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237]

Original Article

Correlation of Chronological, Skeletal, and Dental Age in North

Indian Population
Madhurima Nanda, Anil Singla1, Vinod Sachdev2, Harupinder Singh Jaj1
Department of Orthodontics and Dentofacial Orthopaedics, ITS Dental College, Greater Noida, 1Department of Orthodontics and Dentofacial Orthopaedics,
Himachal Dental College, Sundernagar, 2Department of Pedodontics and Preventive Dentistry, ITS Dental College, Muradnagar-ghaziabad, Uttar Pradesh, India

Abstract
Aim and Objectives: The aim of the study was to find out the correlation between chronological, dental, and skeletal age.
Materials and Methods: Lateral cephalograms and orthopantomograms of 100 subjects of age ranging 9–14 years were obtained for the
estimation of skeletal and dental age. Dental age was assessed using Demirjian’s method; skeletal age was assessed using the new improved
version of the cervical vertebral maturation method given by Baccetti, Franchi, and McNamara. Statistical analysis was carried out. Student’s
t‑test and Spearman’s coefficient correlation were used to assess the relation between chronological, skeletal, and dental age. Results: The
Spearman’s correlation coefficient was 0.777 (P < 0.001) between chronological and dental age, 0.516 (P < 0.001) between chronological and
skeletal age, and 0.563 (P < 0.001) between dental and skeletal age. Conclusion: There is a good correlation between chronological and dental
age in North Indian population which was higher for males as compared to females. A moderate correlation was found between chronological
and skeletal age as well as between dental and skeletal age.

Keywords: Cervical vertebral maturation method, chronological age, Demirjian’s method, dental age, skeletal age

Introduction It has long been recognized that an individual’s chronological

Timing is a fundamental part of treatment planning in
orthodontics, with special regard to dentofacial orthopedics.
Initiating treatment in a growing patient at the right time has
demonstrated significant favorable effects in the correction
of disharmonies in all the three planes of space.[1] To initiate
proper treatment at the right time, it is important to determine
the accurate age of the patient. Age at the onset of puberty
varies from individual to individual and differs with sex,
heredity, population, nutritional, metabolic, and environmental
factors.[2] Various methods to assess the age or maturation status
of an individual are sexual maturation characteristics, height,
weight, chronological age, skeletal development, and dental
development.[3] Several studies have described the correlation
between various methods of age assessment so as to establish
the most effective time for initiating orthodontic treatment in
children.[1‑6]
Somatic maturity and sexual maturity indicators have limited
value for the immediate clinical judgment of a patient’s
maturity stage because these indicators can be applied only
after the serial recording of height or the inception of puberty.[3]
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age does not correlate well with maturational age. Skeletal age
may be retarded or advanced from the actual chronological
age.[6,7]
Skeletal maturation refers to the degree of the development
of ossification in bone.[8] Various areas of the skeleton have
been used: the foot, ankle, hip, elbow, hand–wrist, and the
cervical vertebrae. Hand–wrist radiographs have proved to
be a valuable diagnostic tool in orthodontics.[9,10] Skeletal
maturation assessed on hand–wrist radiographs is considered
as the best indicator of maturity[11] and has been found to be
closely associated with the growth spurt. However, the routine
use of hand–wrist radiographs for assessing the pubertal growth
has raised concerns regarding the radiation safety.[6,12] The
advantage of using   cervical vertebrae maturation  (CVMS)
is that no extra radiation exposure is required since lateral
Address for correspondence: Dr. Madhurima Nanda,
Department of Orthodontics, ITS Dental College, Greater Noida, India.
E‑mail: madhurimananda@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

DOI: How to cite this article: Nanda M, Singla A, Sachdeva V, Jaj HS.
10.4103/IJDS.IJDS_68_17 Correlation of chronological, skeletal, and dental age in North Indian
population. Indian J Dent Sci 2017;9:S13-20.

