FaÂzeruÊ stu podle kefalogramu a ortopantomogramu Phases of growth according to cephalogram and OPG

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1 ORTODONCIE rocïnõâk19 FaÂzeruÊ stu podle kefalogramu a ortopantomogramu Phases of growth according to cephalogram and OPG MUDr. Monika Penkova Ortodonticke oddeï lenõâ, stomatologickaâ klinika FN v Hradci Kra loveâ Department of Orthodontics, Clinic of Stomatology, Hradec Kra loveâ Souhrn Studie oveïrïovala vztahy mezi faâ zemi vyâ voje korïene dolnõâho sï picïaâ ku, kostnõâm zraâ nõâm ruky a krcïnõâpaâ terïe. OtaÂzkou je, zda je mozïneâ stanovit faâzi ruê stu jen hodnocenõâm kefalogramu a ortopantomogramu chrupu, bez doplnï u- jõâcõâho snõâmku ruky se zaâpeï stõâm. SnõÂzÏilo by se ozarïovaâ nõâ pacienta a naâ klady na osï etrïenõâ. Una hodneï vybraneâ ho souboru 182 adolescentuê, 53 chlapcuê veveï ku 11,5-15,5 let a 129 dõâvek ve veï ku 10,5-14,5 let bylo hodnoceno kostnõâ zraâ nõâ obratluê C2, C3, C4 na kefalogramech sï esti stadii CVMI metody Hassela a Farmana a na rtgpraveâ ruky podle SMA metody Fishmana. Stadia vyâ voje korïene dolnõâch staâlyâchsï picïaâkuê F, G, H dle Demirjiana byla urcï ena na ortopantomogramech. U chlapcuê lze nahradit rentgen ruky hodnocenõâm vyâ voje dolnõâho sï picïaâ ku na ortopantomogramu a kostnõâho zraâ nõâ krcïnõâpaâ terïe na kefalogramu, protozïe sama o sobeï korelujõâ s kostnõâm zraâ nõâm ruky, ale mezi nimi vzaâ jemnaâ korelace nenõâ, z odhadu kefalogramu nelze odvodit stav zubnõâho vyâ voje a naopak. U dõâvek lze nahradit rentgen ruky hodnocenõâm dolnõâho sï picï aâ ku na ortopantomogramu, ale kostnõâ zraâ nõâ krcï nõâch obratluê na kefalogramu s kostnõâm zraâ nõâm ruky nekoreluje, v vyâ jimkou trïõâ indikaâ toruê, ktereâ se vaâ zïõâ k uâ plneâ mu zacï aâ tku a konci ruê stu. ProtozÏ e nekoreluje kostnõâ zraâ nõâ krcï nõâ paâ terïe a vyâ voj dolnõâho sï picï aâ ku navzaâ jem, nelze z pohledu na jeden ze snõâmkuê usuzovat na stadium zraânõâcïivyâ voje snõâmku druheâho(ortodoncie 2010, 19, cï. 1, s ). Abstract The relationship between the development of the lower canine, bone maturation of hand and cervical spine was studied. The question is whether it is possible to establish the phase of growth using only cephalogram and OPG, without the X-ray of hand and wrist. This would minimize the amount of radiation and costs. In the sample of randomly chosen 182 adolescents (53 boys between 11.5 and 15.5 years of age, and 129 girls between 10.5 and 14.5) we evaluated the bone maturation of C2, C3, C4 vertebras usingsix stages CVMI according to Hassel and Farman in cephalograms, and X-ray of right hand according to Fishman. The stages of lower permanent canines (F, G, H accordingto Demirjian) root development were assessed with the help of OPGs. In boys the X-ray of hand may be substituted with the evaluation of lower canine development in OPG, and skeletal maturation in cephalogram, as they correlate with bone maturation of a hand. However, there is no correlation between the two - cephalogram assessment does not tell us anything about canine development, and vice versa. In girls the X-ray of hand may be substituted with the assessment of canine development in OPG. However, the bone maturation of cervical vertebrae in cephalogram does not correlate with bone maturation of a hand, the only exception being three indicators related to the very beginning and to the very end of growth (Ortodoncie 2010, 19, No. 1, p ). KlõÂcÏ ovaâ slova: stanovenõâ faâ ze ruê stu, kostnõâ zraâ nõâ ruky a paâ terïe, zubnõâ vyâ voj korïene dolnõâch staâ lyâ ch sï picï aâ kuê Key Words: growth phase assessment, bone maturation of hand and cervical vertebrae, dental development of lower permanent canine roots

2 rocïnõâk19 ORTODONCIE U vod V naâ vrhu ortodontickeâ terapie je duê lezïiteâ individuaâ lnõâ zhodnocenõâ biologickeâ ho veï ku kazïdeâ ho pacienta. Ke stanovenõâ faâze ruê stu jsou pouzïõâvaâny ruê zneâ metody, mimo jineâ odhad kostnõâho zraâ nõâ z rentgenuê ruky, hodnocenõâ krcï nõâch obratluê z kefalogramuê a urcï enõâ zubnõâho veï ku na ortopantomogramech. RuÊ st terapii muê zï e podporovat, stejneï jako jikomplikovat cïicï init nevhodnou. Proto maâ velkyâ vyâ znam spolehliveï prïedvõâdat ocï ekaâvanyâ ruê st v jeho intenziteï, cï ase a smeï ru, prognoâza smeïruruê stu je nejvõâce problematickaâ.ruê stovyâ potenciaâ l, to je vesï keryâ, jesïteïocï ekaâ vanyâ ruê st, lze odvodit ze sumace intenzity, kterou lze jesï teï ocï ekaâ vat do ukoncï enõâ ruê stu. Kostnõ veï k pro ortodontickeâ uâcï ely klasifikujeme do neï kolika stadiõâ, kteraâ lze jednodusï e identifikovat, a kteraâ naâ s orientujõâ zejmeâ na o relativnõâm vztahu k pubertaâ lnõâmu ruê stoveâ mu zrychlenõâ a ukoncï enõâ ruê stu. Jednotlive znaky osifikace jsou ve stejneâ m vztahu k intenziteï ruê stu u deïvcï at iu chlapcuê. [1,2]. DospõÂvaÂnõ je obdobõâ charakteristickeâ variabilnõâmi prïõâruê stky kostnõâch zmeï n, ktereâ se vyskytujõâ ve velmirozdõâlneâ m chronologickeâmveï ku, cozï snizï uje validitu veï ku pro identifikaci stadiõâ vyâvoje. Odhad stavu deï tskeâ ho zraâ nõâ pomaâhaâ k lepsï õâmu stanovenõâ optimaâ lnõâ doby pro neï ktereâ typy ortodontickeâ leâcï by. MezijednotlivyÂmideÏ tmije znacïnyâ rozdõâl ve veï ku, kdy dosaâ hnou podobnyâ ch vyâ vojovyâch udaâ lostõâ. NavõÂc konstitucï nõâ rozdõâly v cï asovaâ nõâ zraâ nõâ, nemoci, systeâ moveâ poruchy a zevnõâ faktory mohou ovlivnit fyziologickeâ zraâ nõâ dõâteï te. Akcelerace ruê stu postavy prïedchaâ zõâ faciaâ lnõâ ruê st o puê l azï jeden rok. VeÏ tsï ina autoruê uvaâ dõâ,zïe ruê stovyâ spurt prïichaâ zõâ asirok po objevu adduktoroveâ ho sezamoidu palce [3, 4, 5,6,7,8,10]. Materia l a metodika U naâ hodneï vybraneâ ho souboru 182 adolescentuê, 53 chlapcuê veveï koveâ m rozmezõâ 11,5-15,5 let a 129 dõâ- Introduction In the plan of orthodontic therapy an important role is played by the individual assessment of biological age of each patient. Various methods are employed to establish the growth phase, e.g. estimation of bone maturation of hand (with X-rays of hand), assessment of cervical vertebras using cephalograms, and the determination of lower canine development according to OPGs. The growth may help in treatment; however, it may also complicate or make the treatment inappropriate. Therefore, we have to be able to make a reliable growth prediction in terms of its intensity, duration and direction (the prediction of growth direction is the most difficult). Growth potential, i.e. expected growth, may be deduced from the intensity which can be expected until the growth will be finished. Skeletal age may be classified (for orthodontics) into several stages which should be easily identified, and which provide the information about relative relationship with pubertal growth spurt and the end of growth. Individual symptoms of ossification are in the same relation to the growth intensity both in boys and girls [1,2]. Adolescence is the period characterized by various bone changes which can appear in a different chronological age, and thus the age is not really valid for the identification of growth stages. The assessment of maturation in children helps to determine the optimum time for some types of orthodontic treatment. The children with the similar development are often of a very different chronological age. Moreover, physiological maturation of a child may be affected by different maturation timing, diseases, syndromes, and exogenous factors. The growth acceleration in body build precedes facial growth by six or twelve months. Most authors state that growth spurt starts about one year after the occurrence of adductor sesamoid of thumb [3,4,5,6,7, 8,10]. Tabulka 1: Klasifikace kostnõâho zraâ nõâ ruky podle Fishmana [4] Table 1: Skeletal Maturity Assessment (SMA) according Fishman[4] Skeletal maturity indicators (SMI) I stadium: EpifyÂza dosahuje stejneâ sïõârïky jako diafyâza SMI 1. proximaâ lnõâ cïlaâ nek trïetõâho prstu PP3= SMI 2. prostrïednõâ cïlaâ nek trïetõâho prstu MP3= SMI 3. prostrïednõâ cïlaâ nek paâteâ ho prstu MP5= II stadium: Osifikace SMI 4. ulnaâ rnõâ sesamoid palce S III stadium: CÏ epicï kovaâ nõâ epifyâz SMI 5. distaâ lnõâ cïlaâ nek trïetõâho prstu DP3cap SMI 6. prostrïednõâ cïlaâ nek trïetõâho prstu MP3 cap SMI 7. prostrïednõâ cïlaâ nek paâteâ ho prstu MP5 cap IV stadium D: Spojenõ epifyâz a diafyâz SMI 8. distaâ lnõâ cïlaâ nek trïetõâho prstu DP3u SMI 9. proximaâ lnõâ cïlaâ nek trïetõâho prstu PP3u SMI 10. prostrïednõâ cïlaâ nek trïetõâho prstu MP3u SMI 11. radius Ru 11 SMI indikaâ toruê na 6 mõâstech palce, trïetõâho prstu, paâteâho prstu a kostivrïetennõâ urcï uje 4 stadia zralosti kostõâ. Skeletal maturity indicators (SMI) Stage I: Epiphysis as wide as diaphysis SMI 1. Third finger - proximal phalanx PP3= SMI 2. Third finger - middle phalanx MP3= SMI 3. Fifth finger - middle phalanx MP5= Stage II: SMI 4. Adductor sesamoid of thumb S Stage III: Capping of epiphysis SMI 5. Third finger - distal phalanx DP3cap SMI 6. Third finger - middle phalanx MP3 cap SMI 7. Fifth finger - middle phalanx MP5 cap Stage IV: Fusion of epiphysis and diaphysis SMI 8. Third finger - distal phalanx DP3u SMI 9. Third finger - proximal phalanx PP3u SMI 10. Third finger - middle phalanx MP3u SMI 11. Radius Ru 11 SMI indicators on 6 places of thumb, 3rd and 5th finger and radius show 4 stages of bone development

