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Differences between male and female mandibular length growth according to panoramic radiograph

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Evaluation of the mandible was used for age and sex determination in the forensic field and it established the treatment planning in dentistry. The present study aims to determine mandibular length growth on male and female group aged 9-25 years old using panoramic radiograph. The research was conducted using analytical cross-sectional design method. The subject of this research was 412 panoramic radioraphs of patients aged 9-25 years old. It involved a total samples of 207 males and 205 females. This research was conducted from May to October 2017 in RSGM Padjadjaran University Bandung to meassure the length and height of mandibula from the point in condyleus to mentone. The MannWhitney test results showed a significant difference in mandibular length between men and women and no significant difference between the right and left mandibular length in men and women. There is a difference between male and female mandibular length growth, in which the increase of growth of mandibular length in female is earlier than that of male. Male mandibular length is greater than female.
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Azhari, et al: Differences between male …
43
RESEARCH ARTICLE
Differences between male and female mandibular length growth according
to panoramic radiograph
Azhari*, Berty Pramatika**, Lusi Epsilawati*
*Department of dentomaxillofacial radiology, Faculty of Dentistry, Padjadjaran University, Bandung, West Java, Indonesia
**Department of dentomaxillofacial radiology, Faculty of Dentistry, Universitas Airlangga, Surabaya, East Java, Indonesia
*Jl Sekeloa Selatan No 1, Bandung, West Java, Indonesia; e-mail: lusifkg92@gmail.com
Submitted: 22nd November 2018; Revised: 31st January 2019; Accepted: 4th February 2019
ABSTRACT
Evaluation of the mandible was used for age and sex determination in the forensic eld and it established the treatment
planning in dentistry. The present study aims to determine mandibular length growth on male and female group aged
9-25 years old using panoramic radiograph. The research was conducted using analytical cross-sectional design
method. The subject of this research was 412 panoramic radioraphs of patients aged 9-25 years old. It involved a total
samples of 207 males and 205 females. This research was conducted from May to October 2017 in RSGM Padjadjaran
University Bandung to meassure the length and height of mandibula from the point in condyleus to mentone. The Mann-
Whitney test results showed a signicant difference in mandibular length between men and women and no signicant
difference between the right and left mandibular length in men and women. There is a difference between male and
female mandibular length growth, in which the increase of growth of mandibular length in female is earlier than that of
male. Male mandibular length is greater than female.
Keywords: gender; growth; mandibular length; panoramic radiograph
Majalah Kedokteran Gigi Indonesia
Vol 5 No 1 – April 2019
ISSN 2460-0164 (print), ISSN 2442-2576 (online)
Available online at https://jurnal.ugm.ac.id/mkgi
DOI: http://doi.org/10.22146/majkedgiind.39164
INTRODUCTION
Growth and development is a process that runs
parallel, and it is inuenced by internal factors (e.g.
heredity, race, sexual, genetic) and external factors
(e.g. nutritional and functional). The mandibular
growth process is a complex process including
intramembranous ossication and endocondral
ossication.1,2 The mandible will be grown in
various directions, such as vertical, horizontal,
transverse, and rotational growth. The acceleration
of mandibular growth is parallel with the accelerated
phase of height growth In other words, the increase
and decrease in skeletal maturation has similar
uctuations with facial growth especially the
mandibular growth.3,4
Evaluation of the mandible was used for age
and sex determination in the forensic eld and
it established the treatment planning in dentistry
(e.g. determination of peak mandibular growth).3,5,6
The mandibular growth was a constant remodeling
process. Bone apposition and bone resorption that
occur as the human gets older causes mandibular
shape and size to change.7 The mandible is a bone
that has many morphological variations and it has
the most post-natal growth, compared to other
facial bones.8,9
Radiographic panoramic turned out to be used
for viewing the bone growth, such as morphological
changes, bone mineralization, and fusion in the
center ossication. Panoramic radiographs are
able to provide morphological information and bone
morphometric during the growth process. Several
studies have shown that panoramic radiographs
olso used to measure the vertical and horizontal
dimensions of the mandible.8,10,11 Calculating of the
height of the mandibular ramus, the length of the
mandibular corpus, the gonial angle, the bigonial
width, and the height of the condyles, is the one
technique to evaluate the growth of the mandible
length. Mandibular growth olso evaluated by
measuring the distance of the landmark point on the
mandible.8,9,10 The aim of this study is to determine
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ISSN 2460-0164 (print)
ISSN 2442-2576 (online)
44
mandibular length of male and female at the age of
9-25 years old using a panoramic radiograph.
