ORIGINAL ARTICLE

Cervical vertebral bone age in girls

Toshinori Mito, DDS,
a
Koshi Sato, DDS, PhD,
b
and Hideo Mitani, DDS, MS, PhD
c
Sendai, Japan
The purpose of this study was to establish cervical vertebral bone age as a new index for objectively
evaluating skeletal maturation on cephalometric radiographs. Using cephalometric radiographs of 176 girls
(ages 7.0-14.9 years), we measured cervical vertebral bodies and determined a regression formula to obtain
cervical vertebral bone age. Next, using cephalometric and hand-wrist radiographs of another 66 girls (ages
8.0-13.9 years), we determined the correlation between cervical vertebral bone age and bone age using the
Tanner-Whitehouse 2 method. The following results were obtained: (1) a regression formula was determined
to obtain cervical vertebral bone age based on ratios of measurements in the third and fourth cervical
vertebral bodies; (2) the correlation coefcient for the relationship between cervical vertebral bone age and
bone age (0.869) was signicantly (P .05) higher than that for the relationship between cervical vertebral
bone age and chronological age (0.705); and (3) the difference (absolute value) between the cervical vertebral
bone age and bone age (0.75 years) was signicantly (P .001) smaller than that between cervical vertebral
bone age and chronological age (1.17 years). These results suggest that cervical vertebral bone age reects
skeletal maturity because it approximates bone age, which is considered to be the most reliable method for
evaluating skeletal maturation. Using cervical vertebral bone age, it might be possible to evaluate maturity in
a detailed and objective manner on cephalometric radiographs. (Am J Orthod Dentofacial Orthop 2002;122:
380-5)
I
t is important to evaluate skeletal maturation in
orthodontic treatment. Skeletal maturation can be
assessed by various indicators: body height,
1
hand-
wrist measurements, menarche, voice change, and den-
tal development. Bone age determined with hand-wrist
radiographs, as in the Tanner-Whitehouse 2 (TW2)
method, is the most popular and reliable parameter for
evaluating skeletal maturation.
1-5
However, this
method requires hand-wrist radiographs.
Cervical vertebrae appear on cephalometric radio-
graphs that orthodontists usually use in planning treat-
ment, and Sato
6
reported that the appearance of the
epiphyseal plate of the odontoid process could be used
as an indicator of the maximum growth peak.
It is well known that the lateral view of cervical
vertebral bodies changes with growth (Fig 1).
7-9
Lam-
parski
10
published an atlas that simulated the morpho-
logical changes in cervical vertebral bodies in puberty
and used these changes to evaluate skeletal maturation.
Hassel and Farman
11
and Garcia-Fernandez et al
12
reported a high correlation between cervical vertebral
maturation using the atlas and skeletal maturation of the
hand-wrist. Their techniques did not require hand-wrist
radiographs and could be used to roughly evaluate
pubertal growth based on cephalometric radiographs.
However, these techniques could not be used to eval-
uate growth in a detailed and objective manner, because
they used an atlas.
The purpose of this study was to establish a new
method for objectively evaluating skeletal maturation
in cephalometric radiographs.
MATERIAL AND METHODS
We examined lateral cephalometric and hand-wrist
radiographs from the les of the Department of Ortho-
dontics, Tohoku University Dental Hospital, Sendai,
Japan. The images in cephalometric radiographs are
1.0625 times the actual size. Group 1 consisted of 22
Japanese girls in each of 8 age groups (ages 7.0-14.9
years), for a total of 176 girls; this group was used to
derive a formula for obtaining cervical vertebral bone
age (Table I). Group 2 consisted of another 66 girls
(ages 8.0-13.9 years, average age 11.0 1.57 years)
and was used to determine the reliability of cervical
vertebral bone age in comparison with bone age by the
TW2 method with hand-wrist radiographs.
On lateral cephalometric radiographs in group 1,
the following cervical vertebrae were traced by pencil
and measured with micrometer calipers: anterior verte-
From the Division of Orthodontics, Department of Lifelong Oral Health
Science, Graduate School of Dentistry, Tohoku University, Sendai, Japan.
a
Graduate student.
b
Assistant professor.
c
Professor and chairman.
Reprint requests to: Toshinori Mito, Division of Orthodontics, Department of
Lifelong Oral Health Science, Graduate School of Dentistry, Tohoku Univer-
sity, 4-1, Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan; e-mail:
mito@mail.cc.tohoku.ac.jp.
Submitted, January 2002; revised and accepted, March 2002.
