Orthodontics
Original Article
EVALUATION OF THE SKELETAL MATURATION USING
LOWER CANINE MINERALIZATION
1
GHULAM RASOOL, BDS, MCPS (Ortho), FCPS, (Ortho)
2
UMAR HUSSAIN, BDS
3
SYED SULEMAN SHAH, BDS
ABSTRACT
Successful orthodontics diagnosis, treatment planning and clinical procedures require a thorough
understanding of growth and development. Prior knowledge to quantify the growth remaining would
be extremely useful for predicting treatment results.
The aim of this study was to investigate the relationship between dental age based on the calcification stages of the mandibular canine and skeletal maturity stages using cervical vertebral maturation among Peshawar population and to determine the clinical value of the mandibular canine as
a growth evaluation index.
Panoramic and lateral cephalograoms of 100 patients from the department of orthodontics
Khyber College of Dentistry were used to determine the dental calcification and cervical vertebral
maturation(CVM) stages by two postgraduate trainees. Dental calcificationof mandibular canine was
determined according to Demirjin et al and CVM staging was done according to Baccetti et al. The
spearman rank correlation was determined between CVM and dental calcification stages.
The highest correlation were among the CS1 and stage E(100%), CS2 and stage F (75%), CS3
and stage G (36%), and CS4 and stage H(51%). The correlation between CVM and dental calcification
were highly significant ( r=0.871 p=0.000).
Key Words: skeletal maturation, calcification, mandibular canine, growth.
INTRODUCTION
Successful orthodontic diagnosis, treatment
planning, and clinical procedures require a thorough
understanding of growth and development.1 It is well
established that in growing subjects facial skeletal
disharmonies, i.e. skeletal malocclusions, can be correctly treated by orthopaedic approaches. Such skeletal
imbalances include; transverse, vertical and sagittal
maxillary deficiency or excess and mandibular deficiency or prognathism which are relatively common
features in certain ethnic populations .2,3 The important
growth phases in such orthodontically treated subjects
are; pre-pubertal, pubertal and post-pubertal growth
phases, each of which is characterized by differential
growth of maxilla and mandible.4
Professor & Head of Orthodontics Department, Khyber College of
Dentistry, Peshawar University Campus, Address: House #4 Street
4, Sector J-I, Phase-II, Hayatabad, Peshawar
E-mail: [email protected] Cell # 0333-9126029
2
FCPS Resident Orthodontics
3
FCPS Resident Orthodontics
Received for Publication:
October 1, 2014
Revision Received:
October 30, 2014
Revision Accepted:
November 2, 2014
1
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
Treatment timing plays a crucial role in the outcomes of all dentofacial orthopaedic treatments for
dentoskeletal imbalances in growing patients.5 Prior
knowledge to quantify the growth remaining would be
extremely useful for predicting treatment results.6 For
growth modiﬁcation to be successful, it is absolutely
essential that it starts at the right time. Optimal timing for treatment is different in various malocclusions.
According to Bacetti et al,5 treatment protocols for
enhancing or restraining maxillary growth is more
effective when performed before the adolescent growth
spurt, whereas treatment regimens aimed to enhance
or restrain mandibular growth produce greater effects
when performed during the pubertal growth spurt
period.
Tooth eruption or emergence is poor indicator of
skeletal maturity.4,7,8 However, dental calciﬁcation
stages detected through radiographic methods appear
to be highly correlated to skeletal maturity.9,10 Dental
maturity assessment can be simply carried out on
panoramic radiograph that are routinely used for
diagnosis in orthodontics with minimal irradiation to
the patient. In pediatric patient, the use of a thyroid
collar is mandatory while taking cephalometric radio629
Evaluation of the skeletal maturation
graphs. However, Wiechmann et al11 and Sansare et
al12 concluded that the thyroid collar masks landmarks
mainly used for analysis of skeletal maturity.
Perinetti et al13 analyzed the diagnostic ability of
the dental maturation phases for the skeletal maturation using the cervical vertebral maturation stages
and concluded that dental and skeletal maturity are
highly correlated. Solmaz Valizadeh and colleagues14
investigated the correlation between the stages of tooth
calcification and the cervical vertebral maturation in
Iranian females. They observed significant correlations
between the two stages in the mandibular first and
second premolars, canine and central incisors. Krisztina
and co-workers15 evaluated the skeletal maturation
using lower first premolar mineralization and reported
significant correlation (r = 0.871, p <0.001) between
CVM and Demirjian's index.
