JICDRO is a UGC approved journal (Journal no. 63927)

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ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 132-139

Correlating the Age Estimated by Nolla's Method and Modified Demirjian Method with Cervical Vertebral Maturation Index: A Cross-Sectional Study


1 Department of Oral Medicine and Radiology, Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India
2 Department of Oral Medicine and Radiology, Panineeya Institute of Dental Sciences, Hyderabad, Telangana, India

Date of Submission20-Mar-2020
Date of Decision24-May-2020
Date of Acceptance17-Jun-2020
Date of Web Publication14-Dec-2020

Correspondence Address:
Dr. Nallan C S K Chaitanya
Department of Oral Medicine and Radiology, Panineeya Institute of Dental Sciences, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jicdro.jicdro_13_20

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   Abstract 


Introduction: Among various methods of dental age (DA) estimation, Demirjian method and Nolla’s method are commonly used. One of the methods of determining cervical vertebral morphology was given by Hassel and Farman. Indian age-specific modified Demirjian method by Acharya has not been utilized in the Hyderabad population, and the age derivation information is sparse. Objectives: To correlate the DA using modified Demirjian’s method and Nolla’s method using orthopantomograph with skeletal maturation by cervical vertebral maturation index (CVMI) method using lateral cephalogram. They were compared and correlated for assessing chronological age (CA) and determining the accuracy. Materials and Methods: Among 200 boys and girls (100 each) between 6 and 21 years, the DA was evaluated using orthopantomogram by Ashith Acharya’s modified Demirjian method and also by Nolla’s method. The skeletal maturation was assessed by CVMI method given by Hassel and Farman using lateral cephalogram. These were compared and correlated with CA. The data derived were statistically analyzed using SPSS software 20.0 version. Results: The maximum underestimation of age was found within the age group of 19–19.9 years using Ashith Acharya’s modified Demirjian method and 18-18.9 years using Nolla’s method with median values of −5.05 and −5.03, respectively. Statistically significant difference was found between CAs and cervical vertebral maturation stages in both genders (P = 0.000). The study showed that girls had a late dental development compared to corresponding cervical maturation. Conclusions: The methods of age estimation were not reliable in predicting the accurate age in the Indian population.

Keywords: Age estimation, cervical vertebra maturation index, children, Nolla method


How to cite this article:
Priyanka JN, Chaitanya NC, Srivani GS, Mounika Y, Reddy GR, Priya B, Sanjna CR, Sahiti R. Correlating the Age Estimated by Nolla's Method and Modified Demirjian Method with Cervical Vertebral Maturation Index: A Cross-Sectional Study. J Int Clin Dent Res Organ 2020;12:132-9

How to cite this URL:
Priyanka JN, Chaitanya NC, Srivani GS, Mounika Y, Reddy GR, Priya B, Sanjna CR, Sahiti R. Correlating the Age Estimated by Nolla's Method and Modified Demirjian Method with Cervical Vertebral Maturation Index: A Cross-Sectional Study. J Int Clin Dent Res Organ [serial online] 2020 [cited 2021 Apr 10];12:132-9. Available from: https://www.jicdro.org/text.asp?2020/12/2/132/303395




   Introduction Top


Age estimation in children and adolescents answers many of the legal questions, status of majority, and criminal liability. In literature, various methods of age estimation have been reported.[1]

Among various methods of dental age (DA) estimation, the most widely accepted method is Demirijian method where Demirijian et al. classified tooth development into eight stages. Later, this method was modified by Ashith Acharya who included 3rd molars and derived a formula for specific Indian population.[2] Another method used was Nolla’s method which classified the tooth development into ten stages such as (0) absence of crypt, (1) presence of crypt, (2) initial calcification, (3) 1/3rd crown completed, (4) 2/3rd crown completed, (5) crown almost completed, (6) crown completed, (7) 1/3rd root completed, (8) two-thirds of root completed, (9) root almost completed – open apex, and (10) apical end of root completed.[3]

Studies have shown interrelationship between skeletal, somatic, and sexual maturity. However, the relationship between dental and skeletal maturity remains still inconsistent. Hand–wrist radiographs are regarded as the best indicators of assessing skeletal maturity.[4] Currently, the cervical vertebral maturation index (CVMI) method, by Hassel and Farman, consisted of six maturational stages based on vertebral morphology (C2, C3, and C4).