Copyright 2002 by the American Association of Orthodontists.
0889-5406/2002/$35.00 0 8/1/126896
doi:10.1067/mod.2002.126896
380
bral body height (AH), vertebral body height (H),
posterior vertebral body height (PH), and anteroposte-
rior vertebral body length (AP) on the third and fourth
cervical vertebrae (Fig 2). The ratios of these parame-
ters were calculated (AH/AP, H/AP, PH/AP, AH/H,
H/PH, and AH/PH). A formula for obtaining cervical
vertebral bone age was determined from the ratios and
the chronological age using a stepwise multiple regres-
sion analysis. Bone age and cervical vertebral bone age
were estimated in group 2 to conrm the validity of this
formula. The correlation and difference between cervi-
cal vertebral bone age and bone age were determined,
as were those between cervical vertebral bone age and
chronological age. Bone age was calculated using
Japanese standards (RUS: radius, ulna, and short
bones)
1,2
with the TW2 method.
All cephalometric radiographs were traced and
measured by 1 operator (T.M.). Intraoperator error was
determined by using 10 cephalometric radiographs
selected randomly from group 1; these were traced and
measured with micrometer calipers, and the same
materials were measured again 10 days later.
Statistical analysis
A paired t test was used to determine if there was a
signicant difference in the average errors and correla-
tion coefcients between cervical vertebral bone age
and bone age, and between cervical vertebral bone age
and chronological age. All analyses were performed
with Statview (SAS Institute, Cary, NY).
RESULTS
Operator error
The average error between the rst and the second
measurements for all parameters (absolute value) was
0.30 0.29 mm (r 0.998, P .001).
Parameters were measured on the third and fourth
cervical vertebrae (Figs 3 and 4). AH
3,4
, H
3,4
, and PH
3,4
increased in an accelerated manner from 10 to 13 years
of age. The ratios of these parameters were calculated.
The formula for calculating cervical vertebral bone age
was determined by stepwise multiple regression analy-
sis with chronological age as a dependent variable and
the ratios of these parameters as independent variables:
Fig 1. Examples of natural maturational changes in cervical vertebrae.
Table I. Composition of group 1
Age group (years) Number Average age (years)
7.0-7.9 22 7.53
8.0-8.9 22 8.53
9.0-9.9 22 9.49
10.0-10.9 22 10.51
11.0-11.9 22 11.40
12.0-12.9 22 12.54
13.0-13.9 22 13.46
14.0-14.9 22 14.55
Total 176 -
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 122, Number 4
Mito, Sato, and Mitani 381
Cervical vertebral bone age 0.20 6.20
AH
3
/AP
3
5.90 AH
4
/AP
4
4.74 AH
4
/PH
4
.
AH
3
/AP
3
and AH
4
/AP
4
increased in an accelerated
manner at about 12 years of age, and AH
4
/PH
4
contin-
ued to increase until about 14 years of age (Fig 5).
Cervical vertebral bone age and bone age in group
2 were calculated to determine the reliability of cervical
vertebral bone age for assessing bone age. The differ-
ence (absolute value) between cervical vertebral bone
age and bone age (0.75 years) was signicantly (P
.001) less than that between cervical vertebral bone age
and chronological age (1.17 years) (Table II). The
Fig 2. Areas of cervical vertebral bodies measured on cephalometric radiographs. Lower lines are
tangent to front and back of lower parts of cervical vertebral bodies. AH
3, 4
, Distance from top of
front part to tangent of lower part; H
3, 4
, distance from top of middle part to tangent of lower part;
PH
3, 4
, distance from top of back part to tangent of lower part; AP
3,4
: Anteroposterior distance at
middle of cervical vertebral body.
Fig 3. Average changes in each part of third cervical
vertebral body (group 1).
Fig 4. Average changes in each part of fourth cervical
vertebral body (group 1).
American Journal of Orthodontics and Dentofacial Orthopedics
October 2002
382 Mito, Sato, and Mitani
correlation coefcient between cervical vertebral bone
age and bone age (0.87) was signicantly (P .05)
higher than that between cervical vertebral bone age
and chronological age (0.71) (Table III, Figs 6 and 7).
DISCUSSION
Material selection
An abnormal cervical vertebral body due to injury,
deformation, degeneration, inammation, tumor, or
other causes
13
is rare, and these conditions were not
seen in the materials used in this study. We examined
only girls because of sex-dependent differences in
growth patterns. Lamparski
10
reported that boys and
girls differed with regard to the timing of morpholog-
ical changes in cervical vertebral bodies. In group 1,
each year during puberty was represented by the same
number of girls to ensure that the reliability of the
formula would not vary with age. The subjects in group
2 were in the same age range as those in group 1.
