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Maxillary growth and maturation during infancy and early childhood

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Objective: To describe maxillary growth and maturation during infancy and early childhood. Materials and methods: Serial cephalograms (N=210) of 30 subjects (15 females and 15 males) from the Bolton-Brush Growth Study were analyzed. Each subject had a series of six consecutive cephalograms taken between birth and 5 years of age, as well as one adult cephalogram. Twelve maxillary measurements (eight linear and four angular) and seven landmarks were used to characterize maxillary growth. Maturation of the linear measures was described as a percentage of adult status. Results: Maxillary and anterior cranial base size increased in both sexes between 0.4 and 5 years of age. The linear anteroposterior (AP) measures (S-SE, SE-N, ANS-PNS) increased almost as much as the vertical measures (S-PNS, SE-PNS, N-A, N-ANS) over the first 5 years. After 5 years of age there was significantly more vertical than AP growth. The size and shape changes that occurred were greatest between 0.4 and 1 years; yearly velocities decelerated regularly thereafter. Overall linear growth changes that occurred between 0.5 and 5 years of age (a span of 4.5 years) were generally greater than the changes in maxillary growth that occurred between 5 and 16 years (a span of 11 years). The linear measures showed a gradient of maturation, with the AP measures being more mature than the vertical measures. Male maxillae were less mature than female maxillae at every age. Conclusions: The maxilla undergoes its greatest postnatal growth change during infancy and early childhood, when relative AP growth and maturation are emphasized.
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Original Article
Maxillary growth and maturation during infancy and early childhood
Utumporn Laowansiri
a
; Rolf G. Behrents
b
; Eustaquio Araujo
c
; Donald R. Oliver
d
;
Peter H. Buschang
e
ABSTRACT
Objective: To describe maxillary growth and maturation during infancy and early childhood.
Materials and Methods: Serial cephalograms (N 5 210) of 30 subjects (15 females and 15 males)
from the Bolton-Brush Growth Study were analyzed. Each subject had a series of six consecutive
cephalograms taken between birth and 5 years of age, as well as one adult cephalogram. Twelve
maxillary measurements (eight linear and four angular) and seven landmarks were used to characterize
maxillary growth. Maturation of the linear measures was described as a percentage of adult status.
Results: Maxillary and anterior cranial base size increased in both sexes between 0.4 and 5 years
of age. The linear anteroposterior (AP) measures (S-SE, SE-N, ANS-PNS) increased almost as
much as the vertical measures (S-PNS, SE-PNS, N-A, N-ANS) over the first 5 years. After 5 years
of age there was significantly more vertical than AP growth. The size and shape changes that
occurred were greatest between 0.4 and 1 years; yearly velocities decelerated regularly thereafter.
Overall linear growth changes that occurred between 0.5 and 5 years of age (a span of 4.5 years)
were generally greater than the changes in maxillary growth that occurred between 5 and 16 years
(a span of 11 years). The linear measures showed a gradient of maturation, with the AP measures
being more mature than the vertical measures. Male maxillae were less mature than female
maxillae at every age.
Conclusions: The maxilla undergoes its greatest postnatal growth change during infancy and
early childhood, when relative AP growth and maturation are emphasized. (Angle Orthod.
2013;83:563–571.)
KEY WORDS: Maxilla; Infancy; Maturation; Growth; Cephalometrics
INTRODUCTION
Postnatal somatic growth is fastest and most intense
during the first 5 years. Greater rates of somatic
growth occur during infancy than at any other time
postnatally.
1
US children, for example, show marked
deceleration of growth in recumbent length during the
first 3 years.
2
Based on the close associations between
somatic and craniofacial growth and development,
3–5
greater rates of craniofacial growth might also be
expected during the first few postnatal years. Although
limited, there is evidence of marked craniofacial growth
during infancy and early childhood. The greatest
amount of postnatal growth in facial depth occurs
between 3 and 6 years of age.
6,7
Farkas et al.
8
showed
that the greatest yearly growth increments in male
head height and length occurred between 1 and
3 years of age. Based on large samples, Ohtsuki et
al.
9
reported greater cranial base growth during the first
5 years than during the remaining postnatal years, with
the greatest anterior and posterior growth changes
occurring during the first 2–3 postnatal years.
Understanding relative craniofacial growth is impor-
tant because it provides an indirect measure of a
structure’s response potential. Relative growth pro-
vides an indication of a structure’s growth response to
growth hormone supplementation
10
and alterations in
masticatory function.
11
Relative growth also makes it
a
Resident, Department of Orthodontics, Saint Louis Univer-
sity, St Louis, Mo.
b
Professor and Chairman, Department of Orthodontics, Saint
Louis University, St Louis, Mo.
c
Professor, Department of Orthodontics, Saint Louis Univer-
sity, St Louis, Mo.
d
Associate Clinical Professor, Department of Orthodontics,
Saint Louis University, St Louis, Mo.
e
Professor and Director of Orthodontic Research, Department
of Orthodontics, Baylor College of Dentistry, Texas A&M Health
Science Center, Dallas, Texas.
