Skeletal maturation in Indonesian and white children assessed with hand-wrist and cervical vertebrae methods

Bridging gaps in age estimation: a cross-sectional comparative study of skeletal maturation using Fishman method and dental development using Nolla method among Egyptians

Estimating the chronological age of humans is a prevalent need in forensic practice. Comparing the accuracy of different age identification methods helps provide the most reliable method for a specific population. This study aimed to compare the accuracy of age assessments using skeletal maturation and dental mineralization in a sample of Egyptians and to assess if combining both methods yields more precise age prediction. A cross-sectional study included 176 Egyptian children and adolescents aged between 8 and 16 who underwent orthopantomograms and hand-wrist radiographs. All radiographs were scored independently for skeletal maturation using the Fishman method and dental development using the Nolla method. While Fishman and Nolla methods were valid and reliable age predictors with variable sex and age group accuracy in Egyptians, the Nolla method showed superior performance. The Nolla method slightly underestimated the chronological age, while the Fishman method slightly over-estimated it, showing median differences of -0.21 and 0.17, respectively. Correlating the estimated age using the Fishman and Nolla methods and the chronological age showed intraclass correlation coefficients of (0.854 and 0.660) and (0.973 and 0.977) for females and males, respectively (P < 0.001). The model adopting the Nolla score exhibited the highest R² (0.973 and 0.968) and the lowest Akaike information criteria (96 and 106) for females and males, respectively, which is comparable to the model adopting both Nolla scores and skeletal maturation indicators. Therefore, we recommend adopting the model incorporating only the Nolla scores for age estimation without the need for further hand and wrist radiography.

Comparison between Two Methods of Skeletal Growth Evaluation: Cervical Vertebrae Maturations and Middle Phalanx Maturation

Aim

Growth measurement has always been essential to identify the best time to employ orthopedic or orthodontic appliances. Optimal timing for orthodontic treatment is strictly linked to the identification of periods of craniofacial growth when treatment is more effective.The aim of this study was to compare two different methods, middle phalanx maturation (MPM) and cervical vertebrae maturation (CVM), used to evaluate the stage of facial growth.

Materials and methods

The research data was collected from July 2018 to April 2019 at the Dental Clinic of the San Gerardo Hospital in Monza. The study included a sample of 98 patients-46 males and 52 females. For each patient, a latero-lateral teleradiography of the skull and an X-ray on the middle finger of the right hand were obtained.The statistical analysis of the comparison of the stages of skeletal maturation obtained by the MPM and CVM methods was performed using the correlation coefficient for ranks of Spearman.

Results

A descriptive statistical analysis of the entire sample of 98 patients was performed (mean age of 12.2 years and median of 12.2 years). The average age of females in every single stage of MPM was significantly lower than the average age of males. Of the total sample, 87 patients (88.8%) showed complete agreement between the two methods.

Conclusion

The results obtained from the statistical analysis of this study allowed us to confirm a satisfactory agreement between the two methods.The intermediate phalanx method is a valid and alternative indicator to CVM for the identification of the puberty growth peak. We can, therefore, consider the MPM method a valid indicator of skeletal maturity.

How to cite this article

Mirabelli L, Bianco E, Pigato G, et al. Comparison between Two Methods of Skeletal Growth Evaluation: Cervical Vertebrae Maturations and Middle Phalanx Maturation. Int J Clin Pediatr Dent 2023;16(2):327-332.

Salivary IGF-1 and Alkaline Phosphatase-Based Modeling for Skeletal Maturity Prediction in Orthodontic Patients

RESULTS

A strong positive correlation was found between CA and cervical stages (r = 0.836, P < 0.001). Based on the regression model analysis, the model which combined IGF-1, ALP, and CA provided the best prediction at P < 0.001 with McFadden's pseudo R 2 value of 0.552 for cervical stage prediction and 0.646 for growth phase prediction. In particular, its predictive ability for the prepubertal, pubertal, and postpubertal growth phases was 95%, 80%, and 90%, respectively.

CONCLUSIONS

A new model with the combination of salivary IGF-1 and ALP with CA can be used as a less invasive method to determine the cervical stage and also growth phase with high predictive ability in healthy subjects.

Identification of dental calcification stages as a predictor of skeletal development phase

OBJECTIVE

This study aimed to establish a correlation between the stages of tooth calcification of mandibular canines and second molars with the phases of skeletal development.

METHODS

In a consecutive series of panoramic, cephalometric and hand-wrist radiographs of 113 individuals (60 females and 53 males) with an average age of 12.24 ± 1.81 years, the stages of mandibular canine and second molar calcification, cervical vertebrae maturation indicators (CVMI) and skeletal maturity indicators (SMI) were classified. The variables were correlated by means of the Spearman's Rank test: chronological age, SMI, CVMI and tooth calcification stages. In order to assess whether the CVMI and tooth calcification stages were significant predictors of the SMI, an ordinal regression analysis was carried out.

RESULTS

The stages of CVMI (OR = 16.92; CI 95% = 6.45-44.39; p< 0.001) and calcification of the second molars (OR = 3.22; CI 95% = 1.50-6.92; p= 0.003) were significant predictors of SMI, however similar result was not observed for canines (OR = 0.52, CI 95% = 0.18-1.54; p= 0.239). Calcification stage E for boys, and E and F for girls corresponded to the pre-peak phase of pubertal growth. Stages G and H for boys, and F and G for girls coincided with peak of growth. In the final growth phase, the majority of second molars presented with root apex closure (stage H).

CONCLUSION

The stages of calcification of the second molar may be considered predictors of the stage of skeletal development in the population studied.

