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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 9  |  Issue : 5  |  Page : 13-20

Correlation of chronological, skeletal, and dental age in North Indian population


1 Department of Orthodontics and Dentofacial Orthopaedics, ITS Dental College, Greater Noida, Uttar Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopaedics, Himachal Dental College, Sundernagar, India
3 Department of Pedodontics and Preventive Dentistry, ITS Dental College, Muradnagar-ghaziabad, Uttar Pradesh, India

Date of Web Publication15-Sep-2017

Correspondence Address:
Madhurima Nanda
Department of Orthodontics, ITS Dental College, Greater Noida
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_68_17

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  Abstract 

Aim and Objectives: The aim of the study was to find out the correlation between chronological, dental, and skeletal age. Materials and Methods: Lateral cephalograms and orthopantomograms of 100 subjects of age ranging 9–14 years were obtained for the estimation of skeletal and dental age. Dental age was assessed using Demirjian's method; skeletal age was assessed using the new improved version of the cervical vertebral maturation method given by Baccetti, Franchi, and McNamara. Statistical analysis was carried out. Student's t-test and Spearman's coefficient correlation were used to assess the relation between chronological, skeletal, and dental age. Results: The Spearman's correlation coefficient was 0.777 (P < 0.001) between chronological and dental age, 0.516 (P < 0.001) between chronological and skeletal age, and 0.563 (P < 0.001) between dental and skeletal age. Conclusion: There is a good correlation between chronological and dental age in North Indian population which was higher for males as compared to females. A moderate correlation was found between chronological and skeletal age as well as between dental and skeletal age.

Keywords: Cervical vertebral maturation method, chronological age, Demirjian's method, dental age, skeletal age


How to cite this article:
Nanda M, Singla A, Sachdev V, Jaj HS. Correlation of chronological, skeletal, and dental age in North Indian population. Indian J Dent Sci 2017;9, Suppl S1:13-20

How to cite this URL:
Nanda M, Singla A, Sachdev V, Jaj HS. Correlation of chronological, skeletal, and dental age in North Indian population. Indian J Dent Sci [serial online] 2017 [cited 2017 Nov 21];9, Suppl S1:13-20. Available from: http://www.ijds.in/text.asp?2017/9/5/13/214934


  Introduction Top


Timing is a fundamental part of treatment planning in orthodontics, with special regard to dentofacial orthopedics. Initiating treatment in a growing patient at the right time has demonstrated significant favorable effects in the correction of disharmonies in all the three planes of space.[1] To initiate proper treatment at the right time, it is important to determine the accurate age of the patient. Age at the onset of puberty varies from individual to individual and differs with sex, heredity, population, nutritional, metabolic, and environmental factors.[2] Various methods to assess the age or maturation status of an individual are sexual maturation characteristics, height, weight, chronological age, skeletal development, and dental development.[3] Several studies have described the correlation between various methods of age assessment so as to establish the most effective time for initiating orthodontic treatment in children.[1],[2],[3],[4],[5],[6]

Somatic maturity and sexual maturity indicators have limited value for the immediate clinical judgment of a patient's maturity stage because these indicators can be applied only after the serial recording of height or the inception of puberty.[3] It has long been recognized that an individual's chronological age does not correlate well with maturational age. Skeletal age may be retarded or advanced from the actual chronological age.[6],[7]

Skeletal maturation refers to the degree of the development of ossification in bone.[8] Various areas of the skeleton have been used: the foot, ankle, hip, elbow, hand–wrist, and the cervical vertebrae. Hand–wrist radiographs have proved to be a valuable diagnostic tool in orthodontics.[9],[10] Skeletal maturation assessed on hand–wrist radiographs is considered as the best indicator of maturity [11] and has been found to be closely associated with the growth spurt. However, the routine use of hand–wrist radiographs for assessing the pubertal growth has raised concerns regarding the radiation safety.[6],[12] The advantage of using cervical vertebrae maturation (CVMS) is that no extra radiation exposure is required since lateral cephalometric radiograph is routinely required for orthodontic diagnosis and treatment planning.[6]

Another measure of assessing physiologic maturation is dental maturity. It is used to estimate the physiological maturity due to ease of recognition of dental developmental stages, together with the availability of periapical or panoramic radiographs in most orthodontic practices.[3] Dental maturity can be determined by the stage of tooth eruption or by the stage of tooth formation.[3],[5],[13],[14],[15] Tooth formation has been found to be a more reliable criterion for determining dental maturation.[16] The most widely used method for the estimation of dental age is the method given by Demirjian et al.[14] in 1973.