Corresponding author: Dr Peter H. Buschang, Professor and
Director of Orthodontic Research, Department of Orthodontics,
Baylor College of Dentistry, 3302 Gaston Ave, Dallas, TX 75246
(e-mail: phbuschang@bcd.tamhsc.edu)
Accepted: October 2012. Submitted: July 2012.
Published Online: November 13, 2012
G
2013 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/071312-580.1 563 Angle Orthodontist, Vol 83, No 4, 2013
possible to directly compare structures, regardless of
absolute size differences. Buschang et al.
12
reported a
growth maturity gradient between 4 and 16 years, with
the maxilla being more mature than the mandible but
less mature than the cranial base or vault. Farkas et
al.
8
showed that, by 1 year of age, head circumference
(87.5%) and length (87.1%) were relatively more
mature than other components of the craniofacial
complex, approaching adult size by 5 years of age. Liu
et al.
13
found that corpus length was consistently the
most mature measure, followed by overall length, then
ramus height during the first 5 postnatal years. The
relative growth of the maxilla during the first 5 years of
life has not been well studied.
Longitudinal studies of maxillary growth are limited,
especially during infancy and early childhood. Maxillary
growth is important due to the substantial vertical
dentoalveolar changes that occur
14
and the potential
role of the midface in coordinating the occlusal and
mandibular relationship.
15
Broadbent et al.
16
reported
that maxillary size (eg, N-ANS, S-N, ANS-PNS)
increased during the first 5 years. While SNA
decreased overall between 1 and 5 years, it did not
change from 2 to 3 years, and it increased slightly from
4 to 5 years. A comprehensive longitudinal evaluation
of maxillary growth and maturation has not previously
been undertaken. The amount of maxillary growth that
occurs and the sites where it is the most active during
the various stages of early development remain largely
unknown.
The purpose of the present study was to describe
the early postnatal growth and maturation of the
maxilla. To evaluate sources of variation explaining
differences in maxillary growth, the effects of sex and
class of occlusion were secondarily evaluated.
MATERIALS AND METHODS
Serial lateral cephalometric records of 30 normal,
untreated, healthy Whites were drawn from the Bolton-
Brush Growth Study.
1
The sample included 15 males
and 15 females, with equal numbers of Angle Class I
or Class II division 1, as categorized by the Bolton
study. Subjects with poor-quality cephalograms were
excluded.
The subjects were chosen based on having good-
quality, serial lateral cephalograms taken some time
during the first year of life (0.4 6 0.1 years), at
approximately 1 year of age, and every year thereafter
until approximately 5 years of age. Each subject also
had to have an adult cephalogram taken at the
minimum ages of 15 and 17 years for females and
males, respectively. The adult female and male
cephalograms were taken at 15.3 6 0.60 and 17.2 6
0.75 years of age, respectively.
Cephalometric Analysis
In total, 210 cephalograms were hand traced,
scanned, and digitized by the primary author using
Dolphin 3D Imaging 10.5 Premium Software (Dolphin
Imaging, Chatsworth, Calif). The cephalograms were
taken at the minimum midsagittal plane to film
distance, producing average magnifications ranging
from 7.4% to 8.4%.
1
Differences due to magnification
were not corrected in the present study.
Seven landmarks were identified on the anterior
cranial base and maxilla of each subject (Figure 1)
using operational definitions (Table 1). Eight linear
measurements were calculated to represent maxillary
and cranial base growth, including presphenoid seg-
ment length (S-SE), fronto-ethmoid segment length
(SE-N), posterior heights of the maxilla (SE-PNS and S-
PNS), anterior heights of the maxilla (N-A and N-ANS),
dentoalveolar height (ANS-Pr), and palatal plane length
(ANS-PNS). Maxillary maturity during the first 5
postnatal years was calculated based on the percent-
age of each linear measure’s adult size. Four angular
measurements were calculated to describe the degree
of maxillary prognathism (SNA), the direction of
maxillary growth (N-S-A), the inclination of the palatal
plane (SN/ANS-PNS, PPA), and the posterior position
of palatal plane relative to cranial base (N-S-PNS).
Reliability was enhanced by having each of the tracings
checked for accuracy by one of the co-investigators.
Statistics
Descriptive and inferential statistics were calculated
using SPSS version 18.0 (SPSS Inc., Chicago, Ill).
Skewness and kurtosis statistics showed that the
variables were normally distributed. Annual growth
velocities were calculated by dividing the differences
between measurements by the corresponding age
differences. Analyses of variance were used to
simultaneously evaluate sex and class effects, as well
as their interactions. The relative maturity of each of
the measures was calculated as the percentage of
adult size.
RESULTS
Absolute Maxillary Growth Changes
Repeated measures analyses of variance showed a
statistically significant (P , .05) class difference for
only one variable (N-S-PNS at 16 years), making it
possible to combine the Class I and Class II subjects.
There were, however, a number of statistically
significant sex differences for ANS-PNS, N-A, and
SE-N as well as for measures describing growth
changes, including the variables SE-N and N-ANS.
