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Table of Contents   
ORIGINAL RESEARCH  
Year : 2020  |  Volume : 31  |  Issue : 3  |  Page : 408-413
Correlation between skeletal development and maxillary canine eruption


Lecturer in Orthodontics, Pedodontics and Preventive Dentistry, Department of Pedodontics, College of Dentistry, University of Mosul, Iraq

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Date of Submission08-Jan-2019
Date of Decision23-May-2019
Date of Acceptance29-Oct-2019
Date of Web Publication06-Aug-2020
 

   Abstract 


Aim: The aim of this study was to find a correlation between the permanent maxillary canine eruption and the cervical vertebral maturation index (CVMI). Materials and Methods: 145 subjects (73 male and 72 female) in the age of 7–14 years were examined radiographically with lateral cephalographs and orthopantomographs. The CVM patterns were evaluated on the lateral cephalograph using the classification of Hassel and Farman. The stage of the permanent maxillary canine eruption has been investigated on the orthopantomographs depending on its vertical height in relation to the adjacent incisor. Descriptive statistics were obtained for both CVMI stages and canine eruption grading. Spearman rank correlation test was used to determine the correlation between both methods. The minimum level of significance was considered less than 0.05 (P < 0.05). Results: Results showed a strong correlation between CVMI and the grading of the maxillary canine eruption in both female and male and the (r) value estimated was 0.862 and 0.758, respectively. Over 90% of deceleration stage of CVMI in both genders show canine eruption (pubertal growth spurt) about 91.66% for female and 95.65% for male and a small percentage of delay eruption 8.33% and 4.35% in female and male gender, respectively, with a predilection to the female gender. Conclusions: A significant correlation between the permanent maxillary canine eruption stages and skeletal maturity was found. The eruption of maxillary canine occurs before the end of pubertal growth. Any delay in the eruption of maxillary canine after the deceleration stage of CVMI, suggesting a chance of impaction.

Keywords: Canine eruption, cephalometric radiograph, cervical vertebrae maturation

How to cite this article:
Mohammad RJ. Correlation between skeletal development and maxillary canine eruption. Indian J Dent Res 2020;31:408-13

How to cite this URL:
Mohammad RJ. Correlation between skeletal development and maxillary canine eruption. Indian J Dent Res [serial online] 2020 [cited 2020 Sep 18];31:408-13. Available from: http://www.ijdr.in/text.asp?2020/31/3/408/291480



   Introduction Top


Growth and development of children are essential for an orthodontist for proper orthodontic treatment planning since critical decisions concerning diagnosis, treatment mechanics and prognosis are affected by the patient's skeletal age.[1] Therefore, researchers were encouraged to develop a process for skeletal maturity assessment depending on the evaluation of the cervical vertebrae commonly represented by lateral cephalometric radiographs.[2]

It is a routine procedure for the orthodontist to take both hand-wrist radiograph for assessing the skeletal maturation and cephalometric radiograph to analyse skeletal morphology and direction of growth patterns. A series of investigations performed in different parts of the world have confirmed the validity of the cervical vertebral maturation (CVM) method, mostly by comparing it with the hand-wrist method.[3] CVM method has been proved to be effective for the estimation of the growth phase according to the morphological characteristics of the second, third and fourth cervical vertebrae in the lateral cephalometric radiographs.[4]

Dental development is one of the important indicators of skeletal maturity. Chronological age is not more commonly used as skeletal maturity identification as it is influenced by genetics, socio-economical and hormonal factors.[2] Some researchers believe that the developmental stages of teeth are less affected than bone mineralization by variation in nutritional and endocrine status, as well as local factors. For that skeletal maturity indicators, correlation with chronological age is considered acceptable.[5] There are two possibilities for the assessment of skeletal maturity. One of them is tooth eruption.[1],[6],[7] The present study is performed to confirm the correlation between the CVM method and the stage of maxillary canine eruption.