3 ORTODONCIE rocïnõâk19 Tabulka 2: CVMI klasifikace kostnõâho zraâ nõâ obratluê dle Hassela a Farmana [3] Table 2: CVMI classification of cervical vertebrae maturation according Hassel and Farman [3] Stadium 1 - INICIACE Spodnõ hranice C2, C3 a C4 je rovnaâ.hornõâ hranice je sï ikmaâ zezadu doprïedu, obratle majõâ tvar klõânu OdpovõÂda stadiõâm SMI 1 a SMI 2 Puberta lnõâ ruê st praâveï zacïõânaâ, % pubertaâ lnõâho ruê stu se ocïekaâvaâ Stadium 2 - ZRYCHLENI Spodnõ hranice C2, C3 je konkaâ vnõâ a C4 je rovnaâ. TeÏ la C3 a C4 tvar kvaâ dru horizontaâ lnõâ OdpovõÂda stadiõâm SMI 3 a SMI 4 ZacÏ alo ruê stoveâ zrychlenõâ, bude jesïteï % pubertaâ lnõâho ruê stu. Stadium 3 - ZMEÏ NA ZrÏetelne konkavity na spodnõâ hranici C2 a C3, pocï õânajõâcõâ konkavita na spodnõâ hranici C4.StõÂny teï la obratluê C3 a C4 tvar kvaâ dru horizontaâ lnõâ OdpovõÂda stadiõâm SMI 5 a SMI 6 Prepuberta lnõâ ruê st se zrychluje smeï rem ke spurtu (peak velocity), bude jesïteï % pubertaâ lnõâho ruê stu. Stadium 4 - ZPOMALENI ZrÏetelne konkavity spodnõâ hranice teï l obratluê C2, C3 a C4.Puberta lnõâ ruê st se dramaticky zpomalõâ, % ruê stu ocï ekaâvaâ. StõÂny teï la obratluê C3 a C4 tvar cï tvercuê OdpovõÂda stadiõâm SMI 7 a SMI 8 Stadium 5 - ZRA NI DokoncÏ enõâ zraâ nõâ krcï nõâch obratluê, ale 5-10% ruê stu ocï ekaâvaâ.vyârazneâ konkavity spodnõâ hranice krcï nõâch obratluê C2, C3 a C4.StõÂn teï la obratluê C3 a C4 tvar cï tvercuê. OdpovõÂda stadiõâm SMI 9 a SMI 10 Stadium 6 - UKONCÏ ENI Hluboke konkavity spodnõâ hranice krcï nõâch obratluê C2, C3 a C4. StõÂny teï l obratluê C3 a C4 se vertikaâ lneï prodluzïujõâ OdpovõÂda stadiu SMI 11 RuÊ st je povazï ovaâ n za ukoncï enyâ, minimaâ lnõâ zmeï ny lze ocï ekaâ vat. Tabulka 3: Pozdnõ stadia vyâvoje dolnõâho sïpicïaâ ku F-H podle Demirjiana [12] Table 3: Later stages of lower canine development F-H according to Demirjian [12] Stadium F SteÏ ny drïenï oveâ dutiny tvorïõâ rovnoramennyâ trojuâ helnõâk. KorÏenova deâ lka je stejnaâ, nebo delsï õâ nezï koronaâ rnõâ vyâsï ka Stadium G SteÏ ny korïenoveâ ho kanaâ lku jsou paralelnõâ a apikaâ lnõâ konec je cïaâstecïneï otevrïen Stadium H Apika lnõâ konec korïenoveâ ho kanaâ lku je zcela uzavrïen. Periodonta lnõâ membraânamaâ stejnou sïõârïku podeâ l celeâ ho korïene iapexu. INITIATION Inferior borders of C2, C3, and C4 are flat at this stage. The vertebrae are wedge shaped, and the superior vertebral borders are tapered from posterior to anterior Corresponded to a combination of SMI 1 and 2 Adolescent growth is just beginning and 80% to 100% of adolescent growth is expected ACCELERATION Concavities are developing in the inferior borders of C2 and C3. The inferior border of C4 is flat. The bodies of C3 and C4 are nearly rectangular in shape Corresponded to a combination of SMI 3 and 4 Growth acceleration is beginning at this stage, with 65% to 85% of adolescent growth expected. TRANSITION Distinct concavities are seen in the inferior borders of C2 and C3. A concavity was beginning to develop in the inferior border of C4. The bodies of C3 and C4 are rectangular in shape Corresponded to a combination of SMI 5 and 6 Adolescent growth is still accelerating at this stage toward peak height velocity, with 25% to 65% of adolescent growth expected. DECELERATION Adolescent growth decelerates dramatically at this stage, with 10% to 25% of adolescent growth expected. Distinct concavities are seen in the inferior borders of C2, C3, and C4. The vertebral bodies of C3 and C4 are becoming more square in shape Corresponded to a combination of SMI 7 and 8 MATURATION Final maturation of the vertebrae took place during this stage, with 5% to 10% of adolescent growth expected. More accentuated concavities are seen in the inferior borders of C2, C3, and C4. The bodies of C3 and C4 are nearly square to square in shape Corresponded to a combination of SMI 9 and 10 COMPLETION Deep concavities are seen in the inferior borders of C2, C3, and C4. The bodies of C3 and C4 are square or are greater in vertical dimension than in horizontal dimension Corresponded to SMI 11 Growth is considered to be complete at this stage. Little or no adolescent growth is expected. Stage F The walls of the pulp chamber form an isosceles triangle. The root length is equal to or greater than the crown height Stage G The walls of the root canal are parallel, but the apical end is partially open. Stage H The root apex is completely closed.the periodontal membrane surrounding the root and apex is uniform in width throughout. vek ve veï ku 10,5-14,5 let byly hodnoceny rtg snõâmky z archivu ortodontickeâ ho oddeï lenõâ Kliniky zubnõâho leâkarïstvõâ Fakultnõ nemocnice v Olomouci. Byly hodnoceny vizuaâ lneï a srovnaâ ny s tabelaâ rnõâmia grafickyâmi standardy podle trïõâ nõâzï e uvedenyâ ch metodik. Kostnõ veï k byl hodnocen na rentgenech praveâ ruky a distaâ lnõâ cï aâ stiprïedloktõâ urcï enõâm 11 SMI indikaâ toruê podle SMA Material and method In the randomly chosen sample of 182 adolescents (53 boys between the ages of , 129 girls between the ages of 10.5 and 14.5) the X-rays from the archives of the Department of Orthodontics, Clinic of Dental Medicine, University Hospital in Olomouc, were evaluated. The assessment was visual, and then follo

4 rocïnõâk19 ORTODONCIE metody Fishmana [4] (Tab. 1). Na kefalogramech byla urcï ena stadia osifikace obratluê krcï nõâ paâ terïe u obratluê C2, C3 a C4 metodou CVMI podle metody Hassela a Farmana [3] (Tab.2). Byla urcï ena stadia vyâvoje korïene dolnõâch staâlyâch sïpicïaâkuê F, G, H podle Demirjiana na ortopantomogramech [10] (Tab. 3). Byla zaznamenaâvaâ na zaâ vislost kostnõâho zraânõâ krcï nõâch obratluê CVMI 1-6 a procentuaâ lnõâ hodnoty hodnocenyâ ch indikaâ toruê kostnõâho zraâ nõâ ruky a stadiõâ vyâ voje korïene staâ leâ ho dolnõâho sï pi cï aâ ku. Pro lepsï õâ prïehlednost jednotlivyâch zaâ vislostõâ kostnõâch a zubnõâho veï ku byly v souboru vybraâ ny dle Fishmanova hodnocenõâ jen nejpokrocï ilejsï õâ SMI indikaâ tory zastizï eneâ u jednotlivyâch osob, a ty byly vztazï eny k vyâvojidolnõâho sïpicïaâ ku. DaÂle byly tyto nejpokrocï ilejsï õâ SMI indikaâ tory rozcï leneï ny tak, jak jejich souvislost se stadii CVMI 1-6 popsali Hassel a Farman [3], a byly vztazïeny k vyâvojisïpicïaâ ku. VyÂpocÏty byly provedeny statistickyâ m systeâ mem STATISTI- CA.cz. Jako testovacõâ statistiky byly uzï ity testy FisheruÊ v a chõâ-kvadraâ t dobreâ shody vzïdy na hladineï vyâznamnostip < 0,05. Vy sledky U chlapcuê pro indikaâ tory kostnõâho zraâ nõâ ruky vzhledem ke kostnõâmu zraâ nõâ krcï nõâ paâ terïe byla statisticky potvrzena zaâ vislost, p 0,05 s vyâjimkou ulnaâ rnõâho sezamoidu, ale prïesto byla variabilita zrïejmaâ. Pro ulnaâ rnõâ sezamoid nebyl vztah statisticky potvrzen. Vztah mezi kostnõâm zraâ nõâ krcï nõâ paâ terïe a vyâ vojem korïene dolnõâho sï picïaâ ku byl statisticky nepotvrzen (p > 0,05), tj. jsou nezaâvisleâ. Pro vztah mezikostnõâm zraâ nõâ ruky a dolnõâm sïpicïaâ kem byla statisticky potvrzena zaâ vislost. P-hodnoty vsï eobecneï nabyâ valy vysï sï õâch hodnot nezï pro vztahy mezi kostnõâm zraâ nõâ ruky a krcïnõâpaâ terïe. Pouze pro ulnaâ rnõâ sezamoid a vyâvoj sïpicïaâ ku byl vztah nepotvrzen (p > 0,05). Pro dõâvky byla statisticky potvrzena signifikantnõâ zaâvislost mezi kostnõâm zraâ nõâm ruky, hodnoceneâ podle Fishmana a kostnõâm zraâ nõâm krcï nõâch obratluê hodnoceneâ metodou Hassela a Farmana CVMI 1-6 pouze pro indikaâ tory SMI 1, SMI 9 a SMI 11, p < 0,05. Ostatnõ indikaâ tory jsou nezaâ visleâ. Vztah mezikostnõâm zraâ nõâ krcïnõâ paâ terïeavyâvojem dolnõâho sïpicïaâ ku je nezaâ vislyâ (p > 0,05). Byla statisticky potvrzena zaâ vislost mezi kostnõâm zraâ nõâm ruky a vyâ vojem sï pi cï aâ ku, kromeï ulnaâ r- nõâho sezamoidu. Ve sledovaneâ m souboru veï tsï ina chlapcuê ocï ekaâ vaâ ruêstbeï hem stadiõâ F a G vyâvoje sïpicïaâ ku, prïedevsïõâmbeïhem stadia F, kolem 47-57% indikaâ toruê kostnõâho zraâ nõâ ruky SMI 1,2 a 3, a asitrïetina chlapcuê beï hem G stadia, uzavrïeneâ apexy meï lo 5% v SMI 1 a po 20% v indikaâ torech SMI 2 a 3. BeÏ hem stadia F se takeâ nevyskytl zïaâ dnyâ indikaâ tor kostnõâho zraâ nõâ ruky ve stadiu unite, sveï dcï õâcõâ pro zpomalenyâruê st. Indika tor SMI 4 se objevil u veïtsï iny, tj. 61 % chlapcuê,prïiuzavrïenyâch apexech a u 19,4 % wed the comparison with tabular and graphic standards according to the three methods given below. Skeletal age was evaluated in X-rays of right hand and wrist - 11 SMI indicators were stated according to the SMA Fishman method [4] (Table 1). Stages of cervical vertebrae C2, C3, C4 ossification were determined in cephalograms using CVMI method according to Hassel and Farman [3] (Table 2). Stages of the lower permanent canines F, G, H root development were determined in OPGs according to Demirjian [10] (Table 3). The relationship between bone maturation of cervical vertebrae CVMI 1-6 and proportion of bone maturation of hand indicators and the stages of lower permanent canine root development was recorded. Only the most advanced SMI indicators in individual persons were chosen according to Fishman, and these were related to canine development. These most advanced SMI indicators were further divided according to Hassel and Farman relation with CVMI stages 1-6 [3], and then they were related to canine development. Calculations were made with the help of the statistical system STATISTI- CA.cz. Fisher and chi-quadrat tests were used as test statistics, the level of significance was p < Results In boys the dependence was statistically proved, p < 0.05, for indicator of bone maturation of hand related to bone maturation of cervical spine, with the exception of ulnar sesamoid. Nevertheless, the variability was apparent. The relationship was not statistically proved for ulnar sesamoid. The relationship between the bone maturation of cervical spine and dental age was not proved statistically (p > 0.05), i.e. they are independent. The interdependence was statistically proved for the relationship between the bone maturation of hand and dental age. In general, P-values were higher than for relationships between the bone maturation of hand and cervical spine. The relationship was not proved only for the relationship between ulnar sesamoid and dental age (p > 0.05). In girls a significant dependence between bone maturation of hand (assessed according to Fishman) and bone maturation of cervical vertebrae (assessed according to Hassel and Farman by CVMI 1-6) only for the indicators SMI 1, SMI 9, and SMI 11 was statistically proved, p < Other indicators are independent. The relation between bone maturation of cervical spine and dental age is independent (p > 0.05). The relationship between bone maturation of hand and dental age was proved, except ulnar sesamoid. In the sample, most boys expect the growth during F and G phases of canine development; especially during F phase (about 47-57% of indicator of bone maturation of hand SMI 1, 2 and 3), and G phase (about one

