|Year : 2021 | Volume
| Issue : 1 | Page : 31-37
Comparative evaluation of cervical vertebrae maturation index and stages of mandibular second molar calcification: A cross-sectional study
Ashutosh Bhardwaj1, Abhijit A Kadu2, B Jayan3, Neetu Kadu4, Uday R Kamat5
1 Graded Spl Orthodontics, MDC Jalandhar, Punjab, India
2 Classified Spl 12 CDU C/0 56 APO, New Delhi, India
3 Commandant Army Dental Centre R&R Delhi Cantt, New Delhi, India
4 Assistant Professor, Sudha Rastogi Dental College and Hospital, Faridabad, Haryana, India
5 Commanding Officer MDC Gaya, Bihar, India
|Date of Submission||28-Aug-2020|
|Date of Decision||11-Sep-2020|
|Date of Acceptance||26-Nov-2020|
|Date of Web Publication||09-Mar-2021|
MDC Jalandhar C/0 56 APO
Source of Support: None, Conflict of Interest: None
Aim: This study aims to evaluate the relationship between stages of mandibular second molar calcification and cervical vertebrae maturity (CVM) staging for the assessment of pubertal growth spurts in patients.
Materials and Methods: Pretreatment panoramic and lateral cephalometric radiographs of 400 patients (200 males and 200 females) were evaluated to ascertain the association of Demirjian index (DI) and CVM method.
Results: A highly significant correlation between Cervical vertebrae maturation Index (CVMI) and DI was calculated using Sakoda adjusted Pearson contingency coefficient (r) and a positive correlation was found between CVM and DI in male samples as r = 0.785 and female sample as r = 0.803.
Conclusion: A highly significant correlation (r = 0.785 for male subjects and 0.803 for female subjects) was found between DI and CVMI and female subjects showed a higher correlation between skeletal and dental maturity compared to male subjects.
Keywords: Cervical vertebrae maturity, dental calcification, skeletal maturation
|How to cite this article:|
Bhardwaj A, Kadu AA, Jayan B, Kadu N, Kamat UR. Comparative evaluation of cervical vertebrae maturation index and stages of mandibular second molar calcification: A cross-sectional study. J Dent Def Sect. 2021;15:31-7
|How to cite this URL:|
Bhardwaj A, Kadu AA, Jayan B, Kadu N, Kamat UR. Comparative evaluation of cervical vertebrae maturation index and stages of mandibular second molar calcification: A cross-sectional study. J Dent Def Sect. [serial online] 2021 [cited 2021 Apr 18];15:31-7. Available from: http://www.journaldds.org/text.asp?2021/15/1/31/310967
| Introduction|| |
In orthodontic clinical practice, an understanding of growth events of body in general and craniofacial structures in particular is of primary importance for successful management of patients. In most individuals, the timing of maturity vary to some extent in accordance with their biological system. The commonly used indicators of biological maturity are maturation of skeleton, sexual maturation and somatic maturation. Among these methods of estimation of biological maturity, skeletal maturity is one of the most reliable indicators as both the beginning and endpoint of its progress is well understood and its maturation spans the entire period of growth.
Skeletal maturation assessed on hand-wrist radiographs is classically considered as one of the best indicator of maturity however its main drawback is that an additional radiograph is required. The commonly used method to access skeletal maturity by studying the maturation stages of cervical vertebrae was first described by Lamparski in 1972 and later elaborated by Hassel and Farman in 1995. This method had the potential advantage of reducing the radiation exposure to the patient as lateral cephalogram is routinely used radiograph for diagnosis and treatment planning.
Dental developmental stages can be easily recognized on panoramic radiographs and can be used for estimation of physiological maturity. The teeth progressively calcify in several easily definable stages so that age can be reliably defined by the stage of calcification. Studies done by Demirjian et al. in 1973 for the estimation of dental age by referring to the radiological appearance of seven teeth on the left side of mandible. Earlier many studies,,,,,,,,,, were conducted to correlate the various skeletal maturity indicators and the mineralization pattern of certain teeth with varied results.
