Radiographic choice for skeletal maturation assessment: a systematic review of Cervical Vertebrae Method and Middle Phalanx Method

The aim of the present study was to conduct a systematic review of the literature to provide an updated guide for clinicians in choosing the most appropriate radiographic method for skeletal age assessment and timing the pubertal growth spurt (PGS). The review followed the PRISMA guidelines and used the PICOS strategy. Eligibility criteria focused on studies published in the last decade, directly comparing the Cervical Vertebrae Method (CVM) and the Middle Phalanx Method (MPM). Two reviewers performed the selection and a third reviewer intervened in cases of disagreement. After screening, thirteen studies were included. The analysis revealed that CVM and MPM are highly correlated and equivalent biological indicators. From the perspective of precision and reliability, the MPM method demonstrated excellent intra-observer reliability and clearly revealed the PGS. Conversely, CVM method showed reproducibility that is not improved by increasing clinical experience, but it achieved excellent accuracy when supported by Deep Learning (DL) and Artificial Intelligence (AI) systems. This review revealed that although MPM remains an excellent biological indicator, the equivalence of results, combined with the routine adoption of cephalometric radiography and the increasing implementation of AI, solidifies CVM as the preferred radiographic method. Consequently, subjecting the patient to an additional hand-wrist radiograph is unwarranted, relegating MPM to the role of a reserve indicator. AI and DL technologies are expected to standardize and drastically improve the objectivity and accuracy of CVM assessments, representing a crucial shift toward objective clinical diagnostics to eliminate the acknowledged inter- and intra-observer variability and optimize radiation dose management. The protocol was registered with the Prospective International Register of Systematic Reviews under number ID 1,110,124.