Hand Wrist Radiography

Orthodontics

1. Hand Wrist Radiography Presented by: Deeksha Bhanotia PG II year 1 Department of Orthodontics & Dentofacial Orthopaedics Guided by: Dr. Mridula Trehan Professor & Head

2. Contents Introduction Growth (need for assessment) Maturity Indicators Methods of assessing skeletal age Hand - Wrist Radiographs Cervical Vertebrae Frontal Sinus Mandibular Canine Calcification Mid-palatal Suture 2 Bones of hand wrist Evolution of hand wrist radiograph Hand Wrist Radiography Technique: Bjork, Grave, Brown Method Fishman Method Hagg and Taranger Method

3. Introduction An understanding of growth events is of primary importance in the practice of clinical orthodontics. Prediction of both the time and the amount of active growth, especially in the craniofacial complex, would be useful to the orthodontist. 3 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

4. The basis for the skeletal age assessment by radiographs is that the different ossification centers appear and mature at different time. Skeletal age has been considered the most reliable method to assess the developmental status. 4 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

5. The hand-wrist radiograph is commonly used for skeletal developmental assessment. The most frequently used method to evaluate skeletal age from hand-wrist radiographs is the Atlas of Greulich and Pyle .  5 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

6. Also, the changes in the epipyhsis of middle phalanx of the third finger (MP 3 ) follow an orderly sequence. Hagg and Taranger studied pubertal growth from the stages of ossification of the middle phalanx of the third finger of the hand (MP 3  stages). 6 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

7. What is Growth? & Why to assess it? 7

8. “ biologically and histologically is a composite of morphogenetic and histogenetic change occurring continuously over a period of time in response to genetic coding and environmental influences ”. 8 Growth Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

9. “ To take advantage of the growth, we must have some idea, first, of its amount, second of its direction and third the element of timing ” 9 Ricketts: Along with this we need to know when the major growth increments are likely to occur Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

10. Combination 10 Why to Assess? Growth is a critical factor in Orthodontic and Orthopaedic Diagnosis Treatment Planning & Orthopaedic Intervention Orthodontic Therapy Orthognathic Surgery Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

11. Biological Age Chronological Age Sexual Age Maturity Indicators Morphological age Dental age Circumpubertal age Skeletal age 11 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

12. Why Skeletal Age ? Skeletal maturation is an integral part of individual patterns of growth & development. The order, rate, time of appearance and progress of ossification in the various ossification centers occurs in a predictable sequence, which can be seen radiographically. A characteristic pattern of progression of ossification of epiphyseal centers can be identified. 12 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

13. Why Skeletal Age ? Different ossification centers appear and mature at different times. The timing of changes vary as each individual has his/her own “Biological Clock”. Skeletal age is considered as the most reliable method as it is closely related to physical growth. 13 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

14. Methods Of Assessing Skeletal Age Hand - Wrist Radiographs Cervical Vertebrae Frontal Sinus Mandibular Canine Calcification Mid-palatal Suture 14 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

15. Evolution of Hand-Wrist X-rays Todd , followed by Greulich & Pyle (1959) – Standard hand and wrist films. Bjork (1972) – 8 development stages maturation of bones of the hand (9-17years) Grave and Brown (1976) – 6 ossification centers to determine skeletal age more accurately 15 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

16. Evolution of Hand-Wrist X-rays Fishman (1982) – Skeletal maturation assessment during adolescence Hagg and Taranger (1980) – 5 Stages of MP3 growth , based on epiphyseal changes Tanner et al, Houston et al, Chapman Rajagopal et al, Madhu et al – Contributed significantly 16 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

17. Radiographic Technique Source to subject distance – 64cm 0° Angulation , without grid 46 Kv , 6.5 mAmp , 0.4 sec 17 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

18. Bones of Hand and Wrist 18 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

19. Hand wrist radiographs Hand wrist region: Made up of numerous small bones These bones show: -Predictable & scheduled pattern of appearance -Ossification -& union from birth to maturity. Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

20. Thus by merely comparing a patient’s hand wrist radiograph with standard radiographs that represent different skeletal ages, we will be able to determine the skeletal maturation status of that individual. 20 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

