Assessment of Skeletal and Dental Maturation of Short and Long-Face Children of South Indian Population

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1 /jp-journals Pradeepraj ORIGINAL Gottimukkala ARTICLE et al Assessment of Skeletal and Dental Maturation of Short and Long-Face Children of South Indian Population 1 Pradeepraj Gottimukkala, 2 Chandra Sekhar Gandikota, 3 Padma Latha Challa 4 Kiran Perumalla, 5 Yudhistar Palla, 6 Shubhaker Rao Juvvadi ABSTRACT The purpose of this study was to compare the chronological age with the skeletal age and the dental age in a sample of 100 subjects in the age group of 9 to 12 years with extreme facial patterns to evaluate the growth status of the children. Materials and methods: Lateral cephalograms, panoramic radiographs and hand-wrist radiographs of 100 subjects were taken, and the subjects were classified according to facial growth pattern. The 50 subjects with the greatest predominance of vertical growth and the other 50 with the greatest predominance of horizontal growth were selected; these subjects comprised the vertical and horizontal groups respectively. Comparisons between groups were made with independent t-tests. Results: A statistically significant difference was noted between the dental ages of the vertical and horizontal groups, with the vertical group having a more advanced skeletal and dental age. Conclusion: Subjects with vertical growth pattern should be expected to have earlier dental maturity than horizontal growers. Keywords: Chronological age, Dental age, Skeletal age, Growth status, Short-face, Long-face. How to cite this article: Gottimukkala P, Gandikota CS, Challa PL, Perumalla K, Palla Y, Juvvadi SR. Assessment of Skeletal and Dental Maturation of Short and Long-Face Children of South Indian Population. J Ind Orthod Soc 2012;46(3): INTRODUCTION When growth modification is the primary concern, craniofacial growth evaluation is an essential part of diagnosis and treatment planning in orthodontics. Many clinicians believe that orthodontic treatment is effective, if it is started during a period of rapid pubertal growth. 1 It has been suggested that growth modification treatment for the maxilla should be started before the peak pubertal growth of the maxilla, 2 and growth modification for the mandible has been shown to be more effective during the peak mandibular growth rather than before this stage. 3 Certain parameters like chronological age, dental development, skeletal maturation, voice change and increase in body height have been suggested to identify the stages of growth. 1 Senior Lecturer, 2,3 Professor and Head, 4,5 Reader, 6 Assistant Professor 1 Department of Orthodontics and Dentofacial Orthopedics, SB Patil Dental College, Bidar, Karnataka, India 2,6 Department of Orthodontics and Dentofacial Orthopedics, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre Hyderabad, Andhra Pradesh, India 3-5 Department of Orthodontics and Dentofacial Orthopedics, Mamata Dental College and Hospital, Khammam, Andhra Pradesh, India Corresponding Author: Pradeepraj Gottimukkala, Senior Lecturer Department of Orthodontics and Dentofacial Orthopedics, SB Patil Dental College, Bidar, Karnataka, India, shubhaker@yahoo.com Received on: 12/10/11 Accepted after Revision: 13/2/ Optimal effectiveness in the use of orthodontic or orthopedic appliances has been associated with skeletal maturation. Functional appliances have been shown to be more effective when used in the peak mandibular growth period rather than earlier. However, because of the high variability in mandibular growth, this association may not be predictive enough for the individual patient. 4 Skeletal maturation is generally determined by using ossification stages of bones of the hand and wrist because of the differential ossification of the bones. Certain skeletal developmental stages of the hand and wrist have been shown to be closely associated with the pubertal growth spurt, and hand radiographs have been used as an indirect method for the assessment of somatic maturity stage. 5 However, the routine use of hand-wrist radiographs has lately been questioned from the radiation-hygiene and safety point of view. 6 Dental maturity can be determined by the stage of tooth eruption or by the stage of tooth formation. Tooth formation is proposed as a more reliable criterion for determining dental maturation The ease of recognition of dental development stages, together with the availability of periapical or panoramic radiographs in most orthodontic or pediatric dental practices are practical reasons for attempting to assess the physiologic maturity without resorting to hand-wrist radiographs. 15,16 MATERIALS AND METHODS The sample for this cross-sectional study was derived from subjects from private schools in and around Khammam district in the state of Andhra Pradesh, India. The sample included 100 subjects, 50 boys and 50 girls in the age group of 9 to 12 years. JAYPEE