   Materials and Methods Top


One hundred forty-five subjects from Mosul city population, (73 male and 72 female) in the age range of 7 to 14 years, admitted to a teaching hospital in Mosul, Iraq, for orthodontic treatment were selected in this study. The individuals who presented with the following criteria are included in this study[8],[9]:

  1. Free of any serious illness.
  2. No abnormal dental condition, e.g. impaction, transposition, congenitally missing teeth, odontomas and cyst.
  3. No previous history of trauma to the face and neck.
  4. No history of orthodontic treatment.
  5. No extraction of any permanent teeth.
  6. No history of congenital and systemic disorders.


All selected subjects were examined radiographically with lateral cephalographs and orthopantomographs (OPG). The radiographs were taken with Ceph-pan X-ray machine type Planmeca–(Finland) with Dimax Pro software version 3.2.1. The X-ray machine was set according to manufacturer's instruction at 78 kVp, 12 mA and 23 s scanning time for cephalometric radiograph and 80 kVp, 12mA and 18 s scanning time for orthopantomographs. The digital images were saved in TIFF (Tagged Image File Format); image manipulation including sharpening filter, high pass filter and contrast enhancement has been used to improve the radiographic images details [Figure 1] and [Figure 2].
Figure 1: Digital lateral cephalograph; (a), original image. Image enhancement with sharpening filter (b), highpass filter (c), and contrast enhancement (d)

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Figure 2: Cervical vertebral maturity stages; (a) Initiation. (b) Acceleration. (c) Transition. (d) Deceleration. (e) Maturation. (f) Completion

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The cervical vertebral maturation index (CVMI) was evaluated by classifying C2, C3 and C4 into six groups depending on their maturation patterns on the lateral cephalograph using Hassel and Farman classification[6],[10],[11],[12],[13],[14] which are defined as follows [Figure 2]:

  1. Initiation: the lower borders of the second, third and fourth cervical vertebrae (C2, C3 and C4) are flat. The bodies of C3 and C4 are trapezoid in shape and the superior vertebral borders are tapered from posterior to anterior.
  2. Acceleration: concavities develop on the inferior borders of C2 and C3, and the inferior border of C4 is flat. The bodies of C3 and C4 are nearly rectangular in shape.
  3. Transition: distinct concavities develop on the inferior borders of C2 and C3, and concavity begins to develop on the inferior border of C4. The bodies of C3 and C4 are rectangular.
  4. Deceleration: distinct concavities are seen on the inferior borders of C2, C3 and C4. The vertebral bodies are becoming more square in shape.
  5. Maturation: more accentuated concavities are seen on the inferior borders of C2, C3 and C4. The bodies of C3 and C4 are nearly square in shape.
  6. Completion: deep concavities are seen on the inferior borders of C2, C3 and C4. The bodies of C3 and C4 are square or greater in vertical dimension than in the horizontal dimension.


The stage of the permanent maxillary canine eruption has been investigated on the orthopantomographs depending on its vertical height in relation to the adjacent incisor which divided into 4 grades[15],[16] [Figure 3], as follows:
Figure 3: Vertical height grades of maxillary canine eruption

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  • Grade-1: Canine cusp tip below the level of cementoenamel junction (CEJ) of the adjacent incisor.
  • Grade-2: Canine cusp tip above the CEJ, but less than halfway up the root of the adjacent incisor.
  • Grade-3: Canine cusp tip more than halfway up the root, but less than the full length of the adjacent incisor.
  • Grade-4: Canine cusp tip above the apical third of the root of the adjacent incisor.


Statistical analysis

The data was statistically analysed using SPSS program version 11.5 (SPSS Inc.) and MS-Excel (Microsoft Office 2010). Descriptive statistics were obtained by calculating the numbers and percentages of all variables for both CVMI stages and maxillary canine eruption grading. To determine the correlation between both methods, the Spearman rank correlation test was used. The level of significance was considered equal to or less than 0.05 (P ≤ 0.05) as the minimum level of significance.