5 ORTODONCIE rocïnõâk19 beï hem stadia F a G vyâvoje sïpicïaâ ku. VeÏtsÏ ina chlapcuê, tj. 58,4 %, bylo v CVMI 1 stadiu kostnõâho zraâ nõâkrcï nõâch obratluê beï hem F stadia vyâvoje sïpicïaâ ku, trïetina meïla G stadium. CVMI 2 stadium se u veïtsï iny chlapcuê shodovalo s F a G stadii vyâvoje dolnõâho sïpicïaâ ku. V souboru dõâvek veïtsï ina ocï ekaâvaâruêstbeï hem stadiõâ H a G, mensïõâ cïaâ st souboru ve stadiu F vyâvoje sïpicïaâ ku. Od indikaâ toruê kostnõâho zraâ nõâ ruky SMI 1 k 3 klesaâ pocï et dõâvek v H stadiu a stoupaâ pocï et v G stadiu. Naopak SMI 4 maâ veïtsï ina, tj. 69,2 %, dõâvek v H stadiu vyâ voje sï picï aâ ku. Stadium kostnõâho zraâ nõâ krcï nõâch obratluê CVMI 1 u 60 % dõâvek nastalo beï hem F stadia vyâvoje sïpicïaâ ku, 10 % beï hem G stadia a 30 % prïiuzavrïenyâch apexech. Stadium kostnõâho zraâ nõâ krcï nõâch obratluê CVMI 2 u veïtsïiny dõâvek nastalo beï hem G a H stadiõâ vyâvoje dolnõâho sïpicïaâ ku, u 42,9 % beï hem G a 46,4 % beï hem H, u 10,7 %beï hem F stadia. Na rozdõâl od chlapcuê, kde roste pocï et H stadiõâ od SMI 1 k 3. Shoda obou pohlavõâ je ve vyâskytu stadia kostnõâho zraâ nõâ krcï nõâch obratluê CVMI 1 beïhem F stadia vyâvoje sïpicïaâ ku, ale u chlapcuê prïevlaâdaâg stadium a u dõâvek H stadium. V CVMI 2 stadiu maâ võâce chlapcuê F a G stadium vyâvoje dolnõâho sïpicïaâ ku, u dõâvek prïevlaâdaâ G a H stadium. U 11 % chlapcuê nastalo stadium CVMI 3 kostnõâho zraâ nõâ krcï nõâch obratluê beï hem F stadia vyâvoje sïpicïaâkuaveïtsï ina souboru maâ H stadium, shodneï u dõâvek je veïtsï ina v H stadiu, roste ale i pocïet v G stadiu vyâvoje sïpicïaâ ku. Indika tory kostnõâho zraânõâ ruky SMI 5, 6, 7, sveïdcï õâcõâ pro ruê stovyâ spurt chlapcuê, nastaly v 70-86% s uzavrïenyâ miapexy, u 10-16,7 % chlapcuê beï hem F stadia vyâ voje dolnõâho sï picï aâ ku a u 14,3-20 % beï hem G stadia. CVMI 3 kostnõâho zraânõâ krcï nõâch obratluê nastalo u 88,9 % chlapcuê. RuÊ stovyâ spurt nastal u veïtsï iny dõâvek, 52,9-62,5 %, prïiuzavrïenyâch apexech, asiu trïetiny beï hem G stadia a u zbyâvajõâcõâch beï hem F stadia zubnõâho vyâvoje. Za rovenï CVMI 3 kostnõâho zraâ nõâ krcï nõâch obratluê nastalo u 61,3% dõâvek prïiuzavrïenyâch apexech, u 35,5 % beï hem G stadia a u zbylyâch v F stadiu zubnõâho vyâvoje. Ve spurtu byla shoda pro obeï pohlavõâ, u dõâvek byly pocï ty H stadiõâ zubnõâho vyâvoje a CVMI 3 asio 10 % nizïsï õâ nezï u chlapcuê. U 77-87,5 % chlapcuê se indikaâ tory kostnõâho zraâ nõâ ruky SMI 7-10 vyskytovaly soucï asneï s uzavrïenyâmi apexy zubu, u 12,5-23% soucï asneï s G stadiem zubnõâho vyâ voje. Stadium kostnõâho zraâ nõâ krcï nõâch obratluê CVMI 4 (zpomalenõâ) u 83,3% chlapcuê beï hem H stadia, u 16,7 % nastalo beï hem G stadia zubnõâho vyâvoje, CVMI 5 nastalo u 60% beï hem H a pro zbytek chlapcuê beï hem G stadia zubnõâho vyâvoje. V CVMI 6 meïlivsï ichni chlapciuzavrïeneâ apexy. U 85-96,3 % dõâvek se indikaâ tory kostnõâho zraâ nõâ ruky SMI 7-10 vyskytovaly soucï asneï s uzavrïenyâ miapexy zubu, u 3,7-15 % soucï asneï s G stadiem zubnõâho vyâvoje. Za rovenï stadium zraâ nõâ krcï nõâch obratluê CVMI 4 (zpomalenõâ) nastalo u 86,4 % dõâvek beï hem H stadia third of boys); 5% had closed apexes in SMI 1, and 20% in SMI 2 and 3. During F phase there was no indicator of bone maturation of hand at unite stage, i.e. slow growth. Indicator SMI 4 was present in majority of boys (61%) together with closed apexes, and in 19.4% during F and G phases of dental development. Most boys, i.e. 58.4%, cervical vertebrae maturation index (CVMI) was 1 during the F phase of dental development; in one third of boys there was G phase of dental development. In most boys CVMI 2 corresponded to F or G phase of dental development. Majority of girls expected growth during H and G phases, the rest in F phase of dental development. From the indicators of hand bone maturation SMI 1-3 the number of girls in H phase of dental development decreases and the number in G phase of dental development increases. SMI 4 is in majority of girls, i.e. 69.2%, at H phase of dental development. CVMI 1 in 60% of girls occurred at F phase, in 10% of girls at G phase of dental development, and in 30% of girls at closed apexes. CVMI 2 in majority of girls occurred at G and H phases of dental development: in 42.9% at G phase, in 46.4% in H phase, and in 10.7% at F phase of dental development. This is the contrary to the situation in boys - H phase increases in SMI 1-3. CVMI 1 at F phase of dental development prevails both in boys and girls; in boys G phase prevails, in girls H phase. In CVMI 2 F and G phases prevail in boys, whilst in girls G and H phases of dental development. CVMI 3 during F phase of dental development was recorded in 11% of boys, majority of boys had H phase of dental development; in majority of girls there was H phase, however the number of girls in G phase of dental development was also increasing. Indicators of hand bone maturation SMI 5, 6, 7 (suggesting growth spurt) were found in 70-86% of boys with closed apexes, in % during F phase of dental development, and in % during G phase. CVMI 3 started in 88.9% of boys. In most girls ( %) growth spurt appeared with closed apexes, in about 30% during G phase, and in the remaining girls during F phase of dental development. CVMI 3 occurred in 61.3% of girls with closed apexes, in 35.5% during G phase, and the rest of girls were at F phase of dental development. During the growth spurt the situation was virtually the same in boys and in girls; H phase of dental development and CVMI 3 was 10% less frequent in girls than in boys. In % of boys indicators of hand bone maturation SMI 7-10 occurred together with closed dental apexes, in % together with G phase of dental development. CVMI 4 (deceleration) was recorded in 83.3% of boys during H phase, and in 16.7% during G phase of dental development. CVMI 5 was recorded in 60% of boys during H phase, and in the rest during G

