Skeletal Maturity Indicators Research Articles

To establish the validity of dental age assessment using Nolla′s method on comparing with skeletal age assessed by hand-wrist radiographs

Background: Skeletal age assessment by hand-wrist radiographs has been found to correlate significantly with the growth status of an individual, but has a known drawback in the form of extra-radiograph and high dose of radiation exposure in comparison to periapical X-rays used commonly in dentistry. Aims and Objectives: The purpose of the study was to assess skeletal age using hand-wrist radiographs and to find the correlation amongst the skeletal, dental, and chronological ages. Materials and Methods : Ninety Indian healthy children in the age group 9-13 years, comprising equal number of males and females, were included in the study. The children were radiographed for hand-wrist of the right hand and intraoral periapical X-ray for right permanent maxillary and mandibular canine. Results: There was high correlation between skeletal maturation indicator and canine calcification stages for both male and female children (0.635, 0.891). Conclusion: Females were more advanced in skeletal maturation than males. Chronological age showed inconsistent correlation with dental and skeletal ages. It was concluded that canine calcification stages can also be used for assessing skeletal maturity.

Dental & Skeletal maturity indicators of Chronological age: Radiographic evaluation amongst children in Gujarat, India

1 Senior Lecturer; Department of Orthodontia; AMC Dental College and Hospital, Ahmedabad, Gujarat, India. 2 The Dean and Head of the Department; Department of Orthodontia; AMC Dental College and Hospital, Ahmedabad, Gujarat, India __________________________________________________________________________________ Abstract: Introduction: Recognizing dental and skeletal developmental stages from cephalometric and panoramic radiographs is very useful to assess physiologic maturity without resorting to any special radiograph. Objectives: 1. Dental age determination from panoramic radiograph using Demirjian method. 2. Skeletal age determination from lateral cephalometric radiograph using Hassel and Farman method. 3. To evaluate the nature of interrelationship between Chronological, Dental and Skeletal age. Methods: The sample for study consisted of 160 radiographs (80 panoramic radiographs and 80 cephalometric radiographs) of 40 boys and 40 girls randomly selected from various schools of Ahmedabad, Gujarat, India in the age group of 6 to 13 years known chronological age. Data was collected and analyzed. Results: A strong correlation exists between Chronological and assessed Dental age in both genders of 7-12age. (r = 0.8) A moderate correlation exists between Chronological and assessed Skeletal age in both genders of 9-13age (r =0.4) A moderate correlation exists between assessed Skeletal and Dental age in both genders of 9-13age (r =0.6) Conclusions: Significant strong correlation was found among Chronological and assessed Dental age. Girls showed an early maturation over boys of the same age group.

Objective Evaluation of Cervical Vertebral Bone Age— Its Reliability in Comparison with Hand-Wrist Bone Age: By TW3 Method

The aim of this study was to establish the validity of a new method for evaluating skeletal maturation by assessing the 3rd and 4th cervical vertebrae seen in the cephalometric radiograph. This study consisted of a sample of 50 patients in the age group of 8 to 14 years of age. Chronologically, they were divided into six groups, based on the age consisting of a minimum of six to a maximum of 10 subjects. All the patients included in the study were females. The selected subjects were clinically examined and then age and date of birth of the patient in years and months was noted. Then lateral cephalograms and hand-wrist radiographs of the patient were taken on the same day with good clarity and contrast. The results suggested that cervical vertebral bone age on cephalometric radiographs calculated with this method is as reliable at estimating bone age as is the Tanner-Whitehouse 3 (TW3) method on hand-wrist radiographs. By determining the cervical vertebral bone age, skeletal maturity can be evaluated in a detailed and objective manner with cephalometric radiographs. The ability to accurately appraise skeletal maturity from cervical vertebral maturation, without the need for additional radiographs, has the potential to improve orthodontic diagnostic and therapeutic decisions. The technique's simplicity and ease of use should encourage this method as a frst level diagnostic tool to assess skeletal maturation. Clinical signifcance: This study revealed that the timing and sequence of ossifcation of the bones in hand and wrist and cervical vertebrae were able to relate the skeletal development of the various skeletal maturity indicators to a child's development. This method provided a mean with which one can determine the skeletal maturity of a person and thereby determine whether the possibility of potential growth existed.