564
LAOWANSIRI, BEHRENTS, ARAUJO, OLIVER, BUSCHANG
Angle Orthodontist, Vol 83, No 4, 2013
Maxillary size increased in both sexes between 0.4
and 5 years of age. The linear AP measures (S-SE,
SE-N, ANS-PNS) increased almost as much as the
vertical measures (S-PNS, SE-PNS, N-A, N-ANS)
over the first 5 postnatal years (Table 2). The
sphenoidal portion of the anterior cranial base (S-SE)
and anterior dentoalveolar height (ANS-Pr) showed
the smallest growth changes, while N-A showed the
greatest. Males were generally larger than females,
with the differences often attaining statistical signifi-
cance. With the exception of S-PNS and SE-PNS, the
linear measurements grew faster in males than
females. The SNA and PPA angles decreased over
time in both sexes. The N-S-A and N-S-PNS angles
increased over time.
Yearly growth velocities of the linear measurements
decelerated over the first 5 postnatal years (Figure 2;
Table 3). They were greatest during the first year and
decreased progressively through the fifth year. During
the first year, several of the linear velocities decreased
by more than 2 mm per year. S-SE showed the lowest
rates of growth after the first year.
The angular measurements also showed the great-
est rates of change during the first year (Figure 3). The
N-S-PNS angle increased 8u–10u during the first year,
3u during the third year, and less than 1u during the fifth
year. Similarly, the palatal plane angle decreased
3u–4u during the first year, approximately 2u during the
third year, and increased slightly during the fifth year.
The N-S-A angle showed progressively less change
Figure 1. Cephalogram and cephalometric tracing along with the seven landmarks digitized.
Table 1. Cephalometric Landmarks Along with Their Abbreviations and Definitions
Landmark Abbreviation Definitions
Sella S Sella turcica, the center of the pituitary fossa of the sphenoid bone
Nasion N Junction of the frontonasal suture at the most posterior point on the curve at the bridge of the nose
Ethmoid registration point SE Intersection of the sphenoidal plane with the averaged greater sphenoidal wings (the
uppermost point of the sphenoethmoidal suture; greater wing of the sphenoid crosses
the cribiform plate or planum sphenoidale)
Posterior nasal spine PNS The most posterior point found at the tip of the posterior spine of the palatine bone on the
posterior part of the hard palate
Anterior nasal spine ANS The tip of the median, sharp bony process of the maxilla at the lower margin of the
anterior nasal opening
A A The deepest midline point on the curve of the maxilla between the anterior nasal spine
and prosthion (relative to ANS-PNS plane)
Prosthion Pr The most anterior, inferior point of the maxillary bone if no tooth has erupted, or its labial
contact with the maxillary central incisors
EARLY MAXILLARY GROWTH AND MATURATION
565
Angle Orthodontist, Vol 83, No 4, 2013
over time. The S-N-A showed small, inconsistent
changes during the first 5 years.
The overall linear growth changes that occurred
between 0.4 and 5 years of age (span of 4.5 years)
were generally greater than the changes in maxillary
growth that occurred between 5 and 16 years (a span
of 11 years). The linear growth changes from 6 to
16 years were greater in males than females, but
only the SE-N difference was statistically significant
(Table 4). The angular changes were also generally
greater during the first 4.5 years than the subsequent
11 years. The PPA, which underwent substantial
changes initially, showed only minor changes after
5 years of age. Before 5 years of age, N-S-PNS
increased approximately three times as much, and
N-S-A increased approximately twice as much, as they
did after 5 years of age. The S-N-A angle decreased
during the first 5 years and increased slightly thereafter.
Table 2. Maxillary Size (mm) and Shape (u) During Infancy and Early Childhood
a
Variables
Age, y
D0.4–5 y
0.41234 5
