|Year : 2018 | Volume
| Issue : 6 | Page : 482-487
|Assessment of skeletal age using hand-wrist radiographs following Bjork system
Hayder A Hashim, Hussain Mansoor, Mohamed H. Hashim Mohamed
Division of Orthodontics, Department of Dentistry, Hamad Medical Corporation, Doha, Qatar
|Date of Submission||01-Sep-2018|
|Date of Acceptance||23-Sep-2018|
|Date of Web Publication||14-Nov-2018|
Prof. Hayder A Hashim
Department of Orthodontics, Hamad Dental Center, P.O. Box 3050, Doha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The knowledge of the skeletal maturation and the stage of the growth of the patients seeking orthodontic treatment are of great value in planning efficient orthodontic therapy. However, different craniofacial structures of patient show variation in growth potential. The routine use of hand-wrist radiograph for growth prediction exposes the patient to extra radiation. Cervical vertebrae in the lateral cephalograph have been recommended as an alternative method. The pubertal growth spurt is a vital period in the orthodontic treatment and should be kept in mind when planning orthodontic treatment in growing children. One of the main objectives of taking hand and wrist radiograph is to determine the amount of growth and get used of it in patients with skeletal discrepancy during adolescence. Further, this will help in the selection of the appliances required, the course of the treatment and the retention after active orthodontic therapy.
Keywords: Bjork system, cervical vertebrae, hand wrist radiograph, skeletal maturation
|How to cite this article:|
Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prevent Communit Dent 2018;8:482-7
|How to cite this URL:|
Hashim HA, Mansoor H, Mohamed MH. Assessment of skeletal age using hand-wrist radiographs following Bjork system. J Int Soc Prevent Communit Dent [serial online] 2018 [cited 2019 May 22];8:482-7. Available from: http://www.jispcd.org/text.asp?2018/8/6/482/245403
| Introduction|| |
The orthodontist deals with growing children and nongrowing adults. Most of the information concerning growth are obtained from cephalography and hand and wrist radiograph. Greulich and Pyle have published Atlas More Details of hand and wrist radiographs of normal healthy children from birth to adulthood, at every 3-month interval. This atlas serves to compare and indicate the skeletal age of the patient. The developmental stage of a child can be determined from several parameters such as height, weight, chronological age, secondary sexual characteristics, skeletal age, and dental age. However, skeletal age has been considered the most reliable method to assess the developmental status.,
Skeletal age is an indicator of physiological development and is distinct from the chronological age. The appearance and union of the different skeletal centers of ossification follows a pattern and schedule from birth to maturity. The radiographic assessment of the bone provides a valuable criterion of an individual's osseous maturation and is referred as the skeletal age. The chronological age of a child may be accelerated of decelerated due to the individual variation of the timing of pubertal growth spurt. Hence, chronological age cannot be considered as a reliable indicator for the evaluation of the maturity status of a child. Thus, biological age or physiological age was considered. Dental age estimation is based on the rate of development and calcification of tooth buds and the progressive sequence of their eruption in the oral cavity. Several methods have been developed to assess the dental age according to the degree of calcification observed in permanent teeth.,, The relationship among the chronological, dental, and skeletal ages is important in diagnosis and treatment. Further, variations of dental and skeletal ages from known chronological age indicate changes in the standard growth pattern.
The hand and wrist radiograph help in estimating the skeletal age of bone for determining the physical maturation status of the child. The bone age is of great help to the orthodontist in coordinating the orthodontic therapy with the growth process. The idea of using hand and wrist radiograph for determining the skeletal age is that; the skeleton in hand and wrist region is made of several small bones; 27 small bones, distal ends of long bones radius and ulna. The development of these bones from the appearance of calcification centers to epiphyseal plate's closure occurs throughout the entire postnatal growth period and therefore provides a useful means of assessing skeletal maturity.,
Growth prediction can be estimated utilizing physiological parameters which include the peak of the growth velocity in standing height, pubertal markers, dental development, and radiological finding of skeletal maturation. It was reported that the evaluation of skeletal maturation with the help of radiographs is considered to be the more reliable approach. The most preferred method is the use of hand-wrist radiographs.,,, The use of hand-wrist radiographs to examine skeletal maturity has been criticized as the patient is exposed to additional radiation. Therefore, analysis of the cervical spine or of the frontal sinus on lateral cephalographs was recommended as an alternative method. However, these methods do not give a precise prediction of how much growth left. The hand-wrist radiograph is commonly used for skeletal developmental assessment., The Atlas of Greulich and Pyle is the most frequently used method to evaluate skeletal age from hand-wrist radiographs. Furthermore, the changes in the epiphysis of the middle phalanx of the third finger (MP3) follow an orderly sequence. Hägg and Taranger studied pubertal growth from the stages of ossification of the middle phalanx of the third finger of the hand (MP 3 stages).
