Microsoft Word - 34-Sau_26901 319 Review Article Biosci. J., Uberlândia, v. 31, n. 1, p. 319-325, Jan./Feb. 2015 RELIABILITY, EFFICACY AND REPRODUCIBILITY OF THE CERVICAL VERTEBRAE MATURATION INDEX (CVMI) VALIDADE, EFETIVIDADE E REPRODUTIBILIDADE DO ÍNDICE DE MATURAÇÃO DAS VÉRTEBRAS CERVICAIS Graziela Oro CERICATO 1 ; Paulo Henrique LUIZ DE FREITAS 2 ; Marcos Alan Vieira BITTENCOURT 3 ; Luiz Renato PARANHOS 2 1. Department of Health Sciences, Sagrado Coração University, Bauru, SP, Brazil; 2. Department of Dentistry, Federal University of Sergipe at Lagarto, SE, Brazil. paranhosortodontia@gmail.com; 3. Dental School, Federal University of Bahia, Salvador, BA, Brazil. ABSTRACT: Assessing skeletal maturation is an important determinant of successful orthodontic treatment planning for children and adolescents. While several methods are used skeletal maturation assessment, the hand-wrist radiograph is one of the most widely used. However, it does require additional exposing growing patients to additional radiation. Information on skeletal maturation can also be retrieved after evaluation of cervical vertebrae, which are commonly portrayed on the lateral cephalometric radiographs included in standard orthodontic documentation. By means of a systematic review of the available literature, this work aimed to verify the reliability, efficacy, and reproducibility of skeletal age determination based on the evaluation of cervical vertebrae. The LILACS, SciELO and PubMed databases were searched using the keywords "cervical vertebrae" and "cervical maturation”. Only texts in Portuguese, Spanish, and English published in the last 10 years were selected. Twenty-nine full articles were retrieved and critically appraised. According to these references, the Cervical Vertebrae Maturation Index appears to be a valid, reliable, and reproducible method for skeletal maturation assessment and may substitute the analysis of hand-wrist radiograph in orthodontic treatment planning. KEYWORDS: Cervical Vertebrae. Radiograph. Cervical Maturation. Systematic Review. INTRODUCTION Assessing skeletal maturation is essential for proper orthodontic treatment planning of children and adolescents since critical decisions concerning diagnosis, treatment mechanics and prognosis are affected by the patient’s skeletal age. Chronological age is not a reliable parameter in determining an individual’s growth potential as it is influenced by genetics, socioeconomical and hormonal factors (MARCELINO; TAVANO, 2005). From the standpoint of orthodontic diagnosis and treatment planning, skeletal maturation is a much more reliable base to support one’s clinical decisions (GENEROSO et al., 2010). As in any diagnostic workup, concerns are raised against “over imaging” in orthodontics. Researchers were therefore prompted to develop a method of assessing skeletal maturity based on evaluation of the cervical vertebrae commonly portrayed in lateral cephalometric films. The rationale is grounded on the fact that cervical vertebrae (CV) undergo changes in shape and size throughout development and growth and, therefore, could be used as reference for the determination of skeletal age. Lamparski (1972) pioneered the field after studying changes occurred in the vertebrae of young women and describing six stages of vertebral maturation. He concluded that changes in vertebral size and shape are determined by the progressive development of concavities in the lower margins of the vertebral body, which grows in height and changes progressively from a trapezoid to a vertical shape. This method of skeletal age assessment was proven statistically valid and