2 JIOS Assessment of Skeletal and Dental Maturation of Short and Long-Face Children of South Indian Population All potential subjects were explained the need and design of the study and a written consent was obtained from their parents. The age group of 9 to 12 years was chosen as the pubertal growth spurt events occur during this period. Subjects with predominantly vertical and horizontal growth pattern were selected for the study. The inclusion criteria for the study were that the subjects were all required to be well nourished and free of any known serious illness, and had normal dental conditions with no previous history of trauma or injury to the face and the hand and wrist regions. Lateral cephalograms, orthopantomograms (OPG) and hand-wrist radiographs of the left hand were obtained from each of the 100 subjects. Exact chronological ages in completed years and months were recorded with reference to the patient s birth date. Linear measurements (Fig. 1) were considered to classify the subject either as having a short or long vertical growth pattern, 17 based on the values of ANS-Me (lower anterior facial height) and N-Me (total anterior facial height). The selection of the cutoff points for the ratio ANS-Me/N-Me was lower or equal to 56% or higher or equal to 58%. Angular measurements (Fig. 2) considered to classify the subject either as having a vertical or horizontal growth pattern 18 are the SN-GoGn (angle between anterior cranial base and Steiner s mandibular plane), NS-Gn/Y-AXIS (the angle between the anterior cranial base and line drawn from point S to Gn) and the FH-GoMe/Frankfort-mandibular angle (angle between Frankfort plane and mandibular plane). ORTHOPANTOMOGRAM (OPG) The panoramic radiographs of all the 100 patients were taken with the help of the Rotograph Plus MR05, Villa System Medical, Italy to assess the dental maturity. The stages of calcification of the permanent teeth in the mandibular left quadrant, from central incisor to second molar, were evaluated on panoramic radiographs. Dental maturity score and dental age determination were made by a single examiner, using the method suggested by Demirjian et al. 19,20 Maturity scores based on seven teeth on the left side of the mandible were recorded. The scores of all seven teeth were added together to give the total maturity score. After the maturity score was calculated, it was converted to the dental age by referring to the tables given by Demirjian 19 in order to get the obtained dental age. HAND-WRIST RADIOGRAPH Hand-wrist radiographs of left hand of all the 100 subjects were taken and the tracings of the films were done using Staedtler Mars Micro 0.3 mm pencil. All the phalanges of the fingers and thumb were drawn along with the carpals, metacarpals and outline of the radius and ulnar bone in the hand-wrist radiographs. SKELETAL AGE DETERMINATION Fig. 1: Linear measurements Skeletal maturation is generally determined by using ossification stages of bones of the hand and wrist because of the availability of different types of bones in the area. Hand-wrist radiographs were analyzed using the Fishman s 21 maturation prediction method to determine skeletal maturation level (advanced, average or delayed) and stage (relative position of the individual in the pubertal growth curve). CERVICAL VERTEBRAL MATURATION INDEX Fig. 2: Angular measurements The standard method of evaluating skeletal maturity has been a hand-wrist radiograph to compare the patient s hand-wrist bones with those in published atlases. To avoid taking an additional radiograph, some researchers sought to relate maturation with dental and skeletal features other than the bones in the hand and wrist. Among maturational indexes, the cervical vertebral maturation method has proved effective in assessing the adolescent growth peak both in body height and mandibular size. Cervical vertebral development of the sample was evaluated by the Hassel and Farman modification of Lamparski s criteria, which assesses maturational changes on the second, third and fourth cervical vertebrae. 22 The Journal of Indian Orthodontic Society, July-September 2012;46(3):

3 Pradeepraj Gottimukkala et al STATISTICAL METHODS The statistical methods performed in this study were the analysis of variance (ANOVA) and the Bonferroni t-test. Means and standard deviations were calculated for all cephalometric variables in each group (Table 1). Normal distribution was verified by the Kolmogorov-Smirnov test. The results of the tests were nonsignificant for all variables. Therefore, t-test for independent samples were used to compare the dental age between groups and the dental and chronological age within groups. The p-value of 0.05 was considered significant. RESULTS The results of the present study showed that the vertical group had more advanced dental age than the horizontal group (10.72 < r < 11.74), representing the early maturation of the permanent teeth in both the male and female subjects with predominantly vertical facial pattern. When the dental age was