In orthodontic treatment planning, knowledge of facial growth velocity, and percentage of facial growth remains as a very important factor for effective growth modification interventions. On the other hand, skeletal maturation staging from the radiographic analysis is a widely used approach to predict the timing of pubertal growth, to estimate growth velocity, and to estimate the proportion of growth remaining. The beginning of ossification of adductor sesamoid has been advocated by some authors as a reliable indicator of the onset of puberty., Other investigators have stated that the appearance of the hook of hamate and the pisiform bone is also a good indicator of the onset of puberty., Ghai et al. concluded that hand, wrist and distal epiphysis of the radius and the ulna present a great number of secondary centers of ossification on the whole, and they can reproduce in a single radiograph. For this reason, they are often chosen as study centers when it is thought to determine the state of skeletal maturation, although other centers of ossification of secondary epiphysis can be used, such as the elbow and the tarsal bones. Some authors, have stressed the use of the hand radiographs to define the specific indicators of the spurt of pubertal growth. Comparison between the cervical vertebra and hand-wrist was used in other studies.,,,
The purpose of hand and wrist radiograph analysis is to determine parameters such as patient's skeletal age, the amount of growth left and to determine whether to use functional appliance or to wait until growth ceased and performed extraction or surgery. Bjork and Helm used four stages of bone maturation, all found at five anatomical sites located on the thumb, second finger, third finger, and radius. However, eight discrete adolescent skeletal maturity indicators covering the entire period of adolescent development are found on these five sites [Figure 1] and [Figure 2]. On the other hand, Fishman used eleven indicators covering the entire period of development. The sequence of ossification progresses through four stages; A-Width of the epiphysis equal to the width of the Diaphysis. B-Sesamoid ossification (small calcified bone at the Thumb) C-Capping Stage. D-Fusion stage. The objective of this review is to give an overview of the current methods of skeletal age assessment and to highlight the simple method of hand-wrist radiograph as an indicator using Bjork system.
| Materials and Methods|| |
Hand and wrist radiograph
The skeleton of the hand and wrist is made of the following [Figure 2]:
- Distal ends of long bones of the forearm (radius and ulna)
The main components of hand and wrist are as follows:
- Joint between radius and navicular (Scaphoid) bones (radiocarpal joint)
- Joint between the trapezium and first metacarpal bones (carpometacarpal joint)
- 3. First metacarpophalangeal joint
- Interphalangeal joint of the thumb
- Proximal interphalangeal joint
- Middle inter-phalangeal joint
- Distal interphalangeal joint.
Each phalange consists of epiphysis and diaphysis. The development of the epiphysis and diaphysis of growing child not only differs in the timing of the maturational events (width, ossification, capping, and fusion [Figure 3] but also in the sequence of these events. On the other, the development stage has considerable influence on orthodontic diagnosis and treatment planning.
In Bjork system, the developmental maturity indicators are in the following order [Figure 4]:
|Figure 4: Skeletal maturity indicators according to Bjork. (a) Epiphysis equal in width to diaphysis second finger (b) Epiphysis equal in width to diaphysis third finger (c) Appearance of adductor sesamoid of the thumb (d) Capping in the middle of third finger (e) Fusion of epiphysis and diaphysis in the distal of third finger (f) Fusion of epiphysis and diaphysis in the proximal of third finger (g) Fusion of epiphysis and diaphysis in the middle of third finger (h) Fusion of the radius|
Click here to view
- Width of epiphysis as wide as diaphysis located at:
- Proximal phalanx of the second finger (PP2)
- Middle phalanx of the third finger (MP3) [Figure 4]a and [Figure 4]b.
