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Gonial angle growth patterns according to age and gender
G Model AANAT-51185; No. of Pages 4
ARTICLE IN PRESS Annals of Anatomy xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Annals of Anatomy journal homepage: www.elsevier.com/locate/aanat
Gonial angle growth patterns according to age and gender Carolina Larrazabal-Moron a,b , Juan A. Sanchis-Gimeno b,∗ a b
University San Vicente Martir, C/Espartero 7., Valencia E46007, Spain Department of Anatomy and Human Embryology, University of Valencia, Faculty of Medicine, Avda. Blasco Ibanez 15, E46010 Valencia, Spain
a r t i c l e
i n f o
Article history: Received 15 July 2017 Received in revised form 16 August 2017 Accepted 6 September 2017 Available online xxx Keywords: Age Gender Gonial angle Mandible Quantitative anatomy
a b s t r a c t Currently there are controversial results about gender and age differences in human gonial angle values. In this context we aimed to ascertain the gender and age differences in the gonial angle values of young Caucasian Mediterranean subjects. We tested the hypothesis of a relation between the gonial angle values and the gender and age of the subjects by means of a prospective study involving 266 subjects. Panoramic ® ® radiographs (Cranex Novus , XMIND Novus Soredex, France) were carried out in order to measure the gonial angle values. We found significant differences between females and males in the subgroups aged ≤10 years old (128.6 ± 3.4 vs 126.8 ± 4.5, p = 0.017), 16–20 years old (119.1 ± 5.6 vs 122.3 ± 7.7, p = 0.011), 21–25 years old (117.6 ± 5.2 vs 120.8 ± 7.0, p = 0.016) and 26–30 years old (117.5 ± 5.4 vs 120.6 ± 5.4, p = 0.019) but not in the subgroup aged 11–15 years old (123.4 ± 5.2 vs 123.5 ± 5.4, p = 0.927). A significant negative correlation was found between age and gonial angle values (r = −0.365, p < 0.001). In sum, females under 10 years of age have significantly higher values than males. The angle values decreased until the age of 11–15 years of age when there were no significant gender differences. Thus, the males aged over 16 years old presented significantly higher values than the females. The decrease in gonial angle values seems to slow or stop from 21 years onwards. Knowledge of the pattern differences will serve for age and gender determination when analyzing human remains. © 2017 Elsevier GmbH. All rights reserved.
1. Introduction Correct assessment of gonial angle values are important in order to establish gender and age when analysing human remains. In this context, assessment of the anatomic gonial angle values according to age and gender has been analysed before (Gungor et al., 2007; Uthman, 2007; Iseri et al., 2008; Gamba Tde et al., 2016) as panoramic radiography (orthopantomography) a useful tool to measure the gonial angle (Zangouei-Booshehri et al., 2012; Khetani et al., 2013) that offers similar results to lateral radiography (Zangouei-Booshehri et al., 2012). Nevertheless, the results of such analyses are controversial as to whether there are gender and age differences in gonial angle values. Some authors (Dutra et al., 2004; Chole et al., 2013; Taleb and Beshlawy, 2015) have encountered no relationship between gonial angle values and age while others have (Tarazona et al., 2010; Ogawa and Osato, 2013; Upadhyay et al., 2012; Bhardwaj et al., 2014). The same can be said of gender, as some studies have revealed significant differences between gender (Huumonen et al.,
夽This paper belongs to the special issue Dentomaxillary. ∗ Corresponding author. Fax: +34 963864170. E-mail address: [email protected] (J.A. Sanchis-Gimeno).
2010; Abu Alhaija et al., 2011; Bhardwaj et al., 2014; Leversha et al., 2016), others, however, have not (Ohm and Silness, 1999; Dutra et al., 2004; Uthman, 2007; Hassan, 2011). In light of the above, this report analyzes patterns of gonial angle evolution with growth that will serve as a basis of age and gender determination in human remains. 2. Methods We tested the hypothesis of a relationship between the gonial angle values and gender and age of the subjects. This study is in accordance with the tenets of the Declaration of Helsinki and was approved by the institutional review board of the University of Valencia (reference number: H1382425184990). Written informed consent was obtained from all subjects or from their parents when they were under 18 years of age. 2.1. Subjects A prospective study involving 266 volunteers (110 females and 156 males) was performed between July 2015 and July 2016 in order to ascertain the differences in gonial angle values of Caucasian Mediterranean subjects aged 5–30 years.
https://doi.org/10.1016/j.aanat.2017.09.004 0940-9602/© 2017 Elsevier GmbH. All rights reserved.
Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004
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ARTICLE IN PRESS
AANAT-51185; No. of Pages 4
C. Larrazabal-Moron, J.A. Sanchis-Gimeno / Annals of Anatomy xxx (2017) xxx–xxx
2
Inclusion criteria comprised Caucasian Mediterranean subjects aged between 5 and 30 years of age, who had no systemic or local pathology, with no disorder at the craniofacial level, and for whom good quality panoramic radiographic studies (orthopantomographies) (i.e. that were well-centered to avoid distortion of any of the structures, that had high image definition, and that did not present overlapping of anatomical details) were available. Exclusion criteria comprised subjects with any local or systemic pathology that could alter the results of the study (for example, patients with congenital anomalies, connective tissue diseases, disorders of a local or general nature that could affect the tooth maturation process or cause tooth disorders regarding number, oligodontia, patients with growth disorders, etc.), patients undergoing orthodontic treatment or having undergone such treatment, patients who had had permanent molars removed, and poor quality panoramic radiographs. To ensure consistency, one investigator was responsible for the selection of radiographs based on the inclusion and exclusion criteria (Leversha et al., 2016). From an initial sample of 300 orthopantomographies of 300 subjects (100%), 34 (11.3%) were excluded from the study after applying the inclusion and exclusion criteria: one orthopantomography study of a Down Syndrome patient (0.3%), 25 orthopantomographies of subjects with ongoing orthodontic treatment or who had undergone such treatment (8.33%), six orthopantomographies (2.0%) of subjects who had had permanent molars removed, and two orthopantomographies (0.66%) with poor image quality. Finally, the sample analyzed in the study numbered 266 panoramic radiographs of 266 subjects (266 left and 266 right gonial angles were measured) with an age range from 5 to 30 years (mean ± SD, 17.3 ± 7.4 years) from an initial sample of 300 subjects (88.7%). One hundred and fifty-six were male (58.6%) and 110 female (41.4%). The 266 subjects were subdivided into five age subgroups: 5–10 year-olds (62 subjects with 124 gonial angles measured), 11–15 year-olds (59 subjects with 118 gonial angles measured), 16–20 year-olds (53 subjects with 106 gonial angles measured), 21–25 year-olds (47 subjects with 94 gonial angles measured), and 26–30 year-olds (45 subjects with 90 gonial angles measured). 2.2. Gonial angle measurements All panoramic radiographs were taken by the same radiographer for standardization purposes (Leversha et al., 2016) and on ® ® the same panoramic unit (Cranex Novus , XMIND Novus Soredex, France). The mean of five consecutive measurements of each gonial angle was performed by another experienced physician who was unaware of the gender and age of the subjects. Gonial angle measurements were performed by measuring between two tangents from the gonion (Fig. 1); the first running superiorly along
Fig. 1. Measurement of the gonial angle in a digital panoramic radiograph used in this study.
the posterior border of the mandibular ramus and the other anteriorly along the inferior border of the body of the mandible (Leversha et al., 2016). 2.3. Statistics The statistical study was carried out by another physician who did not participate in the selection or gonial angle measurements of the patients. G*Power 3 (version 3.0.10) was used to calculate the statistical power of the current study (Faul et al., 2007). We studied a total sample size of n = 532 gonial angles with 266 subjects included in the study and a value of ␣ error probability = 0.05 (corresponding to ␣ level of 5%); the statistical power reached was 0.76. Normality of the data distribution was determined using the Kolmogorov–Smirnov test. As all quantitative variables were normally distributed, the paired t-test and Anova test were used to assess differences between the groups. Pearson’s correlation was used to assess a possible relationship between age and the gonial angle values. A p-value <0.05 was considered statistically significant. All statistical analyses were performed using SigmaPlot v12 software (Systat Software, Inc., San Jose, CA, USA). Data are reported as mean ± standard deviation (SD). 3. Results Table 1 presents the gonial angle values obtained in the entire analyzed sample. The differences when analyzing all values beween females and males were not significant, neither were they when comparing the left and right gonial angle values between females and males. Nevertheless, the difference between the left and right gonial angle values were significant within the female and male groups. Detailed gonial angle values according to age subgroups and gender are presented in Tables 2 and 3. There were statistically significant differences between age subgroups (p < 0.001; Anova test).
