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

radiograph in orthodontics

1. THE USE OF HAND AND WRIST RADIOGRAPH, OPG AND CEPHALOMETRIC RADIOGRAPH FOR THE ASSESSMENT OF GROWTH IN ORTHODONTIC PATIENT BY DR AGHIMIEN OSARONSE UNIVERSITY OF BENIN DENTAL SCHOOL . 29/08/2013 1

2. Outline Introduction Definition of growth Understanding some terminology Growth centre Growth sites chronological age dental age skeletal age 29/08/2013 2

3. Growth predictors clinical predictors radiographic predictors hand-wrist radiograph cephalograph orthopanthomograph Prediction of growth 29/08/2013 3

4. Hand-wrist radiograph Indications Stages and growth of epiphysis Methods of assessment How to analyse the HW-radiograph Skeletal maturation indicators Maturation stage versus maturation level 29/08/2013 4

5. Cephalograph Indication ..as a predictor of growth Importance of cervical vertebrae maturation(CVM). stages of CVM indicators of CVM CVM and mandibular growth CVM and chronological age Clinical relevance in timing 29/08/2013 5

6. Panoramic radiograph Introduction Dental age Dental maturity versus dental eruption Methods of assessing dental age Rationale for using OPG Stages of tooth calcification Weighted score for dental stages Correlation between skeletal maturity and teeth calcification. 29/08/2013 6

7. Conclusion References Appreciation 29/08/2013 7

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 . 29/08/2013 8

9. Growth centre is a location at which independent (genetically controlled) growth occurs. Growth site is a location at which growth occurs 29/08/2013 9

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. g rowth spurt in males and females . 29/08/2013 10

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 29/08/2013 11

12. WHY ASSESS GROWTH? 29/08/2013 12

13. Growth prediction/assessment In doing this, it must take into cognizance; Amount of growth Direction (including rotation) of growth Timing of growth 29/08/2013 13

14. Predictors of growth Clinically ; body height sexual characteristic chronological age dental eruption Radiographically: skeletal maturity cervical vertebrae maturation hand-wrist radiograph dental maturity e.g. OPG 29/08/2013 14

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. 29/08/2013 15

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. 29/08/2013 16

17. HAND-WRIST RADIOGRAPH 29/08/2013 17

18. 29/08/2013 18

19. Indications Before the use of RME Treatment planning of class II and III cases when functional appliance is an option Severe discrepancy between dental and chronological age. Help to predict future skeletal maturation rate and status To predict pubertal growth spurt To predict the skeletal age of patient whose growth is affected by infection, trauma etc. 29/08/2013 19

20. Growth of the epiphysis Widening stage Capping Fusion 29/08/2013 20

21. Stages of epiphyseal growth 29/08/2013 21

22. Skeletal maturation assessment Stages involved; 1 widening 2. Capping 3. Appearance of sesamoid bone of the thumb 4. Fusion These stages are said to be related with different levels of adolescent growth i.e. onset, peak and termination of maximum velocity of growth 29/08/2013 22

23. Methods of SMA using HW-radiograph Fisherman skeletal maturation indicator Bjork, Grave and Brown Hagg and Taranger method (uses the sesamoid of ulnar, metarcarpophalangeal joint of first finger, MP3, DP3 and distal epiphysis of radius). A tlas of Greulich and Pyle 29/08/2013 23

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. 29/08/2013 24

25. Anatomical sites Thumb Middle finger (proximal, middle and distal phalanges) Little finger Radius 29/08/2013 25

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. 29/08/2013 26

27. Stage 1..width of Epiphysis equal that of Diaphysis i.e. E=D Middle finger proximal phalanx…PP3 Middle finger middle phalanx…MP3 Little finger middle phalanx..MP5 Stage II. Adductor sesamoid of thumb..S 4. Centre of ossification medial to the junction of the epiphysis and diaphysis of the proximal phalanx of the thumb 29/08/2013 27

28. Stage III. Capping 5. Middle finger distal phalanx DP3 6. Middle finger middle phalanx MP3 7. Little finger middle phalanx MP5 Stage IV. FUSION 8. Middle finger distal phalanx DP3 9. Middle finger proximal phalanx PP3 10. Middle finger middle phalanx MP3 11. Radius 29/08/2013 28

