Journal of Oral Biology and Craniofacial Research 7 (2017) 27–31

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Original Article

An evaluation of craniofacial growth pattern in North Indian children Vivek Mehta *, R.K. Pandey Department of Pediatric and Preventive Dentistry, Faculty of Dental Sciences, King George Medical University, Lucknow, India

A R T I C L E I N F O

A B S T R A C T

Article history: Received 1 August 2016 Accepted 1 December 2016 Available online 1 February 2017

Objective: The aim of this study was to assess craniofacial growth pattern in children with generalized decreased skeletal age and compare it with the children having normal skeletal age. Materials and methods: Lateral cephalograms and hand wrist radiographs of 40 patients (age group 3–14 years) were taken and skeletal age assessment was done with hand wrist radiographs according to Greulich and Pyle, based on which two groups were made, Group A – Control group (normal skeletal age) and Group B – study group (decreased skeletal age). Group A had a sample size of 21 and Group B, a sample size of 19. These were further divided into subgroups according to age: subgroup (a) – 3 to 6 years, subgroup (b) – 7 to 11 years and subgroup (c) – 12 to 14 years. The skeletal and dental patterns were analyzed with Down’s Cephalometric analysis. Student ‘‘t’’ test was used to verify comparisons in all the subgroups of patients of Group A and Group B. Results: The facial angle and Cant of occlusal plane exhibited maximum difference between the two groups which indicated that mandibular growth was affected more than other bones in diseased child patients. Conclusion: The present study led to the conclusion that craniofacial growth was retarded in children with generalized decreased skeletal age in comparison to healthy child patients. ß 2016 Craniofacial Research Foundation. All rights reserved.

Keywords: Skeletal age Lateral cephalogram Down’s analysis Mandibular growth

1. Introduction Physiologic growth of an individual child is defined as a child’s progress towards completeness of development or maturity. It is a dynamic statement for the general health of that child. Its correlation with skeletal age can be is assessed at any single point through the growth chart, although this information is not very meaningful, still it indicates whether the direction of individual’s growth is average, a variant of the norm, or pathologic. In other words, it is of great significance to find out that the children visiting the dental outpatient departments have skeletal age in concordance with chronological age to rule out any endocrinological disturbances which may influence the treatment planning and treatment outcome for these patients. Bone age assessment, a procedure frequently performed in paediatric radiology is based on a radiological examination of skeletal development of the left-hand wrist and comparison with the chronological age. A discrepancy between these two values indicates abnormalities in skeletal development. General principle

* Corresponding author. Present address: Department of Pediatric and Preventive Dentistry, Faculty of Dentistry, Jamia Millia Islamia, New Delhi 110025, India. E-mail addresses: [email protected] (V. Mehta), [email protected] (R.K. Pandey). http://dx.doi.org/10.1016/j.jobcr.2016.12.001 2212-4268/ß 2016 Craniofacial Research Foundation. All rights reserved.

of orthodontic and orthopaedic treatment in children is to utilize growth of the child considering the amount of growth remaining and the direction in which the forces are to be applied to stimulate growth in desired direction. Ricketts1 believes that ‘‘to take advantage of growth, we must have some idea first of its amount and second of its direction’’. Singer2 has added a third ingredient, the need to know the time when the major growth increments are likely to occur. Thus in addition to studying the craniofacial growth in normal children, it is important to understand the growth in children with deviating growth pattern3 or in children with reduced or accelerated skeletal age so that the clinician would be able to assess the best time for providing orthodontic/orthopaedic treatment to the child and optimal direction of application of force to minimize undesirable effects. 2. Aim The aim of this study was to assess the craniofacial growth pattern in children with generalized decreased skeletal age and compare it with the growth pattern of normal healthy child patients of same chronological age at a tertiary health centre. 3. Material and methods The present study was conducted on 40 North Indian healthy and diseased children, 25 males and 15 females in the age group

[(Fig._1)TD$IG]

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Table 1 Number of samples used in each subgroups of the study. Sub groups

