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An Evaluation of Skeletal Maturation by Hand-Wrist Bone Analysis and Cervical Vertebral Analysis: A Comparitive Study

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The Journal of Indian Orthodontic Society, October-December 2013;47(4):433-437 433

An Evaluation of Skeletal Maturation byHand-Wrist Bone Analysis and CervicalVertebral Analysis: A Comparitive Study

1Srikrishna Chalasani, 2Jeevan Kumar, 3Mandava Prasad,4B Sharath Kumar Shetty, 5Talapaneni Ashok Kumar

ORIGINAL ARTICLE

Received on: 5/3/13Accepted after Revision: 8/10/13

1,3,4Senior Professor and Head, 2Senior Lecturer, 5Professor1Department of Orthodontics and Dentofacial Orthopedics, Hi-tech DentalCollege and Hospital, Bhubaneswar, Odisha, India2,3,5Department of Orthodontics and Dentofacial Orthopedics, NarayanaDental College, Nellore, Andhra Pradesh, India4Department of Orthodontics, KVG Dental College, Sullia, KarnatakaIndia

Corresponding Author: Mandava Prasad, Senior Professor and HeadDepartment of Orthodontics and Dentofacial Orthopedics, NarayanaDental College, Chinthareddypalem, Nellore-524003, Andhra PradeshIndia, Phone: +91-9440976666, e-mail: [email protected]

INTRODUCTION

Skeletal maturation refers to the degree of development ofossification in bone. Size and maturation can varyindependently of each other.1 During growth, every bone goesthrough a series of changes that can be observed radiologically.The sequence of changes is relatively consistent for a givenbone in every person. The timing of changes varies becauseeach person has his or her own biologic clock.2

Because of individual variation in timing, duration andvelocity of growth, skeletal age assessment is essential andhelpful in formulating viable orthodontic treatment plans.3 Thetiming of growth for facial bones and periods of accelerated

or intense physiologic growth must be individualized to betterexploit bone remodeling for correcting skeletaldiscrepancies.4

The classical and most widely used method for skeletalage evaluation is the highly reliable hand-wrist bone analysisperformed by radiograph. The validity of the hand-wrist boneanalysis has been confirmed by numerous studies.5,6 Fishmandeveloped a system of hand-wrist skeletal maturationindicators (SMIs), using four stages of bone maturation at sixanatomic sites on the hand and the wrist.7

The assessment of the degree of cervical vertebralmaturation (CVM) is another method of assessing skeletalmaturation. Lamparski studied the development of cervicalvertebrae and demonstrated the efficacy of the CVM methodin assessing skeletal age.8 The use of a lead collar to protectthyroid gland may hinder full vision of the cervical spine.

Therefore, Hassel and Farman compiled a new method ofCVM indicator (CVMI), which evaluated the visible lateralprofiles of the second, third and fourth cervical vertebrae. Theyestablished categories similar to those identified byLamparski. These categories were closely related to the stagesof skeletal maturity identified by Fishman and based on handbone.3 The authors concluded that changes in the shape of thevertebrae (concavity of the inferior edge and vertical height)can help to determine skeletal maturity and residual growthpotential.1

ABSTRACT

Objective: To evaluate the reproducibility of the concordance between skeletal maturity index stages of hand-wrist radiograph (Fishman) andcervical vertebral maturity index stages of lateral cephalogram (Hassel and Farman).Materials and methods: A radiographic hand-wrist bone analysis and cephalometric cervical-vertebral analysis of 48 patients (24 males and 24females; 7–18 years of age) were examined. The hand-wrist bone analysis was evaluated by the Fishman index, whereas the cervical vertebralanalysis was assessed by the Hassel and Farman (CVMI) method. These measurements were then compared with the hand-wrist boneanalysis, and the results were statistically analyzed by the Cohen concordance index.Results: The Cohen index obtained (mean ± SD) was 0.70 ± 0.02, which is in the good range of agreement. The results also show a correlationof CVMI I with Fishman stages 1-2, CVMI II with Fishman stages 3-4, CVM III with Fishman stages 4-5, CVMI IV with Fishman stages 6- 7,CVMIV with Fishman stages 9-10 and CVMI VI with Fishman stage 11.Conclusion: Vertebral analysis on a lateral cephalogram is as valid as the hand-wrist bone analysis with the advantage of reducing the radiationexposure of growing subjects.Keywords: Cervical vertebrae, hand-wrist bone analysis, Skeletal maturation.

How to cite this article: Chalasani S, Kumar J, Prasad M, Shetty BSK, Kumar TA. An Evaluation of Skeletal Maturation by Hand-Wrist BoneAnalysis and Cervical Vertebral Analysis: A Comparitive Study. J Indian Orthod Soc 2013;47(4):433-437.

10.5005/jp-journals-10021-1201

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Fig. 1: Patient position for hand-wrist radiograph Fig. 2: Patient position for lateral cephalogram

Fig. 4: CVMI 2 (acceleration) and SMI 3-4

Fig. 5: CVMI 3 (transition) and SMI 5-6 Fig. 6: CVMI 4 (deceleration) and SMI 7-8

Fig. 3: CVMI 1 (initiation) and SMI 1-2

MATERIALS AND METHODSParticipantsThe present study involved 48 patients (24 males and 24females, 7-18 years of age).

