An accurate method of predicting mandibular growth potential based on bone maturity

Validation of Machine Learning Models for Craniofacial Growth Prediction

This study identified the most accurate model for predicting longitudinal craniofacial growth in a Japanese population using statistical methods and machine learning. Longitudinal lateral cephalometric radiographs were collected from 59 children (27 boys and 32 girls) with no history of orthodontic treatment. Multiple regression analysis, least absolute shrinkage and selection operator, radial basis function network, multilayer perceptron, and gradient-boosted decision tree were used. The independent variables included 26 coordinated values of skeletal landmarks, 13 linear skeletal parameters, and 17 angular skeletal parameters in children ages 6 to 12 years. The dependent variables were the values of the 26 coordinated skeletal landmarks, 13 skeletal linear parameters, and 17 skeletal angular parameters at 13 years of age. The difference between the predicted and actual measured values was calculated using the root-mean-square error. The prediction model for craniofacial growth using the least absolute shrinkage and selection operator had the smallest average error for all values of skeletal landmarks, linear parameters, and angular parameters. The highest prediction accuracies when predicting skeletal linear and angular parameters for 13-year-olds were 97.87% and 94.45%, respectively. This model incorporates several independent variables and is useful for future orthodontic treatment because it can predict individual growth.

Comparison of three-dimensional maxillary growth across spheno-occipital synchondrosis maturation stages

BACKGROUND

This study aimed to three-dimensionally compare the maxillary growth among the spheno-occipital synchondrosis (SOS) maturation stages in both genders.

METHODS

This is a cross-sectional study of a retrospective type in which cone-beam computed tomography (CBCT) images of 500 patients aged 6 to 25 years (226 males and 274 females) were analyzed. The SOS was evaluated using the four-stage scoring system; completely open, partially fused, semi-fused, or completely fused. The SOS scoring and three-dimensional cephalometric measurements were analyzed by Invivo 6.0.3 software. Descriptive and analytical statistics were performed and a P-value < 0.05 was considered statistically significant.

RESULTS

There was a statistically significant difference in maxillary measurements among SOS maturation stages in both genders (P < 0.05). The mean differences in the maxillary growth among the SOS maturation stages between SOS stages 2 and 3 were higher than those between stages 1and 2 and stages 3 and 4 for maxillary length and height in both genders. However, the mean difference in the maxillary width was higher between SOS stages 1 and 2 than those stages 2 and 3 and stages 3 and 4. On other hand, there may be lesser maxillary growth between SOS stages 3 and 4 for maxillary width, length (in males), and height. The growth curves showed high active growth of the maxilla as the SOS was still fusing (especially stage 2 and 3) than those of the fused (stage 4). Moreover, the acceleration of growth occurred earlier in females than males regarding chronological age but not for SOS maturation stages.

CONCLUSIONS

The SOS maturation stages are valid and reliable maxillary skeletal maturation indicators for three-dimensional maxillary growth in both genders.

Digital analysis of stomatognathic system morphofunctional condition in patients with distal occlusion before and after treatment with the Twin Block appliance

Relevance. For many years studies have evaluated the possibilities of modifying the growth of the maxillofacial complex during orthodontic treatment with functional appliances. Despite the large number of studies devoted to orthodontic treatment of distal occlusion in children and adolescents, there is no consensus among orthodontists on the appropriateness, timing and tactics of such treatment.Material and methods. The article presents the results of the treatment of distal occlusion in children and adolescents aged 7-18 years using the Twin Block appliance. The study included clinical, anthropometric, radiographic and functional research methods.Results. The course of treatment eliminated distal occlusion in all groups; in Group 1, the length of the mandibular body was 64.4 ± 2.8 mm before the treatment and 69.6 ± 2.4 mm after the treatment (p = 0.016); in Group 2, the length of the mandibular body was 69.7 ± 6.6 mm before the treatment and 72.5 ± 6.9 mm after the treatment (p = 0.019); in Group 3, the length of the mandibular body was 69.8 ± 5.6 mm before the treatment and 74.0 ± 4.3 mm after the treatment (p = 0.005). The temporomandibular joints did not show pathological changes; most patients (70%) did not demonstrate anterior position of the condyles after the treatment.Conclusion. Orthodontic treatment of patients aged 7-18 years with distal occlusion using the Twin Block appliance is an effective treatment method. The orthodontic treatment with functional appliances is most reasonable during the period of peak growth when significant skeletal changes are possible to obtain.

