Hand wrist radiographs in orthodontics are obsolete

Surprisingly the hand wrist radiograph is part of the x-rays basically required in orthodontics. Generations of orthodontists believed to be able to predict the special growth spurt during puberty making use of hand wrist radiographs. On behalf of this prediction the orthodontic treatment should be planned at a perfect time which should lead to a shorter treatment duration and better results. This could be appreciated but are these commonly accepted ideas true?

The British Society for the Study of Orthodontics (BOS) has developed several guidelines for the use of radiographs in orthodontics throughout the last years. The fifth edition has been printed in 2016 and is available on the internet. The British guidelines are the most detailed scientific opinion on radiographs in orthodontics, represent an extraordinary pioneering work and are respectfully appreciated around the world. In this thirty-page edition the hand wrist radiographs are just mentioned in two lines: “The use of hand wrist radiographs to predict growth spurts has been shown not to be sufficiently accurate to be of value.“ According to the opinion of the BOS the hand wrist radiographs therefore have limited clinical application. Typically British – it’s not only mentioned but also proved by three diagnostic studies. These couldn’t show a high predictive accuracy of hand wrist radiographs. However,  a sufficient accuracy is required for every diagnostic technique. When there’s a lack of accuracy the technique isn’t valid, in other words: It hasn’t got any positive benefit for the intended purpose and shouldn’t be used. On one hand the hand wrist radiographs don’t show any validity and moreover are a burden for the patients because the radiation plays a potentially serious role in cancerization.

In this light it is truly astonishing that in 2016 the German Society of Orthodontics gave a comment on hand wrist radiographs which almost claims the opposite of the BOS guideline.

The question of validity of hand wrist radiographs isn’t even mentioned in that statement but silently assumed. Instead, the focus is set on describing medical indications and therapies for which hand wrist radiography is helpful in diagnostics. These are the retrusion of the lower jaw, the protrusion of the lower jaw, the anterior and posterior crossbite, the overbite, the open bite and dysgnathic surgery. Or how it is mentioned imprecisely and extensibly by the German Society of Orthodontics: “Skeletal facial malformations and malocclusions which should be treated during the physical growth phases and therefore require growth“ which is unfortunately given in most of the orthodontic treatments. It is all the more curious because in Germany early orthodontic treatment of the primary dentition before the growth spurt is quite common. Regarding this early treatment the hand wrist radiograph wouldn’t even be helpful if the predictive value was good.

Moreover the German Society of Orthodontics recommends the hand wrist radiograph to forecast physical growth even after the orthodontic treatment has been completed. This generous recommendation of a radiograph which lacks of validity by a scientific society isn’t evidence-based and should be revised. Fortunately most of the orthodontists don’t seem to use the hand wrist radiograph any more. Account data from the dentists’ association in North Rhine-Westphalia show that hand wrist radiographs have become a rarity in comparison to panoramic x-rays and cephs. It seems that hand wrist radiographs aren’t very important for modern orthodontics.

A tip for parents and patients: Please refuse a hand wrist radiograph if your orthodontist can’t prove its merits.

You can find a free download of the BOS guidelines here.

You can find a free download of the statement given by the German Society of Orthodontics here.


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