Age group

Group I

Group II

Group A Group B Group C

3–6 years 7–11 years 12–16 years

N=6 N=7 N=7

N=6 N=5 N=6

from 3–14 years out of which 37 children were selected from the Outpatient Department of Pediatrics and Outpatient Department of Pedodontics and Preventive dentistry, C.S.M. Medical University, Lucknow. Healthy children (control group) were selected according to Indian weight standards developed by Aggarwal et al.4 The normal variation range in weight was taken between 3rd and 97th percentile curves for a particular age. The child patients beyond this range were not included in the study. A brief history of each child including name, age, sex, date of birth, name of the school and address was recorded. The informed consent was obtained from the parents and school teachers. The study included hand wrist radiographs of left hand and lateral cephalograms using 800  1000 films. The hand wrist X rays were studied for skeletal age assessment based on atlas by Greulich and Pyle5 and thereafter the sample was categorized into 2 groups – Group A or Control group comprising of 21 patients having normal skeletal age and Group B or Study group comprising of 19 patients having decreased skeletal age. Further the sample was subclassified into subgroups – (a), (b), (c) according to the chronological age of the child. The subgroup (a) consisting 6 of patients in the range of 3–6 years, subgroup (b) of 7 patients in range of 7–11 years and subgroup (c) of 7 patients in the range of 12–14 years. Craniofacial growth for each individual was evaluated by lateral cephalogram. The cephalograms were traced and Down’s analysis was preformed for each individual as it is one of the most commonly used analysis which shows conformity with the present study. The ten different parameters (facial angle, angle of facial convexity, A–B plane angle, mandibular plane angle, Y-axis angle, Cant of occlusal plane, inter-incisal angle, incisors (1) occlusal plane angle, incisor (1) mandibular plane angle, upper incisor (1) to A-Pog line) were evaluated for both the Group A and Group B subjects and presented in Table 1. After analyzing skeletal and dental parameters, Student ‘t’ test was used to verify comparisons in all the subgroups of patients with and without generalized decreased skeletal age.

Fig. 1. Facial angle in subgroup (b) and (c) of Group B (diseased) were greater than Group A while of subgroup (a) were greater in Group A than Group B.

[(Fig._2)TD$IG]

Fig. 2. Angle of facial convexity of only subgroup (c) showed a considerable increase in diseased group (Group A) than normal group (Group B) while the other two subgroups did not show much variation.

[(Fig._3)TD$IG]

4. Results Craniofacial growth parameters of Group A and Group B for three subgroups were summarized in Table 1 and Figs. 1–10. All investigated parameters of Group A and Group B subjects for all the three subgroups showed no significant pattern. Group A subjects are highly variable than Group B. Inter-incisal angle showed the maximum and A–B plane angle the least angle value. Angle of facial convexity, mandibular plane angle, Y-axis plane, Cant of occlusal plane, inter-incisal angle of normal and diseased subjects in all the three subgroups does not differ significantly (p > 0.05). Facial angle and incisor (1) occlusal plane angle in subgroup (a) of diseased were found significantly (p < 0.05) lower than normal while A–B plane in subgroup (c), incisor (1) mandibular plane angle in subgroup (a) and upper incisor (1) to A-Pog line in age subgroup (a) and (b) of Group B were found significantly (p < 0.05) higher than the normal. The high variation in angles of the parameters of Group A in all the subgroups made other comparison insignificant (p > 0.05).

Fig. 3. A–B plane angle showed a great variation between Group A and B with Group A showing negative values and Group B showing positive values in all the three subgroups.

4.1. Correlation of craniofacial growth parameters of Group A All the investigated craniofacial growth parameters of Group A significantly (p < 0.01) correlated with each other except incisor (1) mandibular plane angle and upper incisor (1) to A-Pog line with angle of facial convexity. These significant associated parameters suggest that these are linearly dependent on each other and can be estimated by simple linear regression. Parameters also show positive association with each other except A–B plane angle. Facial angle may be the best indicator parameter for predicting other

[(Fig._4)TD$IG]

[(Fig._7)TD$IG]

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Fig. 7. Interincisal angle did not show much variation between Group A and B in all the subgroups.

[(Fig._8)TD$IG] Fig. 4. Mandibular plane angle did not show much variation between Group A and Group B in all the three subgroups.

[(Fig._5)TD$IG]

Fig. 8. Incisor to occlusal plane angle in Group A was significantly greater than Group B in subgroup (a) but decreased in subgroup (b) and (c).

[(Fig._9)TD$IG] Fig. 5. Y-axis was slightly raised in Group A than Group B in all the three subgroups but no significant variation was seen.

[(Fig._6)TD$IG]

Fig. 9. Incisor to mandibular plane angle in subgroup (a) of Group B was significantly greater than Group A but did not show much difference in subgroup (b) and (c).