21. 21 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

22. Hand wrist radiograph Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

23. Anatomy of hand wrist: 4 bones Distal ends of long bones of forearm : Radius & ulna (long bones) forms the first group of bones. Ulna on medial aspect & radius on distal aspect. Give rise to distal projections respectively called ulnar styloid & radial styloid. Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

24. 1 3 2 4 5 1 3 2 4 5 PHALLANGES Proximal Middle Distal Adductor Sessamoid 24 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

25. Phalanges Small bones forming the fingers. 3 in number in each finger , except thumb which has two phalanges. The phalanges have a pattern of ossification which can be divided in to three stages: Stage 1: epiphysis and diaphysis are equal Stage 2 : epiphysis caps diaphysis Stage 3 : fusion occurs between epiphysis and diaphysis. 25 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

26. Carpals 26 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

27. Carpal bones Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

28. The Carpals 8 small, irregularly placed bones arranged in a proximal & a distal row. Bones of proximal row: scaphoid, lunate, triquetral & pisiform. Bones of distal row: trapezium, trapezoid, capitate & hamate. All these ossifies from one primary center. 28 Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

29. 5 miniature long bones Forms the skeletal framework of palm of hand. 1 to 5 in number, thumb to little finger. Each metacarpal ossify from one primary center ( in its shaft) & secondary center on distal end. Metacarpals Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

30. Indications of hand wrist radiographs In patients who exhibit major discrepancy between dental and chronological age. Determination of skeletal maturity status prior to treatment of skeletal malocclusion such as skeletal class II or class III malocclusion. Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

31. To assess the skeletal age in a patient whose growth is affected by infections, neoplastic or traumatic conditions. Serial assessment of skeletal age using hand wrist radiographs helps not only in assessing the growth of an individual, but also helps to predict future skeletal maturation rate and status. To predict the pubertal growth spurt. Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

32. It is a valuable aid in research aimed at studying the role of heredity, environment, nutrition etc., on the skeletal maturation pattern. It is indicated in patients with skeletal malocclusion needing orthognathic surgery, if undertaken between 16 – 20 years to assess the growth status. Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

33. Commonly used methods are: Atlas Method by Greulich and Pyle Bjork , Grave and Brown Method Singer’s Method of Assessment Fishman’s Skeletal Maturity Indicator Hagg and Taranger Method Phulari BS, Orthodontics Principles and Practice, Edition 1;205-15

34. Bjork, Grave & Brown Method (1972) 34 Width of Epiphysis = Diaphysis 1 3 2 4 5 PP2 Stage 1 MP3 Stage 2 PP2 MP3 3 years before the peak of pubertal growth ♂ - 10.6 yrs. ♀ - 8.1 yrs. ♂ - 12 yrs. ♀ - 8.1 yrs. Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

35. Stage 3 H1 - stage Visible ossification Pisiform Bone Pisi - stage R - stage Ossification of Hamular Process of Hamate Epiphysis = Diaphysis of Radius ♂ - 12.6 yrs. ♀ - 9.6 yrs. Pisiform Bone Hamular Process of Hamate Radius 35 Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

36. Stage 4 H2 - stage First mineralization of Sessamoid Bone S - stage Progressive Ossification of Hamular Process of Hamate ♂ - 13 yrs. ♀ - 10.6 yrs. 36 Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

37. 1 3 2 4 5 Stage 5 37 Capping of Epiphysis PP1 cap - stage MP3 cap - stage Peak of the Pubertal growth ♂ - 14 yrs. ♀ - 11 yrs. R cap - stage PP1 MP3 Radius Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

38. Union of epiphysis and diaphysis at the distal phalanx of middle finger End of pubertal growth. 38 Stage 6 Union of Epiphysis ♂ - 15 yrs. ♀ - 13 yrs. DP3 u - stage 1 3 2 4 5 DP3 Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

39. Union of epiphysis and diaphysis at the proximal phalanx of middle finger 39 Stage 7 ♂ - 15.9 yrs. ♀ - 13.3 yrs. PP3 u - stage 1 3 2 4 5 PP3 Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

40. Union of epiphysis and diaphysis at the middle phalanx of the middle finger 40 Stage 8 ♂ - 15.9 yrs. ♀ - 13.9 yrs. MP3 u - stage 1 3 2 4 5 MP3 Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

41. Complete union of epiphysis and diaphysis of the radius Skeletal growth is finished 41 Stage 9 ♂ - 18.5 yrs. ♀ - 16 yrs. R u - stage Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

42. Clinical Correlation 1 st – 3 rd Stage 4 th & 5 th Stage 6 th – 9 th Stage Corresponds to 3 years before the peak pubertal growth period. Prognosis is good if growth modification is planned Residual growth potential –fixed functional appliances can be planned Union stage –no chance for functional appliance therapy 42 Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482.

