How is maturational age defined and determined using the
             System of Skeletal Maturation Assessment ( SMA )?

                Maturational age is defined in terms of both the maturational
                    stage and the maturational level of the patient.  This approach
                    is different from other existing systems of maturational evaluation
                    and is considered essential if timing and amounts of future growth
                    can be more reliably estimated.  

                   The maturational stage refers to the point of development that has 
                    been reached by the patient relative to the eventual attainment of
                    adulthood.  Maturational stages are referred to in terms of
                    skeletal maturity indicators or SMIs that are identified from
                    inspection of the patient's hand-wrist x-ray.  The 23 SMIs
                    currently utilized in the System of Skeletal Maturation
                    Assessment cover the mid to late childhood and adolescent 
                    periods of development.

                   Identification of skeletal maturity indicators (SMIs) on the
                   hand-wrist x-rays involves an organized inspection of bony
                   ossification events.  These include the initial developmental
                   appearance of selected bones and the maturational progression of 
                   epiphyseal-diaphyseal fusion of selected bones.

                   Maturational level refers to the relationship between the patient's
                    chronologic age relative to the existing stage (SMI) of maturation.
                    Two or more individuals can demonstrate the same SMI at varying
                    chronologic ages.  In other words, an individual can be  
                    maturationally advanced, average or delayed.  The System of
                    Skeletal Maturation Assessment employs 14 subgroups of 
                    maturational levels.  The identification of an individual's level of
                    maturation is extremely significant as it reflects variations in 
                    developmental timing and amounts of skeletal growth.

                     An individual's specific level of maturation can be determined and
                      graphically illustrated.







        selected references: Fishman LS  Radiographic evaluation of skeletal maturation: A
                                              clinically oriented study based on hand-wrist films. Angle Orthod
                                              1982; 52:88-112 

                             Subtelny JD  Early Orthodontic Treatment. Quintessence Pub., 2000
                                              Fishman LS, Chapter 13
                                          Barakat R, Fishman LS.  Indicators of skeletal maturational development
                                               during infancy and childhood (senior research).  Rochester, NY: 
                                               Eastman Dental Center, 1995.



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