1. Introduction Malocclusion has a high prevalence among populations Malocclusion has a high prevalence among populations (Josefsson et al. 2007) (Josefsson et al. 2007) (Chew et al.2006) (Chew et al.2006) The need for orthodontic treatment among Saudi children is 60% The need for orthodontic treatment among Saudi children is 60% (Al Emran et al. 1990) (Al Emran et al. 1990)

2. Introduction In general, In general, class II is more prevalent class II is more prevalent than class III than class III (Danaie et al, 2006) (Danaie et al, 2006) (McLain et al, 1985) (McLain et al, 1985)

3. Introduction Bimaxillary protrusion and class III malocclusion prevalence is more in Saudi population than in western communities Bimaxillary protrusion and class III malocclusion prevalence is more in Saudi population than in western communities (Jones WB, 1987) (Jones WB, 1987)

4. Introduction Skeletal discrepancies, what is the cause?

5. Introduction The reason of skeletal discrepancies is the different growth potentials of different bones of the craniofacial complex The reason of skeletal discrepancies is the different growth potentials of different bones of the craniofacial complex (Riedel, 1952) (Riedel, 1952)

6. Introduction Orthopedic intervention is commonly used to affect the growth potential of skeletal components Orthopedic intervention is commonly used to affect the growth potential of skeletal components (Proffit et al, 1998) (Vig et al, 2000)

7. Introduction The pubertal growth spurt is typically used to modify the growth of the related structures The pubertal growth spurt is typically used to modify the growth of the related structures ( DiBiase A, 2002) ( DiBiase A, 2002) ( Arvystas MG, 1998) ( Arvystas MG, 1998)

8. Introduction How can we detect the How can we detect the “pubertal growth spurt”

9. Introduction The chronological age is a poor indicator of skeletal development The chronological age is a poor indicator of skeletal development (Fishman LS, 1979)

10. Introduction Many diagnostic tools were developed to aid in detection of the growth spurt Many diagnostic tools were developed to aid in detection of the growth spurt

11. Introduction Hand & wrist radiographs is the most commonly used and the most reliable tool Hand & wrist radiographs is the most commonly used and the most reliable tool (Bjork, 1972) (Grave, 1994) (Hagg et al, 1980)

12. Introduction Dental development was widely investigated as a potential predictor of skeletal maturity Dental development was widely investigated as a potential predictor of skeletal maturity (Sierra, 1987) (Anderson et al, 1975) (Green, 1961)

13. Introduction Dental maturity is either assessed by the tooth eruption stages or tooth calcification stages Dental maturity is either assessed by the tooth eruption stages or tooth calcification stages Tooth calicification stages are more reliable Tooth calicification stages are more reliable (Nolla, 1960) (Hotz, 1959)

14. Introduction The relationship between dental maturity and chronological age has been investigated in different populations The relationship between dental maturity and chronological age has been investigated in different populations (Green, 1961) (Uysal et al, 2004) (Krailassiri et al, 2002)

15. Introduction The ability to assess skeletal maturity by the dental development stages using the OPG has many advantages The ability to assess skeletal maturity by the dental development stages using the OPG has many advantages Dental development stages is easy to identify Dental development stages is easy to identify No need for additional exposure for H&W x-ray No need for additional exposure for H&W x-ray

16. Introduction The relationship between skeletal maturity and chronological age for Saudi male children has been recently established The relationship between skeletal maturity and chronological age for Saudi male children has been recently established (Al Hadlag et al, 2007) (Al Hadlag et al, 2007)

17. Introduction The aims: The aims: 1- to establish the dental age for a group of Saudi male children

18. Introduction The aims: The aims: 2- to establish the relationship between dental, skeletal, and chronological ages in the study sample

19. Introduction The aims: The aims: 3- to find the best dental maturity indicator of the skeletal maturity stage in the study sample

20. Materials & Methods The study is a cross sectional descriptive study The study is a cross sectional descriptive study 148 OPG 148 H&W radiographs were obtained from the records of patients attending Collage of Dentistry, KSU 148 OPG 148 H&W radiographs were obtained from the records of patients attending Collage of Dentistry, KSU

21. Materials & Methods Criteria: Criteria: 1- Saudi males with age ranges from 9 to 15 years 2- Free of any serious illness 3- With normal growth and development

22. Materials & Methods Criteria: Criteria: 4- With no abnormal dental condition, e.g. impaction, transposition and congenitally missing teeth 5- With no previous history of trauma or disease to the face and the hand- wrist region