- Ossification of adductor sesamoid located at the thumb(S)
- Capping of epiphysis located at a-, middle phalanx of the third finger (MP3 Cap) [Figure 4]d
- Fusion of epiphysis and diaphysis located at
- Distal phalanx third finger fusion (DP3F)
- Proximal phalanx third finger fusion (PP3F)
- Middle phalanx of third finger fusion (MP3F)
- Radius (R), [Figure 4]e,[Figure 4]f,[Figure 4]g,[Figure 4]h.
Following the diagram in [Figure 5] and [Figure 6], the skeletal age can be determined. The following steps should be followed depending on the presence of the Sesamoid Bone (S) in the hand and wrist radiograph to determine the skeletal maturity stage in hand and wrist radiograph.
|Figure 6: Determination of the skeletal maturity stage from hand and wrist radiograph|
Click here to view
The first step is to look for both the Sesamoid bone (S) and fusion of the epiphysis and diaphysis of the third finger at the distal site (DP3F).
The second step: If the Sesamoid bone (S) is not present. Look for the width of the epiphysis and diaphysis of the proximal phalanx of the second finger (PP2). If they are equal, then look for the width of the epiphysis and diaphysis in the middle of the third finger (MP3). If they are not equal, then the patient is in (PP2) stage, but if they are equal, then the patient is in (MP3) stage.
The third step: If the Sesamoid bone (S) is present look at the third finger in the distal site, if there is fusion or not?
- If there is no fusion between the epiphysis and diaphysis, then the patient in the capping stage (MP3Cap) stage
- If there is fusion in the distal site and no fusion in the proximal and middle site of the third finger, then the patient is in (DP3F)
- If there is fusion in the distal site, then look at the proximal site of the third finger and also at the middle site, if there is no fusion in the middle site, then the patient is in the (PP3F) stage
- However if there is fusion in the distal and proximal and middle sites of the third finger but no fusion in the radius, then the patient is in the (MP3F) stage
- If there is fusion in the radius bone, then the patient is in Radius stage (R) where most of the growth was utilized.
| Discussion|| |
Understanding the growth of the oro-facial region is important when planning orthodontic treatment. Skeletal maturation is an integral part of individual patterns of growth and development. Variation in the maturation status is closely associated with deviation in the timing and magnitude of growth. Due to individual variation in timing, duration, and velocity of growth, skeletal age assessment is essential in formulating viable orthodontic treatment plans. Clinical decisions regarding the use of extra-oral traction forces, functional appliances, extraction versus nonextraction treatment or orthognathic surgery are at least based on growth considerations.
Every growing child matures differently and several methods were proposed as maturity indicators. Among these are the chronological age; dental eruption; dental calcification stages;,,, Hand and wrist, as well as the height; weight; sexual maturation; Frontal sinus; and the Cervical vertebrae; and recently biomarkers. Bacettee et al. and other researchers, introduced the cervical vertebral maturation method [CVM]). This method has gained popularity in recent years. The method is based on the morphological characteristics of the cervical vertebrae at different developmental stages. These stages are correlated with different growth rates in facial structures. Further, the CVM method cover the entire circumpubertal period for both genders by covering all significant phases in craniofacial growth during adolescence and young adulthood. It is important to identify the maximum growth spurt in growing child.
Hand and wrist radiographic examination can give accurate bone age (skeletal age) picture. The hand and wrist were used because it is easy to locate the different developmental stages and ossification centers which will give accurate skeletal age compared to chronological age as it is frequently accelerated or decelerated and it is technically simple to make radiograph. Every method mentioned above has its own advantages, disadvantages, and limitation over the other methods. However, more research is needed to find the best method to assess the maturity of subjects seeking orthodontic treatment. This review presents details of the hand and wrist method introduced by Bjork which is simple and easy to use with minimal radiographs.
| Conclusion|| |
The knowledge of the growth and skeletal maturation stage of the orthodontics patients are of great value for selecting the efficient orthodontic therapy. However, different craniofacial structures of patient show variation in growth potential. The routine use of hand-wrist radiographs for growth prediction exposes the patient to additional radiation. Evaluation using lateral cephalographs has been recommended as alternative method. The pubertal growth spurt is a vital period in the orthodontic treatment and should be kept in mind when planning orthodontic treatment in growing children. One of the main objectives is to make use of growth in patients with skeletal discrepancy during adolescence. This will influence the selection of the appliances, the course of the treatment and the retention after the therapy.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Greulich WW, Pyle SI, Todd TW. Radiographic Atlas of Skeletal Development of the Hand and Wrist. Stanford: Stanford University Press; 1959.
