Original Article

The Cleft Palate-Craniofacial Journal

1-9
Are Dental Maturation, Skeletal Maturation, ª 2020, American Cleft Palate-
Craniofacial Association

and Chronological Age Associated With Article reuse guidelines:

sagepub.com/journals-permissions
DOI: 10.1177/1055665620944776
Complete Cleft Lip and Palate? journals.sagepub.com/home/cpc

Taner Ozturk, DDS, MDS1 , Husniye Gumus, DDS, PhD2, and

Gulce Ozturk, DDS, MDS2

Abstract
Objective: The relationship between dental and skeletal development levels was determined in individuals with cleft lip and palate
and a control group comprising individuals without cleft lip and palate.
Design: Retrospective, cross-sectional study.
Setting: A university clinic specializing in orthodontic and pedodontic care.
Patients: A total of 198 patients with cleft lip and palate (99 females, 11.66 + 2.36 years; 99 males, 12.44 + 2.33 years) and 198
patients without cleft lip and palate (99 females, 11.88 + 2.26 years; 99 males, 12.99 + 2.25 years).
Interventions: None.
Main Outcome Measures: The Demirjian method and cervical vertebra maturation method were used to evaluate panoramic and
lateral cephalometric radiographs, respectively. The Fishman maturation predictors were determined from hand-wrist
radiographs.
Results: Statistically significant correlations were found between the chronological age and the dental age in both the groups
(P < .05). Significant correlations between skeletal maturation indicators and dental maturation indicators were observed in both
groups and sexes (P < .05), with a stronger correlation among teeth with incomplete dental maturation. Dental age was found to
be significantly lower (female, P ¼ .001; male, P ¼ .001) in individuals with cleft lip and palate (female, 11.71 + 2.58 years; male,
12.51 + 2.62 years) compared to those in the control group (female, 12.95 + 2.47 years; male, 13.64 + 2.37 years).
Conclusions: A high correlation between the results of the evaluated radiographic methods and chronological age supports their
use for accurate age estimation in the patients with cleft lip and palate.

Keywords
cleft lip and palate, dental age, skeletal maturation, dental maturation, chronological age, age estimation