Correlative and comparative study of Fishman′s skeletal maturity indicators with CVMI and chronological age in Lucknow population

Abstract Objective: The present study consists of comparison and correlation between the hand-wrist skeletal maturation indicator (SMI) and the cervical vertebral maturation indicator (CVMI) and verification of the reliability of the vertebral index and chronological age in the determination of the stages of the skeletal maturation. Materials and Methods: The study consisted of randomly selected 90 children from Lucknow population with 45 males (age range 10-13 years) and 45 females (age range 9-12 years). Hand wrist radiograph taken for SMI, Lateral cephalogram taken for CVMI. Correlation was made between cervical vertebrae maturation and hand wrist maturation. These two methods and the chronological age were compared using the Newman-Keuls test. Results: There was strong correlation between SMI and CVMI for both male and female (0.849, 0.932). Cervical vertebrae maturation indicator and hand-wrist skeletal maturational indicator (SMI) showed no statistical signi?cant difference for males and females. However, females showed maturation at an early age as compared to males. Chronological age shows significant difference in comparison to skeletal age. Conclusion: It was concluded that CVMI stages can also be used as for assessing skeletal maturity. Cervical vertebrae assessment provided a reliable assessment for pubertal growth spurt, it would be bene?cial to use a lateral cephalogram for skeletal maturity assessment and thereby eliminate the need for an additional radiograph (hand-wrist radiograph). This is cost effective and will also reduce the radiation exposure to the patient.

Skeletal maturity assessment with the use of cone-beam computerized tomography

The aim of the study was to compare cervical vertebrae maturity assessed with the use of cone-beam computerized tomography (CBCT) with the hand-wrist maturation method and cervical vertebrae maturation assessed with the use of lateral cephalography for the assessment of skeletal maturity. Assessment of skeletal maturation was done using skeletal maturity indicators (SMI) from hand-wrist radiography, cervical vertebrae maturity index (CVMI) from CBCT and lateral cephalography (cephalo-CVMI). The Spearman correlation coefficient was used for statistical analysis. We observed a significant relationship between CBCT-CVMI and cephalo-CVMI as well as between CBCT-CVMI and SMI stages. The Spearman correlation coefficient value between CBCT-CVMI and cephalo-CVMI was 0.975 (P < .0001) and between CBCT-CVMI and SMI was 0.961(P < .0001). Cervical vertebrae maturity assessment with CBCT provided a reliable assessment of pubertal growth spurt, and therefore CBCT can be used to assess skeletal maturity.

Determining skeletal maturation using insulin-like growth factor I (IGF-I) test

ObjectiveTo investigate the validity of Insulin like Growth Factor -1(IGF-1) as a skeletal maturity indicator by comparing serum IGF-1 levels with the stages in cervical vertebral maturation (CVM) and in the middle phalanx of the third finger (MP3). Materials and methodsThe study population was selected by using simple random sampling technique and consisted of 30 female subjects in the age range of 8-23 years who had blood sample, cephalometric and MP3 radiographs taken on the same day. Serum IGF-I estimation was carried out on the blood samples using chemiluminescence immunoassay (CLIA) method. CVM was evaluated using method by Baccetti et al and MP3 staging was done using Rajagopal & Kansal method. Mean IGF-1 level between the stages was compared by Kruskal-Wallis and Mann Whitney test. ResultsSerum IGF-1 levels in females correlate well with skeletal maturity determined by CVM and MP3 stages and increase sharply during early pubertal stages followed by a decrease in late puberty. In addition we hypothesis that serum IGF-1 testing can be undertaken as a preliminary screening test in patients in whom the orthodontist predicts the possibility of using myofunctional appliance but in whom the chronologic age is not suggestive for a growth modification therapy. ConclusionsThe finding of the study highlights the fact that the serum IGF-1 estimation can be a valuable tool in assessing skeletal maturation.

Cervical vertebral maturation as a biologic indicator of skeletal maturity

To identify and review the literature regarding the reliability of cervical vertebrae maturation (CVM) staging to predict the pubertal spurt. The selection criteria included cross-sectional and longitudinal descriptive studies in humans that evaluated qualitatively or quantitatively the accuracy and reproducibility of the CVM method on lateral cephalometric radiographs, as well as the correlation with a standard method established by hand-wrist radiographs. The searches retrieved 343 unique citations. Twenty-three studies met the inclusion criteria. Six articles had moderate to high scores, while 17 of 23 had low scores. Analysis also showed a moderate to high statistically significant correlation between CVM and hand-wrist maturation methods. There was a moderate to high reproducibility of the CVM method, and only one specific study investigated the accuracy of the CVM index in detecting peak pubertal growth. This systematic review has shown that the studies on CVM method for radiographic assessment of skeletal maturation stages suffer from serious methodological failures. Better-designed studies with adequate accuracy, reproducibility, and correlation analysis, including studies with appropriate sensitivity-specificity analysis, should be performed.