Björk A, Helm S. Prediction of the age of maximum puberal growth in body height. Angle Orthod 1967;37:134-43.
Rajagopal R, Kansal S. A comparison of modified MP3 stages and the cervical vertebrae as growth indicators. J Clin Orthod 2002;36:398-406.
Boeyer ME, Sherwood RJ, Deroche CB, Duren DL. Early maturity as the new normal: A century-long study of bone age. Clin Orthop Relat Res 2018. DOI: 10.1097/CORR.0000000000000446.
Macha M, Lamba B, Avula JS, Muthineni S, Margana PG, Chitoori P, et al.
Estimation of correlation between chronological age, skeletal age and dental age in children – A cross-sectional study. J Clin Diagn Res 2017;11:ZC01-4.
Baccetti T, Franchi L, De Toffol L, Ghiozzi B, Cozza P. The diagnostic performance of chronologic age in the assessment of skeletal maturity. Prog Orthod 2006;7:176-88.
Mincer HH, Harris EF, Berryman HE. The A.B.F.O. Study of third molar development and its use as an estimator of chronological age. J Forensic Sci 1993;38:379-90.
Olze A, Taniguchi M, Schmeling A, Zhu BL, Yamada Y, Maeda H, et al.
Studies on the chronology of third molar mineralization in a Japanese population. Leg Med (Tokyo) 2004;6:73-9.
Maber M, Liversidge HM, Hector MP. Accuracy of age estimation of radiographic methods using developing teeth. Forensic Sci Int 2006;159 Suppl 1:S68-73.
Bala M, Pathak A, Jain RL. Assessment of skeletal age using MP3 and hand-wrist radiographs and its correlation with dental and chronological ages in children. J Indian Soc Pedod Prev Dent 2010;28:95-9.
] [Full text]
De Sanctis V, Di Maio S, Soliman AT, Raiola G, Elalaily R, Millimaggi G, et al.
Hand X-ray in pediatric endocrinology: Skeletal age assessment and beyond. Indian J Endocrinol Metab 2014;18:S63-71.
Crowder C, Austin D. Age ranges of epiphyseal fusion in the distal tibia and fibula of contemporary males and females. J Forensic Sci 2005;50:1001-7.
Mohammed RB, Reddy MA, Jain M, Singh JR, Sanghvi P, Thetay AA. Digital radiographic evaluation of hand-wrist bone maturation and prediction of age in South Indian adolescents. Hand (N Y) 2014;9:375-83.
Chapman SM. Ossification of the adductor sesamoid and the adolescent growth spurt. Angle Orthod 1972;42:236-44.
Grave KC, Brown T. Skeletal ossification and the adolescent growth spurt. Am J Orthod 1976;69:611-9.
Houston WJ, Miller JC, Tanner JM. Prediction of the timing of the adolescent growth spurt from ossification events in hand-wrist films. Br J Orthod 1979;6:145-52.
Flores-Mir C, Burgess CA, Champney M, Jensen RJ, Pitcher MR, Major PW, et al.
Correlation of skeletal maturation stages determined by cervical vertebrae and hand-wrist evaluations. Angle Orthod 2006;76:1-5.
Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod Dentofacial Orthop 1995;107:58-66.
Ruf S, Pancherz H. Development of the frontal sinus in relation to somatic and skeletal maturity. A cephalometric roentgenographic study at puberty. Eur J Orthod 1996;18:491-7.
Fishman LS. Radiographic evaluation of skeletal maturation. A clinically oriented method based on hand-wrist films. Angle Orthod 1982;52:88-112.
Koshy S, Tandon S. Dental age assessment: The applicability of Demirjian's method in South Indian children. Forensic Sci Int 1998;94:73-85.
Jiménez-Castellanos J, Carmona A, Catalina-Herrera CJ, Viñuales M. Skeletal maturation of wrist and hand ossification centers in normal Spanish boys and girls: A study using the Greulich-Pyle method. Acta Anat (Basel) 1996;155:206-11.
