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Application of periapical radiographic view of 4 mandibular permanent teeth

in orthodontic diagnosis

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J Bagh College Dentistry Vol. 23(1), 2011 Application of periapical radiographic

Application of periapical radiographic view of 4

mandibular permanent teeth in orthodontic diagnosis
Ali I. Al-Bustani B.D.S., M.Sc. (1)

ABSTRACT
Background: Orthodontic treatment decisions during puberty are greatly influenced by the growth phase of the
patient. The possibility of providing a simple approach for pubertal growth diagnosis was the aim of this study.
Materials and Methods: The stages of root development of the mandibular permanent dentition (excepting the third
molars) have been determined radiographically for 62 Iraqi orthodontic patients (33 males and 29 females) aged 11-
15 years.
Results: showed statistically non-significant difference between mandibular right and left dental developmental
stages.
Conclusion: A modified, simplified Dental Maturation Index [DMI] System has been presented, which is based on
examining 4 instead of 7 mandibular teeth as seen in a panoramic radiograph or 2 periapical radiographs.
Keywords: Dental Maturation, Pubertal Growth Prediction, Orthodontic Diagnosis. (J Bagh Coll Dentistry
2011;23(1):94-99).

INTRODUCTION MATERIALS AND METHODS

Orthodontic treatment is greatly carried out
during puberty. Various kinds of skeletal jaw
discrepancies are seen during this period which
can be corrected sufficiently by orthopaedic
appliances if the biological maturation of the
patient permits; otherwise, orthognathic surgery
may be required. So, pubertal growth phase
determination, whether accelerative or
decelerative, plays an important role in
orthodontic diagnosis and treatment planning.
Sexual maturation characteristics, hand-wrist
radiographs, and dental maturation assessment
are some of the common means used to identify
pubertal growth phases.(1-3)
The Dental Maturation Index [DMI]
System(4) is a modern technique for pubertal
growth estimation, which is based on the
determination of the root development for the 7
left permanent mandibular teeth as seen in the
dental panoramic radiograph. However, missing
of one or more of the 7 left permanent
mandibular teeth (excepting third molar) and/or
unavailability of panoramic radiographs
represent difficulties in applying the DMI
system. (4)
This study aimed, firstly, to verify the
possibility of using the periapical radiograph
depending on less number of teeth in applying
the DMI System, and secondly, to compare
between the developmental stages of the
mandibular permanent dentition on the right and
left sides in an attempt to use both sides for
substitution in the diagnosis.
(1) Assist. Prof. Dept. of Orthodontics, College of Dentistry,
University of Baghdad
The sample consisted of 62 healthy Iraqi
adolescent orthodontic patients (33 males and 29
females) between 11 and 15 years of age, none of
them had received previous orthodontic
treatment. Dental panoramic radiograph and 2
periapical radiographs have been taken for every
patient. The periapical radiographs have been
taken for the mandibular right side; one for the
canine and premolar region, and the other for the
second molar region.
The dental maturation of every patient was
assessed according to the method of Demirjian et
al., in which weighted scores are assigned to the
developmental stages of each of the 7 left
permanent mandibular teeth (excluding the third
molar) as seen radiographically (Table 1, Figure
1).(4-6)The sum of the numerical scores provides
an estimate of an individual dental maturation
percentage (DMP). The biological criteria for the
dental developmental stages are described in
table 2. The method just described has been
applied in this study on the mandibular
permanent right and left dentition (excluding the
third molars). Tables 3 and 4 show the
developmental stages of the 7 right and left
permanent mandibular teeth for the males and
females sample subjects, respectively, after
examining their radiographs.
RESULTS
As seen in tables 3 and 4, the central incisor
(I1), lateral incisor (I2), and the first molar (M1)
showed the final developmental stage [stage H]
in almost all the cases, i.e. full root development
with apex closure; whereas the canine (C), first
premolar (PM1), second premolar (PM2), and
the second molar (M2) showed more earlier
maturational stages [stages E, F, and G].

