|Year : 2016 | Volume
| Issue : 3 | Page : 141-145
Radiographic Comparisons between Middle Phalanx of the Third Finger and Cervical Vertebrae Maturation for the Assessment of Skeletal Maturity
HC Meghana1, KN Sri Charan2, GV Pramod3, L Ashok3
1 Department of Oral Medicine and Radiology, A J institute of Dental Sciences, Mangalore, Karnataka, India
2 Department of Internal Medicine, A J Institute of Medical Science, Mangalore, India
3 Department of Oral Medicine and Radiology, Bapuji Dental College and Hospital, Davangere, Karnataka, India
|Date of Web Publication||30-Sep-2016|
H C Meghana
Department of Oral Medicine and Radiology, A J Institute of Dental Sciences, Kuntikan, Mangalore - 575 004, Karnataka
Source of Support: None, Conflict of Interest: None
Sexual maturation characteristics, chronologic age, dental, and skeletal development are some of the more commonly used means to identify stages of growth. Hand wrist radiograph and cervical vertebrae maturation index (CVMI) are more reliable for skeletal development assessment. This study was conducted to compare the skeletal maturity using the maturational stages of middle phalanx of the third finger (MP3) with cervical vertebrae and then to evaluate the reliability of MP3 as a sole skeletal maturity assessment method. Chronological age group of the 112 subjects was 8-16 years for females and 10-18 years for males were selected for the study. Lateral cephalometry and intra oral peri-apical radiograph of MP3 of the left hand of each patient were taken. Then, statistically it was correlated which was highly significant. Skeletal maturation of MP3 and cervical vertebrae stages progress with advancing chronological age. Female subjects were advanced on an average of 2 years earlier than male subjects at every stages of growth spurt. These results suggest that MP3 can substitute CVMI for skeletal maturity evaluation to determine optimal treatment time for various orthodontic procedures. The developmental stages of the MP3 could be used as a sole indicator in assessing the skeletal maturity.
Keywords: Cervical vertebrae maturation index stages, middle phalanx of the third finger stages, skeletal maturity
|How to cite this article:|
Meghana H C, Sri Charan K N, Pramod G V, Ashok L. Radiographic Comparisons between Middle Phalanx of the Third Finger and Cervical Vertebrae Maturation for the Assessment of Skeletal Maturity. J Forensic Sci Med 2016;2:141-5
|How to cite this URL:|
Meghana H C, Sri Charan K N, Pramod G V, Ashok L. Radiographic Comparisons between Middle Phalanx of the Third Finger and Cervical Vertebrae Maturation for the Assessment of Skeletal Maturity. J Forensic Sci Med [serial online] 2016 [cited 2020 Dec 4];2:141-5. Available from: https://www.jfsmonline.com/text.asp?2016/2/3/141/191465
| Introduction|| |
Knowledge of craniofacial growth and development is considered very important for every dental practitioner. This is especially so if the dental practitioner is considering, modifying the dental and facial growth of an individual as part of their treatment.
During growth, every bone goes through a series of changes that can be seen radiographically. The chronologic age of these changes varies because each has his or her own biological clock.  Craniofacial growth prediction can be important for diagnosis, prevention and treatment of malocclusions. 
The developmental status of a child can be assessed with various growth indicators, including chronological age, dental development, height and secondary sexual characteristics and skeletal age. The key issue with any of these growth assessment methods is reliability. 
Skeletal maturation staging from the radiographic analysis is a widely used approach to predict timing of pubertal growth, to estimate growth velocity and to estimate the amount of growth remaining.  The standard method of evaluating skeletal maturity is hand wrist radiograph.  As an alternative to the hand wrist method, cervical vertebral maturation has been evaluated for its correlation with skeletal maturity. It was found to be statistically and clinically reliable in assessing skeletal age and as valid as the hand wrist radiographic method. 
The developmental changes in the middle phalanx of the third finger (MP3) have been used to study the skeletal maturity development since they follow the pubertal growth spurt from the onset to end.  Keeping in mind the as low as reasonably achievable principle, no additional exposure to radiation would be necessary if skeletal maturity can be assessed through routinely taken radiographs.  The high degree of clarity of the intra-oral peri-apical radiographs (IOPARs), availability, the ease with which we can interpret the MP3 skeletal maturity stages, the low cost and minimal patient radiation exposure point to it as a practical technique for the dentist. 
The aim of this study was to compare the skeletal maturity using the maturational stages of MP3 with cervical vertebrae and to assess the reliability of MP3 for skeletal maturity assessment.
| Materials and Methods|| |
The study consisted of 112 subjects, 56 females and 56 males. They were further divided into eight groups according to their age, with an equal distribution of males and females in each age group. The subjects were selected randomly from patients visiting the Departments of Oral Medicine and Radiology.
Ethical clearance was obtained from the responsible committee on human experimentation (institutional). Informed consent was obtained from all the subjects and from the parents or legal guardians of minors. Patients with systemic disorders; congenital or acquired abnormalities of the cervical vertebrae and the middle finger region; a history of trauma to the cervical vertebrae, third finger region of the left hand and patients with a history of bone deformities were excluded from the study group.