The aim of this study was to investigate the relationship between dental age based on the calcification
stages of the mandibular canine and skeletal maturity
assessment using cervical vertebral maturation among
Peshawar population and to determine the clinical
value of the mandibular canine as a growth evaluation
index.
METHODOLOGY
A retrospective cross-sectional study was conducted
from 1st July 2014 to 15th September 2014. Hundred
subjects (both male and females) with age ranging from
8 to 14 years were included in the study. Panoramic
and lateral cephalometric radiographs were taken from
the records of patients in department of Orthodontics,
Khyber College of Dentistry Peshawar. Sampling
was performed according to the convenient sampling
method.
The inclusion criteria were:
• Pakistani Nationality
• No systemic disease that could affect general development like hormonal diseases
• No history of orthodontic treatment
• lateral cephalometric and panoramic radiographs
available with high clarity and good contrast taken
at the same day
• No missing or anomalies (trauma, injury, impaction,
transposition) in dentition
• No history of trauma or surgery in the neck or
dentofacial region.
Lateral cephalometric radiograph of each individual
was taken with a universal counter balancing type of
cephalostat at Radiology Department of Khyber College
of Dentistry, Peshawar. Kodak' X-ray films (8×10) were
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
exposed to 70 KVp, 45 mA for an average of 1.8 sec,
with a tube to film distance of 6 feet. All lateral Cephalograms were placed on illuminator and determination
of CVM stages were done by two postgraduate trainees.
Panoramic radiographs were also placed on illuminator to determine the calcification stage of permanent
mandibular canine on the left side. We did not consider
the maxillary canine because superimposition of the
anatomic structures in this area does not always allow
assessment of the accurate developmental stage of the
teeth. Tooth calcification stages were rated from A to
H according to the method introduced by Demirjian
et al.16 The characteristics of stages are described in
Table 1.
Cervical vertebral maturation staging (CVMS)
was evaluated on lateral cephalometric radiographs,
according to the method described by Baccetti et al.17
This method has been proved useful in the evaluation
of skeletal maturation in a single cephalogram. This
method analyzes the morphology of the second (C2),
third (C3), and fourth (C4) cervical vertebrae and the
patient is classified into one of six stages; CVMS I,
CVMS II, CVMS III, CVMS IV, CVMS V and CVMS
VI which are given below.
Stage 1 (Initiation): Great amount of pubertal
growth expected (80 to 100%). Inferior borders of C2,
C3 and C4 are flat at this stage. The vertebrae are
wedge shaped, and the superior vertebral borders are
tapered from posterior to anterior.
Stage 2 (Acceleration): Growth acceleration begins at this stage. Significant pubertal growth expected
(65% to 85%). Concavities are developing in the inferior
borders of C2. The inferior border of C3 and C4 is flat.
The bodies of C3 and C4 are trapezoidal in shape.
Stage 3 (Transition): Moderate pubertal growth
expected (25% to 65%). Distinct concavities are seen in
the inferior borders of C2 and C3. A concavity is beginning to develop in the inferior border of C4. Atleast one
of C3 or C4 bodies still retains a trapezoidal shape.
Stage 4 (Deceleration): Reduced expectation of
pubertal growth (10 to 25%). Distinct concavities are
seen in the inferior borders of C2, C3 and C4. The vertebral bodies of C3 and C4 are rectangular horizontal
in shape.
Stage 5 (Maturation): Final maturation of the
vertebrae took place during this stage. Insignificant
pubertal growth expected (5 to 10%). More accentuated
concavities are seen in the inferior borders of C2, C3
and C4. The bodies of C3 and C4 are square in shape.
Stage 6 (Completion): Pubertal growth completed
at this stage (little or no growth expected) Deep concavities are seen in inferior border of C2, C3 and C4.
630
Evaluation of the skeletal maturation
The bodies of C3and C4 are square or are greater in
vertical dimension than in horizontal dimension.
Since the radiographs were selected from existing
data, there was no risk of additional radiation exposure to patients. All radiographs were analyzed by two
postgraduate trainees of orthodontics who examined
panoramic and lateral cephalometric radiographs separately. Cases with disagreement between the observers
were excluded.
To examine the intra-observer reliability, 20 subjects were reevaluated by both methods. The agreement
was assessed by weighted kappa statistics. Kappa was
(0.83 ± 0.05) for determination of tooth calcification
stages and (0.91 ± 0.04) for cervical maturation. The
results revealed that the reproducibility of the diagnosis
in our rater was almost perfect. Data were presented
as percentages. The Spearman's correlation coefficients
were used to study the correlation between cervical
vertebral maturation stages and dental calcification
stages. P<0.05 were considered statistically significant.
SPSS 16.0 was used for statistical analysis.