Procedure and Instruments

A hand-wrist bone radiograph (Fig. 1) and lateral cephalogram(Fig. 2) were collected from all the patients. The hand-wristbone analysis was evaluated according to Fishman index.3 The


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index. This was done to assess the inter-rater reliability whenobserving categorical variables, i.e. two differentclassifications tied to the same category, skeletal age.

The comparison of the six stages CVMI method and 11stages Fishman method with Cohen’s kappa leads to aconcordance value (mean ± SD) and outcome of Cohen’s kappaindex value between 0.6 and 0.8 is good correlation of thetwo methods in assessing skeletal maturity.

Statistical Analysis

Statistical analysis was done by Cohen’s kappa static test.

RESULTS

The results of the cervical vertebral analysis and the hand-wrist bone analysis for the 48 patients are shown in Table 2,among the various age and gender distribution (Graph 1). Akappa correlation value of 0.7 was found between the skeletalmaturation stages of both methods. Among males, thecorrelation value was 0.71 and, among females, the value was0.68.

DISCUSSION

The optimal effectiveness of orthodontic treatment isassociated with skeletal maturation. Skeletal maturation is an

Fig. 8: CVMI 5 (completion) and SMI 11

Fig. 7: CVMI 5 (maturation) and SMI 9-10

pubertal peak growth phase is related to mineralization of thesesamoid-metacarpal-phalanx articulation of thumb. The peakgrowth coincides with the capping of epiphysis on the diaphysisof the third finger—distal phalanx, third finger—middlephalanx, fifth finger—middle phalanx. Maturation phase takesplace when fusion starts at the epiphysis on the diaphysis ofthe third finger—distal phalanx.

The cervical vertebral analysis was assessed by Hassel andFarman method, which when compared with hand-wrist boneanalysis (Figs 3 to 8), presents the following advantages:1

A. Appraises three vertebraeB. Restricts stages of growthC. Uses simpler and easily individuated cephalometric points.

The stages of skeletal maturation assessed through thecervical vertebrae were codified through the CVMI stagemethod followed by roman numerals to define skeletalmaturation stages. Only three vertebrae were appraised (C2,C3, C4). This method composed of following six stages.1

Indicators of each individual’s maturity as measured byFishman were compared with Hassel and Farman CVMI’smethod (Table 1) by using Cohen’s Kappa or concordance

Table 1: Correlation of hand-wrist and CVM stages

Hand-wrist Cervical vertebrae Percentile of pubertalindicator stage growth remaining

1-2 1. Initiation 85-100%3-4 2. Acceleration 65-85%5-6 3. Transition 25-65%7-8 4. Deceleration 10-25%9-10 5. Maturation 5-10%11 6. Completion 0%

Table 2: Comparison of SMI vs CVMI among the study population

Hand-wrist CVMI Totalindicator 1 2 3 4 5 6

1-2 17 2 1939.5%

3-4 2 4 612.5%

5-6 3 36.25%

7-8 4 1 510.5%

9-10 1 7 1 918.75%

11 6 612.5%

Total 19 6 7 2 7 7 4839.5% 12.5% 14.5% 4.16% 14.5% 14.5% 100.0%

Total (M + F) n = 48 SMI–CVMIK-value 0.70Agreement strength Good

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Table 3: Comparison of SMI vs CVMI among males

SMI CVMI Total1 2 3 4 5 6

1-2 11 1 1291.6% 8.4% 100.0%

3-4 2 2100.0% 100.0%

5-6 2 2100.0% 100.0%

7-8 3 3100.0% 100.0%

9-10 4 4100.0% 100.0%

11 1 1100.0% 100.0%

Total 11 3 5 0 4 1 2445.8% 12.5% 20.8% 0% 16.6% 4.1% 100%

Males (n = 24) SMI-CVMIK-value 0.71Agreement strength Good

Table 4: Comparison of SMI vs CVMI among females

SMI CVMI Total

1 2 3 4 5 6

1-2 6 1 785.7% 14.3% 100%

3-4 2 2 450% 50% 100%

5-6 1 1100% 100%

7-8 1 1 250% 50% 100%

9-10 1 3 1 520% 60% 20% 100%

11 5 5100% 100%

Total 8 3 2 2 3 6 2433.3% 12.5% 8.3% 8.3% 12.5% 25%

100.0%

Females (n = 24) SMI-CVMIK-value 0.68Agreement strength Good

integral part of individual pattern of growth and developmentand is more closely related to sexual maturity.5,9 It was statedthat to take advantage of growth, we must have an idea of, firstits magnitude, second its direction and third the element oftiming.

To assess the skeletal age of an individual, the use of hand-wrist radiographs has been advocated. Several human growthstudies have shown that the timing of the pubertal growth ofthe craniofacial region is closely related to specificossification events and stages observed in the hand-wrist areaof the skeleton.5,6 Therefore, hand-wrist radiographs haveproved to be a valuable diagnostic tool in orthodontics.