Orthodontics, Pedodontics and Preventive Dentistry94

J Bagh College Dentistry Vol. 23(1), 2011
Table 5 shows the number of matched cases
and the percentage of matching between the right
and left developmental stages of the 7
mandibular permanent teeth for the sample
subjects. All the teeth showed more than 75%
matching between the right and left sides.
Chi-square test has been applied to examine
the difference between the right and left
developmental stages for each tooth (Table 6).
The test showed a statistically non-significant
difference between the right and left sides; in
other words, all the teeth showed significant
coincidence between their right and left
developmental stages.
The Chi-square test has also been used to
examine the difference between the right and left
dental developmental stages for every subject in
the sample (Table 7). Again, most of the sample
subjects demonstrated non-significant difference
between their right and left dental developmental
stages. Only 5 out of 33 male cases and 4 out of
29 female cases showed significant difference.
DISCUSSION
The sample subjects have been selected to be
within the age range 11-15 years since the great
biological individual variation during this period
can lead to difficult determination for the
pubertal growth phase, whereas below and above
this age range the biological maturation for the
individual can be easily determined from the
general outlook (e.g. height of the individual,
appearance of secondary sexual characteristics,
etc.) without the need for a certain system for
biological determination.
The original Dental Maturation Index [DMI]
System (4) determines the pubertal growth phase
depending on the developmental stages of the 7
left permanent mandibular teeth as seen in the
panoramic radiograph. In fact, there are so many
cases in which a tooth or teeth may not be clear
on one side radiographically and/or they may be
congenitally missing or previously extracted, etc.
Therefore, an attempt to use the right and left
sides in diagnosis was one of the aims of this
study.
The Chi-square test revealed a statistically
non-significant difference between the right and
left developmental stages of all the teeth for both
Orthodontics, Pedodontics and Preventive Dentistry95
Application of periapical radiographic
of the males and females (Table 6). Furthermore,
a statistically non-significant difference has been
found between the right and left dental
developmental stages of each subject, excepting
5 of the males and 4 of the females (Table 7). In
other words, from the radiographic point of view,
the periapical radiographs can be relied on in
assessing the dental developmental stages when a
panoramic radiograph can not be obtained.
Moreover, these findings enable the substitution
between the right and left sides when, for any
reason, a tooth or more can not be verified
accurately on one side or in cases with previous
extraction or congenital missing. A high degree
of correlation between the right and left dental
developmental stages has also been demonstrated
by other researchers. (5-9)
When tables 3 and 4 are reviewed, it is clear
that certain teeth [I1, I2, and M1] showed the
final developmental stage [stage H] in almost all
the cases, in comparison with the other teeth [C,
PM1, PM2, and M2] which showed more earlier
developmental stages [E, F, and G]. This is
expected at this age range since the I1, I2, and
M1 are earlier than the other teeth in starting
their development.(10-12) This finding encouraged
the attempt to provide a simpler system
depending on less number of teeth through the
fixation of the sum of numerical scores of the I1,
I2, and M1. The developmental stages of the C,
PM1, PM2, and M2 have been tried in many
steps to develop a Modified DMI System [Figure
2] which gave the same pubertal growth phase
determination for the sample subjects through 3
steps only. The final step included fixation of the
sum of numerical scores of the I1, I2, and M1 at
their final developmental stage [stage H] (45.1
for males, 45 for females).
The Dental Maturation Percentage [DMP]
represents a precise and accurate estimation for
the biological maturation, (13-16) and it was
included in the final step of the original DMI
system (Figure 3). For this reason, great efforts
were done to include the calculation of the DMP
in the final step of the modified DMI system
which played a major role in resulting in similar
diagnosis.
J Bagh College Dentistry Vol. 23(1), 2011 Application of periapical radiographic