The purpose of our study, therefore, is to find out the correlation between chronological age, skeletal age, and dental age in a North Indian population so that an appropriate method of age estimation can be determined and proper treatment instituted timely.


  Materials and Methods Top


The study was carried out in the Department of Orthodontics and Dentofacial Orthopaedics of Himachal Dental College and Hospital, Sunder Nagar (Himachal Pradesh). The sample consisted of 100 pretreatment records (panoramic radiographs, lateral cephalometric radiographs, and history) of patients visiting the dental outpatient department in the age group of 9–14 years. The selection criteria included subjects with:

  • North Indian ethnicity
  • Patients without any systemic diseases those affecting normal growth and development of the bone and teeth
  • No history of previous orthodontic treatment
  • No congenital or acquired malformations of the skeletal or dental origin.


All radiographs were taken with the same X-ray equipment (Planmeca EC Proline 2002).

Assessment of chronological age

The chronological age of the patient was taken as told by the patient.

Assessment of skeletal age

The lateral profile changes of the second, third, and fourth cervical vertebrae were assessed and assigned the CVM stage using the new improved version of the CVM method given by Baccetti et al.[4] in 2002 [Table 1] and [Figure 1]. The advantages of the new version of the CVM method are that mandibular skeletal maturity can be appraised on a single cephalogram and through the analysis of only the second, third, and fourth cervical vertebrae. Definition of CVM at each developmental stage allows the clinician to apply the information derived from a single lateral cephalogram and avoids the definition of stages based on comparative assessment between stage changes as was in the previous methods.[4],[6]
Table 1: Cervical vertebral maturation stages (improved version of the cervical vertebral maturation method given by Baccetti, Franchi and Mc Namara)

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Figure 1: Lateral cephalogram showing cervical vertebrae maturation stages

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Assessment of dental age

Dental age was assessed using the method given by Demirjian et al.[14] which is based on the scoring of the developmental stage of the seven left permanent mandibular teeth. The method's criterion consists of distinct details based on shape criterion and proportion of root length, using the relative value to crown height, rather than on absolute length. Hence, foreshortening or elongated projections of developing teeth will not affect the reliability of assessment [Table 2] and [Figure 2],[Figure 3],[Figure 4],[Figure 5].
Table 2: Developmental stages of teeth (Demirjian et al.)

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Figure 2: Panoramic radiograph showing Demirjian’s stages of tooth development

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Figure 3: Demirjian’s developmental stages

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Figure 4: Demirjian’s score table based on developmental stage of teeth

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Figure 5: Conversion of maturity score to dental age

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Statistical analysis

The correlation between chronologic, dental, and skeletal age was assessed by Student's t-test and Spearman's correlation coefficient, using SPSS software (IBM Corporation, Chicago, USA). Paired t-test was done to find the means and standard deviation of chronological and dental age and to find the correlation between the two. Spearman's test was performed to find out the correlation between chronological, dental, and skeletal age and also separately for males and females.