The following six stages of vertebral maturation were used for the assessment of maturity:

  1. Initiation: C2, C3, and C4 inferior vertebral body borders are flat

    Superior vertebral borders tapered posterior to anterior
  2. Acceleration: Concavities developing in the lower borders of C2 and C3 lower borders of C4 vertebral body is flat

    C3 and C4 are more rectangular in shape
  3. Transition: Distinct concavities in the lower borders of C2 and C3, C4 developing concavity in the lower border of body, C3 and C4 are rectangular in shape
  4. Deceleration: Distinct concavities in the lower borders of C2, C3, and C4

    C3 and C4 are nearly square in shape
  5. Maturation: Accentuated concavities of inferior vertebral body borders of C2, C3, and C4

    C3 and C4 are square in shape
  6. Completion: Deep concavities are present on the inferior vertebral body borders of C2, C3, and C4

    C3 and C4 heights are greater than widths.[5]


Although comparative studies of skeletal maturity and DA have been carried out, no direct comparison between modified Demirjian’s method, Nolla’s method, and the improved CVMI method was found in open literature. Age-specific derivations were missing in Hyderabad population and thus the purpose of this study was to investigate the relationship between DA evaluated using modified Demirjian’s method, Nolla’s method, and skeletal maturity determined by the CVMI method.


   Materials and Methods Top


Study setting

The present study was conducted in the department of oral medicine and radiology from November 2016 to November 2018 for a period of 2 years.

Sample size

A total number of 200 patients, 100 girls and 100 boys in age group between 6 and 21 years, were included in the study after Institutional Ethical Clearance (PMVIDSandRC/EC/DN/0092-16). The informed consent was obtained from the parents before including the participants of minor age group in the study. They were included in the study taking into consideration their last birthday with their chronological age (CA) recorded by their date of birth.

Each individual was subjected to an orthopantomogram (OPG) and lateral cephalometric radiographs with adequate protective measures taking lower third molar eruption into consideration and cervical vertebrae (C2, C3, and C4) morphology in lateral cephalometric view. Patients were excluded from the study if they had incomplete dental or medical history, previously orthodontic treatment, evident systemic diseases and congenital anomalies, premature birth, hypodontia of permanent teeth and hyperdontia, cervical problems, missing or extractions of lower molar teeth.

The following methods were considered for deriving (estimated) age.

Dental age estimation

Nolla’s method

The calcification of permanent dentition was divided into ten stages. Radiographically, eight mandibular teeth on the left quadrant were recorded for stage of calcification with a reading. A sum total was made for eight mandibular teeth to derive a score for eight mandibular teeth. Later, the sum total was matched with the table given by Nolla’s for boys and girls separately [Figure 1].
Figure 1: Nolla's age estimation method

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Modified Demirijian’s method

Indian-specific formulas of Demirjian’s method proposed by Ashith Acharya were utilized as a second method in this study. According to the developmental stages, each tooth was assigned a maturity score and later these scores were summed up and substituted into the formulae which gives the DA of the individual [Figure 2].
Figure 2: Ashith Acharya age estimation method. Ashith Acharya's ten developmental tooth stages. Ashith Acharya's table for girls and boys

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Acharya’s Indian formulas for age estimation (Indian method):

  • For males, age = 27.4351−(0.0097 × S2)+(0.000089 × S3)
  • For females, age = 23.7288−(0.0088 × S2)−(0.000085 × S3).


For assessment of cervical vertebral maturation stages

A single lateral cephalogram was taken where C2, C3, and C4 were visible, thus the skeletal maturity can be assessed. The cervical vertebras are divided into six stages, and these stages can predict the start of the pubertal growth spurt using Hassel and Farman method. The DA of the patient was evaluated using OPG by the above-mentioned two methods, stages of cervical maturation of C2, C3, C4 vertebrae by Hassel and Farman method using lateral cephalometric radiograph. Each of them were compared and correlated with that of CA, thus assessing the reliability of methods of age estimation and cervical vertebra as skeletal maturation tool [Figure 3].
Figure 3: cervical vertebrae maturation indicators given by Brent Hassel and Farman G. Vertebral bodies with respective descriptions of each maturation stage of cervical vertebrae according to the Hassel and Farman's classification (1995). (a) Initiation; (b) Acceleration; (c) Transition; (d) Deceleration; (e) Maturation; (f) Finalization

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Statistical analysis

The obtained data were subjected to statistical analysis using SPSS software version 20.0 (IBM, Chicago. Illinois, USA). Statistical tests such as Pearson’s correlation and one-way analysis of variance (ANOVA) were used, and P < 0.01 was considered statistically significant.