6 rocïnõâk19 ORTODONCIE a u 13,6 % beï hem G stadia zubnõâho vyâvoje, CVMI 5 nastalo u 91,3 % beï hem H a u zbylyâch dõâvek beï hem G stadia zubnõâho vyâ voje. Stadium kostnõâho zraâ nõâ krcï nõâch obratluê CVMI 6 nastalo u 93,3 % dõâvek prïiuzavrïenyâch apexech a u 6,7 % beï hem G stadia zubnõâho vyâvoje. ShodneÏ pro obeï pohlavõâ zpomalenõâ a ukoncï enõâ ruê stu podle kostnõâho zraâ nõâ ruky aniobratluê nenastalo nikdy beï hem F stadia zubnõâho vyâvoje a shodneâ byly ivyâskyty stadiõâ kostnõâho zraâ nõâ krcï nõâch obratluê CVMI 4 a 6. U chlapcuê byl asio 10 % nizïsïõâ vyâskyt H stadiõâ a võâce G stadiõâ zubnõâho vyâvoje, rozdõâl byl takeâ v CVMI 5, kde uveïtsï iny dõâvek prïevlaâ daly H stadia, ale u chlapcuê byl vyâskyt o 30 % mensïõâ. Vztah zubnõâho a kostnõâho zraâ nõâ je tabelaâ rneï sumarizovaâ n v Tab.4, Tab.5, Tab.6 a Tab.7 a graficky znaâ zorneï n zvlaâsït'pro chlapce na Obr. 1a azï 4a a pro dõâvky na Obr. 1b azï 4b. Tabulka 4: Vztah kostnõâho zraâ nõâ ruky a vyâvoje sïpicïaâkuv% Table 4: Relationship of skeletal maturation of a hand and canine development in % Canine development phase Boys Girls F G H F G H DP3= PP3= MP3= MP5= S=S DP3cap MP3cap MP5cap PP3cap DP3u PP3u MP5u MP3u Ru F, G, H: canine development stages acc. Demirjian F, G, H: vyâvojovaâ stadia sïpicïaâ ku podle Demirjiana Tabulka 5: Vztah kostnõâho zraâ nõâ krcï nõâch obratluê a vyâvoje sï picï aâ kuv% Table 5: Relationship between skeletal maturation of cervical vertebrae and canine development in % Canine development phase Boys Girls F G H F G H CVMI CVMI CVMI CVMI CVMI CVMI CVMI 1-6: klasifikace kostnõâho zraâ nõâ krcï nõâch obratluê podle Hassela a Farmana CVMI 1-6: classification of cervical vertebrae maturation acc. Hassel and Farman phase of dental development. At CVMI 6 all boys had closed apexes. In % of girls indicators of hand bone maturation SMI 7-10 were recorded together with closed dental apexes, in % during G phase of dental development. CVMI 4 (deceleration) was recorded in 86.4% of girls during H phase, and in 13.6% of girls during G phase of dental development. CVMI 5 was recorded in 91.3% of girls during H phase, and in the rest of girls during G phase of dental development. CVMI 6 was recorded in 93.3% of girls with closed apexes, and in 6.7% of girls during G phase of dental development. Deceleration and the end of growth according hand bone maturation and cervical vertebrae were not recorded during F phase of dental development neither in girls nor in boys. The same situation for both boys and girls was recorded for CVMI 4 and 6. In boys H Tabulka 6: Vztah kostnõâho zraâ nõâ ruky a vyâvoje sïpicïaâkuv% Table 6: Relationship between hand bone maturation and canine development in % Canine development phase Boys Girls F G H F G H SMI SMI SMI SMI , SMI SMI SMI SMI SMI 1-11: indikaâ tory kostnõâho zraâ nõâ ruky metodou podle Fishmana SMI 1-11: indicators of hand bone maturation acc. Fishman Tabulka 7: Vztah zraâ nõâ ruky podle uâ rovnõâ CVMI a vyâvoje sïpicïaâkuv% Table 7: Relationship between hand maturation according to CVMI and canine development in % Canine development phase Boys Girls F G H F G H SMI 3,4 ~ CVMI SMI 6 ~ CVMI SMI 7,8 ~ CVMI SMI 9,10 ~ CVMI SMI 11 ~ CVMI CVMI 1-6: klasifikace kostnõâho zraâ nõâ krcï nõâch obratluê dle Hassela a Farmana CVMI 1-6: classification of skeletal maturation of cervical vertebrae acc. Hassel and Farman SMI 1-11: indikaâ tory kostnõâho zraâ nõâ ruky metodou SMA podle Fishmana SMI 1-11: indicators of hand bone maturation SMA acc. Fishman

7 ORTODONCIE rocïnõâk19 VeÏtsÏ inou se indikaâ tory kostnõâho zraâ nõâ ruky SMI 1, 2, 3, tj. ocï ekaâvaânõâruê stu, vyskytly u chlapcuê beï hem stadiõâ kostnõâho zraâ nõâkrcï nõâch obratluê CVMI 1, 2 a SMI 1, 2 meïly klesajõâcõâ trend do CVMI 3, ale naposledy se objevily v CVMI 4 stadiu. U chlapcuê meï l SMI 1 maximum v CVMI 1, SMI 2,3 v CVMI 2. Polovina dõâvek ocï ekaâ vala ruêstbeïhem CVMI 2 a indikaâ tory se vyskytly od CVMI 1-3, kdy nastaly naposledy. SMI 1, 2, 3 meï ly podobneâ vyâskyty a nastaly u trïetiny dõâvek beï hem CVMI 1, u poloviny beïhem CVMI 2 a u zbylyâch v CVMI 3. Indika tor kostnõâho zraâ nõâ ruky SMI 4 se vyskytl u chlapcuê iu dõâvek beï hem vsï ech CVMI stadiõâ kostnõâho zraâ nõâ krcï nõâch obratluê 1-6. U cï tvrtiny chlapcuê beï hem CVMI 2,3, 16,7 % beï hem CVMI 4, s klesajõâcõâm trendem k CVMI 6. U cï tvrtiny dõâvek se vyskytl beï hem stadia CVMI 3, kolem 20 % beï hem CVMI 2,5, u 17,5 % v CVMI 4, u 12,5 % beï hem stadia CVMI 6. VeÏtsÏ ina vyâskytu indikaâ toruê kostnõâho zraâ nõâ ruky sveïdcï õâcõâch pro spurt, SMI 5 a 6 nastala u chlapcuê beï hem CVMI 2-4 stadiõâ kostnõâho zraâ nõâ krcï nõâch obratluê, pro SMI 7 v CVMI 3-5. U poloviny dõâvek se indikaâ tory spurtu vyskytly beï hem CVMI 3, ale objevily se od CVMI 1-5. Indika tor kostnõâho zraâ nõâ ruky SMI 5 nastal u trïetiny chlapcuê beï hem stadia CVMI 2, u poloviny chlapcuê beïhem CVMI 3 a u 16,7 % beï hem CVMI 4. SMI 6 nastal utrïetiny chlapcuê beï hem CVMI 3, po 20 % beï hem CVMI 2 a 4, u 15 % beï hem CVMI 5 a u 10 % beï hem CVMI 1. Indika tor SMI 7 nastal u 42,9 % beï hem stadia CVMI 3, u 35,7 % beï hem CVMI 4, u zbylyâchbeï hem CVMI 2,5. Indika tory kostnõâho zraâ nõâ ruky SMI 5-7 nastaly u veïtsï iny dõâvek, tj ,3 %, v CVMI 3 a hodnoty klesaly v porïadõâ SMI 5,7,6. Indika tory SMI 5,6 nastaly takeâ u teâmeïrïtrïetiny dõâvek v CVMI 2, pokles od CVMI 4 k 6. Indika tor SMI 7 se u dõâvek nevyskytoval v CVMI 1 a 6, nastal u veï tsï iny, tj. 44,6 % ve stadiu kostnõâho zraânõâ krcï nõâch obratluê CVMI 3, u 21,4 % beï hem CVMI 2, u 28,6 % beï hem CVMI 4 a u zbylyâch v CVMI 5 stadiu. VeÏtsÏ ina vyâskytu indikaâ toruê kostnõâho zraâ nõâ ruky sveïdcïõâcõâch pro ukoncï enõâ ruê stu nastala u chlapcuê pro SMI 8 a 10 v CVMI 4-6. Indika tor kostnõâho zraâ nõâ ruky SMI 8 nastal u 30,8 % v CVMI 4, u veïtsï iny chlapcuê, tj. 38,5 %, v CVMI 5 stadiu autrïetiny v CVMI 6. Indika tor SMI 9 se vyskytoval beïhem CVMI 2-6, u veïtsï iny chlapcuê, 31,3 %, nastal beïhem CVMI 5 stadia kostnõâho zraâ nõâ krcï nõâch obratluê,u trïetiny v CVMI 4, po 18,8 % beï hem CVMI 3 a 6 a u zbylyâch v CVMI 2. Indika tor kostnõâho zraâ nõâ ruky SMI 10 nastal u poloviny chlapcuê v stadiu CVMI 6, u trïetiny v CVMI 5 a v CVMI 3 u 16,7 % chlapcuê. Indika tor kostnõâho zraânõâ ruky SMI 11 nastal u 50% chlapcuê v obou CVMI 5 a 6. VeÏtsÏ ina vyâskytu indikaâ toruê sveïdcï õâcõâch pro ukoncï enõâ ruê stu nastalo u dõâvek pro SMI 8 a 9 beï hem stadiõâ kostnõâho zraâ nõâ krcï nõâch obratluê CVMI 4-6, pro SMI 10 a 11 beï hem CVMI 5 a 6. phase was 10% less frequent, whilst G phase was more frequent. During CVMI 5 in girls H phase prevailed, whilst in boys the phase was by 30% less frequent. The relationship between canine and bone maturation is summarized in Tables 4-7, and in Figures 1-4 where a) figure is for boys, and b) figure for girls. In boys, indicators of hand bone maturation SMI 1, 2, 3 (growth expectation) occurred mostly during CVMI 1, 2. SMI 1, 2 tended to decrease till CVMI 3, at CVMI 4 they appeared for the last time. The SMI 1 maximum was at CVMI 1, SMI 2, 3 at CVMI 2. In 50% of girls the growth was expected (SMI 1, 2, 3) during CVMI 2, the indicators occurred from CVMI 1 to 3 (at CVMI 3 for the last time). The incidence of SMI 1, 2, 3 was similar, and appeared in one third of girls during CVMI 1, in half of the girls during CVMI 2, and in the rest at CVMI 3. The indicator of hand bone maturation SMI 4 occurred both in boys and girls during all CVMI stages, i.e. 1-6: in 25% of boys during CVMI 2, 3, in 16.7% of boys during CVMI 4, the trend decreased towards CVMI 6. The indicator of hand bone maturation SMI 4 occurred in 25% of girls during CVMI 3, in about 20% of girls during CVMI 2, 5, in 17.5% during CVMI 4, and in 12.5% of girls during CVMI 6. In boys most indicators of hand bone maturation suggesting growth spurt, SMI 5 and 6, occurred during CVMI 2-4; in SMI 7 CVMI was between 3 and 5. In 50% of girls the indicators of growth spurt occurred during CVMI 3, however, they were also recorded since CVMI 1-5. In one third of boys the indicator of hand bone maturation SMI 5 occurred during CVMI 2 phase; in a half of boys during CVMI 3, and in 16.7% of boys during CVMI 4. SMI 6 was recorded during CVMI 3 in one third of boys, during CVMI 2 and 4 in 20% of boys, in 15% during CVMI 5, and in 10% during CVMI 1. SMI 7 indicator was recorded in 42.9% of boys during CVMI 3, in 35.7% during CVMI 4, and in the rest during CVMI 2 and 5. In most girls (i.e %) the indicators of hand bone maturation SMI 5-7 occurred during CVMI 3, the values decreased from CVMI 4 to CVMI 6. SMI 7 indicator was not found in girls in CVMI 1 and 6. In most girls (44.6%) it occurred in CVMI 3, in 21.4% during CVMI 2, in 28.6% in CVMI 4, and in the rest in CVMI 5. Most indicators suggesting the finished hand bone maturation, SMI 8,10, was found in boys during CVMI 4-6. SMI 8 indicator of hand bone maturation occurred with CVMI 4 in 30.8% of boys; with CVMI 5 in 38.5% of boys, and CVMI 6 in one third of boys. SMI 9 was found during CVMI 2-6, in majority of boys it was recorded during CVMI 4, 5, in one third of boys in both, CVMI 3 and 6 in 18.8% each, and CVMI 2 in the rest of boys. SMI 10 indicator of hand bone maturation appeared in CVMI 6 in 50% of boys, in CVMI 5 in one third of