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Female
S-SE 20.0 2.1 22.7 4.6 22.7 2.4 23.0 2.0 23.5 2.3 23.6 1.9 3.7
SE-N 30.0 2.3 32.2 5.9 35.9 3.0 37.0 2.7 35.2 9.4 38.8 2.4 8.5
ANS-PNS 31.6 2.6 35.8 3.0 39.9 2.1 40.6 2.7 42.7 2.0 44.6 2.7 12.9
S-PNS 28.1 3.8 31.7 3.9 34.2 3.9 37.0 2.5 38.4 2.4 39.4 3.7 12.0
SE-PNS 23.7 4.1 28.6 4.8 31.4 5.1 34.4 3.7 36.2 3.7 36.9 4.9 14.4
N-A 32.0 2.7 35.8 3.2 40.9 2.4 43.2 3.8 44.8 3.8 47.1 3.1 15.1
N-ANS 29.2 2.6 31.5 3.0 36.2 2.3 37.7 2.6 39.3 2.9 41.3 2.6 12.2
ANS-Pr 12.1 2.2 13.3 1.9 15.6 2.5 16.5 2.1 17.3 2.5 17.6 2.5 5.3
SNA 82.0 4.9 82.9 4.0 81.0 4.4 80.8 3.8 81.4 3.7 81.6 3.0 16.7
N-S-A 34.8 2.2 35.2 2.9 37.7 2.5 38.7 3.4 39.3 3.1 39.9 2.4 5.1
PPA (SN/ANS-PNS) 13.4 4.1 9.0 6.2 9.1 5.6 6.4 3.5 5.9 3.3 6.4 4.5 20.5
N-S-PNS 51.1 6.4 55.1 7.1 60.8 6.0 63.7 5.3 65.7 4.6 66.9 4.5 27.9
Male
S-SE 19.7 2.3 22.2 2.2 23.1 2.8 23.9 2.1 24.1 2.0 24.5 1.8 4.9
SE-N 30.9 2.5 34.6 2.4 36.9 1.7 38.1 1.5 39.6 1.7 40.4 2.1 9.6
ANS-PNS 32.6 3.6 37.5 3.9 40.5 3.6 42.4 2.8 44.5 2.6 46.1 2.7 13.6
S-PNS 29.1 2.4 33.1 3.2 35.4 4.2 38.2 3.2 39.2 2.7 39.8 3.7 10.7
SE-PNS 25.0 4.9 28.8 4.0 31.9 3.6 35.3 3.1 37.3 3.1 37.9 4.5 12.7
N-A 33.6 2.3 39.6 3.1 43.4 2.6 46.1 2.8 48.4 3.3 49.9 3.6 16.5
N-ANS 30.1 1.8 34.8 2.7 37.0 2.3 39.2 2.9 41.7 2.6 43.2 3.0 13.2
ANS-Pr 11.8 2.3 13.8 2.2 15.0 2.2 16.8 1.9 17.2 1.8 18.0 2.2 6.3
SNA 82.0 4.2 80.5 3.5 79.8 3.6 80.1 3.4 78.9 3.0 79.8 3.2 15.0
N-S-A 35.9 2.4 37.6 1.8 39.1 2.1 39.9 2.2 41.0 2.6 41.1 2.5 5.1
PPA (SN/ANS-PNS) 13.2 6.4 10.3 4.7 8.4 5.1 6.6 4.0 6.8 2.9 7.7 4.5 22.2
N-S-PNS 52.6 10.1 58.7 7.8 61.4 6.2 64.5 5.4 67.6 4.3 67.8 5.0 25.3
a
SD indicates standard deviation. See Table 1 for variable definitions.
Figure 2A. Yearly velocities of linear maxillary measurements
of females.
Figure 2B. Yearly velocities of linear maxillary measurements
of males.
566 LAOWANSIRI, BEHRENTS, ARAUJO, OLIVER, BUSCHANG
Angle Orthodontist, Vol 83, No 4, 2013
Relative Maxillary Maturity
The maturity of the linear measures at 0.4 years
ranged between 49% and 78% for females and
between 50% and 73% for males (Table 5). The
maxilla of males was 1%–10.4% less mature than
the maxilla of females at 0.4 years and 0.1%–9.7%
less mature at 5 years. S-SE was the most mature
measure, having attained 77.9% (females) and 73.1%
(males) of its adult size at 0.4 years of age. SE-PNS
was the least mature measure at 0.4 years of age for
both sexes, having attained 49.2% and 49.9% of its
adult size in females and males, respectively (Figure 4).
Table 3. Year Growth Velocities of the Linear (mm/y) and Angular (u/y) Measures During Infancy and Early Childhood
a
Variables
Age, y
0.4–1 1–2 2–3 3–4 4–5
Mean SD Mean SD Mean SD Mean SD Mean SD
Female
Linear
S-SE 4.7 6.9 0.7 2.3 0.3 0.8 0.5 0.9 0.1 1.1
SE-N 3.0 9.4 3.7 3.8 1.1 1.0 0.7 0.9 3.6 9.5
ANS-PNS 6.5 5.2 4.1 3.3 0.7 2.1 2.1 2.4 1.9 1.6
S-PNS 6.3 7.7 2.5 2.5 2.8 3.8 1.4 2.6 1.0 2.1
SE-PNS 9.3 7.2 2.8 3.5 2.9 4.5 1.9 3.4 0.7 3.0
N-A 7.0 5.9 5.1 2.8 2.3 2.7 1.6 2.7 2.3 2.5
N-ANS 4.6 5.3 4.7* 2.5 1.5 1.4 1.7 1.3 2.0 1.5
ANS-Pr 2.2 3.6 2.2 2.3 1.0 2.1 0.7 2.5 0.3 2.9
Angular
SNA 0.6 7.5 22.0 3.9 20.1 1.7 0.6 2.1 0.2 2.7
N-S-A 1.6 5.4 2.5 3.0 1.0 2.3 0.6 1.8 0.6 1.6
PPA (SN/ANS-PNS) 27.5 12.8 0.1 4.5 22.7 6.1 20.6 4.1 0.6 3.1
N-S-PNS 8.5 13.9 5.7 5.4 2.9 5.5 2.1 4.3 1.2 2.9
Male
Linear
S-SE 4.2 4.3 1.1 1.8 0.7 1.9 0.2 0.8 0.4 0.8
SE-N 6.3 6.5 2.3 1.7 1.1 1.6 1.6 1.0 0.8 1.2
ANS-PNS 8.2 7.7 3.1 3.5 1.9 2.3 2.1 3.0 1.6 1.7
S-PNS 6.6 5.4 2.3 3.5 2.8 2.9 1.0 1.9 0.6 2.9
SE-PNS 6.4 8.8 2.9 4.9 3.4 4.0 2.0 1.6 0.6 3.2
N-A 9.9 5.2 3.8 2.7 2.7 2.8 2.3 2.7 1.5 2.3
N-ANS 7.8 4.2 2.3* 1.7 2.2 2.4 2.5 1.8 1.5 2.1
ANS-Pr 3.3 4.2 1.3 2.3 1.8 1.9 0.4 1.8 0.8 1.9
Angular
SNA 22.4 5.5 20.8 1.5 0.3 2.3 21.2 2.7 0.8 1.8
N-S-A 2.7 3.7 1.4 2.1 0.9 2.3 1.0 1.9 0.1 1.7
PPA (SN/ANS-PNS) 24.9 12.8 21.7 7.3 21.8 5.3 0.2 2.9 0.9 4.0
N-S-PNS 10.2 16.6 2.4 7.2 3.0 5.4 3.2 4.0 0.2 3.8
a
SD indicates standard deviation. See Table 1 for variable definitions.