reliable, with clinical value similar to that of the assessments based on hand-wrist radiographs. Given that lateral cephalometric radiographs are part of the standard orthodontic documentation, others have built upon Lamparski’s original work (HASSEL; FARMAN, 1995; MARCELINO; TAVANO, 2005; DAMIAN et al., 2006; KAMAL et al., 2006; CALDAS et al., 2007; MOSCATIELLO et al., 2008) in order to establish the Cervical Vertebrae Maturation Index (CVMI) (Figure 1). Given the ingenuity and cost-effectiveness of the CVMI, this work aimed to verify, by means of a systematic review of the pertaining literature, the reliability, efficacy, and reproducibility of CV- based methods of skeletal age determination. Received: 25/06/14 Accepted: 22/10/14 320 Reliability, efficacy and reproducibility… CERICATO, G. O. et al. Biosci. J., Uberlândia, v. 31, n. 1, p. 319-325, Jan./Feb. 2015 Figure 1. Representation of the six stages of the Cervical Vertebrae Maturation Index (CVMI) developed by Hassel and Farman (1995). METHODS A systematic literature review was conducted in September, 2014. The search strategy included the terms "cervical vertebrae" and "cervical maturation" joined by the boolean operator “AND”. The LILACS, SciELO and PubMed databases were searched for articles published in Portuguese, English or Spanish during the past ten years and with full text available online. Literature reviews, case reports, theses or dissertations, books, letters to the editor, editorials, and other scientific production not susceptible to systematic reviewing were excluded. Duplicated works were included only once. After retrieval of the selected articles, all were critically and independently appraised by two of the authors (G.O.C. and L.R.P.). All relevant information regarding the assessment of skeletal maturation based on CV evaluation was gathered, tabulated and categorized or compared whenever feasible. RESULTS The initial search produced 23 hits in the LILACS database, 12 hits in the SciELO database and 24 hits in PubMed, totaling 59 possible references for analysis. After an initial screening based on the titles and abstracts, six works were excluded from the LILACS results: two were full theses, two were not directly related to CVMI assessment, one was a literature review, and another one was a duplicate. From PubMed results, six articles were excluded as they were not directly related to the subject, one was a duplicate, and another one more because it was published in French. After the initial screening and removal of duplicates, the amount of references was reduced to 29 (Figure 2). The articles appraised in this study are listed in Table 1. Figure 2. Workflow for article selection. 321 Reliability, efficacy and reproducibility… CERICATO, G. O. et al. Biosci. J., Uberlândia, v. 31, n. 1, p. 319-325, Jan./Feb. 2015 Table 1. List of articles used in the study. Year Author Database Journal Correlation Results 2005 Marcelino et al. LILACS Salusvita Fissured CVMI VMI reliable 2005 Santos et al. LILACS SciELO DentalPress J Orthod CVMI reproducibility VMI reproducible 2006 Damian et al. LILACS SciELO Dental Press J Orthod CVMI x CMI VMI valid 2006 Kamal et al. PubMed J Indian Soc Pedod Prev Dent CVMI x CMI IMV valid 2006 Vieira et al. LILACS SciELO Dental Press J Orthod CVMI x skeletal classes I and II No difference 2007 Caldas et al. LILACS SciELO; PubMed Braz Oral Res New CVMI method VMI valid 2007 Damian et al. SciELO; PubMed J Appl Oral Sci CVMI x growth VMI valid 2008 Moscatiello et al. LILACS SciELO Dental Press J Orthod CVMI x CMI VMI additional 2009 Vieira et al. LILACS SciELO Dental Press J Orthod CVMI x