Introduction and adolescence. The degree of physical maturation can be

One of the most common congenital anomalies, cleft lip and
palate (CLP), is observed in 1 of every 500 to 1000 births
(Mossey & Catilla, 2003). While studies have reported on the
craniofacial disorders observed in patients with CLP, few stud-
ies have demonstrated the delayed development that these
patients undergo compared to normal individuals (Aduss,
1971; Van Dyck et al., 2019). The etiology of CLP can be
affected by an individual’s ethnicity and racial type as well
as by geographical, socioeconomic, and environmental factors
(Altunhan et al., 2012).
Chronological age (CA) is not a reliable factor for assessing
the stage of physical development of an individual in childhood
more accurately determined by examining sexual characteris-
tics, and the results of dental examinations and radiographic
analyses (eg, hand-wrist [HW], lateral cephalometric [LC], and
1
Department of Orthodontics, Erciyes University Faculty of Dentistry,
Kayseri, Turkey
2
Department of Pedodontics, Erciyes University Faculty of Dentistry, Kayseri,
Turkey
Corresponding Author:
Gulce Ozturk, Department of Pedodontics, Erciyes University Faculty of
Dentistry, 38039 Melikgazi, Kayseri, Turkey.
Email: gulcecosar@hotmail.com
2 The Cleft Palate-Craniofacial Journal XX(X)
orthopantomographic [OPG] radiographs). In addition, the
relationships among skeletal, somatic, and dental maturity
(ie, dental age [DA]) has been demonstrated in many studies
(Green, 1961; Fishman, 1979; Demirjian et al., 1985; Rai et al.,
2014; Bindayel et al., 2019;). Also, in a study by Santoro et al.
(2009), it was reported that there were significant differences
between CA and biological age; however, there were no sig-
nificant differences between DA and skeletal age when used in
determining and supporting biological age. Rai et al. (2014)
reported that there were strong correlations between DA and
skeletal age that DA could be used as a biological indicator, and
that females reached maturation earlier than males. Neverthe-
less, the results of studies examining the relationship between
dental maturation and skeletal maturation have been controver-
sial and may have been confounded by the wide variation in
methods used as well as the diverse population groups inves-
tigated (Demirjian et al., 1985; Sağlam & Gazilerli, 2002;
Cunha et al., 2018; Kirzioglu et al., 2019).
Based on the chronological development period, the level of
maturity reached by the skeletal system is called bone matura-
tion (Burstone, 1963). In order to evaluate bone maturity using
radiographic methods, a region that contains various ossifica-
tion points that grow, differentiate, and fuse from birth to adult-
hood should be examined. The HW area is the most convenient
region to examine in the body and results in the lowest possible
marginal error. Furthermore, the diagnostic validity and effec-
tiveness of analyzing this region have been demonstrated
(Greulich & Pyle, 1959; Flores-Mir et al., 2004). The method
for evaluating cervical vertebrae maturation (CVM) that was
developed by Lamparski (1972) is frequently used as an alter-
native method for determining the skeletal maturity level of an
individual (Lamparski, 1972; Hassel & Farman, 1995). A cor-
relation between the CVM stages and facial growth has been
demonstrated. Additionally, CVM evaluation has also been
associated with the Fishman HW method that was revised by
Hassel & Farman (1995). The latter method has been recently
updated by Bacetti et al. (2002), thereby improving its ease of
application.
The DA and skeletal age have been suggested as indicators
of an individual’s biological age, and these factors may vary
with CA (Bindayel et al., 2019). However, compared to the
DA, the skeletal age of an individual may be affected to a larger
extent by hormonal, environmental, external, and nutritional
factors, and its correlation with CA may be weaker than that
of DA. Due to its reliability, DA is more useful for predicting
the birth dates of children (Lewis & Garn, 1960). Therefore, the
accurate determination of DA is extremely important in ortho-
dontics, and it is considered that it can increase the reliability of
determining its relationship with skeletal maturation. A small
number of studies have suggested that dental and skeletal
maturation in patients with CLP is slower than in normal indi-
viduals (Harris & Hullings, 1990; Van Dyck et al., 2019).
However, there are currently no studies that have demonstrated
the exact mechanisms behind the relationship among CA, DA,
dental maturation, and skeletal maturation in individuals with
CLP. Therefore, our aim was to evaluate and compare CA, DA,
dental maturation, and skeletal maturation in patients with and
without CLP. Additionally, we investigated potential relation-
ships between CLP and dental/skeletal maturation. The null
hypothesis of our study was that CA and DA would correlate
in all the skeletal maturation stages in young individuals with
CLP or non-CLP.
Material and Methods
This comparative, cross-sectional study was approved by the
Clinical Researches Ethics Committee of the Erciyes Univer-
sity (Approval no: 2019/686). According to the results of a
power analysis (with the G*Power software, version 3.0.10;
Franz Faul, Universitat Kiel) performed based on a previous
study that used a similar method, it was found that at least 9
individuals were required in the subgroups (to Fishman
Maturation Predictors subgroups) of each of the CLP and con-
trol groups under 85% power and at a significance level of 0.05
(Uysal et al., 2004). We examined the clinical and radiological
records of 198 patients (99 female, mean age 11.66 + 2.36
years; 99 male, mean age 12.44 + 2.33 years) who applied to
Erciyes University, Faculty of Dentistry, Departments of Ped-
odontics and Orthodontics in Kayseri, Turkey between 2015
and 2019, and who had unilateral or bilateral CLP. The control
group consisted of 198 patients (99 female, mean age 11.88 +
2.25 years; 99 male, mean age 12.99 + 2.25 years) without
CLP who were randomly selected from among healthy indi-
viduals who had registered for a dental appointment for any
reason. Informed consent form was obtained from the parents
and legal guardians of the patients for participation in the
study. The participants included in this group were matched
with the study group patients in terms of age and sex. Tables 1
and 2 present the distribution of the CA and DA based on the
skeletal maturity indicators and the sex of the participants.
The following inclusion criteria were used to select patients
(1) with complete bilateral or unilateral CLP who underwent
lip-palate operations before they were 2 years old; (2) with no
other syndromes or systemic diseases; (3) who were not
affected by growth retardation and malnutrition; (4) without
congenitally missing teeth in the mandible; (5) without a pre-
vious history of trauma to the face, neck, hands, or HW region;
and (6) with complete and adequate clinical and radiographic
records.
The OPG, LC, and HW radiographs of each patient were
obtained by the same technician on the same day (Figure 1).
The OPG radiographs were taken with the patient’s mouth
closed and with the teeth in contact with the bite stick of the
device (Planmeca Proline CC 2002; Planmeca). All HW and
LC radiographs were taken at the same distance and intensity
with the same device (Orthoceph OP300; Instrumentarium). To
minimize the occurrence of possible skeletal and dental evalua-
tion errors, each radiograph was examined twice. When a dis-
crepancy was observed between the results of the first and
second evaluations, the evaluation indicating a lower develop-
mental stage was utilized.
Ozturk et al 3

Table 1. Distribution and Comparison of Chronological and Dental Ages in All the Female Participants Grouped by Skeletal Maturity
Indicators.a

