THE USE OF HAND AND WRIST RADIOGRAPH, OPG AND CEPHALOMETRIC RADIOGRAPH FOR THE ASSESSMENT OF GROWTH IN ORTHODONTIC PATIENT

07/04/2023 1

THE USE OF HAND AND WRIST RADIOGRAPH, OPG AND CEPHALOMETRIC RADIOGRAPH FOR

THE ASSESSMENT OF GROWTH IN ORTHODONTIC PATIENT

BYDR AGHIMIEN OSARONSE

UNIVERSITY OF BENIN DENTAL SCHOOL.

07/04/2023 2

Outline

Introduction Definition of growth Understanding some terminology Growth centre Growth sites chronological age dental age skeletal age

07/04/2023 3

Growth predictors clinical predictors radiographic predictorso hand-wrist radiographo cephalographo orthopanthomographPrediction of growth

07/04/2023 4

Hand-wrist radiograph

Indications Stages and growth of epiphysisMethods of assessmentHow to analyse the HW-radiographSkeletal maturation indicatorsMaturation stage versus maturation level

07/04/2023 5

CephalographIndication..as a predictor of growthImportance of cervical vertebrae maturation(CVM). stages of CVM indicators of CVM CVM and mandibular growth CVM and chronological age Clinical relevance in timing

07/04/2023 6

Panoramic radiographIntroductionDental age Dental maturity versus dental eruption Methods of assessing dental ageRationale for using OPGStages of tooth calcification Weighted score for dental stagesCorrelation between skeletal maturity and teeth

calcification.

07/04/2023 7

ConclusionReferencesAppreciation

07/04/2023 8

Introduction

Growth is define as an increase in size or number. Genetic and environment influences have been greatly implicated.

If environmental factors can make a significant impact on facial growth then the possibility exists for clinicians to alter facial growth with appliances.

07/04/2023 9

Growth centre is a location at which independent (genetically controlled) growth occurs.

Growth site is a location at which growth occurs

07/04/2023 10

Growth

1. pattern; it relates the spatial proportion of growth over a period of time e.g. cephalocaudal gradient of growth.2. variability;

3. Timing. Same thing happen to different individual at different time e.g. growth spurt in males and females.

07/04/2023 11

• Chronological age- simply put it is time of an individual since birth.

• Dental age. This relates the age at which the various teeth in the mouth are formed.

• Developmental/skeletal stage. This is a more accurate biologic marker of growth. It shows the variability at different time of the growth pattern e.g. growth spurt using onset of sexual maturation

07/04/2023 12

WHY ASSESS GROWTH?

07/04/2023 13

Growth prediction/assessment

In doing this, it must take into cognizance;1. Amount of growth2. Direction (including rotation) of growth3. Timing of growth

07/04/2023 14

Predictors of growth1. Clinically; body height sexual characteristic chronological age dental eruption

2. Radiographically: skeletal maturity cervical vertebrae maturation hand-wrist radiograph dental maturity e.g. OPG

07/04/2023 15

Assessment of height and sexual maturation has been shown to indicate when an individual reaches the growth spurt.

Sex hormones stimulate the cartilage to grow faster which correlate with the growth spurt.

07/04/2023 16

Radiographic assessment

Since growth of the jaws follows a somatic growth pattern, observation of the developmental stage of other parts of the skeleton would give an indication of the stage of facial development hence, the skeletal maturation assessment with hand-wrist and cervical vertebrae maturation observations.

07/04/2023 17

HAND-WRIST RADIOGRAPH

07/04/2023 18

07/04/2023 19

Indications

1. Before the use of RME2. Treatment planning of class II and III cases when

functional appliance is an option3. Severe discrepancy between dental and chronological

age.4. Help to predict future skeletal maturation rate and

status5. To predict pubertal growth spurt6. To predict the skeletal age of patient whose growth is

affected by infection, trauma etc.

07/04/2023 20

Growth of the epiphysis

1. Widening stage2. Capping3. Fusion

07/04/2023 21

Stages of epiphyseal growth

07/04/2023 22

Skeletal maturation assessment

Stages involved;1 widening2. Capping3. Appearance of sesamoid bone of the thumb4. FusionThese stages are said to be related with different levels of adolescent growth i.e. onset, peak and termination of maximum velocity of growth

07/04/2023 23

Methods of SMA using HW-radiograph

1. Fisherman skeletal maturation indicator2. Bjork, Grave and Brown3. Hagg and Taranger method (uses the

sesamoid of ulnar, metarcarpophalangeal joint of first finger, MP3, DP3 and distal epiphysis of radius).