teeth Positive correlation 2010 Caldas et al. SciELO; PubMed Braz Oral Res Computer CVMI Valid 2010 Generoso et al. PubMed Braz Oral Res CVMI x classes I and II Sexual dimorphism 2010 Jaqueira et al. LILACS, SciELO, PubMed Braz Oral Res CVMI three methods Bacetti et al. higher reproducibility 2010 Joshi et al. LILACS Rev Clín Pesq Odontol CVMI x CMI VMI reliable 2010 Mayari and Lugo LILACS Rev Cubana Estomatol CVMI x CMI VMI reliable 2010 Warmeling et al. LILACS; SciELO Rev odontociênc CVMI x CMI VMI more reliable 2011 Martins et al. LILACS Braz Dent Sci CVMI x CMI VMI reliable 2011 Baptista et al. LILACS J Health Inform Computerized CVMI Valid 2011 Mahajan PubMed Indian J Dent Res CVMI x CMI Positive correlation 2011 Różyło-Kalinowska et al. PubMed Eur J Orthod CVMI x teeth Positive correlation 2011 Sachan et al. PubMed Indian J Dent Res CVMI x teeth Positive correlation 2012 Armond et al. LILACS; SciELO Braz Oral Res CVMI x malocclusion Positive correlation 2012 Altan et al. PubMed Eur J Orthod CVMI VMI reliable 2012 Kothavade et al. PubMed J Indian Soc Pedod Prev Dent CVMI x teeth Canine not reliable 2012 Perinetti et al. PubMed Eur J Orthod CVMI x teeth Lower second molar valid 2012 Mayari LILACS Rev Cubana Estomatol CVMI x teeth Positive correlation 2013 Aguiar et al. LILACS; PubMed Braz Dent J Formula CVMI method VMI invalid 2013 Prasad et al. PubMed J Nat SciBiol Med CVMI x CMI Good correlation 2013 Valisadeh et al. PubMed Iran J Radiol CVMI x teeth Positive correlation 2013 Matsui et al. LILACS; SciELO Dental Press J Orthod CVMI X growth in rats Positive correlation Thirty-eight percent (11/29) of the articles reviewed compared the cervical vertebrae maturation index (CVMI) against the carpal maturation index (CMI), while the other 62% (18/29) compared CVMI with other variables such as chronological age, stages of pubertal growth 322 Reliability, efficacy and reproducibility… CERICATO, G. O. et al. Biosci. J., Uberlândia, v. 31, n. 1, p. 319-325, Jan./Feb. 2015 spurt, among others. The most commonly used method for cervical vertebrae assessment was the one developed by Hassel and Farman (1995) (55%, 16/29), followed by Bacetti’s method (2002) (24%, 7/29). Alternative methods were employed in the remaining 21% of our sample of papers. DISCUSSION Assessing skeletal maturity is essential for determining the growth stage by the time of orthodontic diagnosis so that treatment planning is determined by the most appropriate approach for that particular stage. Usually, a clinician can determine how mature is the skeleton based on the ossification of selected bones from the hand and wrist (MARCELINO et al., 2005; MAHAJAN, 2011). However, this method requires an additional radiographic film, with more exposure to radiation outside of the craniofacial region. In a quest to avoid unnecessary exposure to radiation and to reduce redundant diagnostic material, some have correlated the morphological changes that occur in CV to mandibular growth (GENEROSO et al., 2010; DAMIAN et al., 2011), Angle malocclusions (VIEIRA et al., 2006; ARMOND et al., 2012), skeletal age (CALDAS et al., 2007; CALDAS et al., 2010; AGUIAR et al., 2013), and dental age (VIEIRA et al., 2009; RÓŻYŁO-KALINOWSKA et al., 2011; SACHAN et al., 2011; KOTHAVADE et al., 2012; MAYARÍ, 2012; VALIZADEH et al., 2013). Several authors (DAMIAN et al., 2006; KAMAL et al., 2006; JOSHI et al., 2010; MAYARÍ and LUGO, 2010; WARMELING et al., 2010; MARTINS et al., 2011; ALTAN et al., 2012; MAHAJAN, 2012; MAYARÍ, 2012; PRASAD et al., 2013) have made estimates of skeletal growth potential by assessing CV radiographically and comparing the data