Table 1: Self-weighted scores for the dental Table 2: Biological criteria for determining
developmental stages(5,6) the dental developmental stages A to H(5,6).
Stage Stage Description
In both uniradicular and multiradicular teeth, a
Tooth 0 A B C D E F G H beginning of calcification is seen at the superior
A level of the crypt, in the form of an inverted cone
Boys or cones. There is no fusion of these calcified
M2 0.0 1.7 3.1 5.4 8.6 11.4 12.4 12.8 13.6 points.
Fusion of the calcified points forms one or
M1 0.0 5.3 7.5 10.3 13.9 16.8 B several cusps, which unite to give a regularly
outlined occlusal surface.
PM2 0.0 1.5 2.7 5.2 8.0 10.8 12.0 12.5 13.2
Enamel formation is complete at the occlusal
PM1 0.0 4.0 6.3 9.4 13.2 14.9 15.5 16.1 C a surface. Its extension and convergence toward the
cervical region is seen.
C 0.0 4.0 7.8 10.1 11.4 12.0
b The beginning of a dentinal deposit is seen.
I2 0.0 2.8 5.4 7.7 10.5 13.2 The outline of the pulp chamber has a curved
c shape at the occlusal border.
I1 0.0 4.3 6.3 8.2 11.2 15.1
The crown formation is completed down to the
Girls D a cementoenamel junction.

M2 0.0 1.8 3.1 5.4 9.0 11.7 12.8 13.2 13.8
M1 0.0 3.5 5.6 8.4 12.5 15.4
PM2 0.0 1.7 2.9 5.4 8.6 11.1 12.3 12.8 13.3
PM1 0.0 3.1 5.2 8.8 12.6 14.3 14.9 15.5
C 0.0 3.7 7.3 10.0 11.8 12.5
I2 0.0 2.8 5.3 8.1 11.2 13.8
I1 0.0 4.4 6.3 8.5 12.0 15.8
REFERENCES
1. Moorrees CFA, Fanning EA, Hunt EE. Age variation
of formation stages for ten permanent teeth. J Dent
Res 1963; 42: 1490-4.
2. Demirjian A et al. Interrelationships among measures
of somatic, skeletal, dental, and sexual maturity. Am
J Orthod 1985; 88(5): 433-8.
3. Sierra AM. Assessment of dental and skeletal
maturity – A new approach, Angle Orthod 1987;
3:194-208.
4. Hafez S, El-Zahid H, El-Kalla EH, Comparative
study of dental maturation between two groups of
Egyptian and Saudi children, Egypt Orthod J 1994; 9:
29-37.
5. Al-Bustani AI, Ismail AM, Al-Izzi MK. The dental
maturation as an indicator for the pubertal growth
estimation. J Coll Dentistry 2002; 13:42-54.
6. Demirjian A, Goldstein H, Tanner JM, A new system
of dental age assessment. Hum. Biol 1973; 45: 211-
27.
7. Demirjian A. Dentition, In: Falkner F and Tanner JM
(eds.), Human Growth, Vol. 2, New York, Plenum
Press, 1978. p. 413-44.
8. Nolla CM. The development of the permanent teeth.
J Dent Child 1960; 27(4): 254-63.
The superior border of the pulp chamber in
uniradicular teeth has a definite curved form,
being concave toward the cervical region. The
b
projection of the pulp horns, if present, gives an
outline like an umbrella top. In molars, the pulp
chamber has a trapezoidal form.
Beginning of root formation is seen in the form of
c a spicule .
E Uniradicular teeth
The walls of the pulp chamber now form straight
lines, whose continuity is broken by the presence
a of the pulp horn, which is larger than in the
previous stage.
b The root length is less than the crown height.
Molars
Initial formation of the radicular bifurcation is
a seen in the form of either a calcified point or a
semilunar shape.
b The root length is still less than the crown height.
F Uniradicular teeth
The walls of the pulp chamber now form a more
a or less isosceles triangle. The apex ends in a
funnel shape.
The root length is equal to or greater than the
b crown height.
Molars
The calcified region of the bifurcation has
developed further down from its semilunar stage
a
to give the roots a more definite and distinct
outline, with funnel-shaped endings.
The root length is equal to or greater than the
b crown height.
The walls of the root canals are now parallel
G a (distal root in molars).
The apical ends of the root canals are still
b partially open(distal root in molars).
The apical end of the root canal is completely
H a
closed (distal root in molars).
The periodontal membrane has a uniform width
b around the root and the apex .

