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ORIGINAL ARTICLE
Year : 2006  |  Volume : 24  |  Issue : 3  |  Page : 127-135
 

Comparative evaluation of hand wrist radiographs with cervical vertebrae for skeletal maturation in 10-12 years old children


Department of Orthodontics, D. A. V. Dental College, Yamuna Nagar, Haryana, India

Correspondence Address:
M Kamal
Tulsi Lok and Sons, Outer Quilla Road, Shant Mai Chowk, Rohtak - 124 001, Haryana
India
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DOI: 10.4103/0970-4388.27901

PMID: 17065779

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   Abstract 

A comparative evaluation of hand wrist and cervical vertebrae was done to know the validity of cervical vertebrae as maturity indicators. A sample of 50 subjects (25 females and 25 males) in the age group of 10-12 years were selected on criteria of normal occlusion and the result showed that cervical vertebrae can be used with the same confidence as hand wrist radiographs to evaluate skeletal maturity, thus avoiding the need for an additional radiograph.


Keywords: Cervical radiograph, hand wrist radiograph, skeletal maturation


How to cite this article:
Kamal M, Ragini, Goyal S. Comparative evaluation of hand wrist radiographs with cervical vertebrae for skeletal maturation in 10-12 years old children. J Indian Soc Pedod Prev Dent 2006;24:127-35

How to cite this URL:
Kamal M, Ragini, Goyal S. Comparative evaluation of hand wrist radiographs with cervical vertebrae for skeletal maturation in 10-12 years old children. J Indian Soc Pedod Prev Dent [serial online] 2006 [cited 2014 Oct 24];24:127-35. Available from: http://www.jisppd.com/text.asp?2006/24/3/127/27901



   Introduction Top


Skeletal age refers to the degree of development of ossification of the bone. Because of individual variations in timing, duration and velocity of growth, skeletal age assessment is essential and helpful in formulating viable orthodontic treatment plans. During growth every bone goes through a series of changes that can be seen radiologically. The sequence of change is relatively constant for a given bone in every person but the timing of the changes varies because each person has his or her own biological clock.[1]

The hand wrist radiograph is considered to be the most standardized method of skeletal assessment. Assessment of skeletal maturation using hand wrist radiograph as an index based upon time and sequence of appearance of carpal bones and certain ossification events has been reported by many investigators.

Fishman[2] developed a system of skeletal maturation assessment based on four stages of maturation at six anatomic sites located on thumb, third finger, fifth finger and radius. He described 11 adolescent skeletal maturation indicators on the six sites predicting the entire period of adolescence and reported the percentage of growth completed corresponding to each maturity indicator.

Hassel and Farman[1] developed cervical vertebrae as maturity indicators by assessing the lateral profile changes of second, third and fourth vertebrae. The cervical vertebrae maturity indicators were evaluated against skeletal maturation index established from hand wrist radiograph by Fishman. The method has the advantage of eliminating the need for an additional radiographic exposure since the vertebrae are already recorded in the lateral cephalogram taken as a pretreatment record.


   Materials and Methods Top


This study was conducted in the Department of Orthodontics at D.A.V. Dental College and Hospital, Yamuna Nagar, Haryana.

The sample consisted of 50 subjects (25 females and 25 males) in the age range of 10-12 years. The children were selected from schools located in urban areas of Yamuna Nagar.

The samples were selected on the following criteria:

a) Angle's Class I molar relationship

b) Normal occlusion with zero to minimum crowding / spacing (0-2 mm)

c) No history of extraction

d) No history of any orthodontic treatment

e) No history of any badly decayed / filled tooth

f) Pleasant soft tissue profile

Protocol and method

Selected subjects were clinically examined and the following points were recorded:

  1. Age and date of birth: The age considered was his or her chronological age in completed years, without taking the months into consideration.
  2. Sex: As males and females attain puberty at different times in life, the total samples were differentiated into males and females.


Material

  1. Sample size of 50 children (25 males and 25 females) were selected
  2. Radiographs-hand wrist, lateral cephalogram
  3. Matte acetate tracing paper
  4. Lead pencil-4H
  5. Radiograph viewer


Grouping of sample was done as below.



Radiographs

Lateral cephalogram

Lateral cephalograms were taken on Gendex Orthoralix 9200 at 70 Kvp, 6 mA, with exposure time of 0.80 s using Kodak Diagnostic film (T-mat), green base of size 8 in. ´ 10 in. Distance from X-ray source to the subject's midsagittal plane was fixed at 5 feet.