Table 1 Gonial angle values obtained in the whole sample analyzed (mean◦ ± SD).
Female Male p-Valuea † a
n (%)
All
Left
Right
p-Valuea
220 (41,4%) 312 (58.6%) –
122.7 ± 6.7 122.8 ± 7.0 0.902
121.4 ± 7.1 121.6 ± 6.8 0.851
123.9 ± 6.1 123.9 ± 7.1 0.987
0.004† 0.006† –
Statistically significant. Student’s t test.
Table 2 Gonial angle values by age subgroup in all subjects analyzed (mean◦ ± SD).
n (%) Mean ± SD
5–10 years
11–15 years
16–20 years
21–25 years
26–30 years
124 (23.3%) 127.8 ± 4.0
118 (22.2%) 123.4 ± 6.7
106 (19.9%) 121.3 ± 7.1
94 (17.7%) 119.9 ± 6.9
90 (16.9%) 119.3 ± 5.9
Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004
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C. Larrazabal-Moron, J.A. Sanchis-Gimeno / Annals of Anatomy xxx (2017) xxx–xxx Table 3 Gonial angle values by age subgroup and gender (mean◦ ± SD). Female (n = 220)
5-10 years 11-15 years 16-20 years 21-25 years 26-30 years † a
Male (n = 312)
n
Mean ± SD
n
Mean ± SD
p-valuea
68 48 36 38 30
128.6 ± 3.4 123.4 ± 5.2 119.1 ± 5.6 117.6 ± 5.2 117.5 ± 5.4
56 70 70 56 60
126.8 ± 4.5 123.5 ± 5.4 122.3 ± 7.7 120.8 ± 7.0 120.6 ± 5.4
0.017† 0.927 0.011† 0.016† 0.019†
Statistically significant. Student’s t test.
Fig. 2. Gonial angle values by gender and age.
The differences in gonial angle values were also significant between females and males in all age subgroups with the exception of the subgroups of males and females aged 11–15 years old. Fig. 2 presents the decrease in gonial angle values by gender and age. A significant negative correlation between age and gonial angle values was found (Pearson’s correlation coefficient, r = −0.365, p < 0.001). 4. Discussion We present the gonial angle values of a sample of young healthy subjects aged 5–30 years old in a study carried out by means of panoramic radiography (orthopantomography) which offers similar results to lateral radiography (Zangouei-Booshehri et al., 2012). The measurements were carried out in a masked fashion and our results were obtained from a sample of young subjects who had not undergone orthodontic treatment. Bilgic et al. (2015) revealed that nearly one-third of the evaluated population would have a mandatory need for orthodontic treatment. As orthodontic treatment is increasing worldwide it is possible that gonial angle values may be affected by these orthodontic treatments. Thus, our results are of particular importance for orthodontic treatment and surgeons in order to plan reconstructive surgery for mandibular hypoplasia. We found a significant negative correlation between age and gonial angle values with significant differences between the age subgroups analyzed: the younger subjects (5–10 years old) had higher values and the older subjects (26–30 years old), lower values. Our sample also showed that females have significantly higher values than males at the age of 5–10 years. The angle values decreased until the age of 11–15 years old when there were no significant differences between females and males. Thus, the males aged over 16 years old presented significantly higher values than the females. The decrease in
3
gonial angle values seems to slow down or stop from 21 years onwards as the values that the subjects aged 21–25 and 26–30 years are almost the same in both females and males. On the other hand, the study carried out by Upadhyay et al. (2012) found no significant differences between gender in any age subgroups. When analyzing the gonial angle vaIues, Tarazona et al. (2010) found a significant decrease in values with increase in age. Ogawa and Osato (2013) found a significant decrease in gonial angle values with aging from an initial value of 129.5◦ to a final value of 122.78◦ . Bhardwaj et al. (2014) also found significant differences in the angle values in their 25–34 year-old, 35–44 year-old and 45–54 year-old subgroups. In their panoramic radiography study carried out on subjects aged from 13.5 to 19.5 years old, Haavikko et al. (1978) found a decrease of 2.6◦ in the gonial angle values. Altonen et al. (1977) carried out a study on subjects aged 5–19 and found that from the initial age the angle values decreased until the age of 15–18 years old. The gonial values decreased from 130.6◦ and 131.0◦ in males and females to 128.2◦ and 128.4◦ in both males and females. Upadhyay et al. (2012) found a decrease in the gonial angle values with mean values of 133.96◦ ± 8.15, 129.36◦ ± 7.58, and 127.29◦ ± 10.88 in their 6–16 year-old, 17–35 year-old, and 35–72 year-old subgroups, respectively. Nevertheless, Chole