Studies are therefore required for the same reason to find out the correlation between dental maturation and skeletal maturation so that growth status can be predicted in a more precise manner by assessment of dental developmental stages along with lateral cephalograms without resorting to multiple hand-wrist radiograph. The aim of present study was to evaluate the relationship between skeletal maturity indicators, i.e., stages of mandibular second molar calcification and cervical vertebrae maturity (CVM) staging for the assessment of pubertal growth spurts in patients and to evaluate whether the mandibular second molar calcification stages can be used as a reliable diagnostic marker to assess skeletal maturity.
| Materials and Methods|| |
The study was carried out using panoramic and lateral cephalometric radiographs to compare the relationship between cervical vertebrae maturation index (CVMI), and stages of mandibular second molar calcification Demirjian index (DI). A sample of 400 children in the age group of 8–18 years of mixed Indian population (200 males and 200 females) were chosen from the pretreatment records of patients attending clinics for orthodontic treatment at Military Dental facility for the year 2015–2018. Further, these groups were divided into 4 subgroups having 50 pairs each of radiographs of study subject. The radiograph sets of the subject were divided into two groups. Group M consisting of males (n = 200) and group F consisting of females (n = 200). On the basis of completed age each group was further divided into four subgroups (I, II, III, and IV), and each consisting of 50 pair of radiographs of the subject. Inclusion criteria includes panoramic and lateral cephalometric radiographs of children between 8 and 18 years of age and radiographs of good quality of subjects with full complement of permanent teeth at that age. Exclusion criteria includes: (1) Radiographs of subjects with developmental problems affecting growth and development, for example, craniofacial syndromes. (2) Evidence of trauma and/or surgery affecting face. (3) History of previous orthodontic treatment. (5) Radiograph of subject with abnormal dental conditions including impactions, transposition and congenital missing teeth.
Following the distribution of subject to respective groups the lateral cephalogram and orthopantograms are evaluated and data were complied. A data sheet on A4 size landscape sheet was used to record the stages of all the radiographs of the study subject. Each master data sheet [Figure 1] have figure of CVM staging (CVM-6) as recommended by Baccetti et al., [Table 1] and stages of calcification (A to H) of mandibular left second molar as per DI, for ready referencing [Table 2]. The second third and fourth cervical vertebra were manually traced on the lateral cephalogram using standard technique using 4H pencil and acetate tracing paper. The tracing was photostat/digitized as pasted (as shown in the picture) on the master sheet in the space assigned to facilitate easy comparison and for allotment of CVMI stages. The tracing of mandibular second molar was done using the same technique and photostat/digitized and pasted on the space assigned on the data sheet. The above-mentioned procedure was done for all the selected radiographs of study subjects and 400 data sheet were generated. A master data sheet was then generated on MS Excel work sheet and would essentially consisting of subject code, group, CVMI stage and DI. The data so obtained were subjected to statistical analysis for obtaining correlation between CVMI and mandibular second molar calcification developmental stages (Demirgian index).
|Figure 1: Performa for assessment of cervical vertebrae maturation index and Demirjian index of each patient|
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All the tracing and data recording were performed by a single operator and weighted Kappa statistics was applied for intraobserver reliability.
The collected data were subjected to statistical analysis using SPSS version 21 Armonk, NY : IBM Corp. for analysis. To establish the intraobserver reliability, weighted Kappa Statistics was performed. Descriptive statistics was performed by calculating mean, standard deviation, frequencies and percentages. Summarized data was presented using tables and graphs. Chi-square test was used for comparison between categorical variables (demographic). Normal distribution of variables was checked using Shapiro–Wilk test. The correlation between CVMI and DI for age and gender was calculated using Sakoda adjusted Pearson contingency coefficient (r). Level of statistical significance was set at P ≤ 0.05.
| Results|| |
Demographic details were computed for the complete sample and shown in [Table 3]. The intraobserver reliability was found excellent for both cervical vertebrae maturation indicator (CVMI) staging (Kappa statistics value = 0.89) and mandibular second molar calcification stages (DI) (Kappa statistics value = 0.909), hence showing excellent strength of agreement. The values were found to be statistically significant (P < 0.0001) [Table 4].