Cleft lip-palate group Control group

N CA DA r (P value) N CA DA r (P value)
Mean age 99 11.66 + 2.36 11.71 + 2.58 .886 (<.001) 99 11.88 + 2.26 12.95 + 2.47 .882 (<.001)
Fishman Maturation PP3 9 8.47 + 0.62 8.25 + 1.41 .778 (.005) 9 8.98 + 1.96 9.60 + 2.53 .980 (<.001)
Prediction MethodMP3 9 9.16 + 0.53 9.06 + 1.30 .807 (.009) 9 9.02 + 1.07 9.61 + 1.83 .940 (<.001)
MP5 9 9.62 + 0.79 9.60 + 1.12 .710 (.032) 9 9.17 + 0.95 10.42 + 1.56 .228 (.588)
S 9 10.41 + 0.85 11.08 + 1.06 .288 (.452) 9 11.06 + 1.00 12.05 + 1.68 .903 (.001)
DP3cap 9 10.80 + 0.71 10.95 + 1.57 .529 (.116) 9 11.95 + 0.99 13.47 + 1.29 .164 (.673)
MP3cap 9 11.90 + 0.72 12.41 + 1.30 .507 (.200) 9 11.97 + 1.10 13.38 + 0.65 .582 (.100)
MP5cap 9 11.92 + 0.96 12.27 + 1.52 .240 (.534) 9 12.48 + 1.26 14.23 + 0.90 .155 (.690)
DP3u 9 12.81 + 0.66 11.85 + 1.03 .600 (.088) 9 13.39 + 0.73 14.17 + 0.88 .317 (.406)
PP3u 9 13.61 + 0.61 14.06 + 1.58 .494 (.176) 9 13.38 + 0.89 14.14 + 0.85 .576 (.105)
MP3u 9 14.40 + 0.94 14.41 + 1.56 .527 (.144) 9 14.21 + 0.76 15.29 + 1.01 .204 (.599)
Ru 9 16.01 + 0.32 15.79 + 0.49 .610 (.081) 9 14.81 + 1.15 15.79 + 0.63 .063 (.872)
Cervical Vertebral CVM I 24 8.96 + 0.81 8.80 + 1.31 .837 (<.001) 20 8.47 + 0.46 9.15 + 1.35 .662 (.001)
Maturation Method CVM II 16 10.25 + 0.99 10.68 + 1.72 .618 (.011) 15 10.85 + 1.16 11.94 + 1.71 .744 (.002)
CVM III 21 12.09 + 1.09 11.77 + 1.00 .506 (.016) 20 12.10 + 1.20 13.59 + 1.11 .179 (.450)
CVM IV 16 12.49 + 1.19 12.94 + 1.38 .214 (.427) 21 12.91 + 0.79 13.91 + 0.58 .173 (.455)
CVM V 22 14.72 + 1.49 14.79 + 1.79 .749 (<.001) 23 14.37 + 0.98 15.43 + 0.88 .269 (.215)
Abbreviations: CA, chronological age; DA, dental age; N, number of patients; r, Pearson correlation coefficient; SD, standard deviation.
a
Data are given as mean + SD. Statistical significance degree: P < .05.

Table 2. Distribution and Comparison of Chronological and Dental Ages in All Male Participants Grouped by Skeletal Maturity Indicators.a

Cleft lip-palate group Control group

N CA DA r (P value) N CA DA r (P value)
Mean age 99 12.44 + 2.33 12.51 + 2.62 .882 (<.001) 99 12.99 + 2.25 13.64 + 2.37 .899 (<.001)
Fishman Maturation PP3 9 8.83 + 1.46 8.50 + 1.34 .976 (<.001) 9 9.10 + 1.37 9.21 + 0.80 .424 (.255)
Prediction MethodMP3 9 9.65 + 0.70 10.07 + 1.65 .748 (.021) 9 9.48 + 1.31 10.03 + 1.63 .851 (.004)
MP5 9 11.89 + 0.77 11.79 + 1.20 .761 (.017) 9 11.45 + 0.96 12.00 + 1.06 .636 (.035)
S 9 11.25 + 1.30 11.17 + 1.22 .559 (.118) 9 12.87 + 0.51 14.07 + 0.73 .297 (.438)
DP3cap 9 11.24 + 1.18 10.94 + 1.97 .656 (.040) 9 13.15 + 0.95 14.57 + 1.00 .177 (.648)
MP3cap 9 12.72 + 0.92 12.69 + 2.33 .618 (.076) 9 13.69 + 0.95 14.36 + 0.88 .081 (.825)
MP5cap 9 13.34 + 0.72 12.84 + 2.09 .559 (.117) 9 13.68 + 0.91 14.50 + 1.08 .647 (.060)
DP3u 9 13.97 + 1.41 13.94 + 2.19 .852 (.004) 9 14.05 + 0.72 14.22 + 1.57 .409 (.274)
PP3u 9 13.82 + 0.86 13.74 + 1.47 .555 (.121) 9 14.94 + 0.80 15.57 + 0.65 .073 (.852)
MP3u 9 14.83 + 0.95 15.01 + 1.39 .863 (.003) 9 15.14 + 0.61 15.82 + 0.53 .332 (.382)
Ru 9 16.22 + 0.62 15.94 + 0.12 .199 (.608) 9 15.62 + 0.85 15.98 + 0.05 .212 (.892)
Cervical Vertebral CVM I 14 8.77 + 0.69 8.81 + 1.28 .906 (<.001) 18 9.55 + 1.42 9.97 + 1.50 .777 (<.001)
Maturation Method CVM II 25 11.32 + 1.19 11.53 + 1.65 .672 (<.001) 13 11.54 + 1.48 12.23 + 1.82 .754 (.003)
CVM III 23 12.44 + 1.18 12.43 + 1.94 .661 (.001) 25 13.37 + 0.79 14.31 + 0.90 .300 (.136)
CVM IV 20 13.80 + 1.03 13.82 + 2.02 .589 (.006) 23 14.17 + 1.02 14.74 + 1.31 .458 (.021)
CVM V 17 15.62 + 1.03 15.59 + 0.99 .753(<.001) 19 15.36 + 0.78 15.93 + 0.22 .273 (.258)
Abbreviations: CA, chronological age; DA, dental age; N, number of patients; r, Pearson correlation coefficient; SD, standard deviation.
a
Data are given as mean + SD. Statistical significance degree: P < .05.