Skeletal maturation evaluation using mandibular second molar calcification stages

To investigate (1) the relationships between the stages of mandibular second molar calcification and skeletal maturity; and (2) whether second molar calcification stages can be used as a reliable diagnostic tool to determine skeletal maturity. Samples were derived from panoramic radiographs and lateral cephalograms of 300 subjects (137 males and 163 females) with ages ranging from 9 to 18 years, and estimates of dental maturity (Demirjian Index [DI]) and skeletal maturity (cervical vertebrae maturation indicators [CVMI]) were made. A highly significant association (C* = 0.854 for males and 0.866 for females) was found between DI and CVMI. DI stage E corresponded to stage 2 of CVMI (pre-peak of pubertal growth spurt) and DI stages F and G corresponded to stages 3 and 4 of CVMI (peak of pubertal growth spurt). DI stage H was associated with stages 5 and 6 of CVMI (end of pubertal growth spurt). A highly significant association exists between DI and CVMI. Mandibular second molar DI stages are reliable indicators of skeletal maturity.

혼합치열기 정상교합아동의 수완부골과 경추골의 성숙도 비교 연구

이번 연구의 목적은 소아환자의 골격성숙도 평가를 위해 경추골과 수완부골 방사선 사진의 상호연관도를 연구하는 것이다. 성적인 특징, 연령, 치아 발육, 신장, 체중과 골격성장은 성장 단계를 확인하기 위해 사용되는 일반적인 방법이다. 청소년기 전이나 청소년기 동안 성장잠재력에 대한 평가는 매우 중요하다. 본 연구는 6~18세 아동을 대상으로 측면 두부 방사선 사진과 수완부골 방사선 사진을 촬영하여 골격성숙 단계를 비교 평가하였다. 1. 일반연령은 Skeletal Maturity Indicators(SMI)와 Cervical Vertebrae Maturation(CVM)에 비하여 적절한 골격성숙도 표시자가 되지 못하였다. 2. SMI와 CVM의 골격성숙도는 여자의 경우 남자에 비해 더 빨랐다. 3. SMI 1, 2는 CVM 1, SMI 3, 4는 CVM 2, SMI 5, 6은 CVM 3에 해당하는 연관관계가 나타났다. 4. SMI와 CVM에 대한 측정자의 재현성 및 신뢰도는 우수하였다. 이상의 결과로 CVM도 SMI와 같이 교정치료에 있어 골격성숙도를 평가하는 적절한 방법이 될 수 있다. The purpose of study is for the certified correlations of hand-wrist radiograph with cervical vertebrae for skeletal maturation in children. Normal evaluation devices of growth stage is sexual feature, biological age, tooth development stage, height and weight. Evaluation of growth potential is very important for childhood and puberty. The skeletal developmental stages were evaluated by using the hand-wrist radiograph and cephalometric radiograph that obtained from 6 to 18 years old children. 1. Chronologic age was not more suitable indicator of skeletal development compared to Skeletal Maturity Indicators(SMI) and Cervical Vertebrae Maturation(CVM) stages. 2. SMI and CVM stages for females occurred earlier than that for male. 3. SMI 1 and 2 stages were corresponded to CVM 1; SMI 3,4 = CVM 2; SMI 5,6 = CVM 3. 4. Reproducibility and reliability of observer for SMI and CVM were excellent. This results suggest CVM stage is comparable to SMI stage in terms of evaluating the skeletal development.