4. Atlas of Greulich and Pyle

07/04/2023 24

Leonard Fisherman system (1982)

Eleven indicators were used on the 6 anatomical sites and they were correlated with period of adolescence.

The skeletal maturation was describe during the various stages of growth of the epiphysis.

07/04/2023 25

Anatomical sites

1. Thumb2. Middle finger (proximal, middle and distal

phalanges)3. Little finger4. Radius

07/04/2023 26

In the infantile stage (up to 10 years of age), the suture was broad and smooth, whereas in the juvenile stage (from 10 to 13 years) it had developed in a more typical squamous suture with overlapping sections. Finally, during the adolescent stage (13 and 14 years of age) the suture was wavier with increased interdigitation.

07/04/2023 27

Stage 1..width of Epiphysis equal that of Diaphysis i.e. E=D

1. Middle finger proximal phalanx…PP32. Middle finger middle phalanx…MP33. Little finger middle phalanx..MP5

Stage II. Adductor sesamoid of thumb..S4. Centre of ossification medial to the junction of the epiphysis and diaphysis of the proximal phalanx of the thumb

07/04/2023 28

Stage III. Capping 5. Middle finger distal phalanx DP36. Middle finger middle phalanx MP37. Little finger middle phalanx MP5Stage IV. FUSION8. Middle finger distal phalanx DP39. Middle finger proximal phalanx PP310. Middle finger middle phalanx MP311. Radius

07/04/2023 29

07/04/2023 30

Correlation of the ossificationstages of hand–wrist bone and skeletal growth velocity

The various indicators outlined have been related to the various stages of skeletal development.Also the variation for the different sex have also been stated.

07/04/2023 31

What is the use;

07/04/2023 32

Ossification of adductor sesamoid of thumb (S) occurs shortly before or at the beginning of the pubertal growth spurt. During the third stage of hand–wrist maturation diaphysis is covered by the cap-shaped epiphysis. The MP3cap stage of hand–wrist ossification marks the peak of the pubertal growth.

07/04/2023 33

Visible union of epiphysis and diaphysis at the distal phalanx of the middle finger (DP3fusion) signify the end of pubertal growth.

Complete union of epiphysis and diaphysis of the radius (R fusion) indicate that the ossification of all the hand bone is completed and skeletal growth is finished.

07/04/2023 34

According to Bjork, the pubertal growth spurt ends even earlier, with complete fusion of the third distal phalanx (DP3fusion).

07/04/2023 35

How to assess the HW-radiograph

1. The key stage of development is initially checked rather than looking out for the SMI

2. Check for the ossification of S3. if absent then the SMI indicated will be that

of widening4. If present the then capping and fusion SMI

should be assessed.

07/04/2023 36

11-grade scheme by Fisherman

07/04/2023 37

.

Maturation stage VS Maturation level

07/04/2023 38

Maturation level

1. Early 2. Average3. Late

07/04/2023 39

Early vs. late maturer

Late maturer instead of experiencing a decline in the late stage of pubertal growth experience the catch-up growth with additional incremental growth.Hence, if a patient is a late maturer it thus mean that one has the advantage of an additional incremental growth.

07/04/2023 40

Note the age of maturation stage

07/04/2023 41

CEPHALOMETRIC RADIOGRAPH

07/04/2023 42

Indications

1. Assessment of completion of active growth in studies dealing with the long-term effects of orthodontic/orthopedic treatment strategies.

2. To identify clinically the adequate time for intervention in subjects who need surgery for the late correction of facial disharmonies.

07/04/2023 43

Cephalograph is a standardise true lateral radiograph of the skull, face and the jaws.

The cervical vertebrae represented on the cephalograph have been invaluable in assessing patient growth.

07/04/2023 44

Assessing growth

1. For prediction of growth spurt2. predicting the correct direction of growth

07/04/2023 45

Predicting growth spurt

Six stages of vertebral maturation were described by Baccetti and co-workers (2005).Lamparski used the C2-C6 vertebrae.

Hassel and Farman identified six stages of vertebral maturation and created an index that defined more thoroughly the changes in the 2nd-4th cervical vertebrae

07/04/2023 46

Stages of CVM

1. Initiation 2. Acceleration 3. Transition 4. Deceleration 5. Maturation 6. completion

07/04/2023 47

indicators

1. Concavity of the lower border2. Shape of the vertebrae;’ trapezoidRectangular horizontallyRectangular verticallysquare

07/04/2023 48

07/04/2023 49

1. Initiation. Very significant amount of adolescent growth

expected C2, C3, and C4 inferior vertebral body borders are

flat. Superior vertebral borders are tapered posterior to

anterior i.e. trapezoids2. Acceleration. Significant amount of adolescent growth expected. Concavities developing in lower borders of C2 and

C3. Lower border of C4 vertebral body is flat. C3 and C4 are more trapezoid in shape.

