ORIGINAL ARTICLE

A practical method for determining pubertal

growth spurt
Trn zer,
a
Jalen Deveciog lu Kama,
b
and Senem Yig it zer
c
Diyarbakir, Turkey
Introduction: It is important to evaluate skeletal maturation in orthodontic treatment. Hand-wrist and cervical
maturation stages have been shown to be correlated with skeletal growth changes during puberty. The
cervical vertebrae have 6 maturation phases, whereas the medial phalange of the third nger has 5 stages;
a modied version has 6 stages. The purpose of this study was to determine the correlation of the cervical
vertebrae maturation index with the modied medial phalange index. Methods: Lateral cephalometric and
left-hand medial phalange radiographs of 150 males between the ages of 9 and 19 who were referred for
orthodontic treatment were examined. Results: The 6 modied medial phalange stages were found to
correlate with the 6 cervical vertebral maturation stages. Conclusions: Because cervical vertebrae stage is
a reliable maturation indicator, the medial phalange of the third nger can be used instead to assess a
subjects skeletal maturation. (Am J Orthod Dentofacial Orthop 2006;130:131.e1-131.e6)
T
he biologic aspects of facial growth are funda-
mentally important in dentofacial orthopedics.
Cephalometric studies indicate that the facial
growth rate is not constant throughout the development
period. The beginning, intensity, onset, and duration of
the pubertal peak of facial growth have great variations
among patients.
1,2
Chronological age, dental development, body weight,
height, menarche, and voice and breast changes have been
shown to be unreliable and impractical for estimating the
pubertal growth spurt.
1-4
Hand-wrist and cervical vertebae maturation (CVM)
stages have been shown to be correlated with skeletal
growth changes during puberty.
1-6
A number of studies
have found close correlations between changes in bone
morphology, density, and epiphyseal-diaphyseal stages
and the pubertal growth spurt.
1-4
Although most studies
used the entire hand and wrist region, the third nger has
also been used. The usefulness of the cervical vertebrae in
estimating pubertal growth has also been the topic of some
studies.
7-9
The use of the cervical vertebrae has the
advantage of not requiring an additional radiograph. Stud-
ies of the CVM stages have shown correlation with the
hand-wrist stages of maturation, which thus provide a
practical means for estimating facial and mandibular
growth. Regardless of the methodhand-wrist, third
nger, or cervical vertebraethey all require longitudinal
follow-up for accuracy. Knowing the stage does not allow
a clinician to determine the timing of maturation with
sufcient accuracy. This is particularly important for girls
because they have shorter pubertal spurts and complete
their growth earlier than do boys.
Hgg and Taranger
1
used the medial phalanges of
the third nger (MP3) to determine the pubertal growth
spurt. They primarily used the developmental changes
in the epiphyseal region of the third nger. Rajagopal
and Kansal
10
added an additional bone stage to the
method of Hgg and Taranger
1
: the MP3-HI, which
occurs between MP3-H and MP3-I and reects changes
in the metaphyseal region of the third nger.
The purpose of this study was to determine the
correlation of the 6 CVM stages of Kkkeles et al
7
with the 6 modied MP3 stages of Hgg and Taranger
1
and Rajagopal and Kansal.
10
SUBJECTS AND METHODS
One hundred fty patients, 9 to 19 years of age,
were selected at random from 300 male patients re-
ferred for orthodontic treatment. They had not under-
gone orthodontic treatment. Those with anomalies of
the ngers or the vertebrae were excluded. Two pa-
tients reported that they had broken their hands, and, in
1 patient, the sternocleidomastoid muscle was short;
they were also excluded. Radiographs of high clarity
and good contrast were used.
For the medial phalange radiograph, the patients
left hand was placed on the table of a standard
a
Assistant professor, Faculty of Dentistry, Department of Orthodontics, Uni-
versity of Dicle, Diyarbakir, Turkey.
b
Professor, Faculty of Dentistry, Department of Orthodontics, University of
Dicle, Diyarbakir, Turkey.
c
Department of Endodontics, Oral Health Center, Diyarbakir, Turkey.
Reprint requests to: Trn zer, Faculty of Dentistry, Department of Orthodontics,
University of Dicle, 21280 Diyarbakir, Turkey; e-mail, torun@dicle.edu.tr.
Submitted, October 2005; revised and accepted, January 2006.
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.01.019
131.e1
periapical x-ray machine. The cone was directed to the
MP3 perpendicularly and touched the nger slightly.
The criteria of Rajagopal and Kansal
10
were used to
evaluate these radiographs.
