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| FORENSIC ODONTOLOGY SECTION: ORIGINAL ARTICLE |
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| Year : 2017 | Volume
: 29
| Issue : 4 | Page : 362-367 |
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Correlation between Dental Maturity by Demirjian Method and Skeletal Maturity by Cervical Vertebral Maturity Method using Panoramic Radiograph and Lateral Cephalogram
Madhusudhanan Mallika Mini, Valsa Thomas, Tinky Bose
Department of Oral Medicine and Radiology, Government Dental College, Thiruvananthapuram, Kerala, India
| Date of Submission | 01-Jul-2017 |
| Date of Acceptance | 29-Jan-2018 |
| Date of Web Publication | 15-Feb-2018 |
Correspondence Address:
Madhusudhanan Mallika Mini
Department of Oral Medicine and Radiology, Government Dental College, Thiruvananthapuram - 695 013, Kerala
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaomr.jiaomr_61_17
 Abstract | | |
Introduction: Radiographs are effective tools in assessing the stages of bone maturation in dentistry. The cervical vertebral maturation method is a proven effective tool in assessing the adolescent growth spurt than hand-wrist radiographs in an individual. Assessment of dental calcification stages are a reliable method for determining dental maturity. Panoramic imaging can be used as the primary imaging modality for assessing maturity if a correlation can be found out between tooth calcification stages and cervical vertebral maturation stages. This study was conducted to determine the correlation between dental maturity stage and cervical vertebral maturity stage and to estimate predictor variables for cervical vertebral maturation stages (CVMS) stratified by gender in a tertiary hospital setting. Materials and Methods: A descriptive study was conducted among patients accessing orthodontic care in radiology outpatient clinic, Oral Medicine and Radiology department, Government Dental College Thiruvananthapuram for a period of 15 months. Participants were selected between the ages of 8 and 16 years. Panoramic radiographs and lateral cephalograms were used to determine dental maturity stages using Demirjian method and CVMS using Bacetti and Franchi method, respectively. Results: One hundred patients (males = 46, females = 54) were included in the study; the spearman rank order correlation revealed significant relationship. The correlation ranged from 0.61 to 0.74 for females and 0.48 to 0.51 for males. Second premolar showed highest correlation and canine the lowest for both females and males. Stage G of mandibular second premolar signifies the pubertal growth period in this study population. By ordinal regression model, G stage of second premolar was found to be a significant predictor in males and stage H followed by G and F in females for the age group of 12–14 years. Conclusion: Dental maturation stages were significantly correlated with CVMS. The development stages of mandibular second premolar had the strongest correlation with cervical vertebral maturity in both males and females. G stage of mandibular second premolar can be clinically used as a maturity indicator in the pubertal growth period. Moreover, G stage of second premolar can be used as a significant predictor for the age group of 12–14 years in both males and females.
Keywords: Cervical vertebral maturation, dental maturation, growth prediction, pubertal growth period
How to cite this article:
Mini MM, Thomas V, Bose T. Correlation between Dental Maturity by Demirjian Method and Skeletal Maturity by Cervical Vertebral Maturity Method using Panoramic Radiograph and Lateral Cephalogram. J Indian Acad Oral Med Radiol 2017;29:362-7 |
How to cite this URL:
Mini MM, Thomas V, Bose T. Correlation between Dental Maturity by Demirjian Method and Skeletal Maturity by Cervical Vertebral Maturity Method using Panoramic Radiograph and Lateral Cephalogram. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 Oct 29];29:362-7. Available from: https://www.jiaomr.in/text.asp?2017/29/4/362/225563 |
| Introduction | |  |
Human growth shows considerable variation in the chronological ages at which each child reaches similar developmental events. Growth assessment is important for age estimation in forensic sciences and for growth modification in orthodontics and dentofacial orthopedics. Timing of orthopedic growth modification therapy is typically linked with individual's peak of skeletal maturity to maximize the growth potential. Considerable variation in the development among children of the same chronological age have led to the introduction of the concept of developmental or physiologic age based upon the degree of maturation of different systems and tissues. Various biologic ages such as morphologic, sexual, skeletal, and dental have been proposed for this purpose.[1]
The use of hand-wrist radiography is recognized as a reliable parameter to evaluate the skeletal age of the patient and to estimate skeletal maturation.[2] Skeletal maturation assessed by cervical vertebral maturation stage (CVMS) assessment is mostly accepted now as it is performed on lateral cephalograms, a radiograph often used in orthodiagnosis and also does not require extra radiation, especially considering the age of the patient. The method proposed by Baccetti et al.[3] was used in this study as this method has a comparable high reliability and validity as hand-wrist analysis. It anticipates the occurrence of mandibular growth peak which happens between stages two and three.