07/04/2023 50

3. Transition . Moderate amount of adolescent growth expected Distinct concavities seen in lower borders ofC2 and

C3. C4 developing concavity in lower border of vertebral

body. C3 and C4 are rectangular in shape.

4. Deceleration. Small amount of adolescent growth expectedDistinct concavities in lower borders of C2, C3, and C4. C3 and C4 are nearly square in shape.

07/04/2023 51

5. Maturation. Insignificant amount of adolescent growth expected. Accentuated concavities on inferior borders of C2,

C3, and C4. C3 and C4 are square in shape.

6. Completion. Adolescent growth is completed. Deep concavities are present on inferior borders of

C2,C3, and C4. C3 and C4 heights are greater than widths.

07/04/2023 52

Stages of CVM

Cervical stage 1. The lower borders of all the three vertebrae (C2-C4) are flat. The bodies of both C3 and C4 are trapezoid in shape.

07/04/2023 53

Cervical stage 2 . A concavity is present at the lower border of C2 but C3 and C4 are still trapezoids.

07/04/2023 54

Cervical stage 3 Concavities at the lower borders of both C2 and C3 are present. The bodies of C3 and C4 may be either trapezoid or rectangular horizontal in shape.

07/04/2023 55

Cervical stage 4 Concavities at the lower borders of C2, C3, and C4 now are present. The bodies of both C3 and C4 are rectangular horizontal in shape.

07/04/2023 56

Cervical stage 5 .The concavities at the lower borders of C2, C3, and C4 still are present. At least one of the bodies of C3 and C4 is squared in shape.

07/04/2023 57

Cervical stage 6. The concavities at the lower borders of C2, C3, and C4 still are evident. At least one of the bodies of C3 and C4 is rectangular vertical in shape.

07/04/2023 58

stage Peak of mandibular growth occur

1 2 years after

2 1 year after

3 The year within

4 1-2year before

5 Ended 1 year before

6 Ended 2 year before

07/04/2023 59

Mittal S.K. et al(2011) Indian subjects

07/04/2023 60

CVM VS HW-radiograph

San Román and colleagues concluded that the best correlation was the concavity at the lower border compare to the shape and height of the vertebrae.

‘’The best parameter to assess maturation stages is when the concavity on the lower border of the vertebral bodies is greater than 1 mm.’’

07/04/2023 61

Clinical relevance in timing

1. Class II treatment is most effective when it includes the peak in mandibular growth;

2. Class III treatment with maxillary expansion and protraction is effective in the maxilla only when it is performed before the peak (CS1 or CS2), whereas it is effective in the mandible during both prepubertal and pubertal stages;

07/04/2023 62

3. skeletal effects of rapid maxillary expansion for the correction of transverse maxillary deficiency are greater at prepubertal stages, while pubertal or postpubertal use of the rapid maxillary expander entails more dentoalveolar effects

07/04/2023 63

PANORAMIC RADIOGRAPH

07/04/2023 64

Introduction

A panoramic radiograph reveal the entire dentition in a single firm. The panoramic radiograph has been used to assess dental maturity, which is used as an indicator of the biological maturity of growing children.

07/04/2023 65

Dental age

Dental maturity VS dental eruption

07/04/2023 66

Methods of assessing dental age

1. Calcification e.g. Demirjian et al2. Measurement of the crown height, apex

width, and root length of the teeth observed in radiographs. Mornstad et al.

3. Time of eruption; Gustafson and Koch

07/04/2023 67

Why not intra-oral radiograph?

07/04/2023 68

Rationale for OPG

1. Easier to make in children and nervous patient compare to intra-oral radiograph.

2. As a full mouth radiograph it is consider to deliver less dose of radiation.

3. Little distortion for mandibular picture

07/04/2023 69

Demirjian's Technique

The stage is consider to be an indicator of maturity and not necessarily the size that can not really be quantified.

Tooth calcification stage is assessed on OPG.Eight stages of calcifications were outlined

07/04/2023 70

STAGE A. In both uniradicular and multiradicular teeth, a beginning of calcification is seen at the superior level of the crypt in the form of an inverted cone or cones. The is no fusion of these calcified points.

07/04/2023 71

STAGE B. fusion of the calcified points to give a regular outlined occlusal surfaceSTAGE C. a. enamel formation is complete at the occlusal surface. Its extension and convergence towards the cervical region is seen. b. the beginning of dentinal deposit is seen c. the outline of the pulp chamber has a curved shape at the occlusal border

07/04/2023 72

Stage D. a. the crown formation is completed down to the cemento-enamel junction b. the superior border of the pulp chamber in the uniradicular teeth has a definite curved form, being concave towards the cervical region. The projection horns if present, gives an outline like an umbrella top. In molars the pulp chamber has a trapezoidal form. c. beginning of root formation is seen in the form of a spicule.