[(Fig._10)TD$IG] Fig. 6. Cant of occlusal plane was greater in Group B than Group A in subgroup (b) and (c) but decreased in subgroup (a).

parameters. Similarly, angle of facial convexity (r = 0.54, p < 0.05) and inter incisal angle (r = 0.60, p < 0.01) negatively and significantly (p < 0.05) correlated with chronological age suggest the inverse relationship significantly (p < 0.05) and parameters angle of facial convexity and inter incisal angle also can be estimated through CA by simple linear regression i.e. without using cephalogram. 4.2. Correlation of craniofacial growth parameters of Group B Craniofacial growth parameters of Group B also correlated significantly (p < 0.05) with each but less in comparison to normal.

Fig. 10. Upper incisor (1) to A-Pog line in age subgroup (a) and (b) of Group B were found significantly higher than Group A.

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Correlation of facial angle with angle of facial convexity, Y-axis angle, Cant of occlusal plane, inter-incisal angle, incisor (1) occlusal plane angle; A–B plane angle with incisor (1) occlusal plane angle; Y-axis angle with upper incisor (1) to A-Pog line; Cant of occlusal plane with inter-incisal angle, incisor (1) occlusal plane angle, upper incisor (1) to A-Pog line; inter-incisal angle with Incisor (1) occlusal plane angle; incisor (1) occlusal plane angle with upper incisor (1) to A-Pog line and incisor (1) occlusal plane angle with upper incisor (1) to A-Pog line were found significant (p < 0.05). Correlation between chronological age of Group B subjects with facial angle, Y-axis angle, Cant of occlusal plane, inter-incisal angle and incisor (1) occlusal plane angle were found significant (p < 0.05). The significantly correlated parameters of Group B subjects with CA can also be estimated by linear regression analysis i.e. without using cephalogram. Like Group A, facial angle of Group B subjects may be the best indicator parameter for predicting other parameters. 4.3. Comparison of craniofacial growth parameters of Group A and Group B Comparing correlations of craniofacial growth parameters of normal with diseased, correlation coefficient between facial angle and Cant of occlusal plane (r = 0.90, Group A; r = 0.79, Group B) and of A–B plane angle with incisor (1) occlusal plane angle (r = 0.44, Group A; r = 0.50, Group B) of normal and diseased were found significant (p < 0.05) but opposite in directions (angle) and hence may be considered as differentiating parameters of Group A and B. Similarly, correlation coefficient of chronological age with facial angle (r = 0.29, Group A; r = 0.73, Group B) and angle of facial convexity (r = 0.54, Group A; r = 0.09, Group B) also showed an opposite directions of the angle in Group A and Group B subjects. Craniofacial growth parameters especially of Group A were found highly variable than the Group B. Facial angle and incisor (1) occlusal plane angle in sub age Group (a) of Group B were found significantly (p < 0.05) lower than Group A while A–B plane in subgroup (c), incisor (1) mandibular plane angle in age sub Group A and upper incisor (1) to A-Pog line in age subgroup (a) & (b) of Group B were found significantly (p < 0.05) higher than Group A. The high variation in angles of the parameters of Group A subjects in all the subgroups were accounted insignificant (p > 0.05). Craniofacial growth parameters especially of Group A correlated well with each other than Group B. Facial angle of both Group A and B subjects were found the most reliable parameter for estimating other parameters. Facial angle and Cant of occlusal plane were found the most differencing parameters of Group A and B subjects. Similarly, with respect to chronological age, the facial angle and angle of facial convexity were found the most suitable differencing parameters. 5. Discussion Childhood encompasses major changes in body composition and sexual development which is influenced by a variety of factors that may be genetic, environmental, hormonal, socioeconomic or nutritional. There are various orthopaedic or functional techniques that utilize amount as well as direction of growth of craniofacial skeleton of the child. Hence, in order to plan treatment in a growing child, it is imperative to know the skeletal age of the child rather than just the chronological age, and to also have an estimation of the amount of craniofacial growth remaining and the bones in the craniofacial skeleton that may be alter skeletal maturation. Thus this study was planned to assess craniofacial growth pattern in children with generalized decreased skeletal age so that a correlation could be achieved as to which skeletal and dental