Orthodontics, Pedodontics and Preventive Dentistry96

 J Bagh College Dentistry Vol. 23(1), 2011 Application of periapical radiographic

Table 3. The developmental stages of the 7 Table 4. The developmental stages of the 7
right and left permanent mandibular teeth right and left permanent mandibular teeth
(Males). (Females).
RIGHT LEFT RIGHT LEFT
Case M2 M1 PM2 PM1 C I2 I1 I1 I2 C PM1 PM2 M1 M2 Case M2 M1 PM2 PM1 C I2 I1 I1 I2 C PM1 PM2 M1 M2
1 E H F F FHH HHF F F H E 1 E H F G FHH HHF G F H E
2 F H F G FHH HHF G E H F 2 E H E F GH H H HG F E H E
3 E H F G FHH HHF G F H E 3 F H G G GH H H HH G G H F
4 F H F G GH H H HG G F H F 4 E G F G GG H H HG G F G E
5 E H E E FHH HHF E E H E 5 E G F F FHH HHF F F G E
6 E H E F FHH HHF F E H E 6 E H E E FHH HHF E E H E
7 E H E F FHH HHF F E H E 7 E H F G GH H H HG G F H E
8 E H F F FHH HHF F F H E 8 E H G G GH H H HG G F H E
9 F H E F FHH HHF F E H F 9 E G E F FHH HHF F E G E
10 E H F G F H H HHF G F H E 10 E H F F GH H H HG F F H E
11 E H G G G H H H HG G G G E 11 E G E G F H H HHF G E G E
12 G H H H G H H H HG G G H G 12 E H F G G H H H HG F F H E
13 F H F F GH H HHF F F H F 13 F G E F FHH HHF F E G E
14 F H G H G H H H HG H G H F 14 E H F F FHH HHF F F H E
15 G H G G G H H H HG H E H G 15 E H G G G H H H HG G F H F
16 F H F F GH H H HG F F H F 16 G H F H G H H H HG F G H G
17 G H G G G H H H HG G G H F 17 F H F G G H H H HG G F H F
18 G H G H G H H H HG G G H F 18 G H F F GH H H HG G G H G
19 F H F G G H H H HG G F H F 19 E H F F GH H H HH G G H F
20 F H E F GH H H HG G E H F 20 G H F G G H H H HG G F H G
21 F H G G G H H H HG G G H G 21 F H F G H H H H HH G F H F
22 G H H H H H H H HH G G H F 22 F H G G G H H H HG G G H F
23 H H H H H H H H HG H H H G 23 G H G H H H H H HG G G H F
24 F H G G F H H H HG G G H G 24 G H G G G H H H HG G G H G
25 G H G G G H H H HG G G H G 25 E H F F GH H H HG F F H F
26 G H F H G H H HHF H G H G 26 F H H H G H H H HG G G H F
27 G H G G H H H H HG G G H F 27 F H F G G H H H HG G F H F
28 G H G G G H H H HG G G H G 28 G H G G G H H H HG G G H G
29 F H G G G H H H HG G G H F 29 F H F F GH H H HG F F H F
30 F H G H F H H H HG G G H F
31 F H F H H H H H HG G G H F Table 5: Percentage of matching between
32 G H H H G H H H HG H H H G the right and left sides for the 7 mandibular
33 G H G H G H H H HG G F H G permanent teeth [Males and Females]
MALES FEMALES
Total Matched %of Total Matched %of
Tooth
Cases Cases Matching Cases Cases Matching
I1 33 33 %100 29 29 %100
I2 33 33 %100 29 28 %96.5
C 33 26 %78.8 29 26 %89.6
PM1 33 25 %75.7 29 23 %79.3
PM2 33 26 %78.8 29 23 %79.3
M1 33 32 %96.9 29 29 %100
M2 33 26 %78.8 29 24 %82.7