07/04/2023 73

STAGE E. UNIRADICULAR TEETH: a. the walls of the pulp chamber now form straight lines whose continuity is broken by the presence of the pulp horn, which is larger than in the previous stage. b. the root length is less than the crown height MOLARS. a. initial formation of the radicular bifurcation is seen in the form of either a calcified points or a semi-lunar shape b. the root length is still less than the crown height

07/04/2023 74

STAGE F. UNIRADICULAR TEETH: a. the walls of the pulp chamber now forma more or less isosceles triangle. The apex ends in a funnel shape b. the root length is equal to or greater than the crown height

MOLARS. a. the calcified region of the bifurcation has developed further down from its semi-lunar stage to give the roots a more definite and distinct outline with funnel shaped endings b. the root length is equal to or greater than the crown height.

07/04/2023 75

STAGE G. The walls of the root canal are now parallel and its apical end is still partially opened(distal root in molars)

STAGE H. a. the apical end of the root canal is completely closed(distal root in molars).

b. the periodontal membrane has a uniform width around the root and the apex

07/04/2023 76

Self weighted score for dental stages

07/04/2023 77

07/04/2023 78

Correlation between skeletal maturity and teeth calcification.

Mittal S.K. et al(2011) investigated the relationship between skeletal maturity using CVM and teeth calcification. Conclusion was follows;

A. The second molar showed the highest correlation and the.

B. Stage F of tooth calcification corresponded to onset of peak height velocity (stage 2 of CVMI) .

07/04/2023 79

C. Stage G of tooth calcification in canine; first premolar and second molar (except for second premolars in males) corresponded to peak of pubertal growth spurt (stage 3 of CVMI).

D. Root formation of the canine as well as the first premolar was completed in the majority of the subjects at stage 5 of CVMI. For all the teeth except third molar root formation was completed at stage 6 of CVMI.

07/04/2023 80

Conclusion

Understanding the development patterns of every growing patient is one of the prerequisites for successful orthodontic treatment. Many treatment modalities will yield a better result in less time if properly correlated with the facial growth patterns that are associated with the patient. Growth related appliances such as functional appliances can yield excellent result if properly timed.

07/04/2023 81

If the results from cephalograph and OPG correlate well with the HW-radiograph then the routinely radiographs taken for orthodontic patients will suffice for accurate assessment of growth. This is taking into cognizance the ALARA RULE i.e As Low As Reasonably Achievable for the dose of x-ray patient should be expose to.

07/04/2023 82

References

1. Kiran S, Sharma VP, Tandon P, Tikku T, Verma S, Srivastava K. To establish the validity of dental age assessment using Nolla's method on comparing with skeletal age assessed by hand-wrist radiographs. J Orthod Res 2013;1:11-5.

2. A.Šidlauskas et al. Mandibular Pubertal Growth Spurt Prediction. Part One: Method Based on the Hand-Wrist Radiographs. Stomatologija, Baltic Dental and Maxillofacial Journal, 7:16-20, 2005

07/04/2023 83

3. Van De Graff; Human anatomy 6th Edition, 2001. skeletal system- introduction and axial skeleton 6:131-171.4. David Justin Sander ,May 2009. Use of cervical vertebra maturation stages in assessment of young orthodontic patients to estimate growth potential

07/04/2023 84

5. Damian V, Timo P, Andreas J. Reliability of growth prediction with hand – wrist radiographs. European Journal of Orthodontics 31 (2009) 438–442

6. Tiziano B, Lorenzo F, McNamara AJ. The Cervical Vertebral Maturation (CVM) Method for the Assessment of Optimal Treatment Timing in Dentofacial Orthopedics. Semin Orthod 11:119–129 © 2005

07/04/2023 85

7. B. Rai, S. Anand: Relationship of Hand wrist and panoramic radiographs. The Internet Journal of Forensic Science. 2008 Volume 3 Number 1. DOI: 10.5580/dd08 Sulaiman AL-Emran . Dental Age Assessment of 8.5 to 17 Year-old Saudi Children Using Demirjian’s Method. The Journal of Contemporary Dental Practice, Volume 9, No. 3, March 1, 2008

07/04/2023 86

9. Demirjian A, Goldstein H, Tanner J.M. A new system of dental age assessment. Hum Biol 1973; 45 : 211-227.

07/04/2023 87

Thanks for listening.