parameters are severely affected in these children. This might help in formulation of a treatment plan for these children, so that optimum results could be achieved with minimum side effects. Bone age is an important parameter when children with growth disorders are investigated, and it is the basis for calculation of height prediction. Hand-wrist radiographs have been used for determination of maturation and subsequent evaluation of growth potential during preadolescence and adolescence. Thus in our study, assessment of bone age was done with the help of left hand wrist radiographs as recommended by Greulich and Pyle5 and substantiated as an accurate indicator of skeletal age as proven in various previous studies.6–11 Even though the standards in this atlas have been prepared by using American children, they have been employed in the present study due to the absence of any such standards published exclusively for Indian children as evidenced by Shah et al.11 As far as study of craniofacial growth is concerned, Down’s analysis done on tracings of lateral cephalograms provide a broad overview of skeletal and dental parameters related to facial harmony of any individual.12 It has been used as a cephalometric tool to aid in orthodontic case analysis and planning and is easily reproducible.13,14 Although McNamara’s analysis has been used to compare the dentofacial pattern of Bunt and Brahmin children.15 The paediatric age group data compiled by Kapoor16 showed agreement with the findings of our study. When children of decreased skeletal age are studied cephalometrically, they showed some variations from the healthy children with normal skeletal age. The deviation from normal growth may be due to various factors which in our study population was mainly attributed to patients with thalessemia or protein energy malnutrition. Thalessemia is a chronic familial hemolytic anaemia found commonly in countries bordering the Mediterranean Sea. In the present study a delay in maturation rates when compared with skeletal age assessments was evident. Before 4–5 years of age, the rates are nearly normal but they are slower as age increases. Our findings are in agreement with the results of Johnston et al.17 Protein energy malnutrition formed the second major group in the present study. Malnutrition is one of the major health problems in developing country. Bone age of diseased subjects was found to be delayed. Craniofacial morphology was not altered much. The results of the study corroborated with the findings of Steward et al.18 and Garn et al.19 The analysis of the chronological age and bone age revealed that bone age in diseased individuals is found less than their chronological age and bone age due to alteration in calcium phosphorus metabolism. Highly significant relationship of diseased chronological age and bone age which is evidenced by Steward et al.18 and Garn et al.19 who affirmed that malnutrition might be a cause of delayed skeletal age. The craniofacial growth parameters were recorded from lateral cephalogram of skull. The various craniofacial growth parameters recorded are facial angle, angle of facial convexity, A–B plane angle, mandibular plane angle, Y-axis angle, inter incisal angle, Cant of occlusal plane, incisor occlusal plane and incisor mandibular plane angle of normal subject were observed in accordance with the finding of Kapoor.16 While the parameter for the diseased individual comprised of a number of illness of varying magnitude, they cannot be compared as a whole. Thalessemia subjects showed a delay of the bone maturation as reaffirmed by Johnston et al.17 and Adelman et al.20 reviewed that orthodontic treatment has to be initiated in thalessemia patients since cephalofacial deformity increased with age and the disease process did not interfere with the bone activity associated with orthodontic tooth movement. The typical findings in subjects with thalessemia are a class II skeletal pattern, short cranial base length, short cranial length, short mandible, increased anterior and reduced posterior vertical

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dimensions and severe facial disfigurement as narrated by Alhaija et al.21 Bone age was delayed in protein energy malabsorption and males were affected more than females in accordance with studies of Tanner et al.22 and Frisancho et al.23 Malnutrition affected the maturation of the skeleton more than the teeth as confirmed by Steward et al.18 and Garn et al.19 According to a recent study conducted by Nathani et al.,24 frontal sinus can also be used as predictor for evaluation of growth patterns. In fact it has been found to be more reliable than maxillary sinus in assessment of different types of malocclusions.25 Furthermore Meka et al. have used a modified custom made software for the cephalometric analysis and established lateral cephalometric norms among Nalgonda children with mixed dentition.26 Thus this study supports the fact that the craniofacial growth in children with decreased skeletal age as a result of various diseases is different from healthy children and the timing for treatment and its direction is of paramount importance in imparting favourable results to the patients. Although we agree that the sample size is very small and inconsequential in formulating a hypothesis but it is still valuable in forming a basis for the thought process of studying diseased children with decreased skeletal age which may be done in further studies. 6. Conclusion The present study led to the conclusion that craniofacial growth was retarded in children with generalized decreased skeletal age in comparison to healthy child patients of normal skeletal age. The facial angle and Cant of occlusal plane exhibited maximum difference between the two groups which indicated that mandibular growth was affected more than other bones in child patients with decreased skeletal age. We recommend that further investigations need to be done with a larger sample size to arrive at a definitive diagnosis. Conflicts of interest The authors have none to declare. References 1. Rickets RM. Facial and denture changes during orthodontic treatment as analysed from the temporomandibular joint. Am J Orthodont. 1955;41:163–179. 2. Singer J. Physiologic timing of orthodontic treatment. Angle Orthod. 1980;50:322– 333.