A correlative study of dental age and skeletal maturation

Skeletal age had been assessed by comparison between maturation of hand-wrist with stages of cervical vertebrae or canine calcification stages in past and this had been closely related to craniofacial growth. The importance of pubertal growth spurt in various types of orthodontic therapies is already established. Hence, this study was aimed to evaluate the relationship of skeletal maturity by hand-wrist with cervical vertebral maturation indicators and canine calcification stages. The study consisted of randomly selected 90 children from Lucknow population with 45 males (age range 10-13 years) and 45 females (age range 9-12 years). Lateral Cephalogram, hand-wrist x-ray, and periapical x-rays of maxillary and mandibular right canines were taken. Mean, standard deviation was calculated of different groups. Correlation was made among cervical vertebral maturation, hand wrist maturation, and canine calcification stages at various age groups. There was strong correlation between skeletal maturation indicator and cervical vertebral maturation indicator for both male (0.849) and female (0.932), whereas correlation between skeletal maturation indicator and canine calcification was good for both male and female (0.635, 0.891). It was concluded that cervical vertebral maturation indicator and canine calcification stages can also be used for assessing skeletal maturity.

Establishing a diagnostic tool for assessing optimal treatment timing in Indian children with developing malocclusions

Objective: To interrelate chronological age, cervical vertebrae maturational stage and dental calcification stages and to establish latter as first level diagnostic tool to estimate timing of pubertal growth spurt. Materials and Methods: Sample derived from pretreatment panaromic and lateral cephalometric radiographs of patients 8-14 years old. Study sample divided into three groups depending upon Angle’s molar relation: Group I, Group II, Group III. According to chronological age, into: Group A: 8-11 years Group B:11-14 years, further separating males and female subjects in each group. Demirjian et al method was used to assess dental maturity and for skeletal maturity the New Improved Version of Cervical Vertebrae Maturation Method by Baccetti, Franchi and Mc Namara. Statistical analysis was performed using SPSS software package. Chi Square test and Spearman rank-order correlation coefficients measured the association between skeletal maturity indicators and dental calcification stages and statistical significance tested. Results&Conclusions: In females, permanent mandibular second molar Stage E signified circumpubertal phase corresponding with skeletal age CVMS II and for males, it was permanent mandibular first premolar stage E. Early orthodontic interventions for Angle’s Class I and Class II malocclusions should be performed at the circumpubertal period represented by CVMS II in Indian children and for Angle’s Class III malocclusion, facemask therapy beneficial in the prepubertal phase. Females showed higher significant correlation among skeletal and dental calcification stages compared to males.

Correlation of Dental Calcification and Skeletal Maturaty Indicators

Assessing maturational status and pubertal growth spurt of patient have a considerable influence on diagnosis, treatment planning, and the outcome of orthodontic treatment. The hand – wrist radiograph is commonly used for the assessment skeletal development. There is association between skeletal maturity and different stages of dental calcification, thus stages of dental calcification might be used as a first – level diagnostic tool to estimate the timing of the pubertal growth spurt. The study analyzed the effectiveness of using tooth calcification stage instead of hand – wrist radiograph to assess skeletal maturity. A total of 200 subjects (100 males 100 females) with mean age 12.23 ± 2.33 years visiting the Children‟s Hospital and the Institute Of Child Health Lahore, were included in the study. The skeletal maturity indicators and dental calcification stages were evaluated. Result showed that the canine stage F coincided with the MP3 stage and indicates the onset of a period of accelerating growth. The canine stage G was related to S stage and MP3CAP stage, and was indicative of rapid growth velocity.

Evaluation of skeletal maturation by comparing the hand wrist radiograph and cervical vertebrae as seen in lateral cephalogram

Aim of this study was to determine the validity of cervical vertebrae radiographic assessment to predict skeletal maturation. Left-hand wrist and lateral cephalometric radiographs of 100 Bangalore children aged 8-18 years, divided into 10 groups of 10 subjects each with equal distribution of males and females, were measured. On left-hand wrist radiograph, the classification of Fishman was used to assess skeletal maturation. Cervical vertebrae maturation was evaluated with lateral cephalometric radiograph, using the stages developed by Hassel and Farman. The changes in hand wrist and cervical vertebrae were correlated. Significant association was observed between skeletal maturation indicator stages and cervical vertebrae maturation indicator stages. Correlation coefficient was found to be significant (P<0.0001). The results of the study indicated that the cervical vertebrae maturation and hand wrist skeletal maturation was significantly related.