Dental maturity is also an indicator of biological maturity of growing children. Among dental age estimations, Demirjian [4] method is the most accepted one. Rather than just enlargement of the tooth this method attempts to classify tooth mineralization by maturation changes in tooth development. If a strong association exists between skeletal maturity and dental calcification stages, the stages of dental calcification might be used as a first level indicator to estimate the timing of pubertal growth spurt. The relationship between tooth calcification stages and skeletal maturity has been reported. Racial variation among these have also been reported.[5],[6],[7],[8],[9] There are no such reported studies in Kerala regarding the correlation between dental and skeletal maturation. This study aims to develop a correlation between dental maturity stages and CVMS so that it can be used as a first level indicator as well as the predictive value of dental maturation stages and age group.
| Materials and Methods | | |
The study was conducted from June 2012 to August 2013 (15 months) in radiology outpatient clinic, Department of Oral Medicine and Radiology, Government Dental College, Thiruvananthapuram after obtaining clearance from the ethical committee. Panoramic radiographs and lateral cephalograms of 100 patients (males-46 and females-54) between the ages 8 and 16 years were obtained. The participants were divided into six groups based on their CVMS. Inclusion criteria were availability of a panoramic radiograph of adequate quality and those who had a complete mandibular dentition either erupted or unerupted without any medical history affecting its development. Exclusion criteria included image deformity affecting the estimation of tooth development, hypodontia, gross pathology, and missing mandibular permanent teeth except the third molars.
Dental maturity assessment
Dental maturity was assessed according to the calcification stages of individual teeth.[4] The developmental stages of the left mandibular permanent canines, first and second premolars, and second molars were rated on an 8-stage scale from A to H [Figure 1]:
- Calcification of single occlusal points without fusion of different calcifications.
- Fusion of mineralization points; the contour of the occlusal surface is recognizable.
- Enamel formation is complete at the occlusal surface, and dentin formation has commenced. The pulp chamber is curved, and no pulp horn is visible.
- Crown formation is complete to the level of the cementoenamel junction. Root formation has commenced. The pulp horns are beginning to differentiate, but the walls of the pulp chamber remain curved.
- The root length remains shorter than the crown height. The walls of the pulp chamber are straight, and the pulp horns are more differentiated than in the stage D. In molars, the radicular bifurcation has started to calcify.
- The walls of the pulp chamber form an isosceles triangle, and the root length is equal to or greater than the crown height. In molars, the bifurcation has developed sufficiently to give the roots a distinct form.
- The walls of the root canal are parallel, but the apical end is partially open. In molars, only the distal root is rated.
- The root apex is completely closed (distal root in molars). The periodontal membrane surrounding the root and apex is uniform in width throughout.
Skeletal maturity assessment
Skeletal maturity was evaluated by the CVM method. According to the CVM method, the morphology of the bodies of the second (C2), third (C3), and fourth (C4) cervical vertebrae are rated on a six-level scale from cervical stage (CS) 1 to CS6 [Figure 2]:
- CS1: The lower borders of all three vertebrae (C2-C4) are flat. The bodies of both C3 and C4 are trapezoid in shape.
- CS2: A concavity is present at the lower border of C2. The bodies of both C3 and C4 are still trapezoid in shape.
- CS3: Concavities at the lower borders of both C2 and C3 are present. The bodies of C3 and C4 may be either trapezoid or rectangular-horizontal in shape. The growth peak occurs the year after this stage.
- CS4: Concavities at the lower borders of C2, C3, and C4 are present. The bodies of both C3 and C4 are rectangular-horizontal.
- CS5: At least one of the bodies of C3 and C4 is square. If not square, the body of the other cervical vertebra is rectangular-horizontal.
- CS6: At least one of the bodies of C3 and C4 is rectangular-vertical in shape.