Orthodontics, Pedodontics and Preventive Dentistry97

J Bagh College Dentistry Vol. 23(1), 2011 Application of periapical radiographic

Table 6: Chi-square test between the

right and left developmental stages for
each tooth
Males Females
Tooth
P-value Sig. P-value Sig.
I1 1.0000 NS 1.0000 NS
I2 1.0000 NS 0.3221 NS
C 0.0663 NS 0.1460 NS
PM1 0.0884 NS 0.1151 NS
PM2 0.0540 NS 0.0806 NS
M1 0.3221 NS 1.0000 NS
M2 0.0548 NS 0.0764 NS

Table 7: Chi-square test between the

right and left dental developmental
stages for every subject
Males Females
Case No.
P-value Sig. P-value Sig.
1 0.3173 NS 0.3173 NS
2 0.3173 NS 0.3173 NS
3 0.3173 NS 0.0822 NS
4 0.3173 NS 0.0822 NS Figure 1: Developmental stages of the
5 0.3173 NS 0.3173 NS permanent dentition.(5,6)
6 0.3173 NS 0.3173 NS
7 0.3173 NS 0.3173 NS 9. Liliequist B, Lundberg M. Skeletal and tooth
8 0.0833 NS 0.0822 NS development. Acta Radiol 1971; 11: 97-112.
9 0.3173 NS 0.3173 NS 10. Scott JH, Symons NBB. Introduction to Dental
10 0.3173 NS 0.3173 NS Anatomy, 9th ed. Edinburgh, Churchill Livingstone:
11 0.0733 NS 0.3173 NS 1982. p. 3-7, 42, 154.
Woelfel JB, Scheid RC, Dental Anatomy: Its
12 0.0421 S 0.0833 NS Relevance to Dentistry, 5th ed, Baltimore, Williams
13 0.0522 NS 0.3173 NS and Wilkins Company, 1997: 2-3.
14 0.3173 NS 0.3173 NS 11. Brand RW, Isselhard DE, Anatomy of Orofacial
15 0.0622 NS 0.0833 NS Structures, 6th Edition, St. Louis, Mosby, 1998: 244-
16 0.3173 NS 0.0822 NS 247, 286-287.
17 0.0833 NS 0.3173 NS 12. Pelsmaekers B et al. The genetic contribution to
dental maturation, J Dent Res 1997; 76(7): 1337-40.
18 0.0722 NS 0.0411 S 13. Janson GR et al., Dental maturation in subjects with
19 0.3173 NS 0.0433 S extreme vertical facial types, Eur. J. Orthod., 1998:
20 0.0833 NS 0.3173 NS 20(1): 73-78.
21 0.0833 NS 0.3173 NS 14. Kotilainen J, Pirinen S. Dental maturity is advanced
22 0.0412 S 0.3173 NS in Fragile X syndrome, Am J Med Genet 1999;
23 0.0433 S 0.0433 S 83(4): 298-301.
15. Gaethofs M et al. Delayed dental age in boys with
24 0.0722 NS 0.3173 NS constitutionally delayed puberty. Eur J Orthod 1999;
25 0.3173 NS 0.3173 NS 21(6): 711-5.
26 0.0833 NS 0.0422 S
27 0.0833 NS 0.3173 NS
28 0.3173 NS 0.3173 NS
29 0.3173 NS 0.3173 NS
30 0.0423 S - -
31 0.0422 S - -
32 0.3173 NS - -
33 0.0833 NS - -

Orthodontics, Pedodontics and Preventive Dentistry98

 J Bagh College Dentistry Vol. 23(1), 2011 Application of periapical radiographic

At least 2 of the following teeth are

At < Stage F

STEP 1 C, PM2, M2 yes Accelerative Growth Phase

No
At least 2 of the followings
are attained:

STEP 2 v C at stage H yes Decelerative Growth Phase

v PM2 at stage H
v M2 at stage G or H

No
Calculate the Dental Maturation
Percentage for C,PM1,PM2,M2

v Add 45.1 for males

STEP 3 v Add 45 for females yes Accelerative Growth Phase

DMP < 97.6

No
Decelerative Growth Phase
Figure 2 : Schematic presentation of the Modified DMI System

Figure 3: The DMI [Dental Maturation Index] System for Pubertal Growth Estimation

Orthodontics, Pedodontics and Preventive Dentistry99

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