The relationship determination between menarche and the peak of skeletal maturation using hand wrist and cervical vertebrae index

Background: Menarche and skeletal maturation indices are physiological maturation indicators that can be used to establish the maturation stage of individual patient in orthodontic treatment, especially in orthodontic growth modification and orthognatic surgery. Purpose: The purpose of this study was to determine the relationship between menarche and the peak of skeletal maturation using hand-wrist and cervical vertebrae indexes. Methods: This was an observational diagnostic research with 220 female of Deutero-Malay Indonesian subjects aged 8-17 years from Dental Hospital Faculty of Dentistry Universitas Padjadjaran, and some privates orthodontic practice in Bandung. All subjects had hand-wrist radiograph and lateral cephalogram. Menarche data were collected through interview with the subjects and their parents. There were 89 subjects who already had menarche but only 84 of them remembered the month and year of their menarche. The stage of hand-wrist skeletal maturation was analyzed using Fishman method and cervical vertebrae maturation was analyzed using Baccetty et.al., method. results: The result indicates that the menarche age of Indonesian DeuteroMalay subject were 12.47 ± 0.73 year. The youngest age of were 10.92 ± 0.0 year and the oldest were 13.83 ± 0.23 year. Conclusion: Menarche could be used as an indicator that the pubertal growth peak has been exceeded and to predict the end of the pubertal growth. This study showed that 0.49 years after MP3cap stage of hand-wrist skeletal maturation index and 0.69 years after CVMS2 stage of cervical vertebrae skeletal maturation index, the subject of Indonesian Deutero-Malay will have their menarche.


Kata kunci: Menarke, indeks maturasi hand-wrist, indeks maturasi vertebra servikal, subjek Indonesia ras Deutero-Malayid
Correspondence: Endah Mardiati, c/o: Fakultas Kedokteran Gigi, Universitas Padjadjaran.Jl.Sekeloa Selatan I No. 1 Bandung 40132, Indonesia.Email: endah_mardiati@yahoo.com introduction Growth and development is an important factor in the treatment of orthodontic growth modification and orthognatic surgery of skeletal class II and class III maloclusion.5][6] In orthodontic treatment, cervical vertebrae maturation indicators can be observed directly on the lateral cephalogram that commonly used to determine the diagnosis of orthodontic treatment. 6ome studies showed that hand-wrist maturation index has polimorphism and sexual dimorfism 7,8 whereas cervical vertebrae maturation index still controversi.0][11] Under these conditions menarche can be use as maturation index for determining the pubertal growth stages in female.Menarche is a physiological maturation indicator that easily identified through interview with patient or parents.Some studies showed that menarche reached approximately one year after the peak of skeletal growth. 4,11The purpose of this study was to determine the relationship between menarche and the peak of skeletal maturation using hand-wrist and cervical vertebrae indexes of Indonesian Deutero-Malay subjects.In Indonesia, menarcheal data has been widely studied, but how it relates to the skeletal maturation is still unknown.

materials and methods
This study was a diagnostic observational study.The subjects were 220 girls aged 8-17 years from orthodontic clinic Faculty of Dentistry, Universitas Padjadjaran, and some private specialist orthodontic practice in Bandung.Eighty nine subjects had menarche but only 85 subjecs remember their menarche.The subjects of this study have hand-wrist radiograph and lateral cephalogram with inclusion criteria, such as: Indonesian Deutero-Malay, healthy, not suffering from serious diseases or systemic diseases, does not suffer from defects in dento-craniofacial structures, never have experienced with trauma in the neck and hand-wrist.
Hand-wrist maturation index of Fishman method and cervical vertebrae maturation index of Baccety et al., 5 method was used to analyzed the skeletal maturation stage, while menarche data was obtained retrospectively by interviewing the subject and parents.Subjects who did not remember their menarche were not included for analysis. 12and-wrist maturation indicators of Fishman method consists 11 skeletal maturation indicator (SMI), which is epiphysis width equal with diaphysis width (SMI1-SMI3), ossification of sesamoid bone (SMI4), capping of epiphysis to the diaphysis (SMI5-7) and fusion of epiphysis and diaphysis (SMI8-11) (Figure 1).Skeletal maturation indicator 1-4 shows the acceleration of pubertal growth, SMI 5-7 shows the peak of pubertal growth and SMI 8-11 figure 1. Location of assessment indicator hand-wrist maturation of Fishman method. 13TURITY INDICATORS shows a decrease and followed by the cessation of skeletal growth. 12Cervical vertebrae maturation of Baccety method consists of 5 stages indicator, using the changes of the 3 rd an 4 th cervical vertebrae body that can be observed on lateral sefalogram (Figure 2). 5 CVMS1 and CVMS2 showed pubertal growth acceleration, CVMS3 , showed peak pubertal growth and CVMS 4-CVMS5 showed a decline and cessation of pubertal growth.To determine the validity and reliability of measurements, hand-wrist and lateral cephalogram from 10 subjects was randomly selected.Measurements were performed 3 times with two weeks of interval.There were no significant differences for the determination of the handwrist maturation stage (p=0.042)and for vertebrae maturation stage (p=0.375).
Statistical analysis was performed using SPSS 17 to determine the mean and standard deviation of handwrist and cervical vertebrae maturation stages and the relationship with the menarche (p=0.05).