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Nanda, et al.: Correlation of chronological, skeletal and dental age
cephalometric radiograph is routinely required for orthodontic
diagnosis and treatment planning.[6]
Another measure of assessing physiologic maturation is dental
maturity. It is used to estimate the physiological maturity due
to ease of recognition of dental developmental stages, together
with the availability of periapical or panoramic radiographs
in most orthodontic practices.[3] Dental maturity can be
determined by the stage of tooth eruption or by the stage of
tooth formation.[3,5,13‑15] Tooth formation has been found to be
a more reliable criterion for determining dental maturation.[16]
The most widely used method for the estimation of dental age
is the method given by Demirjian et al.[14] in 1973.
The purpose of our study, therefore, is to find out the correlation
between chronological age, skeletal age, and dental age in a
North Indian population so that an appropriate method of age
estimation can be determined and proper treatment instituted
timely.
Materials and Methods
The study was carried out in the Department of Orthodontics
and Dentofacial Orthopaedics of Himachal Dental College
and Hospital, Sunder Nagar (Himachal Pradesh). The sample
consisted of 100 pretreatment records (panoramic radiographs,
lateral cephalometric radiographs, and history) of patients
visiting the dental outpatient department in the age group of
9–14 years. The selection criteria included subjects with:
• North Indian ethnicity
• Patients without any systemic diseases those affecting
normal growth and development of the bone and teeth
• No history of previous orthodontic treatment
• No congenital or acquired malformations of the skeletal
or dental origin.
All radiographs were taken with the same X‑ray equipment
(Planmeca EC Proline 2002).
Assessment of chronological age
The chronological age of the patient was taken as told by the
patient.
Assessment of skeletal age
The lateral profile changes of the second, third, and fourth cervical
vertebrae were assessed and assigned the CVM stage using the
new improved version of the CVM method given by Baccetti
et al.[4] in 2002 [Table 1 and Figure 1]. The advantages of the new
version of the CVM method are that mandibular skeletal maturity
can be appraised on a single cephalogram and through the analysis
of only the second, third, and fourth cervical vertebrae. Definition
of CVM at each developmental stage allows the clinician to apply
the information derived from a single lateral cephalogram and
avoids the definition of stages based on comparative assessment
between stage changes as was in the previous methods.[4,6]
Assessment of dental age
Dental age was assessed using the method given by Demirjian
et al.[14] which is based on the scoring of the developmental stage
S14
Table 1: Cervical vertebral maturation stages (improved
version of the cervical vertebral maturation method given
by Baccetti, Franchi and Mc Namara)
Stages Features
CVMS I The lower borders of all the three vertebrae are flat, with
the possible exception of a concavity at the lower border
of C2 in almost half of the cases
The bodies of both C3 and C4 are trapezoid in shape
(the superior border of the vertebral body is tapered from
posterior to anterior
CVMS II Concavities at the lower borders of both C2 and C3 are
present
The bodies of C3 and C4 may be either trapezoid or
rectangular horizontal in shape
CVMS III Concavities at the lower borders of C2, C3, and C4 now
are present
The bodies of both C3 and C4 are rectangular horizontal
in shape
CVMS IV The concavities at the lower borders of C2, C3, and C4
still are present
At least one of the bodies of C3 and C4 is squared in
shape. If not squared, the body of the other cervical
vertebra still is rectangular horizontal
CVMS V The concavities at the lower borders of C2, C3, and C4
still are evident
At least one of the bodies of C3 and C4 is rectangular
vertical in shape. If not rectangular vertical, the body of
the other cervical vertebra is squared
CVMS: Cervical vertebrae maturation stage
Figure 1: Lateral cephalogram showing cervical vertebrae maturation
stages
of the seven left permanent mandibular teeth. The method’s
criterion consists of distinct details based on shape criterion
and proportion of root length, using the relative value to crown
height, rather than on absolute length. Hence, foreshortening
or elongated projections of developing teeth will not affect the
reliability of assessment [Table 2 and Figures 2‑5].
Statistical analysis
The correlation between chronologic, dental, and skeletal age
was assessed by Student’s t‑test and Spearman’s correlation
coefficient, using SPSS software (IBM Corporation,
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Nanda, et al.: Correlation of chronological, skeletal and dental age

Chicago, USA). Paired t‑test was done to find the means correlation was found between the two with a value of 0.516
and standard deviation of chronological and dental age and which is statistically significant. Furthermore, a positive
to find the correlation between the two. Spearman’s test was correlation was found between skeletal age and dental age
performed to find out the correlation between chronological, with a value of 0.563 [Table 7 and Figure 8].
dental, and skeletal age and also separately for males and
females. The results suggest a stronger correlation between
chronological and dental age r as compared to correlation
between chronological and skeletal age and between skeletal
Results
and dental age.
The frequency distribution for age and sex are shown in
Table 3, Figures 6 and 7. Means,standard deviations ,mean
and standard difference and significance values are shown
in Tables 4-6. When the correlation was tested between the
chronological and dental age, a good correlation with a value
of 0.777 was found which is statistically significant [Table 7
and Figure 8]. A higher correlation was found in males (0.835)
as compared to females (0.743) [Table 7 and Figure 9]. The
correlation was also calculated between chronological age
and skeletal age using Spearman’s coefficient, and a fair

Table 2: Developmental stages of teeth (Demirjian et al.)

