2020, Number 4
Stages of digito-palmar bone maturation in patients of the Clínica de Ortodoncia de la Universidad de Ixtlahuaca compared to the criteria established by Björk, Grave and Brown, from August 2016-July 2018
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ABSTRACT
A descriptive and cross-sectional study was carried out, the objective was to compare the stages of digito-palmar bone maturation according to the criteria established by Björk, Grave and Brown, in patients attending the Orthodontic Clinic of Universidad de Ixtlahuaca CUI, in the period of August 2016 to June 2018. A sample of 202 hand-wrist radiographs of patients aged 6 to 12 years was studied. The stages of bone maturation were determined through the method of Björk, Grave and Brown by radiographic analysis and analysis by age. Finally, it was concluded that in the evaluation of the growth potential presented by myofunctional orthopaedic patients, the hand-wrist radiography is irreplaceable by dentoalveolar or orthopantomographic radiographies, since it allows an assertive diagnosis and a complete measurement of skeletal ossification.INTRODUCTION
The historical background of radiology dates back to the 19th century. Wilhelm Conrad Röntgen who was a physicist and chemist (1845 to 1923) discovered X-rays on 8 November 1895. The first pioneer who devoted himself to the use of X-rays as an indispensable part of clinical analysis was Edmund Kell and also the one who took the first dental radiography.1
Subsequently, various techniques were developed, such as digito-palmar radiography, which briefly consists of placing the palm of the untrained hand against the cassette containing the film, with the fingers apart and without flexing them. The patient should be protected with a 2 mm thick lead apron (according to NOM-229). The distance from the focal point to the film is 75 cm.1,2
In order to describe radiographic projections, it is necessary to have a detailed understanding of the structure of the anatomy of the hand and fingers. The skeletal anatomy of the hand consists of 27 bones in total, classified as follows: eight carpal bones, five metacarpal bones and fourteen phalanges (Figure 1).3 In clinical orthodontics, measurement of physical development and assessment of skeletal age is relevant.4
The hand-wrist radiograph analysis of the Björk, Grave and Brown method describes the ossification characteristics detected at the level of the phalanges, carpal bones and radius (biological age), together with the chronological age analysis, as shown in the anatomy of the skeleton of the hand between 8 and 18 years of age.5
From the analysis of the hand radiograph (Figure 2), the nine stages of maturation according to Björk, Grave and Brown consist of:
- • Phase I: of waiting. First stage: the epiphysis of the proximal phalanx of the index finger (PP2=) shows the same width as the diaphysis. Second stage: the epiphysis of the second phalanx of the middle finger (MP3=) shows the same width as the diaphysis.
- • Phase II: acceleration. Third stage: it is assessed according to three ossification characteristics. Stage Pisi, visible ossification of the pisiform bone; stage H1, ossification of the hook of hamate bone; stage R=, equivalent width of the epiphysis and diaphysis of the radius. Fourth stage: S, visible ossification of the sesamoid bone; H2, advanced ossification of the hook of hamate bone.
- • Phase III: maximum pubertal growth. Fifth stage: stage MP3cap, the epiphysis surrounds the diaphysis like a cap at the level of the second phalanx of the middle finger. Stage PP1cap, the epiphysis surrounds the diaphysis like a cap at the proximal phalanx of the thumb. Stage Rcap, the epiphysis surrounds the diaphysis like a cap on the radius.
- • Phase IV: decreasing. Sixth stage: DP3u, visible fusion of the epiphysis and diaphysis of the distal phalanx of the middle finger. Seventh stage: PP3u, visible fusion of the epiphysis and diaphysis of the proximal phalanx of the middle finger. Eighth stage: MP3u, visible fusion of the epiphysis and diaphysis of the middle phalanx.
- • Phase V: end of growth. Ninth stage: Ru, complete ossification of the epiphysis and diaphysis of the radius.
The three stages of growth and development of the phalanges are assessed according to the ratio of the epiphysis to the diaphysis, as shown below.
- • First stage: the epiphysis is the same width as the diaphysis. It begins approximately three years before the pubertal growth spurt.
- • Second stage: cap stage, where the epiphysis surrounds the diaphysis like a cap. It coincides with the maximum pubertal growth spurt, and corresponds to the 5th stage of maturation of the skeleton of the hand.