MATERIALS AND METHODS
This research used analytical cross-sectional design
method and conducted from May until October
2017, at oral maxillofacial radiology department,
Dental Hospital Padjadjaran University, Bandung,
Indonesia. This research has been approved by the
ethics committee of Medical Faculty, Padjadjaran
University, Bandung (processing number: 745/
UN6.C.10/PN/2017). The Panoramic X-ray has a
current of 110, 230 V, 50/60 Hz, 1.3 KW of Picasso
Trio type brand from Vatech, E-WOO Technology
Co., Ltd. Korea.
The inclusion criteria of the research objects
are good quality panoramic radiographs taken
in May to October 2017 of patient aged 9 to 25
years old. The exclusion criteria are mandibular
panoramic radiographs showing growth abnor-
malities, pathological lesions, fracture, and ortho-
dontic instruments. The samples in this study were
divided into 3 groups of age groups based on
Indonesian Ministry of Health 2009, i.e. age group
A (9-11 years), age group B (12-16 years) and age
group C (17-25 years). The mandibular length was
measured with the the mandibular ramus height
(measured from the condyle point to the gonion
point) and the mandibular width (measured from
the gonion point to the menton point), Figure 1.
This study used SPSS version of IBM version
24 for statistical data analysis. The Kolmogorov-
Smirnov assumption test was used to assay the
normality of data distribution of mandibular length.
The Mann-Whitney U test was used to determine
the differences in mandibular length between
male and female. It was also used to determine
the differences between right and left mandibular
length for both male and female.
RESULTS
The study used 412 panoramic radiographs
consisting of 207 panoramic radiographs of male
patients and 205 radiographs of female patients
aged 9-25 years. The males and females mandibular
length in each age group are presented in Table 1.
The result of the Kolmogorov-Smirnov
normality test (Table 2) on the left-right mandibular
variables in males and females showed p-value of
<0.05, which means that the data are not normally
distributed. Thus, the researchers used the Mann-
Whitney U test, and the result of which is presented
in Table 3. Mann-Whitney test results show a
signicant difference in mandibular length between
male and female. Mann-Whitney U test was also
used to evaluate the difference between the right
and left mandibular length of both male and female
(Table 4). The results show that there is no signicant
difference between right and left mandibular length
of both male and female patients.
Figure 1. The mandibular length of both the right and left side was measured using Ez
Implant software in millimeter. The Ez Softwear impant is a softwear carried by Picaso
3D x-ray machineCo (Condylion): the most superior point in the mandibular condyle;
Go (Gonion): the most inferior and posterior point of the angle of the mandible; Me
(Menton): the lowest point on the mandibular symphisis on the mid-sagittal line
Azhari, et al: Differences between male …
45
Table 1. The mandibular length based on gender in 9-25 years old
Sex Age group Age Right mandibular
length (mm) SD Left mandibular length
(mm) SD
Male A
9
10
11
115.94
118.60
122.24
3.99
3.36
3.77
116.01
117.18
121.41
4.67
2.76
4.28
B
12
13
14
15
16
133.32
135.87
144.96
147.75
148.57
2.92
3.24
3.82
3.87
3.62
132.31
134.52
145.04
145.30
147.23
1.78
2.74
4.05
3.68
2.12
C
17
18
19
20
21
22
23
24
25
152.42
152.21
152.22
153.77
153.12
153.12
153.16
153.45
154.59
4.97
4.03
5.36
5.43
4.95
4.87
5.05
4.51
3.77
151.34
150.47
151.86
152.95
152.03
151.72
151.84
152.01
153.74
4.92
4.71
4.36
5.81
4.96
4.86
4.99
4.43
4.41
Female A
9
10
11
109.12
124.90
129.47
2.89
3.87
3.54
108.85
122.75
129.34
4.07
4.54
4.07
B
12
13
14
15
16
131.81
135.75
137.85
139.31
142.67
3.78
4.74
1.47
1.96
3.59
129.97
135.17
137.94
139.31
141.96
4.79
4.75
1.95
1.96
3.42
C
17
18
19
20
21
22
23
24
25
142.56
142.61
142.16
143.18
143.70
143.10
144.73
145.50
147.84
5.84
3.57
4.52
3.28
3.66
4.69
4.35
4.01
3.38
141.49
142.09
141.47
141.80
142.28
142.32
145.33
145.33
147.47
5.79
4.60
4.49
3.55
3.97
4.20
3.21
4.21
4.51
Table 2. Kosmogorov-Smirnov normality test
Variable Sex Statistic Df p-value
Right mand bular length Male
Female
.202
.146
207
205
.000
.000
Left mandibular length Male
Female
.211
.172
207
205
.000
.000
Table 3. Mann-Whitney test of mandibular length of male and female
Mandibular length Sex Mean rank Z p-value
Right mandibular length Male
Female
256.94
155.57 -8.640 .000
Left mandibular length Male
Female
255.24
157.29 -8.348 .000
Majalah Kedokteran Gigi Indonesia. April 2019; 5(1): 43 – 49
ISSN 2460-0164 (print)
