Indian Journal of Dental Research

: 2011  |  Volume : 22  |  Issue : 6  |  Page : 882-

A correlative study of dental age and skeletal maturation

Kiran Sachan1, Vijay Prakash Sharma2, Pradeep Tandon3,  
1 Department of Orthodontics and Dentofacial Orthopedics, Uttar Pradesh Dental College and Research Centre, Lucknow, Uttar Pradesh, India
2 Department of Orthodontics, Chandra Dental College, Safedabad, Barabank, India
3 Department of Orthodontics, KGMC, Lucknow, Uttar Pradesh, India

Correspondence Address:
Kiran Sachan
Department of Orthodontics and Dentofacial Orthopedics, Uttar Pradesh Dental College and Research Centre, Lucknow, Uttar Pradesh


Introduction: Skeletal age had been assessed by comparison between maturation of hand-wrist with stages of cervical vertebrae or canine calcification stages in past and this had been closely related to craniofacial growth. The importance of pubertal growth spurt in various types of orthodontic therapies is already established. Aims and Objectives: Hence, this study was aimed to evaluate the relationship of skeletal maturity by hand-wrist with cervical vertebral maturation indicators and canine calcification stages. Materials and Methods: The study consisted of randomly selected 90 children from Lucknow population with 45 males (age range 10-13 years) and 45 females (age range 9-12 years). Lateral Cephalogram, hand-wrist x-ray, and periapical x-rays of maxillary and mandibular right canines were taken. Statistical Analysis: Mean, standard deviation was calculated of different groups. Correlation was made among cervical vertebral maturation, hand wrist maturation, and canine calcification stages at various age groups. Results: There was strong correlation between skeletal maturation indicator and cervical vertebral maturation indicator for both male (0.849) and female (0.932), whereas correlation between skeletal maturation indicator and canine calcification was good for both male and female (0.635, 0.891). Conclusion: It was concluded that cervical vertebral maturation indicator and canine calcification stages can also be used for assessing skeletal maturity.

How to cite this article:
Sachan K, Sharma VP, Tandon P. A correlative study of dental age and skeletal maturation.Indian J Dent Res 2011;22:882-882

How to cite this URL:
Sachan K, Sharma VP, Tandon P. A correlative study of dental age and skeletal maturation. Indian J Dent Res [serial online] 2011 [cited 2021 Jun 17 ];22:882-882
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Human growth shows considerable variation in the chronologic ages at which individual children reach similar developmental events. Chronologic age alone is not sufficient for assessing the stage of development of a growing child. Accurate information is provided by developmental stages, such as skeletal maturation, secondary sexual characters, and maturation of different tissue system. [1],[2],[3]

One of the important diagnostic tools used in determining whether pubertal growth has started, is occurring or finished had been the hand-wrist radiographic evaluation. Now cervical vertebral skeletal maturation is also found to be a reliable method apart from hand-wrist radiograph. Tooth development is also a useful measure of maturity, since it represents a series of recognizable changes that occur in the same sequence from an initial event to a constant end point. [4]

The present study was conducted

to evaluate skeletal age using hand-wrist radiograph, lateral cephalogram for cervical vertebrae and intraoral periapical X-ray for maxillary and mandibular right canine;to compare and correlate cervical vertebral maturity indicator with skeletal maturity indicators for different age subgroup;to compare and correlate canine calcification stages with skeletal maturity indicators and its validity and applicability in assessing skeletal age of a patient.

 Materials and Methods

The present study was conducted on randomly selected 90 healthy children from Lucknow population in the age group of 9-13 years. 45 males and 45 females children were selected. The sample was selected from the outpatient Department of Orthodontics and Dentofacial orthopedics, KGMC Lucknow, and various schools.

Criteria for case selection

The entire sample had parental Lucknow origin.None of the subjects selected had undergone orthodontic treatment.All the subjects selected were moderately built and were of growing age with no history of deformities, bone diseases and major illness in the past.None of the subjects showed any facial asymmetry.No history of trauma or surgery in the dentofacial region.The subjects with muscular dystrophy, congenital abnormalities affecting growth and development, traumatic lesions of cervical vertebrae, jaw, hand and wrist were excluded.

All the subjects were divided in to two groups: Group 1 consisted of males and Group 2 consisted of females. Each group was further divided into three subgroups on the basis of age as shown in [Table 1].{Table 1}

The present study was based on lateral cephalometric radiographs, hand-wrist radiographs, maxillary and mandibular right canine radiographs of 90 samples. The sample consisted of 45 males (age ranges 10-13 years) and 45 females (age ranges 9-12 years).


Lateral cephalometric radiograph of each individual was taken with a universal counter balancing type of cephalostat at the Faculty of Dental Sciences, King George's Medical College Lucknow. Kodak' X-ray films (8 × 10) were exposed to 70 KVp, 45 mA for an average of 1.8 sec, with a tube to film distance of 6 feet.