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3. Fishman LS. Radiographic evaluation of skeletal maturation: a clinically oriented method based on hand-wrist films. Angle Orthod. 1982;52:88–112. 4. Ghai OP. 5th ed. Text Book of Essential Pediatrics. vol. 6. 1996. 5. Greulich WW, Pyle SI. Radiographic Atlas of Skeletal Development of the Hand and Wrist. 2nd ed. California: Stanford University Press; 1959. 6. Kucukkeles N, Acar A, Biren S, Arun TJ. Comparison between cervical vertebrae and hand-wrist maturation for the assessment of skeletal maturity. J Clin Pediatr Dent. 1999;24:47–52. 7. Mora S, et al. Skeletal age determinations in children of European and African descent: applicability of the Greulich and Pyle standards. Pediatr Res. 2001;50:624–628. 8. Varkkola O, Ranta H, Metsaniitty M, Sajantila A. Age assessment by the Greulich and Pyle method compared to other skeletal X-ray and dental methods in data from Finnish child victims of the Southeast Asian Tsunami. Forensic Sci Med Pathol. 2011;7(December (4)):311–316. 9. Pechnikova M, Gibelli D, De Angelis D, de Santis F, Cattaneo C. The ‘‘blind age assessment’’: applicability of Greulich and Pyle, Demirjian and Mincer aging methods to a population of unknown ethnic origin. Radiol Med. 2011;116(7):1105–1114. 10. Randall T, et al. Applicability of the Greulich and Pyle skeletal age standards to black and white children of today. Am J Dis Child. 1993;147(12):1329–1333. 11. Shah PN, Joshi MR, Daruwala NR. The interrelationship between facial areas and other body dimensions. Angle Orthod. 1980;50(1):45–53. 12. Downs WB. Variations in facial relationships: their significance in treatment and prognosis. Am J Orthod. 1948;34(10):812–840. 13. Downs WB. The role of cephalometry in orthodontic case analysis and diagnosis. Am J Orthod. 1952;38:162–182. 14. Downs WB. Analysis of the dentofacial profile. Angle Orthod. 1956;26: 191–212. 15. Bhat M, Sudha P, Tandon S. Cephalometric norms for Bunt and Brahmin children of Dakshina Kannada based on McNamara’s analysis. J Indian Soc Pedo Prev Dent. 2001;19(June (2)):41–51. 16. Kapoor DN. A Handbook of Cephalometric Norms for Indian Ethnic Groups. An Official Publication of Indian Orthodontic Society; 2015: 31. 17. Johnston FE, Hertzog KP, Malina RM. Longitudinal growth in thalessemia major. Am J Dis Child. 1966;112:396–401. 18. Steward TD. New developments in evaluating in evidence from the skeleton. J Dent Res. 1963;42:264–273. 19. Garn SM, Lewis AB, Kerewsky RS. Genetic, nutritional and maturational correlates of dental development. J Dent Res. 1965;44(suppl 1):228–242. 20. Adelman AB. Cooley’s anemia from an orthodontic viewpoint. N Y State Dent J. 1965;31:405–408. 21. Alhaija ESA, Hattab NF, Omari M. Cephalometric measurements and facial measurements and facial deformities in subjects with beta-thalessemia major. Eur J Orthod. 2002;24(1):9–19. 22. Tanner JM. Growth at Adolescence. 2nd ed. Oxford: Blackwell Scientific Publications; 1962:34–43. 23. Frisancho AR, Sanchez J, Pallardel D, Yanez I. Adaptive significance of small body size under poor socioeconomic conditions in Southern Peru. Am J Phys Anthrop. 1973;39:255–262. 24. Nathani R, Diagavani P, Shrivastav S, Kamble R, Gupta D, Korde S. Evaluation of frontal sinus as a growth predictor in horizontal, vertical and average growth pattern in children from 8 to 11 years: a cephalometric study. J Indian Orthod Soc. 2016;50:101–105. 25. Dhimant I, Singla A, Mahajan V, Jaj HS, Seth V, Negi P. Reliability of frontal sinus with that of maxillary sinus in assessment of different types of skeletal malocclusions. J Indian Orthod Soc. 2015;49:96–203. 26. Meka M, Sandipamu TR, Reddy RE, Natta S, Aduri R, Dande SS. Establishing lateral cephalometric norms for Nalgonda children with mixed dentition. J Orthod Res. 2015;3:134–137.

An evaluation of craniofacial growth pattern in North Indian children.

The aim of this study was to assess craniofacial growth pattern in children with generalized decreased skeletal age and compare it with the children h...
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