8 rocïnõâk19 ORTODONCIE Indika tor kostnõâho zraâ nõâ ruky SMI 8 se u dõâvek nevyskytoval beï hem CVMI 1 a 2, nastal u 30,4 % v CVMI 4, veïtsï ina byla u 37,5 % beï hem CVMI 5 a u 26,8 % dõâvek v CVMI 6, u zbylyâch v CVMI 3. Indika tor SMI 9 nastal u 28,3 % v CVMI 4, veïtsï ina byla u 36,7 % dõâvek beï hem CVMI 5 a u 25 % v CVMI 6, u zbylyâch v CVMI 1,2. IndikaÂtor kostnõâho zraâ nõâ ruky SMI 10 nastal u 17,1 % dõâvek v CVMI 4 a veïtsï ina byla u 46,3 % v CVMI 5 a u 36,6 % beï hem CVMI 6 stadia kostnõâho zraâ nõâ krcï nõâch obratluê. Indika tor kostnõâho zraâ nõâ ruky SMI 11 nastal u 37 % beï hem CVMI 5 a veïtsï ina byla u 55,6 % beï hem CVMI 6 stadia kostnõâho zraâ nõâ krcï nõâch obratluê, u zbylyâch v CVMI 4. boys, and in CVMI 3 in 16.7% of boys. SMI 11 occurred with CVMI 5-6 in 50% each. In girls most indicators suggesting the finished growth, SMI 8 and 9 occurred with CVMI 4-6, SMI 10 and 11 with CVMI 5 and 6. SMI 8 was not recorded during CVMI 1 and 2; it was found in CVMI 4 in 30.4%, CVMI 5 in 37.5%, CVMI 6 in 26.8%, CVMI 3 in the remaining girls. SMI 9 occurred with CVMI 4 in 28.3%, CVMI 5 in 36.7%, CVMI 6 in 25%, and CVMI 1 and 2 in the remaining girls. SMI 10 was recorded together with CVMI 4 in 17.1%, CVMI 5 in 46.3%, CVMI 6 in 36.3%. SMI 11 occurred with CVMI 5 in 37%, with CVMI 6 in 55.6%, and with CVMI 4 in the remaining girls. Ru MP3u MP5u PP3u DP3u PP3cap MP5cap MP3cap DP3cap S=S MP5= MP3= PP3= DP3= F G H 0% 20% 40% 60% 80% 100% Obr. 1a: Vztah kostnõâho zraâ nõâ ruky a vyâvoje sïpicïaâ ku v % - chlapci. F, G, H: vyâvojovaâ stadia sïpicïaâ ku podle Demirjiana Fig. 1a: Relationship of skeletal maturation of a hand and canine development in % - boys. F, G, H: canine development stages acc. Demirjian Ru MP3u MP5u PP3u DP3u PP3cap MP5cap MP3cap DP3cap S=S MP5= MP3= PP3= DP3= F G H 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obr. 1b: Vztah kostnõâho zraâ nõâ ruky a vyâvoje sïpicïaâ ku v % - dõâvky. F, G, H: vyâvojovaâ stadia sïpicïaâ ku podle Demirjiana Fig. 1b: Relationship of skeletal maturation of a hand and canine development in % - girls. F, G, H: canine development stages acc. Demirjian

9 ORTODONCIE rocïnõâk19 CVMI 6 CVMI 5 CVMI 4 CVMI 3 F G H CVMI 2 CVMI 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obr. 2a: Vztah kostnõâho zraâ nõâkrcï nõâch obratluê avyâvoj sïpicïaâ ku v % - chlapci. CVMI 1-6: klasifikace kostnõâho zraâ nõâkrcïnõâch obratluê dle Hassela a Farmana. F, G, H: vyâvojovaâ stadia sïpicïaâ ku dle Demirjiana Fig. 2a: Relationship between skeletal maturation of cervical vertebrae and canine development in % - boys. CVMI 1-6: classification of cervical vertebrae maturation acc. Hassel and Farman. F, G, H: canine development stages acc. Demirjian CVMI 6 CVMI 5 CVMI 4 CVMI 3 F G H CVMI 2 CVMI 1 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obr. 2b: Za vislost kostnõâho zraâ nõâ krcï nõâch obratluê na vyâvojisï pi cï aâ ku v % - dõâvky. F, G, H: vyâvojovaâ stadia sï pi cï aâ ku dle Demirjiana Fig. 2b: Relationship between skeletal maturation of cervical vertebrae and canine development in % - girls. CVMI 1-6: classification of cervical vertebrae maturation acc. Hassel and Farman. F, G, H: canine development stages acc. Demirjian Diskuse ZvyÂsledkuÊ studie plyne, zï e u chlapcuê by bylo mozïneâ nahradit rentgen ruky po celou dobu trvaâ nõâ pubertaâlnõâho ruê stu, ale u dõâvek je to mozïneâ pouze v uâ plneâ mu zacï aâ tku a konciruê stu. Velka variabilita mezi indikaâ tory kostnõâho zraâ nõâ navzaâ jem ivuêcï izubnõâmu veï ku podle vyâvoje dolnõâho sï pi cï aâ ku byla zrïejmaâ u jednotlivcuê na prvnõâ pohled. Je nutneâ prïedpoklaâ dat docï asneâ disharmonie mezizubnõâm a teï lesnyâ m/kostnõâm vyâ vojem. Mnoho autoruê sejizï zabyâvalo touto problematikou. Discussion The results show that radiographs of a hand could be substituted with indicators of canine development during the whole period of pubertal growth in boys, whilst in girls this can be applied only at the very beginning and end of their growth. The great variability between the individual indicators of bone maturation, and between bone maturation and development of lower canine, was evident. We have to assume temporary disharmonies between dental and body/bone development. This has been already discussed by many experts

10 rocïnõâk19 ORTODONCIE VsÏ edesaâtyâch letech ve sveâ studii Green, Lammons a kol. hodnotili zubnõâ veï k podle pocï tu zubuê prorïezanyâch do uâ st a studie Demishe a kol. se tyâkala kalcifikace võâcehrbolkovyâ ch zubuê, ktereâ obvykle ukaâ zaly malyâ vztah mezizubnõâm veï kem a ostatnõâmi indikaâ tory zraâ nõâ. Take Garn a spol. popsalive sveâ studii jen slabyâ vztah mezitrïetõâmimolaâ ry a kostnõâm vyâvojem. EngstroÈ m, EngstroÈ m a Sagne v longitudinaâ lnõâ studii popsalivysokou shodu mezivyâ vojem dolnõâho trïetõâho molaâ ru, kostnõâm zraâ nõâm a chronologickyâm veï kem. Shuttleworth popsal, zïe dõâvky s cï asnyâm vrcholem ruêstoveâ ho zrychlenõâ majõâ drïõâveï jsï õâ vyâmeï nu zubuê [1]. Bushang, Tanguay a Patterson popsaliv roce 1985, zïe mechanismus kontroly zubnõâho vyâ voje je nezaâ vislyâ na teïlesneâ m a pohlavnõâm zraâ nõâ. PruÊ meï rnyâ veï k vyâ skytu jednotlivyâ ch udaâ lostõâ se signifikantneï li sï il, ale byla signifikantnõâ shoda veï kuvyâ skytu ulnaâ rnõâho sezamoidu, 75 % kostnõâho zraâ nõâ, menarche a vrcholu pubertaâ lnõâho ruêstoveâ ho zrychlenõâ. Chronologicky veï k, kdy dõâvky dosaâhly 90 % zubnõâho vyâ voje nesouvisel signifikantneï s ostatnõâmi indikaâ tory zraâ nõâ a nastalo u nejmladsï õâch ve veï ku 9,90 let, 75 % kostnõâho zraâ nõâ ve veï ku 10,39 let, objevenõâ ulnaâ rnõâho sezamoidu nastalo v 10,98 letech, vrchol ruê stoveâ ho spurtu v 11,97 letech, menarche v 12,91 letech. Vrchol ruê stoveâ ho spurtu a objev sezamoidu byly nejvariabilneï jsï õâ indexy, ale menarche a zubnõâ zraâ nõâ byly meâ neï variabilnõâ [1]. BjoÈ rk a Helm jizï drïõâve popsalirozdõâl 1 rok meziobjevenõâm ulnaâ rnõâho sezamoidu a vrcholem ruê stoveâ ho zrychlenõâ, Chapman udaâ val rozdõâl mezizmõâneï nyâ mi9,4 meïsõâcuê ve studii rentgenuê, zõâskaâ vanyâch kazïdeâtrïimeïsõâce [8,9]. Nekonzistence vyâ sledkuê je zpuê sobena rozdõâlnyâ mimetodamia blõâzï õâ se shromaâ zï deï nyâ m datuê m. NeÏ kterïõâ autorïipouzï ili jedno stadium zubnõâho vyâ voje, zatõâm co jinõâ pouzï ili odlisïneâ zpuê soby pro analyâzu vyâsledkuê (tj. pouzï itõâ specifickyâch veï kuê, nebo kombinaci vsï ech veïkuê ) [1]. Fishman v roce 1979 zkoumal vztahy mezi chronologickyâm a kostnõâm veï kem v populacia potvrdil, zïe meïrïenõâhornõâa dolnõâcï elisti vykazuje nejveïtsï õâshodu s vrcholem ruê stoveâ ho zrychlenõâ postavy, veï tsï ina vrcholuê krïivek faciaâ lnõâho ruê stu se s vrcholem ruê stu postavy neshoduje. AcÏ kolidõâvky majõâ chronologicky cï asneï jsïõâ ruêstoveâ rychlosti, vztah mezi celkovyâ m a kraniofaciaâ lnõâm ruê stem je pro obeï pohlavõâ stejnyâ. Jedinci s cï asneïjsïõâm kostnõâm veï kem majõâ cï asneïjsï õâ pubertaâ lnõâ faciaâ lnõâ ruê st, naopak jedinci s opozï deï nyâ m kostnõâm veï kem majõâ opozïdeï nyâ pubertaâ lnõâ faciaâ lnõâ ruê st. PruÊ meï rneï zrajõâcõâ deïvcï ata majõâ naâ stup menarcheâ brzy po maximu pubertaâ lnõâho ruê stoveâ ho spurtu, pozdneï zrajõâcõâ deâ le po maximu pubertaâ lnõâho ruê stoveâ ho spurtu [10]. Fishman v roce 1987 po rozsaâ hleâ smõâsï eneâ longitudinaâ lnõâ studii 4000 osob vytvorïil SMA systeâ m urcï enõâ kostnõâho zraâ nõâ. MeÏ rïenõâm urcï ityâ ch rozmeï ruê maxily In the 60s, Green, Lammons et al., evaluated dental age according to the number of erupted teeth. The work by Demish et al. dealt with calcification of teeth with more cusps. These works showed only a slight association between dental age and other indicators of maturation. Garn et al. reported only a slight association between third molars and bone development. In their longitudinal study, EngstroÈ m, EngstroÈ m and Sagne recorded a great correspondence between the development of lower third molar, bone maturation, and chronological age. Shuttleworth concluded in girls early growth spurt is related to earlier change of dentition [1]. In 1985, Bushang, Tanguay and Patterson proved that the mechanism controlling dental development does not depend on physical or sexual maturation. The mean age of individual events was significantly different; however, there was a congruity of the age when ulnar sesamoid occurred together with 75% of bone maturation, menarche, and the maximum of growth spurt. Chronological age in which girls were at 90% of dental development was not related to other indicators of maturation; the earliest occurrence was reported at the age of 9.90, 75% of bone maturation at the age of 10.39, ulnar sesamoid at the age of 10.98, peak of height velocity at 11.97, menarche at the age of The most variable indexes were represented by peak of height velocity and sesamoid, whilst menarche and dental development were less variable [1]. BjoÈ rk and Helm stated that between ulnar sesamoid occurrence and the maximum of growth spurt there is 1 year lap. Chapman stated the period at 9.4 months based on his evaluation of X-rays taken every three months [8,9]. Inconsistent results are due to different methods used. Some authors worked with just one stage of dental development, others used different techniques for the analysis of the data (e.g. specific age groups or combinations of different age groups) [1]. In 1979, Fishman focused on the relationship between chronological and bone age in the population, and proved that measurements of the maxilla and the mandible correspond best with the maximum of body growth spurt. However, most peaks of facial growth do not correspond to the peaks of the growth spurt of the body. From the chronological point of view, the girls have earlier growth spurt, however, the relationship between the overall growth and craniofacial growth is the same in both sexes. Individuals with earlier bone age have earlier pubertal facial growth; on the contrary, individuals with late bone age have late pubertal facial growth. Girls with the average time of maturation have menarche soon after the maximum of pubertal growth spurt; those with later maturation reach the menarche later after peak of pubertal growth spurt [10]