obtained to that retrieved from hand-wrist films. While not all papers from our sample verified the reliability of methods that estimate skeletal maturation based on CV assessments, most authors agreed that different CV evaluation methods can deliver satisfactory and sufficiently reliable estimates of the degree of skeletal maturation. In addition, works comparing CV assessments to the analysis of ossification events in the hand and wrist did not verify significant statistical differences for intra- and inter-examiner agreement levels (SANTOS et al., 2005; DAMIAN et al., 2006; JAQUEIRA et al., 2010; SACHAN et al., 2011). Jaqueira et al. (2010) carried out a study comparing three different CV-based methods to assess skeletal maturation and showed that the method proposed by Bacetti et al. (2002) is the most reliable and reproducible one. The greater advantage of determining skeletal maturation by lateral cephalometric radiographs would be that it is already part of routine orthodontic documentation. Thus, additional films and consequent exposure to radiation (hand- wrist radiograph) are waived (DAMIAN et al., 2006; KAMAL et al., 2006; MOSCATIELLO et al., 2008; MAYARI; LUGO, 2010; WARMELING et al., 2010; JOSHI et al., 2011; MARTINS et al., 2011; ALTAN et al., 2012; PRASAD et al., 2013). However, the greatest challenge in using CV as an indicator of skeletal maturation seems to be the correct staging described by Hassel and Farman (1995). For proper staging, radiograph quality and knowledge of vertebral anatomy are essential. Indeed, Generoso et al. (2010) suggested that intermediate stages might exist among the established CVMI stages, as some anatomical traits are not covered by the standard CVMI. Therefore, developing a more precise method would require including more stages or changing the assessment from visual-subjective into a more objective nature. Changes in cervical vertebrae parallel the ossification events in the hand and wrist, suggesting that radiograph-based determination of skeletal maturation is reliable (MAYARÍ; LUGO, 2010; MAHAJAN, 2011). However, the lack of an obvious convergence of both methods at the final growth stages does not provide for unequivocal support of CV-based assessments. While different methods for CV assessment methods have been proposed, most of them were based on the subjective analyses of morphological changes in the vertebral bodies. The traits assessed usually include: 1. Changes in the shape of the vertebral body, from a wedge-shaped leaning cranially and dorsoventrally to downward rectangular, then square, and at last to a upward rectangular shape; 2. Changes in the caudal concavity of the vertebral body, from flat to a more evident concavity throughout growth. Due to the high level of subjectivity of the original analyses, some authors proposed that vertebral bodies be measured from the third and fourth cervical vertebrae, thereby establishing a formula to assess skeletal age more objectively (CALDAS et al., 2007; CALDAS et al., 2010; BAPTISTA et al., 2011). However, Aguiar et al. 323 Reliability, efficacy and reproducibility… CERICATO, G. O. et al. Biosci. J., Uberlândia, v. 31, n. 1, p. 319-325, Jan./Feb. 2015 (2013) suggested that this method fails to provide good estimates of skeletal maturation. There has been a trend towards the use of either dental age or dental calcification stages as an aid to determining skeletal maturation (VIEIRA et al., 2009; RÓŻYŁO-KALINOWSKA et al., 2011; KOTHAVADE et al., 2012; MAYARÍ, 2012; PERINETTI et al., 2012; PRASAD et al., 2013; VALIZADEH et al., 2013). Many of these works pointed out that dental