Chronological Age
The CA of the patients was calculated using Microsoft Office
Excel (T1 [date of radiographic and clinical records]  T0
[date of birth]/365) and evaluated in years.
Dental Maturation and Age
Panoramic radiographs were used to determine the DA of the
individuals included in the study. The evaluation of these
radiographs was performed using the 8-stage scale according
to the Demirjian method (Demirjian et al., 1973; Demirjian &
Goldstein, 1976). Based on the dental developmental stage, the
central and lateral incisors, canines, first and second premolars,
and first and second molars in the left mandibular quadrant were
quantified for males and females separately, using standard
tables. Subsequently, the total score was obtained by calculating
the sum of the numerical values, and the DA was determined
based on the sex and score derived via the standard tables.
4 The Cleft Palate-Craniofacial Journal XX(X)
Hand-Wrist Radiography Evaluation
In order to determine the level of skeletal maturation of the HW
on HW radiographs, the maturation indicators that were sug-
gested by Fishman (1979) (Fishman Maturational Predictors
[FMP]) were used. For each group, the maturation stages were
classified from 1 to 11. The skeletal and tooth age were eval-
uated separately for each HW maturation stage.
Cervical Vertebrae Maturation Evaluation
The cervical vertebra analysis was performed on the LC radio-
graphs. To evaluate the CVM, we used an improved method
developed by Bacetti et al. (2002). Compared to the other
methods, this method has the following advantages: (1) it eval-
uates only 3 vertebrae, (2) it limits the developmental stages,
and (3) it uses simpler and easily identifiable points.
Statistical Analysis
All statistical tests were performed with the Stata statistical anal-
ysis software (Stata Statistical Software: Release 15; StataCorp
LLC). The level of statistical significance was set at P < .05.
 For each group and sex, the CA and DA calculations
were performed based on the stages that were deter-
mined by implementing both the FMP and the CVM
skeletal maturation methods. Descriptive statistics are
presented as means and standard deviations.
 Percentage distributions of each tooth group were deter-
mined based on the dental maturation stages.
 Pearson’s rank correlation coefficient was used to eval-
uate the relationship between the dental maturation stage
(of each tooth) and skeletal maturation stage and
between the DA and the CA (based on the age groups
and sex of the participants).
 An independent samples t test was used to evaluate the
difference between the CA, DA, and DA–CA for each
group and sex.
Results
The intraexaminer correlation coefficient (ICC) was calculated
for the OPG, CVM, and HW evaluations of 50 patients. The
ICC coefficient was .972 (0.942-0.989; P > .05) for the OPG
evaluation, 0.942 (0.923-0.963; P ¼ .455) for the CVM evalua-
tion, and 0.981 (0.970-0.989; P ¼ .256) for the HW evaluation.
In both the groups, the mean CA and DA of the 198 female
participants and 198 male participants included in the study
were determined, and their distribution based on the skeletal
maturation stages (FMP and CWM) is presented in Table 1 for
female and 2 for male participants. There was a positive corre-
lation between CA and DA in the female participants in both
the groups (Table 1). Based on the FMP periods, significant
correlations between the DA and the CA were found in both
groups in the first and second maturation stages in the female
participants (Table 1). In the third stage, there was a positive
correlation between the DA and CA only in the CLP group
(r ¼ .710, P ¼ .32); however, no statistically significant rela-
tionship was found in the control group (r ¼ .228, P ¼ .588). In
the fourth stage, there was a positive correlation between the
DA and the CA only in the control group (r ¼ .903, P ¼ .001);
however, no statistically significant relationship was found in
the CLP group (r ¼ .288, P ¼ .452). When the relationship
between the DA and the CA was evaluated based on the stages
assessed by the CVM method, a positive correlation was found
in both groups in the first 2 stages. In the CLP group, the
relationship between the DA and CA in the third (r ¼ .506,
P ¼ .016) and fifth (r ¼ 0.749, P < .001) stages of the adult
period was statistically a significant strong correlation, whereas
no significant correlation was observed in the control group
(third, r ¼ .179, P ¼ .450; fifth, r ¼ .269, P ¼ .215).
There was a positive correlation between the CA and the DA
in the male participants in both the groups (Table 2). Based on
the FMP periods, significant correlations between the DA and
the CA were found in both groups in the second and third
maturation stages in male participants (Table 2). In the first
(r ¼ .976, P < .001), fifth (P ¼ .656, P ¼ .040), eighth
(r ¼ .852, P ¼ .004), and tenth (r ¼ .863, P ¼ .003) stages,
there was a positive correlation between the DA and CA only in
the CLP group; however, no statistically significant relation-
ship was found in the control group (first, r ¼ .424, P ¼ .255;
fifth, r ¼ 0.177, P ¼ .648; eighth, r ¼ .409, P ¼ .274, and tenth,
r ¼ .332, P ¼ .382). When the relationship between the DA and
the CA was evaluated based on the stages assessed by the CVM
method, a positive correlation was found in both groups in the
first, second, and fourth stages (P < .05). In the CLP group, the
relationship between the DA and the CA in the third (r ¼ .661,
P ¼ .001) and fifth (r ¼ .753, P < .001) stages of the adult
period was a statistically significant strong correlation, whereas
no significant correlation was observed in the control group
(third, r ¼ .300, P ¼ .136; fifth, r ¼ .273, P ¼ .258).
Sex-based differences in DA, CA, and DA  CA (difference
between DA and CA) were further investigated in both the
groups (Table 3). In both the groups, DA and CA exhibited a
statistically significant difference between the female and the
male participants (P < .05). Accordingly, the DA and CA of the
male participants in both the groups (CLP, DA: 12.51 + 2.62
year, CA: 12.44 + 2.33 year; Control, DA: 13.64 + 2.37 year,
CA: 12.99 + 2.25 year) were significantly higher than those of
the female participants (CLP, DA: 11.71 + 2.58 year, CA:
11.66 + 2.36 year; Control, DA: 12.95 + 2.47 year, CA:
11.88 + 2.26 year). When the DA  CA was evaluated, the
difference (DA: 0.69 year; CA: 1.11 year) was higher in the
female participants (1.06 + 1.16 year) compared to those in the
male participants (0.65 + 1.04 year) in the control group. In
the CLP group, no significant difference was found between
the girls and boys in terms of the DA and CA differences.
Table 4 presents the comparison of the female and male
participants between the control and the CLP groups in terms
of sex. The DA values of the girls in the CLP group (11.71 +
2.58 year) were found to be significantly lower than those in the
Ozturk et al 5