   Results Top


Age and gender characteristics

The present study comprised of 200 patients (74 boys and 126 girls) in the age group of 6–21 years divided into 14 groups between 6–6.9 years and 21–21.9 years. Maximum number of patients participated were within the age group of 15–15.9 years and least number of patients were within the age group of 6–6.9 years. The number of boys participated was more within age between 13 and 13.9 years and number of girls was maximum within 15–15.9 years [Table 1].
Table 1: Age and gender distribution of the study population

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Correlation between chronological age and estimated dental age using Demirjian Indian-specific formulae for overall sample (n = 200)

The mean values obtained were 15.64 years with respect to the estimated CA and 13.32 years for dental estimated age. The mean difference between the CA and estimated DA was 2.31 years in overall population using Demirjian Indian-specific formulae. When correlation between CA and DA for overall sample (n = 200) (Demirjian Indian specific formulae) was done using Pearson’s correlation, the coefficient value was 0.607, which was statistically significant at the 0.01 level (two tailed), having a positive correlation with a large strength of association [Table 2].
Table 2: Correlation between Chronological age and estimated dental age for overall sample (n=200)

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Thus, it could be observed that there were significant differences between the CA and estimated DA for overall population.

Difference between chronological age and dental age from Indian formulae in all age groups for overall sample (n = 200)

Differences between the CA and estimated DA from Indian formulae in overall sample (n = 200) were observed. Maximum underestimation of age was found in the age group of 19–19.9 years, with a median value of −5.05, and least underestimation of age was found in the age group of 10–10.9 years, with a median value of −0.54 [Graph 1].



Error of age estimation (in years) between the DA and CA in boys and girls when Demirjian Indian-specific formula was used having majority of patients in all age groups, i.e., 43 (58.2%) boys and 76 (60.4%) girls, had >±2 years difference between CA and DA. Other values are depicted in [Table 3].
Table 3: Error of age estimation (in years) of Demirjian population-specific formulae in boys and girls

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Correlation between chronological age and estimated dental age (Nolla’s method) for overall sample (n = 200)

The mean scores were 15.65 years for CA and 12.74 years for dental estimated age. The mean difference between the CA and estimated DA was 2.9 years in overall population using Nolla’s method.

When correlation between CA and DA for the overall sample (n = 200) (Nolla’s method) was done using Pearson’s correlation, the coefficient value was 0.684, which was statistically significant at the 0.01 level (two tailed); having a positive correlation with a large strength of association shows differences between the ages estimated [Table 4].
Table 4: Correlation between chronological age and estimated dental age (Nolla's method) for overall sample (n=200)

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Difference between chronologic age and DA using Nolla’s method in all age groups for overall sample (n = 200) showed maximum underestimation of age as the age increased from 13–13.9 years to 21–21.9 years. Maximum underestimation of age was found in the age group of 18–18.9 years with a median value of −5.03 and less underestimation was found in the group 12–12.9 years with a median value of −0.25 [Table 5].
Table 5: Difference between chronological age and dental age (Nolla's method) in all age groups for overall sample (n=200)

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Error of age estimation (in years) between the DA and CA in boys and girls when Nolla’s method was done in all age groups, i.e., 44 (59.4%) boys and 95 (75.3%) girls, had >±2 years difference between CA and DA. Values pertaining to other groups are depicted in [Table 6].
Table 6: Error of age estimation (in years) of Nolla's method in boys and girls (n=200)

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It was clearly observed that the large majority of individuals showed discrepancy in age by 2 years in this method.

Cervical vertebral maturation index and chronological age

The output from the ANOVA table indicated that there was statistically significant difference between the group means, i.e., P = 0.000. Therefore, there was difference between CA to that of different cervical vertebral maturational stages. Relation between CA and cervical vertebrae maturity stages for overall sample (n = 200) that there was advanced stages of CVMI when correlated with CA [Graph 2].




