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.
• Outline
 Introduction
 Definition of growth
 Understanding some terminology
 Growth centre
 Growth sites
 chronological age
 dental age
 skeletal age
 Growth predictors
 clinical predictors
 radiographic predictors
o hand-wrist radiograph
o cephalograph
o orthopanthomograph
 Prediction of growth
• 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
• 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
• 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.
•
 Conclusion
 References
 Appreciation
• 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.
Growth centre is a location at which independent (genetically controlled)
growth occurs.
Growth site is a location at which growth occurs
• 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.
• 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
WHY ASSESS GROWTH?
• 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
• 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
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.

• 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.
HAND-WRIST RADIOGRAPH
• 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.
• Growth of the epiphysis
1. Widening stage
2. Capping
3. Fusion

• Stages of epiphyseal growth

• 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
• 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 adolescence.
The skeletal maturation was describe during the various stages of growth of the
epiphysis.
• Anatomical sites
1. Thumb
2. Middle finger (proximal, middle and distal phalanges)
3. Little finger
4. Radius
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
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
 • 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.
• What is the use;
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.
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 of widening
4. If present the then capping and fusion SMI should be assessed.
• 11-grade scheme by Fisherman
.
Maturation stage VS Maturation level
• Maturation level
1. Early
2. Average
3. Late
• 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.
• Note the age of maturation stage
CEPHALOMETRIC RADIOGRAPH
• 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.

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.
• Assessing growth
1. For prediction of growth spurt
2. predicting the correct direction of growth

The CVM method, first described by Lamparski, is based on assessing the shape of
the cervical bodies, as seen in routine lateral cephalograms . More recently, Franchi
et al and Baccetti et al confirmed the validity of Lamparski's original method as a
biologic indicator for both mandibular and somatic skeletal maturation. They
continued to modify Lamparski's method using longitudinal growth records from
the University of Michigan Growth Study, making it applicable to both sexes,
easier to use, and suitable for most patients. Baccetti et al reported good
reproducibility with this method of assessing CVM.

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
• Stages of CVM
1. Initiation
2. Acceleration
3. Transition
4. Deceleration
5. Maturation
6. completion
• indicators
1. Concavity of the lower border
 2. Shape of the vertebrae;’
 trapezoid
 Rectangular horizontally
 Rectangular vertically
 square
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.
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.
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.
• 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
shape.
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.
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.
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.
• Mittal S.K. et al(2011) Indian subjects

Application
• to Dentofacial Orthopedics
The clinical application of the method to dentofacial ortho-pedics becomes
relevant for those treatment protocols that benefit from the inclusion of the period
of accelerated man-dibular growth. CVM method can be useful as a maturational
index to detect the optimal time to start treatment of man-dibular deficiencies by
means of functional jaw orthope-dics.25,26 It has been demonstrated that the
effectiveness of functional treatment of Class II skeletal disharmony depends
strongly on the biological responsiveness of the condylar car-tilage, which in turn
is related to the growth rate of the man-dible.27
When CS1 or CS2 are diagnosed in the individual patient with mandibular
deficiency, the clinician can wait at least one additional year for a radiographic
reevaluation aimed to start treatment with a functional appliance. The appearance
of a definite concavity at the lower border of C2 indicates that the growth spurt is
approaching, that is, that the year of the peak will start approximately 1 year after
this stage. CS3 represents the ideal stage to begin functional jaw orthopedics, as
the peak in mandibular growth will occur within the year after this observation. In
the sample examined here, total mandib-ular length exhibited an average increase
of 5.4 mm in the year following CS3, a significantly greater increment when
compared with the growth interval from CS1 to CS2 (about 2.5 mm), from CS2 to
CS3 (again about 2.5 mm), and to the postpeak between-stage intervals (1.6 mm
and 2.1 mm for the intervals from CS4 to CS5 and from CS5 to CS6, respec-
tively).

• 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.’’
• 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 effects
PANORAMIC RADIOGRAPH
• 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.
• Dental age
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
Why not intra-oral radiograph?
• 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
• 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
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.
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
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.
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
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.
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
• 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 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) .
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.
• 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.
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.
• 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
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
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
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
9. Demirjian A, Goldstein H, Tanner J.M. A new system of dental age assessment.
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Thanks for listening.