Deep learning-based prediction of mandibular growth trend in children with anterior crossbite using cephalometric radiographs

BACKGROUND

It is difficult for orthodontists to accurately predict the growth trend of the mandible in children with anterior crossbite. This study aims to develop a deep learning model to automatically predict the mandibular growth result into normal or overdeveloped using cephalometric radiographs.

METHODS

A deep convolutional neural network (CNN) model was constructed based on the algorithm ResNet50 and trained on the basis of 256 cephalometric radiographs. The prediction behavior of the model was tested on 40 cephalograms and visualized by equipped with Grad-CAM. The prediction performance of the CNN model was compared with that of three junior orthodontists.

RESULTS

The deep-learning model showed a good prediction accuracy about 85%, much higher when compared with the 54.2% of the junior orthodontists. The sensitivity and specificity of the model was 0.95 and 0.75 respectively, higher than that of the junior orthodontists (0.62 and 0.47 respectively). The area under the curve value of the deep-learning model was 0.9775. Visual inspection showed that the model mainly focused on the characteristics of special regions including chin, lower edge of the mandible, incisor teeth, airway and condyle to conduct the prediction.

CONCLUSIONS

The deep-learning CNN model could predict the growth trend of the mandible in anterior crossbite children with relatively high accuracy using cephalometric images. The deep learning model made the prediction decision mainly by identifying the characteristics of the regions of chin, lower edge of the mandible, incisor teeth area, airway and condyle in cephalometric images.

Comparison of spheno-occipital synchondrosis maturation stages with three-dimensional assessment of mandibular growth

BACKGROUND

This study aimed to compare spheno-occipital synchondrosis (SOS) maturation stages with a three-dimensional assessment of mandibular growth.

METHODS

This is a cross-sectional study of a retrospective type, in which cone-beam computed tomography (CBCT) images of 500 patients aged 6 to 25 years (226 males and 274 females) were analyzed. The SOS was evaluated using the four-stage scoring system; completely open, partially fused, semi-fused, or completely fused. The SOS scoring and three-dimensional cephalometric measurements were analyzed by Invivo 6.0.3 software. Descriptive and analytical statistics were performed, and a P-value < 0.05 was considered statistically significant.

RESULTS

There was a statistically significant difference in mandibular measurements among SOS maturation stages in both sexes (P < 0.05). The skeletal growth increments of mandibular variables across the SOS stages had higher mean differences between SOS stages 2 and 3 than those between stages 1 and 2 and stages 3 and 4 in both sexes. The mandibular growth curves increased with chronological age (earlier in females) and SOS maturation stages (mostly in stages 1, 2, and 3 than stage 4).

CONCLUSIONS

The SOS maturation stages are valid and reliable mandibular skeletal indicators as evaluated with three-dimensional cephalometric mandibular measurements. The findings of growth increments and constructed growth curves of mandibular growth might be helpful in diagnosis and treatment planning.

Correlation between Salivary Levels of IGF-1, IGFBP-3, IGF-1/IGFBP3 Ratio with Skeletal Maturity Using Hand-Wrist Radiographs

Objective: The relevance of growth determination in orthodontics is driving the search for the most precise and least invasive way of tracking the pubertal growth spurt. Our aim was to explore whether minimally invasive salivary estimation of biomarkers Insulin-like growth factor (IGF-1) and Insulin-like growth factor binding protein-3 (IGFBP-3) could be used to estimate skeletal maturity for clinical convenience, especially in children and adolescent age groups. Materials and Method: The cross-sectional study was conducted on 90 participants (56 girls and 34 males) with ages ranging from 6 to 25 years. Each subject’s hand-wrist radiograph was categorized based on skeletal maturity, and saliva samples were estimated for IGF-1 and IGFBP-3 using the respective ELISA kits. Kruskal−Wallis nonparametric ANOVA was applied to compare different skeletal stages. Results: The study demonstrated low salivary IGF-1 levels at the prepubertal stage, with increase during pubertal onset and peak pubertal stage followed by a decline during pubertal deceleration to growth completion. Spearman’s correlation coefficient demonstrated a strong positive association (r = 0.98 p < 0.01) between salivary IGF/IGFBP-3 ratio and different stages of skeletal maturity. Conclusion: Salivary IGF-1, IGFBP-3, and IGF/IGFBP-3 ratio could serve as a potential biochemical marker for predicting the completion of skeletal maturity.