Quantitative skeletal evaluation based on cervical vertebral maturation: a longitudinal study of adolescents with normal occlusion

The study aims were to investigate the correlation between vertebral shape and hand-wrist maturation and to select characteristic parameters of C2-C5 (the second to fifth cervical vertebrae) for cervical vertebral maturation determination by mixed longitudinal data. 87 adolescents (32 males, 55 females) aged 8-18 years with normal occlusion were studied. Sequential lateral cephalograms and hand-wrist radiographs were taken annually for 6 consecutive years. Lateral cephalograms were divided into 11 maturation groups according to Fishman Skeletal Maturity Indicators (SMI). 62 morphological measurements of C2-C5 at 11 different developmental stages (SMI1-11) were measured and analysed. Locally weighted scatterplot smoothing, correlation coefficient analysis and variable cluster analysis were used for statistical analysis. Of the 62 cervical vertebral parameters, 44 were positively correlated with SMI, 6 were negatively correlated and 12 were not correlated. The correlation coefficients between cervical vertebral parameters and SMI were relatively high. Characteristic parameters for quantitative analysis of cervical vertebral maturation were selected. In summary, cervical vertebral maturation could be used reliably to evaluate the skeletal stage instead of the hand-wrist radiographic method. Selected characteristic parameters offered a simple and objective reference for the assessment of skeletal maturity and timing of orthognathic surgery.

Midpalatal Suture Ossification and Skeletal Maturation: A Comparative Computerized Tomographic Scan and Roentgenographic Study

The main aim of this study was to evaluate and compare the ossification of the midpalatal suture using cross-sectional maxillary occlusal radiograph and computerized tomographic scan of the hard palate in the axial direction. The percentage of the ossification thus obtained was correlated with the skeletal maturation indicators like (CVMI categories and MP3 stages) in Group I subjects (8.0-16.0 years) and with chronological age in group II subjects (16.1-25.0 years). The radiograph of the middle phalanx of the third finger and lateral cephalogram in occlusion were taken for the Group I subjects. The total sample size of the study comprised of 21 subjects with transverse maxillary deficiency. The percentage of the ossification of the midpalatal suture was calculated using suture obliteration index described by Persson and Thilander. The results of the study revealed that the total amount of ossification of the MPS in Group I subjects with computerized tomographic scan (22.56 ΁ 3-62%) was significantly less compared to cross-sectional maxillary occlusal radiograph (5822 ΁ 3.79) at the end of skeletal maturation (p < 0-001). There was sudden spurt in the ossification of the MPS after CVMI category 4/MP3 H stage. In Group II subjects CT scan again showed significantly less amount of the ossification (40.78 ΁ 19,73) compared to maxillary occlusal radiograph (60.32 ΁ 14,41) in the total length of the MPS (p < 0.05). Thus CT scan of the hard palate showed less than 50% of the midpalatal suture ossification at the age of 25 years approximately. This was due to advantages of the computed tomographic technology. i.e. no superimposition of the overlying and adjacent structure, exact localization and accurate assessment of the MPS ossification over the conventional radiography.

Reliability of Permanent Mandibular Canine Calcification as an Indicator of Skeletal Maturity in Karnataka Population

ABSTRACT Aims The purpose of this study was to assess the reliability of permanent mandibular canine tooth calcification as an indicator of skeletal maturity in Karnataka population by comparing it with the ossification stages of the middle phalanx of the left third finger and also to compare the sexual dimorphism in the timing of these events. Methods This study was performed on 100 subjects (50 boys and 50 girls) of South Indian origin aged 10 to 14 years. Radiovisiographs of the middle phalanx of the left third finger and Orthopantomographs were obtained and assessed for the stages of calcification using the methods described by Hagg and Taranger and by Demirjian et al respectively. The correlation between various stages of lower canine calcification and stages of MP3 ossification was assessed for both the sexes using Chi-square test and percentage distributions. Results The associations were statistically significant only between MP3-F and canine F stages in both sexes (88% for boys, 59% for girls) and MP3-H and canine H stages in boys (100%). Also girls showed an advanced trend in dental maturation. Conclusion The mandibular canine calcification stages alone are not as reliable an indicator as MP3 stages for assessing the skeletal maturity in Karnataka population.