   Discussion Top


Age estimation using dentition could be an accurate measure of chronologic age that seems to be independent of exogenic factors such as malnutrition or disease.[6],[7] The aim of an ideal age estimation method is to arrive at an age as close to the CA as possible. Various age estimation methods have been tested and reported in literature on different ethnic populations. Only few studies on the Indian population have been reported.[8],[9] Thus, the need was felt, to determine the age using Demirjian’s method modified by Ashith Acharya and Nolla’s methods in various South Indian population groups. Similarly, the importance of skeletal age and maturation has also been recognized. Skeletal maturation assessed on hand–wrist radiographs is classically considered the best indicator of maturity. The assessment of the degree of the cervical vertebrae maturation (CVM) is another method of assessing skeletal maturation.[10],[11] The cervical vertebrae can be easily seen in lateral cephalometric radiographs and are also suitable to study the age in young individuals. Only few studies have reported the usefulness of cervical vertebrae for age estimation.[12]

Various studies have been conducted among different parts of the world which reported a strong relationship between skeletal, sexual, and somatic maturation. However, data pertaining to comparison of the age determined by dental maturity and skeletal maturity in Indian population using Indian formulae were inconclusive.[13]

Hence, this study was undertaken to assess the relationship between the age determined by DA formulae and cervical vertebral maturity.

Panoramic radiographs were taken using standard parameters with adequate protective measures. They were analyzed for the developmental stages of teeth according to the stages given by both the modified Demirjian’s method using Indian formulae and Nolla’s methods. Panoramic images are more comfortable and cause less radiation in comparison to a full-mouth intraoral periapical radiographic series.[14]

In the present study, the relation between the dental and CA was evaluated. The mean DA in the overall sample (n = 200) was 13.32 ± 2.9 years and the CA was 15.64 ± 3.02 years. In both the genders, the lowest value of mean difference was seen in the age group of 15–15.9 years and a marked difference was seen in the age group of 7–7.9 years.

The modified Demirjian’s Indian specific formulae had underestimated the age with maximum error in the age group of 15–15.9 years similar to various other studies.[15],[16],[17],[18] Underestimation of age by the modified Demirjian’s method may probably be because of cultural and ethnic differences between the populations. Furthermore, it may be because of differences in nutrition, socioeconomic status, and dietary habits in different population groups. Thus, the formulae might not be applicable to the Hyderabad population. Development of Indian weighted maturity scores might increase the accuracy of this method. Although this method of determining the stage of tooth development, no variations were noticed in the interobserver agreeability and intraobserver bias during our study.

When Nolla’s method was used to study the relationship between the DA and CA, the mean DA was 12.74 ± 2.63 years and the CA was 15.64 ± 3.02 years.

The lowest value of mean difference was seen in the age group between 7 and 7.9 years and the highest value of mean difference was seen in the age group between 18 and 18.9 years.

Briffa et al., in 2005, showed that the Nolla’s method overestimated the CA by up to 6 months in boys and underestimated the CA up to 1 year in girls.[19] Shruti et al., in 2014, showed underestimation of age in the group of 9 years and above.[6] Miloglu et al. conducted a study on Turkish males using the Nolla’s method and inferred that the mean difference in the dental and CA ranged from −0.5 to 0.0 years, proving the accuracy of Nolla’s method above any other method of DA estimation. Similar statistics were obtained by Caro and Contreras.[20],[21] The Nolla’s method underestimated the age with maximum error in the age group of 18–18.9 years. The limitation of Nolla’s method is that it can be used in younger age group only.

According to the CVM index method, CS1–CS2 indicated the period before the peak of growth; the pubertal growth spurt comes during CS3–CS4; and CS5–CS6 was the period after the peak. In the present study, there was statistically significant difference between CA s and cervical vertebral maturation stages at P ≤ 0.01 in the overall sample of 200. These results suggested that girls had a higher predilection toward late dental development when compared to same cervical maturation stages. The main advantage of CVM method that it eliminated radiation exposure as the lateral cephalogram is routinely used for diagnosis and treatment planning in orthodontic clinics, thus complying with as low as reasonably achievable principle. However, cervical vertebral maturation method required longitudinal follow-up for accuracy.

Nolla’s method and modified Demirjian’s method using Indian-specific formulae of age estimation were not found to be accurate in both the age groups in Hyderabad population and also showed a difference between CA s among different cervical vertebral maturational stages. Studies involving larger sample size and a population-specific data for the children of South India for DA estimation should be developed.


   Conclusions Top


The Nolla’s method and modified Demirjian’s method were found not to be reliable methods of DA estimation in Hyderabad population. Conducting the study on a larger sample size and deriving a regressive formula may help in estimating the DA in this population.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

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