PowerPoint Presentation

HAND WRIST RADIOGRAPHCoojacinto, S.Celajes, S.

Introduction as an indicator of skeletal maturityChronological age is often not sufficient for assessing the developmental stage and somatic maturity of the patient.The biological age is determined from the skeletal, dental and morphologic age and the onset of pubertyDue to individual variations in timing, duration and velocity of growth, skeletal age assessment is essential in formulating variable orthodontic treatment plans.2Skeletal maturity indicators provide an objective diagnostic evaluation of stage of maturity in an individual.Methods available to assess the skeletal maturity of an individualUse of hand wrist x-raysEvaluation of skeletal maturation using cervical vertebraeAssessment of maturity by clinical and radiographic examination of different stages of tooth developmentClinical significanceTo determine the amount of significant facial cranial growth potential left and potential vector of facial development.To decide the onset of treatment timing and type of effective treatment.To evaluate the treatment prognosis.To understand the role of genetics and environment on the skeletal maturation pattern.Anatomical Landmarks Suitable for Skeletal Maturity AssessmentHead and NeckSkullCervical VertebraeUpper limbShoulder joint-ScapulaElbowHand wrist and fingersLower limbFemur and humerusHip jointKneeAnkleTooth mineralization as an indicatorFrontal sinusHand Wrist RadiographsSkeletal age assessment is often done with the help of hand wrist radiograph which can be considered as the Biological clock.Hand wrist region is made up of numerous small bones. These bones show a predictable and scheduled pattern of appearance, ossification and union from birth to maturity. Hence, this is one of the most important regions to study growth.Nine developmental stages are there according to Bjrk (1972), Grave and Brown (1976). The ossification events are localized in the area of the phalanges, carpal bones and radius.Biological age and Hand wrist radiographOrthodontic treatment progresses more quickly during growth spurts. Generally, children experience a pattern of fast growth, followed by a slow growth in late childhood and then accelerated and peak growth in adolescence.Because children begin this growth sequence at different ages, chronological age is a poor indicator of childs development. Hand-wrist radiograph is a useful tool in identifying a childs skeletal development.Brief history about hand wrist radiographAfter Roentgen demonstrate his new radiographic history in 1895, Ronaldo, in 1896, introduced the idea of using the comparative size and shape of the radiographic shadows of growing bones as indicators of rate of growth and maturity.In early 1900s, Pryor, Rotch and Crampton began tabulating indicators of maturity on sequential radiographs of the growing hand and wrist.9Todd compiled hand-wrist data that was further elaborated on by Greulich and Pyle in atlas form. In 1936, Flory indicated that beginning of calcification of the carpal sesamoid was a good guide to determine the period immediately before puberty. The appearance of the adductor sesamoid has been highly correlated to peak height velocity and start of adolescent growth spurt.Fishman developed a system of hand wrist skeletal maturation indicators using 4 stages of bone maturation at 6 anatomic sites on the hand and wrist.Hagg and Taranger created a method using the hand wrist radiograph to correlate certain maturity indicators to the pubertal growth spurt. Anatomy of Hand-WristThe hand wrist region is made up of 4 groups of bonesDistal ends of long bones of forearmCarpalMetacarpalsPhalanges

Anatomy of skeleton of hand

Indications of hand-wrist radiographsIn patients who exhibit major discrepancy between dental and chronologic age.Determination of skeletal maturity status prior to treatment of skeletal malocclusion.To assess the skeletal age in a patient whose growth is affected by infections, neoplastic or traumatic conditions.Help to predict future skeletal maturation rate and status.To predict the pubertal growth spurt.Methods of Assessing Skeletal AgeThe comparison atlas of Greulich and Pyle (1959)The processes that use specific indicators that relate skeletal maturation to the pubertal growth curver, such as the methods described byBjrk (1972)Fishman (1982)Hagg and Taranger (1982)Greulich and Pyle (1959)

Bjrks method of assessmentBjrk utilizes certain anatomical sites located on the phalanges, abductor sesamoid, carpal and radius bone, which have predictable and consistent time of onset of ossification.

Divided the maturation process of hand bones into developmental stages.

Fishman (1982)Based on the observation of ossification events localized in the area of the finger phalanges, carpal bone and radius.There is a close correlation between sequence of hand-wrist ossification and mandibular-growth status.Most commonly used methods to assess skeletal maturation.Fishman (1982)Leonard S. Fishman outlined four stages of bone maturation found at six anatomical sites located on the thumb, 3rd finger, 5th finger and radius.Eleven skeletal maturity indicators are found in these six anatomic sites.

Four stages:Epiphysis equal in width to diaphysisAppearance of adductor sesamoid thumbCapping of epiphysisFusion of epiphysis.

PP3 width

MP3width

MP5width

SDP3capMP3cap

MP5cap

DP3fuse

PP3fuse

MP3fuse

RfuseHagg and Taranger (1982)Introduced a method using the hand-wrist radiograph to correlate certain maturity indicators to the pubertal spurt and noted that the stages of ossification of middle phalanx of third finger of a hand (MP3) follow the pubertal growth spurt from the onset to the end.Described a method in which skeletal development is assessed by ossification of the ulnar sesamoid of the metacarpophalangeal joint of the first finger (S) and certain specified stages of three epiphyseal bones; the middle and distal phalanges of the 3rd finger (MP3 and DP3) and the distal epiphysis of the radius (R).

References:

Moyers, R., Handbook of Orthodontics, 4th ed.Enlow, Handbook of Facial Growth, 1982Fishman, L., Radiographic evaluation of Skeletal maturity A clinically oriented method based on Hand-wrist films. Vol. 52, No. 2., April 1982Antana S, 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.