compared with the chronological age of the subjects in each group, the vertical group demonstrated more advanced dental age in relation to chronological age; the opposite was seen in the horizontal group. When the skeletal age was compared with the chronological age of the subjects in each group, the male vertical group demonstrated more advanced skeletal age in relation to the chronological age; the opposite was seen in the remaining groups. When the skeletal age was compared with the dental age of the subjects in each group, the vertical showed advanced dental age in both the male and female groups; the horizontal groups showed more advanced skeletal age in both male and female groups. DISCUSSION The present study was to determine the dental age, and skeletal age and compare them with the chronological age in both male and female subjects with extreme vertical patterns. For the selection of the 100 subjects with different facial patterns, linear (the ratio of ANS-Me/N-Me lower or equal to 56% or higher or equal to 58%) 17,23 and angular (SN-GoGn, NS-Gn, FH- GoMe) cephalometric variables were standardized. 18 The method used in this study for determination of maturation of the permanent teeth was suggested by Demirjian et al 19 because of its simplicity and universal acceptance and is relatively recent compared with other similar methods. Results of the present study demonstrated a statistically significant difference between dental development of subjects with predominantly vertical growth pattern and those with a predominantly horizontal growth pattern. The male vertical group had a mean chronological age of years; mean skeletal age of years; and mean dental age of years; the male horizontal group had a mean chronological age of years; mean skeletal age of years; and mean dental age of 10.3 years (Table 2). More advanced dental age and skeletal age were observed for the vertical group, representing earlier dental and skeletal maturation of subjects with predominantly vertical growth. Horizontal group showed advanced chronological age when compared with the skeletal age and dental age, representing delayed skeletal and dental maturation of subjects with predominantly horizontal growth. The female vertical group had a mean chronological age of 10.2 years; mean skeletal age of years; and mean dental age of years; the female horizontal group had a mean chronological age of years; mean skeletal age of 10.9 years; and mean dental age of 9.78 years (Table 3). Nanda 24 observed that subjects with skeletal open bite and increased lower anterior face height (LAFH) had earlier pubertal growth spurts than those with deepbite and reduced LAFH. Nanda and Rowe 25 observed that subjects with skeletal open bite and increased LAFH had earlier maturation of craniofacial growth than subjects with deepbite and reduced LAFH. Precocity of approximately 9 months was found in dental maturation of Table 1: Mean age of horizontal and vertical growing boys and girls Mean SD N p-value Post-hoc test Horizontal male Age (1) Skeletal age (2) < > 3 Dental age (3) > 3 Vertical male Age (1) Skeletal age (2) < > 1 Dental age (3) > 1 Horizontal female Age (1) Skeletal age (2) < > 3 Dental age (3) > 3 Vertical female Age (1) Skeletal age (2) < > 1 Dental age (3) > 1 Overall in all the four groups, there was significant difference in various age parameters (<0.001, <0.001, <0.001 and <0.001 respectively). Post-hoc results show that: Among horizontal male and female growers, age and skeletal age were significantly higher than dental age Among vertical male and female growers, skeletal age and dental age was significantly higher than normal age 150 JAYPEE

4 JIOS Assessment of Skeletal and Dental Maturation of Short and Long-Face Children of South Indian Population Table 2: Comparison of chronological, skeletal and dental ages of horizontal and vertical growing males Male Age Horizontal Vertical Skeletal age Horizontal Vertical Dental age Horizontal <0.001 Vertical Vertical Independent sample t-test. Among males, there was a significant difference in horizontal and vertical growers for skeletal age and dental age. Table 3: Comparison of chronological, skeletal and dental ages of horizontal and vertical growing females Female Age Horizontal Vertical Skeletal age Horizontal Vertical Dental age Horizontal <0.001 Vertical Among females, there was a significant difference in horizontal and vertical growers for dental age. Table 4: Comparison between male and female horizontal growers Horizontal Age Male Female Skeletal age Male Female Dental age Male Female Female Independent sample t-test. Among horizontal, skeletal age was significantly different for males and females. Table 5: Comparison between male and female vertical growers Vertical Age Female Male Female Skeletal age Male <0.001 Female Dental age Male Female Independent sample t-test. Among vertical, skeletal age was significantly different for males and females. subjects with vertical growth patterns in relation to those with horizontal growth patterns. This difference can be considered clinically significant, especially concerning treatment time, which usually lasts 18 to 24 months. When the mean dental ages observed in this study were compared with the mean chronological ages of the subjects in each group, male and female subjects in the vertical group showed a more advanced mean dental age than mean chronological age (Table 5). On the contrary, the horizontal group had a more delayed mean dental age compared with mean chronological age. Therefore, the use of chronological age in tables of dental development might misguide the professional if individual growth patterns are not considered. 