Recent advances in skeletal maturity studies
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RECENT ADVANCES IN SKELETAL MATURITY STUDIES
JERUN JOSE
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INTRODUCTION HISTORY METHODS TO STUDY GROWTH RECENT ADVANCES IN GROWTH STUDIESModified CVMIModified Hagg and TarangerMaxillary canine eruption and skeletal maturity
CONTENTS
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Serum Dehydroepiandrosterone and skeletal maturitySerum PTHrP and skeletal maturityIGF-1 and skeletal maturityGCF and Alkaline phosphatase activity in skeletal maturityMasseter muscle conduction velocity and direction of mandibular growth
CONCLUSION REFERENCES
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Growth of the craniofacial skeleton is a complex mechanism. In growth studies we are assessing pattern of growth, sites of growth, amount and rate of growth, direction and factors influencing growth.
INTRODUCTION
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Proffit
1. Measurement approaches
2. Experimental approaches
METHODS TO STUDY GROWTH
Text book of craniofacial growth , Sridhar Premkumar
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Measurement approaches
Measurements taking from living animals. Do not harm animal or human beings
1. Craniometry
2. Anthropometry
3. Cephalometry
4. 3D imaging
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Experimental approaches
Procedure is invasive, cause harm to the animals1. Vital staining 2. Radioactive tracer3. Autoradiography4. Implant radiography
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Sarnat in 1986 classified the growth measurement methods as1. Direct measurements2. Indirect measurements
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Direct measurements Anthropometry Vital staining Histological methods Histochemical methods Implants
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Indirect measurements Impressions and casts Photographs Radioautographs Radiographs Serial cephalometric radiography and
implantation
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Hippocratus in BC 450 studied about human skull forms.
Leminus in 1567 first mentioned the red staining properties of root of madder in bone.
Duhamel introduced implants in the study of growth of bones in 1742
History
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Robinson and Sarnat in 1955 used serial cephalometric radiography along with implant in pig for growth study of mandible.
Mcnamara and Graber (1975) and Bjork in 1963 used implants in humans for growth study.
CVM indicators by Lamparski in 1972 Leonard s Fishman, in 1982 developed skeletal
maturity indicator using handwrist radiography.
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RECENT ADVANCES IN GROWTH STUDIES
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Proposed by Lamparski (1972) 1st modification by Hassel and Farman in
1995 The method of Hassel and Farman uses the
second through the fourth vertebrae to avoid the defect in the original method.
Modified cervical vertebrae maturation
Skeletal maturation evaluation using cervical vertebrae.AJODO, Jan 1995
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SEMIN IN ORTHOD- 2005
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Cervical stage 1 (CS1). The lower borders of all the three vertebrae (C2-C4)are flat. The bodies of both C3 and C4 are trapezoid in
shape (the superior border of the vertebral body is tapered from posterior to anterior.
The peak in mandibular growth will occur on average 2 years after this stage.
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Cervical stage 2 (CS2). A concavity is present at the lower border of C2. The bodies of both C3 and C4 are still trapezoid
in shape. The peak in mandibular growth will occur on
average 1 year after this stage.
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Cervical stage3 (CS3). Concavities at the lower borders of both C2 and C3
are present. The bodies of C3 and C4 may be either trapezoid
or rectangular horizontal in shape. The peak in mandibular growth will occur during
the year after this stage.
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Cervical stage 4 (CS4) Concavities at the lower borders of C2, C3, and
C4 now are present. The bodies of both C3 and C4 are rectangular
horizontal in shape. The peak in mandibular growth has occurred
within 1 or 2 years before this stage.
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Cervical stage 5 (CS5) The concavities at the lower borders of C2, C3, and C4
still are present. At least one of the bodies of C3 and C4 is squared in
shape. If not squared, the body of the other cervical vertebra still
is rectangular horizontal. The peak in mandibular growth has ended atleast 1 year
before this stage.
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Cervicalstage6(CS6) The concavities at the lower borders of C2, C3, and
C4 still are evident. At least one of the bodies of C3 and C4 is
rectangular vertical in shape. If not rectangular vertical, the body of the other
cervical vertebra is squared The peak in mandibular growth has ended at least 2
years before this stage.
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By Rajagopal et al (2002) Additional bone stage between MP3-H and
MP3-I, which is called MP3-HI stage has been added.
Modified Hagg and Taranger
A comparison of modified MP3 stages and the cervical vertebrae as growth indicators. JCO -2002 Jul;36(7):398-406
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Comprises 6 stages, 1.MP3-F stage is the start of the curve of pubertal growth
spurt: the epiphysisis as wide as the metaphysis The ends of the epiphysis are tapered and rounded; the
metaphysis shows no undulation; and the radiolucent gap (representing the cartilaginous epiphyseal growth plate) between the epiphysis and the metaphysisis wide
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2.MP3-FG stage is the acceleration of the curve of the pubertal growth spurt: the epiphysisis as wide as the metaphysis the metaphysis begins to show as light undulation radiolucent gap between the metaphysis and the
epiphysisis wide.