Development and validation of a formula for objective assessment of cervical vertebral bone age

Background and aim

Determination of skeletal maturity and bone age from cervical vertebrae has been well documented. Most methods described use subjective evaluation of morphological characteristics of cervical vertebrae and may be prone to variability and error. A few objective methods have also been developed, specific for certain populations and genders. The aim of this study was to establish and validate an objective method to determine cervical vertebral bone age from lateral cephalometric radiographs, for Asian South Indian patients of both genders.

Methods

Ninety boys and 90 girls between 9 and 15 years of age were recruited, and their lateral cephalograms were taken. Using measurements made from the third and fourth cervical vertebrae, a formula to determine cervical vertebral bone age was derived using stepwise regression analysis. To validate the formula, a separate sample of 30 boys and 30 girls was chosen, and hand-wrist radiographs and lateral cephalograms were obtained. Cervical vertebral bone age (CVBA) was determined by applying the formula derived. Bone age was also calculated using the Tanner-Whitehouse 3 method. The bone ages determined by both methods were compared to each other and chronological age, using one-way ANOVA, Tukey’s post hoc analysis, and Pearson’s correlation coefficient.

Results

The formulae derived in the current study to determine CVBA differed for both genders. No statistically significant difference was found between CVBA, bone age derived by the Tanner-Whitehouse 3 method, and chronological age for both boys (p value = 0.425) and girls (p value = 0.995). A moderate to strong positive correlation was found between CVBA, bone age, and chronological age.

Conclusion

The formulae derived in this study were validated and are reliable for objectively determining cervical vertebral bone age and skeletal maturation from lateral cephalograms for Asian South Indian patients of both genders.

Factors influencing dental arch form

Dental arch length, bilateral intermolar distance, morphology of the anterior teeth, and bilateral intercanine distance have been reported as factors influencing the determination of dental arch form. However, studies evaluating the factors that influence the determination of the above-mentioned components are limited. Therefore, to verify these points, the present study aimed to examine factors influencing the determination of dental arch form using statistical methods.Data obtained from sample dental casts were analyzed using principal component and cluster analyses. By principal component analysis, 23 sets of information were summarized into three components for the maxilla and four for the mandible. As a result of cluster analysis using principal component scores, the maxillary and mandibular dental arches were classified into four forms, respectively.Dental arch length is an important indicator of dental arch size and is influenced by the bilateral interincisor distance of the maxilla and mandible, and the mesiodistal crown width of the incisors and premolars. In the mandible, canine width also affects dental arch length. Dental arch width also influences the determination of dental arch form. However, the distance between the anterior teeth and the distance between the molars are independent and have no effect on each other.

Longitudinal evaluation of the association between Insulin-like growth factor-1, Bone specific alkaline phosphatase and changes in mandibular length

The aim of the current longitudinal study was to assess the levels of serum Bone-specific alkaline phosphatase (BALP) and serum Insulin like growth factor-1 (IGF-1) in different cervical vertebral maturation index (CVMI) stages and observe their association with the mandibular growth. Blood samples and lateral cephalograms of 63 subjects (age group of 11–17 years) were obtained at two time points, 12 months apart. On the basis of CVMI, all subjects were divided into six groups based on whether the subjects remained in same CVMI stage or transitioned to the next CVMI stage. Annual mandibular length was related with serum BALP and serum IGF-1 levels estimated using ELISA. Serum IGF-1 and BALP attained highest levels at CVMI stage 3 with peak BALP levels observed earlier than IGF-1. Although a positive correlation was determined between IGF-1 and BALP but BALP followed skeletal growth pattern more precisely. Overall IGF-1 and BALP were negatively correlated with mandibular length with notable growth in CVMI groups 3–3 (P < 0.01), 3-4 (P < 0.01), 4-4 (P < 0.001) and 5-5 (P < 0.001). In conclusion, BALP is a potential biomarker for skeletal growth assessment. However, the mandibular growth pattern was independent of changes in IGF-1 and BALP.

A practical formula for determining growth

PURPOSE

We aimed to establish a practical method to evaluate skeletal age using cervical vertebrae.

