# A Statistical Procedure for Exploring a Skeletal Age-Explicative Tool for Growing Patients
## 4 Discussion
However, the statistical analysis showed that the dental maturation stage was not a statistically significant explicator because the assessment of skeletal age had a very low explicative value. The reason for this result could be ascribed to the first premolars always showing a high degree of maturation in patients aged [13; 14; 15; 16; 17; 18; 19], like in the present sample. Therefore, the results of the present study are partially supported by recent research of [PERSON] et al., who assessed that dental age is a reliable marker for chronological age, and skeletal maturation aligns closely with chronological age. While BMI appears to be weakly correlated with skeletal and dental growth, further research is necessary to fully understand its impact [50]. Finally, another variable studied in the present research article was the staging of the skeletal maturation of the midpalate suture. Methods have been proposed using either 3D images [27] or occlusal radiographs [51]; for the present study, the \"BOKA Grading System\" was used, because it is a method based on OPG and thus does not require additional radiographs. The obtained results suggested that the midpalate suture's maturation has a role in the definition of skeletal age when stage 3 of maturation is observed. In other words, this result should be interpreted as stage 3 midplatal suture maturation being an indicator of a higher stage of skeletal age, such as SM3 or SM4. This is a very important outcome since midpalate suture maturation has never been correlated to skeletal age assessment before, apart from a study by [PERSON] et al. that demonstrated a correlation between the cervical vertebrae maturation and the fusion of the midpalate suture, which seems to occur after the pubertal growth spurt when the cervical vertebrae maturation is at stage four (the first maturation stage after the pubertal spurt) [52]. The limitations of the present study are represented by the retrospective sampling, even though care was taken to avoid selection biases by enrolling the patients in a rigid chronological order. Due to the cross-sectional design, it was not possible to verify the actual distance of the patient from the pubertal growth spurt, which is easily identifiable in females with menarche, but it is more difficult in males. Therefore, the evaluation of the second phalanx of the third finger was considered as a reference, but only a longitudinal study over a very long period would allow us to confirm and validate the skeletal age estimation from the proposed methods. Moreover, since the radiograph of the second phalanx of the third finger is useful in pubertal subjects, most of the subjects enrolled in the study were in SM2 or SM3, while there were fewer subjects in SM1 and SM4. Finally, there are other methods available in the pediatric field for the assessment of the skeletal age [53; 54; 55] which were not considered in this study, like the cervical maturation method on cephalospor. However, sometimes the estimate of skeletal maturation should be performed prior to taking a cephalospor, or to identify when to take a cephalospor to start planning a treatment. Therefore, it was preferred to evaluate a statistical tool that relied only on screening exams, like OPGs.