Table 3. Comparison Between the Dental Age and Chronological Age Mean Values (Mean ¼ DA  CA) of Both Sexes in the Groups.a

Cleft lip-palate Control

Female Male Mean difference P value Female Male Mean difference P value
DA 11.71 + 2.58 12.51 + 2.62 0.72 .030 12.95 + 2.47 13.64 + 2.37 0.69 .044
CA 11.66 + 2.36 12.44 + 2.33 0.78 .019 11.88 + 2.26 12.99 + 2.25 1.11 .001
DA–CA 0.05 + 1.20 0.06 + 1.23 0.01 .923 1.06 + 1.16 0.65 + 1.04 0.41 .009

Abbreviations: CA, chronological age; DA, dental age; SD, standard deviation.
a
Data are given as mean + SD. Statistical significance degree P < .05.

Table 4. Comparison Between the Dental Age and Chronological Age Mean Values (Mean ¼ DA  CA) in the Main Groups in Terms of Sex.a

CLP Control Mean CLP Control

Female Female difference P value Male Male Mean difference P value
DA 11.71 + 2.58 12.95 + 2.47 1.24 .001 12.51 + 2.62 13.64 + 2.37 1.13 0.001
CA 11.66 + 2.36 11.88 + 2.26 0.22 .499 12.44 + 2.33 12.99 + 2.25 0.55 .091
DA–CA 0.05 + 1.20 1.06 + 1.16 1.01 <.001 0.06 + 1.23 0.65 + 1.04 0.59 <.001
Abbreviations: CA, chronological age; DA, dental age; SD, standard deviation.
a
Data are given as mean + SD. Statistical significance degree P < .05.

control group (12.95 + 2.47 year; P ¼ .001). Similarly, the DA
values of the boys with CLP (12.51 + 2.62 year) were also
significantly lower than of those in the control group (13.64 +
2.37 year; P ¼ .001). The DA  CA of both the girls (0.05 +
1.20 year) and boys (0.06 + 1.23 year) in the CLP group was
lower than that of those in the control group (females: 1.06 +
1.16 year; males: 0.65 + 1.04 year); therefore, the dental
development values in both sexes were lower than the control
values (P < .001).
The results of the correlation analyses between dental
maturation indicators and skeletal maturation indicators are
provided in Table 5 for both sexes. When the relationship
between the results of the skeletal maturation indicator assess-
ments (FMP and CVM) and stages of the central incisor tooth
was evaluated separately for girls with CLP (FMP, r ¼ .278,
P ¼ .005; CVM, r ¼ 0.267, P ¼ .007) compared to girls in the
control group (FMP, r ¼ 0.161, P ¼ .112; CVM, r ¼ .150,
P ¼ .0141), we observed a low positive correlation between the
dental maturation stage and FMP and CVM method results.
Nevertheless, significant positive correlations between the
maturation stage of the other teeth and the FMP and CVM
results were found in both the groups. For the male participants,
it was found that there was a significant correlation between
dental maturation indicators and skeletal maturation indicators
in both the control and the CLP groups.
The evaluation of the relationships between the DA and CA
and the results of the CVM and FMP methods in terms of sex is
provided in Table 6. There was a significant (P < .05) positive
strong correlation (r > .750) between DA and CA and CVM and
FMP results in both groups for both sexes (Table 6).
Discussion
Conventional age and maturation stage estimation methods
may not be sufficiently effective in determining the age of a
child. These methods may exaggerate the age of an individual
and underestimate the potential for individual growth (Harris
et al., 1980). It is known that some dentofacial anomalies, such
as hemifacial microsomia or craniosynostosis, including CLP,
affect the growth and development of the associated structures
(Gorlin et al., 2001). In particular, CLP is more closely related
to the dental area, and the differences in tooth development and
tooth eruption times may be indicative of the association that
this disorder has with the oral cavity (Harris & Hullings, 1990;
Huyskens et al., 2006). The effect of racial and individual
differences on the results of HW radiographs and the evaluation
of cervical vertebrae and skeletal maturation has been exam-
ined previously (Lamparski, 1972; Uysal et al., 2006; Bindayel
et al., 2019). Consequently, it was found that LC and HW
radiographs used for the CVM and FMP methods correlate with
each other in normal individuals and have high reproducibility
(Cunha et al., 2018). However, there is no study in the literature
in which the CVM and FMP methods were evaluated together
with DA in female and male patients with CLP. However, both
skeletal maturation estimation methods have advantages and
disadvantages. The disadvantage is that it is easier to evaluate a
large number of bone structures for the evaluation of matura-
tion in the FMP method, while additional radiography is
required (Fishman, 1979). In CVM method, both dentofacial
features and skeletal maturation can be evaluated with a single
radiography especially in orthodontic and anthropometric eva-
luations (Bacetti et al., 2002). For this reason, this study was
conducted to investigate the relationship between the CA and
DA, with the cervical vertebra and HW skeletal maturation
predictors associated with CLP.
Owing to the data we obtained, our null hypothesis was
partially proved. Although CA and DA were not correlated in
all the maturation stages, they were found to be more strongly
correlated, especially in male individuals with CLP. As stated
in the literature, the dental maturation stage and DA differ in
6 The Cleft Palate-Craniofacial Journal XX(X)