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46
DISCUSSION
Based on the the study, the increase of mandibular
length for group A and B in both male and female
is parallel with the increase of the age. Mandibular
length growth in female increases dramatically
between the ages of 9-11 years. The mandibular
length of female aged 10-11 years old is greater
than the male mandible. The female mandibular
size increased by 109.12 mm to 124.90 mm in the
right side and 108.85 mm to 122.75 mm in the left
side between 9 and 10 years of age. It indicates
that the mandibular growth rates in female aged
9-10 years are faster than that of the males.
The male mandibular length increased by
122.24 mm to 133.32 mm in the right side and
121.41 mm to 132.31 mm in the left side between
11 and 12 years of age. It show that the increase of
mandibular growth rate in male began at 11 years
old. The mandibular growth rate in male is greater
than that of female at 11 years old and the growth
continues until the end of puberty.
Research on different ethnicities performs
that there is a variation of the mandibular growth
peak time. The study by Bordini and Mellion et
al12,13 in the United States reports that the peak
growth during puberty in female starts at 9-10 years
old, whereas in male it starts at 11-12 years old.
Research conducted by Jeelani et al in Pakistan
highlights that the peak of skeletal growth in female
occurs at the age of 11.7 years in female and 13.3
years old in male.14 Research conducted in French-
Canadian female reveals that the peak growth
in female occurs between the ages of 11.4-12.8
years.15
Mandibular growth has unique characteristics,
both in terms of size and in terms of the rate of growth.
Bone growth and biological maturation at puberty is
a dynamic process that is regulated by genetic and
environment factors. Skeletal maturation changes
and bone mineral deposition that coincides with the
period of puberty is an important component in the
evaluation of growth during the period of puberty.
Puberty is characterized by increasing skeletal
growth acceleration, including mandibular bone.16,17
The cellular factor that affects bone growth
at puberty is the proliferation and differentiation
of chondrocytes. This process will slow down with
age, and once proliferation of chondrocytes stops,
growth will stop in adulthood. The most inuential
hormone in puberty bone growth is growth
hormone, insulin-like growth factor, estrogen and
testosterone. These hormones will increase about
1.5-3 times during puberty.16-18
The growth pattern of each individual is
different, one of the factors that play an important
role in inuencing the growth pattern is sex factor.
Sex will affect growth tempo, growth time, skeletal
maturity and dental maturity. The difference in
puberty timing between male and female affects
skeletal maturity. Female growth peak is earlier
than that of male. The pattern of female skeletal
growth is rapid and brief, while the pattern of male
skeletal growth is slow and long.8,19
Mandibular growth in the post pubertal age
group (17-25 years) in both male and female showed
a relatively constant mandibular size, indicating a
decreased mandibular growth. The decrease of
mandibular growth is due to decreased hormones
that play an important role in bone growth, such as
sex hormone steroids, growth hormone and insulin-
like growth factor-1 (IGF-1).20
The results of this study are similar to those
of Olayemi et al research. The results of Olayemi’s
study on 83 Nigerian population subjects aged
16-23 years shows that, after the age of 17, the
mandibular growth had decelerated.21 The research
Table 4. Mann-Whitney U test of right and left side of mandibular length based on gender
Sex Mandibular length Mean rank Z p-value
Male Right side
Left side
215.44
199.56 -1.350 .177
Female Right side
Left side
211.39
199.51 -1.006 .314
Azhari, et al: Differences between male …
47
of a craniofacial post-pubertal growth in subjects
aged 16, 18, and 20 years using a cephalogram
shows that the craniofacial growth from 16-18
years is greater than that of 18-20 years of age.22
The average growth of mandibular in Danish male
is about 3 mm at 16-17 years, and the growth
declines until it reaches the state of no growth at
the age between 21-22 years.23
Based on Table 1, at the age of 25 (group C),
the male mandibular length was ± 154.59 mm in the
right side and ±153.74 mm in the left side, whereas
female mandibular length was ±147.48 mm in the
right side and ±147.47 mm in the left side. The
Mann-Whitney U test results showed that there was
a signicant difference between male and female
mandibular length.
