Dissertation presentation

EVALUATION OF SKELETAL MATURATION BY
COMPARING THE HAND WRIST RADIOGRAPH AND
CERVICAL VERTEBRAE AS SEEN IN LATERAL
CEPHALOGRAM
www.indiandentalacademy.comwww.indiandentalacademy.com

IntroductionIntroduction
Introduction

 Growth biologically and histologically is a
composite of morphogenetic and histogenetic
changes occurring continuously over a period
of time in response to genetic coding and
environmental influences.
 It is one of the most myriad variations in nature
and plays an important role in the etiology of
malocclusion and also helps in the evaluation
of
diagnosis
treatment planning
retention and stability of a casewww.indiandentalacademy.comwww.indiandentalacademy.com

 The developmental status of a child is usually
assessed in relation to events that take place
during the progress of growth.
 Various biological parameters like
chronological age, dental development, height
and weight measurements, sexual maturation
have been used to identify stages of growth.

 The chronologic age have little or no place
in the assessment of maturational status of a
child since it is governed by various factors
like genetic, epigenetic, environmental,
nutritional, hormonal etc.
 Height and weight measurements are one of
the powerful tools in growth assessment but
become impractical in clinical orthodontics as
it requires longitudinal data and needs time
and repeated observations.

 Dental age being used as an
indicator for maturity is a simple
but not so accurate method
because of wide variations in
eruption timing of teeth due to
the influence of local and
environmental factors.
 Many researchers have agreed that skeletal
maturity is also closely related to the
craniofacial growth, and bones of hand wrist
and cervical vertebrae are very reliable
parameters in assessing it.www.indiandentalacademy.comwww.indiandentalacademy.com

 The complete hand wrist radiograph involves
30 bones and assessment of these stages is
one elaborate task which needs
 Time
 Experience
 Involves increased radiation exposure
therefore putting a question mark on
ALARA (As Low As Reasonably
Achievable) principle

 To assess the skeletal age of an individual by
interpretation of the cervical vertebrae as seen
in lateral cephalogram which is obtained as a
standard pre-treatment diagnostic record.
 To correlate and evaluate the changes in the
shape and size of the cervical vertebrae with
the skeletal maturity index on a hand wrist
radiograph.
AIMS AND OBJECTIVES

MethodologyMethodology
 Total strength of the sample – 100Total strength of the sample – 100
 Age group – 8 to 18 yearsAge group – 8 to 18 years
 No. of groups – 10No. of groups – 10
 No. of subjects - 10 with equal distribution of male andNo. of subjects - 10 with equal distribution of male and
female subjectsfemale subjects
 The criteria for selection - Patients with normalThe criteria for selection - Patients with normal
occlusion, malocclusion, those undergoing orthodonticocclusion, malocclusion, those undergoing orthodontic
treatment with no congenital disorders and falling intotreatment with no congenital disorders and falling into
the norms of Indian society.the norms of Indian society.
 Radiographs taken –Radiographs taken – Lateral cephalogramLateral cephalogram
Left hand wrist radiographLeft hand wrist radiograph

METHODOLOGY APPLIED FOR THE STUDY
• Both radiographs were taken on the same day and were
traced using a radiographic illuminator

 To evaluate the maturational patterns of the
indicators in the hand wrist, eleven grade
system of Fishman was used.
 This system uses only four stages of bone
maturation, all found at six anatomical sites
located on the
 Thumb
 Third finger
 Fifth finger
 Radius
Assessment of skeletal maturation using SMIs
from hand wrist radiograph as an indicator

 Sequence of the four ossification stages
progress through –
 Epiphyseal widening on selected phalanges
 Ossification of the adductor sesamoid of the
thumb
 Capping of selected epiphysis over their
diaphysis and
 Fusion of selected epiphysis and diaphysis.