RESULTS
The mean age was 11.48±1.9 years. Female to
male ratio was 1.22:1. Thirteen year was the most
common age group (31%) followed by age 12 (17%).
Females were more than males patients. The common
CVM stage was CS2 followed by CS4. The most prevalent calcification was stage G followed stage H. (ref.
Table 2)
The highest correlation were among the CS1 and
stage E (100%), CS2 and stage F (75%) , Cs3 and stage
G (36%), and CS4 and stage H (51%). The common CVM
stage was CS2 in this study and calcification stage was
stage G. (ref. Table 3). The correlation between CVM
and dental calcification were highly significant (r=0.871
and p=0.000). (ref. Table 4)
The most common CVM stage was CS4 followed by
CS2 while in female the most common was CS3 and
CS4 followed by CS1. (Table 5)
DISCUSSION
The orthodontists should consider both the diagnostic records and the growth potential of the jaws.
Although orthodontic treatment is able to modify the
jaw growth and improve the dentofacial relationships,
its ability is restricted to the extent of jaw growth that
might occur. Many investigators have studied the
optimal time for treating patients with orthodontic
functional appliances and it is known that periods of
accelerated growth can contribute to correct those kinds
of skeletal imbalances.18 The pubertal growth spurt
can be assessed by some indicators such as increase in
body height,19 skeletal maturation of the hand-wrist20
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
and cervical vertebral maturation.21 In this study, we
investigated the correlation between cervical vertebral maturation stages and the calcification stages of
mandibular canine to know the correlation between
the tooth calcification and the CVM stages.
It is generally accepted that a strong relationship
do exists between skeletal, sexual, and somatic maturation,22 but contributions to the correlation between
dental age and skeletal maturity are inconclusive.23
Lack of concordance may result, at least in part, from
differences in evaluation methods of dental and skeletal
maturity. Discrepancies in the number, age, and racial
background of the studied subjects conditioned by ethnic
origin, climate, nutrition, socio-economic status, and
industrialization are the main reasons for variability
of the results in many studies.24
Panoramic radiographs are routinely available in
orthodontic departments and the method of dental age
determination described by Demirjian et al is based
on the calcification stage of the seven left mandibular
teeth, which are clearly visible on radiographs. The
criteria of the method comprise the shape and proportion of root length (using the relative value to crown
height rather than absolute tooth length) and thus
the influence of radiographic projection is minimal.6
In the majority of available studies, skeletal maturity
was assessed by means of hand wrist radiographs and
the dental calcification in which the mandibular region
is clearly visible.25-27 So panoramic radiographs were
used in current the study for determination of dental
calcification stages.
There are numerous standard scales for grading
the dental calciﬁcation stages. The method proposed
by Demirjian et al5 was selected in the present study
because its criteria consist of distinct details based on
shape and proportion of root length, using the relative
value to crown height rather than on absolute length.
Foreshortened or elongated projections of developing
teeth will not affect the reliability of assessment.28
The skeletal age for each hand-wrist radiograph can
be used according to the method described in the atlas
of Greulich and Pyle.29 Which is quick and relatively
easy to learn and carry out. Because it is less time consuming in practice than the bone stage and weighting
system of Tanner et al30 shows greater reproducibility
between observers, The Greulich and Pyle method
seems to be highly practical for clinical use in skeletal
age assessment.31 It is, however, essential to know that
the differences exists between the local population and
the reference population used to deﬁne the standards
in the atlas. Thus, the given skeletal age values or
standard plates might differ and should be recalibrated
for each local population.26
Solmaz et al14 showed in a study which consists of
four hundred females (age range, 8 to 14 years). They
631
Evaluation of the skeletal maturation
TABLE 1: STAGES OF TOOTH CALCIFICATION C TO H, ACCORDING TO DEMIRJIAN ET AL.