11 ORTODONCIE rocïnõâk19 SMI 11 SMI 10 SMI 9 SMI 8 SMI 7 SMI 6 F G H SMI 4 SMI 3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obr. 3a: Vztah kostnõâho zraâ nõâ ruky a vyâvoje sïpicïaâ ku v % - chlapci. SMI 1-11: indikaâ tory kostnõâho zraâ nõâ ruky podle Fishmana Fig. 3a: Relationship between skeletal maturation of cervical vertebrae and canine development in % - boys. SMI 1-11: indicators of hand bone maturation acc. Fishman SMI 11 SMI 10 SMI 9 SMI 8 SMI 7 SMI 6 F G H SMI 4 SMI 3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obr. 3b: Za vislost kostnõâho zraâ nõâ ruky SMA na vyâvojisïpicïaâ ku v % - dõâvky. SMI 1-11: indikaâ tory kostnõâho zraâ nõâ ruky metodou SMA dle Fishmana Fig. 3b: Relationship between skeletal maturation of cervical vertebrae and canine development in % - girls. SMI 1-11: indicators of hand bone maturation acc. Fishman a mandibuly potvrdil, zï e chlapcizrajõâ deâ le nezï dõâvky, mandibula roste rychleji nezï maxila, a potvrdil pozdnõâ mandibulaâ rnõâ ruê stoveâ spurty pro obeï pohlavõâ. CÏ asneï zralõâ obou pohlavõâ obecneï vykazujõâ shodneï kratsï õâ trvaânõâ obdobõâ adolescence, pruê meï rneï a pozdneï zralõâ chlapci majõâ kratsï õâ trvaâ nõâ obdobõâ adolescence, nezï pruê meï rneï a pozdneï zraleâ dõâvky. VyÂvoj zraânõâcï asto zuê staâvaâ v relativneï stejneâm raâ mci- cï asnyâ, pruêmeï rnyâ a pozdnõâ - beïhem prodlouzï eneâ cï asoveâ periody a cï asto iskrz celeâ adolescencï nõâ obdobõâ, ale neï kdy muêzïe pruêbeï h adolescence zahrnovat posun z jedneâ relativnõâ etapy zraânõâ do Following the extensive longitudinal study of 4000 individuals, Fishman in 1987 created a SMA system for the assessment of bone maturation. Based on measurements of some dimensions of maxilla and mandible, he deduced that in boys the maturation takes more time than in girls, that mandible grows more rapidly than maxilla. He also confirmed late mandibular growth spurt for both boys and girls. In general, early mature boys and girls show shorter adolescence; in boys with average or late maturation adolescence is usually shorter than in girls with average or late maturation

12 rocïnõâk19 ORTODONCIE SMI 11 ~ CVMI 6 SMI 9,10 ~ CVMI 5 SMI 7,8 ~ CVMI 4 F G H SMI 6 ~ CVMI 3 SMI 3,4 ~ CVMI 2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obr.4a: Vztah zraâ nõâ ruky podle uâ rovnõâ CVMI a vyâvoje sïpicïaâ ku v % - chlapci. CVMI 1-6: klasifikace kostnõâho zraâ nõâ krcïnõâch obratluê dle Hassela a Farmana. SMI 1-11: indikaâ tory kostnõâho zraâ nõâ ruky podle Fishmana. Fig. 4a: Relationship between hand maturation according to CVMI and canine development in % - boys. CVMI 1-6: classification of cervical vertebrae maturation acc. Hassel and Farman. SMI 1-11: indicators of hand bone maturation acc. Fishman SMI 11 ~ CVMI 6 SMI 9,10 ~ CVMI 5 SMI 7,8 ~ CVMI 4 F G H SMI 6 ~ CVMI 3 SMI 3,4 ~ CVMI 2 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Obr.4b: Za vislost zraâ nõâ ruky SMA dle uâ rovnõâ CVMI na vyâvojisïpicïaâ ku v % - dõâvky. CVMI 1-6: klasifikace kostnõâho zraânõâ krcï nõâch obratluê dle Hassela a Farmana. SMI 1-11: indikaâ tory kostnõâho zraâ nõâ ruky podle Fishmana. Fig. 4b: Relationship between hand maturation according to CVMI and canine development in % - girls. CVMI 1-6: classification of cervical vertebrae maturation acc. Hassel and Farman. SMI 1-11: indicators of hand bone maturation acc. Fishman jineâ.veïtsï ina z SMI stadiõâ a podskupin stadiõâ zraâ nõâ prokaâ zala pruê meï rnou chronologickou chybu okolo 3-5 meï sõâcuê. RozdõÂlne zaâ konitosti se objevily prïisrovnaânõâ podskupin navzaâ jem, nebo prïisrovnaâ nõâ obou pohlavõâ. Hodnoty chronologickeâ ho veï ku mohou byâ t odhadnuty v rozmezõâ asi5 meïsõâcuêameâneï [11]. Hassel a Farman v roce 1995 popsalisrovnaâ nõâ SMI- CVMI skupin, kde byly pozorovaâ ny vyâ razneâ anatomickeâ charakteristiky krcï nõâch obratluê, unikaâ tnõâ pro kazï- Maturation periods can be divided into three categories - early, average and late. The process remains usually within the same category over the whole period of adolescence. Sometimes there may be a shift from one category to another. Most SMI stages and phases of maturation showed mean chronological error of about 3-5 months. Differences were recorded between individual subgroups and/or between the two sexes. Chronological age may be estimated within 5 months or less [11]