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3.MP3-G stage is the maximum point of the pubertal growth spurt: the sides of the epiphysis have thickened and cap its metaphysis, forming a sharp distal edge on at least 1side; marked undulations in the metaphysis give it a “Cupid's bow” appearance. The radiolucent gap between the epiphysis and the
metaphysisis moderate.
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4.MP3-H stage is the deceleration of the curve of the pubertal growth spurt
fusion of the epiphysis and the metaphysis begins
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5.MP3-Hi stage is the maturation of the curve of the pubertal growth spurt The superior surface of the epiphysis has a smooth
concavity The metaphysis shows a smooth,convex surface
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6.MP3-I stage is the end of the pubertal growth spurt fusion of the epiphysis and the metaphysis is
complete. There is no radiolucent gap between the
metaphysis and the epiphysis.
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Hagg and Taranger reported that all canines and premolars are usually erupted by the end of the pubertal growth spurt .
This was confirmed with the hand wrist.
Eruption of maxillary canine and skeletal maturity
AJODO 2008
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CS1 and CS2 –Prepubertal stages CS3 and CS4 – Pubertal stages CS5 and CS6 – Post pubertal stages
Digramatic representn of 6 stages of CVM, SEMIN IN ORTHOD- 2005
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Erupting permanent canine in a 12 year 9 month old patient with CS3 stage .
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In 56.6% of patients, the canine erupts in the dental arch at least 1 year before the pubertal growth spurt.
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Puberty is a neuro endocrinal event with the pituitary and hypothalamus playing a major role in its initation.
Both the pituitary and hypothalamus are together called gonadostat.
In puberty, gonadotropin releasing hormone is secreted from the hypothalamus, which stimulates the pituitary to secrete gonadotropins (FSH, LH)
SERUM DEHYDRO EPIANDROSTERONE SULPHATE AND SKELETAL MATURATION
EJO- 2012, VOL 34
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These gonadotropins stimulate the gonads to secrete the sex steroids testosterone and estrogen, which inturn affects skeletal maturity in puberty.
For the gondaotropins to iniate its action, it requires stimulation from the adrenal gland.
Adrenal gland secretes steroids like dehydroepiandrosterone (DHEA) and its sulphated conjugate dehydroepiandrosterone sulphate (DHEAS). Auches and Rainey 2004
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They are present in circulation approximately 3 years prior to puberty.
This period is termed as adrenarche These steroids can stimulate growth and
proliferation of epiphyseal cartilage and potentiate action of growth hormone (GH)
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DHEAS has been foud to enhance bone deposition to increse bone mineral density, and to maintain the cancellous and cortical bone mass by way of protective action in osteoblasts.
Serum levels of DHEAS are high in neonates, after which there is a decrease , then a rapid increase in the serum levels from 7 years of age in females and 8 years of age in males, with a gradual increase until it attains adult value.
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Serum PTHrP and skeletal maturation
Parathyroid hormone related protein (PTHrP) regulate multiple steps in the development of the growth plate and seconadary cartilage at the head of condyle during skeletal morphogenesis.
2013,vol- 143
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Compared with Bacceti`s cervical vertebrae stages. There were low levels of serum PTHrP levels at the pre
pubertal stage (CS1) of circumpubertal development with an increase in the mean serum PTHrP levels from CS1 to peak levels in late puberty(CS5).
There was a decline between CS5 andCS6, with the values at the post pubertal stage (CS6) less than those values at the pre pubertal stage (CS1)
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Normal assay range of PTHrP was 0.5-15ng/mL. ELISA test was used in the study. Also found that serum PTHrP levels were at their
peak 2 years later than the peak height velocity. Showed a reduction in the mean serum PTHrP levels
from 14.5ng per milli liter of blood in the late pubertal stage to 8.3ng per milli liter in the post pubertal stage.
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Insulin-like growth factorI (IGF-I) is a polypeptide hormone synthesized mainly by the liver.
It is a member of a group of hormones termed insulin-like growth factors.
Insulin like growth factor 1 and skeletal maturity
2012, Vol 142
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It is considered a mediator of growth-hormone function.
It is involved in the growth of almost every organ and plays a major role in postnatal growth and precisely in the process of longitudinal bone growth.
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Salmon and Daughaday were the first to discover IGF-I as a mediator of growth-hormone function, which was termed the sulphation factor.
Several studies reported that its serum levels in children and adolescents followed a pattern that was closely related to the pubertal growth curve.
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Low in the prepubertal stages followed by a sharp increase at puberty and, after pubertal growth had ceased, returning to lower base line values.
ELISA is used for detection of IGF 1 Masoud et al used radioimmuno assay for
detection of IGF1 in their studies.AJODO- 2009
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Different assays were comparably accurate, especially in healthy subjects.
