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Year : 2017  |  Volume : 9  |  Issue : 2  |  Page : 84-87

Comparison of middle phalanx of the middle finger and cervical vertebrae as skeletal maturity indicators

1 Department of Pedodontics and Preventive Dentistry, GSL Dental College, Rajahmundry, Andhra Pradesh, India
2 Department of Pedodontics and Preventive Dentistry, Vishnu Dental College, Bhimavaram, Andhra Pradesh, India
3 Department of Pedodontics and Preventive Dentistry, Lenora Dental College, Rajahmundry, Andhra Pradesh, India

Date of Web Publication26-May-2017

Correspondence Address:
Pavitra Tripura Javangula
Department of Pedodontics and Preventive Dentistry, GSL Dental College, Rajahmundry, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_16_17

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Objectives: To investigate the relationship between chronological age and the stages of maturation of cervical vertebrae maturation index (CVMI) and the middle phalanx of the middle finger (MP3) and to determine the correlation between CVMI and MP3. Materials and Methods: A cross-sectional study included 100 children (boys - 50, girls - 50) aged 8–14 years based on nonprobability quota sampling. The study included digital radiographs of the MP3 of the right hand and conventional lateral cephalograms. Chronological age was assessed by the date of birth, MP3 maturation by Rajagopal and Kansal's criteria, and CVMI development by Hassel and Farman's method. Statistical Analysis: Spearman's rank-order correlation coefficient was applied to measure the association between stages of MP3 and CVMI. Results: Progressive stages of MP3 and CVMI were seen as chronological age advanced. Girls showed an advanced trend than boys in both MP3 and CVMI stages. MP3 and CVMI stages showed a strong positive correlation (r + 0.836, P < 0.01). Conclusions: MP3 and CVMI both are equally good indicators of skeletal maturity. Assessment of skeletal maturity on lateral cephalogram (CVMI) is advantageous as it avoids the need for an additional radiograph.

Keywords: Cervical vertebrae maturation index, maturity indicators, middle phalanx of the middle finger, skeletal maturity

How to cite this article:
Javangula PT, Uloopi K S, Vinay C, Rayala C, Kumar N M, Chandra S P. Comparison of middle phalanx of the middle finger and cervical vertebrae as skeletal maturity indicators. Indian J Dent Sci 2017;9:84-7

How to cite this URL:
Javangula PT, Uloopi K S, Vinay C, Rayala C, Kumar N M, Chandra S P. Comparison of middle phalanx of the middle finger and cervical vertebrae as skeletal maturity indicators. Indian J Dent Sci [serial online] 2017 [cited 2021 Feb 27];9:84-7. Available from: http://www.ijds.in/text.asp?2017/9/2/84/207100

  Introduction Top

The developmental status of a child is usually assessed in relation to the events that take place during the process of growth.[1] Growing individuals differ not only in the timing of these maturational events but also in the sequence of these events.[2] Hence, the chronological age may not be sufficient to assess the stage of maturity of a child. Considerable variations in the children of the same chronological age have led to the concept of biologic or physiologic age.[3]

Several biologic indicators have been evaluated as potential markers of an individual's peak of growth. Although some biologic markers, such as secondary sexual characteristics and physical body measurements, are considered suitable indicators of the skeletal maturation, they cannot be used to predict the timing of maximum growth due to their retrospective nature.[4] Alternatively, direct evaluation of skeletal maturity level by observing certain bony maturation markers among different parts of the body is more valuable as a diagnostic tool in forecasting the prospective adolescent growth spurt and planning the growth modification therapy.[5]

The hand wrist radiograph is commonly used for the assessment of skeletal maturation. Furthermore, the changes in the epiphysis of the middle finger follows an orderly sequence.[2] On the other hand, as recording middle phalanx of the middle finger (MP3) stages is a simpler and economical, it was used to assess the skeletal maturity.[6]

More recently, the evaluation of skeletal maturity utilizing lateral cephalometric radiographs through the assessment of cervical vertebral maturation has gained more attention. The ability to estimate skeletal maturity stage from routine diagnostic lateral cephalometric radiographs has the additional benefit of saving the patient from an additional exposure to radiation by eliminating the need for a hand-wrist radiograph.[7]

Relationships between skeletal maturation determined by cervical vertebrae and hand-wrist radiographs have been previously reported in various populations. However, very few studies have assessed the relationship between MP3 and cervical vertebrae maturation index (CVMI) in different populations. Hence, the present study was executed to evaluate the correlation between the CVMIs and the MP3 in determining the skeletal maturity stage of growing South Indian children.