Patient positioning procedure

  1. Radiograph was taken with the Frankfurt horizontal plane parallel to floor.
  2. Teeth in centric occlusion.
  3. Lips at repose or relaxed position.


Hand wrist radiographs

Hand wrist radiographs of left hand were taken using SRS/SRD-300 at 50 Kvp, 6 ma, with exposure time of 0.60 s using Nieue plus blue base films of size 8 in. ´ 10 in. The distance between the hand and the X-ray source was kept 100 cm.

  1. The film in a cassette, was placed on the table with its long axis parallel to the long axis of hand in pronation.
  2. Patient stood with his / her left forearm resting on the film placed on the table with fingers slightly separated and the axis of the hand wrist and forearm in a straight line.
  3. The center of the tube was half way between the tips of the fingers and distal end of the radius.


Radiographs were exposed and developed using the standard developer and fixer in a dark room by the same operator to eliminate errors. Any radiograph that had poor contrast was discarded.

Since relative measurement and not absolute measurement is used in the study, magnification is of minimal concern.

Method of tracing the films

  1. The radiographic films were covered on one side with the matte acetate tracing paper.
  2. The tracings of the films were done using 4H lead pencil.
  3. All the phalanges of the fingers and thumb were drawn along with the carpals, metacarpals and outline of the radius and ulnar bone in the hand wrist radiographs.
  4. In the lateral cephalograms, three parts of the cervical vertebrae were traced; these entities include the dens odontoid process - C2, body of the third cervical vertebrae - C3 and the body of the fourth cervical vertebrae - C4.


Elimination of error

The tracings were evaluated by an independent evaluator to evaluate interoperator error.

SMI gives the percentage of adolescent growth completed as shown below.



Cervical vertebrae development was evaluated from the lateral cephalogram according to Hassel and Farman's method (1995) as shown in the chart given below.[1]

Percentage of growth remaining by Hassel and Farman



After the evaluation of cervical vertebrae, the lateral cephalogram was paired with its respective hand wrist radiograph of the same patient.

Cervical vertebrae maturation index (CVMI) indicate percentage of growth remaining and is common for males and females.

Comparison and correlation

Each CVMI is designated equivalent to two skeletal maturation indicators (SMI) levels. Percentage of growth completed according to SMI was taken to evaluate the growth status in males and females [Figure - 1][Figure - 2][Figure - 3][Figure - 4][Figure - 5].




   Observation and Results Top


The following results were drawn from the statistical analysis.

The [Table - 1] shows the mean, minimum, maximum and standard deviation values of the variables - Age, CVMI score, SMI score and growth. The minimum value of chronological age is 10 years and maximum is 12 years with a mean of 11.34 years and standard deviation is 0.7453. The minimum value for CVMI score is 1 and maximum is 5 with a mean of 2.1000 and standard deviation of 1.0152. The minimum value of SMI score is 1 and maximum is 10 with a mean of 3.7200 and standard deviation of 2.0607. The minimum value of percentage of growth completed according to SMI is 0% and maximum value is 96.14% with a mean of 28.0311 and standard deviation of 22.9451.

The [Table - 2]a shows that on evaluation of 50 subjects by both the evaluators, i.e., evaluator A and evaluator B, 44 subjects were showing positive correlation between the SMI and CVMI scores, whereas 6 subjects were not showing a positive correlation between SMI and CVMI scores. Forty-three subjects were in agreement with evaluator A and evaluator B, but 1 case was different for both the evaluators, for which Kappa Test was applied to calculate the percentage of agreement between the two evaluators.

Correlation is significant at ' P ' < 0.001 level as per [Table - 2]b. The interoperator error test was done using an independent evaluator and the agreement was calculated using the Kappa test. It gave a value of 8.11 or the percentage of agreement is 81% for which ' P ' value turns out to be 0.000, which shows that correlation is significant at ' P ' < 0.001 level. It indicates that the evaluation by the operator is consistent.

Results scoring for SMI and CVMI was correlated according to Karl Pearson correlation coefficient test. The test shows that there is no significant difference between the two techniques for total number of samples. The 'r' value turns out to be 0.892 with a ' P ' value of 0.000, which is statistically significant at ' P ' < 0.001 level [Table - 3]a.

Correlation is highly significant at ' P ' < 0.001 level as per [Table - 3]b. The scoring for SMI and CVMI was correlated according to Kari Pearson correlation coefficient test. The test shows that there is no significant difference between the two techniques in males. The 'r' value turns out to be 0.892 with a ' P ' value of 0.000, which is statistically significant at ' P ' < 0.001 level.