* Indicates statistical significance.
Figure 3A. Yearly velocities of angular maxillary measurements
of females.
Figure 3B. Yearly velocities of angular maxillary measurements
of males.
EARLY MAXILLARY GROWTH AND MATURATION
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Angle Orthodontist, Vol 83, No 4, 2013
The other measures graded more or less regularly
between these two. With the exception of ANS-Pr,
the vertical measures were consistently less mature
than the AP measures, regardless of sex. This
graded pattern was maintained until 2 years of age
in females and 3 years of age in males, at which point
ANS-Pr became and remained the most mature
measure.
DISCUSSION
Growth rates were greatest during the first year and
then decelerated over the next four years. Rapid
deceleration of growth during the early years has been
previously described for general somatic growth. For
example, rates of growth in recumbent length for
males decrease from approximately 25 cm/y during the
first year to 0 cm/y during the third year.
2
The greatest
Table 4. Comparison of Linear and Angular Measurements Between T1–T6 and T6–T7
a
Variables
Females Males
0.4–5 y 1–5 y 5–16 y
Prob
Differences
DT1–T6 vs
DT6–T7
0.4–5 y 1–5 y 5–16 y
Prob
Differences
D0.4–5 y vs
D5–16 yMean Change/y SD Mean Mean Change/y SD Mean Change/y SD Mean Mean Change/y SD
Linear
S-SE 3.7 0.8 2.2 0.9 2.0 0.2 0.9 0.016 4.9 1.1 2.1 2.2 2.4 0.2 1.3 0.002
SE-N 8.5 1.9 1.8 6.7 6.5 0.6 1.9 0.010 9.6 2.1 3.7 5.8 8.5 0.8 1.9 0.273
ANS-PNS 12.9 2.8 4.2 8.9 6.8 0.6 3.1
,.001 13.6 3.0 4.2 8.6 9.1 0.8 3.5 0.012
S-PNS 12.0 2.6 3.3 7.8 10.4 0.9 3.9 0.090 10.7 2.3 3.6 6.7 11.2 1.0 4.3 0.829
SE-PNS 14.4 3.1 3.9 8.3 11.1 1.0 4.5 0.011 12.7 2.8 5.0 9.1 12.9 1.2 3.9 0.994
N-A 15.1 3.3 2.9 11.3 11.7 1.1 3.2 0.032 16.5 3.6 2.5 10.4 13.4 1.2 4.3 0.029
N-ANS 12.2 2.7 2.7 9.8 12.1 1.1 3.1 0.915 13.2 2.9 2.4 8.4 12.7 1.2 2.6 0.404
ANS-Pr 5.3 1.2 3.4 4.2 20.9 20.1 3.4 0.002 6.3 1.4 3.4 4.2 0.8 0.1 3.5 0.002
Angular
N-S-PNS 16.7 3.6 7.1 21.3 4.2 0.4 4.1
,.001 15.0 3.3 9.3 20.7 5.8 0.5 4.6 0.004
N-S-A 5.1 1.1 2.0 4.6 3.1 0.3 2.1 0.032 5.1 1.1 2.0 3.5 2.7 0.2 3.0 0.022
SNA 20.5 20.1 3.8 22.6 0.6 0.1 1.9 0.423 22.2 20.5 3.7 22.6 0.2 0.0 2.9 0.036
PPA (SN/
ANS-
PNS) 27.9 21.7 4.6 11.8 0.7 0.1 6.8
,.001 25.3 21.2 6.2 9.1 20.8 20.1 3.8 0.021
a
SD indicated standard deviation; bold indicated statistically significant (p,.05) differences. See Table 1 for variable definitions.