29. 29/08/2013 29

30. Correlation of the ossification stages 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. 29/08/2013 30

31. What is the use; 29/08/2013 31

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 MP3 cap stage of hand–wrist ossification marks the peak of the pubertal growth. 29/08/2013 32

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. 29/08/2013 33

34. According to Bjork, the pubertal growth spurt ends even earlier, with complete fusion of the third distal phalanx (DP3fusion). 29/08/2013 34

35. How to assess the HW-radiograph The key stage of development is initially checked rather than looking out for the SMI Check for the ossification of S if absent then the SMI indicated will be that of widening If present the then capping and fusion SMI should be assessed. 29/08/2013 35

36. 11-grade scheme by Fisherman 29/08/2013 36

37. . Maturation stage VS Maturation level 29/08/2013 37

38. Maturation level Early Average Late 29/08/2013 38

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. 29/08/2013 39

40. Note the age of maturation stage 29/08/2013 40

41. CEPHALOMETRIC RADIOGRAPH 29/08/2013 41

42. Indications 1. A ssessment of completion of active growth in studies dealing with the long-term effects of orthodontic/orthopedic treatment strategies. 2. T o identify clinically the adequate time for intervention in subjects who need surgery for the late correction of facial disharmonies. 29/08/2013 42

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. 29/08/2013 43

44. Assessing growth For prediction of growth spurt predicting the correct direction of growth 29/08/2013 44

45. Predicting growth spurt S ix 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 2 nd -4 th cervical vertebrae 29/08/2013 45

46. Stages of CVM 1. Initiation 2. Acceleration 3. Transition 4. Deceleration 5. Maturation 6. completion 29/08/2013 46

47. indicators Concavity of the lower border Shape of the vertebrae;’ trapezoid Rectangular horizontally Rectangular vertically square 29/08/2013 47

48. 29/08/2013 48

49. 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. trapezoids 2. 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. 29/08/2013 49

50. 3. Transition . Moderat e 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 expected Distinct concavities in lower borders of C2, C3 , and C4. C3 and C4 are nearly square in shape . 29/08/2013 50

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. 29/08/2013 51

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. 29/08/2013 52

53. Cervical stage 2 . A concavity is present at the lower border of C2 but C3 and C4 are still trapezoids. 29/08/2013 53

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. 29/08/2013 54

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. 29/08/2013 55

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. 29/08/2013 56

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. 29/08/2013 57

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 29/08/2013 58

59. Mittal S.K. et al(2011 ) I ndian subjects 29/08/2013 59

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 .’’ 29/08/2013 60

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; 29/08/2013 61

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 dentoalveola r effects 29/08/2013 62

63. PANORAMIC RADIOGRAPH 29/08/2013 63

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. 29/08/2013 64

65. Dental age Dental maturity VS dental eruption 29/08/2013 65

66. Methods of assessing dental age Calcification e.g. Demirjian et al M easurement of the crown height, apex width, and root length of the teeth observed in radiographs . Mornstad et al. Time of eruption; Gustafson and Koch 29/08/2013 66

67. Why not intra-oral radiograph? 29/08/2013 67

68. Rationale for OPG Easier to make in children and nervous patient compare to intra-oral radiograph. As a full mouth radiograph it is consider to deliver less dose of radiation. L ittle distortion for mandibular picture 29/08/2013 68

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 29/08/2013 69

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. 29/08/2013 70

71. STAGE B. fusion of the calcified points to give a regular outlined occlusal surface STAGE 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 29/08/2013 71

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. 29/08/2013 72

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 29/08/2013 73

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. 29/08/2013 74

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 29/08/2013 75

76. Self weighted score for dental stages 29/08/2013 76

77. 29/08/2013 77

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; The second molar showed the highest correlation and the. Stage F of tooth calcification corresponded to onset of peak height velocity (stage 2 of CVMI) . 29/08/2013 78

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. 29/08/2013 79

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. 29/08/2013 80

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. 29/08/2013 81

82. References 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 29/08/2013 82

83. 3. Van De Graff; Human anatomy 6 th 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 29/08/2013 83

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 29/08/2013 84

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/dd0 8 Sulaiman AL- E mran . 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 29/08/2013 85

86. 9. Demirjian A, Goldstein H, Tanner J.M. A new system of dental age assessment. Hum Biol 1973; 45 : 211-227 . 29/08/2013 86

87. Thanks for listening. 29/08/2013 87