Table 5. Correlation Coefficients Between the Skeletal and Dental Maturity Stages of the Participants Based on Sex.a

Females Males

Cleft lip-palate Control Cleft lip-palate Control

r value P value r value P value r value P value r value P value

Fishman Maturation 1st I .278 .005 .161 .112 .279 .005 .222 .025
Prediction Method 2nd I .500 <.001 .427 <.001 .367 <0.001 .366 <.001
C .779 <.001 .728 <.001 .670 <.001 .748 <.001
1st PM .803 <.001 .701 <.001 .720 <.001 .681 <.001
2nd PM .741 <.001 .702 <.001 .724 <.001 .764 <.001
1st M .529 <.001 .613 <.001 .485 <.001 .445 <.001
2nd M .797 <.001 .775 <.001 . 808 <.001 .773 <.001
Cervical Vertebral 1st I .267 .007 .150 .141 .270 .007 .220 .026
Maturation Method 2nd I .489 <.001 .439 <.001 .336 .001 .379 <.001
C .764 <.001 .794 <.001 .690 <.001 .765 <.001
1st PM .793 <.001 .788 <.001 .718 <.001 .709 <.001
2nd PM .744 <.001 .795 <.001 .731 <.001 .773 <.001
1st M .501 <.001 .681 <.001 .470 <.001 .459 <.001
2nd M .776 <.001 .830 <.001 .793 <.001 .766 <.001

Abbreviations: C, Canine; I, Incisor; M, Molar; PM, Premolar; r, Pearson correlation coefficient.

a
Statistical significance degree: P < .05.

Table 6. Comparison Between the Skeletal Maturation and Dental Age of the Participants by Groups.a

Females Males

Cleft lip-palate Control Cleft lip-palate Control

r value P value r value P value r value P value r value P value

DA-CVM .830 <.001 .862 <.001 .766 <.001 .833 <.001
DA-FMP .858 <.001 .815 <.001 .765 <.001 .824 <.001
CA-CVM .872 <.001 .899 <.001 .882 <.001 .866 <.001
CA-FMP .947 <.001 .863 <.001 .877 <.001 .873 <.001
DA-CA .886 <.001 .882 <.001 .862 <.001 .899 <.001
CVM-FMP .909 <.001 .893 <.001 .926 <.001 .931 <.001
Abbreviations: CA, chronological age; CVM, cervical vertebrae maturation method; DA, dental age; FMP, Fishman maturation prediction method; r, Pearson
correlation coefficient.
a
Statistical significance degree: P < .05.