Table 5. Maxillary Maturity, as a Percentage of Adult Size, During Infancy and Early Childhood
a
Variables
Age, y
0.4 1 2 3 4 5
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
Female
S-SE 77.9 8.5 85.9 8.8 88.8 5.2 89.9 3.7 91.8 4.3 92.4 3.3
SE-N 66.7 4.9 70.9 12.2 79.3 5.7 81.8 4.4 83.3 5.4 85.9 3.5
ANS-PNS 62.0 8.8 69.9 7.4 77.9 5.9 79.3 6.0 83.4 5.4 87.0 5.0
S-PNS 56.5 6.1 63.7 8.3 68.6 7.2 74.3 4.6 77.2 5.3 79.2 6.9
SE-PNS 49.2 8.9 59.8 10.5 65.5 9.8 71.6 5.5 75.6 6.8 77.0 9.4
N-A 54.3 3.8 61.2 6.6 69.7 4.4 73.6 6.6 76.3 6.4 80.2 4.4
N-ANS 54.5 5.6 59.0 5.8 67.8 3.3 70.7 4.8 73.8 4.6 77.5 4.7
ANS-Pr 74.9 18.0 81.7 17.0 94.8 17.2 101.1 17.5 105.1 17.1 107.9 22.0
Male
S-SE 73.1 8.8 82.2 6.6 86.0 7.8 88.8 4.7 89.8 5.5 91.2 4.5
SE-N 63.2 6.7 70.7 3.6 75.6 2.6 77.9 3.8 81.1 3.4 82.6 3.3
ANS-PNS 59.2 6.0 68.3 8.0 73.7 6.8 77.2 6.1 81.0 5.0 83.9 5.5
S-PNS 57.5 5.8 65.2 5.9 69.6 7.8 74.9 5.1 77.0 4.0 78.3 7.3
SE-PNS 49.9 10.4 57.2 6.5 62.9 6.5 69.5 3.3 73.5 3.8 74.7 7.1
N-A 53.3 3.8 62.6 3.7 68.6 5.0 72.9 4.5 76.6 5.8 78.9 5.8
N-ANS 54.2 3.6 62.5 3.0 66.3 3.1 70.3 3.8 74.7 3.5 77.4 3.8
ANS-Pr 64.5 16.3 75.3 15.4 81.8 14.7 91.5 15.5 93.6 15.5 98.2 18.3
a
SD indicates standard deviation. See Table 1 for variable definitions.
568 LAOWANSIRI, BEHRENTS, ARAUJO, OLIVER, BUSCHANG
Angle Orthodontist, Vol 83, No 4, 2013
changes in cranial base growth also occur during the
first 5 postnatal years, especially during the first 2–
3 years.
9
Liu et al.
13
found that mandibular growth
changes were also greatest during the first 6 months
and decreased progressively thereafter. It appears that
the decelerating pattern of rapid growth observed
immediately after birth reflects a continuation of the
even more rapid growth that occurs prenatally.
Figure 4B. Percent adult status of males 0.4–5 years of age.
Figure 4A. Percent adult status of females 0.4–5 years of age.
EARLY MAXILLARY GROWTH AND MATURATION
569
Angle Orthodontist, Vol 83, No 4, 2013
The overall growth changes that occurred during the
first 5 postnatal years were generally greater than the
changes that occurred between 5 and 16 years. Broad-
bent et al.
16
found that the growth of ANS-PNS from 1 to
5 years was slightly less than the growth that occurred
between 5 and 16 years, as were the changes of N-
ANS. However, that study started at 1 year of age, while
the present study started at 0.4 years, and the greatest
growth changes occurred during the first year.
The relationship of the anterior maxilla to the anterior
cranial base changed only slightly during infancy and
early childhood. SNA decreased 0.4u and 2.2u in
females and males, respectively. While using a smaller
sample of subjects from the Bolton records, Broadbent
et al.
16
showed that SNA decreased 1.2u and 1.5u for
females and males, respectively. Ohtsuki et al.
18
reported greater decreases in the SNA angle between
birth and 5 years of age. SNA decreases may
represent a relative posterior repositioning of the
maxilla associated with greater relative forward repo-
sitioning of the anterior cranial base or with the
pronounced flexing of the cranial base the occurs
during the first few postnatal years.
9
This suggests that
N is moving forward relatively more than A.
18
Unlike the anterior region, the posterior aspect of the
maxilla underwent substantial posterior repositioning
relative to the cranial base between birth and 5 years
of age. The N-S-PNS angle increased 15u–16u,5u–6u
of which occurred during the first year. Ohtsuki et al.
18
also reported a substantial increase of this angle
between birth and 5 years of age. In contrast, Brodie
19
reported that PNS advances slightly relative to the S-N
line (S was their stable references point) from birth to
1 year of age, and then maintains a straight forward
growth direction. As previously suggested, the N-S-
PNS angle might be expected to increase with the
relative posterior repositioning of the maxilla.
During the first 5 years of life, absolute AP maxillary
growth was similar to vertical growth, while vertical
growth outpaced AP growth during later childhood and
adolescence. Farkas et al.
8
reported that the AP
growth of the head was significantly greater than
vertical growth before 5 years, while vertical growth
was greater after 5 years. This difference explains why
the AP maxillary measures are more mature than the
vertical measures during infancy and early childhood.
Similar patterns reported by Liu et al.
13
found that the
mandibular corpus length (Go-Gn) was consistently
more mature than ramus height (Co-Go) during the
first 5 years. Fields
20
also reported that the vertical
facial growth was the last dimension to be completed.
On average, late vertical growth increments are
greater in girls than in boys and occur in the maxilla.
The maxilla of males was 1% to 10.4% less mature
than the maxilla of females at 0.4 years, and 0.1% to
9.7% less mature at 5 years. Buschang et al.,
12
who
also quantified craniofacial relative maturity, found that
the maxilla of 4.5 years of males was 1%–2% less
mature than the maxilla of females. Liu et al.
