European Journal of Cardiovascular Medicine

Numerous factors, including genetic, ethnic, dietary, hormonal, environmental, and climatic conditions, affect an individual's development [1,2]. Numerous techniques, including chronological age, biological age, morphologic age, skeletal age, dental age, circumpubertal age, behavioural age, mental age, and self-concept age, can be used to establish an individual's age, according to Stewart RE and Barber TK [2]. The most obvious and straightforward way to calculate a child's developmental age is by using their date of birth. However, as developmental stages differ from person to person, chronological age is not a reliable indicator of stage of development [2, 3]. As a result, attempts were undertaken to ascertain the developmental age of a child through the use of skeletal age (skeletal maturation) and dental age (calcification of teeth). Two concepts, tooth emergence and tooth calcification, can be used to estimate dental age. Of these, tooth calcification stages are thought to be a more reliable predictor than tooth emergence because they are less affected by systemic and local causes [3–7]. Using Demirjian's approach, dental age was estimated based on calcification stages. The radiographic and schematic depictions of tooth development and simplicity that make this method the most widely regarded [4,8].

On the other hand, distinct ossification phases and a distinctive pattern of ossification progression of epiphyseal centres establish skeletal age [9]. Fishman LS suggested using the cervical vertebrae in lateral cephalograms and the ossification sites visible in hand and wrist radiographs [10]. However, for a variety of reasons, including radiation exposure, high cost, large equipment, and the visibility of the vertebra, its use in paediatric patients is minimal [10,11].

Abdel Khader HM was the first to assess the validity of MP3's five phases using intraoral periapical radiography [12]. Rajagopal R and Kansal S improved the MP3 technique further by adding the MP3HI stage [13]. It's common knowledge that a child's developmental stage doesn't always correspond with their actual age. But when it comes to determining an individual's developmental stage, dental and skeletal age have stronger relationships and are more accurate and dependable than chronological age [14, 15]. The dental ages of the study subjects were compared to their chronological ages.

For this cross-sectional study, 400 patients between the ages of 6 and 14 who saw the outpatient department of forensic medicine at Government Medical College Anantapuramu, Andhra Pradesh, India between May 2022 and April 2023 were screened. The study comprised well-fed Indian children with pure ancestral lineage from India who required skeletal maturity evaluation for orthodontic assessment.

Statistical Analysis

SPSS version 17.0 was used by a lone assessor to log the data and do statistical analysis on it. Pearson's and Spearman's tests were used to examine the relationship between the research population's chronological age, dental age, and skeletal age. To guarantee the correctness of the results, twenty subjects were chosen at random and remeasured by a third researcher who was unaware of the first findings. The values that each researcher obtained varied very little or not at all.

The investigation's findings demonstrated a statistically significant relationship between the MP3 skeletal stages, dental age (as determined by the Demirjian method), and the patients' chronological age. In males, there was a substantial association between all MP3 stages and age, both biological and dental. With the exception of a strong but non-significant association between dental age and chronological age in the H stage of the middle phalanx's ossification in the MP3 region, the circumstances in females were essentially the same as those in males. The ossification stages of the middle phalanx in the MP3 region and the continuous variables of dental age and chronological age exhibited a strong positive Spearman's correlation in males, whereas it was less pronounced but still significant in females.

Table 1: The relationship between chronological age and dental age

To facilitate tracking, each x-ray was assigned a unique identification number. By deducting the patients' birth dates from the radiograph date, the chronological ages of the patients were determined. Extraoral pictures were obtained using a digital panoramic radiography machine with exposure times of 8 MA, 71 kvp, and 14.1 seconds. Letter grades ranging from A to H were given to the patient's seven permanent teeth on the left side of the jaw. For each developmental stage, the scores were calculated by comparing dental blueprints to x-rays using Demirjian's criterion. The ratings were translated into scores using Demirjian's normative tables for girls and boys.

The total maturity score was calculated by adding the seven teeth. The Demirjian normative tables for girls and boys can be used to convert this maturity score into dental age with ease. The modified MP3 approach was established in this inquiry using an MP3 radiograph; this kind of digital radiography uses exposure parameters of 8 MA, 70 kvp, and 0.32 seconds.

Accurate age assessment is beneficial to the medical and dentistry communities since it facilitates the identification of age-related illnesses and ailments. Accurately determining the patient's age and developmental stage is crucial for early correction of bone and dental deformities in children. This information also influences the treatment plan and its overall outcome. In the current study, the child's chronological age was ascertained using the birth date (found in the birth documents). It was computed by subtracting the birthdate from the radiography exposure date. To make statistical calculations based on annual age estimates simpler, decimals were used. Dental age was determined using the Demirjian method, whereas skeletal age was determined using digital radiography and a modified MP3 methodology [14].