Stage C
Complete enamel formation on occlusal surface, dentin formation started, curved pulp chamber,
no pulp horns
Stage D
Complete crown formation to CEJ*, root formation started, curved pulp chamber, pulp horns
begin differentiation
Stage E
Root shorter than crown, straight pulp chamber walls, pulp horns more differentiated, radicular
bifurcation calcification started
Stage F
Isosceles triangle form of the pulp chamber, the root length equal to or greater than crown, distinct root form because of sufficiently calcified bifurcation
Stage G
Parallel walls of the root canal, open apical end
Stage H
Completely closed root apex, uniform periodontal membrane surrounding the root and apex
TABLE 2: FREQUENCIESOF AGE, GENDERS, CERVICAL VERTEBRAL MATURATION, AND
CALCIFICATION STAGES OF PATIENTS
Age
%ages
Genders
%ages
CVM Stages
%ages
Calcification stages
%ages
7
1
Male
45
CS1
10
E
7
8
10
CS2
32
F
24
9
9
CS3
21
G
38
10
9
CS4
28
H
31
11
13
CS5
7
12
17
CS6
2
13
31
14l
10
Total
100
Total
100
Total
100
Female
Total
55
100
TABLE 3: CORRELATION BETWEEN CERVICAL VERTEBRAL MATURATION AND MANDIBULAR
CANINE CALCIFICATION STAGES
C Cervical vertebral maturation stage (%)
CS1
CS2
CS3
CS4
CS5
CS6
Mandibular Canine
E
7
0
0
0
0
0
Calcification Stages
F
3
18
2
1
0
0
G
0
13
14
11
0
0
H
0
1
5
16
7
2
TABLE 4: CORRELATION BETWEEN CERVICAL VERTEBRAL MATURATION AND DENTAL
CALCIFICATION STAGES IN MANDIBULAR CANINE
Pearson across mandibular
canine calcification stages
0.781
P-value
0.000
Pearson correlation across cervical
vertebral maturation stages
0.781
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
P-value
0.000
632
Evaluation of the skeletal maturation
TABLE 5: CERVICAL VERTEBRAL MATURATION
OF PATIENTS ACCORDING TO AGE
Gender
Male
Female
CVM stage
Mean age (years)
CS1
8.50
CS2
11.33
CS3
11.38
CS4
13.00
CS5
14.00
CS1
8.00
CS2
10.12
CS3
11.77
CS4
12.92
CS5
12.20
CS6
14.00
Fig 1: CVM staging according to Baccetti et al
determine the dental maturational stage, calcification
of the mandibular teeth except for third molars. To
evaluate the stage of skeletal maturation, cervical
vertebral morphologic changes were assessed on lateral
cephalometric radiographs according to the method
explained by Baccetti et al. Spearman's correlations
between the teeth calcification and cervical vertebral
maturation stages – except for the permanent incisors
and first molar – were found to be high (r=0.702-0.75)
and they also reported that a significant relation between the two classifications exists (P < 0.001). The
current study differs in some respects from Solmaz’s
study; only mandibular canine calcification was determined in this study and both genders were included.
The present study results are in agreement with the
Solmaz et al (r= 0.781 and p= 0.000).
Sachan and colleagues32 evaluated the relationship
of skeletal maturity by cervical vertebral maturation indicators and canine calcification stages. Their
study consisted of randomly selected 90 children from
Lucknow population with 45 males (age range 10-13
years) and 45 females (age range 9-12 years). Lateral
Cephalogram, and periapical x-rays of maxillary and
mandibular right canines were taken. Mean, standard
deviation was calculated of different groups. Correlation was made among cervical vertebral maturation
Pakistan Oral & Dental Journal Vol 34, No. 4 (December 2014)
and canine calcification stages at various age groups.
They also studied the correlation between CVM and
hand wrist radiograph. They showed strong correlation
between skeletal maturation indicator and cervical
vertebral maturation indicator for both male (0.849)
and female (0.932), whereas correlation between skeletal maturation indicator and canine calcification was
good for both male and female (0.635, 0.891). In the
current study both genders were studied jointly and
comparison with the hand wrist radiographs were not
performed to avoid unnecessary radiation to patients.
The present’s study results are comparable to Sachan
et al.
Goyal and co-workers 33 assessed, the relationship
between cervical vertebrae maturation and mandibular canine calcification stages to know whether the
mandibular canine calcification stages can be used as
indicators to determine skeletal maturity. A descriptive,
retrospective, and cross-sectional study was designed.
Pre-treatment orthopantomograms (OPGs) and lateral
cephalograms of 99 males and 110 females of Rwanda
ethnicity were selected. The cervical vertebrae maturation index (CVMI) proposed by Hassel and Farman
was used to evaluate the skeletal maturation level,
and the mandibular canine calcification stages were
assessed with the Demirjian Index (DI). A significant
correlation was found between the CVMI and DI stages, as evaluated by the correlation coefficient values
(0.599 for males and 0.719 for females). Canine stage F
and canine stage E could represent highest correlation
with CVMI 2 stage and indicate the onset of a period of
accelerating growth. In the present study CVM assessment was made according to Baccetti et al17 and stage
E showed highest correlation with CVM1 (100%) (Table
5). Goyal’s study support this study as far as stage F
with CVM2 and coefficient of correlation between DI
and CVMI is concerns.
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