Predictive accuracy of estimating mandibular growth potential by regression equation using cervical vertebral bone age

Introduction

The maturational changes both in size and shape of cervical vertebrae had been widely used not only to assess skeletal maturity but also to predict the same using regression equation. Thus, the aim of this cross-sectional study was to check the predictive accuracy of estimating mandibular growth potential in the North Indian population by regression equation of Mito et al.

Materials and Methods

A total of 200 subjects divided into two groups, Group I had 100 adult subjects (18-20 years) and Group II had 100 young subjects (9-14 years) were subdivided according to the gender (50 subjects in each group). Seven linear parameters on cervical vertebral bodies of C3 and C4 were measured to derive cervical vertebral age and applied to the regression equation to estimate the mandibular growth potential in Group II. The mandibular length was measured for both the groups from Co-Gn. The mean value of the actual mandibular length in Group I was statistically evaluated against the corresponding mean value of the predicted mandibular growth potential of Group II.

Results

The actual mandibular length (Group I) and calculated mandibular length obtained by adding mandibular growth potential (from regression equation) to the mandibular length of Group II did not differ significantly for both males and females. Chronological age showed a statistically significant difference and poor correlation with bone age, in Group II.

Conclusion

The regression equation of Mito et al. using cervical vertebral bone age has proven to be applicable and accurate in predicting mandibular growth potential in growing young Indian individuals and can be of diagnostic and prognostic value in growth modification procedures in Orthodontics.

Determination of Pubertal Growth Plot Using Hand-wrist and Cervical Vertebrae Maturation Indices, Dental Calcification, Peak Height Velocity, and Menarche

Introduction:

Pubertal growth stages are important periods in orthodontic treatment with functional appliances and orthognathic surgery. Pubertal growth prediction, which determines the amount of growth that has taken place and estimates the remaining growth, can influence diagnosis, treatment goals, treatment plans, and orthodontic treatment outcomes, especially in cases requiring growth intensity or growth completion. Determination of pubertal growth stages is more accurate when performed using physiological maturation indicators than chronological age. There are several maturation indices that can be used to predict the pubertal growth stage, such as hand-wrist maturation, cervical vertebrae maturation index (CVMS), dental calcification, peak height velocity of body height (PHV), and menarche in females. The aim of this study was to identify the differences and correlation between hand-wrist, CVMS maturation stages, peak height velocity (PHV), canine and M2 calcification stages, and menarche age (of female subjects). The study also aimed to describe the pubertal growth curve plot of female and male subjects.

Materials and Methods:

This is a retrospective study with a cross-sectional approach, which included 279 females and 144 males aged 8-17 years. Subjects had digital lateral cephalograms, hand-wrist, and panoramic radiographs. The hand-wrist maturation stage was analyzed using the Fishman method, CVMS using Baccetti et al.’s method, and the stages of dental maturation were assessed using Demirjian and Goldstein method. PHV was measured from standing height using a wall-mounted plastic stadiometer, while menarche was analyzed through interviews. Statistical analysis by ANOVA, post hoc analysis, and Spearman’s rank correlation coefficient were determined with Excel Mega Stat.

Results:

There were significant differences between females and males in CVMS and hand-wrist (P< 0.05) except for radius union (Ru). No significant differences in canine and M2 calcification between females and males were observed. PHV females increased by 7.89 cm at 11-12 years, while males increased by 9.9 cm at 13-14 years. Menarche occurred at the age of 12.2 years on average, with the oldest being 14.7 years and the youngest being 9.6 years. The correlation between females’ and males’ hand-wrist and CVMS was very high. The lowest correlation in females was between menarche and CVMS and in males, it was between PHV and canine.

Conclusion:

Maturation stages of hand-wrist, CVMS, and PHV females were earlier than males. Pubertal growth curves plot of females tended to skew to the left, demonstrating that the time from the beginning to the peak of pubertal growth is shorter than that from the peak to the end of pubertal growth, while pubertal growth curves plot of males tended to skew to the right, demonstrating that the time from the beginning to the peak of pubertal growth is longer than that from the peak to the end of pubertal growth.

Evaluation of Bone Age in Children: A Mini-Review

Bone age represents a common index utilized in pediatric radiology and endocrinology departments worldwide for the definition of skeletal maturity for medical and non-medical purpose. It is defined by the age expressed in years that corresponds to the level of maturation of bones. Although several bones have been studied to better define bone age, the hand and wrist X-rays are the most used images. In fact, the images obtained by hand and wrist X-ray reflect the maturity of different types of bones of the skeletal segment evaluated. This information, associated to the characterization of the shape and changes of bone components configuration, represent an important factor of the biological maturation process of a subject. Bone age may be affected by several factors, including gender, nutrition, as well as metabolic, genetic, and social factors and either acute and chronic pathologies especially hormone alteration. As well several differences can be characterized according to the numerous standardized methods developed over the past decades. Therefore, the complete characterization of the main methods and procedure available and particularly of all their advantages and disadvantages need to be known in order to properly utilized this information for all its medical and non-medical main fields of application.

Age estimation in the living: A scoping review of population data for skeletal and dental methods

Age estimation of living individuals has become a crucial part of the forensic practice, especially due to the global increase in cross-border migration. The low rate of birth registration in many countries, hence of identification documents of migrants, especially in Africa and Asia, highlights the importance of reliable methods for age estimation of living individuals. Despite the fact that a number of skeletal and dental methods for age estimation have been developed, their main limitation is that they are based on specific reference samples and there is still no consensus among researchers on whether these methods can be applied to all populations. Though this issue remains still unsolved, population information at a glance could be useful for forensic practitioners dealing with such issues. This study aims at presenting a scoping review and mapping of the current situation concerning population data for skeletal (hand-wrist and clavicle) and dental methods (teeth eruption and third molar formation) for age estimation in the living. Two hundred studies on the rate of skeletal maturation and four hundred thirty-nine on the rate of dental maturation were found, covering the period from 1952 and 2020 for a total of ninety-eight countries. For most of the western and central African countries there are currently no data on the rate of skeletal and dental maturation. The same applies to the countries of the Middle East, as well as the eastern European countries, especially as regard the skeletal development.