results
Menarche is an indicator of physiological maturation that can be used to determine the stages of pubertal maturation through interviews with patient or parents.Study showed that menarche occur one year after the peak of pubertal growth and indicate that skeletal growth has been decline and less effective for orthodontic growth modification treatment. 6The result of this study showed  that initial acceleration of pubertal growth, PP3= is reached at 9.41 ± 0.14 years.The peak of pubertal growth (MP3cap) indicator was reached at 11.82 ± 0.56 years (Tabel 1), the peak of pubertal growth of cervical vertebrae CVMS II is at 10.62 ± 0.98 years and CVMS III at 12.58 ± 1.2 years, while the average of menarche was 12.30 years (Table 2).One year after the peak of skeletal growth, female would have their menarche, and in this study, if menarche was associated with indicators of hand-wrist maturation and cervical vertebrae maturation indicator, showed that 0.47 years after MP3cap and 1.69 years after CVMS2 or 0.49 years before CVMS3, the subjects would have menarche. 12he mean of menarche shown in Table 3.

discussion
Identification of pubertal growth stage, to determine how much the growth has been taken, or how long it will be finished, very important especially in orthodontic growth modification treatment and orthognatic surgery.Studies showed that the success of preventive and interseptive treatment in maxillo-mandibular disharmony, was in the begining until around the peak of pubertal growth, while orthogantic surgery was after pubertal growth has been completed. 1,2he result of this study showed that using hand-wrist skeletal maturation index, initial acceleration stage of pubertal growth (PP3) is at 9.41 ± 0.14 years and the peak of pubertal growt (MP3cap) was reached at 11.82 ± 0.56 year (Table 1), while using cervical vertebrae maturation index the acceleration stage CVMS1 is at 9.91 ± 0,89 year, and the peak of pubertal growth (CVMS3) is 12.58 ± 1.28 year (Table 2).The average of menarche was 12.30 years (Table 3).If menarche was associated with skeletal maturation index showed that after 0.47 years of MP3cap stage and 1.69 years after CVMS2 or 0.49 years before CVMS3, the subjects would have menarche.The results of the study in Taiwan, from 148 subjects, showed that the average age of menarche is 11.97 years, and the average of menarche occurs at the stage IV-V NTUH-SMI and V, and between stages III and IV. 13 The clinical implication in orthodontic treatment, patient who has menarche, has been in a decline stage of pubertal growth, and interceptive orthodontic treatment for maxillomandibular disharmony using functional appliances would have insignificant result.By knowing menarche of a patient, it can be used to predict how long the pubertal growth will be completed so that orthognatic surgery can be done without the risk of relaps due to the growth.
The result of this study indicate that the final stage of pubertal growth (Ru stage) using hand-wrist maturation indicator will be achieved in 3.63 years after menarche, while the final stage of cervical vertebrae maturation indicator (CVMS5) will achieved 2.84 years after menarche.Menarche data in this study was obtained retrospectively, by interviews with subjects and their parents.Most subjects remember the exact month and year using indicators of special events like her birthday, school holiday, fasting month or new year eve.Some menarche data in Indonesia, showed that rural children menarche occured at 11.46 ± 0.99 years while urban children occured at 11.87 ± 0.99 years. 14The research of Batubara 15 in seven provinces in Indonesia, menarche occured from the age of 12.5 years to 13.6 year. .In this study the mean of menarcheal age was 12.30 ± 073 year with the youngest was 10.92 years and the oldest was 13.83 years.In industrial country the age menarche in USA shows at the age of 12.5 years.In European countries the average menarche in Turkish was estimated as 13.30 year, Swedia 13,05 ±5. .7][18] For some countries in Asia, average menarche in Taiwan occured at the age of 11.97 year, in Japan at the age of 12.2 year, and in Korea at the age of 13.10 ± 0.06 year .0][21] This differences can be caused by many factors such as the sample size, genetic, geographic, racial and etnic. 11he conclusion of this research is that menarche in Indonesia Deutero-Malay girls varies between the age of 10.92 ± 0.00 years to 13.31 ± 0.23 years with a mean of 12.30 ± 0.73 years.Menarche is associated with skeletal maturation stage hand-wrist and cervical vertebrae maturation stage, 0.47 years after MP3cap stage (11.83 years) and 1.69 years after CVMS2 or 0, 49 years before the stage CVMS3 (12.79 years) the subjects will have their menarche.Menarche can be used for determining the active growth stage of a girl and to predict the finished of pubertal growth.

table 1 .
The age of hand-wrist maturation stages of pubertal growth (year)

table 2 .
The

table 3 .
The mean age of menarche (year)