each CVM stage (Fang et al., 2020). Similarly, it was found that
the age during each stage differs. However, unlike in the liter-
ature, we found that dental maturation evaluated in the left
mandibular teeth of both female and male individuals corre-
lated with the results of FMP and CVM methods for each tooth.
Thus, we demonstrated that determining DA is a simple avail-
able clinical technique to confirm the skeletal maturation stage.
Various methods have been proposed to determine DA
among patients with different diseases and conditions (Kirzio-
glu & Ceyhan, 2012; Bagattoni et al., 2019; Kirzioglu et al.,
2019). In a previous study, it was stated that calculating the DA
based on the early or late retention of teeth would be inaccurate
as opposed to measuring the degree of tooth calcification
(Malot-Steinberg, 1978). Indeed, the Demirjian method is
based on the degree of calcification of the teeth and has been
shown to have the highest level of consistency on repeated
measurements, compared to other methods. Furthermore, the
Demirjian method has been demonstrated to yield values that
closely approximate CA (Olze et al., 2005). Therefore, the
8-stage Demirjian method was used in our study.
In many clinical situations, the differences based on an indi-
vidual’s sex may affect the results; therefore, in order to avoid
this, the females and males were examined separately (Harris
et al., 1980; Demirjian et al., 1985). When the data we obtained
in our study were evaluated, the DA  CA in both female and
male individuals with CLP appeared to be very close although
not negative. The DA and DA  CA values were found to be
significantly lower in the children with CLP compared to in the
boys and girls in the control group. In previous studies, it has
been found that the dental development in individuals with
CLP lags behind that of normal individuals (Harris & Hullings,
1990; Heidbüchel et al., 2002; Bindayel et al., 2019). In our
study, it was found that CA and DA differ based on the differ-
ent skeletal growth stages in both female and male individuals.
Ozturk et al
Figure 1. A, Orthopantomographic radiography used to determine dental age and maturation. B and C, Lateral cephalometric and hand-wrist
radiographs used to evaluate skeletal maturation.
It has been observed that these differences occur in the periods
when individuals are approaching the developmental growth
period and when they are considered to be within this period
because the period of growth may vary between individuals and
sexes (Proffit et al., 2012; Litsas et al., 2016). When the rela-
tionship between DA and CA was evaluated based on the
maturational growth periods, especially when the FMP method
was used, it was observed that it was possible to use the rela-
tionship in more periods of time in male individuals with CLP.
On using the CVM method, there was a significant relationship
between CA and DA in all the maturational growth periods in
male individuals with CLP whereas in females, it was found to
be significant in the first, second, fourth, and fifth stages. This
is in line with the information in the literature outlining that the
relationship between the CVM or FMP method results and
dental maturation can be significant in different periods (Fang
et al., 2020; Macha et al., 2017). In our study, it was found that
the results of the dental and skeletal maturation evaluation
7
methods were positively correlated in terms of sex in both the
CLP and the control groups. However, in female individuals
with CLP, the development of the first incisor tooth was found
to be significantly correlated with skeletal maturity compared
to in the controls. It was observed that there was a correlation
between the dental and the skeletal maturation stages in all the
other teeth in female individuals and in all the teeth in the male
mandibular left quadrant. It was considered that the reason
might be that female individuals reach dental maturity earlier
than male individuals (Macha et al., 2017). In this respect, the
dental maturation method seems more usable in female indi-
viduals with CLP compared to in control individuals to confirm
the growth and development of patients. When the relationship
between the results of the dental and skeletal maturation eva-
luation methods (LC, HW, and DA) was examined, a statisti-
cally significant relationship was found, which was similar to
the results of previous studies (Uysal et al., 2006; Cunha et al.,
2018); in addition, a stronger correlation was found between
8 The Cleft Palate-Craniofacial Journal XX(X)
the results of the FMP and CVM methods both in the CLP and
control groups.
The results of this study suggest that the relationship
between the dental calcification stages and skeletal maturity
indicators in individuals with CLP may potentially allow clin-
icians to accurately determine the stages of the pubertal growth
period on panoramic radiographs. In addition, it was found that
the results of the CVM and FMP methods correlate with DA
and that they corroborate each other when skeletal maturation
is to be determined. The CA can roughly reflect a person’s
biological age. However, in order to determine and confirm
the maturity of a person, the DA and skeletal maturation levels
should be included as additional information sources in diag-
nosis and treatment planning in individuals with CLP similar to
in individuals without CLP. It is important to know that the
results of these methods are highly correlated with each other,
especially in clinical, observational, and forensic cases.
Conclusions
In this study, the relationships between CA, DA, dental matura-
tion, cervical vertebra maturation, and HW maturation were
determined among patients with CLP and an age- and sex-
matched control group, leading to the following conclusions:
1. In both the groups and sexes, the correlations among the
CA, DA, and skeletal maturation indicators were high.
2. The results of both the FMP method and dental matura-
tion method demonstrated significant correlations in
both groups and sexes.
3. The dental maturation stage of the first incisor and the
results of the CVM and FMP skeletal maturation meth-
ods were positively correlated in female individuals
with CLP.
4. DA  CA and DA values of the female and male indi-
viduals with CLP were lower compared to the control
values. The DA of individuals with CLP was quite close
to their CA. Therefore, it can be concluded that DA lags
behind compared to in individuals without CLP.