Evaluation of the reliability of a practical digital dental X-ray method for the first metacarpophalangeal joint to assist the skeletal age in peripubertal orthodontic period

OBJECTIVE

This study aimed to evaluate the validity of using of digital dental X-ray for the thumb region in assessment of skeletal maturation stage around functional orthodontic treatment time.

MATERIALS AND METHODS

The sample consisted of 200 patients (100 males and 100 females) aged between (9.5-18) years. Each patient underwent a hand-wrist radiograph and a digital radiograph for the thumb region taken by a dental X-ray machine. Skeletal changes were studied in the sesamoid bone and first Metacarpophalangeal joint region, and compared to Björk method.

RESULTS

Good correlation was noted between our thumb method stages (Th index) and hand-wrist maturation stages, so Th index has a good validity and reliability in assessment of maturation stages, in addition to its simplicity, accuracy and advantages in saving time, cost and decreasing radiographic exposure compared with hand-wrist maturation stages.

Bone age assessment with various machine learning techniques: A systematic literature review and meta-analysis

BACKGROUND

The assessment of bone age and skeletal maturity and its comparison to chronological age is an important task in the medical environment for the diagnosis of pediatric endocrinology, orthodontics and orthopedic disorders, and legal environment in what concerns if an individual is a minor or not when there is a lack of documents. Being a time-consuming activity that can be prone to inter- and intra-rater variability, the use of methods which can automate it, like Machine Learning techniques, is of value.

OBJECTIVE

The goal of this paper is to present the state of the art evidence, trends and gaps in the research related to bone age assessment studies that make use of Machine Learning techniques.

METHOD

A systematic literature review was carried out, starting with the writing of the protocol, followed by searches on three databases: Pubmed, Scopus and Web of Science to identify the relevant evidence related to bone age assessment using Machine Learning techniques. One round of backward snowballing was performed to find additional studies. A quality assessment was performed on the selected studies to check for bias and low quality studies, which were removed. Data was extracted from the included studies to build summary tables. Lastly, a meta-analysis was performed on the performances of the selected studies.

RESULTS

26 studies constituted the final set of included studies. Most of them proposed automatic systems for bone age assessment and investigated methods for bone age assessment based on hand and wrist radiographs. The samples used in the studies were mostly comprehensive or bordered the age of 18, and the data origin was in most of cases from United States and West Europe. Few studies explored ethnic differences.

CONCLUSIONS

There is a clear focus of the research on bone age assessment methods based on radiographs whilst other types of medical imaging without radiation exposure (e.g. magnetic resonance imaging) are not much explored in the literature. Also, socioeconomic and other aspects that could influence in bone age were not addressed in the literature. Finally, studies that make use of more than one region of interest for bone age assessment are scarce.

Validity of the Demirjian and Fishman Methods for Predicting Chronological Age Amongst Yemeni Children

Objectives

There has been an increasing need for reliable chronological age (CA) estimation in several aspects, including orthodontic treatment needs and legal, civil and forensic purposes. This study aimed to assess the validity of the Demirjian and Fishman methods in predicting the CA of Yemeni children.

Methods

This descriptive cross-sectional study was conducted at seven schools in Sana’a, Yemen, between December 2016 and December 2017. One orthopantomograph and one left hand-wrist X-ray were obtained for each child to calculate the dental age (DA) and skeletal age (SA) which were correlated and compared with the CA.

Results

A total of 358 Yemeni children aged 8–16 years were included in this study. The mean CA, DA and SA were 12.00 ± 2.25, 11.34 ± 2.42 and 12.39 ± 1.65 years, respectively. The Demirjian method significantly underestimated the CA by 0.58 ± 1.25 years in the total sample and 0.73 ± 1.30 and 0.40 ± 1.17 years in males and females, respectively (P <0.001). The Fishman method significantly underestimated the CA by 0.23 ± 1.19 and 0.44 ± 1.26 years in the total sample and in males, respectively (P ≤0.02). The Fishman method insignificantly underestimated the females CA by 0.02 ± 1.08 years (P = 0.898).

Conclusions

Yemeni CA is highly correlated to DA and SA estimated by the Demirjian and Fishman methods, respectively. The Fishman method was more accurate amongst Yemeni females. Results showed that Yemeni children are delayed in dental development and skeletal maturity.

Staging hand-wrist and cervical vertebrae images: a comparison of reproducibility

OBJECTIVES

The aim of this study was to compare the reproducibility of skeletal maturation assessments by raters with similar orthodontic experience using hand-wrist (HW) and cervical vertebral maturation (CVM) methods.

METHODS

HW and lateral cephalometric radiographs from 15 subjects (8 males and 7 females; ages, 9-16 years) were selected randomly. HW skeletal maturation was evaluated by the method of Greulich and Pyle, and CVM staging was evaluated by the method of Baccetti et al. Six orthodontic residents evaluated all images at three time periods: T₁, initial evaluation; T₂, re-evaluation after 7 days and T₃, final evaluation after 5 weeks. Intra- and interexaminer reproducibility was evaluated with the intraclass correlation coefficient; the limits of agreement (LoA) were determined by using the Bland-Altman method.