Hand-wrist radiograph was taken by placing the left and right hand and wrist on the cassette with fingers slightly separated. Screen film and target film distance was 90 cm. The film was exposed to 20 mA current for an average of 0.5 s.

Intraoral periapical radiograph of maxillary and mandibular right canine region was taken by using the bisecting angle technique with film size 31 × 41 mm Kodak. The film was exposed to 60 kV power for 1.4 s.

In the present study, radiographic interpretation was made as per the system developed to interpret skeletal maturation given by;

Fishman; [5] on hand wrist radiographs as skeletal maturity indicator (SMI) as shown in [Figure 1].{Figure 1}Lamparski; [6] on lateral cephalogram, the cervical vertebrae as skeletal maturity indicators (CVMI) as shown in [Figure 2]. [Figure 3] shows correlation between SMI given by Fishman and CVMI stages.{Figure 2}{Figure 3}C.M. Nolla; [4] on intraoral periapical radiographs showing stages of calcification. [Figure 4] shows different stages of canine calcification.{Figure 4}

Error of measurements

To evaluate the magnitude of error in the measurements of various stages of tooth development and skeletal maturation, repeated determination was carried out on 10 individuals at an interval of 15 days. These tracings were analyzed separately and two sets of reading were obtained from each case. The reliability of the measurements tested by "t" test was not found to be statistically significant.

Statistical analysis

Mean, standard deviation, and standard error were calculated for all the groups and correlation coefficients were computed for the samples collected. The student "Newman Keul's test" was employed to evaluate the difference between the mean values of chronological age and skeletal age as assessed by skeletal maturation and canine calcification stages.


[Table 2] shows age assessment as per Fishman's method.{Table 2}

[Table 3] shows the age assessed by CVMI using C3 as a guide as given by Lamparski.{Table 3}

[Table 4] and [Table 5] shows norms for maturation of canines for boys and girls respectively by Nolla's method.{Table 4}{Table 5}

[Table 6] shows comparison of chronologic age with skeletal age assessed by SMI, CVMI and calcification stages of maxillary and mandibular canine.{Table 6}

[Table 7] shows correlation of age by SMI with age by CVMI and by calcification stages of maxillary and mandibular right canine.{Table 7}


In the present study, there was a significant difference between chronological age and skeletal age assessed by SMI and CVMI. This supported the fact that skeletal maturation showed variation in comparison to chronological age. [7],[8] Hence, use of chppronologic age to assess maturation status is questionable.

This study was supported by a study done by Hunter [9] which showed a significant difference between the mean chronological age and skeletal age. This study was also supported by Fishman, [5] Schour and Masseler. [3] There is insignificant difference between chronological age and age assessed by maxillary and mandibular right canine. This indicated that dental maturation in terms of development of canine also increased as chronological age progressed. This study was supported by, Lemons and Gray6. [10]

The result of this correlative study suggested that strong correlation was found between skeletal age assessed by SMI and CVMI in both males and females. This suggests that CVMI could also be used for assessing skeletal age. This study was supported by Lamparski [6] and Hassel and Farman. [1]

Correlation between age assessed SMI and canine calcification stages of maxillary and mandibular right canine was highly significant for males and females.

This study was supported by Lewis and Garn, [11] Green [12] Lauterstein, [13] Chertkow, [14] Demirjian and Bushchang, [15] Sierra, [16] Coutinho and Bushchang et al., [17] Considering this study it could be stated that canine could also be used as a skeletal maturity indicator.

As per this study, canine calcification stage 9 was related to capping of the third middle phalanx and appearance of the adductor sesamoid of the thumb. Hence, maxillary and mandibular canine calcification stage 9 confirmed the attainment of peak height velocity (PHV).

Intermediate stage of canine calcification between 8 and 9 could be used to identify the early stage of pubertal growth spurt. As these stages could be assessed on IOPA, this could prove more economical and convenient as armamentarium required is much simpler, even radiation dose is less.

It can be inferred that chronological age could not be used reliably for assessing skeletal maturity but strong correlation was observed between SMI and CVMI, SMI and maxillary and mandibular canine calcification stages. This confirmed the reliability and validity of cervical vertebrae maturation indicator and canine calcification stages to be used as skeletal maturity indicator. This also eliminated the use of additional radiographic exposure (Hand-wrist radiograph) of patients in orthodontic practice because cervical vertebrae are already recorded in lateral cephalogram and canine is recorded on panoramic radiograph.

To conclude, it could be stated that assessment of maturation is of utmost importance in certain orthodontic protocols like for myofunctional therapy, before starting with rapid maxillary expansion and for timing of ortho-surgical procedures (surgery for mandibular setback should carried out only after mandibular growth has completed). To further validate the results of this study, it should be carried out on larger sample size and varied age groups.


Skeletal maturation was more advanced in comparison to chronological age in both males and females.There was strong correlation between age assessed by SMI and CVMI.There was good correlation between age assessed by SMI and canine calcification stages.CVMI and canine calcification stages could also be used as a skeletal maturity indicator besides SMI.


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