When the study sample was correlated for CVMI and DI stages, it was revealed that 82 subjects were in CVMI Stage 3 and out of which 4.9% were in Stage E, 31.7% were in Stage F, 58.5% were in Stage G and 4.9% were in Stage H. Seventy subjects were in CVMI stage 4 and out of that 5.7% were in Stage F, 67.1% were in Stage G and 27.1% were in stage H [Table 5]. The correlation between CVMI and DI was calculated using Sakoda adjusted Pearson contingency coefficient (r) and a positive correlation was found between CVMI and DI in male samples as r = 0.785 and this relation was found to be statistically significant (P < 0.0001) [Table 6] and [Graph 1] and [Graph 2].
|Table 5: Correlation between cervical vertebrae maturation index and Demirjian stages in overall study sample|
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|Table 6: Correlation between cervical vertebrae maturation index and demirjian stages for male subjects|
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The correlation between CVMI and DI was calculated using Sakoda adjusted Pearson contingency coefficient (r) and a positive correlation was found between CVMI and DI in female samples as r = 0.803 and this relation was found to be statistically significant (P < 0.0001) [Table 7] and [Graph 3].
|Table 7: Correlation between cervical vertebrae maturation index and demirjian stages for female study subjects|
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Comparative evaluation of [Table 6] and [Table 7] revealed that except at CVMI Stage 1, males are ahead of female in dental maturity at all other CVMI stages.
For all groups, there was a positive correlation between CVMI and DI which was calculated using Sakoda adjusted Pearson Contingency Coefficient and correlation was found to be statistically significant (P < 0.005).
| Discussion|| |
There may be wide variations in individual timing, duration, and velocity of growth and estimation of skeletal age is essential in formulating viable orthodontic treatment plans. There are many methods of evaluation of skeletal maturation which includes physiological parameters, radiographic methods and use of certain biological markers like Serum Insulin-like growth factor-1 level, Serum Parathyroid hormone-related protein levels, and Gingival Alkaline phosphatase levels. Radiographic assessment includes Hand wrist radiographs, tooth calcification stages,,,,, CVMI stages.,,Among the various radiographic methods for estimation skeletal maturation the CVMI is most commonly used in clinical practice and its reliability and validity has been proved by the systematic review and meta-analysis. In past, it was proposed that tooth calcification stages can be used for estimation of skeletal maturity and various classification systems were devised for evaluating the stages of tooth mineralization which includes Gleiser and Hunt, Nolla, Garn et al., and Demirjian et al. Among these Demirjian et al. put forth a system of dental age assessment using seven teeth (from central incisor to the second molar) on the left side of the mandible to achieve dental maturity scores. They categorized the tooth development into 8 stages rated on a scale from “A” to “H” with radiographic images. The Demirjian's original method of scoring the calcification stages from A to H on panoramic radiograph was adopted in the present study because its criteria consist of distinct details based on shape criteria and proportion of root length, using the relative value to crown height rather than on absolute length. Orthopantomogarm can be used to assess status of dental maturity because it is routinely done in orthodontic practice.
This study combined the observations of the changes in the calcification stages of mandibular second molar and the changes in the cervical vertebrae during skeletal maturation in both male and female study samples. Various studies have suggested a strong correlation between mandibular second molar calcification and skeletal maturity.,, These studies were done on the groups of individuals with defined ethnic, racial, and social characteristics precisely. In our study we had considered a mixed Indian population (i.e., individuals from North, South, East and Western states of India). We could consider such a heterogeneous population as the study was done on samples derived from pretreatment records of patients reporting for treatment at government organization belonging to various states of country. In most of the previous and recent studies the population assessed has been of a particular ethnic background and results can only be extrapolated to that particular population only. The strength of our study is the inclusion of sample without any racial and ethnic preferences. We analyzed mandibular second molar in our study as it tends to complete its development around the age of 16–17 years this age range includes the pubertal growth spurt which is one of the most significant assessment for orthodontic intervention. In many recent studies, the calcification of second molar has shown highest correlation with skeletal maturity.
In our study, the left permanent mandibular second molar calcification was assessed for assessing skeletal maturity, which was in accordance with Demirgian who also performed the study on the left side of mandible.