RESULTS

The intraexaminer reliability assessed by intraclass correlation coefficient was scored as good for both of methods (T₁-T₂-T₃ HW = 0.89 and CVM = 0.80; T₁-T₂ HW = 0.87 and CVM = 0.77; T₂-T₃ HW0 = 0.90 and CVM = 0.81), as well as the interexaminer evaluation, with the exception of HW-T₁, which scored excellent (0.92). The width of LoA from Bland-Altman plot of cervical vertebra method was narrower (CVM T₁-T₂: -2.3 and +1.8; CVM T₂-T₃: -2.0 and +2.0) than the HW method (HW T₁-T₂: -3.9 and +4.8; HW T₂-T₃: -4.0 and +3.5).

CONCLUSIONS

Both HW and CVM methods presented good reproducibility for intra- and interexaminer correlation assessments. The small LoA indicated that the CVM is a reproducible method.

The Difference in Cervical Vertebral Skeletal Maturation between Cleft Lip/Palate and Non-Cleft Lip/Palate Orthodontic Patients

Objective

The aim was to evaluate differences in the cervical vertebral skeletal maturity of unilateral cleft lip and palate (UCLP) and non-cleft lip/palate (non-CLP) Saudi male orthodontic patients.

Method

This cross-sectional multicenter study took place at the dental school, King Saud University and King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia, between October 2014 and September 2015. The records of Saudi male orthodontic patients with UCLP (n = 69) were collected. Cervical vertebral maturation was assessed using their cephalometric radiographs. The records of 138 age-matched non-CLP Saudi male orthodontic patients served as controls.

Results

There was a significant difference in skeletal maturity between the UCLP and non-CLP groups, as evident in the delayed skeletal development among the UCLP participants. Moreover, pubertal growth spurt onset was significantly earlier in the non-cleft participants in comparison with the UCLP participants (p = 0.009).

Conclusions

There is delayed skeletal maturity among the UCLP Saudi male population in comparison with their non-CLP age-matched peers.

Bone Age: A Handy Tool for Pediatric Providers

Pediatricians have relied on methods for determining skeletal maturation for >75 years. Bone age continues to be a valuable tool in assessing children's health. New technology for bone age determination includes computer-automated readings and assessments obtained from alternative imaging modalities. In addition, new nonclinical bone age applications are evolving, particularly pertaining to immigration and children's rights to asylum. Given the significant implications when bone ages are used in high-stake decisions, it is necessary to recognize recently described limitations in predicting accurate age in various ethnicities and diseases. Current methods of assessing skeletal maturation are derived from primarily white populations. In modern studies, researchers have explored the accuracy of bone age across various ethnicities in the United States. Researchers suggest there is evidence that indicates the bone ages obtained from current methods are less generalizable to children of other ethnicities, particularly children with African and certain Asian backgrounds. Many of the contemporary methods of bone age determination may be calibrated to individual populations and hold promise to perform better in a wider range of ethnicities, but more data are needed.

Estimation of Correlation between Chronological Age, Skeletal Age and Dental Age in Children- A Cross-sectional Study

Introduction

In the modern era, identification and determination of age is imperative for diversity of reasons that include disputed birth records, premature delivery, legal issues and for validation of birth certificate for school admissions, adoption, marriage, job and immigration. Several growth assessment parameters like bone age, dental age and the combination of both have been applied for different population with variable outcomes. It has been well documented that the chronological age does not necessarily correlate with the maturational status of a child. Hence, efforts were made to determine a child's developmental age by using dental age (calcification of teeth) and skeletal age (skeletal maturation).

Aim

The present study was aimed to correlate the chronological age, dental age and skeletal age in children from Southeastern region of Andhra Pradesh, India.

Materials and Methods

Out of the total 900 screened children, only 100 subjects between age groups of 6-14 years with a mean age of 11.3±2.63 for males and 10.77±2.24 for females were selected for the study. Dental age was calculated by Demirjian method and skeletal age by modified Middle Phalanx of left hand third finger (MP3) method. Pearson's and Spearman's correlation tests were done to estimate the correlation between chronological, dental and skeletal ages among study population.

Results

There was a significant positive correlation between chronological age, dental age and all stages of MP3 among males. Similar results were observed in females, except for a non-significant moderate correlation between chronological age and dental age in the H stage of the MP3 region.

Conclusion

The results of the present study revealed correlation with statistical significance (p<0.05) between chronological, dental and skeletal ages among all the subjects (48 males and 52 females) and females attained maturity earlier than males in the present study population.

Determination and correlation of lower limb anatomical parameters and bone age during skeletal growth (based on 1005 cases)

The aim of this study was to evaluate bone age and its correlation with the lower limbs' developing skeletal anatomy during growth. 1005 children and young adults were evaluated for bone age and 14 different parameters measured on lower-limb reconstructions from radiological examinations carried out with an EOS 2D/3D system in the course of routine orthopedic indicated diagnostic practice. Cervical vertebral morphology evaluation for bone age using the Hassel-Farman method, which describes six stages of maturity, was selected. Intra- and inter-observer reliability tests for this method, and for the EOS 3D reconstructions were performed. Statistical analysis were performed using Spearman correlation, multiple linear regression, and t-test. The intra- and inter-observer reliability of the Hassel-Farman method and the EOS 3D lower-limb reconstruction were found to be excellent. Interestingly one bone age stage could include individuals across a 12.1 year range, and conversely individuals of the same calendar age could be of one of 3.2 different bone age stages. In the prepubertal age groups all six bone stages could be observed. Bone age revealed a stronger relationship, lower standard deviations with groups and proved to be a better discriminating variable than the calendar age by collodiaphyseal angle, femoral, and tibial torsion, femorotibial rotation, and mechanical tibiofemoral angle. Bone age is an indicator of skeletal maturity and may more accurately describe the growth of some lower limb parameters. As a result we suggest the consideration of bone age when evaluating lower-limb biomechanic-anatomical parameters. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1431-1441, 2017.