Assessment of the study sample
Panoramic radiographs and lateral cephalogram of the study participants were taken using a Proline X-ray unit (Planmeca PM 2002 cc Helsinki, Finland) equipped with Lanex regular screens and films (Eastman Kodak Company, Rochester, New York) using manual exposure parameters. The participants were positioned properly on the machine. Films were processed manually in a well-equipped light proof dark room. The first evaluation was carried out using a light box and tracing was done using 3H lead pencil and matte acetate tracing paper by a trained observer possessing knowledge of neither age nor gender. In the panoramic radiograph, left mandibular canine, premolars, and second molars were drawn and in the lateral cephalogram three parts of cervical vertebrae were traced; these entities include the dense odontoid – C2, body of the third cervical vertebrae – C3 and the body of the fourth cervical vertebrae – C4. The determined developmental stages of teeth were entered into tables in a computer database. The images were then digitalized and stored in a computer data base and evaluation of calcification was carried out on the computer screen. This method enabled magnification of selected regions of interest for an accurate assessment of developmental stages.
Statistical analysis
All statistical analyses were performed with SPSS for Windows, version 16, IBM, U.S. The mean age of each CVM stage and each gender was calculated. Demirjian developmental stages from D–H (ordinal variable) and CVMS from CS1 to CS6 (ordinal variable) were designated as numbers. Spearman rank order correlation coefficient between the cervical vertebral maturation stages and developmental stages of five individual teeth were calculated to find the most correlated teeth. Percentage distribution for calcification stages of individual teeth and CVMS were calculated to find the most commonly distributed developmental stage in each cervical vertebra stage. Ordinal regression was done to estimate predictor variables for CVMS from dental maturity stages and age group stratified by gender.
Pilot study
To assess interobserver reliability of the radiographic finding, a sample of 20 patients were selected for data collection. The radiographs were examined by a second observer who was blinded to the results of first observer. Good interobserver agreement (kappa > 0.8) was seen between the two observations.
| Results | | |
One hundred panoramic and lateral cephalogram radiographs were assessed by the criteria of Demirjian method and Bacetti et al. method, respectively. Most patients included in the study were from in and around Thiruvananthapuram district of Kerala state. Distribution of chronological age in the sample showed variation from 8 to 16 years, with a mean age of 12.85 ± 1.62 [Table 1]. The participants were divided into three age groups as per the pubertal age grouping.
Based on CVMS assessment, the mean chronological age of girls was significantly lower than boys except CVMS 2, with the appearance of each stage being consistently earlier in females than in males with a gap of at least 1–2 years. In stage CVMS 3 in which onset of pubertal age group occurs, the mean chronological age was 12.25 ± 0.99 for females and 13.60 ± 1.10 for males. CVMS 3 had the highest frequency of 44%. Number of females was less than males in the first two stages. Postpubertal stages (CVMS 5 and CVMS 6) had less number of patients. The final stages of dental maturation stages, F, G, and H, appeared more frequently and earlier in females than men. Second premolar was having the highest correlation with CVMS (r = 0.74 for females and r = 0.69 for males) [Table 2]. Canine had the lowest correlation (r = 0.61 for females and r = 0.48 for males). Females had higher correlation coefficient than males. First premolar had more correlation than second molar in males where it was reverse for females.
In the present study, the development of mandibular second premolar had the highest correlation coefficient with CVMS among male and female participants [Table 3]. Among male participants, in CVMS 1–2, the percentage distribution of stage F was 55–80%. In CVMS 3, stage G showed the highest percentage distribution of 60%. In CVMS 4–6, stages H showed the highest percentage distribution. Among female participants, F stage was 50–66% for CVMS 1–2, and in CVMS 3, stage G had the highest frequency of 62%. In CVMS 4–6, stages H was having highest frequency distribution of 69–100%. Based on these results, the preliminary conclusion is that stage G of mandibular second premolar signifies the beginning of the pubertal growth spurt in this study population. The ordinal regression (logit) was performed with the lowest (E stage of second premolar and age group < 12 years) as the reference value [Table 4]. The model for males showed G stage of second premolar as a significant predictor for the age group of 12–14 years. In females, stage H showed the highest predictor value followed by G and F stage for the age group of 12–14 years.
| Discussion | | |
Numerous studies have been conducted in different parts of the world and a strong relationship exists between skeletal, sexual, and somatic maturation; however, studies showing correlation between dental maturity and skeletal maturity are inconclusive.[4] Hence, in this study, the correlation between CVMS and the calcification stages of teeth was investigated in Thiruvananthapuram. If this is true, a single panoramic radiograph which is of routine use may be recommended to predict skeletal maturation stages as an alternative to other methods that require more radiation exposure to patients.