23. Materials & Methods Criteria: Criteria: 6- With no history of orthodontic treatment

24. Materials & Methods Dental maturity: From the OPG From the OPG Using Demirjian method Using Demirjian method

25. Materials & Methods Demirjian method: 7 left mandibular teeth were used 7 left mandibular teeth were used Each tooth was given a letter Each tooth was given a letter from A to H from A to H Depending on its calcification stage Depending on its calcification stage

26. Materials & Methods Demirjian method: Then each tooth was given a score Then each tooth was given a score The total score of the teeth is converted into an age The total score of the teeth is converted into an age

27. Materials & Methods A cusp tips are calcified B calcified cusps are united C enamel formation is complete, dentin deposition has commeneced D crown formation is complete to the CEJ E the walls of the pulp chamber are straight, root length is less than crown hight, also radicular bifurcation is visible F the root length is equal to or greater than crown height, the apex has a funnel shape G walls of the root canal are parellel but apex is partially open H apex is completely closed, PDL space is uniform around root apex

28. Materials & Methods Skeletal maturity stages: From the Hand & Wrist From the Hand & Wrist Using the Fishman’s method Using the Fishman’s method 6 stages were used 6 stages were used

29. Materials & Methods Fishman’s method PP2: the epiphysis of the proximal phalanx of the second finger equals its diaphysis PP2: the epiphysis of the proximal phalanx of the second finger equals its diaphysis MP3: the epiphysis of the middle phalanx of the third finger equals its diaphysis MP3: the epiphysis of the middle phalanx of the third finger equals its diaphysis S stage: the first mineralization of the ulnar sesamoid bone S stage: the first mineralization of the ulnar sesamoid bone MP3cap: the epiphysis the middle phalanx of the third finger caps its diaphysis MP3cap: the epiphysis the middle phalanx of the third finger caps its diaphysis DP3u: complete epiphyseal union of the distal phalanx of the third finger DP3u: complete epiphyseal union of the distal phalanx of the third finger MP3u: complete epiphyseal union the middle phalanx of the third finger MP3u: complete epiphyseal union the middle phalanx of the third finger A pre-PP2 stage was assigned to any subject who has not reached PP2 stage. A pre-PP2 stage was assigned to any subject who has not reached PP2 stage.

30. Materials & Methods Skeletal age: “Greulich and Pyle’s Radiographic Atlas of Skeletal Development of the Hand and Wrist”

31. Materials & Methods One examiner took the dental assessments The other took the skeletal assessments Chronological age was taken by referring to records

32. Materials & Methods

33. Results Intra-examiner Reliability Intra-examiner Reliability Dental assessment (average) Skeletal age assessment Skeletal maturity assessment Spearman-Brown correlation 0.9350.9810.995

34. Sample distribution according to age Sample distribution according to age Mean age = 11.92 ± 1.49 Results

35. Results Comparison between skeletal and chronological ages Comparison between skeletal and chronological ages Age Group9 yrs10 yrs11 yrs12 yrs13 yrs14 yrs15 yrsTotal Skeletal age N524313629167148 Mean 9.0009.16710.53211.68112.70713.719 15.357 11.537 Std. Dev.0.7071.5441.4021.3640.8821.3661.4062.118 A-S0.0000.8330.4680.3190.2930.281-0.3570.382 P value1.000 0.015 * 0.0730.1690.0840.4230.526 0.001 *

36. Comparison between dental and chronological ages Comparison between dental and chronological ages Results Age Group 9 yrs10 yrs11 yrs12 yrs13 yrs14 yrs15 yrsTotal Dental age N524313629167148 Mean 10.1810.158 10.632 12.02813.02014.75015.84312.039 Std. Dev.0.6461.0501.0781.2721.7822.0101.7052.176 A-D-1.180-0.1580.368-0.028-0.020-0.750-0.843-0.120 P value 0.015 * 0.4680.0670.8960.9510.1560.2390.315

37. Results Investigation of the relation between skeletal and dental maturity markers Investigation of the relation between skeletal and dental maturity markers

41. Challenges No saudi literature No saudi literature 3000 records yielded only 130 pairs 3000 records yielded only 130 pairs DOB documentation is neglected DOB documentation is neglected Lack of digitalization of records Lack of digitalization of records We lacked previous knowledge about this issue We lacked previous knowledge about this issue