In view of the limitations and disadvantages of hand-wristradiographs, Hassel and Farman introduced a method that usesthe CVMI to assess skeletal maturation, and some authors havefound it to be simple, effective and clinically reliable forassessing skeletal maturity.1

The comparison between the hand-wrist bone analysis andthe cervical vertebral analysis in our sample revealed aconcordance with good kappa correlation value of 0.7, whichwas found in the study population between hand-wrist skeletalmaturation and CVM assessed by the Fishman and Hassel andFarman analyses respectively. Similar results were observedin the previous literature.10

A good agreement was seen in males (0.71) (Table 3) andfemales (0.68) (Table 4), when SMI and CVMI stages werecompared. The findings of this study show that agreementstrengths of SMI versus CVMI among 13 to 14 and 17 to 18years age groups in study population was good (0.68 and 0.75),whereas 11 to 12 and 15 to 16 years age groups showedmoderate agreement (0.43 and 0.49).

Females were more in the advanced maturity stages ascompared to the males, indicating that faster maturation occursin females as compared to males. This was indicated by thepercentage of sample size (25%, five females) showed theCVMI stage 6, whereas only one male subject (4.1%) in thestudy population showed the CVMI stage 6 (Tables 3 and 4).The investigations from this study on the rate of maturation infemales have been illustrated in previously publishedliterature.12 However; the difference in the SMI and CVMI

Table 5: Skeletal age assessment of the sample collected after theinterpretation of the radiographs

CVMI vs SMI Male Percentage Female Percentage

Similar 21 87.5 18 75Dissimilar 3 12.5 6 25

Graph 1: Age and gender distribution of the study population


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scores between males and females was statistically notsignificant.

After careful examination of the studies of the CVMmethods, we had questions regarding the specific methodology.Many authors reported interobserver and intraobserverreproducibility of the CVMI method. In all, the citedinterobserver and intraobserver reproducibility exceeds 90(Table 5).1,5,6,11

There is definitely a need for further study with a largersample size as this can show a much better correlation betweenCVMI and skeletal maturity than the observations was madein this study and hence can affirm and confirm that CVMI is amuch better method than the study of hand-wrist radiograph.However, the need for a longitudinal study is overdue and ifdone will be useful and appreciated. This is because it is morereliable than a cross-sectional study and it is also moreindividualized.

CONCLUSION

There was a good concordance between the 11 stages ofskeletal maturity indicator (Fishman) and the six stages ofCVMI. The CVMI (Hassel and Farman) can be a better choicefor predicting skeletal maturity of an individual because of itssimplicity and reliability.

REFERENCES

1. Hassel B, Farman AG. Skeletal maturation evaluation usingcervical vertebrae. Am J Orthod Dentofacial Orthop 1995;107:58-66.

2. Silveira AM, Fishman LS, Subtelny JD, Kassebaum DK. Facialgrowth during adolescence in early, average and late maturers.Angle Orthod 1992;62(3):185-190.

3. Fishman LS. Chronological versus skeletal age, an evaluation ofcraniofacial growth. Angle Orthod 1979;49(3):181-189.

4. Moore RN, Moyer BA, DuBois LM. Skeletal maturation andcraniofacial growth. Am J Orthod Dentofacial Orthop 1990;98:33-40.

5. Flores-Mir C, Burgess CA, Champney M, Jensen RJ, PitcherMR, Major PW. Correlation of skeletal maturation stagesdetermined by cervical vertebrae and hand-wrist evaluations.Angle Orthod 2005;76(1):1-5.

6. Uysal T, Ramoglu SI, Basciftci FA, Sari Z. Chronological andskeletal maturation of the cervical vertebrae and hand-wrist: isthere relationship? Am J Orthod Dentofacial Orthop 2006;130:622-628.

7. Fishman LS. Radiographic evaluation of skeletal maturation. AngleOrthod 1982;52(2):88-112.

8. Soegiharto BM, Cunningham SJ, Moles DR. Skeletal maturationin Indonesian and White children assessed with hand-wrist andcervical vertebrae methods. Am J Orthod Dentofacial Orthop2008;134:217-226.

9. Demirjian A, Buschang PH, Tanguay R, Patterson DK.Interrelationship among measures of somatic, skeletal, dental andsexual maturity. Am J Orthod 1985;88:433-438.

10. Gandini P, Mancini M, Andreani F. A comparison of hand-wristbone and cervical vertebral analysis in measuring skeletalmaturation. Angle Orthod 2006;76(6):984-987.

11. Franchi L, Baccetti T, McNamara J. Mandibular growth as relatedto cervical vertebral maturation and body height. Am J OrthodDentofacial Orthop 2000;118:335-340.

12. Kolodziej RP, Southard TE, Southard KS, Casko JS, JakobsenJR. Evaluation of antegonial notch depth for growth prediction.Am J Orthod Dentofacial Orthop 2002;121:357-363.

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