  Results Top


The frequency distribution for age and sex are shown in [Table 3], [Figure 6] and [Figure 7]. Means, standard deviations, mean and standard difference and significance values are shown in [Table 4], [Table 5], [Table 6]. When the correlation was tested between the chronological and dental age, a good correlation with a value of 0.777 was found which is statistically significant [Table 7] and [Figure 8]. A higher correlation was found in males (0.835) as compared to females (0.743) [Table 7] and [Figure 9]. The correlation was also calculated between chronological age and skeletal age using Spearman's coefficient, and a fair correlation was found between the two with a value of 0.516 which is statistically significant. Furthermore, a positive correlation was found between skeletal age and dental age with a value of 0.563 [Table 7] and [Figure 8].
Table 3: Frequency distribution of subjects for age group by sex

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Figure 6: Sample distribution based on age groups

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Figure 7: Pie diagram representing sex distribution

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Table 4: Means and standard deviations of chronological and dental age

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Table 5: Mean difference and standard deviation between chronological and dental age

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Table 6: Correlation between chronological and dental age

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Table 7: Correlation between chronological, dental and skeletal age

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Figure 8: Correlation between chronological, dental and skeletal age

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Figure 9: Correlation between chronological, dental and skeletal age in males and females

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The results suggest a stronger correlation between chronological and dental age r as compared to correlation between chronological and skeletal age and between skeletal and dental age.

The correlations were also compared among the two age groups, i.e., between 9–11 years and 12–14 years using the Spearman test only [Table 8] and [Figure 10].
Table 8: Correlation between chronological, dental and skeletal age in 9-11 years and 12-14 years

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Figure 10: Correlation between chronological, dental and skeletal age in 9.11-years and 12-14 years

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It was found that, in the 9–11-year age group, correlation between chronological and dental age (0.730) and between skeletal and dental age (0.504) was significant whereas it was nonsignificant between chronological and skeletal age (0.271).

In the 12–14-year age group, a significant correlation was found between chronological and dental age (0.497) whereas the correlation between chronological and skeletal age (0.205) as well as between skeletal and dental age was nonsignificant (0.261).

These results indicate that the correlation decreases as the age of an individual increases.


  Discussion Top


Accurate age estimation is considered to be of great importance in dental and medical practices. It is of particular interest to the orthodontist as information aids in diagnosis and treatment planning.

There are various methods for the evaluation of CVM. In this study, the cervical vertebral development was evaluated using the new improved version of the CVM method by Baccetti et al.[4] in 2002.

Dental age is of particular interest to the orthodontist in planning treatment of different types of malocclusion in relation to maxillofacial growth. The method of assessment of dental age by tooth mineralization is more accurate as tooth mineralization is a constant, ongoing process and eruption may be influenced by local factors: ankylosis, early or delayed extraction of the deciduous tooth, impaction, and crowding of the permanent teeth.[14],[16] Panoramic radiographs were used because they are easier to take than intraoral radiographs in young or nervous children; they give less radiation for a full mouth radiograph, and the picture of the mandibular region they produce is little distorted.[14] However, the left mandibular teeth are seen more clearly and have been widely used to assess the degree of calcification.[14],[17] The most widely used method,[3],[12],[17] by Demirjian et al.,[14] is being used in this study.

The present study represents a basic cross-sectional investigation to establish the relationship between the dental age, skeletal age, and chronological age in a sample of North Indian population.

The correlation between the dental age and chronological age was found to be good with a value of 0.779. The findings confirm with the findings of the studies done earlier by Green,[5] Ogodescu et al.,[18] Różyło-Kalinowska et al.,[19] Hegde and Sood,[20] Rai et al.,[21] and Mittal et al.[22] Further, the correlation was found to be more in males (0.835) as compared to females (0.761). The findings are supported by the study conducted by Różyło-Kalinowska et al.[19] in Polish children, in which correlation in males was slightly more in comparison to females. The correlations when compared between the two age groups (9–11 years and 12–14 years) included in the study was found to be more in the age group of 9–11 years (0.730) as compared to the 12–14 years (0.497). This tendency for the scoring system to be less accurate in the older age groups is a common finding in the previous studies.[23] The longer duration of the late stages of tooth development compared with the earlier may in part explain this observation.