- Patients of chronological age:
- Females: 8-16 years
- Boys: 10-18 years.
- Patients who required skeletal maturation assessment, for diagnosis and interceptive orthodontic treatment planning.
Periapical radiographs for recording the MP3 stages were taken using the following procedure:
Lateral cephalograms for recording the cervical vertebrae maturation index (CVMI) stages were taken in natural head position.
- The subject was instructed to place the left hand with the palm downward on a flat table
- The middle finger was centered on an IOPA film, parallel with the long axis of the film
- The cone of the dental X-ray machine was positioned perpendicular to the film and X-ray exposure was made.
Evaluation: Radiographic assessment of the cervical vertebrae was done according to the method proposed by Lamparski  and modified by Hassel and Farman [Figure 1]. ,
CVMI 1 - Initiation stage:
CVMI 2 - Acceleration stage:
- Inferior borders of C-2, C-3, and C-4 are flat
- The third and fourth are wedge-shaped, and the superior vertebral borders are tapered from posterior to anterior
- 80-100% of pubertal growth remains.
CVMI 3 - Transition stage:
- Concavities on the inferior borders of C-2 and C-3 begin to develop
- Inferior border of C-4 vertebrae remains flat
- Vertebral bodies of C-3 and C-4 are nearly rectangular in shape
- 65-85% of pubertal growth remains.
CVMI 4 - Deceleration stage:
- Distinct concavities are seen in inferior borders of C-2 and C-3 vertebrae
- Concavity is developing in inferior border of C-4
- Vertebral bodies of C-3 and C-4 are rectangular in shape
- 25-65% of pubertal growth remains.
CVMI 5 - Maturation stage:
- Distinct concavities can be observed on the inferior borders of C-2, C-3 and C-4 vertebrae
- Vertebral bodies of C-3 and C-4 begin to be square in shape
- 10-25% of pubertal growth remains.
CVMI 6 - Completion stage:
- Marked concavities are observed on the inferior borders of C-2, C-3, and C-4 vertebrae
- Vertebral bodies of C-3 and C-4 are almost square in shape
- 5-10% of pubertal growth remains.
Hägg and Taranger  have described five stages of MP3 growth [Figure 2].
- Deep concavities are observed on the C-2, C-3 and C-4 vertebrae
- Vertebral bodies are greater vertically than horizontally
- Pubertal growth has been completed.
- MP3F stage: Epiphysis is as wide as metaphysis and it denotes the onset of pubertal growth spurt
- MP3FG stage: Epiphysis is as wide as metaphysis and there is a distinct and/or lateral border of the epiphysis forming a line of demarcation at right angle to the lateral border
- MP3G stage: The sides of the epiphysis had thickened and also capped its metaphysis forming a sharp edge distally at one or both
- MP3H stage: Fusion of epiphysis and metaphysis has begun. It is the deceleration period of pubertal growth spurt
- MP3I stage: Fusion of epiphysis and metaphysis was complete. It marks the end of pubertal growth spurt.
One-way ANOVA was used for age comparison between stages. Since assessment was done as stages (CVMI and MP3), nonparametric methods were used for analysis. Category data were analyzed by Chi-square test for associations with contingency co-efficient. Spearman's rank correlation coefficient was used to measure the relationship. Inter-examiner error, reliability analysis was performed using Kruskal-Wallis ANOVA test. Intra-examiner error, reliability analysis was performed using Wilcoxon's signed rank sum test.
| Results|| |
[Table 1] gives correlation between MP3 stages and chronological age. The statistical analysis using ANOVA (F) revealed, for males an F = 44.7 and for females an F = 38.8. This indicates a highly significant correlation between MP3 stages and chronological age in both the genders. As the chronological age in each group was progressing, the MP3 stages too were advancing with skeletal maturation.
|Table 1: Correlation between middle phalanx of the third finger stages and chronological age |
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[Table 2] gives correlation between MP3 and CVMI stages. The correlation was studied using Chi-square test (χ2 ) and the χ2 value is 166.7. The contingency coefficient is 0.77 and the P < 0.001, which indicates that this correlation is very highly significant.
|Table 2: Correlation between middle phalanx of the third finger and cervical vertebrae maturation index stages |
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[Table 3] gives the distribution of MP3 stages into prepeak, peak, and postpeak according to CVMI stages. Prepeak stage is represented by CVMI 1 and CVMI 2 stage, peak stage is represented by CVMI 3 and CVMI 4 stage, and postpeak is represented by CVMI 5 and CVMI 6 stage. Distribution of MP3 stages into prepeak, peak, and postpeak according to CVMI stages was studied using Chi-square test and the χ2 value is 127.7. The contingency coefficient is 0.73 and the P < 0.001, which indicates that the correlation between the MP3 stages and CVMI stages is highly significant.
|Table 3: The distribution of middle phalanx of the third finger stages into prepeak, peak and postpeak according to cervical vertebrae maturation index stages |
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| Discussion|| |
Various studies Hassel and Farman,  García-Fernandez et al.,  Kucukkeles et al.,  agree that hand wrist maturity assessment and cervical vertebrae maturity assessment are clinically useful skeletal maturity indicators for the assessment of the pubertal growth period. However, studies Gabriel et al.,  Baptista et al., (2012),  Nestman et al.,  have shown that there is overall poor reproducibility of the CVM method.