5. On evaluating the maturational growth process by the
FMP method in male individuals with CLP, a stronger
correlation was found between DA and CA.
6. Similar to in individuals without CLP, skeletal matura-
tion method results correlate with dental maturation in
individuals with CLP.
7. The high correlations between the results of the evalu-
ated methods in this study support their use for correct
age estimation.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Taner Ozturk https://orcid.org/0000-0003-1670-286X
Gulce Ozturk https://orcid.org/0000-0002-5838-5025
References
Aduss H. Craniofacial growth in complete unilateral cleft lip and
palate. Angle Orthod. 1971;41(3):202-213.
Altunhan H, Annagur A, Konak M, Ertugrul S, Ors R, Koc H.The
incidence of congenital anomalies associated with cleft palate/cleft
lip and palate in neonates in the Konya region, Turkey. Br J Oral
Maxillofac Surg. 2012;50(6):541-544.
Bacetti T, Franchi L, McNamara JAJr. An improved version of the
cervical vertebral maturation (CVM) method for the assessment of
mandibular growth. Angle Orthod. 2002;72(4):316-323.
Bagattoni S, D’Alessandro G, Gatto MR, Piana G. Applicability of
Demirjian’s method for age estimation in a sample of Italian chil-
dren with Down syndrome: a case-control retrospective study.
Forensic Sci Int. 2019;298(1):336-340.
Bindayel NA, Alsultan M, Hayek S, Almoammer K. Comparison
between chronological age and dental ages of Saudi patients with
cleft lip and palate. J Contemp Dent Pract. 2019,20(5):603-608.
Burstone CJ. Process of maturation and growth prediction. Am J
Orthod Dentofacial Orthop. 1963;49(12):907-919.
Cunha AC, Cevidanes LH, Sant’Anna EF, Guedes FR, Luiz RR,
McNamara JA, Franchi L, Ruellas ACO. Staging hand-wrist and
cervical vertebrae images: a comparison of reproducibility. Den-
tomaxillofac Radiol. 2018;47(5):20170301.
Demirjian A, Buschang PH, Tanguay R, Patterson DK. Interrelation-
ships among measures of somatic, skeletal, dental, and sexual
maturity. Am J Orthod. 1985;88(5):433-438.
Demirjian A, Goldstein H. New systems for dental maturity based on
seven and four teeth. Ann Hum Bio. 1976;3(5): 411-421.
Demirjian A, Goldstein H, Tanner JM. A new system of dental age
assessment. Hum Biol. 1973;45(2):211-227.
Fang X, Fan C, Jiang C, Qing X, Wenlin X, Xu T, Zhonghui T, Xiaolin
X. Relationship between dental calcification of mandibular teeth
and cervical vertebrae maturity in patients with unilateral complete
cleft lip and palate [published online April 02, 2020]. Oral Radiol.
2020. doi:10.1007/s11282-020-00433-2
Fishman LS. Chronological versus skeletal age, an evaluation of cra-
niofacial growth. Angle Orthod. 1979;49(3):181-189.
Flores-Mir C, Nebbe B, Major PW. Use of skeletal maturation based
on hand-wrist radiographic analysis as a predictor of facial growth:
a systematic review. Angle Orthod. 2004;74(1):118-124.
Gorlin RJ, Cohen MM Jr, Hennekam RC. Syndromes of the Head and
Neck. Oxford University Press; 2001.
Green LJ. The interrelationships among height, weight and chronolo-
gical, dental and skeletal ages. Angle Orthod. 1961;31(3):189-193.
Greulich W, Pyle S. Radiographic Atlas of Skeletal Development of
the Hand and Wrist. Stanford University Press; 1959.
Harris E, Hullings J. Delayed dental development in children with
isolated cleft lip and palate. Arch Oral Biol. 1990;35(6):469-473.
Harris EF, Weinstein S, Weinstein L, Poole AE. Predicting adult
stature: a comparison of methodologies. Ann Hum Biol. 1980;
7(3):225-234.
Ozturk et al
Hassel B, Farman AG. Skeletal maturation evaluation using cervical
vertebrae. Am J Orthod Dentofacial Orthop. 1995;107(1):58-66.
Heidbüchel KL, Kuijpers-Jagtman AM, Ophof R, Van Hooft RJ.
Dental maturity in children with a complete bilateral cleft lip and
palate. Cleft Palate Craniofac J. 2002;39(5):509-512.
Huyskens RW, Katsaros C, Van’t Hof MA, Kuijpers-Jagtman AM.
Dental age in children with a complete unilateral cleft lip and
palate. Cleft Palate Craniofac J. 2006;43(5):612-615.
Kirzioglu Z, Ceyhan D. Accuracy of different dental age estimation
methods on Turkish children. Forensic Sci Int. 2012;216(1-3):
61-67.
Kirzioglu Z, Ceyhan D, Bayraktar C. Dental age estimation by differ-
ent methods in patients with amelogenesis imperfecta. Forensic Sci
Int. 2019;298:341-344.
Lamparski D. Skeletal Age Assessment Utilizing Cervical Vertebrae.
[master’s thesis]. University of Pittsburgh, Pittsburgh; 1972.
Lewis AB, Garn SM. The relationship between tooth formation and
other maturational factors. Angle Orthod. 1960;30(2):70-77.
Litsas G, Athanasiou AE, Papadopoulos MA, Ioannidou-Marathiotou
I, Karagiannis V. Dental calcification stages as determinants of the
peak growth period. J Orofac Orthop. 2016;77(5):34-49.
Macha M, Lamba B, Avula JSS, Muthineni S, Margana PGJS, Chit-
oori P. Estimation of correlation between chronological age, ske-
letal age and dental age in children—a cross-sectional study. J Clin
Diagn Res. 2017;11(9):ZC01-ZC04.
Malot-Steinberg J. Pr évision de l’ éruption dentaire. Revue
d’Orthopédie Dento-Faciale. 1978;12(3):233-242.
9
Mossey PA, Catilla EE. Global Registry and Database on Craniofa-
cial Anomalies: Report of a WHO Registry Meeting on Craniofa-
cial Anomalies; 2006.
Olze A, Bilang D, Schmidt S, Wernecke KD, Geserick G, Schmeling
A. Validation of common classification systems for assessing the
mineralization of third molars. Int J Legal Med. 2005;119(1):
22-26.
Proffit WR, Fields HW Jr, Sarver DM. Contemporary Orthodontics. 5
ed. Elsevier; 2012.
Rai V, Saha S, Yadav G, Tripathi AM, Grover K. Dental and skeletal
maturity—a biological indicator of chronologic age. J Clin Diagn
Res. 2014;8(9):ZC60-ZC64.
Sağlam AMŞ, Gazilerli Ü. The relationship between dental and ske-
letal maturity. J Orofac Orthop. 2002;63(6):454-462.
Santoro V, De Donnoa A, Marrone M, Campobasso CP, Introna F.
Forensic age estimation of living individuals: a retrospective anal-
ysis. Forensic Sci Int. 2009;193(1-3):129. e1-e4.
Uysal T, Ramoglu SI, Basciftci FA, Sari Z. Chronologic age and
skeletal maturation of the cervical vertebrae and hand-wrist: is
there a relationship? Am J Orthod Dentofacial Orthop. 2006;
130(5):622-628.
Uysal T, Sari Z, Ramoglu SI, Basciftci FA. Relationships between
dental and skeletal maturity in Turkish subjects. Angle Orthod.
2004;74(5):657-664.
Van Dyck J, Cadenas Llano PMD, Willems G, Verdonck A. Dental
development in cleft lip and palate patients: a systematic review.
Forensic Sci Int. 2019;300:63-74.