13
reported
that male mandibles were 3.3%–3.9% less mature
than female mandibles at 0.4 years. The maturity
differences indicate that females have less growth
potential than males for birth onwards.
Anterior dentoalveolar height (ANS-Pr) showed
greater increases in maturation than the other mea-
sures during the first 3 years, closely approaching its
adult size by 4–5 years. Buschang et al.
12
showed that
anterior maxillary height had attained over 100% of
adult size by 5.5 years of age, with size decreasing
rapidly thereafter, followed by size increases. Savara
and Singh
21
and Singh and Savara
22
reported the
greatest increases in the growth of ANS-Pr during the
first 5 years, followed by decreases between 6 and
8 years due to loss of primary central incisors. This
indicates that appositional bone growth of the alveolar
process occurs rapidly during the first 2–3 years to
accommodate both the deciduous and permanent teeth
prior to the early mixed dentition phase of development.
With the exception of ANS-Pr, which showed a
different maturity pattern related to the developing
dentition, the various measures showed a graded
pattern of maturation, with the vertical measures being
less mature than the AP measures. Buschang et al.
12
were the first to report a maturity gradient for the entire
craniofacial complex, showing that the vertical aspect
of the maxilla (N-ANS) was also less mature than the
AP (ANS-PNS) at 4.5 years of age, with percent
maturity coinciding with the values obtained in the
present study. It has also been shown that the AP
dimensions of the mandible are more mature than its
vertical dimensions.
12,13
While it remained relatively unchanged after 5 years
of age, the palatal plane angle (PPA) decreased
substantially during the first 5 years. Although no
descriptive statistics were provided, Brodie’s
19
illustra-
tion representing 21 white males also showed that the
PPA decreases during the first 5 years of life. The
decreases could be explained by the growth of the orbit,
which grows rapidly during the first few years along with
the rest of the nervous system, and contributes greatly
to the vertical growth of the anterior part of the maxilla.
The roof of the orbit, AP length of the orbital floor, orbital
breadth, orbital height, and orbital volume grow most
rapidly during the first year of life.
23
CONCLUSIONS
N Maxillary and anterior cranial base growth rates are
the greatest during the first year, and then deceler-
ated over the next 4 years.
570
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Angle Orthodontist, Vol 83, No 4, 2013
N Overall growth changes during the first 5 postnatal
years are generally greater than the changes
between 5 and 16 years.
N The absolute growth of the AP measures is
comparable to the growth of the vertical measures,
whereas vertical growth outpaces AP growth during
late childhood and adolescence.
N ANS-Pr is the most mature during the first 3 years,
closely approaching its adult size by 4–5 years.
N The maxilla of males is 1%–10.4% less mature than
females at 0.4 years, and 0.1% to 9.7% less mature
at 5 years.
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Study design: Validation of classification system. Objectives: To externally validate the Proximal Humerus Ossification System (PHOS) as a reliable skeletal maturity scoring system and to assess the learning curve associated with teaching the procedure to individuals of varying levels of experience. Background: Assessment of skeletal maturity is essential for treatment decisions in Adolescent Idiopathic Scoliosis (AIS). PHOS is a five-stage system that uses the proximal humeral physis in assessing skeletal maturity and has been shown to reliably grade skeletal age leading up to and beyond peak growth age (PGA). This system is advantageous in the AIS patient, as it is often captured in standard scoliosis films. Methods: A medical student, an orthopedic surgery resident (PGY-2), spine fellow, and experienced scoliosis surgeon in his 25th year in practice were given a three-slide PHOS learning module. Each participant rated 100 X-rays on two separate occasions, separated by 1 week. Intra- and inter-observer reliability, as well as cross-institutional reliability, were calculated using intraclass correlation coefficients (ICC) with 95% confidence intervals [CI95]. Results: Average intra-observer reliability ICC between scoring sessions was 0.94 [0.92, 0.96] and inter-observer reliability by level of training were 0.94 [0.91, 0.96], 0.93 [0.9, 0.95], 0.94 [0.91, 0.96], 0.96 [0.94, 0.97] for the medical student, PGY-2, fellow, and attending, respectively. Reliability across institutions was 0.99 [0.98, 0.99]. Combined rating observations (n = 400) showed 82% exact matches, as well as 17% and 1% mismatches by 1 and 2 stages, respectively. Similar to the PHOS developers, we found PHOS stage 3 to occur immediately after PGA. Conclusion: PHOS is easily learned and employed by raters with varying levels of training. It comprises a five-stage system to reliably measure bone age leading up to PGA and thereafter. This new system relies on visualization of the proximal humerus, which is readily available on standard scoliosis X-rays. Level of evidence: Level III.