et al. (2013), Dutra et al. (2004), and Taleb and Beshlawy (2015) found no relationship between age and gonial angle values. We found no significant differences when comparing the gonial angle values of all female and male subjects (122.7 ± 6.7 and 122.8 ± 7.0, respectively, p = 0.902), our results being similar to those obtained by Ohm and Silness (1999), Dutra et al. (2004), Uthman (2007) and Hassan (2011). Nevertheless, other authors found significant gender differences. Bhardwaj et al. (2014) obtained significant higher values in females than in males (122.10 ± 6.04 and 117.66 ± 6.54, respectively). Huumonen et al. (2010) also found higher gonial angle values in females than in males (127.3 ± 6.4 and 123.3 ± 7.4, respectively), and Abu Alhaija et al. (2011) found gonial angle values of 125.10 ± 7.06 in females and 123.43 ± 7.85 in males; the gender differences were also significant. Xie and Ainamo (2004) analyzed the gonial angle value differences between gender in one subgroup of subjects at a mean age of 27 years, in a second subgroup at a mean age of 64 years, and in a third subgroup of subjects aged over 80 years. They found significant differences between males and females in their first two subgroups, but no gender differences in older edentulous subjects. We found no significant differences when comparing the left (121.4 ± 7.1 and 121.6 ± 6.8, p = 0.851) and right (123.9 ± 6.1 and 123.9 ± 7.1, p = 0.987) gonial angle values of the entire sample of males and females. However, we found that the right gonial angle was significantly higher than the left in females (123.9 ± 6.1 versus 121.4 ± 7.1; p = 0.004) and males (121.6 ± 6.8 versus 123.9 ± 7.1; p = 0.006). Altonen et al. (1977) observed greater right gonial angle values, but the differences between left and right were not significant. Nevertheless, Chole et al. (2013) and Bhardwaj et al. (2014) found significantly greater left angle values. On the other hand, other authors found no significant differences between the left and right gonial angle values (Dutra et al., 2004; Uthman, 2007; Upadhyay et al., 2012; Zangouei-Booshehri et al., 2012). Finally, it must be taken into account that the sample of the present study was made up of young Caucasian Mediterranean subjects, thus different outcomes would be expected if another population were evaluated because the gonial angle varies in different human population groups (Taleb and Beshlawy, 2015).
Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004
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5. Conclusions In summary, our study has shown that Caucasian Mediterranean female subjects under 10 years of age have significantly higher values than males. The angle values decreased until the age of 11–15 years after which there were no significant gender differences. Thus, the males aged over 16 years presented significantly higher values than the females, and finally, the decrease in gonial angle values seems to slow or stop from 21 years onwards. Knowledge of the pattern differences will serve as a basis in age and gender determination when analyzing human remains. Role of the funding source None. References Abu Alhaija, E.S., AlBhairan, H.M., AlKhateeb, S.N., 2011. Mandibular third molar space in different antero-posterior skeletal patterns. Eur. J. Orthod. 33, 570–576. Altonen, M., Haavikko, K., Mattila, K., 1977. Developmental position of lower third molar in relation to gonial angle and lower second molar. Angle Orthod. 47, 249–255. Bhardwaj, D., Kumar, J.S., Mohan, V., 2014. Radiographic evaluation of mandible to predict the gender and age. J. Clin. Diagn. Res. 8, ZC66–ZC69. Bilgic, F., Gelgor, I.E., Celebi, A.A., 2015. Malocclusion prevalence and orthodontic treatment need in central Anatolian adolescents compared to European and other nations’ adolescents. Dent. Press J. Orthod. 20, 75–81. Chole, R.H., Patil, R.N., Balsaraf Chole, S., Gondivkar, S., Gadbail, A.R., Yuwanati, M.B., 2013. Association of mandible anatomy with age, gender, and dental status: a radiographic study. ISRN Radiol. 2013, 453763. Dutra, V., Yang, J., Devlin, H., Susin, C., 2004. Mandibular bone remodelling in adults: evaluation of panoramic radiographs. Dentomaxillofac. Radiol. 33, 323–328. Faul, F., Erdfelder, E., Lang, A.G., Buchner, A., 2007. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav. Res. Methods 39, 175–191. Gamba Tde, O., Alves, M.C., Haiter-Neto, F., 2016. Mandibular sexual dimorphism analysis in CBCT scans. J. Forensic Leg. Med. 38, 106–110.