Madhu et al., (2003)  stated that CVMI methods require elaborate equipment. He also added that; the radiation exposure time and dose were also high. To overcome the above shortcomings Abdel-Kader (1999) has suggested a method for assessing the skeletal maturity by radiographically recording the MP3. ,,
The aim of this study was to provide the clinician with a simple and reliable tool to help determine growth potential in the adolescent patient with minimal radiation exposure. This was to be accomplished by using anatomic changes of the MP3 observed on a standard IOPAR taken with a dental X-ray machine to determine skeletal maturity.
Growth modification treatment procedures are most effective when started 2-3 years before the peak in the pubertal growth spurt.  There are differences in the onset of the circumpubertal periods between males and females. To ensure that the subjects were in or close to the circumpubertal period, different age ranges for the sexes were selected for this study.
In this study, the correlation was highly significant (P < 0.001) between MP3 stages and chronological age for both genders. These findings are in agreement with the previous studies conducted by Madhu et al., (2002),  Negi,  and Bala et al. 
Correlation between CVMI and chronologic age was highly significant (P < 0.001) in both genders. These findings are in agreement with the previous study of Hassel and Farman in 1995. 
Correlation between the MP3 and CVMI were assessed using Chi-square test. A value of 166.7 was obtained with a contingency coefficient of 0.77 and it was found to be highly significant. This result is in agreement with Rajagopal and Kansal,  Negi. 
In both MP3 and CVMI stages, females were an average of 2 years more skeletally mature than males at the beginning, peak and pubertal growth spurt. This suggests that males retained the active growth phase up to an average of 2 years longer than females and the growth modification treatment could be started at a delayed chronologic age in the males compared to females. Similar sexual dimorphism has been reported in the growth studies by Hägg and Taranger  Negi  and Bala et al. 
The inter-examiner variability was assessed using the Kruskal-Wallis test and intra-examiner variability by the Wilcoxon's signed rank sum test. Radiographs of twenty cases were examined by three observers and re-evaluated after 3 weeks. There were a few differences between the examiners in assessing the skeletal maturity, and it was found to not be statistically significant. Hence, from these findings, we conclude that the assessment of the developmental stages of MP3 could be used as a sole indicator with good reliability in assessing the skeletal maturity. Similar results have been observed by Madhu et al.,  and Ozer et al. 
In a previous study conducted by Kucukkeles et al.,  the CVMI stages were categorized into prepeak, peak, and postpeak stages. This study categorized the CVMI 1 and CVMI 2 in prepeak, CVMI 3 and CVMI 4 in peak, and CVMI 5 and CVMI 6 in to postpeak stages. Our study evaluated the distribution of MP3 stages into prepeak, peak, and postpeak according to CVMI stages. It was observed that the prepeak is represented by MP3F and MP3FG in 100% of samples collected. The peak is represented by MP3FG, MP3G, and MP3H in 97.1% of samples collected. The postpeak is represented by MP3H, MP3 I in 97.1% of samples collected. Thus, we further categorized MP3 stages into prepeak, peak, and postpeak growth periods.
Another interesting observation was noted on comparing the corresponding chronological age in males and females according to MP3 stages. The initiation of the prepeak stage of growth was achieved at 11.1 years in boys and 9 years in girls. The peak stage of growth was achieved at 12.8 years for boys and 11.1 years for girls. The active growth phase was found to be complete at 16.6 years for boys and 14.8 years for girls. Our results support the study conducted by Madhu et al.,  According to the MP3 staging in our study, we suggest that the initiation of orthodontic treatment has a better prognosis if the treatment is started in the prepeak stage, i.e., 11.1 years in boys and 9 years in girls.
By looking at the MP3 on an IOPAR, the orthodontist can now evaluate the skeletal maturity of the patient. Along with other clinical data, the MP3 stage aids the clinician in evaluating the patient's growth potential and thereby the appropriate timing and method of orthodontic treatment. We believe that, in the presence of malocclusions associated with skeletal deviations, dentofacial orthopedic treatment performed during periods of greater growth velocity often results in less treatment time.
| Conclusion|| |
Financial support and sponsorship
- Correlation between MP3 stages, CVMI stages with chronologic age was statistically highly significant
- Correlation between the MP3 stages and CVMI was found to be statistically highly significant
- The MP3 stage can be used as an alternative to CVMI in assessing the skeletal maturity
- Determining skeletal maturity using the MP3 radiograph is a simple and highly reliable method with significantly lower radiation exposure
- In both MP3 and CVMI skeletal maturity assessment methods, each stage blends into the next and it is sometimes difficult to differentiate borderline cases
- Female subjects were on average 2 years earlier in their skeletal maturation than male subjects confirming the existence of sexual dimorphism in skeletal maturation between genders.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]