calcification stages have moderate to weak correlation with skeletal age, either with the Nolla (VIEIRA et al., 2009; SACHAN et al., 2011; KOTHAVADE et al., 2012; VALIZADEH et al., 2013) or the Demirjian classification (RÓŻYŁO-KALINOWSKA et al., 2011; MAYARÍ, 2012; PERINETTI et al., 2012). Perinetti et al. (2012) stated that the use of tooth- based methods are limited, suggesting that dental age would not be a good replacement for either carpal radiographs or teleradiographs in the assessment of skeletal maturation. CONCLUSION Based on our review of the pertaining literature, the Cervical Vertebrae Maturation Index (CVMI) appears to be a valid, reliable, and reproducible method for the analysis of skeletal maturation. Among the indexes presented in literature, the one developed by Hassel and Farman (1995) is the most commonly used, while the index proposed by Bacetti et al. (2002) is considered the most reproducible. However, the transition from standard assessments to CV-based ones should not be abrupt, but gradual, at least until the clinician becomes familiar with the new method and replicates his own analysis reliably and consistently. RESUMO: A determinação da fase de maturação esquelética é ponto fundamental no tratamento ortodôntico de crianças e adolescentes, e muitos métodos são utilizados com este objetivo, sendo a análise da radiografia de mão e punho o mais comumente difundido no meio ortodôntico. Entretanto, esta informação também pode ser obtida por meio de radiografias cefalométricas laterais, com base na avaliação das vértebras cervicais, eliminando a necessidade de exposição a mais de radiação e o custo associado de novos exames. O objetivo deste trabalho foi checar, com base na literatura, a confiabilidade, a efetividade e a reprodutibilidade do método de estimativa da idade esquelética, por meio das vértebras cervicais. Para tanto, foi realizada uma revisão crítica da literatura, utilizando as palavras-chave “vértebras cervicais” e “maturação cervical”. Foram encontrados 29 artigos nas bases de dados LILACS, PubMed e SciELO. De acordo com as referências encontradas, o Índice de Maturação das Vértebras Cervicais pode ser considerado um método válido, confiável e reprodutível na análise da maturação óssea, podendo ser utilizado na prática ortodôntica, em substituição à análise da radiografia de mão e punho. PALAVRAS-CHAVE: Vértebras Cervicais. Radiografia. Maturação cervical. Revisão Sistemática. REFERENCES AGUIAR, L. B. V.; CALDAS, M. P.; HAITER NETO, F.; AMBROSANO, G. M. B. A methodology to measure cervical vertebral bone maturation in a sample from low-income children. Brazilian Dental Journal, Ribeirão Preto, v. 24, n. 1, p. 30-34, 2013. http://dx.doi.org/10.1590/0103-6440201301787 ALTAN, M.; NEBIOGLU, O.; ISERI, H. Growth of the cervical vertebrae in girls from 8 to 17 years: a longitudinal study. European Journal of Orthodontics, London, v. 34, n. 3, p. 327-334, 2012. http://dx.doi.org/10.1093/ejo/cjr013 ARMOND, M. C.; GENEROSO, R.; FALCI, S. G. M.; RAMOS-JORGE, M. L.; MARQUES, L. S. Skeletal maturation of the cervical vertebrae: association with various types of malocclusion. Brazilian Oral Research, São Paulo, v. 26, n. 2, p. 145-150, 2012. http://dx.doi.org/10.1590/S1806-83242012005000003 BACCETTI, T.; FRANCHI, L.; MCNAMARA, J. A. An improved version of the Cervical Vertebral Maturation (CVM) method for the Assessment of Mandibular Growth. The Angle Orthodontist, Appleton, v. 72, n. 4, p. 316-323, 2002. 