may be used when treating adolescent forearm fractures as it does not require imaging past the metacarpals. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.