Skeletal age is thought to be more precise and dependable than chronological age since ossification changes in bone form and size may be immediately viewed. Although the technique created by Fishman LS, which makes use of the four stages of bone maturation at six anatomic sites on the hand and wrist, is gaining popularity, there are worries over the increased radiation exposure. Goto S et al. employed the degree of ossification of the distal phalanx of the first digit to determine whether or not an individual will continue to grow and develop properly following radiation exposure. Abdel-Kader HM evaluated skeletal development using these MP3 phases that were evident on IOPA films. He then enumerated the advantages of digital radiography over conventional radiography, which included shorter exposure times (5x faster) and the lack of darkroom operations (better image clarity). Another principle of this approach is As Low as Reasonably Achievable [15].

This study aims to clarify the controversy concerning the relationship between skeletal and dental development by analysing children's chronological, dental, and skeletal ages. In their study of Ohioan youngsters, Lewis AB and Gran SM could not find a statistically significant difference between skeletal and dental maturation. However, Sierra A. M. discovered a strong association between dental and skeletal age in a study including 153 Caucasian children aged 8 to 12 who were undergoing orthodontic treatment [16].

In the current study, there was a significant statistical significance between skeletal age, dental age, and chronological age among male participants. Hegde RJ and Sood PB reached the same conclusions when comparing dental age to chronological age. According to a study by Uysal T et al., there is a strong link between the stages of tooth calcification and skeletal maturation. This suggests that the stages of dental calcification could have therapeutic significance as a maturity indicator for pubertal growth. A substantial link was identified between dental and skeletal age in another study involving eighty-one children between the ages of eight and fourteen [17].

With the exception of the H stage of MP3, the current study showed a statistically significant relationship between the chronological age, dental age, and skeletal age in females. Compared to boys, females acquired skeletal maturity later, but before they reached chronological and dental ages. Studies on 500 Turkish children by Uysal T. et al. and Soegiharto BM. et al. show that girls usually reach maturity before boys. However, research by Chertkow S. and Paul F. on 140 Caucasian children and Krailassiri S. et al. on 261 Thai participants found no statistically significant difference between the sexes. Based on the association between dental and skeletal age, there was a significant difference between the HI and I phases in boys and girls [18]. The average chronological ages of boys and girls in the Mangalore community changed according to MP3 stages, according to research by Madhu S et al. The gap could be explained by variations in the population's age, ethnicity, nutrition, and measurement technique.

Using a sample of kids aged 6 to 14, the researchers applied Demirjian's method and discovered that it was very accurate, with an overestimation of only 0.63 years for boys and 0.59 years for girls. The researchers Hegde RJ and Sood PB found 0.14 years of overestimation, Koshy S and Tandon S found 3.04 years, Prabhakar AR et al. found 1.20 years, and women found 0.04 years. The age estimated by Demirjian's method may be overestimated due to differences in diet, social position, ethnicity, and standard tables created for the French-Canadian community [19].

While many research have been done to test the existence of a relationship between dental age, skeletal age, and chronological age, very few of these studies have been published in the literature. Even though age can be easily calculated, development cannot be accurately predicted by age alone. It is questionable whether the Demirjian approach is helpful and widely accepted in cases of anodontia, ethnic discrepancy, and differences in age estimation across geographic locations, despite its excellent reproducibility and dependability. Skeletal age assessment methods with a high degree of accuracy in determining an individual's growth status can be selected because a basic digital radiograph of MP3 can be selected that meets all requirements, such as easy estimation, reliability, good reproducibility, and low radiation exposure in compliance with the ALARA principle. Skeletal age and dental age have a high link, however this does not mean that it is the only reliable indication of growth. While there isn't a universally accepted way to calculate an individual's age, dental calcification stages could be a helpful addition to skeletal maturity [20].

Researchers have looked into dental and skeletal ages as viable alternatives to chronological age as a measure of maturity due to the constraints of chronological age. For both sexes, there was a significant relationship between dental age and chronological age. In the sample employed for this investigation, the HI and I phases of MP3 showed statistically different correlations between dental age and chronological age, with females maturing earlier than males. The suggested technique of utilising MP3 in conjunction with digital radiography may enable the determination of bone age more precisely, conveniently, and with a reduced radiation exposure.

[1] Kurita LM, Menezes AV, Casanova MS, Neto FH. Dental maturity as an indicator of chronological age: radiographic assessment of dental age in a Brazilian population. J Appl Oral Sci. 2007;15:99-104.

[2] Stewart RE, Barber TK. Pediatric dentistry, 1st ed. USA, CV. Mosby Company.

[3] Warhekar AM, Wanjari PV, Phulambrikar T. Correlation of radiographic and  chronological age in human by using Demirjian’s method: A radiographic study.  J Indian Acad Oral Med Radiol. 2011;23:01-04.

[4] Demirjian A, Goldstein H, Tanner M. A new system of dental age assessment.  Human Biology. 1973;45:211-27.

[5] Basran G, Ozer T, Hamamci N. Cervical vertebral and dental maturity in Turkish  subjects. Am J Orthod Dentofac Orthop. 2007;131:447.e13-20.

[6] Ogodescu AE, Ogodescu A, Szabo K, Tudor A, Bratu E. Dental maturity-a biologic indicator of chronological age: Digital radiographic study to assess  dental age in Romanian children. International Journal of Biology and Biomedical Engineering. 2011;5:32-39.