Lateral cephalograms were taken in natural head
position by using standard procedures, with the patient
standing erect and looking straight into his or her own
eyes in a mirror on the wall. The criteria of Lamparski
8
were used.
Comparative evaluation of the modied MP3 stages
and the CVM index (CVMI) produced the following
ndings. Figure 1 shows the rst maturation stage of
the cervical vertebrae and medial phalange of the third
nger.
MP3-F stage: start of the pubertal growth spurt
These features were observed by Hgg and
Taranger.
1
1. Epiphysis is as wide as metaphysis.
These additional features were observed in this
study as described by Rajagopal and Kansal.
10
2. Ends of epiphysis are tapered and rounded.
3. Metaphysis shows no undulation.
4. Radiolucent gap (representing cartilageous epiphy-
seal growth plate) between epiphysis and metaph-
ysis is wide.
CVMI-1: initiation stage of cervical vertebrae
1. C-2, C-3, and C-4 inferior vertebral body borders
are at.
2. Superior vertebral borders are tapered from poste-
rior to anterior (wedge shape).
3. 80% to 100% of pubertal growth remains.
Figure 2 shows the second maturation stage of
cervical vertebrae and medial phalange of the third
nger.
MP3-FG stage: acceleration of the pubertal growth
spurt
These features were observed by Hgg and
Taranger.
1
1. Epiphysis is as wide as metaphysis.
Fig 1. First maturation stage of cervical vertebrae and
medial phalange of third nger.
Fig 2. Second maturation stage of cervical vertebrae
and medial phalange of third nger.
Fig 3. Third maturation stage of cervical vertebrae and
medial phalange of third nger.
American Journal of Orthodontics and Dentofacial Orthopedics
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131.e2 zer, Kama, and zer
2. Distinct medial or lateral border of epiphysis
forms line of demarcation at right angle to distal
border.
These additional features were observed in this
study as described by Rajagopal and Kansal.
10
3. Metaphysis begins to show slight undulation.
4. Radiolucent gap between metaphysis and epiphysis
is wide.
CVMI-2: Acceleration stage of cervical vertebrae
1. Concavities develop in the lower borders of C-2
and C-3.
2. Lower border of C-4 vertebral body is at.
3. C-3 and C-4 are more rectangular in shape.
4. 65% to 85% of pubertal growth remains.
Figure 3 shows the third maturation stage of cervi-
cal vertebrae and medial phalange of the third nger.
MP3-G stage: maximum point of pubertal growth
spurt
These features were observed by Hgg and
Taranger.
1
1. Sides of epiphysis have thickened and cap its metaph-
ysis, forming sharp distal edge on at least 1 side.
These additional features were observed in this
study as described by Rajagopal and Kansal.
10
2. Marked undulations in metaphysis give it Cupids
bow appearance.
3. Radiolucent gap between epiphysis and metaphysis
is moderate.
CVMI-3: transition stage of cervical vertebrae
1. Distinct concavities are seen in lower borders of
C-2 and C-3.
2. Concavity is developing in lower border of C-4.
3. C-3 and C-4 are rectangular in shape.
4. 25% to 65% of pubertal growth remains.
Figure 4 shows the fourth maturation stage of
cervical vertebrae and medial phalange of the third
nger.
Fig 4. Fourth maturation stage of cervical vertebrae
and medial phalange of third nger.
Fig 5. Fifth maturation stage of cervical vertebrae and
medial phalange of third nger.
Fig 6. Sixth maturation stage of cervical vertebrae and
medial phalange of third nger.
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zer, Kama, and zer 131.e3
MP3-H stage: deceleration of the pubertal growth
spurt
These features were observed by Hgg and
Taranger.
1
1. Fusion of epiphysis and metaphysis begins.
These additional features were observed in this
study as described by Rajagopal and Kansal.
10
2. At least 1 side of epiphysis forms obtuse angle to
distal border.
3. Epiphysis is beginning to narrow.
4. Slight convexity is seen under central part of
metaphysis.
5. Typical Cupids bow appearance of metaphysis is
absent, but slight undulation is distinctly present.
6. Radiolucent gap between epiphysis and metaphysis
is narrower.
CVMI-4: deceleration stage of cervical vertebrae
1. Distinct concavities are seen in lower borders of
C-2, C-3, and C-4.
2. C-3 and C-4 are nearly square in shape.
3. 10% to 25% of pubertal growth remains.
Figure 5 shows the fth maturation stage of cervical
vertebrae and medial phalange of the third nger.
MP3-HI stage: maturation of the pubertal growth
spurt
These features of this new stage were observed in
this study as described by Rajagopal and Kansal.
10
1. Superior surface of epiphysis shows smooth con-
cavity.