The radioimmunoassay technique requires special laboratories that should have been equipped for radiation control.
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IGF-I serum levels peaked at stage 4 of the cervical vertebral maturation index with a mean value of 835.6ng/mL.
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IGF-I mean values increased gradually from stage1 (initiation) of cervical vertebral maturation to the peak level at stage4 (deceleration) and then declined gradually to approach base line levels at stage 6 (completion).
Stages 3 and 4 showed a difference between boys and girls. Girls had higher values in stage3 (transition), indicating their earlier onset of puberty, and boys showed higher values in stage 5 (maturation), indicating their more delayed pubertal growth spurt.
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Pattern of IGF-I in relation to the stages of the cervical vertebral maturation index.
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Gingival crevicular fluid (GCF) is a potential source of biomarkers, with molecular constituents that derive mainly from serum, and also from the interstitial fluids of periodontal tissues.
Gingival crevicular fluid protein content and alkaline phosphatase
activity in relation to pubertal growth phase
ANGLE ORTHOD-2012
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ALP is an enzyme that is necessary for bone mineralization, with its activity shown to be correlated with local tissue remodeling during orthodontic tooth movement and periodontal inflammation.
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This study was proposed as a non invasive diagnostic aid for the determination of optimal treatment timing in functional jaw orthopedics.
Both the volume and total protein content of the GCF have been used extensively to calculate the concentrations of the different GCF constituents, for their normalization.
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Total GCF protein content is not a reliable indicator of the different growth phases. While confirming that total GCF ALP activity would be a reliable biologic indicator of skeletal maturation.
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GCF ALP activity is a promising diagnostic tool for identification of the growth phases in individual subjects when expressed as the total, rather than the normalized
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Moss and Rankow reported that the function of the stomatognathic muscle affects the growing cranioface and plays a role in its morphogenesis
Masseter muscle conduction velocity and direction of mandibular growth
AJODO- 2005
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Human skeletal muscle fibers are classified into 2 types—-fast-twitch (F type or type 1) and slow twitch (S type or type 2) —based on contractility and tissue images, and muscle function is characterized by the composition ratio of these types of muscle fibers.
There is a strong correlation between the muscle conduction velocity (MCV) measured by using an electromyogram and the muscle fiber composition,
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MCV increases as the proportion of type II fibers increases.
It has been reported that the diameter of muscle fiber is proportional to MCV
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Ogata et al reported that a long face, in which the lower facial height is long, has a lower conduction velocity of the masseter muscle in maximum voluntary contraction and more type 1 fibers than a short face.
Therefore, by understanding the muscle fiber composition of the masseter muscle in childhood, it might be possible to predict the direction of growth of the mandible or vertical craniofacial morphology with non invasive methods.
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PROCEDURE The subjects sat on a dental chair in a shielded room, and
head positions were adjusted so that the Frankfort horizontal plane became parallel to the floor.
They were asked not to change their head positions on biting. Once they were relaxed, they were asked to perform 100%
maximum voluntary contraction (MVC) to measure the MCV of the masseter muscle.
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Bite-taking was done before performing MVC by using a silicon impression in the rest position of the mandible.
The MCV of the masseter muscle was measured when the subject clenched the silicon, to protect the teeth and periodontium and to increase the reproducibility of occlusion and muscle position.
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After the skin over the masseter muscle was thoroughly cleaned with rubbing alcohol on cotton to decrease impedance, the electrodes were attached to the skin with electrode paste.
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The position and direction of the left masseter muscle were confirmed through manipulation when the subject clenched her teeth, and electrodes were attached to the center of the left masseter muscle and at a point where the bottom of the electrode reached 5 mm above the mandibular plane.
The long axes of the electrode arrays were arranged to be parallel to the running direction of the masseter muscle.
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The subjects were asked to continuously perform voluntary contraction for approximately 3 seconds, and wave forms of the action potential were recorded.
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Measurement of propagation delay
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MCV of the masseter muscle was low in a long face, when the lower facial height is long, compared with that in a short face.
A strong correlation between MCV and the composition ratio of muscle fibre.
The proportion of type I fibers might be higher in a long face than in a short face.
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For growth modification to be successful, it is absolutely essential that it start at the right time. So we need more accurate growth assessment methods in our profession.
CONCLUSION
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Text book of craniofacial growth by Sridhar Premkumar. Tiziano Baccetti, Lorenzo Franchi, Simona De Lisa,
Veronica Giuntin.Eruption of the maxillary canines in relation to skeletal maturity. Am J Orthod Dentofacial Orthop 2008;133:748-51
SophieGray, Hamza Bennani. Morphometric analysis of cervical vertebrae in relation to mandibular growth. Am J Orthod Dentofacial Orthop 2016;149:92-8
REFERENCES
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