In the present study, a moderate correlation (0.563) was seen between dental and skeletal age. The value was more for females (0.551) as compared to males (0.513). Our findings confirm with the study done by Różyło-Kalinowska et al.[19] in Polish children in whom moderate but significant correlations were found between dental calcification and skeletal maturation based on CVM method. A greater correlation seen in females in our study corroborates with findings of other studies done on Indian population by Rai,[21] Gupta et al.,[23] and Mittal et al.[22] Varying results have been seen in literature pertaining to skeletal and dental age. 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 and socioeconomic status, and industrialization are the main reasons for variability in many studies.[15] Furthermore, when the correlation was compared for different age groups, a positive correlation was seen in the younger age group, i.e., 9–11 years (0.504) as compared to the older age group (0.261) again confirming the low applicability of Demirjian et al.[14] method in older age groups.

The correlation found between chronological and skeletal age in our study is moderate but significant (0.516). Furthermore, the significance is more for females as compared to males. This is in accordance with the studies conducted by Alkhal et al.[6] and Uysal et al.,[12] in which significant correlation is seen between chronological age and CVM and the correlation values are more for females as compared to males.

A review of correlation coefficients in this study indicates that the degree of association was closer between chronological age and dental age than between dental age and skeletal age or chronological and skeletal age.

The correlation values between chronological and dental age were also compared with different populations: Polish,[19] (0.79 for males and 0.77 for females), Davangere [24] (0.94 in males and 0.95 in females), and Belgaum population [20] (0.985 for males and 0.988 for females.). The correlation values of dental age and skeletal age in our population (0.513 in males and 0.551 in females) were also comparable to other population.[19],[22],[23] We also compared the correlation between chronological age and skeletal age of our population with other ethnic populations: Southern Chinese [6] (0.757 for males and 0.787 for females) and Turkish (0.68 in males and 0.82 in females).[12]

The reason for the difference among different populations is unclear and could be due to population difference.[25] The differences can also be explained by difference in sample size, method of age calculation, age groups, the age and sex distribution of the original study population, and statistical methodologies. Racial variations in the relationship have been suggested. Mappes et al.[15] indicated that the predominant ethnic origin of the population, climate, nutrition, socioeconomic levels, and urbanization are causative factors of these racial variations.


  Conclusion Top


Following conclusions were drawn from the study:

  1. A good correlation was found between chronological and dental age. The correlation between dental and skeletal age and between chronological and skeletal age was also found to be moderate. Furthermore, a decrease in correlation with age was seen
  2. When compared for sexes, it was found that the correlation between chronological and dental age was more for males as compared to females whereas correlation between dental and skeletal age as well as between chronological age and skeletal age was found to be more for females
  3. The good correlation between dental and chronological age suggests that the dental age can be used to predict the appropriate chronological age for orthodontic intervention. However, to know the exact chronological age from the estimated dental age for the North Indian population linear regression equation can be used.


It can be concluded that although various methods of age assessment are used, the applicability can vary due to the ethnic differences between populations. Hence, the maturity standards should be based on studies made on the same population. Further studies with extensive and large samples are required in the future to investigate the relationship between chronological, dental, and skeletal age in North Indian population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Franchi L, Baccetti T, De Toffol L, Polimeni A, Cozza P. Phases of the dentition for the assessment of skeletal maturity: A diagnostic performance study. Am J Orthod Dentofacial Orthop 2008;133:395-400.  Back to cited text no. 1
    
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Björk A, Helm S. Prediction of the age of maximum puberal growth in body height. Angle Orthod 1967;37:134-43.  Back to cited text no. 2
    
3.
Krailassiri S, Anuwongnukroh N, Dechkunakorn S. Relationships between dental calcification stages and skeletal maturity indicators in Thai individuals. Angle Orthod 2002;72:155-66.  Back to cited text no. 3
    
4.
Baccetti T, Franchi L, Mcnamara JA Jr. An improved version of the Cervical Vertebral Maturation (CVM) method for the assessment of mandibular growth. Angle Orthod 2002;72:316-23.  Back to cited text no. 4
    
5.
Green LJ. The interrelationships among height, weight and chronological, dental and skeletal ages. Angle Orthod 1961;31:189-93.  Back to cited text no. 5
    
6.
Alkhal HA, Wong RW, Rabie AB. Correlation between chronological age, cervical vertebral maturation and fishman's skeletal maturity indicators in Southern Chinese. Angle Orthod 2008;78:591-6.  Back to cited text no. 6
    