   Results Top


There is an approximation in the number and percentage of different stages of cervical vertebrae maturation index in the total samples of both female and male [Table 1]. [Table 2] shows the distribution of maxillary canine eruption grades according to the stages of CVMI for female samples. The highest percentage of grade 4 (66.6%) and grade 3 (81.65%) of maxillary canine eruption found in the initiation and transition stages of CVMI, respectively, whereas the transition stage of CVMI is distributed in grades 2 (44.45%) and 1 (55.55%) of the canine eruption index, and 91.66% of grade 1 in the canine eruption corresponded with deceleration stage of CVMI. Spearman's correlation coefficient test shows a statistical correlation between eruption grades of maxillary canine and CVMI (0.862, P < 0.05).
Table 1: Distribution of CVMI in the female and male samples

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Table 2: Distributions of the different eruption grades of maxillary canine according to the CVMI stages in female subjects

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The distribution of maxillary canine eruption grades and the stages of CVMI for male samples were shown in [Table 3], where the highest percentage of grade 4 (83.33%) of maxillary canine eruption found in the initiation. The transition stages of CVMI are distributed in grades 3 (58.8%) and 4 (41.17%) of the canine eruption index. Where grade 2 (80%) corresponded with the acceleration stage of CVMI, and 95.65% of grade 1 in the canine eruption corresponded with deceleration stage of CVMI. Spearman's correlation coefficient test shows a statistical correlation between eruption grades of maxillary canine and CVMI (0.758, P < 0.05).
Table 3: Distributions of the different eruption grades of maxillary canine according to the CVMI stages in male subjects

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   Discussion Top


In Orthodontics, it is apparent that the timing of the treatment inception may be critical as the selection of a specific treatment plan. Starting the treatment at the patient's optimal maturation stage resulted in successful treatment with minimal evidence of failure. Growth prediction can be evaluated using physiological parameters such as peak growth velocity in standing height, pubertal markers, dental development and radiological analysis of skeletal maturation.[17],[18],[19] Dental age assessment is one of the most important aspects among various other maturity indicators in orthodontic diagnosis, especially for treatment planning of orthodontic therapy.[20] Dental age has been widely explored as a possible predictor of skeletal maturity which can be evaluated by either the stage of tooth eruption or the stage of tooth formation observed in radiographs.[5],[21],[22]

In the present, the age criteria of the samples in the study include the patients from 7 to 14 years because this age group are at different stages of skeletal maturity since the beginning of pubertal growth spurt occurs on an average of 10 years in females and 12 years in males, thus offering the best chance to accomplish the objectives of orthodontic treatment. There is no score at the maturation and completion stages of CVMI; these two stages represent the post-pubertal growth over 14 years of age, where the skeletal growth and dental development rates are declined and nearly completed.[23],[24],[25],[26] The CVMI used as a biological indicator of individual skeletal maturity in this study due to its practical applications on the lateral cephalogram, which is a type of radiograph used routinely in orthodontic diagnosis and the CVMI method appears to be a powerful diagnostic tool.[8],[27],[28]

The study was designed to correlate the skeletal maturation and maxillary canine eruption to estimate the stage of growth and the possible treatment that can be carried out. The results showed a strong correlation between CVMI and the grading of maxillary canine eruption in both female and male and the (r) value estimated was 0.862 and 0.758, respectively. These findings were supported by other studies.[29],[30],[31] Another finding is that the grading of maxillary canine eruption shows a higher percentage of grade 3 (81.65%) in the females at the initiation stage of CVMI than males, where the initiation stage of CVMI in the males distributed between grade 3 (58.8%) and grade 4 (41.17%) of canine eruption index. This finding related to the skeletal and dental maturation at the initiation stage in the female than male gender.[32] In addition, the canine erupted earlier in females' gender than males, where 55.55% of acceleration stage of CVMI in the female shows canine eruption (G1) in comparison with males (20%).