Ossification of the Medial Clavicular Epiphysis on Chest Radiographs: Utility and Diagnostic Accuracy in Identifying Korean Adolescents and Young Adults under the Age of Majority

The aim of our study was to evaluate the utility and diagnostic accuracy of the ossification grade of medial clavicular epiphysis on chest radiographs for identifying Korean adolescents and young adults under the age of majority. Overall, 1,151 patients (age, 16-30) without any systemic disease and who underwent chest radiography were included for ossification grading. Two radiologists independently classified the ossification of the medial clavicular epiphysis from chest radiographs into five grades. The age distribution and inter-observer agreement on the ossification grade were assessed. The diagnostic accuracy of the averaged ossification grades for determining whether the patient is under the age of majority was analyzed by using receiver operating characteristic (ROC) curves. Two separate inexperienced radiologists assessed the ossification grade in a subgroup of the patients after reviewing the detailed descriptions and image atlases developed for ossification grading. The median value of the ossification grades increased with increasing age (from 16 to 30 years), and the trend was best fitted by a quadratic function (R-square, 0.978). The inter-observer agreements on the ossification grade were 0.420 (right) and 0.404 (left). The area under the ROC curve (AUC) was 0.922 (95% CI, 0.902-0.942). The averaged ossification scores of 2.62 and 4.37 provided 95% specificity for a person < 19 years of age and a person ≥ 19 years of age, respectively. A preliminary assessment by inexperienced radiologists resulted in an AUC of 0.860 (95% CI, 0.740-0.981). The age of majority in Korean adolescents and young adults can be estimated using chest radiographs.

Reliability of cervical vertebral maturation staging

INTRODUCTION

Growth and its prediction are important for the success of many orthodontic treatments. The aim of this study was to determine the reliability of the cervical vertebral maturation (CVM) method for the assessment of mandibular growth.

METHODS

A group of 20 orthodontic clinicians, inexperienced in CVM staging, was trained to use the improved version of the CVM method for the assessment of mandibular growth with a teaching program. They independently assessed 72 consecutive lateral cephalograms, taken at Liverpool University Dental Hospital, on 2 occasions. The cephalograms were presented in 2 different random orders and interspersed with 11 additional images for standardization. The intraobserver and interobserver agreement values were evaluated using the weighted kappa statistic.

RESULTS

The intraobserver and interobserver agreement values were substantial (weighted kappa, 0.6-0.8). The overall intraobserver agreement was 0.70 (SE, 0.01), with average agreement of 89%. The interobserver agreement values were 0.68 (SE, 0.03) for phase 1 and 0.66 (SE, 0.03) for phase 2, with average interobserver agreement of 88%.

CONCLUSIONS

The intraobserver and interobserver agreement values of classifying the vertebral stages with the CVM method were substantial. These findings demonstrate that this method of CVM classification is reproducible and reliable.

Correlation between cervical vertebral maturation and chronological age in a group of Iranian females

BACKGROUND

Correlation between chronological age at different stages of cervical vertebral maturation (CVM) is important in clinical orthodontic practice. The objective of this study was to evaluate the correlation between CVM stage and chronological age in a group of Iranian female patients.

MATERIALS AND METHODS

This study was conducted on 196 digital lateral cephalometry of female patients with the age ranged 9-14 years. The CVM stage was determined with two calibrated examiners, using the method developed by Baccetti and its correlation with mean chronological age was assessed by the Spearman rank-order. The intra and inter-agreements were evaluated by weighted Kappa statistics in overall diagnosis of stages, in addition to determination of presence or absent of concavities at the lower border of second, third and fourth cervical vertebrae and the shapes of the third and fourth vertebrae. P < 0.05 was considered as significant.

RESULTS

The correlation coefficient between CVM stages and chronological age was relatively low (r = 0.62). The least amount of inter-observer agreement was determined to be at the clinical decision of the shape of the fourth vertebra.

CONCLUSION

Regarding the low reported correlation, the concomitant usage of other skeletal indicators seems necessary for precise determination of physiological age of the patients.

Accuracy of two dental and one skeletal age estimation methods in 6-16 year old Gujarati children

Introduction:

Age estimation is of immense importance not only for personal identification but also for treatment planning in medicine and dentistry. Chronologic age conveys only a rough approximation of the maturational status of a person, hence dental and skeletal ages have been explored as maturity indicators since decades. The tooth maturation provides a valuable indicator of dental age and serves as a better index of the maturation of a child as compared to other maturity indicators.

Aims and Objectives:

To test the applicability of Demirjian's and Willem's dental age assessment methods as well as Greulich and Pyle skeletal age assessment method in children residing in Gandhinagar district.

Materials and Methods:

The study consisted of randomly selected 180 subjects (90 males and 90 females) ranging from 6 to 16 years age and residing in Gandhinagar district. Dental age estimation was performed from radiovisuograph (RVG) images of mandibular teeth of left quadrant by both Demirjian's and Willem's methods. Skeletal age estimation was done from right hand wrist radiograph by Greulich and Pyle method. The differences between the chronological age and the estimated dental and skeletal ages were statistically tested using paired ‘t’ test. The correlation between chronological age, dental and skeletal age estimation methods was confirmed statistically by Pearson's correlation. The reproducibility of the estimations was statistically tested using the Pearson's Chi-square test.

Results:

Amongst the age estimation methods used in this study, the Willem's dental age estimation method proved to be the most accurate and consistent.