SMI 1 - The third finger proximal
phalanx shows equal width of
epiphysis and diaphysis
SMI 2 - Width of epiphysis equal to
that of diaphysis in the middle
phalanx of third finger

SMI 3 - Width of epiphysis
equal to that of diaphysis in the
middle phalanx of fifth finger
SMI 4 - Appearance of
adductor sesamoid of the
thumb

SMI 5 - Capping of
epiphysis seen in distal
SMI 6 - Capping of
epiphysis seen in middle

SMI 7 - Capping of epiphysis
seen in middle phalanx of
fifth finger
SMI 8 - Fusion of epiphysis
and diaphysis in the distal

SMI 9 - Fusion of
epiphysis and diaphysis in
proximal phalanx of third
finger
SMI 10 - Fusion of epiphysis
and diaphysis in middle

SMI 11 - Fusion of epiphysis and
diaphysis seen in the radius

Assessment of skeletal maturation using
cervical vertebrae
 Hassel and Farman method,modification of
Lamparski’s criteria
 Maturational changes of the second, third and
fourth cervical vertebrae were noted.
Six distinct stages of growth can be related to
the skeletal maturity indicator developed by
Fishman.

Initiation stage of cervical vertebrae (CVMI – 1)
(skeletal maturity indicator 1 and 2)
• C2, C3 and C4 inferior
vertebral body borders
are flat.
• Superior vertebral
borders of C3 and C4
are tapered from
posterior to anterior
(wedge shape)
• 100% of pubertal growth
remains.

Acceleration stage of cervical vertebrae (CVMI – 2)
(skeletal maturity indicator 3 and 4)
• Concavities begin to
develop on the inferior
borders of C2 and C3
• Inferior border of fourth
vertebrae remains flat
• Vertebral bodies of C3
and C4 are nearly
rectangular in shape
• 6585% of pubertal
growth remains.

Transition stage of cervical vertebrae (CVMI – 3)
(skeletal maturity indicator – 5 & 6)
• Distinct concavities
seen in lower
borders of C2 and
C3
• Developing
concavity seen in
lower border of body
of C4
growth remains.www.indiandentalacademy.comwww.indiandentalacademy.com

Deceleration stage of cervical vertebrae (CVMI – 4)
(skeletal maturity indicator – 7 & 8)
• Distinct concavities
in lower borders of
C2 C3 and C4 are
observed.
• C3 and C4 are
nearly square in
shape
growth remains

Maturation stage of cervical vertebrae (CVMI – 5)
(skeletal maturity indicator 9 &10)
• Accentuated
concavities of inferior
of C2, C3 and C4 are
observed
• C3 and C4 are square
in shape
growth remains

Completion stage of cervical vertebrae (CVMI – 6)
(skeletal maturity indicator 11)
• Deep concavities are
present for inferior
of C2, C3 & C4
• C3 & C4 height are
greater than widths
• Pubertal growth has
been completed

 SMI scores and CVMI scores were obtained
and analyzed with reference to –
 chronological age and sex.
 SMI and CVMI were compared with each
other and their correlation was established
statistically.
 Data obtained was fed into the computer and
statistical analysis was performed for the same
using the software “Statistical Package for Social
Sciences” SPSS for windows (version 10.0) and
analysed accordingly.
RESULTS

STRIKING FEATURES –
 The maturation development for females was
earlier than their male counterparts.
 Growth spurts existed for a longer duration in
males as compared to their female counterparts.
 Mean age for INITIATION (SMI1)
FEMALES 8.00 ± 0.00 years
MALES 8.43 ± 0.535 years
 Mean age of COMPLETION (SMI 11)
FEMALES 16.18 ± 0.874 years
MALES 16.56 ± 0.527 years

 Mean age of both the sexes for CVMI is steadily
increasing in relation to an increase in CVMI
grade.
 Mean age for the initiation
FEMALES- 8.73 ± 0.405 years
MALES- 8.83 ± 0.937 years
 The mean age for maximum puberty growth spurt
FEMALES-13.00 ± 1.414 years
MALES- 13.40 ± 0.548 years
 Eleven discrete stages of SMI can be confidently
correlated to corresponding 6 stages of CVMI in
both male and female subjects.

