 Today we are going to discuss about Skeletal Maturity Indicators which is one of the most important topic in orthodontics. So I will be covering this topic under following headaches. One is clinical importance of Skeletal Maturity Indicator, different method to assess the Skeletal Maturity, indication for the hand wrist radiograph, anatomy of hand wrist and various methods to assess the Skeletal Maturity. Every individual matures differently. Due to individual variations in timing, duration and velocity of growth, Skeletal age assessment is essential in formulating viable orthodontic treatment plan. So the assessment of Skeletal Maturity is very important for diagnosis, treatment goals, treatment planning and outcome of orthodontic treatment. Coming to the clinical importance of Skeletal Maturity Indicators, it helps to evaluate the physical maturity and a characteristic pattern of a notification progression. It also helps to evaluate the extent of active growth over any remaining growth during treatment period. So if you are getting the patient at the right age and when the patient is at the growth spot stage, we always can correct the patient's profile with different functional appliance depending upon the cases. So in this case, we can see the patient is having a convex profile and a vertical growth pattern. So we try to correct it by a high pull headgear with a twin block, that is vertical twin block. And in this case again, patient is having a convex profile and a torn ethical, just try to correct it with Frankel appliance. So these portions we will be covering in the Functional Appliance section. The next clinical important is to assess the growth status in orthodontic patients. That is because we always need to confirm that the growth has been completed and then surgery has to be performed. Otherwise, the thing is that if patient is having a late matricular growth, that always can affect the stability of the treatment results and can cause some amount of relax. So to assess that, we always need to assess the skeletal maturity of the patients that growth has been completed and then surgery has to be performed. This patient who had a clastry profile, we did some pre-surgical orthodontics and then surgery had been performed after assessing the growth status of the patient. So we can see the change of profile from concave to straight profile and this result is relatively stable because we did the surgery after the growth had been completed. When coming to the different methods to assess the skeletal maturity, one is height, weight, chronological age, sexual maturation, frontal sinus, biological age or physiological age, hand rest maturity, cervical vertebrae, dental eruption and dental calcification stages and biomarkers. Today we are going to deal with hand rest maturity. When coming to the indication for the hand rest radiograph, one is the patients who exhibit a major discrepancy between dental and chronological age. The other one needs to predict the pivotal growth spur. The next one is prior to the treatment of skeletal malocclusion such as skeletal class 2 or clastry in a growing patient as we have seen that in the previous pictures and discussion. Indicated in patients with skeletal malocclusion needing orthodontic surgery, this again we have discussed to predict the future skeletal maturation rate and status and to study the role of heredity, environment and nutrition on the skeletal maturation. Coming to the anatomy of hand rest, we can divide hand rest into phalanges, metocouples, carpals and distal end of long bones which is nothing but radius and ulna. Then over to carpals, we can divide carpals into distal and proximal row which consist of 8 small bones and each appears in a predictable pattern. And we can always remember this code because this is one of the important question in the MCQ exams. Okay over to metocouples, we can divide it into 5 miniature long bones which form the framework of palm of hand. Okay over to phalanges, we can divide phalanges into distal, middle and proximal phalanges and all the fingers are three phalanges except the thumb which don't have middle phalanges. Okay now we need to discuss some basic terms that we need to know. One is epiphysis and one is diaphysis. Epiphysis is nothing but the rounded edges of the long bone over here and diaphysis is nothing but the long means section of the long bone. So between epiphysis and diaphysis, we can always put it as a term like metaphysis and this is considered to be the growth plate. So what we need to know the terms are like epiphysis and diaphysis because with this we just need to know the status and notification of the phalanges because in stage one it is to be considered as with the epiphysis and diaphysis are equal that we can see over here. In the next stage what we can see is over here it is that it can cap, this epiphysis will cap the diaphysis over here and in stage three we can see there is complete fusion of epiphysis and diaphysis and we can't see any differentiation between what is epiphysis and what is diaphysis. Okay coming to the last part of the anatomy of hand waste. What we need to know is this is a small bone, it appears as a small nodular bone that is in the region of the tongue and the appearance of this bone is having a great clinical significance in orthodontics. So this is how the anatomy of hand waste looked like in the kiddies around one year. You can see epiphysis just started appearing and you can see some carpal bones and when kiddies around three years of age we can see some more carpal bones then after that we can clearly appreciate the epiphysis and when she reaches around 18 years of age we can see there is complete fusion of epiphysis and diaphysis and we can see all the carpal bones, the smoy bones over here. So based on the appearance of different bones what we have previously discussed different methods have been employed to assess the skeletal maturity using hand waste radiograph. These are the most commonly used methods, one is atlas method, one is a method by Jog Grave Brown, one is Swishman's, a Hag and Thunger method, Sinker's method. So what we are going to discuss is all about Jog Grave and Brown method which is one of the most commonly used methods that is used in orthodontics. So coming to Jog Grave and Brown method they have divided skeletal development into nine stages and each of these stages represent a level of skeletal maturity. So coming to stage one we can see that epiphysis and diaphysis of the proximal phalanx of the index finger are equal and we can put it as a chord like PP2 and it always occurs three years before the peak of pubertal growth spur. So coming to the stage two we can see epiphysis and diaphysis of the middle phalanx of the middle finger are equal. We can chord it as a MP3 and it can be noticed prior to the beginning of pubertal growth spur. In stage three there are three different ossification areas, one is a Pisces stage where there is ossification of Pisces form. We can appreciate this from the speaker. Then after that it's one stage where there is ossification of Hamela process of Hamate. Then our stage where epiphysis and diaphysis of radias are equal. Stage four we can see two different stages. One is a stage where there is appearance of allana as a small head bone of the thumb. It's the smallest nodular bone. Then after that it's two stage where there is increased ossification of Hamela process of the Hamela. The stage is very important because it marks the beginning of pubertal growth spur and we can always expect to see this stage in males around 13 years of age and females around 10 and a half years of age. In stage five we can see capping of diaphysis by the epiphysis in three different areas. One we can see that in the middle phalanx of the third finger, one in the proximal phalanx of the thumb and one in the radias. So we can use this called as mp3 kia, pp1 kia and r kia. In stage six we can see the union between epiphysis and diaphysis of the distal phalanx of the middle finger that is dp3. We can name it as and this stage constitute the end of pubertal growth spur that we can always see approximately in males around 15 years of age and females around 13 years of age. Seven we can see a year after pubertal growth spur. Here we can see there is the union of epiphysis and diaphysis of the proximal phalanx of the little finger that is pp5. In stage eight we can see there is fusion between the epiphysis and diaphysis of the middle phalanx of the middle finger that can call it as mp3. Coming to the last stage there we can see the end of skeletal growth with the fusion of epiphysis and diaphysis of the radias. In females we can see it around 16 years of age and in males around 18 and a half years of age. That completes the nine stages that is given by jog, grieve and crown. This method is very easy and there are different methods that is given by different authors and you all can stick to one method. So to conclude the best preparation for tomorrow is doing your best today. I hope everybody understood and in case if any doubt you always can get back to us. I really thank Dr. Zahid to give this opportunity. I hope everyone is fine and stay safe. All the wishes and thank you.