Stages Features Figure 2: Panoramic radiograph showing Demirjian’s stages of tooth
Stage A Calcification of single occlusal points without fusion of development
different calcifications
Stage B Fusion of the calcified points forms one or several cusps
which unite to give a regularly outlined occlusal surface
Stage C Enamel formation has been completed at the occlusal surface
and dentin formation has commenced
The pulp chamber is curved, and no pulp horns are visible
Stage D Crown formation has been completed to the level of the
amelocemental junction. Root formation has commenced
The pulp horns are beginning to differentiate, but the walls of
the pulp chamber remain curved
Stage E The root length remains shorter than the crown height. The
walls of the pulp chamber are straight, and the pulp horns
have become more differentiated than in the previous stage
In molars, the radicular bifurcation has commenced to calcify
Stage F The walls of the pulp chamber now form an isosceles
triangle, and the root length is equal to or greater than the
crown height Figure 3: Demirjian’s developmental stages
In molars, the bifurcation has developed sufficiently to give
the roots a distinct form
Stage G The walls of the root canal are now parallel, but the apical
end is partially open
In molars, only the distal root is rated
Stage H The root apex is completely closed (distal root in molars).
The periodontal membrane surrounding the root and apex is
uniform in width throughout

Table 3: Frequency distribution of subjects for age group

by sex
Age Sex distribution
Male Female Total
9‑11 years 23 27 50
12‑14 years 26 24 50
Total 49 51 100 Figure 4: Demirjian’s score table based on developmental stage of teeth

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Nanda, et al.: Correlation of chronological, skeletal and dental age

Figure 5: Conversion of maturity score to dental age

Figure 6: Sample distribution based on age groups

Figure 7: Pie diagram representing sex distribution

Table 4: Means and standard deviations of chronological
and dental age In the 12–14‑year age group, a significant correlation
SEX AGE Means n SD SEM was found between chronological and dental age  (0.497)
Sex Chronological age 11.52 100 1.586 0.159 whereas the correlation between chronological and skeletal
Dental age 11.385 100 2.1110 0.2111 age  (0.205) as well as between skeletal and dental age was
Male Chronological age 11.41 51 1.525 0.214 nonsignificant (0.261).
Dental age 11.575 51 2.0089 0.2813
Female Chronological age 11.63 49 1.654 0.236
These results indicate that the correlation decreases as the age
Dental age 11.188 49 2.2157 0.3165 of an individual increases.
SD: Standard deviation, SEM: Standard error of mean
Discussion
The correlations were also compared among the two age Accurate age estimation is considered to be of great
groups, i.e., between 9–11 years and 12–14 years using the importance in dental and medical practices. It is of particular
Spearman test only [Table 8 and Figure 10]. interest to the orthodontist as information aids in diagnosis
It was found that, in the 9–11‑year age group, correlation and treatment planning.
between chronological and dental age (0.730) and between There are various methods for the evaluation of CVM. In this
skeletal and dental age  (0.504) was significant whereas study, the cervical vertebral development was evaluated using
it was nonsignificant between chronological and skeletal the new improved version of the CVM method by Baccetti
age (0.271). et al.[4] in 2002.

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Nanda, et al.: Correlation of chronological, skeletal and dental age

Table 5: Mean difference and standard deviation between chronological and dental age
Paired differences t df P
Mean SD SEM 95% CI of the difference
Lower Upper
Chronological age‑estimated dental age 0.1350 1.3248 0.1325 −0.1279 0.3979 1.019 99 0.311
SEM: Standard error mean, CI: Confidence interval, SD: Standard deviation

Table 6: Correlation between chronological and dental age

Age n Correlation Significant
sex Chronological age and 100 0.779 0.000
estimated dental age
Male Chronological age and 49 0.817 0.000
estimated dental age
Female Chronological age and 51 0.761 0.000
estimated dental age