Correlation is highly significant at ' P ' < 0.01 level. The scoring for SMI and CVMI was correlated according to Kari Pearson correlation coefficient test. The test shows that there is no significant difference between the two techniques in females. The 'r' value turns out to be 0.858 with a ' P ' value of 0.000, which is statistically significant at ' P ' < 0.001 level [Table - 3]c.

The [Table - 4] shows the percentage of similar and dissimilar assessments of correlation between SMI and CVMI status of hand wrist and cervical vertebrate at 10, 11 and 12 years of age for the whole sample. It shows a 100% correlation between SMI and CVMI scores at 10 and 11 years of age and 76% at 12 years of age.

The [Table - 5] shows percentage of similar and dissimilar assessments of correlation between the SMI and CVMI scores of hand wrist and cervical vertebrae as assessed by patient age for males and females. There is a 100% correlation in males as well as females at 10 and 11 years of age and a 100% of correlation in males at 12 years of age but only 76% of correlation in females at 12 years of age, indicating that maturity indicators are less reliable for females during the later stages of growth than during the initial stages.


   Discussion Top


Knowledge of maturation status of a child plays an important role in the diagnosis, treatment planning and eventual outcome of the treatment.

Skeletal maturity among all is the most commonly used index in routine clinical work and is closely related to the sexual and somatic maturity.[3] The present study was undertaken with the aim to check the validity of cervical vertebrae as maturity indicators in adolescents of Yamuna Nagar. Every person matures on an individual schedule and it is here that the value of skeletal age becomes apparent.[4] An age group of 10-12 years was chosen because males and females have their maximum circumpubertal growth spurt during this period.[5] Adolescent spurt has been recognized as an extremely active period of accelerated growth.

On an average, pubertal growth spurt begins at the age of 10 years in girls and 12 years in boys; so the total sample was segregated into males and females and the age range selected was 10-12 years because this pubescent period offers the best opportunity to accomplish the objectives of orthodontic treatment in the shortest time.[6]

Hand wrist radiographs, although the most standardized method to evaluate skeletal maturation, are being criticized because of

a. Additional radiation exposure and expense to the patient[1],[7]

b. Regions of the skeleton differ in their development; hand wrist is a small component of the skeletal system and may not always be representative[8]

c. The interpretation from the hand wrist radiographs gives a general idea about the amount of growth and not about the direction of growth[8]

To overcome the disadvantages of hand wrist radiographs, mainly the additional exposure to the patient, researchers diverted their mind to determine skeletal maturation from those clinical records that are routinely used for orthodontic diagnosis and treatment planning. The most commonly used diagnostic record is the lateral cephalogram.

The first seven cervical vertebrae in the spinal column constitute cervical spine. The first two, namely,  Atlas More Details and axis, are quite unique; and the third through seventh have great similarity.[9] Maturational changes can be observed in these vertebrae from birth to full maturity. These anatomical changes of cervical vertebrae observed on lateral cephalogram have been used to determine skeletal maturity.

Lamparski was the first to use cervical vertebrae as indicators for skeletal maturation. Cervical vertebrae C2 to C6 were used in this study. Since these vertebrae were already recorded in the routine lateral cephalogram, there was no need for additional radiographic exposures.

Use of thyroid collar blocks 5th and 6th cervical vertebrae out of radiograph images. This disadvantage was overcome by Hassel and Farman.[1] They used only the 2nd, 3rd and 4th cervical vertebrae, which can be visualized even with the use of thyroid collar.

The present study combines the observations of changes in the bones of hand wrist and changes in the cervical vertebrae during skeletal maturation. The shapes of cervical vertebrae were seen to differ at each of the skeletal developments. This provided a means to determine skeletal maturity of an individual and thereby determine whether the possibility of potential growth existed.

The CVMI gives the percentage of growth remaining. The shapes of vertebral bodies of C3 and C4 changed from wedge shaped to rectangular to square to 'greater in dimension vertically than horizontally,' as skeletal maturity progressed. The inferior vertebral borders are flat when immature and become concave when mature. When two successive SMI and CVMI groups were combined, it was observed that distinct cervical vertebrae anatomic characteristics were unique to each of their groupings. Eleven SMI groupings were condensed to six SMI groupings.[3]



Cervical vertebrae maturation was correlated with various stages of development in hand wrist bones. According to SMI score of Fishman, every subject was individually analyzed with reference to skeletal maturation of both hand wrist and cervical vertebrae and with reference to chronological age, sex and percentage of growth completed according to SMI.