2. Metaphysis shows smooth, convex surface, almost
tting into reciprocal concavity of epiphysis.
3. No undulation is present in metaphysis.
4. Radiolucent gap between epiphysis and metaphysis
is insignicant.
CVMI-5: maturation stage of cervical vertebrae
1. Accentuated concavities of C-2, C-3, and C-4
inferior vertebral body borders are observed.
2. C-3 and C-4 are square in shape.
3. 5% to 10% of pubertal growth remains.
Figure 6 shows the sixth maturation stage of cervi-
cal vertebrae and medial phalange of the third nger.
MP3-I stage: end of pubertal growth spurt
These features were observed by Hgg and
Taranger.
1
1. Fusion of epiphysis and metaphysis are complete.
These additional features were observed in this
study as described by Rajagopal and Kansal.
10
2. No radiolucent gap exists between metaphysis and
epiphysis.
3. Dense, radiopaque epiphyseal line forms integral
part of proximal portion of middle phalanges.
CVMI-6: completion stage of cervical vertebrae
1. Deep concavities are present in C-2, C-3, and C-4
inferior vertebral body borders.
2. C-3 and C-4 are greater in height than in width.
3. Pubertal growth is complete.
Statistical analyses of the data were performed by
kappa test with software (SPSS for Windows, release
10.0, SPSS, Chicago, Ill).
RESULTS
For reliability and reproducibility of the assessment
of the CVM stages, the percentage of interoperator
agreement was 98%; the staging performed by 2
operators (T.. and J.D.K.) did not agree in 3 obser-
vations. For the MP3 observations, interoperator agree-
ment was 96.6%; this means that 5 observations did not
agree. Intraoperator agreement was assessed by reeval-
uating the radiographs 3 weeks later. One lm was
observed differently; thus, intraoperator agreement was
99.3%.
The CVM stages and MP3 maturational phases had
89.3% agreement (Table). The distribution is seen in
Figure 7. The CVMI-1 and MP3-F phases, and the
CVMI-6 and MP3-I phases demonstrated 100% agree-
ment. These are the rst and last stages; this means that
they are more accurate than the others. In the other
stages, some borderline cases blend into each other.
DISCUSSION
Determination of maturation and subsequent eval-
uation of growth potential are extremely important. Our
goal was to evaluate the validity of a new and practical
method, which consisted of changes in the MP3, to
assess mandibular skeletal maturation.
Skeletal maturation can be assessed from lateral
cephalometric radiographs. Cervical vertebrae show
different shapes at each skeletal development level.
Many researchers have reported that the cervical ver-
tebrae method is a reliable maturational indicator.
8,11,12
Tanner et al
13
classied ossication in hand-wrist
Table. Similarity between CVM stages and MP3 mat-
urational phases
Subjects (n) Percentage (%)
Similar 134 89.3
Dissimilar 16 10.7
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131.e4 zer, Kama, and zer
radiographs with the TW2 method. Hgg and Tar-
ranger
1
introduced the 5 maturation stages of the hand
and wrist; these were modied from the classication
of Tanner et al
13
as a reliable biologic indicator of
facial growth. Chapman
14
was the rst to use dental
radiographs to determine the ossication of the ulnar
cecamoid. Abdel-Kader
15
used dental radiographs to
assess the maturation stages of the MP3.
Determining residual growth is an important factor in
orthodontic treatment. Sometimes the whole treatment
plan depends on the growth factor. It is not always
possible to take lateral cephalometric radiographs, and it is
more advantageous to take periapical radiographs than
lateral cephalograms. The third-nger lmstill requires an
additional procedure, but taking a periapical radiograph
instead of a hand-wrist radiograph is practical, easy, and
less expensive when a cephalometric radiograph is not the
standard radiograph in orthodontic treatment.
We found the 6 CVM stages to be strictly correlated
with the 6 modied maturation stages of the third
nger, but skeletal maturation is a continuing process.
We divided cervical vertebrae and third-nger maturity
into 6 groups. Each maturation stage blends into the
next, and it is difcult to classify in some borderline
cases. There can be mistakes, but these should not be of
great clinical importance. The stage does not always
determine the exact timing of maturation accurately.
This is particulary important in girls because they have
shorter pubertal spurts and complete their growth ear-
lier than do boys.
CONCLUSIONS
This study has shown that the 6 modied stages of
the MP3 are correlated to the stages of CVM and thus
can be another useful method to assess a patients
skeletal maturation.
Growth, particularly during puberty, is of value in
the treatment of skeletal deviations regardless of the
exact mechanism of correction. Therefore, any method
that might help identity growth acceleration or decel-
eration is helpful.
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