Dental age is of particular interest to the orthodontist in

planning treatment of different types of malocclusion in
relation to maxillofacial growth. The method of assessment
of dental age by tooth mineralization is more accurate as tooth
mineralization is a constant, ongoing process and eruption
may be influenced by local factors: ankylosis, early or delayed
extraction of the deciduous tooth, impaction, and crowding of
the permanent teeth.[14,16] Panoramic radiographs were used
because they are easier to take than intraoral radiographs
in young or nervous children; they give less radiation for
a full mouth radiograph, and the picture of the mandibular
region they produce is little distorted.[14] However, the left
mandibular teeth are seen more clearly and have been widely
used to assess the degree of calcification.[14,17] The most
widely used method,[3,12,17] by Demirjian et  al.,[14] is being
used in this study.
The present study represents a basic cross‑sectional
investigation to establish the relationship between the dental
age, skeletal age, and chronological age in a sample of North
Indian population.
The correlation between the dental age and chronological
age was found to be good with a value of 0.779. The findings
confirm with the findings of the studies done earlier by
Green,[5] Ogodescu et  al.,[18] Różyło‑Kalinowska et  al.,[19]
Hegde and Sood,[20] Rai et al.,[21] and Mittal et al.[22] Further, the
correlation was found to be more in males (0.835) as compared
to females (0.761). The findings are supported by the study
conducted by Różyło‑Kalinowska et al.[19] in Polish children,
in which correlation in males was slightly more in comparison
to females. The correlations when compared between the two
age groups (9–11 years and 12–14 years) included in the study
was found to be more in the age group of 9–11 years (0.730)
as compared to the 12–14 years (0.497). This tendency for the
scoring system to be less accurate in the older age groups is a
common finding in the previous studies.[23] The longer duration
of the late stages of tooth development compared with the
earlier may in part explain this observation.
Figure 8: Correlation between chronological, dental and skeletal age
In the present study, a moderate correlation (0.563) was seen
between dental and skeletal age. The value was more for
females (0.551) as compared to males (0.513). Our findings
confirm with the study done by Różyło‑Kalinowska et al.[19] in
Polish children in whom moderate but significant correlations
were found between dental calcification and skeletal
maturation based on CVM method. A greater correlation seen
in females in our study corroborates with findings of other
studies done on Indian population by Rai,[21] Gupta et al.,[23]
and Mittal et al.[22] Varying results have been seen in literature
pertaining to skeletal and dental age. Lack of concordance may
result, at least in part, from differences in evaluation methods
of dental and skeletal maturity. Discrepancies in the number,
age, and racial background of the studied subjects conditioned
by ethnic origin, climate, nutrition and socioeconomic status,
and industrialization are the main reasons for variability
in many studies.[15] Furthermore, when the correlation was
compared for different age groups, a positive correlation
was seen in the younger age group, i.e., 9–11 years (0.504)
as compared to the older age group (0.261) again confirming
the low applicability of Demirjian et al.[14] method in older
age groups.
The correlation found between chronological and skeletal age
in our study is moderate but significant (0.516). Furthermore,
the significance is more for females as compared to males.
This is in accordance with the studies conducted by Alkhal
et al.[6] and Uysal et al.,[12] in which significant correlation is
seen between chronological age and CVM and the correlation
values are more for females as compared to males.
A review of correlation coefficients in this study indicates that
the degree of association was closer between chronological

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Nanda, et al.: Correlation of chronological, skeletal and dental age

Table 7: Correlation between chronological, dental and skeletal age

Spearman's test Correlation coefficient Skeletal age (CVMS stage) Chronological age Estimated dental age
Spearman’s rho Skeletal age (CVMS stage)
Correlation coefficient 1.000 0.516** 0.563**
Significant (two‑tailed) ‑ 0.000 0.000
n 100 100 100
Chronological age
Correlation coefficient 0.516** 1.000 0.777**
Significant (two‑tailed) 0.000 ‑ 0.000
n 100 100 100
Estimated dental age
Correlation coefficient 0.563** 0.777** 1.000
Significant (two‑tailed) 0.000 0.000 ‑
n 100 100 100
Spearman’s Skeletal age (CVMS stage)
rho (female) Correlation coefficient 1.000 0.591** 0.551**
Significant (two‑tailed) - 0.000 0.000
n 51 51 51
Chronological age
Correlation coefficient 0.591** 1.000 0.743**
Significant (two‑tailed) 0.000 ‑ 0.000
n 51 51 51
Estimated dental age
Correlation coefficient 0.551** 0.743** 1.000
Significant (two‑tailed) 0.000 0.000 ‑
n 51 51 51
Spearman’s Skeletal age (CVMS stage)
rho (male) Correlation coefficient 1.000 0.506** 0.513**
Significant (two‑tailed) ‑ 0.000 0.000
n 49 49 49
Chronological age
Correlation coefficient 0.506** 1.000 0.835**
Significant (two‑tailed) 0.000 ‑ 0.000
n 49 49 49
Estimated dental age
Correlation coefficient 0.513** 0.835** 1.000
Significant (two‑tailed) 0.000 0.000 ‑
n 49 49 49
CVMS: Cervical vertebrae maturation stage, **Correlation is significant at the 0.01 level (2tailed)