Fig 5. Average changes in parameters chosen by step-
wise multiple regression analysis (group 1).
Fig 6. Scattergram of cervical vertebral bone age (VA)
and chronological age (CA) (group 2); ***P .001.
Fig 7. Scattergram of cervical vertebral bone age (VA)
and bone age (BA) (group 2); ***P .001.
Table II. Differences between cervical vertebral bone
age (VA) and bone age (BA) and chronological age
(CA)
Average difference (years)
(absolute value)
VA and BA 0.75 0.56
VA and CA 1.17 0.86
Average 1SD.
Signicant (P .001) differences were found between VA and BA,
and between VA and CA (absolute values).
Table III. Correlation between cervical vertebral bone
age (VA) and bone age (BA) and chronological age
(CA)
Correlation coefcient
VA and BA 0.869***
VA and CA 0.705***
Average 1SD; ***P .001.
Correlation coefcients between VA and BA, and between VA and
CA were also signicant (P .05).
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 122, Number 4
Mito, Sato, and Mitani 383
Therefore, it should be reasonable to apply the formula
determined from group 1 to obtain cervical vertebral
bone age in group 2.
Method
Almost all previous evaluations in puberty with
cervical vertebrae on cephalometric radiographs either
used or referred to the atlas reported by Lamparski.
10
The use of an atlas is convenient because changes in
cervical vertebral bodies can be evaluated with regard
to growth in the atlas. However, an atlas cannot be used
to evaluate growth in an objective and detailed manner
because the results can differ from operator to operator,
and an atlas also cannot be used to calculate age as the
TW2 method can. Thus, the method used in this study
is more objective than those used in most previous
studies. Cervical vertebral bone age can be easily
calculated based on an analysis of cephalometric radio-
graphs. A program to automatically calculate cervical
vertebral bone age is needed to increase objectivity.
We measured vertebral bodies in cervical vertebrae
because various investigators
11,12,14-16
have suggested
a relationship between changes in cervical vertebral
bodies and growth, and vertebral bodies are easy to
measure. We selected the third and fourth vertebral
bodies and omitted other cervical vertebrae for various
reasons: the rst cervical vertebra (atlas) does not show
the body, the second cervical vertebra (axis) shows
very little morphological change and is difcult to
measure, and the fth cervical vertebra might not
appear clearly on cephalometric radiographs. We used
ratios to calculate cervical vertebral bone age because
this considers only the shape of cervical vertebrae and
discounts their size. When deriving the formula for
cervical vertebral bone age, we used chronological age
instead of bone age determined from hand-wrist radio-
graphs. There were 2 reasons for this: (1) generally,
average chronological age corresponded with average
bone age when there was no great deviation within
groups, and (2) chronological age had little operator
error compared with bone age.
The measurement error averaged only 0.30 0.29
mm on the cephalometric radiographs, and there was a
strong correlation between the rst measurement and
that taken 10 days later (r 0.998, P .001). The
average difference between these measurements was as
small as 0.35 mm for the fourth posterior vertebral
body height (PH
4
), which showed the greatest measure-
ment error. Therefore, this method was sufciently
accurate to assess skeletal development.
Reliability of cervical vertebral bone age
As shown in Table III, the correlation coefcient
between cervical vertebral bone age and bone age by
the TW2 method (r 0.869) was signicantly (P
.05) higher than that between cervical vertebral bone
age and chronological age (r 0.705). Furthermore,
the difference between cervical vertebral bone age and
bone age (0.75 years) was signicantly (P .001)
smaller than that between cervical vertebral bone age
and chronological age (1.17 years). Cervical vertebral
bone age is thought to more closely approximate bone
age by the TW2 method rather than chronological age.
Cervical vertebral bone age might reect skeletal ma-
turity because it can approximate bone age by the TW2
method on hand-wrist radiographs; the TW2 is consid-
ered to be the most reliable method for measuring the
degree of maturity.
CONCLUSIONS
The results suggest that cervical vertebral bone age
on cephalometric radiographs is as reliable at estimat-
ing bone age as is the TW2 method on hand-wrist
radiographs. By determining the cervical vertebral bone
age, skeletal maturity can be evaluated in a detailed and
objective manner with cephalometric radiographs.
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Mito, Sato, and Mitani 385