Over 90% of deceleration stage of CVMI in both genders shows canine eruption (pubertal growth spurt) about 91.66% for female and 95.65% for male, a small percentage of delay eruption 8.33% and 4.35% in female and male gender, respectively, with predilection to the female gender. These findings supported by many studies have shown a strong prevalence for this anomaly in females (female: male = 2.3:1 or 3:1).[33],[34],[35] In orthodontic treatment planning, the effectiveness depends on the patient's skeletal maturity stage being around the pubertal growth spurt. Make that the evaluation of canine eruption was started earlier in female than male, and specialist follow-up should be advised to the patients.

But, Bin et al.,[36] Ericson and Kurol[37] and Montasser et al.,[38] found this percent to be approximately equal in males and females, without a sign to indicate a propensity for earlier skeletal maturation of girls or boys. The incidence of impacted maxillary permanent canines has been reported by Ericson and Kurol[39] and Cernochova et al.,[40] to be 0.9% to 2.0%, where Abu-Hussein et al.[41] found that the percentage is about 3.7%. Therefore, the higher percentage of unerupted maxillary canine in the present study may be related to the difference in the sample size which is smaller as compared with other studies mentioned above. This limitation should be considered in the next studies.

The relationship of maxillary canine eruption and skeletal maturity has been evaluated by cervical vertebrae maturation index (CVMI) suggesting that the canine could erupt in acceleration and deceleration stages of CVMI at the peak pubertal growth spurt,[31],[40] any delay in the eruption of maxillary canine after deceleration stage of CVMI, suggesting a chance of impaction. These findings come in agreement with other studies[29],[30] reported that “the eruption of the permanent maxillary canine can occur at any stage in skeletal maturation before the end of the pubertal growth spurt (CS1-CS4). A post-pubertal stage (CS5 or CS6) without an erupted maxillary canine indicates delayed eruption and suggests canine impaction.”

To reduce radiation exposer with children, the simple assessment of dental development by canine eruption grading on panoramic radiographs is routinely available in orthodontic clinics, represent practical seeking to assess skeletal maturity without resorting to hand-wrist or lateral cephalometric radiographs. The high radiation dose making their use is doubtful concerning excessive radiation exposure.[1],[5],[27],[42],[43] Dental maturity assessment with maxillary canine eruption offers the advantage over CVMI, as a simple procedure to improve orthodontic diagnostic and therapeutic decisions that can be carried out on panoramic radiographs which provide minimal irradiation to the patient and easy determination of the eruption stages of teeth. Many studies supported dental eruption, which is the most noticeable and easily determined indicator of dental maturation.[44],[45] According to Nolla,[44] dental eruption has also been reported to be more variable than the calcification sequence in the dentition. In controversy, other studies found that dental eruption is a transient event and influenced by great environmental factors due to the longest period of calcification and complicated sequence of movements during the course of the eruption. Therefore, it is an unreliable criterion for determining dental maturation.[5],[46],[47],[48]


   Conclusions Top


  1. A significant correlation between the permanent maxillary canine eruption stages and skeletal maturity was found.
  2. The eruption of permanent maxillary canine occurs in the acceleration and deceleration stages of CVMI before the end of pubertal growth (CVMI).
  3. Any delay in the eruption of maxillary canine after the deceleration stage of CVMI, suggesting a chance of impaction.
  4. Dental maturity assessment with maxillary canine eruption offers the advantage over CVMI, as a simple procedure to improve orthodontic diagnostic and therapeutic decisions.
  5. Orthopantomographs can be used easily to determine the eruption stages of teeth with minimal irradiation to the patient.
  6. Evaluation of canine eruption should be started earlier in girls than boys, and the follow-up was suggested to the patients.


Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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Correspondence Address:
Dr. Ruba J Mohammad
Lecturer in Orthodontics, Pedodontics and Preventive Dentistry, Department of Pedodontics, College of Dentistry, University of Mosul
Iraq
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdr.IJDR_29_19

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