 The present study shows thatThe present study shows that
chronological age is not achronological age is not a
reliable indicator of maturationreliable indicator of maturation
and did not correlate withand did not correlate with
skeletal maturation indicatorsskeletal maturation indicators
(SMI and CVMI).(SMI and CVMI).
 These results are inThese results are in
confirmation with studiesconfirmation with studies
conducted by Bjork and Helmconducted by Bjork and Helm
(1967), Brown (1976),(1967), Brown (1976),
Fishman (1979, 1982, 1987)Fishman (1979, 1982, 1987)
and Hagg and Tarangerand Hagg and Taranger
(1982).(1982).
DISCUSSION

 Various authors like Greulich and Pyle (1950),Various authors like Greulich and Pyle (1950),
Nanda (1955), Bjork (1967), Fishman (1979,Nanda (1955), Bjork (1967), Fishman (1979,
1982, 1987),Lamparski (1972), Hagg and1982, 1987),Lamparski (1972), Hagg and
Taranger (1982), Grave and Brown (1976), haveTaranger (1982), Grave and Brown (1976), have
concluded that the skeletal maturity ofconcluded that the skeletal maturity of
craniofacial region is most closely related tocraniofacial region is most closely related to
bones of hand and wrist and cervical vertebraebones of hand and wrist and cervical vertebrae
plays a vital role in assessing it.plays a vital role in assessing it.

 Many investigators namely Helm et al (1971),Many investigators namely Helm et al (1971),
Tanner (1975), Grave and Brown (1976), Hagg,Tanner (1975), Grave and Brown (1976), Hagg,
Taranger (1980), Fishman (1982), haveTaranger (1980), Fishman (1982), have
delineated several specific ossification stagesdelineated several specific ossification stages
that occurred before, at or after peak heightthat occurred before, at or after peak height
velocity.velocity.
 The identification of skeletal maturation levelThe identification of skeletal maturation level
provides a useful means of identification ofprovides a useful means of identification of
specific points along the progressive path ofspecific points along the progressive path of
adolescent growth. It is analogous to mileageadolescent growth. It is analogous to mileage
signs posted along a highway between twosigns posted along a highway between two
cities.cities.

 Cervical vertebrae radiograph does not score
over the hand wrist radiograph in revealing the
maturity status of an individual.
 However, it is as good as a hand wrist radiograph
for its diagnostic value in those patients where
we do not need to know the exact skeletal age of
a patient.
CONCLUSION

 This can be helpful to know whether the patient
will grow during the one or two years treatment
period and whether the percentage of growth can
reasonably be expected during the time when
orthopaedic treatment is initiated.
 All this at a significantly reduced radiation
exposure to the patient and less elaborate
armamentarium itself places cervical vertebrae in
the same platform as a hand wrist radiograph.

 Definitely a need forDefinitely a need for
further study with a largerfurther study with a larger
sample is required as itsample is required as it
can show much highercan show much higher
correlation than thecorrelation than the
reading we have seen inreading we have seen in
this study.this study.
affirmation confirmation
To say that this is a much better method than the
study of hand wrist radiographwww.indiandentalacademy.comwww.indiandentalacademy.com

 It is rightly said that “what we do today, rightIt is rightly said that “what we do today, right
now, will have an accumulated effect on all ournow, will have an accumulated effect on all our
tomorrows”. So, to take advantage of growth wetomorrows”. So, to take advantage of growth we
must have an idea of first its magnitude, secondmust have an idea of first its magnitude, second
its direction and third the element of timing. Useits direction and third the element of timing. Use
of the element of timing of maximum growth inof the element of timing of maximum growth in
conjunction with one’s knowledge of magnitudeconjunction with one’s knowledge of magnitude
and direction, readily transforms orthodontics toand direction, readily transforms orthodontics to
a profession ofa profession of “Face Forming, As Well As Tooth“Face Forming, As Well As Tooth
Positioning”.Positioning”.

Thank You

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