Hägg U, Taranger J. Maturation indicators and the pubertal growth spurt. Am J Orthod 1982;82:299-309.
Flores-Mir C, Nebbe B, Major PW. Use of skeletal maturation based on hand-wrist radiographic analysis as a predictor of facial growth: A systematic review. Angle Orthod 2004;74:118-24.
Bakerly SD, Saleh F. Correlation of adductor metacarpophalangeal sesamoid ossification stages with dentofacial profile changes. Eur Sci J 2013;9:450-69.
Grave KC. Timing of facial growth: A study of relations with stature and ossification in the hand around puberty. Aust Orthod J 1973;3:117-22.
Fishman LS. Maturational patterns and prediction during adolescence. Angle Orthod 1987;57:178-93.
Ghai O, Paul V, Bagga A. Essential pediatrics. 9th
. Edition. New Delhi India: CBS Publisher and distributors 2018. p. 11.
Hunter CJ. The correlation of facial growth with body height and skeletal maturation at adolescence. Angle Orthod 1966;36:44-54.
Bowden BD. Epiphysial changes in the hand/wrist area as indicators of adolescent stage. Aust Orthod J 1976;4:87-104.
Moorrees CF, Fanning EA, Hunt EE Jr. Age variation of formation stages for ten permanent teeth. J Dent Res 1963;42:1490-502.
Singer J. Physiologic timing of orthodontic treatment. Angle Orthod 1980;50:322-33.
Demirjian A, Buschang PH, Tanguay R, Patterson DK. Interrelationships among measures of somatic, skeletal, dental, and sexual maturity. Am J Orthod 1985;88:433-8.
Kucukkeles N, Acar A, Biren S, Arun T. Comparisons between cervical vertebrae and hand-wrist maturation for the assessment of skeletal maturity. J Clin Pediatr Dent 1999;24:47-52.
Flieger R, Matys J, Dominiak M. The best time for orthodontic treatment for Polish children based on skeletal age analysis in accordance to refund policy of the Polish National Health Fund (NFZ). Adv Clin Exp Med 2018;27:1-6.
De Stefani A, Bruno G, Siviero L, Crivellin G, Mazzoleni S, Gracco A. Middle phalanx maturation of the third finger (MPM) method in the evaluation of skeletal age in a growing orthodontic patient. Int Orthod 2018;16:499-513.
Green LJ. The interrelationships among height, weight and chronological, dental and skeletal ages. Angle Orthod 1961;31:189-93.
Nolla CM. The Development of Permanent Teeth. In: University of Michigan; 1952.
Demisch A, Wartmann P. Calcification of the mandibular third molar and its relation to skeletal and chronological age in children. Child Dev 1956;27:459-73.
Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol 1973;45:211-27.
Demirjian A, Goldstein H. New systems for dental maturity based on seven and four teeth. Ann Hum Biol 1976;3:411-21.
Hägg U, Taranger J. Skeletal stages of the hand and wrist as indicators of the pubertal growth spurt. Acta Odontol Scand 1980;38:187-200.
Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Semin Orthod 2005;11:119-29.
Perinetti G, Baccetti T, Di Leonardo B, Di Lenarda R, Contardo L. Dentition phase and chronological age in relation to gingival crevicular fluid alkaline phosphatase activity in growing subjects. Prog Orthod 2011;12:100-6.
Baccetti T, Franchi L, McNamara JA Jr. An improved version of the cervical vertebral maturation (CVM) method for the assessment of mandibular growth. Angle Orthod 2002;72:316-23.
Soegiharto BM, Moles DR, Cunningham SJ. Discriminatory ability of the skeletal maturation index and the cervical vertebrae maturation index in detecting peak pubertal growth in indonesian and white subjects with receiver operating characteristics analysis. Am J Orthod Dentofacial Orthop 2008;134:227-37.
Caldas Mde P, Ambrosano GM, Haiter Neto F. Computer-assisted analysis of cervical vertebral bone age using cephalometric radiographs in Brazilian subjects. Braz Oral Res 2010;24:120-6.
Szemraj A, Wojtaszek-Słomińska A, Racka-Pilszak B. Is the cervical vertebral maturation (CVM) method effective enough to replace the hand-wrist maturation (HWM) method in determining skeletal maturation? – A systematic review. Eur J Radiol 2018;102:125-8.
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