- • Third stage: U stage (u = union) where the epiphysis ossifies with the diaphysis. It signifies the completion of the pubertal growth spurt and corresponds to the 6th, 7th, 8th and 9th stage of hand maturation.5
Table 1 shows the relationship of the ossification stages of hand bones and bone age as in Figure 2, for the period from 8 to 18 years of life. Mean values, according to age, are given for boys and girls.5 Table 2 was designed according to the needs of the present project, showing the relationship of the ossification stages of hand bones and bone age, in the period from 8 to 18 years of age.
MATERIAL AND METHODS
A descriptive, cross-sectional study was carried out. The data came from the population of patients aged 6 to 12 years who attend dental consultations at the Orthodontic Clinic of the of Universidad de Ixtlahuaca CUI (UICUI), in the municipality of Ixtlahuaca de Rayon. The hand-wrist radiographs were used from patients who were seen in the period August 2016 to June 2018, which were in the clinic's integrated clinical record.
As for the selection criteria, patient records were included if they were between 6 and 12 years of age, clinical records with a history of trauma in the carpal region were excluded, and clinical records without carpal radiographs were eliminated. The study variables were age, sex and stages of bone maturation.
The comparison study had the following specific objectives:
- 1. According to our design, to obtain the index of bone maturation stages according to Björk, Grave and Brown's criteria.
- 2. To compare bone maturation through digito-palmar radiography of each patient attending the UICUI by age and sex in relation to the established criteria.
- 3. To illustrate each of the stages of bone maturation for their individual identification and description.
- 4. To establish the ideal age for starting myofunctional orthodontics treatment in growing patients who come to the UICUI. From the skeletal age of the fourth stage of bone maturation.
RESULTS
The sample consisted of a total of 202 digito-palmar radiographs, of which 90 were male and 112 female. The research carried out was a comparative study of the stages of digito-palmar bone maturation according to the criteria established with the method of Björk, Grave and Brown, applied to patients attending the UICUI, in the period from August 2016-June 2018.
The index of the nine stages of bone maturation was obtained according to the criteria of Björk, Grave and Brown. In addition, it was established that the ideal age for starting myofunctional orthodontics treatment is from the skeletal age of the fourth stage of bone maturation.
The tables are presented by sex and show the radiographic analysis by stage of bone maturation (biological age) and the analysis by age (chronological age), where similar results are observed. Figure 3 shows female patients in the waiting phase and stage 5o. On the other hand, the male sex has no similar behaviour in any stage of maturation as shown in Figure 4.
DISCUSSION
In the field of dentistry, orthopaedics is concerned with the correction of malocclusions at an early age, in relation to tooth discrepancy and positioning. Some treatments are favoured if they are carried out when the individual is close to the type of growth and at a certain stage of development. Therefore, it is important to reliably determine the bone age, which will provide data to act appropriately and ensure the success of the treatment.6,7
The importance of our study lies in comparing a population with the criteria established by Björk, Grave and Brown,5 and identifying an ideal age for initiating myofunctional orthodontics treatment in patients aged 6 to 12 years.
Bone age is an indicator that allows a more accurate estimation of the maturation of the individual, and previous reports have indicated the use of the ossification patterns of various skeletal elements to establish it.
Chronological age is not an adequate indicator of maturation, but bone age calculated with Hand-Wrist Radiograph provides the necessary information to determine growth disturbances in the individual. Because there are a large number of ossification centres, it is important to understand and interpret the age of the bone.
Dental age, like bone age, acts as an index of biological maturation by assessing the eruption and degree of tooth germ formation through orthopantomography. The two aforementioned indicators mark the beginning of the pubertal thrust, when it peaks as well as when it declines.6,8-10 This is how we can speak of a growth rhythm, which establishes the prepubertal growth spurts depending on sex and varies in relation to chronological age. That is, such variations determine the speed and duration of the growth process.5 Generally, pubertal growth spurt begins in females between the ages of 10 and 12 years, and in males between the ages of 12 and 14 years. Our study demonstrates the evident growth spurt, in female patients it occurs at the correct ages or before the established parameters, while in male patients it occurs later.
We found that, out of 42 females, 26 of them, corresponding to 61%, are above the growth spurt. On the other hand, out of seven men, one of them corresponds to 14%, which gives a parameter below the growth spurt with a variation margin of 3-6 years.
A deviation of ± 2 years between chronological age and biological age is required in order to speak of growth disorders,5 and our results are in line with this standard deviation.
The actual criteria for assessing bone development are: 1) growth in a given unit of time and 2) development to maturity.