The results of this study are similar to those
of Generosos’ et al, Marquizin et al, and Liu’ et al
studies.24-26 Generoso et al conducted a study on
40 male and 40 female puberty ages in Brazil. It
revealed that the male mandibular length was
greater than that of female in various malocclusion
classes.24 The longitudinal studies conducted by
Weber et al in a Caucasian race sample aged 16-
18 years showed that the male mandibular length
was longer than that of females.25 The size of
the mandible in female over the age of 14 years
is relatively constant, whereas in male it is still
increasing.24,25
The longitudinal studies conducted by Liu
et in 48 samples consisting of 24 females and 24
Caucasian race males showed that there were
signicant differences in mandibular size between
males and females. The size of the male mandible
is greater than that of female. The mandibular size
differences between male and female are due to
different bone remodeling activities, which are
inuenced by genetic condition, muscle mass, and
sex hormone differences secreted in males and
females.26
The bone and muscle growth difference
between male and female on children until
adolescent are affected by testosterone and
estrogen hormone. Bone and muscle growth in
male during puberty is dominated by elevated
levels of testosterone and Insulin Growth Factor
(IGF-1). The increase of testosterone cause
increased muscle mass and muscle strength. IGF-1
will stimulate the proliferation of muscle progenitor
cells, affecting the calcium-regulating pathway that
stimulates contractile muscle ber. IGF-1 also has
a role in bone anabolism. The muscles release
the muscle-specic phosphatase (MIP/ MTMR14;
MIPKO) factor to be detected by the bone and
affect bone structure and strength. The combination
of high-pressure changes and tense moments will
cause the bone growth pattern to be dominated by
the periosteal apposition. Thus, muscle and bone
growth in males naturally runs in a parallel way.27,28
Females have high estrogen levels and low
testosterone levels resulting in a rapid bone mass
increase, but not with the width of the bone. The
increase of bone mass occurs because the increase
of endosteal apposition is greater than that of the
periosteal apposition. In young adults, there is a
muscle-bone relationship difference between males
and females.27,28
The average difference between mandibular
length of the right and left sides of male and female
is relatively small and the statistical test reveals
that there is no signicant different between the
right mandibular length and the left mandibular
length in both males and females. The average
mandibular length of the right mandible is relatively
greater than the length of left mandibular in both
male and female. The difference between the right
and left mandibular lengths is 1-2 mm. Al-Zubair
and Agrawal et al, reported that the mandibular
dimension was considered asymmetric when the
difference between the two sides was more than
2-3 mm, while Gribel BF et al also reported that
the left and right mandibular differences of 4-5 mm
was still considered as a normal asymmetry of face
dimensions.29,30
Some researches reveal that facial asymmetry
is more common to occur on the right side with the
same distribution between males and females.31,32
This condition is probably because the growth on
the right side of the face is more dominant than
that of the left side; it happens to the larger brain
dimensions on the right side as well. Another
mechanism that is considered to affect facial
Majalah Kedokteran Gigi Indonesia. April 2019; 5(1): 43 – 49
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48
asymmetry is the unbalanced development of
neural crest cells. Some researchers reveal that
neural crest cell migration occurs earlier on the
right side, resulting in development delays on the
left side.31,32
The result of this study shows that there is
a large standard deviation, which indicates the
existence of individual variations. Since this is a
cross sectional study, it is necessary to do further
research with a longitudinal method to get a better
bone and dental growth description.
CONCLUSSION
It is possible to conclude that there is a difference
in mandibular length growth between males and
females. The increase of mandibular growth on
females is earlier than that of males. Similarly, the
female mandibular growth decrease is earlier than
that of the male. The mandibular length on males
has increased dramatically in the early adolescent
age group so that by the end of puberty, the size of
the mandible on male is greater than that of female.
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