| 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
| Introduction|| |
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. 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.
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. 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.
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. 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. There are two possibilities for the assessment of skeletal maturity. One of them is tooth eruption.,, The present study is performed to confirm the correlation between the CVM method and the stage of maxillary canine eruption.
| Materials and Methods|| |
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,:
- Free of any serious illness.
- No abnormal dental condition, e.g. impaction, transposition, congenitally missing teeth, odontomas and cyst.
- No previous history of trauma to the face and neck.
- No history of orthodontic treatment.
- No extraction of any permanent teeth.
- 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,,,,, which are defined as follows [Figure 2]:
- 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.
- 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.
- 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.
- Deceleration: distinct concavities are seen on the inferior borders of C2, C3 and C4. The vertebral bodies are becoming more square in shape.
- 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.
- 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, [Figure 3], as follows:
- 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.
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|| |
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 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|| |
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.,, 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. 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.,,
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.,,, 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.,,
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.,, 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. 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).,, 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., Ericson and Kurol and Montasser et al., 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 and Cernochova et al., to be 0.9% to 2.0%, where Abu-Hussein et al. 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,, 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, 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.,,,, 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., According to Nolla, 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.,,,
| Conclusions|| |
- A significant correlation between the permanent maxillary canine eruption stages and skeletal maturity was found.
- The eruption of permanent maxillary canine occurs in the acceleration and deceleration stages of CVMI before the end of pubertal growth (CVMI).
- Any delay in the eruption of maxillary canine after the deceleration stage of CVMI, suggesting a chance of impaction.
- Dental maturity assessment with maxillary canine eruption offers the advantage over CVMI, as a simple procedure to improve orthodontic diagnostic and therapeutic decisions.
- Orthopantomographs can be used easily to determine the eruption stages of teeth with minimal irradiation to the patient.
- 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
Conflicts of interest
There are no conflicts of interest.
| References|| |
Arvindbhai SB, Yusuf AR, Channamallappa RG, Pawar R, Phaphe S, Mane P. Radiographic evaluation of skeletal maturity using maxillary canine and mandibular second molar calcification stages in Western Maharashtra Population- A retrospective study. Inter J Contemp Med Res 2016;3:1750-4.
Cericato GO, Luiz De Freitas PH, Bittencourt MA, Paranhos LR. Reliability, efficacy and reproducibility of the cervical vertebrae maturation index (CVMI). Biosci J 2015;31:319-25.
Prasad M, Ganji VS, George SA, Talapaneni AK, Shetty SK. A comparison between cervical vertebrae and modified MP3 stages for the assessment of skeletal maturity. J Nat Sc Biol Med 2013;4:74-80.
] [Full text]
Trakinienė G, Smailienė D, Kučiauskienė A. Evaluation of skeletal maturity using maxillary canine, mandibular second and third molar calcification stages. Europ J Orthod 2016;38:398-403.
Kumar S, Singla A, Sharma R, Virdi MS, Anupam A, Mittal B. Skeletal maturation evaluation using mandibular second molar calcification stages. Angle Orthod 2012;82:501-6.
Vildana D, Alisa T, Amila Z, Ismeta R, Enita N. Skeletal maturity assessment using mandibular canine calcification stages. Acta Med Acad 2016;45:128-34.
Al-Balbeesi HO, Al-Nahas WN, Laila FB, Bin Huraib MS, Alhaidari R, Alwadai Gh. Correlation between skeletal maturation and developmental stages of canines and third molars among Saudi subjects. Saudi Dent J 2018;30:74-84.
Sandeep G, Sonia G. Comparative evaluation of permanent mandibular canine and second molar calcification stages for assessment of the skeletal maturity. Rwanda Med J 2013;70:12-8.
Yadav V, Loomba A, Autar R. A comparative evaluation of dental calcification stages and skeletal maturity indicators in North-Indian children. Nat J Maxillofac Surg 2017;8:26-33.
Hassel B, Farman AG. Skeletal maturation evaluation using cervical vertebrae. Am J Orthod Dentofac Orthop 1995;107:58-66.
O'Reilly TM, Yanniello JG. Mandibular growth changes and maturation of cervical vertebrae – A longitudinal cephalometric study. Angle Orthod 1988;58:179-84.
Patil R, Reddy GV, Ramlal G, Reddy KJ. A correlative study between hand-wist maturation and cervical vertebrae for the assessment of skeletal age. J Indian Aca Oral Med Radiol 2013;25:99-103.
Carruitero MJ. Correlation between the skeletal maturation stages of two radiographic methods in peruvians. J Int Oral Health 2017;9:289-92. [Full text]
Mini MM, Thomas V, Bose T. Correlation between dental maturity by Demirjian method and skeletal maturity by cervical vertebral maturity method using panoramic radiograph and lateral cephalogram. J Indian Acad Oral Med Radiol 2017;29:362-7. [Full text]
Pitt S, Hamdan A, Rock P. A treatment difficulty index for unerupted maxillary canines. Europ J Orthod 2006;28:141-4.
Counihan K, Al-Awadhi EA, Butler J. Guidelines for the assessment of the impacted maxillary canine. Dent Update 2013;40:770-7.
Chapman SM. Ossification of the adductor sesamoid and the adolescent growth spurt. Angle Orthodontist 1972;42:236-45.
Houston WJB, Miller JC, Tanner JM. Prediction of the timing of the adolescent growth spurt from ossification events in hand-wrist films. Br J Orthodont 1979;6:142-52.
