"cephalocaudal gradient of growth." This simply means that there is an axis of increased growth extending from the head toward the feet.
Chronological don’t give a true picture of the facial growth.Dental age include eruption and maturation.
adrenal component of the system is referred to as adrenarche. DHEA reaches a critical level at about age 10 that correlates with the initiation of sexual attraction. Dehydroepiandrosterone ;DHEA
Various areas of the skeleton have been used : the foot, the ankle, the hip, the elbow, the hand wrist, and the cervical vertebrae. The presence of a juvenile growth spurt in girls accentuates this tendency for significant acceleration of jaw growth in the mixed dentition. If most girls are to receive orthodontic treatment while they are growing rapidly, the treatment must begin during the mixed dentition rather than after all succedaneous teeth have erupted
It is likely that a juvenile acceleration in growth is related to the intensity of adrenarche and not surprising that a juvenile acceleration is more prominent in girls because of the greater adrenal component of their early sexual development.
Unlike neural growth, somatic bone growth seems to be more an intrinsic property of the bones and under fairlytight genetic control. Growth is fairly rapid in the early years, but slows in the prepubertal period. The pubertalgrowth spurt is a time of very rapid growth
Pattern of growth is the maintenance of the configuration of the face over time.
Primary growth centres and secondary growth sites.
Widening of the epiphysis is relative to the diaphysis and later extend to the width of the diaphysis.The edges of the epiphysis flattened and point towards the diaphysis in the capping stage.Fusion begin at the middle and extend laterally until they form one solid bone.
Orthodontists have regularly taken hand – wrist radiographs of their patients to determine remaining craniofacial growth before the beginning of treatment.
Sesamoid bones are those formed in tendons in response to stress as the tendon move across the joint. They vary in number. A constant sesamoid bone present in everybody is the patella. For the suture in the skull they are called Wormian bones.
There is also the possibility of juvenile acceleration (adrenarche). Infancy is birth-3years, childhood 3-12 years, adolescence is 12-18years and adulthood is > 18years
Note the systematic approach
Maturational stages refer to specific development events, identified on hand-wrist x-rays, and are directly related to the progression of maturation during childhood and adolescence. The maturational level is used to associate individual maturational stage with her or his chronological age. This further classify them as either early, average or late.
The modified CVM uses C2-C4 as they are visible when a protective collar is worn.
Lamparski identified two specific maturity indicators on the cervical vertebrae to assist in the evaluation:The initiation and development of concavities on the lower border of the vertebral body. the increase in height of the vertebral body, from tapered, to rectangular, to square, to higher than wide
A series of short-term studies has demonstrated statistically and clinically significant correction of the Class II dentoskeletal relationships when either functional appliances or fixed appliances in combination with Class II elastics are used during the circumpubertal period i.e. CS3
Prepubertal orthopedic treatment of Class III malocclusion is effective both in the maxilla (which shows a supplementary growth of about 2 mm over Class III untreated controls) and in the mandible (restriction in growth of about 3.5mmover controls), whereas treatment of Class III malocclusion at puberty is effective at the mandibularlevel only (restriction in growth of about 4.5mmover controls).
Since children with the same chronological age may show differences in their developmental biological stages, estimation of dental development was considered more reliable as an indicator of biological maturity in children than chronological age.
Developmental criteria include; amount of dentinal deposits, change in the shape of the pulp chamber e.tc.
Morrees et al made use of periapical radiographs.
Note tooth eruptio0n correspond to a particular stage of development. Most likely stage F as two-third of root is require for eruption.
Thirdmolar showed the lowest correlation for male and female subjects
Mandibular incisor and first molars were not rated because apical closure had already taken place.
THE USE OF HAND AND WRIST RADIOGRAPH, OPG AND CEPHALOMETRIC RADIOGRAPH FOR THE ASSESSMENT OF GROWTH IN ORTHODONTIC PATIENT
THE USE OF HAND AND WRIST
RADIOGRAPH, OPG AND CEPHALOMETRIC
RADIOGRAPH FOR THE ASSESSMENT OF
GROWTH IN ORTHODONTIC PATIENT
DR AGHIMIEN OSARONSE
UNIVERSITY OF BENIN DENTAL SCHOOL.
Definition of growth
Understanding some terminology
o hand-wrist radiograph
Prediction of growth
Stages and growth of epiphysis
Methods of assessment
How to analyse the HW-radiograph
Skeletal maturation indicators
Maturation stage versus maturation level
..as a predictor of growth
Importance of cervical vertebrae
stages of CVM
indicators of CVM
CVM and mandibular growth
CVM and chronological age
Clinical relevance in timing
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
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
Growth centre is a location at which
independent (genetically controlled) growth
Growth site is a location at which growth
1. pattern; it relates the spatial proportion of
growth over a period of time e.g.
cephalocaudal gradient of growth.