The percentages of similar and dissimilar assessments at different age groups for males and females were determined, there is a 100% correlation at ages 10 and 11 years and 76% correlation for females. It suggests that skeletal maturity indicators are less reliable for females as compared to males, which has also been reported by Bambha and Natta.[10]

Certain treatment can be planned according to the above values - for example, twin block can be planned at or just after peak growth velocity, CVMI stage 3 and 4.[11] Ideal time to initiate orthopedic expansion is during the early maturation stage of CVMI 1 to 2.[12]. Orthognathic surgery should be planned at or after CVMI 6.[4] From all the above findings, it can be seen that cervical vertebrae can be used as maturation indicators with the same confidence as hand wrist radiographs. Neither the chronological age nor the stages of dental development are reliable in helping to establish the child's stage of skeletal development.

It might be better and would permit a more objective diagnostic evaluation if skeletal age is considered as a basis to help formulate a treatment plan. Cervical vertebrae have the same potential as hand wrist radiographs for determining the skeletal maturation of an individual, thus protecting the patient from an additional radiographic exposure.

The values were tabulated and subjected to statistical analysis and the following conclusions were drawn from the study.

  1. Wide variation in chronological age for different maturity levels suggests that chronological age is a poor indicator of maturity. Skeletal maturity indicators provide a more valid basis than chronological age for growth status of individuals.
  2. Females are ahead of males at all levels of skeletal maturity, indicating early age of maturational development for females.
  3. Females tend to achieve higher percentage of their growth than males, especially during the age of 11-12 years. At 10 years of age, there is very less variation in the percentage of growth completed in males and females.
  4. Cervical vertebrae developmental changes are same for males and females but females develop the changes earlier.
  5. Skeletal maturity indicators are less reliable for females as compared to males during the 12th year of age.
  6. Maturation indicators of brief duration are more informative than those of longer duration.
  7. Skeletal maturation being a continuous process is categorized by distinct events in continuum; so it is difficult to differentiate borderline cases.
  8. There is no significant difference between the two techniques of evaluation. This shows that cervical vertebrae can be used with the same confidence as the hand wrist radiographs to evaluate skeletal maturity, thus avoiding the need for an additional radiograph.


 
   References Top

1.Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod Dentofac Orthop 1995;107: 58-66.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Fishman LS. Maturational patterns and prediction during adolescence. Angle orthod 1987;57:178-93.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Revelo B, Fishman LS. Maturational evaluation of ossification of the midpalatal suture. Am J Orthod Dentofac Orthop 1994;105:288-92.  Back to cited text no. 3  [PUBMED]  
4.Fishman LS. Radiographic Evaluation of skeletal maturation. A clinically oriented method based on hand wrist films. Angle Orthod 1982;52:88­112.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Bambha JK, Natta PV. Longitudinal study of facial growth in relation to skeletal maturation during adolescence. Am J Orthod 1963;49:481-93.  Back to cited text no. 5    
6.Mitani H, Sato K. Comparison of mandibular growth with other variables during puberty. Angle Orthod 1992;62:217-23.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Garcia Fernandez P, Torre H, Flores L, Rea J. The cervical vertebrae as maturational indicators. J Clin Orthod 1998;32:221-5.  Back to cited text no. 7    
8.Smith RJ. Misuse of handwrist radiographs. Am J Orthod 1980;77:75-8.  Back to cited text no. 8  [PUBMED]  
9.Franchi L, Baccetti T, McNamara Jr. Mandibular growth as related to cervical vertebral maturation and body height. Am J Orthod Dentofac Orthop 2000;118:335-40.  Back to cited text no. 9    
10.Bambha JK, Natta PV, Longitudinal study of facial growth in relation to skeletal maturation during adolescence. Am J Orthod 1963;49:481-93.   Back to cited text no. 10    
11.Baccetti T, Franchi L, Ratner LT, McNamara JA Jr. Treatment timing for twin block therapy. Am J Orthod Dentofac Orthop 2000;118:159­78.  Back to cited text no. 11    
12.Suda N, Suzuki MI, Hirosa K, Hiyama S. Effective treatment plan for maxillary protraction. Is bone age useful to determine the treatment plan? Am J Orthod Dentofac Orthop 2000;118:55-62.  Back to cited text no. 12    


    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10], [Figure - 11], [Figure - 12], [Figure - 13], [Figure - 14], [Figure - 15], [Figure - 16], [Figure - 17], [Figure - 18]

    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4], [Table - 5]


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