METHODS

The study consisted of hand-wrist and cephalometric radiographs of 324 subjects (167 girls, 157 boys; age range, 7.3-17.2 years). Skeletal ages of the subjects were calculated from hand-wrist radiographs, and cervical vertebral bodies were measured using cephalometric radiographs. A single formula based on C3 and C4 vertebral body heights with different coefficients for each gender was derived using ridge regression analysis.

RESULTS

The correlation coefficients for vertebral and hand-wrist bone age were 0.825 and 0.856 for girls and boys, respectively. The correlations among vertebral bone age and C3 and C4 vertebral body heights were also found to be significant. The intraclass correlation (ICC) score was found to be 0.914, which shows high consistency between the two measurements of the same investigator for each C3 and C4 vertebral body height result.

CONCLUSION

The formula derived for evaluating skeletal age in cephalometric radiographs is reliable and can be applied to both girl and boy subjects for legal requirements or therapeutic needs of age estimation.

Predicting mandibular growth increment on the basis of cervical vertebral dimensions in Iranian girls

BACKGROUND

The purpose of this longitudinal study was to establish an equation to predict incremental mandibular length on the basis of the analysis of the cervical vertebrae on a single cephalometric radiograph and to compare the predictive accuracy with the method by Mito et al.

METHODS

Data consist of a group of 33 Iranian girls, 9 to 11 years old with two lateral cephalometric radiographs taken at a 24-month interval. For each individual, on the lateral cephalometric radiographs, points and lines for the description of the morphologic characteristics of the third and fourth cervical vertebral bodies were traced and measured. The real mandibular length increment (MLI) in this period was determined by the difference between the second (24 months) and first (baseline) radiographs: MLI=Ar-Pog (second)-Ar-Pog (first). An equation was determined to calculate mandibular length increments on the basis of the measurements in the third and fourth cervical vertebral bodies. The predictive accuracy was assessed using multiple regression analysis.

RESULTS

The adjusted R2 for this equation was 54.9% which is a reliable value for evaluating prediction accuracy .The average error between the predicted increment and the actual increment was 0.149 mm for our method and 5.87 mm for the method by Mito et al.

DISCUSSION

There are two items that contributed to easier and better prediction accuracy in our equation: (1) higher R2 and (2) fewer independent variables. In our subjects, the prediction accuracy was lower when using Mito et al.'s method, which could be due to genetic and environmental factors and selected age range.

CONCLUSION

These results indicate that cervical vertebral measurements, obtained in lateral cephalograms, are able to predict properly the mandibular growth potential.

[Indications for radiography in orthodontics and dentofacial orthopedics]

The risks associated with the use of ionizing radiation are a constant concern not only for practitioners but also for legislators who have included this ethical rule in the Code of public safety. It proposes reduction of risks by insisting that all X-Rays be taken only when they accord with one of the fundamental principles of X-Ray protection: they must be justified by clear diagnostic need. In direct application of this principle the French government in 2006 published a guide for the management of radiological and dental and stomatological examinations. However, this document dealt only slightly with orthodontics, a field in which the flourishing and burgeoning of radiological techniques made it urgent that regulations for use of X-Rays in orthodontics be brought up to date on an ongoing and permanent basis. The objective of this article is, accordingly, after presentation of a systematic and critical analysis of the lit erature, to propose up-to-date recommendations for proper taking of orthodontic X-Ray films.

[Cervical vertebrae: Mandibular growth dynamism indicators?]

A study of mandibular growth maturation was performed on a population of 103 patients during orthodontic treatment (69 girls and 34 boys) from 11 to 16 years, having initially a Class II skeletal discrepancy. The relationship between wrist maturation indices and the cervical vertebrae maturation was studied by Lamparski classification. Significant correlations were found between Björk stages, MP3=, MP3 cap and MP3 U and respectively Lamparski stages as CVS 2, CVS 3-4 and CVS 5-6. This retrospective longitudinal study identified three mandibular variables at three different maturation stages according to Björk classification and to the six stages of Lamparski classification. The relationships between these different maturation stages and a quantitative mandibular response permit to estimate optimal time for our orthodontic therapy. The results indicate a significant increase in mandibular length between CVS 4 and CVS 5, suggesting the persistence of a condylar response to a stimulation therapy after CVS3 or CVS 4 stages (MP3 cap). Mandibular growth seems to continue after MP3 U stage or CVS 5 stage.