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An accurate volumetric analysis protocol for secondary alveolar cleft reconstruction is essential. It can help confirm favorable times for bone grafting, determine which graft material is more effective, and improve surgical techniques. This study aimed to introduce a novel protocol for precisely calculating the bone formation ratio (BF%) using computer-aided engineering. The helical computed tomography (CT) datasets of 14 patients who underwent alveolar cleft reconstruction was included in this study. CT scans performed preoperatively and 1 year postoperatively were evaluated by two investigators. Digital Imaging and Communications in Medicine (DICOM) data were reconstructed as three-dimensional (3D) images using Mimics software and processed by Geomagic Wrap 2017. Using the Boolean operation, the newly formed bone of the alveolar cleft was segmented by identifying the differences between pre- and postoperative 3D images. The volumetric assessment and morphological analysis of the newly formed bone could be determined in a precise manner, the mean BF% was 47.7%±16.4%, the mean time required for calculating was 23.57±3.64 minutes. For the difference in the volume of newly formed bone between the two observers, the intraclass correlation coefficient (ICC) was 0.92, p<0.001. This method is clinically practical and precise measurement, which has good reproducibility for evaluating outcome of different grafting materials for alveolar clefts.
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Lengths and angles within the cranial base and vault were measured in cephalometric radiographs of 220 boys and 177 girls ranging in age from 0 to 18 years. These children were participants in The Fels Longitudinal Growth Study. The present study is based on mixed longitudinal data derived from 1861 radiographs for boys and 1401 radiographs for girls. In this study, the anatomical parts of the cranial base are designated as follows: cranial base (nasion-basion), anterior cranial base (nasion-sella), fronto-ethmoidal segment (nasion-sphenoethmoidale), presphenoid segment (sphenoethmoidalesella), posterior cranial base (sella-basion), basisphenoid segment (sella-sphenoccipital), and basioccipital segment (sphenoccipital-basion). Endocranial points are used in the calvarial area for the vertex and anterior and posterior limits. Moreover, three angles are measured (nasion-sella-basion; sella-nasion-point A; nasion..sella-posterior nasal spine). Changes with age in the mean values for each dimension are described. The statistical significance of the observed age changes was tested by linear regression analysis for each variable after dividing the samples into three age groups (0-3, 4-6, 7-18 years). Contrary to reported findings, both basisphenoid and basioccipital segments increase steadily with age in each sex. The angle sella-nasion-point A decreases until the age of 10 years in boys and 9 years in girls; at older ages there is a tendency to increase with age in each sex.
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To construct a growth chart of the mandible throughout gestation. A prospective cross-sectional study of normal singleton pregnancies was conducted. Measurements of the fetal mandibular transverse and antero-posterior diameters were performed with high-resolution transvaginal and transabdominal ultrasonography in 490 pregnant women with singleton low-risk pregnancies between 11 and 31 weeks' gestation. The mandibular transverse and antero-posterior diameters were recorded by week of gestation and the ratio was calculated: mandibular ratio (MR) = 1.7759 - 0.01047 x gestational week. There was a negative linear correlation (-1.047%) for each incoming week of gestation. Normal values (+/-1SD and 2SD) were established. The present data provides a normal range of fetal mandibular diameters during normal pregnancies and introduces a new parameter, the mandibular ratio, for the intrauterine assessment of the fetal mandibular development.
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To describe the growth, maturation, and remodeling changes of the mandible during infancy and early childhood. Seven Bolton-Brush Growth Study longitudinal cephalograms (N = 336) of each of 24 females and 24 males, taken between birth and 5 years of age, as well as early adulthood, were traced and digitized. Five measurements and nine landmarks were used to characterize mandibular growth, remodeling, and degree of adult maturity. Overall, mandibular length showed the greatest growth changes, followed by ramus height and corpus length. Corpus length was the most mature of the three linear measures; ramus height was less mature than overall mandibular length. The greatest growth rates occurred between 0.4-1 year; yearly velocities decelerated thereafter. The ramus remodeled superiorly only slightly more than it remodeled posteriorly. Male mandibles were significantly (P < or = .05) larger, displayed greater growth rates, and were significantly less mature than female mandibles. There were no significant differences in mandibular growth or maturation between Class I and Class II patients. The mandible displays decelerating rates of growth and a maturity gradient during infancy and early childhood, with males showing more growth and being more mature than females.
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Skeletal and chronologic ages of both female and male populations were compared relative to the degree of concurrence between the two age-indices at the various age levels. Maxillary and mandibular cephalometric measurements were similarly compared for both sex groups. Individual's comparisons of facial changes were made relative to their respective chronologic and skeletal ages. The significance of a skeletal vs. chronologic age discrepancy and its relationship to the timing of facial growth was demonstrated. Clinical implications were discussed.
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Five measurements of the head were taken between 1 year and 18 years of age in 1,537 North American Caucasians. By 1 year of age, the circumference (87.5%) and length (87.1%) of the head showed the highest levels of developmental level compared with their adult size. By 5 years, the developmental level of all measurements in head width, head length, and circumference increased, closely approaching maturation. Head length reached full maturation at 10 years in females (182.7 mm), and at 14 years in males (189.2 mm). In females, head width showed the most advanced maturation at 14 years (142.7 mm). In males, most of the head measurements matured at 15 years of age. Adult head height was approached at 13 years in both sexes (113.3 mm in males and 109.8 mm in females). Early rapid growth in head height and head length took place between 1 and 4 years of age, and between 1 and 6 years in forehead width. The head width and head circumference showed continuous but mild growth rates throughout this period.