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.
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2. Outline
Introduction
 Definition of growth
 Understanding some terminology
 Growth centre
 Growth sites
 chronological age
 dental age
 skeletal age
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3. Growth predictors
 clinical predictors
 radiographic predictors
o hand-wrist radiograph
o cephalograph
o orthopanthomograph
Prediction of growth
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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
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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
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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.
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7. Conclusion
References
Appreciation
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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.
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9. Growth centre is a location at which
independent (genetically controlled) growth
occurs.
Growth site is a location at which growth
occurs
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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. growth spurt in
males and females.
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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
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12. WHY ASSESS
GROWTH?
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13. 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
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14. 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
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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.
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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.
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17. HAND-WRIST RADIOGRAPH
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18. 29/08/2013 18

19. 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.
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20. Growth of the epiphysis
1. Widening stage
2. Capping
3. Fusion
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21. Stages of epiphyseal growth
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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
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23. 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
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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.
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25. Anatomical sites
1. Thumb
2. Middle finger (proximal, middle and distal
phalanges)
3. Little finger
4. Radius
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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.
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27. 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
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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
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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.
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31. What is the use;
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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 MP3cap stage of hand–wrist
ossification marks the peak of the pubertal
growth.
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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.
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34. According to Bjork, the pubertal growth spurt
ends even earlier, with complete fusion of the
third distal phalanx (DP3fusion).
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35. 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.
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36. 11-grade scheme by Fisherman
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37. .
Maturation stage VS Maturation level
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38. Maturation level
1. Early
2. Average
3. Late
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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.
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40. Note the age of maturation stage
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41. CEPHALOMETRIC RADIOGRAPH
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42. 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.
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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.
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44. Assessing growth
1. For prediction of growth spurt
2. predicting the correct direction of growth
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45. 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
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46. Stages of CVM
1. Initiation
2. Acceleration
3. Transition
4. Deceleration
5. Maturation
6. completion
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47. indicators
1. Concavity of the lower border
2. Shape of the vertebrae;’
 trapezoid
Rectangular horizontally
Rectangular vertically
square
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48. 29/08/2013 48

49. 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.
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50. 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

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.
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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.
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53. Cervical stage 2 . A
concavity is present
at the lower border
of C2 but C3 and C4
are still trapezoids.
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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.
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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.
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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.
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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.
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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 before29/08/2013 58

59. Mittal S.K. et al(2011) Indian subjects
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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.’’
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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;
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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
dentoalveolar effects
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63. PANORAMIC RADIOGRAPH
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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.
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65. Dental age
Dental maturity VS dental eruption
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66. 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
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67. Why not intra-oral radiograph?
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68. 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
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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
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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.
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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
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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.
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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
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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.
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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
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76. Self weighted score for dental stages
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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;
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) .
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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.
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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.
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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.
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82. 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
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83. 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
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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
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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-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
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86. 9. Demirjian A, Goldstein H, Tanner J.M. A new
system of dental age assessment. Hum Biol
1973; 45 : 211-227.
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87. Thanks for listening.
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