Literature review revealed several studies in different populations suggesting low, moderate, and high correlation between each individual teeth and CVMS. These studies showed that correlation varies between ethnic populations. Population specific studies are necessary to find correlated teeth with skeletal maturity.[1],[2],[5] Our study sample included 46 males and 54 females. Distribution of chronological age in the sample showed range variation from 8 to 16 years, with a mean age of 12.85 ± 1.62 years.
In stage CVMS3, which indicates the onset of pubertal age group, the mean chronological age was 12.25 ± 0.99 for females and 13.60 ± 1.10 for males. This is consistent with earlier reports regarding the age of beginning of pubertal growth spurt in Indian population. In the study by Kiran et al.,[6] it was 13.2 for males and 11.8 for females, and 14.5 for males and 12.5 for females in a study by Mittal et al.[8]
The association between dental and skeletal maturity has been debated.[10],[11],[12],[13],[14],[15],[16] Some studies suggest little correlation between dental and skeletal maturity while others indicate the opposite.[17] According to research on the correlation among the skeleton, teeth, body, and secondary sexual characteristics, dental maturity is the best indicator for evaluating the stages of growth and development in the pubertal period with levels of calcification of teeth, considered to be important biologic parameters in such evaluations.[18],[19],[20],[21],[22],[23],[24] Different methods for evaluating dental age and skeletal age have resulted in discrepancies between studies.
The correlation between dental maturation stages and CVMS ranged 0.61–0.74 for females and 0.48–0.69 for males. For both females and males, mandibular second premolar was having the highest correlation of 0.74 and 0.69, respectively. Mandibular canine had the lowest correlation (0.61 for females and 0.48 for males). Females had a high correlation coefficient than males. First premolar had more correlation than second molar in males whereas it was reverse for females. Another study by Mittal et al.[8] in an Indian population showed the sequence in males as canine (0.62), first premolar (0.64), second premolar (0.66), and second molar (0.75); in females, the order was canine (0.65), first premolar (0.78), second premolar (0.79), and second molar (0.81), which also showed that canine had the lowest correlation.
Studies reporting low correlation between dental age and pubertal growth have found the maturity of canine to more closely relate to peak high velocity of puberty than other teeth.[25],[26],[27],[28],[29] In the present study, canine and skeletal maturity indicator was 0.61 for females and 0.48 for males. Findings of Coutinho et al.[24] and Hedayathi et al.[26] showed a close relation between mandibular canine calcification stage G and presence of adductor sesamoid (CVMS3).
The correlation coefficient indicates that second premolar has the highest relationship (0.74 in females and 0.69 in males), which is in concordance with the findings of Krailassiri et al.[1] (0.69 for females and 0.66 for males) and Kalinowska et al.[27] (r = 0.59 in females). Mittal et al.,[8] in a study on correlation between determination of skeletal maturation using cervical vertebrae and dental calcification stages among Indian subjects, suggested stage G of canine; first premolar and second molar correspond to peak of pubertal growth spurt. In this study CVMS 5 and 6 showed the last stages of development for the canine, first, and second premolar in a majority of patients, supporting the suggestions of Krailassiri et al.[1]
The dissimilarity between this and earlier studies may be partially attributable to the different methods used to assess skeletal maturity and dental maturity. Associations between the teeth and skeleton also appear to vary among races/ethnic groups and geographic regions. In the growth stage when the sesamoid bone has just appeared, among Africans, the root apex of the canine is completely closed (stage H), whereas in Europeans the apical end is partially open (stage G). Geographic variation in tooth and skeletal maturation between midwestern and midsouthern American adolescents has also been demonstrated.[1]
| Conclusion | | |
Many authors still emphasize the importance of parallel evaluation of both maturity indices in a growing child. However, the simplicity of the evaluation of the development of teeth as well as the widespread availability of intra and extraoral radiographs is decisive in the application of the dental maturity method as a tool for the initial evaluation of the level of skeletal maturity of a child.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]
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