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Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod Dentofacial Orthop 1995;107:58-66.  Back to cited text no. 8
    
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Soegiharto BM, Cunningham SJ, Moles DR. Skeletal maturation in Indonesian and white children assessed with hand-wrist and cervical vertebrae methods. Am J Orthod Dentofacial Orthop 2008;134:217-26.  Back to cited text no. 9
    
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Flores-Mir C, Nebbe B, Major PW. Use of skeletal maturation based on hand-wrist radiographic analysis as a predictor of facial growth: A systematic review. Angle Orthod 2004;74:118-24.  Back to cited text no. 10
    
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Grave KC, Brown T. Skeletal ossification and the adolescent growth spurt. Am J Orthod 1976;69:611-9.  Back to cited text no. 11
    
12.
Uysal T, Sari Z, Ramoglu SI, Basciftci FA. Relationships between dental and skeletal maturity in Turkish subjects. Angle Orthod 2004;74:657-64.  Back to cited text no. 12
    
13.
Chertkow S. Tooth mineralization as an indicator of the pubertal growth spurt. Am J Orthod 1980;77:79-91.  Back to cited text no. 13
    
14.
Demirjian A, Goldstein H, Tanner JM. A new system of dental age assessment. Hum Biol 1973;45:211-27.  Back to cited text no. 14
    
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Mappes MS, Harris EF, Behrents RG. An example of regional variation in the tempos of tooth mineralization and hand-wrist ossification. Am J Orthod Dentofacial Orthop 1992;101:145-51.  Back to cited text no. 15
    
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Fanning EA. Effect of extraction of deciduous molars on the formation and eruption of their successors. Angle Orthod 1962;32:44-5.  Back to cited text no. 16
    
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Al-Emran S. Dental age assessment of 8.5 to 17 year-old Saudi children using Demirjian's method. J Contemp Dent Pract 2008;9:64-71.  Back to cited text no. 17
    
18.
Ogodescu AE, Ogodescu A, Szabo K, Tudor A, Bratu E. Dental maturity- a biologic indicator of chronological age: Digital radiographic study to assess Dental age in Romanian children. Int J Biol Biomed Eng 2011;5:32-40.  Back to cited text no. 18
    
19.
Różyło-Kalinowska I, Kolasa-Rączka A, Kalinowski P. Relationship between dental age according to Demirjian and cervical vertebrae maturity in polish children. Eur J Orthod 2011;33:75-83.  Back to cited text no. 19
    
20.
Hegde RJ, Sood PB. Dental maturity as an indicator of chronological age: Radiographic evaluation of dental age in 6 to 13 years children of Belgaum using Demirjian methods. J Indian Soc Pedod Prev Dent 2002;20:132-8.  Back to cited text no. 20
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21.
Rai B, Kaur J, Anand SC, Jain R, Sharma R, Mittal S. Accuracy of the Demirjian method for the Haryana population. Internet J Dent Sci 2008;6:1-4.  Back to cited text no. 21
    
22.
Mittal SK, Singla A, Virdi MS, Sharma R, Mittal B. Co-Relation between determination of skeletal maturation using cervical vertebrae and dental calcification stages. Internet J Forensic Sci 2011;4:1-9.  Back to cited text no. 22
    
23.
Gupta KP, Garg S, Grewal PS. Establishing a diagnostic tool for assessing optimal treatment timing in Indian children with developing malocclusions. J Clin Exp Dent 2011;3:18-24.  Back to cited text no. 23
    
24.
Prabhakar AR, Panda AK, Raju OS. Applicability of Demirjian's method of age assessment in children of Davangere. J Indian Soc Pedod Prev Dent 2002;20:54-62.  Back to cited text no. 24
[PUBMED]    
25.
Liversidge HM, Chaillet N, Mörnstad H, Nyström M, Rowlings K, Taylor J, et al. Timing of Demirjian's tooth formation stages. Ann Hum Biol 2006;33:454-70.  Back to cited text no. 25
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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