43. Fishman’s Method 43 4 Stages of Bone Maturation Epiphysis equal in width to diaphysis Appearance of adductor sesamoid of the thumb Capping of epiphysis Fusion of epiphysis 1 st Stage 2 nd Stage 3 rd Stage 4 th Stage Fishman L S. Radiographic evaluation of skeletal maturation. Angle Orthod ; 1982; 52:89-111

44. Anatomic Sites 44 6 Anatomical Sites Thumb - Sesamoid Third finger – PP3, MP3, DP3 Fifth finger – MP5 Radius Fishman L S. Radiographic evaluation of skeletal maturation. Angle Orthod ; 1982; 52:89-111

45. Skeletal Maturity Indicators 45 PP3 MP3 Epiphysis = Diaphysis MP5 Sessamoid Ossification DP3 MP3 Capping PP5 DP3 PP3 Fusion MP3 RADIUS Fishman L S. Radiographic evaluation of skeletal maturation. Angle Orthod ; 1982; 52:89-111

46. Hand Wrist Observation Scheme 46 Ossification Adductor sesamoid Thumb No? Width PP3 Width MP3 Width 3. MP5 Yes? Fusion 8. DP3 Capping Fusion 5. DP3 6. MP3 7. MP5 9. PP3 10. MP3 11. Radius No Yes Fishman L S. Radiographic evaluation of skeletal maturation. Angle Orthod ; 1982; 52:89-111

47. Stages of ossification of the sessamoid , middle and distal phalanx of third finger and the epiphyses of the radius are considered Five stages of development of MP3 region 1. MP3F stage 4. MP3-H stage 2. MP3-FG stage 5. MP3-I stage 3. MP3-G stage Hagg & Taranger’s Method 47 Hagg U,Taranger J .Maturational indicators and the pubertal growth spurt. Am J Orthod , 1982; 88:299-309.

48. Rajagopal and Kansal have added an additional bone stage between MP3 ‑  H and MP3 ‑  I, which they called the MP3 ‑HI stage. The modified six stages of MP3 can be easily compared with that of CVMI, which can be recorded on a standard periapical X‑ray film and dental X‑ray machine. Modified Hagg and Taranger A comparison between cervical vertebrae and modified MP3 stages for the assessment of skeletal maturity J Nat Sci Bio Med 4(1):74-80

49. The aim of this study was to determine whether the six modified MP3 stages described by Rajagopal and Kansal could be correlated with the six stages of cervical vertebrae maturation indices (CVMI), as described by Hassel and Farman. To evaluate the feasibility of recording MP3 stages using standard dental radiographic film for assessment of skeletal maturity. To assess the correlation among the chronological age, cervical vertebral maturity indicators and MP3 maturity stages. 49 A comparison between cervical vertebrae and modified MP3 stages for the assessment of skeletal maturity J Nat Sci Bio Med 4(1):74-80

50. MP3-HI stage modification by Rajgopal and Kansal A comparison between cervical vertebrae and modified MP3 stages for the assessment of skeletal maturity J Nat Sci Bio Med 4(1):74-80

51. Method by Greulich and Pyle In 1937, an atlas, “Atlas of Skeletal Maturation of the Hand” published by Todd. Greulich and Pyle based their atlas partly on the atlas by Todd. Since their atlas was first published in 1950 they were able to use all the radiographs obtained in the original study. Widek T, Genet P, Ehammer T, Schwark T, Urschler M. Bone age estimation with the Greulich -Pyle atlas using 3T MR images of hand and wrist. Foren Sci Int 2021 ;319:110654.