Conclusion:

Although various age estimation methods do exist, the results are varied in different populations due to ethnic differences. However, till new tables are formulated, the Willem's method (Modified Demirjian method) can be accurately applied to estimate chronological age for the population residing in Gandhinagar district.

The cervical vertebrae maturation (CVM) method cannot predict craniofacial growth in girls with Class II malocclusion

INTRODUCTION

The cervical vertebrae maturation (CVM) method is used to determine the timing of treatment of Class II malocclusion. Because its performance has not been tested in patients with Class II, the objective of this study was to evaluate the effectiveness of the CVM method in predicting craniofacial growth in Class II malocclusion.

METHODS

Twenty-nine untreated girls with Class II malocclusion were identified among participants of the Nijmegen Growth Study. Each girl had a series of cephalograms taken semi-annually from 9 to 14 years of age. The CVM status was established by five observers on a cephalogram taken at 9 years; mandibular and maxillary length and anterior face height were assessed on all available cephalograms. Method error was evaluated with kappa statistics and Bland-Altman (BA) plots. Regression analysis was used to determine if CVM grade can predict the amount of facial growth.

RESULTS

The mean kappa for intra-rater agreement during grading with CVM was 0.36 (fair agreement). BA plots demonstrated acceptable agreement for cephalometric measurements. The regression analysis demonstrated that the only chronologic age was associated with the facial growth. The largest effect of age was for condylion-gnathion (Cd-Gn) and articulare-gnathion (Ar-Gn)-for every additional 6 months the Cd-Gn increases by 1.8mm [95 per cent confidence interval (CI): 1.7, 1.9, P < 0.001] and Ar-Gn increases by 1.59mm (95 per cent CI: 1.52, 1.67, P < 0.001). The CVM grade could not predict the change of cephalometric variables.

CONCLUSIONS

There is no evidence to support the hypothesis that the CVM method can predict the amount of craniofacial growth in girls with Class II malocclusion.

[Contribution of the cervical vertebral maturation (CVM) method to dentofacial orthopedics: update]

The successful orthopedic treatment of skeletal Class II malocclusions is closely related to the reasoned determination of the optimal time to initiate the treatment. This is why various methods have been proposed to assess skeletal maturation, such as a hand-wrist radiograph or the cervical vertebral maturation (CVM) method. The hand-wrist radiograph was up to now the most frequently used method to assess skeletal maturation. However, the clinical and biological limitations of this technique, as well as the need to perform an additional radiograph, were reasons to develop another method to explore the maturation stages of visible cervical vertebrae on a simple lateral cephalometric radiograph. The authors compare the 2 methods and prove the greater contribution of the CVM method compared to the hand-wrist radiograph.

The skeletal maturation status estimated by statistical shape analysis: axial images of Japanese cervical vertebra

OBJECTIVES

To evaluate axial cervical vertebral (ACV) shape quantitatively and to build a prediction model for skeletal maturation level using statistical shape analysis for Japanese individuals.

METHODS

The sample included 24 female and 19 male patients with hand-wrist radiographs and CBCT images. Through generalized Procrustes analysis and principal components (PCs) analysis, the meaningful PCs were extracted from each ACV shape and analysed for the estimation regression model.

RESULTS

Each ACV shape had meaningful PCs, except for the second axial cervical vertebra. Based on these models, the smallest prediction intervals (PIs) were from the combination of the shape space PCs, age and gender. Overall, the PIs of the male group were smaller than those of the female group. There was no significant correlation between centroid size as a size factor and skeletal maturation level.

CONCLUSIONS

Our findings suggest that the ACV maturation method, which was applied by statistical shape analysis, could confirm information about skeletal maturation in Japanese individuals as an available quantifier of skeletal maturation and could be as useful a quantitative method as the skeletal maturation index.

Maturation of the middle phalanx of the third finger and cervical vertebrae: a comparative and diagnostic agreement study

OBJECTIVE

Diagnostic agreement on individual basis between the third middle phalanx maturation (MPM) method and the cervical vertebral maturation (CVM) method has conjecturally been based mainly on overall correlation analyses. Herein, the true agreement between methods according to stage and sex has been evaluated through a comprehensive diagnostic performance analysis.

SUBJECTS AND METHODS

Four hundred and fifty-one Caucasian subjects were included in the study, 231 females and 220 males (mean age, 12.2 ± 2.5 years; range, 7.0-17.9 years). The X-rays of the middle phalanx of the third finger and the lateral cephalograms were examined for staging by blinded operators, blinded for MPM stages and subjects' age. The MPM and CVM methods based on six stages, two pre-pubertal (1 and 2), two pubertal (3 and 4), and two post-pubertal (5 and 6), were considered. Specifically, for each MPM stage, the diagnostic performance in the identification of the corresponding CVM stage was described by Bayesian statistics.

RESULTS

For both sexes, overall agreement was 77.6%. Most of the disagreement was due to 1 stage apart. Slight disagreement was seen for the stages 5 and 6, where the third middle phalanx shows an earlier maturation.

CONCLUSIONS

The two maturational methods show an overall satisfactorily diagnostic agreement. However, at post-pubertal stages, the middle phalanx of the third finger appears to mature earlier than the cervical vertebrae. Post-pubertal growth phase should thus be based on the presence of stage 6 in MPM.

Digital radiographic evaluation of hand-wrist bone maturation and prediction of age in South Indian adolescents

BACKGROUND

In the growing years, indicators of the level of maturational development of the individual provide the best means for evaluating biologic age and the associated timing of skeletal growth. The relative stage of maturity of a child may be determined by comparing the child's hand-wrist radiograph to the known standards of skeletal development.

AIMS AND OBJECTIVES

In this study, we assessed various levels of skeletal maturation and also identified the relationship between chronological age (CA) and maturation stage using the hand-wrist radiographs in adolescents of Indian origin.