Guias clínicos e radiográficos utilizados para a predição do surto de crescimento puberal

OBJETIVO: o objetivo desse artigo é chamar a atenção para a organização das informações disponíveis nos exames e durante o tratamento ortodôntico de indivíduos em crescimento, as quais servem como guias para a predição do estágio do surto de crescimento puberal. CONCLUSÃO: tais informações fornecem oportunidades de acréscimos no diagnóstico e prognóstico dos casos e na tomada de decisões do planejamento, evolução do tratamento e da fase de contenção, principalmente daqueles pacientes que apresentam más oclusões associadas a desarmonias esqueléticas.

Longitudinal study of relative growth rates of the maxilla and the mandible according to quantitative cervical vertebral maturation

INTRODUCTION

The purpose of this study was to investigate the relative growth rates (RGR) of the maxilla and the mandible according to quantitative cervical vertebral maturation (QCVM) of adolescents with normal occlusion.

METHODS

Mixed longitudinal data were used. The sample included 87 adolescents (32 boys, 55 girls) from 8 to 18 years of age with normal occlusion, selected from 901 candidates. Sequential lateral cephalograms and hand-wrist films were taken once a year for 6 consecutive years. The growth magnitude (GM) and RGR of the maxilla and the mandible were measured and analyzed.

RESULTS

GM and RGR were not always consistent, because subjects had different periods of time between the QCVM stages. GM was not as reliable as RGR. RGR had no significant sex differences in the maxilla and the mandible, in spite of different decelerating curves. However, statistically significant sex differences were found in the GM of mandibular measurements. The greatest growth potentials were not synchronized between the maxilla and the mandible. For both sexes, the greatest RGR of maxillary length and height was in QCVM stage I; then, deceleration occurred. The greatest RGR of mandibular length and height was in QCVM stage II, and the next largest was in QCVM stage I.

CONCLUSIONS

Understanding the RGR can provide references for orthodontic treatment and orthognathic surgery.

Maxillary distraction osteogenesis in the adolescent cleft patient: three-dimensional computed tomography analysis of linear and volumetric changes over five years

OBJECTIVE

To assess the results of maxillary distraction osteogenesis with the Rigid External Distraction System using three-dimensional computed tomography scan volume-rendered images with respect to stability and facial growth at three time frames: preoperative (T0), 1-year postoperative (T1), and 5-years postoperative (T2).

DESIGN

Retrospective analysis.

SETTING

Tertiary.

PATIENTS

A total of 12 patients with severe cleft maxillary hypoplasia were treated between June 30, 1997, and July 15, 1998. The mean age at surgery was 11 years 1 month.

INTERVENTIONS

Le Fort I maxillary distraction osteogenesis. Distraction was started 2 to 5 days postsurgery at a rate of 1 mm per day. The consolidation period was 3 months. No face mask was used. A paired t test was used for statistical analysis.

MAIN OUTCOME MEASURES

Overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes.

RESULTS

From T0 to T1, there were statistically significant increments of overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes. The T1 to T2 period demonstrated a reduction of overjet (30.07%) and ANB (54.42%). The maxilla showed a stable SNA and a small but statistically significant advancement of the ANS point. There was a significant increase in the mandibular volume. However, there was no significant change in the maxillary and pterygoid volumes.

CONCLUSIONS

Maxillary distraction osteogenesis demonstrated linear and volumetric maxillary growth during the distraction phase without clinically significant continued growth thereafter. Overcorrection is required to take into account recurrence of midface retrusion over the long term.

Relationship between cranial and mandibular growth and the stages of maturation of the cervical vertebrae