52. In order to determine the skeletal age using the modified Greulich and Pyle method one uses the atlas that they have developed. The sex of the patient is one of the most important pieces of information, because females develop quicker than males. The atlas is divided into two parts, one for the male patients and one for the female patients. Each part contains standard radiographic images of the left hand of children ordered by chronological age. Widek T, Genet P, Ehammer T, Schwark T, Urschler M. Bone age estimation with the Greulich -Pyle atlas using 3T MR images of hand and wrist. Foren Sci Int 2021 ;319:110654.

53. The first step in an analysis is to compare the given radiograph with the image in the atlas that corresponds closest with the chronological age of the patient. Next one should compare it with adjacent images representing both younger and older children. When comparing the radiograph against an image in the atlas there are certain features a physician should use as maturity indicators. Widek T, Genet P, Ehammer T, Schwark T, Urschler M. Bone age estimation with the Greulich -Pyle atlas using 3T MR images of hand and wrist. Foren Sci Int 2021 ;319:110654.

54. Singer’s method of assessment Proposed by Julian Singer in 1980. Described 6 stages: Stage1: (early): absence of pisiform , hook of hamate & epiphysis of proximal phalanx of 2 nd finger being narrower than its diaphysis . Stage 2: ( prepubertal ): initial ossification of hook of hamate , pisiform & proximal phalanx of 2 nd finger being equal to its epiphysis. Singer J. Physiologic timing of orthodontic treatment. Angle Orthod 1980; 50:320-333.

55. Stage 3: (pubertal onset): beginning of calcifiaction of ulnar sesamoid, increased width of epiphysis of proximal phalanx of 2 nd finger & increased calcifiaction of hook of hamate & pisiform. Stage 4: (pubertal ): calcified ulnar sesamoid & capping of diaphysis of middle phalanx of 3 rd finger by its epiphysis. Stage 5: (pubertal deaceleration ): calcified ulnar sesamoid, fusion of epiphysis of distal phalanx of 3 rd finger with its shaft, & epiphysis of radius & ulna not fully fused with respective shafts. Stage 6: (growth completion ): no remaining growth sites seen. Singer J. Physiologic timing of orthodontic treatment. Angle Orthod 1980; 50:320-333.

56. Cervical vertebrae maturation as an indicator of skeletal maturity In a study done by Paola it was seen that Vertebral analysis on a lateral cephalogram is as valid as the hand-wrist bone analysis with the advantage of reducing the radiation exposure of growing subjects. Angle Orthodontist 2006;76 (6)

57. CVMI 1- Initiation: Inferior borders of 2nd 3rd and 4th cervical vertebrae are flat at this stage. The third and fourth vertebrae are wedge shaped and the superior vertebral borders are tapered from posterior to anterior. 100% of pubertal growth remains. Very significant amount of adolescent growth expected. CVMI STAGES by Hassel and Farman (1995) Hassel B, Farman A G. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod , 1995; 107:58-61

58. CVMI 2 -Acceleration: Concavities on the inferior borders of second and third vertebrae begin to develop. Inferior border of fourth vertebrae remains flat. Vertebral bodies of third and fourth are nearly rectangular in shape. 65-85% of pubertal growth remains. Hassel B, Farman A G. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod , 1995; 107:58-61

59. CVMI 3- Transition Distinct concavities are shown on the inferior borders of second and third vertebrae. A concavity begins to develop on the inferior border of fourth vertebrae. Vertebral bodies of third and fourth are rectangular in shape. 25-65% of pubertal growth remains. Hassel B, Farman A G. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod , 1995; 107:58-61

60. CVMI 4- Deceleration stage Distinct concavities can be observed on the inferior borders of second, third and fourth cervical vertebrae. Vertebral bodies of third and fourth begin to be more square in shape. 10-25% of pubertal growth remains. Hassel B, Farman A G. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod , 1995; 107:58-61

61. CVMI 5- Maturation stage Marked concavities are observed on the inferior borders of second, third and fourth cervical vertebrae. Vertebral bodies of third and fourth are almost square in shape. 5-10% of pubertal growth remains. Hassel B, Farman A G. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod , 1995; 107:58-61

62. CVMI 6- Completion Deep concavities are observed on the second, third and fourth cervical vertebrae. Vertebral bodies are greater vertically than horizontally. Pubertal growth has been completed. Hassel B, Farman A G. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod , 1995; 107:58-61

63. Frontal sinus development as an indicator for somatic maturity at puberty Ruf and Pancherz (1996) Sabine Ruf and Hans Pancherz evaluated the development of the frontal sinus to the longitudinal data of the subject’s growth charts. Results showed that Frontal sinus growth velocity at puberty is closely related to body height growth velocity. Ruf S, Pancherz H. Frontal sinus development as an indicator for somatic maturity at puberty?. Am J O rthod Dentofac O rthop 1996 1;110(5):476-82.

