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radiograph in orthodontics

radiograph in orthodontics



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  • development implies an increase in specialisation of function….Houston et al., 1993
  • Growth centres; epiphyseal plate, cartilaginous nasal septum, cranial base synchondrosesGrowth sites; sutures, condylar cartilage
  • "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
  • 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.


  • Outline Introduction  Definition of growth  Understanding some terminology  Growth centre  Growth sites  chronological age  dental age  skeletal age 29/08/2013 2
  • Growth predictors  clinical predictors  radiographic predictors o hand-wrist radiograph o cephalograph o orthopanthomograph Prediction of growth 29/08/2013 3
  • 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
  • Cephalograph Indication  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
  • 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
  • Conclusion References Appreciation 29/08/2013 7
  • 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
  • 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
  • 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. 29/08/2013 10
  • • 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
  • WHY ASSESS GROWTH? 29/08/2013 12
  • Growth prediction/assessment In doing this, it must take into cognizance; 1. Amount of growth 2. Direction (including rotation) of growth 3. Timing of growth 29/08/2013 13
  • Predictors of growth 1. Clinically; body height sexual characteristic chronological age dental eruption 2. Radiographically: skeletal maturity cervical vertebrae maturation hand-wrist radiograph dental maturity e.g. OPG 29/08/2013 14
  • 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
  • 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
  • HAND-WRIST RADIOGRAPH 29/08/2013 17
  • 29/08/2013 18
  • Indications 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 chronological age. 4. Help to predict future skeletal maturation rate and status 5. To predict pubertal growth spurt 6. To predict the skeletal age of patient whose growth is affected by infection, trauma etc. 29/08/2013 19
  • Growth of the epiphysis 1. Widening stage 2. Capping 3. Fusion 29/08/2013 20
  • Stages of epiphyseal growth 29/08/2013 21
  • 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
  • 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 29/08/2013 23
  • 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
  • Anatomical sites 1. Thumb 2. Middle finger (proximal, middle and distal phalanges) 3. Little finger 4. Radius 29/08/2013 25
  • 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
  • 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 29/08/2013 27
  • 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
  • 29/08/2013 29
  • 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
  • What is the use; 29/08/2013 31
  • 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. 29/08/2013 32
  • 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
  • According to Bjork, the pubertal growth spurt ends even earlier, with complete fusion of the third distal phalanx (DP3fusion). 29/08/2013 34
  • 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 of widening 4. If present the then capping and fusion SMI should be assessed. 29/08/2013 35
  • 11-grade scheme by Fisherman 29/08/2013 36
  • . Maturation stage VS Maturation level 29/08/2013 37
  • Maturation level 1. Early 2. Average 3. Late 29/08/2013 38
  • 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
  • Note the age of maturation stage 29/08/2013 40
  • 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. 29/08/2013 42
  • 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
  • Assessing growth 1. For prediction of growth spurt 2. predicting the correct direction of growth 29/08/2013 44
  • 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 29/08/2013 45
  • Stages of CVM 1. Initiation 2. Acceleration 3. Transition 4. Deceleration 5. Maturation 6. completion 29/08/2013 46
  • indicators 1. Concavity of the lower border 2. Shape of the vertebrae;’  trapezoid Rectangular horizontally Rectangular vertically square 29/08/2013 47
  • 29/08/2013 48
  • 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. 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
  • 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 expected Distinct concavities in lower borders of C2, C3, and C4. C3 and C4 are nearly square in shape.29/08/2013 50
  • 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
  • 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
  • Cervical stage 2 . A concavity is present at the lower border of C2 but C3 and C4 are still trapezoids. 29/08/2013 53
  • 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
  • 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
  • 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
  • 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
  • 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 before29/08/2013 58
  • Mittal S.K. et al(2011) Indian subjects 29/08/2013 59
  • 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
  • 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
  • 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 29/08/2013 62
  • PANORAMIC RADIOGRAPH 29/08/2013 63
  • 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
  • Dental age Dental maturity VS dental eruption 29/08/2013 65
  • 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 29/08/2013 66
  • Why not intra-oral radiograph? 29/08/2013 67
  • 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 29/08/2013 68
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • 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
  • Self weighted score for dental stages 29/08/2013 76
  • 29/08/2013 77
  • 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) . 29/08/2013 78
  • 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
  • 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
  • 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
  • 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 29/08/2013 82
  • 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 29/08/2013 83
  • 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
  • 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-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 29/08/2013 85
  • 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
  • Thanks for listening. 29/08/2013 87