  Materials and Methods Top

Ethical clearance was obtained from the Institutional Ethical Review Board (VDC/IERB/4136B/2011). The present cross-sectional study included 100 children (boys - 50, girls - 50) of age group 8–14 years attending the Outpatient Department of Pediatric Dentistry, requiring orthodontic treatment through non-probability proportional quota sampling. Well-nourished children without any serious illness, without previous history of trauma or injury to the head, neck, and wrist area were included in the study.

The study included the digital radiographs of the MP3 of the right hand and conventional lateral cephalograms for cervical vertebrae. Both radiographs were taken on the same day. Chronological age of an individual was precisely calculated by the date of birth.

Method of recording middle phalanx of the middle finger

The digital radiographs of MP3 region were taken using the standard radiographic machine and a digital radiographic system (Dr. Suni, Digital radiography System, Suni Medical Imaging Inc., USA); the exposure parameters were 70 kVp, 7 mA, 0.16 s.

For capturing the digital radiographic image, the patient was instructed to place his/her right hand on the table, with the fingers spread apart. The third finger of the concerned subject was kept straight along the long axis of the intraoral dental charged couple device (CCD, size # 2) with the MP3 placed in the center of the CCD. The cone of the radiographic machine was positioned perpendicular to the area of interest and in light contact with the middle finger of the right hand.

The MP3 stages were assessed based on the changes in the epiphyseal and metaphyseal region into six stages of growth according to Rajagopal and Kansal's criteria [Figure 1].[8]
Figure 1: Six stages of middle phalanx of the middle finger development.

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Method of recording cervical vertebrae maturation index

The lateral cephalometric radiographs were taken using an extraoral radiographic machine (Xmind Panoceph) and X-ray film of size 8 × 10 inches. The radiographs were obtained with the patient positioned at the Frankfort horizontal plane parallel to the floor and the X-ray beam was perpendicular to the head. The patient was instructed to stand erect and look straight into his/her own eyes in a mirror on the wall and placing the teeth in centric occlusion and the lips relaxed. Distance from X-ray source to the subject's midsagittal plane was fixed at 5 feet.

The stages of maturation of cervical vertebrae were assessed from the lateral cephalograms according to Hassel and Farman's method.[9] They have described six stages based on the anatomical changes in the shape of 2nd, 3rd, and 4th cervical vertebrae [Figure 2].
Figure 2: Six stages of cervical vertebral maturation indices.

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Radiographic assessment

All assessments were performed in a darkened room with a radiographic illuminator to ensure contrast enhancement of the images. All the radiographs were assessed by two examiners independently. The kappa value for MP3 was 0.81 and 0.76 for CVMI indicating a significant degree of reliability between the examiners.

Statistical analysis

Statistical analysis was performed using the SPSS software package (Version 16.0, SPSS Inc., Chicago, IL, USA). Spearman's rank-order correlation coefficient was applied to measure the association between stages of MP3 and CVMI. The level of significance was set at 1% level.

  Results Top

Sample distribution

The sample size selected for the study consisted of 100 subjects with equal number of boys and girls. The subjects were divided into groups based on the chronological age [Table 1].
Table 1: Sample distribution according to age and sex

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Interexaminer correlations showed significant reliability of all readings by high coefficient values ranging from r = 0.98 to 0.99 (P < 0.01).

Chronological age versus middle phalanx of the middle finger and cervical vertebrae maturation index stages

The present study revealed that the maturation of the MP3 and CVMI progressed with advancing age. It was observed that as chronological age increased the MP3 and CVMI stages advanced. In girls, MP3 and CVMI stages were more advanced than boys [Table 2] and [Table 3].
Table 2: Mean chronological age in relation to middle phalanx of the middle finger

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Table 3: Mean chronological age in relation to cervical vertebrae maturation index stages

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Skeletal maturity indicators (middle phalanx of the middle finger vs. cervical vertebrae maturation index)

A strong positive correlation was observed between stages of MP3 and CVMI in both boys and girls (P < 0.01). However, the correlation coefficient was higher in girls (r = 0.881) than boys (r = 0.771) [Table 4].
Table 4: Correlation between stages of middle phalanx of middle finger and cervicalvertebral maturation index stages (Spearman correlation coefficient)

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  Discussion Top

Human growth has one of the most myriad variations in nature. Because of the infinite number of genetic possibilities present, no two individuals are exactly alike.[1] Conventional maturation indicators may overestimate the developmental stage of the child and consequently underestimate the growth potential.[10] The maturational status can have considerable influence on the diagnosis, treatment planning, and eventual outcome of orthodontic treatment. Clinical decisions regarding the use of extraoral traction force, functional appliances, extraction versus non-extraction treatment, or orthognathic surgery are mainly based on growth considerations.[11]