13 ORTODONCIE rocïnõâk19 dou z teï chto skupin. Jedena ct SMI (kostnõâ maturacïnõâ index) stadiõâ odpovõâdaâ sï esti stadiõâm CVMI (index zraânõâ krcï nõâch obratluê ). Kostnõ zraâ nõâ odpovõâdaâ stupnivyâ voje osifikace kosti. RozmeÏ r a zraâ nõâ se mohou meï nit nezaâvisle na sobeï. Kostnõ zraânõâ teï sneï jisouvisõâ se sexuaâ lnõâm zraâ nõâm, nezï sruê stem postavy do vyâsï ky. BeÏ hem ruê stu prochaâ zejõâ vsï echny kostiseâ riõâ zmeï n, ktereâ lze pozorovat na kefalogramu. PorÏadõ zmeï n je relativneï staâleâ pro danou kost jedneâ osoby. CÏ asovaâ nõâ zmeï n je ruê zneâ a odpovõâdaâ biologickyâ m hodinaâ m kazï deâ ho jedince. AzÏ na vyâjimky lze vsï eobecneï rïõâci,zï e tyto jevy jsou reprodukovatelneâ a mohou byât zaâ kladem srovnaâ nõâ meziruê znyâmi jedinci [3]. Litt a Vaughan v roce 1987 zjistili z ruê stovyâch referencï nõâch dat americkyâch deï tõâ,zï e iniciace spurtu odpovõâdaâ stadiu F a stadium G trvaâ pruêmeï rneï 0,4 roku prïed vrcholem ruê stoveâ rychlostiu dõâvek a pruê meï rneï 1,3 roku prïed vrcholem ruê stoveâ rychlostiu chlapcuê. ShodneÏ se zaâveï ry studie Coutinho, Bushang a Miranda z roku 1993, kterïõâ zkoumalizaâ vislosti vyâ voje dolnõâho sï picï aâ ku a kostnõâho zraâ nõâ ruky, autorïidoporucï ujõâ vyâ voj dolnõâho sïpicïaâ ku jako indikaâ tor pro deï tskeâ kostnõâ zraâ nõâ [1]. Popsali, zï e indikaâ tory MP3, PP5 a sezamoid vykazujõâ nejvysïsï õâ shodu s vyâvojem dolnõâho sïpicïaâ ku pro obeï pohlavõâ. BeÏ hem F stadia vyâvoje dolnõâho sïpicïaâkuseveïtsïinou jesïteï nevyskytuje S, ale jsou stejneï sï irokeâ epifyâzy a diafyâ zy strïednõâho cï laâ nku prostrïednõâho prstu a paâ teâ ho prstu. Stadium G, ktereâ koinciduje s erupcõâ dolnõâho sï picï aâ ku do dutiny uâ stnõâ, nastaâ vaâ pruê meï rneï 1 rok prïed vrcholem ruê stoveâ ho zrychlenõâ u chlapcuê a 5 meï sõâcuê prïed vrcholem ruê stoveâ ho zrychlenõâ u dõâvek, zaâ rovenï 0,4 roku prïed vrcholem ruê stoveâ ho zrychlenõâ byl jizï u 81 % osob prïõâtomnyâ adduktorovyâ sezamoid a u 87 % byl capping epifyâzy a diafyâzy strïednõâho cïlaâ nku trïetõâho a paâteâho prstu. H stadium vyâvoje dolnõâho sïpicïaâ ku nastalo nejcïasteï jis fuâ zõâ epifyâ z a diafyâz. HaÈ gg a Taranger udaâ vajõâ, zï e vrchol ruê stoveâ ho zrychlenõâ maâ teï sneï jsï õâ vztah ke kostnõâmu stadiu trïetõâho prstu nezï ke stadiu radia, nebo adduktoroveâ ho sezamoidu [3,13]. Buschang popsal velmi teï snyâ vztah mezi MP3cap a vrcholem ruê stoveâ ho zrychlenõâ. Vza jemneâ vztahy mezikostnõâm, teï lesnyâ m a sexuaâ lnõâm zraâ nõâm se ukazujõâ shodneï silneâ. Na zubnõâm zraâ nõâ jsou nezaâ visleâ [12]. Chertkow v roce 1980 dolozï ila mozï nost klinicky pouzï õât stadium G vyâvoje dolnõâho sïpicïaâ ku jako indikaâtoru pubertaâ lnõâho ruê stoveâ ho spurtu pro beï losï skeâ deïti [14]. Pancherz a Szyska ve sveâ studii z roku 2000, kteraâ zahrnovala 48 osob ve veïku8azï 12 let, sledovalikorelacimezimetodou hodnocenõâ kostnõâho veï ku krcï nõâch obratluê Hassela a Farmana a rentgenuê distaâ lnõâ cï aâ sti ruky podle HaÈ gga a Tarangera a vrcholem ruê stoveâho zrychlenõâ teï lesneâ ho ruê stu. Uva dõâ, zï e kefalogram muê zï e plneï nahradit rentgeny distaâ lnõâ cï aâ stiruky [15]. In 1995, Hassel and Farman compared SMI-CVMI groups and reported substantial anatomical characteristics of cervical vertebrae, unique for each group. Eleven SMI stages correspond to six CVIM stages. Bone maturation corresponds to the degree of bone ossification. Dimensions and maturation may alter independent to each other. Bone maturation is closely related to sexual development rather than to body growth. During the growth all bones undergo a series of changes which are seen in cephalograms. The order of changes is relatively stable for a bone of one individual person. Timing of changes may be different and corresponds to biological clocks of each individual. These phenomena can be reproduced, and thus they may become the basis for comparisons between different individuals [3]. In 1987, Litt and Vaughan studied growth reference data of American children. They found out that the growth spurt beginning corresponds to F phase, and G phase lasts 0.4 years on average before the maximum of growth spurt in girls, and 1.3 years in boys. Their results correspond to those given by Coutinho, Bushang and Miranda (1993) who studied the relationship between the lower canine development and hand bone maturation. The authors recommended to take the development of the lower canine as the indicator for children bone maturation [1]. They stated that indicators MP3, PP5 and sesamoid show the maximum correspondence with the development of the lower canine in both girls and boys. In F phase of the lower canine development, S does not usually occur yet; however, the epiphyses are as wide as diaphyses in the middle phalanx of third finger and the fifth finger. G phase, coinciding with the lower canine eruption, starts 1 year before the growth spurt in boys, and 5 months in girls. Adductor sesamoid was already present 0.4 years before the growth spurt in 81% of individuals, capping of epiphysis and diaphysis of the middle phalanx of the third and fifth fingers was found in 87% of individuals. H phase of the lower canine development was most often accompanied with fusion of epiphyses and diaphyses. HaÈ gg and Taranger report that the maximum of growth spurt is more closely related to the bone phase of third phalangs than to radium or adductor sesamoid phase [3,13]. Buschang described a very close relationship between MP3cap and the maximum of growth spurt. Relationships between skeletal, physical and sexual development are very strong. They are independent of dental maturation [12]. In 1980 Chertkow informed about the possible clinical use of G phase of the lower canine development as the indicator of pubertal growth spurt for Caucasian children [14]. In their 2000 study of 48 individuals between the age of 8 and 12, Pancherz and Szyska focused on the correlation of the assessment method of skeletal age of cervical vertebrae (Hassel and Farman), and X

14 rocïnõâk19 ORTODONCIE Snadne rozpoznaâ nõâ stadiõâ vyâ voje zubu, spolecï neï s beï zï neï pouzï õâvanyâ miintraoraâ lnõâmirentgeny a ortopanomogramy ve veï tsï ineï ortodontickyâ chadeï tskyâ ch stomatologickyâ ch praxõâch, jsou reaâ lnyâ m duê vodem pro zkusmeâ odhadnutõâ individuaâ lnõâho fyziologickeâ ho zraâ nõâ bez nutnostimnohonaâ sobneï zhotovovat rentgeny ruky a vycï kat s nimi azï do obdobõâ, kdy budou nezbytneï nutneâ pro leâ cï bu konkreâ tnõâho pacienta. Pohled na krcï nõâ obratle na kefalogramu pacienta muê zï e ortodontistovi pomociorientacïneï vyhodnotit kostnõâ veï k v daneâ chvõâli a poskytne mu zaâ rovenï informaci o tom, jakyâ ruêstmuêzïe v nejblizï sï õâ budoucnostiocï ekaâ vat. U neï kteryâ ch jedincuê vsï ak nejsou ruê stoveâ zmeï ny dostatecï neï zrïetelneâ a je tedy vhodneâ zhotovit rentgen ruky, zejmeâ na u dõâvek v obdobõâ spurtu, kdy korelace kostnõâch veï kuê nastala jen v SMI 1 (rovneâ epifyâ zy a diafyâ zy proximaâ lnõâho cïlaâ nku trïetõâho prstu), SMI 9 (fuâ ze epifyâzy a diafyâzy proximaâ lnõâho cïlaâ nku trïetõâho prstu), SMI 11 (fuâ ze epifyâzy a diafyâzy radia). RuÊ st je kontinuaâ lnõâ proces a indikaâ tory kostnõâho veï ku jsou pouze jasneï vymezeneâ dõâlcï õâ body v celeâm procesu ruê stu. KazÏda faâze ruê stu plynule prïechaâzõâ v naâsledujõâcõâ, proto nenõâ vzï dy snadneâ prïesneï zarïadit hranicïnõâprïõâpady. V souborech obou pohlavõâ jako nejzralejsï õâ indikaâ tory kostnõâho zraâ nõâ ruky nebyly zastizï eny SMI 1 (rovneâ epifyâzy a diafyâzy proximaâ lnõâho cïlaâ nku trïetõâho prstu), SMI 2 (rovneâ epifyâ zy a diafyâ zy mediaâ lnõâho cï laâ nku trïetõâho prstu), SMI 5 (capping epifyâ zy a diafyâ zy distaâ lnõâho cïlaâ nku trïetõâho prstu), cozï muêzïebyât zpuê sobeno vyâskytem teï chto indikaâ toruê v ranneï jsï õâm veï ku, nezï byla spodnõâ hranice veï koveâ ho rozmezõâ meâ ho souboru, daâle malyâ m souborem a veï tsï õâm podõâlem cï asneï zralyâch v souborech. Je mozïneâ,zï e pro odhad kostnõâho zraâ nõâjsou platneïjsïõâ pro obdobõâ ocï ekaâ vaâ nõâ ruê stu indikaâ tory kostnõâho zraâ nõâ ruky SMI 3 (rovneâ epifyâzy a diafyâzy mediaâ lnõâho cïlaâ nku paâteâ ho prstu) a SMI 4 (adduktorovyâ sezamoid) a pro spurt indikaâ tory kostnõâho zraâ nõâ ruky SMI 6 (capping epifyâzy a diafyâzy mediaâ lnõâho cïlaâ nku trïetõâho prstu) a SMI 7 (capping epifyâzy a diafyâzy mediaâ lnõâho cïlaâ nku paâteâho prstu), na rozdõâl od SMA dle Fishmana. RozdõÂly vyâ sledkuê teâ to studie vuê cï ifishmanoveï SMA, ale iobeï ma dalsï õâm metodaâ m, mohly nastat proto, zïe zde nebyl braâ n ohled na cï asneï, pruêmeï rneï a pozdneï zrajõâcõâ jedince a nesouladem mezi jednotlivyâmiveïky navzaâ jem. RozdõÂly vyâ sledkuê teâ to studie vuê cï iostatnõâm metodaâ m mohlo zpuê sobit pouheâ vizuaâ lnõâ hodnocenõâ krcï nõâch obratluê na kefalogramech, ale pro praxiby patrneï meïrïenõâ rozmeï ruê a uâ hluê obratlovyâch teï l mohlo byât cï asoveï naâ rocï neâ. rays of distal part of the hand (according to HaÈ gg and Taranger), and the maximum of body growth spurt. They came to the conclusion that a cephalogram can fully substitute radiographs of distal parts of hand [15]. Intraoral radiographs, OPGs, and rather easy recognition of the tooth development stages allow to estimate individual physiological maturation without multiple radiographs of hand. X-rays should be used only when required for the individual treatment plan made for a concrete patient. An orthodontist may assess actual skeletal age according to cervical vertebrae in cephalograms; he can also estimate the growth trend in the near future. However, in some individuals growth changes are not clear enough, and therefore, a hand radiograph is recommended esp. in girls at the period of growth spurt, in which the correlation of skeletal ages occurred only in SMI 1 (equal width of epiphyses and diaphyses of the proximal phalanx of the third finger), SMI 9 (fusion of epiphyses and diaphyses of the proximal phalanx of the third finger) and SMI 11 (fusion of epiphysis and diaphysis of radius). Growth should be seen as a continual process. Indicators of skeletal age are only points on the growth line. Each phase of growth passes smoothly into the following one; therefore, it is often difficult to decide about the borderline cases. SMI 1 (epiphyses and diaphyses of proximal phalanx of the third finger have equal width), SMI 2 (equal width of epiphyses and diphyses of medial phalanx of the third finger), SMI 5 (capping of epiphysis of distal phalanx of the third finger) were not recorded among the indicators of skeletal maturation of hand. This may be due to the occurrence of the indicators at the earlier age (which was not included in our sample), a small sample of individuals, and greater proportion of early mature individuals in the sample. It may be that SMI 3 (equal width of epiphyses and diaphyses of medial phalanx of the fifth finger), and SMI 4 (adductor sesamoid) are more important indicators at the period of growth expectation. SMI 6 (capping of epiphysis of medial phalanx of the third finger) and SMI 7 (capping of epiphysis of medial phalanx of the fifth finger) may be more appropriate indicators of growth spurt, contrary to SMA according to Fishman. Differences between our results and Fishman SMA, as well as the other two methods, may be due to the fact that we did not take into consideration individuals with early, average and late maturation, and also due to incongruity between individual ages. Differences may be also due to the fact that cervical vertebrae were evaluated only visually in cephalograms. Our study recorded high incidence of H phases of the lower canine development in girls. This suggests that in the sample there were more individuals with early dental maturation according to the lower canine