64. The peripheral border of the frontal sinus was traced, and the highest ( Sh ) and lowest ( Sl ) points of the sinus extension relative to the nasion sella line were marked. Perpendicular to the interconnecting line (Sh-S1), the maximum width of the frontal sinus was assessed Ruf S, Pancherz H. Frontal sinus development as an indicator for somatic maturity at puberty?. Am J O rthod Dentofac O rthop 1996 1;110(5):476-82.

65. Frontal sinus shows a well defined pubertal peak ( Sp ), which on an average, occurs 1.4 years after the pubertal body height peak. (Bp). Ruf S, Pancherz H. Frontal sinus development as an indicator for somatic maturity at puberty?. Am J O rthod Dentofac O rthop 1996 1;110(5):476-82.

66. Mid Palatal Suture Revelo B,Fishman LS. Maturational evaluation of ossification of midpalatal suture. Am J Orthod , 1994;105:288-292

67. The purpose of this study was to determine whether a positive correlation exists between adolescent maturational development and the approximation of the mid palatal suture The mid palatal suture is formed by three parts. These include : - Interpremaxillary -Maxillary - Interpalatine Revelo B,Fishman LS. Maturational evaluation of ossification of midpalatal suture. Am J Orthod , 1994;105:288-292

68. The following key landmarks and planes were identified : Point A – most ant. point of the premaxilla Point B – most post. point on the posterior wall of incisive foramen Point P – point tangent to a line connecting the posterior walls of the greater palatine foramens Revelo B,Fishman LS. Maturational evaluation of ossification of midpalatal suture. Am J Orthod , 1994;105:288-292

69. Result Stages of ossification of the midpalatal suture were compared with the Fishman’s standards of skeletal maturation indicators. Very little mid palatal approx. existed during SMI 1 – 2. Revelo B,Fishman LS. Maturational evaluation of ossification of midpalatal suture. Am J Orthod , 1994;105:288-292

70. Very large increases in approximation from SMI 8 – 11 Maturational development is related to mid palatal fusion in ways that can provide information to better time maxillary expansion It is best to accomplish this before SMI 9 and ideal time to initiate it is between SMI 1 – 4 Revelo B,Fishman LS. Maturational evaluation of ossification of midpalatal suture. Am J Orthod , 1994;105:288-292

71. Hassel B, Farman A G.”Skeletal maturation evaluation using cervical vertebrae” Am J Orthod , 1995; 107:58-61. Julian Singer “ Physiologic timing of orthodontic treatment”. Angle Orthod , 1980; 50:320-333. Hagg U,Taranger J “ Maturational indicators and the pubertal growth spurt”. Am J Orthod , 1982; 88:299-309. Revelo B,Fishman LS,” Maturational evaluation of ossification of midpalatal suture”. Am J Orthod , 1994;105:288-292. References

72. Fishman L S,” Radiographic evaluation of skeletal maturation”. Angle Orthod ; 1982; 52:89-111 A comparison between cervical vertebrae and modified MP3 stages for the assessment of skeletal maturity. Journal of Natural Science Biology and Medicine 4(1):74-80 Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prev Comm Dent 2018; 8(6):482. Ruf S, Pancherz H. Frontal sinus development as an indicator for somatic maturity at puberty?. Am J O rthod Dentofac O rthop 1996 1;110(5):476-82. Widek T, Genet P, Ehammer T, Schwark T, Urschler M, Scheurer E. Bone age estimation with the Greulich -Pyle atlas using 3T MR images of hand and wrist. Foren Sci Int 2021 ;319:110654.

73. Thank You