A correlative study of dental age and cervical vertebrae maturation

The operational goal of orthodontics in a growing child is to maximize the growth potential and guide towards a pattern of optimal development. Growth standards are generally based on chronological age that alone provides little insight for indentifying the stage of development progression. The study was aimed to explore if canine calcification and cervical vertebrae maturation could be used for assessment of skeletal maturity. The study comprised of 45 males (10-13 years) and 45 females (9-12 years). Hand wrist radiograph was employed as skeletal maturity indicator, Lateral cephalogram to show cervical vertebrae maturation and intra-oral periapical X-ray of right maxillary and mandibular canine for dental maturation. Statistically strong correlations were drawn between the three variables. Statistically strong correlation were found between skeletal and cervical vertebrae maturation in both males and females (r = 0.849, 0.932), skeletal maturity indicator and canine calcification for both male and female (r = 0.635, 0.891), Indicating thereby that cervical vertebrae maturation and canine calcification can be useful for assessing skeletal maturity.

Quantification of cranial base growth during pubertal growth

To quantify longitudinal cranial base growth from prepubertal through postpubertal stages of development, as defined by biological indicators of individual skeletal maturity (cervical vertebral maturation - CVM) method and to determine if there is sexual dimorphism resulting from cranial base growth. A longitudinal cephalometric study. The Dental School of Paulista University, Brazil. 36 subjects (21 females, 15 males) who were part of a longitudinal growth study and exhibited normal facial and normal vertical growth patterns. Growth maturation of cervical vertebrae stages was assessed by two examiners independently. Cranial base measurements were carried out by one individual and repeated after one month. The growth increments over time were assessed with the one-way repeated-measures analysis of variance and post hoc Tukey multiple comparisions. There were no significant gender differences. There was a significant increase in all cephalometric measures between the different time points. Ba-Na showed the greatest amount of growth (mean change=2.8 mm). From T2-T3, the greatest amount of growth was found for Se-Na (mean change=3.4 mm) and the lowest for CC-Na (mean change=1.4 mm). Comparing overall changes (T1-T3) all the measurements showed statistically significantly increases (P<0.05). For all comparisons of between-stage changes the cranial base grew more than 2.0 mm during the pubertal growth. Linear variables of cranial base showed significant growth during pubertal stages (pre-peak, peak and post-peak). No significant differences.

The Development of the Cervical Vertebrae as an Indicator of Skeletal Maturity: Comparison with the Classic Method of Hand-wrist Radiograph

The objective of this study was to compare three methods with which to determine the skeletal maturity of children. The methods were Greulich & Pyle's atlas method based on hand-wrist radiographs (1959), and the cervical vertebrae methods based on lateral cephalograms of Lamparski (1972) and San Roman et al. (2002). We evaluated hand-wrist radiographs and the lateral cephalograms of 392 children (195 girls and 197 boys age 7-18). The morphology of the second (C2), third (C3) and fourth (C4) cervical vertebrae was assessed and the stage of skeletal maturity determined along with chronological age. Our results revealed a significant correlation (p <or= 0.05) between the skeletal maturity of the cervical vertebrae and the skeletal maturity of the hand. The correlation coefficients between the skeletal maturity of the cervical vertebrae and chronological age were obviously lower. The correlation coefficients were higher when using the method of San Roman et al. (2002) rather than Lamparski's method (1972). Our results show that in assessing skeletal maturity, the lateral cephalogram can replace the hand-wrist radiograph, thus reducing the patient's exposure to radiation.

Skeletal maturation evaluation using mandibular third molar development in adolescents

Objective: To estimate dental maturity using the Demirjian Index for the mandibular third molar and investigate the relationships between dental maturity and skeletal maturity among growing children. Methods: The samples were derived from panoramic, lateral cephalometric and hand-wrist radiographs of 270 female subjects registered as patients at the orthodontic department, dental hospital, Yonsei University. Dental maturity [Demirjian Index (DI)] and skeletal maturity [skeletal maturation indicators (SMIs)] and cervical vertebrae maturation indicators (CVMIs)] were estimated from these radiographs. Results: There was a significant correlation (r = 0.64) between SMIs and DI, and a similar correlation (r = 0.59) was observed between CVMIs and DI (p ＜ 0.001). If DI was above Stage E, then the SMI was above Stage 10 and the CVMI was above Stage 5. There was a weak correlation (r = 0.26) between age at menarche and DI (p ＜ 0.001). There was no significant difference in DI among Class I, II or III malocclusions. Conclusions: Dental maturity evaluation using the mandibular third molar will be an adjunctive tool in combination with cervical vertebrae and hand-wrist maturity evaluations.