324 Reliability, efficacy and reproducibility… CERICATO, G. O. et al. Biosci. J., Uberlândia, v. 31, n. 1, p. 319-325, Jan./Feb. 2015 BAPTISTA, R. S.; HUMMEL, A. D.; FINKELSZTAIN, R. A.; ORTOLANI, C. L. F.; PISA, I. T. Desenvolvimento e avaliação de um classificador de padrões para análise do crescimento facial pelo método de maturação vertebral cervical. Journal of Health Informatics, São Paulo, v. 3, n. 2, p. 64-68, 2011. CALDAS, M. P.; AMBROSANO, G. M. B.; HAITER-NETO, F. Use of cervical vertebral dimensions for assessment of children growth. Journal of Applied Oral Science, Bauru, v. 15, n. 2, p. 144-147, 2007. http://dx.doi.org/10.1590/S1806-83242010000100020 CALDAS, M. P.; AMBROSANO, G. M. B.; HAITER-NETO, F. Computer assisted analysis of cervical vertebral bone age using cephalometric radiographs in Brazilian subjects. Brazilian Oral Research, São Paulo, v. 24, n. 1, p. 120-126, 2010. http://dx.doi.org/10.1590/S1806-83242010000100020 DAMIAN, M. F.; WOITCHUNAS, F. E.; CERICATO, G. O.; CECHINATO, F.; MORO, G.; MASOCHIN, M. E. et al. Análise da confiabilidade e da correlação de dois índices de estimativa da maturação esquelética: índice carpal e índice vertebral. Revista Dental Press de Ortodontia e Ortopedia Facial, Maringá, v. 11, n. 5, p. 110-120, 2006. http://dx.doi.org/10.1590/S1415-54192006000500012 DAMIAN, M. F.; CECHINATO, F.; MOLINA, R. D.; WOITCHUNAS, F. E. Relationship between cranial and mandibular growth and the stages of maturation of the cervical vertebrae. Journal of Applied Oral Science, Bauru, v. 15, n. 2, p. 115-119, 2011. http://dx.doi.org/10.1590/S1678-77572007000200008 GENEROSO, R.; SADOCO, E. C.; ARMOND, M. C.; GAMEIRO, G. H. Evaluation of mandibular length in subjects with Class I and Class II skeletal patterns using the cervical vertebrae maturation. Brazilian Oral Research, São Paulo, v. 24, n. 1, p. 46-51, 2010. http://dx.doi.org/10.1590/S1806-83242010000100008 HASSEL, B.; FARMAN, A. G. Skeletal maturation evaluation using cervical vertebrae. American Journal of Ortohodontics and Dentofacial Orthopedics, St. Louis, v. 107, n. 1, p. 58-66, 1995. JAQUEIRA, L. M. F.; ARMOND, M. C.; PEREIRA, L. J.; ALCÂNTARA, C. E. P.; MARQUES, L. S. Determining skeletal maturation stage using cervical vertebrae: evaluation of three diagnostic methods. Brazilian Oral Research, São Paulo, v. 24, n. 4, p. 433-437, 2010. http://dx.doi.org/10.1590/S1806- 83242010000400010 JOSHI, V. V.; IYENGAR, A. R.; NAGESH, K. S.; GUPTA, J. Comparative study between cervical vertebrae and hand-wrist maturation for the assessment of skeletal age. Revista de Clínica e Pesquisa Odontológica, Curitiba, v. 6, n. 3, p. 207-213, 2010. KAMAL, M.; RAGINI; GOYAL, S. Comparative evaluation of hand wrist radiographs with cervical vertebrae for skeletal maturation in 10-12 years old children. Journal of Indian Society of Pedodontics and Preventive Dentistry, Chandigarh, v. 24, n. 3, p. 127-135, 2006. http://dx.doi.org/10.4103/0970-4388.27901 KOTHAVADE, D. S.; PANDEY, R. K.; NAGAR, A. An assessment of the relationship between cervical vertebrae maturation index and eruption of permanent maxillary canines. Journal of Indian Society of Pedodontics and Preventive Dentistry, Chandigarh, v. 30, n. 4, p. 301-304, 2012. http://dx.doi.org/10.4103/0970-4388.108925 LAMPARSKI, D. G. Skeletal age assessment utilizing cervical vertebrae. Dissertação (Master) – University of Pittsburgh, Pittsburgh, 1972. MAHAJAN, S. Evaluation of skeletal maturation by comparing the hand wrist radiograph and cervical vertebrae as seen in lateral cephalogram. Indian Journal of Dental Research, Ahmedabad, v. 22, n. 2, p. 309- 316, 2011. http://dx.doi.org/10.4103/0970-9290.84310 MARCELINO, E.; TAVANO, O.; CARVALHO, I. M. M. As vértebras cervicais como estimadoras do crescimento e desenvolvimento em pacientes portadores de fissura lábio-palatal. Salusvita, Bauru, v. 24, n. 1, p. 11-19, 2005. 