23 The explanation for earlier dental maturation of subjects with vertical growth patterns in comparison to those having horizontal growth is based mainly on the intrinsic characteristics of each of these facial types, in addition to genetic aspects. 23 When the mean skeletal ages observed in this study were compared with the mean chronological ages of the subjects in each group, male and female subjects in the vertical group showed a more advanced contrary The Journal of Indian Orthodontic Society, July-September 2012;46(3):

5 Pradeepraj Gottimukkala et al mean skeletal age than mean chronological age. On the contrary, the horizontal group had a more delayed mean skeletal age compared with mean chronological age (Table 4). When the mean dental ages observed in this study were compared with the mean skeletal ages of the subjects in each group, male and female subjects in the vertical group showed a more advanced mean dental age than mean skeletal age (Table 5). On the contrary, the horizontal group had a more delayed mean dental age compared with mean skeletal age. These differences are suggestive of considerable interregional variation in growth tempos. Such differences infer the use of the few regionally specific published norms as nationwide standards for the tempo of growth. 26 Although the continued use of hand-wrist films may be routinely indicated for adolescent males, the available literature does not justify this radiologic exposure in female patients lacking obvious developmental pathosis. 27 Beni Solow et al 28 presented evidence for a relationship between craniocervical posture in prepubertal children and the direction of facial development during the subsequent period of growth. The CVM is a valid indicator of skeletal growth during the circumpubertal period, providing information for timing of growth modification. 29 The ability to accurately evaluate skeletal maturity from the cervical vertebrae, without the need for additional radiographs, has the potential to improve orthodontic diagnostic and therapeutic decision. 30 The skeletal age estimate of the male adolescent spurt onset has one-third (36%) the variation of the chronological age estimate and is a more accurate indicator of the timing of the spurt than in chronological age as suggested by Earl O Bergerson. 31 Bjork and Helm 32 from their study concluded that both the skeletal and dental maturation should be registered in clinical orthodontics and the important criteria of maturation at puberty are the age at maximum pubertal growth in body height, the age at ossification of the ulnar sesamoid of the thumb, and, in girls, the age at the menarche. The findings of the study performed by Lorenzo Franchi et al demonstrate the validity of the method of cervical vertebral maturation for the evaluation of skeletal maturity and for the identification of the pubertal peak in craniofacial growth rate in individual subjects. 33 CONCLUSION The conclusions from this study include: Patients with a predominantly vertical growth pattern showed advanced skeletal age and dental age when compared with chronological age. The pattern is the same for both male and female subjects. Delayed skeletal age and dental age as compared with chronological age were seen in horizontal growers. The pattern is the same for both male and female subjects. When the skeletal age was compared with the dental age of the subjects in each group, the vertical groups showed advanced dental age in both male and female subjects; the horizontal groups showed more advanced skeletal age in both male and female subjects. 152 A clinical implication of this study permits us to conclude that orthodontic therapy should be started earlier in patients with a predominantly vertical growth than those with a predominantly horizontal growth pattern. REFERENCES 1. Proffit WR. Treatment timing: Effectiveness and efficiency, Treatment timing: Orthodontics in four dimensions. Craniofacial Growth Series 2002;39: Baccetti T, Franchi L, McNamara JA. The cervical vertebral maturatioin (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Semin Orthod 2005;11: Pancherz H, Hägg U. Dentofacial orthopedics in relation to somatic maturation. Am J Orthod 1985;88: Flores-Mir C, Nebbe B, Major PW. 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