The technique for assessing skeletal maturity consists of visual inspection of the developing bones, their initial appearance, and their subsequent ossification-related changes in shape and size.[12] The complete hand wrist involves 30 bones, and assessment of these stages is an elaborate task which needs time, experience and also involves increased radiation exposure.[1] Evaluation of hand wrist radiographs includes eleven discrete adolescent skeletal maturational indicators, covering the entire period of adolescence. Moreover, seven out of these eleven indicators are present in the middle finger. Therefore, in this study, the radiograph was restricted to the middle finger.[13] Rajagopal and Kansal's criteria is selected over other criteria to assess MP3 maturation, as it is an improved version that describes distinct changes in the metaphyseal region.[8]

We have followed Hassel and Farman's method for determining CVMI, since only 2nd, 3rd, and 4th cervical vertebrae were evaluated which can be visualized even with the use of thyroid collar.[14] The present study observed the changes in the MP3 and cervical vertebrae during skeletal maturation and has assessed whether CVMI has the same potential as MP3 for determining the skeletal maturation of an individual.

A wide range of chronological values were determined for the different stages of MP3 and CVMI in boys and girls. These values demonstrated a significant difference between boys and girls in the initiation and completion of active growth. The mean age for initiation of active growth was found to be 9.7 ± 1.5 in boys and 8.8 ± 0.7 years in girls. The mean age for the completion of the growth was 13.9 ± 0.4 years in girls. However, the mean age for the completion of growth in boys could not be represented in the sample as it included 8–14 years wherein active growth can be still expected beyond 14 years in boys.

The MP3 and CVMI stages were more advanced in girls than in boys. Similar sexual dimorphism regarding the maturational parameters was reported in the literature.[15],[16] The girls tend to achieve all the stages earlier than boys, indicating the need to initiate any kind of dentofacial orthopedic treatment earlier in them when compared to boys.

The MP3 and CVMI stages were positively correlated, which suggests that either of them can be used with the same confidence in assessing the skeletal maturity which is in accordance with the previous studies.[8],[15],[16] In contrast, few studies reported in the literature showed a lower correlation coefficient between skeletal maturity indicators than in the present study.[17],[18] These variations in correlation among different populations might be due to the difference in racial and ethnic background, sample selection, sample size, gender, and the methodology used for skeletal maturation assessment.

A greater correlation between MP3 and CVMI was observed in girls than in boys in our study, which was in harmony with the findings reported previously in the literature.[15],[16] On the contrary, Kamal et al. found higher correlation among boys than in girls which could be attributed to age of the study population and also uneven distribution of boys and girls.[14]

There was a good concordance between stages of CVMI and MP3. Physiological maturity was earlier in girls when compared to the individuals of the same chronological age of the opposite sex. Chronological age was not a valid predictor of assessing the skeletal maturity because of significant variations in the distribution of CVMI and MP3 stages with respect to individual chronological age distribution.

  Conclusions Top

High correlation values observed between MP3 and CVMI imply that both of them are equally good as skeletal maturity indicators. Therefore, in routine clinical practice, relying upon maturational stages of cervical vertebrae for assessing the skeletal age may be advantageous over MP3, thus eliminating the need for an additional radiograph.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mahajan S. Evaluation of skeletal maturation by comparing the hand wrist radiograph and cervical vertebrae as seen in lateral cephalogram. Indian J Dent Res 2011;22:309-16.  Back to cited text no. 1
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Fishman LS. Chronological versus skeletal age, an evaluation of craniofacial growth. Angle Orthod 1979;49:181-9.  Back to cited text no. 4
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Prasad M, Ganji VS, George SA, Talapaneni AK, Shetty SK. A comparison between cervical vertebrae and modified MP3 stages for the assessment of skeletal maturity. J Nat Sci Biol Med 2013;4:74-80.  Back to cited text no. 15
Hegde DY, Baliga S, Yeluri R, Munshi AK. Digital radiograph of the middle phalanx of the third finger (MP3) region as a tool for skeletal maturity assessment. Indian J Dent Res 2012;23:447-53.  Back to cited text no. 16
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Gandini P, Mancini M, Andreani F. A comparison of hand-wrist bone and cervical vertebral analyses in measuring skeletal maturation. Angle Orthod 2006;76:984-9.  Back to cited text no. 18


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]

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