MATERIALS AND METHODS

Three hundred and thirty hand-wrist digital radiographs of individuals aged 8 to 18 years were evaluated for skeletal maturity levels using Fishman's method. The data was analysed using the SPSS software package (version 12, SPSS Inc., Chicago, IL, USA). Regression analysis was performed for calculating bone age of both males and females. Spearman's rank-order correlation coefficients were estimated separately for males and females to assess the relation between CA and maturation level.

RESULTS

An association between skeletal maturation indicator stages and CA (r = 0.82) was significant. Interestingly, female subjects were observed to be advanced in skeletal maturity compared to males. Regression equations were derived to calculate bone age in males, females and the whole sample.

CONCLUSION

The results of this study showed significant association between hand-wrist skeletal maturation levels and CA. Digital radiographic assessment of hand-wrist skeletal maturation can be used as a better choice for predicting average bone age of an individual because of its simplicity, reliability and lesser radiation exposure.

The reliability of Fishman method of skeletal maturation for age estimation in children of South Indian population

Introduction:

Determining the age of a person in the absence of documentary evidence of birth is essential for legal and medico-legal purpose. Fishman method of skeletal maturation is widely used for this purpose; however, the reliability of this method for people with all geographic locations is not well-established.

Aims and Objectives:

In this study, we assessed various stages of carpal and metacarpal bone maturation and tested the reliability of Fishman method of skeletal maturation to estimate the age in South Indian population. We also evaluated the correlation between the chronological age (CA) and predicted age based on the Fishman method of skeletal maturation.

Materials and Methods:

Digital right hand-wrist radiographs of 330 individuals aged 9-20 years were obtained and the skeletal maturity stage for each subject was determined using Fishman method. The skeletal maturation indicator scores were obtained and analyzed with reference to CA and sex. Data was analyzed using the SPSS software package (version 12, SPSS Inc., Chicago, IL, USA).

Results:

The study subjects had a tendency toward late maturation with the mean skeletal age (SA) estimated being significantly lowers (P < 0.05) than the mean CA at various skeletal maturity stages. Nevertheless, significant correlation was observed in this study between SA and CA for males (r = 0.82) and females (r = 0.85). Interestingly, female subjects were observed to be advanced in SA compared with males.

Conclusion:

Fishman method of skeletal maturation can be used as an alternative tool for the assessment of mean age of an individual of unknown CA in South Indian children.

Correlation between three-dimensional morphological changes of the hyoid bone with other skeletal maturation methods in adolescents

OBJECTIVE

The study compares growth changes of hyoid bone in cone-beam computed tomography (CBCT) with conventional skeletal maturation methods to examine their potential implications in the development of a three-dimensional method.

STUDY DESIGN

Subjects (n = 62, 11-17 years of age) were exposed to CBCT at a six-month interval (T1/T2/T3). Ten-hyoid distances were compared with age, hand wrist skeletal maturation index (SMI), and cervical vertebral maturation stage (CS).

RESULTS

The length of greater cornua (GC) was most frequently, moderate to highly correlated with age (right: 0.57/0.53/0.58; left: 0.45/0.50/0.48), SMI (right: 0.52/0.40/0.45; left: 0.42 at T3), and CS (right: 0.52 at T1), followed by the length of the hyoid bone with age (right: 0.50/0.49/0.47; left: 0.44/0.47 at T1/T2), SMI (right: 0.45/0.41 at T1/T2), and CS (right: 0.48 at T1). The width of body of the hyoid (HB) width was correlated with age (0.43/0.44/0.44). The GC-HB gap was correlated with age (right: -0.41 at T3) and SMI (right: -0.42 at T1).

CONCLUSION

Peripubertal hyoid maturation did not yield sufficient diagnostic information for considerations in the development of a 3D-skeletal maturation method.

Objective evaluation of cervical vertebral bone age' its reliability in comparison with hand-wrist bone age: by TW3 method

AIM

The aim of this study was to establish the validity of a new method for evaluating skeletal maturation by assessing the 3rd and 4th cervical vertebrae seen in the cephalometric radiograph.

MATERIALS AND METHODS

This study consisted of a sample of 50 patients in the age group of 8 to 14 years of age. Chronologically, they were divided into six groups, based on the age consisting of a minimum of six to a maximum of 10 subjects. All the patients included in the study were females. The selected subjects were clinically examined and then age and date of birth of the patient in years and months was noted. Then lateral cephalograms and hand-wrist radiographs of the patient were taken on the same day with good clarity and contrast.

RESULTS

The results suggested that cervical vertebral bone age on cephalometric radiographs calculated with this method is as reliable at estimating bone age as is the Tanner-Whitehouse 3 (TW3) method on hand-wrist radiographs. By determining the cervical vertebral bone age, skeletal maturity can be evaluated in a detailed and objective manner with cephalometric radiographs.

CONCLUSION

The ability to accurately appraise skeletal maturity from cervical vertebral maturation, without the need for additional radiographs, has the potential to improve orthodontic diagnostic and therapeutic decisions. The technique's simplicity and ease of use should encourage this method as a frst level diagnostic tool to assess skeletal maturation. Clinical signifcance: This study revealed that the timing and sequence of ossifcation of the bones in hand and wrist and cervical vertebrae were able to relate the skeletal development of the various skeletal maturity indicators to a child's development. This method provided a mean with which one can determine the skeletal maturity of a person and thereby determine whether the possibility of potential growth existed.