Quantification of the expectation of craniofacial growth during the pubertal growth spurt (PGS) is helpful in orthodontic diagnosis and treatment planning. Thus, this study investigated whether the stages of the vertebral maturation index (VMI) would be valid for estimating cranial and mandibular growth during the initial stages of PGS, testing the null hypothesis that these structures do not demonstrate differential growth dependent on the maturation stage. A study population of 45 patients of both genders with 2 lateral cephalometric radiographs, taken at a 12-month interval, was selected from files. All patients should not have been previously submitted to orthodontic treatment and should be before or during the peak stage of PGS. The S-N and Co-Gn cephalometric measurements were traced on both radiographs of each patient, by computed cephalometric tracings, for evaluation of skull and mandible, respectively. The growth of these structures was established by the difference between the measurements obtained on both tracings. The VMI stage was also estimated on the radiographs, determining the position of patients on the PGS curve at two periods, baseline and after 12 months. Cephalometric tracings and VMI estimates were performed by two calibrated examiners. Descriptive statistics revealed that both cephalometric measurements increased during the study period, especially Co-Gn, which demonstrated (ANOVA and Tukey's test; 5% significance level), a statistically significant peak of development (p = 0.001), when the patient was in the VMI stage representing the PGS peak. It was concluded that the VMI stages were valid for the analysis of cranial growth and especially of mandibular growth at the initial stages of PGS, thus rejecting the null hypothesis.

Bone age estimation based on phalanx information with fuzzy constrain of carpals

The proposed automatic bone age estimation system was based on the phalanx geometric characteristics and carpals fuzzy information. The system could do automatic calibration by analyzing the geometric properties of hand images. Physiological and morphological features are extracted from medius image in segmentation stage. Back-propagation, radial basis function, and support vector machine neural networks were applied to classify the phalanx bone age. In addition, the proposed fuzzy bone age (BA) assessment was based on normalized bone area ratio of carpals. The result reveals that the carpal features can effectively reduce classification errors when age is less than 9 years old. Meanwhile, carpal features will become less influential to assess BA when children grow up to 10 years old. On the other hand, phalanx features become the significant parameters to depict the bone maturity from 10 years old to adult stage. Owing to these properties, the proposed novel BA assessment system combined the phalanxes and carpals assessment. Furthermore, the system adopted not only neural network classifiers but fuzzy bone age confinement and got a result nearly to be practical clinically.

Predicting mandibular growth potential with cervical vertebral bone age

This study assessed the possibility of using cervical vertebral bone age determined from cephalometric radiographs to predict mandibular growth potential. The subjects were 2 groups of 20 Japanese girls and young women: one group to derive a formula for predicting mandibular growth potential, the other to compare predicted values with actual values. Each group included subjects in the initial stage of the pubertal growth period and the final stage of growth in early adulthood. A formula for predicting mandibular growth potential that included cervical vertebral bone age and the actual growth of the mandible (condylion-gnathion) was determined with regression analysis. Cervical vertebral bone age, bone age on hand-wrist radiographs, and chronological age were inserted into the formula, and actual values and values predicted with these parameters of the formula for mandibular growth potential were compared. The formula found mandibular growth potential (in millimeters) = -2.76 x cervical vertebral bone age + 38.68. The average error between the value predicted by cervical vertebral bone age and the actual value (1.79 mm) was significantly less (P <.001) than that between the actual value and the value predicted by chronological age (3.48 mm) and approximately the same as that between the actual value and the value predicted by bone age (2.09 mm). The formula derived from this study might be useful for treating orthodontic patients in the growth stage.

Cervical vertebral bone age in girls

The purpose of this study was to establish cervical vertebral bone age as a new index for objectively evaluating skeletal maturation on cephalometric radiographs. Using cephalometric radiographs of 176 girls (ages 7.0-14.9 years), we measured cervical vertebral bodies and determined a regression formula to obtain cervical vertebral bone age. Next, using cephalometric and hand-wrist radiographs of another 66 girls (ages 8.0-13.9 years), we determined the correlation between cervical vertebral bone age and bone age using the Tanner-Whitehouse 2 method. The following results were obtained: (1) a regression formula was determined to obtain cervical vertebral bone age based on ratios of measurements in the third and fourth cervical vertebral bodies; (2) the correlation coefficient for the relationship between cervical vertebral bone age and bone age (0.869) was significantly (P <.05) higher than that for the relationship between cervical vertebral bone age and chronological age (0.705); and (3) the difference (absolute value) between the cervical vertebral bone age and bone age (0.75 years) was significantly (P <.001) smaller than that between cervical vertebral bone age and chronological age (1.17 years). These results suggest that cervical vertebral bone age reflects skeletal maturity because it approximates bone age, which is considered to be the most reliable method for evaluating skeletal maturation. Using cervical vertebral bone age, it might be possible to evaluate maturity in a detailed and objective manner on cephalometric radiographs.