age and dental age than between dental age and skeletal age
or chronological and skeletal age.
The correlation values between chronological and dental age
were also compared with different populations: Polish,[19]
(0.79 for males and 0.77 for females), Davangere[24] (0.94 in males
and 0.95 in females), and Belgaum population[20] (0.985 for males
and 0.988 for females.). The correlation values of dental age and
skeletal age in our population (0.513 in males and 0.551 in females)
were also comparable to other population.[19,22,23] We also
compared the correlation between chronological age and skeletal
age of our population with other ethnic populations: Southern
Chinese[6] (0.757 for males and 0.787 for females) and Turkish
(0.68 in males and 0.82 in females).[12]
The reason for the difference among different populations
is unclear and could be due to population difference.[25] The
differences can also be explained by difference in sample
size, method of age calculation, age groups, the age and sex
distribution of the original study population, and statistical
methodologies. Racial variations in the relationship have been
suggested. Mappes et al.[15] indicated that the predominant ethnic
origin of the population, climate, nutrition, socioeconomic levels,
and urbanization are causative factors of these racial variations.
Conclusion
Following conclusions were drawn from the study:
1. A good correlation was found between chronological and
dental age. The correlation between dental and skeletal
age and between chronological and skeletal age was
also found to be moderate. Furthermore, a decrease in
correlation with age was seen

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Nanda, et al.: Correlation of chronological, skeletal and dental age

Table 8: Correlation between chronological, dental and skeletal age in 9‑11 years and 12‑14 years
Age Spearman's test Correlation coefficient Skeletal age (CVMS stage) Chronological age Estimated dental age
9‑11 Spearman’s rho Skeletal age (CVMS stage)
Correlation coefficient 1.000 0.271 0.504*
Significant (two‑tailed) ‑ 0.057 0.000
n 50 50 50
Chronological age
Correlation coefficient 0.271 1.000 0.730*
Significant. (two‑tailed) 0.057 ‑ 0.000
n 50 50 50
Estimated dental age
Correlation coefficient 0.504* 0.730* 1.000
Significant (two‑tailed) 0.000 0.000 ‑
n 50 50 50
12‑14 Spearman’s rho Skeletal age (CVMS stage)
Correlation coefficient 1.000 0.205 0.261
Significant (two‑tailed) ‑ 0.153 0.068
n 50 50 50
Chronological age
Correlation coefficient 0.205 1.000 0.497*
Significant (two‑tailed) 0.153 ‑ 0.000
n 50 50 50
Estimated dental age
Correlation coefficient 0.261 0.497* 1.000
Significant (two‑tailed) 0.068 0.000 ‑
n 50 50 50
*Correlation is significant at the 0.01 level (two‑tailed). CVMS: Cervical vertebrae maturation stage

Figure 9: Correlation between chronological, dental and skeletal age in

Figure 10: Correlation between chronological, dental and skeletal age in
males and females
9–11-years and 12-14 years

2. When compared for sexes, it was found that the
correlation between chronological and dental age
was more for males as compared to females whereas
correlation between dental and skeletal age as well as
between chronological age and skeletal age was found
to be more for females
3. The good correlation between dental and chronological
age suggests that the dental age can be used to
predict the appropriate chronological age for
orthodontic intervention. However, to know the exact
chronological age from the estimated dental age for
the North Indian population linear regression equation
can be used.
It can be concluded that although various methods of age
assessment are used, the applicability can vary due to the ethnic
differences between populations. Hence, the maturity standards
should be based on studies made on the same population.
Further studies with extensive and large samples are required in
the future to investigate the relationship between chronological,
dental, and skeletal age in North Indian population.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.

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Nanda, et al.: Correlation of chronological, skeletal and dental age
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Indian Journal of Dental Sciences  ¦  Volume 9  ¦  Supplement 1  ¦  2017