3. Timing. Same thing happen to different
individual at different time e.g. growth spurt in
males and females.
• 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
In doing this, it must take into cognizance;
1. Amount of growth
2. Direction (including rotation) of growth
3. Timing of growth
Predictors of growth
cervical vertebrae maturation
dental maturity e.g. OPG
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.
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.
1. Before the use of RME
2. Treatment planning of class II and III cases when
functional appliance is an option
3. Severe discrepancy between dental and
4. Help to predict future skeletal maturation rate
5. To predict pubertal growth spurt
6. To predict the skeletal age of patient whose
growth is affected by infection, trauma etc.
Growth of the epiphysis
1. Widening stage
Skeletal maturation assessment
3. Appearance of sesamoid bone of the thumb
These stages are said to be related with different
levels of adolescent growth i.e. onset, peak and
termination of maximum velocity of growth
Methods of SMA using HW-radiograph
1. Fisherman skeletal maturation indicator
2. Bjork, Grave and Brown
3. 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
Leonard Fisherman system (1982)
Eleven indicators were used on the 6 anatomical
sites and they were correlated with period of
The skeletal maturation was describe during the
various stages of growth of the epiphysis.
2. Middle finger (proximal, middle and distal
3. Little finger
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.
Stage 1..width of Epiphysis equal that
of Diaphysis i.e. E=D
1. Middle finger proximal phalanx…PP3
2. Middle finger middle phalanx…MP3
3. 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
Correlation of the ossification
stages of hand–wrist bone and skeletal
The various indicators outlined have been
related to the various stages of skeletal
Also the variation for the different sex have also
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
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.
According to Bjork, the pubertal growth spurt
ends even earlier, with complete fusion of the
third distal phalanx (DP3fusion).
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 S
3. if absent then the SMI indicated will be that
4. If present the then capping and fusion SMI
should be assessed.
Maturation stage VS Maturation level
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
Hence, if a patient is a late maturer it thus mean
that one has the advantage of an additional
Note the age of maturation stage
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.
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
1. For prediction of growth spurt
2. predicting the correct direction of growth
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
Very significant amount of adolescent growth
C2, C3, and C4 inferior vertebral body borders are
Superior vertebral borders are tapered posterior
to anterior i.e. trapezoids
Significant amount of adolescent growth
Concavities developing in lower borders of C2
Lower border of C4 vertebral body is flat.
C3 and C4 are more trapezoid in shape.
3. Transition .
Moderate amount of adolescent growth
Distinct concavities seen in lower borders ofC2
C4 developing concavity in lower border of
C3 and C4 are rectangular in shape.
Small amount of adolescent growth expected
Distinct concavities in lower borders of C2, C3,
C3 and C4 are nearly square in shape.29/08/2013 50
Insignificant amount of adolescent growth
Accentuated concavities on inferior borders of
C2, C3, and C4.
C3 and C4 are square in shape.
Adolescent growth is completed.
Deep concavities are present on inferior borders
of C2,C3, and C4.
C3 and C4 heights are greater than widths.
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.
Cervical stage 2 . A
concavity is present
at the lower border
of C2 but C3 and C4
are still trapezoids.
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
Cervical stage 4
Concavities at the lower
borders of C2, C3, and
C4 now are present. The
bodies of both C3 and C4
horizontal in shape.
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
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
vertical in shape.
stage Peak of mandibular growth
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 before29/08/2013 58
Mittal S.K. et al(2011) Indian subjects
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
‘’The best parameter to assess maturation
stages is when the concavity on the lower
border of the vertebral bodies is greater than 1
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;
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
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
Dental maturity VS dental eruption
Methods of assessing dental age
1. Calcification e.g. Demirjian et al
2. 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
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
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
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
fusion of the calcified points to give a regular
outlined occlusal surface
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
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.
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
b. the root length is less than the crown height
a. initial formation of the radicular bifurcation is
seen in the form of either a calcified points or a
b. the root length is still less than the crown
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
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
b. the root length is equal to or greater than the
The walls of the root canal are now parallel and
its apical end is still partially opened(distal root in
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
Self weighted score for dental stages
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
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
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.
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
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
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.
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2001. skeletal system- introduction and axial
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cervical vertebra maturation stages in
assessment of young orthodontic patients to
estimate growth potential
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