Verma D, Peltomäki T, Jäger A. Reliability of growth prediction with hand – wrist radiographs. Europ J Orthod 2009;31:438-42.
Gustafson G, Koch G. Age estimation up to 16 years of age based on dental development. Odontol Revy 1974;25:297-306.
Basaran G, Ozer T, Hamamci N. Cervical vertebral and dental maturity in Turkish subjects. Am J Orthod Dentofac Orthop 2007;131:447.e13-20.
Sukhia RH, Fida M, Azam SI. Dental age table for a sample of Pakistani children. Eur J Orthod 2012;34:77-82.
Baccetti T, Franchi L, McNamara A Jr. An improved version of the cervical vertebral maturation (CVM) method for the assessment of mandibular growth. Angle Orthod2002;72:316-23.
Majeed O, Quadeer TA. Assessment of skeletal maturation and its correlation to chronological age using the cervical vertebral maturation method in a tertiary care hospital. J Pak Dent Assoc 2014;23:153-8.
Palanisamy V, Rao A, Shenoy R, Baranya SS. Correlation of dental age, skeletal age, and chronological age among children aged 9-14 years: A retrospective study. J Indian Soc Pedod Prev Dent 2016;34:310-4.
] [Full text]
Perinetti G, Contardo L. Reliability of growth indicators and efficiency of functional treatment for skeletal class II malocclusion: Current evidence and controversies. BioMed Res Inter 2017;2017:1367691. doi: 10.1155/2017/1367691.
Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral maturation (CVM) method for the assessment of optimal treatment timing in dentofacial orthopedics. Sem Orthodont 2005;11:119-29.
Santiago RC, Miranda Costa LF, Vitral RW, Fraga MR, Bolognese AM, Maia LC. Cervical vertebral maturation as a biologic indicator of skeletal maturity: A systematic review. Angle Orthod 2012;82:1123-31.
Baccetti T, Franchi L, De Lisa S, Giuntini V. Eruption of the maxillary canines in relation to skeletal maturity. Am J Orthod Dentofacial Orthop 2008;133:748-51.
Kothavade DS, Pandey RK, Nagar A. An assessment of the relationship between cervical vertebrae maturation index and eruption of permanent maxillary canines. J Indian Soc Pedod Prev Dent 2012;30:301-4.
] [Full text]
Hassan S, Shaikh A, Fida M. Dental age and skeletal maturity stages in patients with impacted versus erupted maxillary canines. OHDM 2014;13:945-9.
Hasan BM, Abuaffan AH. Correlation between chronological age, dental age and skeletal maturity in a sample of sudanese children. Global J Med Res J Dent Otolaryng 2016;16:13-21.
Becker A, Smith P, Behar R. The incidence of anomalous lateral incisors in relation to palatally-displaced cuspids. Angle Orthod 1981;51:24-9.
Ericson S, Kurol J. Incisor resorption caused by maxillary cuspids. A radiographic study. Angle Orthod 1987;57:332-46.
Becker A. The Orthodontic Treatment of Impacted Teeth. 2nd
ed. London: Informa UK; 2007. p. 23-93.
Bin I, Becker A, Shalhav M. Position of the maxillary permanent canine in relation to anomalous or missing lateral incisors: A population study. Eur J Orthod 1986;8:12-6.
Ericson S, Kurol J. Resorption of incisors after ectopic eruption of maxillary canines: A CT study. Angle Orthod 2000;70:415-23.
Montasser MA, Viana G, Evans CA. Secular trends in the timing of skeletal maturation as assessed by the cervical vertebrae maturation method. Europ J Orthod 2017;39:188-93.
Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbance. Eur J Orthod 1986;8:133-40. Cited by Cernochova P, Krupa P, Izakovicova-Holla L. Root resorption associated with ectopically erupting maxillary permanent canines: A computed tomography study. Eur J Orthod 2011;33:483-91.
Cernochova P, Krupa P, Izakovicova-Holla L. Root resorption associated with ectopically erupting maxillary permanent canines: A computed tomography study. Eur J Orthod 2011;33:483-91.
Abu-Hussein M, Watted N, Feştila Da, Borbély P. Surgical-orthodontic treatment of impacted canines. J Dent Med Sci 2015;14:97-104.
Al-Bustani A. Application of periapical radiographic view of four mandibular permanent teeth in orthodontic diagnosis. J Bagh Coll Dentistry 2011;23:94-9.
Valizadeh S, Eil N, Ehsani S, Bakhshandeh H. Correlation between dental and cervical vertebral maturation in Iranian females. J Radiol 2013;10:1-7.
Nolla CM. The development of the permanent teeth. J Dent Child 1960;27:254-63.
Van der Linden FP. Transition of the Human Dentition. Ann Arbor, Mich: Center for Human Growth and Development, University of Michigan; 1979.
Newcomb MR. Recognition and interception of aberrant canine eruption. Angle Orthod 1959;29:161-8.
Demirjian A, Goldstein H, Tanner M. A new system for dental age assessment. Hum Biol 1973;45:211-27.
Rozylo-Kalinowska I, Kolasa-Raczka A, Kalinowski P. Dental age in patients with impacted maxillary canines related to the position of the impacted teeth. Eur J Orthod 2011;33:492-7.
Dr. Ruba J Mohammad
Lecturer in Orthodontics, Pedodontics and Preventive Dentistry, Department of Pedodontics, College of Dentistry, University of Mosul
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]