325 Reliability, efficacy and reproducibility… CERICATO, G. O. et al. Biosci. J., Uberlândia, v. 31, n. 1, p. 319-325, Jan./Feb. 2015 MARTINS, M. M.; OLIVEIRA, P. C. B.; GOLDNER, M. T. A.; MIGUEL, J. A. M. Skeletal maturation of cervical vertebrae and hand-wrist region. Brazilian Dental Science, São José dos Campos, v. 14, n. ½, p. 4-8, 2011. MAYARÍ, G. T. Indicadores de maduración esquelética y dental en pacientes de ortodoncia com menarquía. Revista Cubana de Estomatología, Ciudad de La Habana, v. 49, n. 1, p. 3-10, 2012. MAYARÍ, G. T.; LUGO, R. O. Evaluación de la maduración ósea a través de lãs vértebras cervicales en pacientes de ortodoncia. Revista Cubana de Estomatología, Ciudad de La Habana, v. 47, n. 3, p. 326-335, 2010. MOSCATIELLO, V. A. M.; LEDERMAN, H.; MOSCATIELLO, R. A.; FALTIN JÚNIOR, K.; MOSCATIELLO, R. M. Maturação das vértebras cervicais e sua correlação com a idade óssea da mão e punho como indicadores no tratamento ortodôntico. Revista Dental Press de Ortodontia e Ortopedia Facial, Maringá, v. 13, n. 4, p. 92-100, 2008. http://dx.doi.org/10.1590/S1415-54192008000400011 PERINETTI, G.; CONTARDO, L.; GABRIELI, P.; BACETTI, T.; LENARDA, R. Diagnostic performance of dental maturity for identification of skeletal maturation phase. European Journal of Orthodontics, London, v. 34, n. 4, p. 487-492, 2012. http://dx.doi.org/10.1093/ejo/cjr027 PRASAD, M.; GANJI, V. S. K.; GEORGE, S. A.; TALAPANENI, A. K.; SHETTY, S. K. A comparison between cervical vertebrae and modified MP3 stages for the assessment of skeletal maturity. Journal of Natural Science, Biology and Medicine, Mumbai, v. 4, n. 1, p. 74-80, 2013. RÓŻYŁO-KALINOWSKA, I.; KOLASA-RĄCZKA, A.; KALINOWSKI, P. Relationship between dental age according to Demirjian and cervical vertebrae maturity in Polish children. European Journal of Orthodontics, London, v. 33, p. 75-83, 2011. http://dx.doi.org/10.1093/ejo/cjq031 SACHAN, K.; SHARMA, V. P.; TANDON, P. A correlative study of dental age and skeletal maturation. Indian Journal of Dental Research, Ahmedabad, v. 22, n. 6, p. 882, 2011. http://dx.doi.org/10.4103/0970- 9290.94698 SANTOS, E. C. A.; BERTOZ, F. A.; ARANTES, F. M.; PIZZO REIS, P. M. Avaliação da reprodutibilidade do método de determinação da maturação esquelética por meio das vértebras cervicais. Revista Dental Press de Ortodontia e Ortopedia Facial, Maringá, v. 10, n. 2, p. 62-68, 2005. http://dx.doi.org/10.1590/S1415- 54192005000200009 VALIZADEH, S.; EIL, N.; BAKHSHANDEH, H. Correlation between dental and cervical vertebral maturation in Iranian females. Iranian Journal of Radiology, Tehran, v. 10, n. 1, p. 1-7, 2013. VIEIRA, A. M.; CARLOS, R. G.; PAULA , A. V.; BOTHREL, J. R. S.; ARMOND, M. C.; RIBEIRO, A. Avaliação cefalométrica em norma lateral entre indivíduos Classe I e II esqueléticas com a maturação óssea das vértebras cervicais. Revista Dental Press de Ortodontia e Ortopedia Facial, Maringá, v. 11, n. 6, p. 62-72, 2006. http://dx.doi.org/10.1590/S1415-54192006000600009 VIEIRA, C. L.; OLIVEIRA, A. E. F.; RIBEIRO, C. C. C.; LIMA, A. A. S. J. Relação entre os índices de maturação das vértebras cervicais e os estágios de calcificação dentária. Revista Dental Press de Ortodontia e Ortopedia Facial, Maringá, v. 14, n. 2, p. 45-53, 2009. http://dx.doi.org/10.1590/S1415-54192009000200006 WARMELING, D.; RODRIGUES, K. M.; ZASTROW, M. D.; THIESEN, G. Comparative study of two skeletal maturation evaluation indexes. Revista Odonto Ciência, Porto Alegre, v. 25, n. 2, p. 188-193, 2010. http://dx.doi.org/10.1590/S1980-65232010000200016