Assessment of skeletal maturation based on cervical vertebrae in CBCT

Diagnosis of skeletal age in adolescents helps orthodontists select and time treatments. Currently this is done using lateral cephalometric radiographs. This study evaluates the application of the conventional method in cone-beam computer tomographic (CBCT) images to bring forth assessment of skeletal maturation in three-dimensions. Ninety-eight lateral cephalometric radiographs and CBCT scans were collected from orthodontic patients between 11 to 17 years of age over an 18-month period. CBCT scans were examined in seven sagittal slices based on cervical vertebral maturation staging (CVMS). Collected CVMS values were compared with those from corresponding lateral cephalometric radiograph. CVMS measured from CBCT and lateral cephalometric radiographs were the same on average. However, they were not consistent with each other and scored interclass correlation coefficient of 0.155 in validity test. Interoperator reliability was weak (0.581). Adaptation of cervical vertebrae maturation staging in CBCT requires further clarifications or modifications to become consistent with lateral cephalometric examinations and to become a reliable method. Alternatively, a completely new method may be developed consisting of maturational indicators or landmarks unique to CBCT imaging.

Cervical vertebrae maturation method morphologic criteria: poor reproducibility

INTRODUCTION

The cervical vertebrae maturation (CVM) method has been advocated as a predictor of peak mandibular growth. A careful review of the literature showed potential methodologic errors that might influence the high reported reproducibility of the CVM method, and we recently established that the reproducibility of the CVM method was poor when these potential errors were eliminated. The purpose of this study was to further investigate the reproducibility of the individual vertebral patterns. In other words, the purpose was to determine which of the individual CVM vertebral patterns could be classified reliably and which could not.

METHODS

Ten practicing orthodontists, trained in the CVM method, evaluated the morphology of cervical vertebrae C2 through C4 from 30 cephalometric radiographs using questions based on the CVM method. The Fleiss kappa statistic was used to assess interobserver agreement when evaluating each cervical vertebrae morphology question for each subject. The Kendall coefficient of concordance was used to assess the level of interobserver agreement when determining a "derived CVM stage" for each subject.

RESULTS

Interobserver agreement was high for assessment of the lower borders of C2, C3, and C4 that were either flat or curved in the CVM method, but interobserver agreement was low for assessment of the vertebral bodies of C3 and C4 when they were either trapezoidal, rectangular horizontal, square, or rectangular vertical; this led to the overall poor reproducibility of the CVM method. These findings were reflected in the Fleiss kappa statistic. Furthermore, nearly 30% of the time, individual morphologic criteria could not be combined to generate a final CVM stage because of incompatible responses to the 5 questions. Intraobserver agreement in this study was only 62%, on average, when the inconclusive stagings were excluded as disagreements. Intraobserver agreement was worse (44%) when the inconclusive stagings were included as disagreements. For the group of subjects that could be assigned a CVM stage, the level of interobserver agreement as measured by the Kendall coefficient of concordance was only 0.45, indicating moderate agreement.

CONCLUSIONS

The weakness of the CVM method results, in part, from difficulty in classifying the vertebral bodies of C3 and C4 as trapezoidal, rectangular horizontal, square, or rectangular vertical. This led to the overall poor reproducibility of the CVM method and our inability to support its use as a strict clinical guideline for the timing of orthodontic treatment.

Developmental steps of the human cervical spine: parameters for evaluation of skeletal maturation stages

The central objective of this investigation was to focus on the development of the cervical spine observed by lateral cephalometric radiological images of children and adolescents (6-16 years old). A sample of 26 individuals (12 girls and 14 boys) was classified according to stages of cervical spine maturation in two subcategories: group I (initiation phase) and group II (acceleration phase). The morphology of the cervical spine was assessed by lateral cephalometric radiographs obtained in accordance with an innovative method for establishing a standardized head posture. A total of 29 linear variables and 5 angular variables were used to clarify the dimensions of the cervical vertebrae. The results suggest that a few measurements can be used as parameters of vertebral maturation both for males and females. The aforementioned measurements include the inferior depth of C2-C4, the inferior depth of C5, the anterior height of C4-C5, and the posterior height of C5. We propose original morphological parameters that may prove remarkably useful in the determination of bone maturational stages of the cervical spine in children and adolescents.

Geometric morphometric evaluation of cervical vertebrae shape and its relationship to skeletal maturation

INTRODUCTION

Cervical vertebrae shape has been proposed as a diagnostic factor for assessing skeletal maturation in orthodontic patients. However, evaluation of vertebral shape is mainly based on qualitative criteria. Comprehensive quantitative measurements of shape and assessments of its predictive power have not been reported. Our aims were to measure vertebral shape by using the tools of geometric morphometrics and to evaluate the correlation and predictive power of vertebral shape on skeletal maturation.

METHODS

Pretreatment lateral cephalograms and corresponding hand-wrist radiographs of 98 patients (40 boys, 58 girls; ages, 8.1-17.7 years) were used. Skeletal age was estimated from the hand-wrist radiographs. The first 4 vertebrae were traced, and 187 landmarks (34 fixed and 153 sliding semilandmarks) were used. Sliding semilandmarks were adjusted to minimize bending energy against the average of the sample. Principal components analysis in shape and form spaces was used for evaluating shape patterns. Shape measures, alone and combined with centroid size and age, were assessed as predictors of skeletal maturation.

RESULTS

Shape alone could not predict skeletal maturation better than chronologic age. The best prediction was achieved with the combination of form space principal components and age, giving 90% prediction intervals of approximately 200 maturation units in the girls and 300 units in the boys. Similar predictive power could be obtained by using centroid size and age. Vertebrae C2, C3, and C4 gave similar results when examined individually or combined. C1 showed lower correlations, signifying lower integration with hand-wrist maturation.

CONCLUSIONS

Vertebral shape is strongly correlated to skeletal age but does not offer better predictive value than chronologic age.