For each site, a series of recognisable ossification phases is established. The ossification centres are observed and compared until the standard that most closely resembles the radiograph is found.5,11
The ideal age for starting myofunctional orthodontics treatment is achieved at the fourth stage of digito-palmar bone maturation, i.e. it is reached shortly before or at the beginning of the pubertal growth spurt.12 Following the criteria established by the method of Björk, Grave and Brown, where stage characteristics are presented:
- S: beginning of mineralisation of the ulnar sesamoid bone of the thumb metacarpophalangeal joint.
- H2: advanced ossification of the Hook of hamate bone.
In our results there is an age difference, with the fourth stage of maturation occurring between 6 and 12 years of age in male and female patients.
CONCLUSIONS
In the evaluation of the growth potential of myofunctional orthodontics patients, the hand-wrist radiograph is irreplaceable for dentoalveolar (intraoral) radiography or orthopantomography, as it allows from an assertive diagnosis to a complete measurement of skeletal ossification.
Our study shows the importance, whether for the specialist teacher, the student or the general dentist, of having basic knowledge about growth and development of the individual because the specific needs of each patient can be observed using bone age.
There are maturation indicators (stages of the Björk, Grave and Brown method) in the bones of the hand that provide a reliable method when performing radiographic analysis, which estimate skeletal age and provide a diagnosis for the appropriate treatment plan.
The research shows that the female sex from the age of six years presents early bone maturation, and the male sex from the age of 11 years presents late bone maturation. Among the factors that modify bone maturation are: growth, development, hormone secretion, menarche, nutrition, secondary sexual characters, among others. Similarity was found with Björk, Grave and Brown, who determine that the first stage of bone maturation is from 8.1 years of age in the female sex, and in the male sex at 10.6 years of age.
Our research work seeks to promote both the sense of prevention to correct malocclusions and the measurement through the relationship tables. We propose our design by stage and age, because it allows us to decide whether or not the patient can use interceptive orthodontics or functional orthopaedics treatment; it also allows for follow-up despite the limitations of chronological age.
Discovering the needs of each person according to the lifestyle and environment that surrounds them, feeds back into the comparison of the criteria established by Björk, Grave and Brown applied to the patient population of the Universidad de Ixtlahuaca CUI by type of race, ethnicity, culture and environmental factors.
REFERENCES
Diario Oficial de la Federación. Secretaría de Salud. Norma Oficial Mexicana NOM-229-SSA1-2002, Salud ambiental. Requisitos técnicos para las instalaciones, responsabilidades sanitarias, especificaciones técnicas para los equipos y protección radiológica en establecimientos de diagnóstico médico con rayos X [Internet]. Disponible en: http://www.dof.gob.mx/nota_detalle.php?codigo=4931612&fecha=15/09/2006
Bastardo R, Figueroa A, Rueda V, Ortiz M, Quirós O, Farías M et al. Correlación entre edad cronológica y edad ósea – edad dental en pacientes del diplomado de ortodoncia interceptiva, UGMA 2007. Revista Latinoamericana de Ortodoncia y Ortopedia. 2009. Disponible en: https://www.ortodoncia.ws/publicaciones/2009/art-27/
Rodríguez CEC, Quirós O, Farias M, Rodón S, Lerner H. Grado de concordancia entre la edad carpal y edad cronológica de ocho pacientes estudiados en el diplomado de ortodoncia interceptiva de la Universidad Gran Mariscal de Ayacucho (UGMA), del año 2006. Revista Latinoamericana de Ortodoncia y Ortopedia. 2007. Disponible en: https://www.ortodoncia.ws/publicaciones/2007/art-13/
AFFILIATIONS
1 Licenciatura en Cirujano Dentista. Universidad de Ixtlahuaca CUI. México.
2 Especialista en Ortodoncia de la Universidad Autónoma del Estado de México. Licenciatura en Cirujano Dentista. Universidad de Ixtlahuaca CUI. México.
3 Maestro en Ciencias Odontológicas. Investigador, Instituto de Investigación y Estudios en Salud. Profesor de la Licenciatura en Cirujano Dentista. Universidad de Ixtlahuaca CUI. México.
4 Maestra en Educación y Administración Escolar. Profesor de la Licenciatura en Cirujano Dentista. Universidad de Ixtlahuaca CUI. México.
CORRESPONDENCE
Edith Velázquez Velázquez. E-mail: edith7592@hotmail.comReceived: Septiembre 2019. Accepted: Abril 2022.