15 ORTODONCIE rocïnõâk19 U dõâvek se jevõâ v teâ to studii vysokyâ vyâskyt H stadiõâ zubnõâho vyâ voje dolnõâho sï pi cï aâ ku, v souboru bylo patrneï zastoupeno võâce osob s cï asnyâm zraâ nõâm podle vyâvoje dolnõâho sïpicïaâkuvuêcï iostatnõâm zraâ nõâm a projevil se vliv sexuaâ lnõâho dimorfismu. ZaÂveÏr 1. U obou pohlavõâ nebyl nalezen statisticky vyâznamnyâ vztah mezikostnõâm zraâ nõâm krcï nõâ paâ terïe a zubnõâm veï kem podle vyâvoje dolnõâho sïpicïaâ ku. 2. ZubnõÂ veï k podle vyâvoje dolnõâho sïpicïaâ ku nesouvisõâ s ostatnõâmivyâ vojovyâ misysteâ my a vykazuje nizï sï õâ kolõâsaânõâvzaâ vislosti na chronologickeâmveï ku a zdaâ se, zïe je kontrolovaâ n nezaâ visle. 3. Pro obeï pohlavõâ byl potvrzen statisticky vyâznamnyâ vztah mezikostnõâm zraâ nõâm ruky a zubnõâm veïkem podle vyâvoje dolnõâho sïpicïaâ ku, s vyâjimkou ulnaârnõâho sezamoidu, kde zaâ vislost nebyla zjisïteï na. 4. Korelace kostnõâho zraâ nõâ ruky a paâ terïe maâ teï sneïjsïõâ vztah nezï je vztah mezizraâ nõâm ruky a zubnõâm veï kem podle vyâvoje dolnõâho sïpicïaâ ku. 5. U chlapcuê byla potvrzena statistickaâ zaâ vislost kostnõâho zraâ nõâ ruky a kostnõâho zraâ nõâ krcï nõâ paâ terïe, pouze pro ulnaâ rnõâ sezamoid byla korelace slabsï õâ. PrÏesto variabilita byla zrïejmaâ. 6. U dõâvek nebyl vztah mezikostnõâm zraâ nõâm ruky a kostnõâm zraâ nõâm krcï nõâch obratluê nalezen. Pouze pro indikaâ tory kostnõâho zraâ nõâ ruky SMI 1 (rovneâ epifyâzy a diafyâzy proximaâ lnõâho cïlaâ nku trïetõâho prstu), SMI 9 (fuâ ze epifyâ zy a diafyâ zy proximaâ lnõâho cï laâ nku trïetõâho prstu) a SMI 11 (fuâ ze epifyâzy a diafyâzy radia) byl vyâsledek statisticky signifikantnõâ. 7. U chlapcuê je mozïneâ nahradit rentgen ruky hodnocenõâm zubnõâho veï ku na ortopantomogramu a kostnõâho zraâ nõâ krcï nõâch obratluê na kefalogramu, protozï e sama o sobeï korelujõâ s kostnõâm zraâ nõâm ruky, ale mezinimi vzaâ jemnaâ korelace nenõâ, takzï e z odhadu kefalogramu nelze odvodit stav zubnõâho vyâ voje a aninaopak z ortopantomogramu nelze usuzovat na stav zraâ nõâ paâ terïe. U dõâvek je mozïneâ nahradit rentgen ruky hodnocenõâm zubnõâho veï ku na ortopantomogramu, ale kostnõâ zraânõâ krcï nõâch obratluê na kefalogramu s kostnõâm zraâ nõâm ruky nekoreluje, kromeï trïõâ indikaâ toruê SMI 1, SMI 9 a SMI 11, ktereâ sevaâzïõâkuâ plneâ mu zacïaâ tku a konciruê stu. ProtozÏe nekoreluje kostnõâ zraâ nõâ krcïnõâ paâ terïe a zubnõâ vyâvoj navzaâ jem, nelze z pohledu na jeden ze snõâmkuê usuzovat na stadium zraânõâcïivyâvoje snõâmku druheâ ho. 8. Studie potvrdila, zï e z praktickeâ ho hlediska je zaâsadnõâ hodnotit jednotliveâ ho pacienta jako celek, braât vuâ vahu komplex vsï ech jeho projevuê ruê stu a vyâvoje zraânõâ,azï e nelze spoleâ hat jen na jednu vysï etrïovacõâ metodu. development, and the fact may be also due to the impact of sexual dimorphism. Conclusion 1. There was found no statistically significant relationship between skeletal maturation of cervical spine and dental age assessed according to the lower canine development (valid for both sexes). 2. Dental age set according to the lower canine development does not relate to other systems of development, and shows smaller oscillation in relation to chronological age. It seems that dental age is controlled independently. 3. There was proved statistically significant relationship between hand bone maturation and dental age according to the lower canine development (valid for both sexes), the only exception being ulnar sesamoid in which the relationship was not found. 4. There is closer relationship between skeletal maturation of hand and spine than between hand maturation and dental age according to the lower canine development. 5. In boys the statistical dependence of hand bone maturation and skeletal maturation of cervical spine was proved; only in case of ulnar sesamoid the correlation was not so strong. However, the variability is rather evident. 6. In girls the relationship between hand bone maturation and skeletal maturation of cervical vertebrae was not found. The results were statistically significant only for the indicators SMI 1 (equal width of epiphyses and diaphyses of proximal phalanx of the third finger), SMI 9 (fusion of epiphysis and diaphysis of proximal phalanx of the third finger), and SMI 11 (fusion of epiphysis and diaphysis of radius). 7. In boys the radiograph of a hand may be substituted with assessment of dental age in OPG, and skeletal maturation of cervical vertebrae in cephalogram, as they correlate with hand bone maturation. However, there is no correlation between them. Therefore, we cannot use cephalogram to estimate dental development or OPG to assess the spine maturation. In girls radiograph of a hand may be substituted with the assessment of dental age in OPG. However, skeletal maturation of cervical vertebrae in cephalogram does not correlate with hand bone maturation - with exception of SMI 1, SMI 9, and SMI 11 related to the very beginning and end of growth. Since cervical vertebrae maturation does not correlate with dental development, we cannot use one radiograph to assess maturation stage or development of the other radiograph. 8. Our study proved that it is fundamental to assess a patient as the whole, to consider all manifestations of growth and maturation, and that it is not acceptable to rely only on one examination method

16 rocïnõâk19 ORTODONCIE hips between mandibular canine calcification stages and skeletal maturity. Amer. J. Orthodont. dentofacial Orthop. 1993, 104, cï. 3, s KamõÂnek, M.; SÏ tefkovaâ, M.: Ortodoncie I. (skriptum). Olomouc: Nakladatelstvõ UP Olomouc, Hassel, B.; Farman, A. G.: Skeletal maturation evaluation using cervical vertebrae. Amer. J. Orthodont. dentofacial Orthop. 1995, 107, cï. 1, s Fishman, L. S.: Maturation patterns and prediction during adolescence. Angle Orthodont. 1987, 57, cï. 3, s Kra snicï anovaâ, H.; ZemkovaÂ, D.: RuÊ st a biologickyâ veïk. CÏ s. Pediat. 1991, 46, cï. 12, s Lebl, J.; Kra snicï anovaâ, H.: RuÊst deï tõâ a jeho poruchy, Praha: Galen, s. ISBN Kra snicï anovaâ, H.: Vztah sexuaâ lnõâ a kostnõâ maturace a hodnocenõâ biologickeâho veï ku v pediatrii. CÏ s. Pediat. 2005, 60, cï. 6, s BjoÈ rk, A.; Helm, S.: Prediction of the age of maximum puberal growth in body height. Angle Orthodont. 1967, 37, cï. 2, s Chapman, S. M.: Ossification of the adductor sesamoid and the adolescent growth spurt. Angle Orthodont. 1972, 42, cï. 3, s Fishman, L. S.: Chronological versus skeletal age, an evaluation of craniofacial growth. Angle Orthodont. 1979, 49, cï. 3, s Fishman, L. S.: Radiologic evaluation of skeletal maturation. Angle Orthodont. 1982, 52, cï. 2, s Demirjian, A.; Goldstein, H.; Tanner, J. M.: A new system of dental age assessment. Human Biology 1973, 45, cï. 2, s HaÈ gg, U.; Taranger, J.: Maturation indicators and the pubertal growth spurt (Abstract). Amer. J. Orthodont. 1982, 82, cï. 4, s Chertkow, S.: Tooth mineralization as an indicator of the pubertal growth spurt. Amer. J. Orthodont. 1980, 77, cï. 1, s Pancherz, H.; Szyska, M.: Analyse der Halswirbelkorper statt der Handknochen zur Bestimmung der skelettalen und somatischen Reife. Informationen aus Orthodontie & Kieferorthop., 2000, 32, cï. 2, s Literatura/References 1. Coutinho, S.; Buschang, P. H.; Miranda, F.: Relations- RozsÏteÏpy 2010 ± 1. informace OddeÏlenõ ortodoncie a rozsïteïpovyâch vad 3. LFUK FNKV Praha pro vaâs porïaâdaâ i v roce 2010 rozsïteïpovyâ seminaârï, ktereâho se kazïdorocïneï uâcïastnõâ prïednõâ cïesïtõâ odbornõâci na danou problematiku. Na rok 2010 pro VaÂs prïipravujeme takeâ prïednaâsïky zahranicïnõâch specialistuê. Akce se konaâ pod zaâsïtitou CÏ OS. Datum konaânõâ: CÏ as: , hod MõÂsto: OddeÏlenõ ortodoncie a rozsïteïpovyâch vad Stomatologicke kliniky FNKV Praha ± posluchaârna Dopolednõ cïaâst - pro postgraduaâlnõâ studenty ortodoncie: zaâkladnõâ principy leâcïby pacientuê s rozsïteïpem Odpolednõ cïaâst - pro odbornou verïejnost se zaâjmem o uvedenou problematiku Svou uâcïast, prosõâm, sdeïlte: BlizÏsÏõ informace: Dr. M. Kot'ovaÂ, Dr. W. UrbanovaÂ: MUDr. Agata Mohammad TrÏinec-OldrÏichovice, Kurz pro ortodontickeâ asistentky, technika otiskovaânõâ, praâce sestry v soukromeâ ordinaci Kontakt: MUDr. Agata Mohammad, tel.: , ,

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