The present study revealed that the maturation of the cervical vertebrae and mandibular second molar development progresses with age. In all groups, the CVMI stages and mandibular second molar calcification stages increases gradually with age however it occurs at different rate in the periods of growth. Except in CVMI Stage 1, in all other stages female were more advanced (less mean age) compared to male subjects. Fishman, also demonstrated a significant difference between the male and female in the age of onset and progression of adolescent skeletal maturity. This is supported by Hagg and Taranger, who observed that there was a 2 years sexual difference in age at the beginning, peak and end of the pubertal growth spurt. Chapman, also observed in their study that girls are ahead of boys in skeletal maturation.
In our study, the age correlation for gender at various stages of mandibular second molar calcification was found to be statistically not significant. This finding is supported by Demirjian and Levesque, who stated that “there is no difference between boys and girls in the median age of attainment of the first two stages, A and B”. His data suggested the importance of sexual dimorphism during the period of root development rather than crown development.
In the present study, the association between CVMI and DI were found to be positively correlated (male r = 0.785, female r = 0.803 with P < 0.0001) and statistically significant in both male and female study samples [Table 6] and [Table 7]. This is in agreement with the study conducted by Engstrom et al. Another study supporting these results was Ingrid Różyło-Kalinowska et al., which concluded that a moderate, but statistically significant, correlation between Demirjian's dental developmental stages and the maturation stages of the cervical vertebrae exists. Their findings also suggested the usefulness of dental calcification stages as a simple first-level diagnostic tests to determine skeletal maturity.
One of the important objectives of this study was to estimate the strength of association between skeletal (CVMI) and dental variables DI (mandibular second molar calcification). Skoda adjusted Pearson contingency coefficient (r) was used and the correlation was estimated according to age and gender. This association was stronger for female compared to male sample, this is in agreement with a study conducted by Kumar et al. A clinically important fact that has proved from our study is that males tend to have a more advanced dental maturity development compared to females, considering the same CVM stage. Male subjects particularly in CVMI Stage 3 and 4 (pubertal growth spurt phase) were in advanced stage of DI. In male subjects CVMI Stage 3 was most frequently associated with Stage G (62.0%) and CVMI Stage 4 was associated with Stage G (60.5%) and Stage H (31.6%). In female subjects CVMI Stage 3 was associated with DI Stages F (40.6%) and Stage G (53.1%) and CVMI Stage 4 with Stage G (75%) and Stage H (21.9%) both. Thus, it is proved that female who were in advanced stage in cervical vertebrae maturation, were lagging behind in dental development at the same CVMI stage with the male counter parts. This is a clinically relevant and useful outcome of study. In the majority of the earlier studies, including the present one, a statistically significant correlation between dental and skeletal maturity in both gender at all stages was confirmed.
Uniform trends were not observed on relating skeletal maturation and dental developmental variables to each other according to age and sex. Hence, if we are exploring the possibility of replacing CVMI methods with the mandibular second molar development, our study indicates that this indicator cannot be fully matched with CVMI stages for the assessment of pubertal growth status. Thus, mandibular second molar might be an adjunct to cervical vertebrae maturation but not a substitute for it. Radiolographic skeletal maturation indicators should be used to augment other observations by the orthodontist and one diagnostic test should not be relied on too heavily.
| Summary and Conclusion|| |
- It has been observed in the present study that the female subjects were attaining the cervical vertebrae maturation at an early age compared to male subjects. However, the mandibular second molar calcification stages were more advanced in male subjects as compared with female subjects at the same CVMI stage
- The CVMI Stage 2 (prepubertal growth spurt stage) corresponds to Stage E of DI for Mandibular second molar calcification on OPG and CVMI Stage 3 and 4 (peak of pubertal growth spurt) corresponds to Stage F and G of DI for mandibular second molar calcification. CVMI Stage 5 and 6 (End of pubertal growth spurt) corresponds to Stage H of DI
- A highly significant correlation (r = 0.785 for male subjects and 0.803 for female subjects) was found between DI and CVMI and female subjects showed a higher correlation between skeletal and dental maturity compared to male
- Dental and skeletal maturity are highly correlated, although the diagnostic performance of dental maturity for the identification of any stage of skeletal maturity is limited
- The calcification stages of mandibular second molar can be used as a reliable indicator for evaluation of growth stages in clinical practice, however, it should be used as an adjunct to cervical vertebrae maturation but not a substitute for it.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]