Gungor, K., Sagir, M., Ozer, I., 2007. Evaluation of the gonial angle in the Anatolian populations: from past to present. Coll. Antropol. 31, 375–378. Haavikko, K., Altonen, M., Mattila, K., 1978. Predicting angulational development and eruption of the lower third molar. Angle Orthod. 48, 39–48. Hassan, A.H., 2011. Mandibular cephalometric characteristics of a Saudi sample of patients having impacted third molars. Saudi Dent. J. 23, 73–80. Huumonen, S., Sipilä, K., Haikola, B., Tapio, M., Söderholm, A.L., Remes-Lyly, T., Oikarinen, K., Raustia, A.M., 2010. Influence of edentulousness on gonial angle, ramus and condylar height. J. Oral Rehabil. 37, 34–38. Iseri, H., Kisnisci, R., Altug-Atac, A., 2008. Ten-year follow-up of a patient with hemifacial microsomia trated with distraction osteogenesis and orthodontics: an implant analysis. Am. J. Orthod. Dentofac. Orthop. 134, 296–304. Khetani, M.A., Collett, B.R., Speltz, M.L., Werler, M.M., 2013. Healthrelated quality of life in children with hemifacial microsomia: parent and child perspectives. J. Dev. Behav. Pediatr. 34, 661–668. Leversha, J., McKeough, G., Myrteza, A., Skjellrup-Wakefiled, H., Welsh, J., Sholapurkar, A., 2016. Age and gender correlation of gonial angle, ramus height and bigonial width in dentate subjects in a dental school in Far North Queensland. J. Clin. Exp. Dent. 8, e49–e54. Ogawa, T., Osato, S., 2013. Growth changes of the mandibular body with eruption of mandibular third molars: analysis of anatomical morphometry and quantitative bone mineral content by using radiography. Ann. Anat. 195, 143–150. Ohm, E., Silness, J., 1999. Size of the mandibular jaw angle related to age, tooth retention and gender. J. Oral Rehabil. 26, 883–891. Taleb, N.S.A., Beshlawy, M.E., 2015. Mandibular Ramus and Gonial angle measurements as predictors of sex and age in an Egyptian population sample: a digital panoramic study. J. Forensic Res. 6, 308. Tarazona, B., Paredes, V., Llamas, J.M., Cibrian, R., Gandía, J.L., 2010. Influence of first and second premolar extraction or non-extraction treatments on mandibular third molar angulation and position. A comparative study. Med. Oral Patol. Oral Cir. Bucal 15, e760–e766. Upadhyay, R.B., Upadhyay, J., Agrawal, P., Rao, N.N., 2012. Analysis of gonial angle in relation to age, gender, and dentition status by radiological and anthropometric methods. J. Forensic Dent. Sci. 4, 29–33. Uthman, A.T., 2007. Retromolar space analysis in relation to selected linear and angular measurements for an Iraqi sample. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 104, e76–e82. Xie, Q.F., Ainamo, A., 2004. Correlation of gonial angle size with cortical thickness, height of the mandibular residual body, and duration of edentulism. J. Prosthet. Dent. 91, 477–482. Zangouei-Booshehri, M., Aghili, H.A., Abasi, M., Ezoddini-Ardakani, F., 2012. Agreement between panoramic and lateral cephalometric radiographs for measuring the gonial angle. Iran J. Radiol. 9, 178–182.
Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004
ARTICLE IN PRESS Annals of Anatomy xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Annals of Anatomy journal homepage: www.elsevier.com/locate/aanat
Gonial angle growth patterns according to age and gender Carolina Larrazabal-Moron a,b , Juan A. Sanchis-Gimeno b,∗ a b
University San Vicente Martir, C/Espartero 7., Valencia E46007, Spain Department of Anatomy and Human Embryology, University of Valencia, Faculty of Medicine, Avda. Blasco Ibanez 15, E46010 Valencia, Spain
a r t i c l e
i n f o
Article history: Received 15 July 2017 Received in revised form 16 August 2017 Accepted 6 September 2017 Available online xxx Keywords: Age Gender Gonial angle Mandible Quantitative anatomy
a b s t r a c t Currently there are controversial results about gender and age differences in human gonial angle values. In this context we aimed to ascertain the gender and age differences in the gonial angle values of young Caucasian Mediterranean subjects. We tested the hypothesis of a relation between the gonial angle values and the gender and age of the subjects by means of a prospective study involving 266 subjects. Panoramic ® ® radiographs (Cranex Novus , XMIND Novus Soredex, France) were carried out in order to measure the gonial angle values. We found significant differences between females and males in the subgroups aged ≤10 years old (128.6 ± 3.4 vs 126.8 ± 4.5, p = 0.017), 16–20 years old (119.1 ± 5.6 vs 122.3 ± 7.7, p = 0.011), 21–25 years old (117.6 ± 5.2 vs 120.8 ± 7.0, p = 0.016) and 26–30 years old (117.5 ± 5.4 vs 120.6 ± 5.4, p = 0.019) but not in the subgroup aged 11–15 years old (123.4 ± 5.2 vs 123.5 ± 5.4, p = 0.927). A significant negative correlation was found between age and gonial angle values (r = −0.365, p < 0.001). In sum, females under 10 years of age have significantly higher values than males. The angle values decreased until the age of 11–15 years of age when there were no significant gender differences. Thus, the males aged over 16 years old presented significantly higher values than the females. The decrease in gonial angle values seems to slow or stop from 21 years onwards. Knowledge of the pattern differences will serve for age and gender determination when analyzing human remains. © 2017 Elsevier GmbH. All rights reserved.
1. Introduction Correct assessment of gonial angle values are important in order to establish gender and age when analysing human remains. In this context, assessment of the anatomic gonial angle values according to age and gender has been analysed before (Gungor et al., 2007; Uthman, 2007; Iseri et al., 2008; Gamba Tde et al., 2016) as panoramic radiography (orthopantomography) a useful tool to measure the gonial angle (Zangouei-Booshehri et al., 2012; Khetani et al., 2013) that offers similar results to lateral radiography (Zangouei-Booshehri et al., 2012). Nevertheless, the results of such analyses are controversial as to whether there are gender and age differences in gonial angle values. Some authors (Dutra et al., 2004; Chole et al., 2013; Taleb and Beshlawy, 2015) have encountered no relationship between gonial angle values and age while others have (Tarazona et al., 2010; Ogawa and Osato, 2013; Upadhyay et al., 2012; Bhardwaj et al., 2014). The same can be said of gender, as some studies have revealed significant differences between gender (Huumonen et al.,
夽This paper belongs to the special issue Dentomaxillary. ∗ Corresponding author. Fax: +34 963864170. E-mail address: [email protected] (J.A. Sanchis-Gimeno).
2010; Abu Alhaija et al., 2011; Bhardwaj et al., 2014; Leversha et al., 2016), others, however, have not (Ohm and Silness, 1999; Dutra et al., 2004; Uthman, 2007; Hassan, 2011). In light of the above, this report analyzes patterns of gonial angle evolution with growth that will serve as a basis of age and gender determination in human remains. 2. Methods We tested the hypothesis of a relationship between the gonial angle values and gender and age of the subjects. This study is in accordance with the tenets of the Declaration of Helsinki and was approved by the institutional review board of the University of Valencia (reference number: H1382425184990). Written informed consent was obtained from all subjects or from their parents when they were under 18 years of age. 2.1. Subjects A prospective study involving 266 volunteers (110 females and 156 males) was performed between July 2015 and July 2016 in order to ascertain the differences in gonial angle values of Caucasian Mediterranean subjects aged 5–30 years.
https://doi.org/10.1016/j.aanat.2017.09.004 0940-9602/© 2017 Elsevier GmbH. All rights reserved.
Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004
G Model
ARTICLE IN PRESS
AANAT-51185; No. of Pages 4
C. Larrazabal-Moron, J.A. Sanchis-Gimeno / Annals of Anatomy xxx (2017) xxx–xxx
2
Inclusion criteria comprised Caucasian Mediterranean subjects aged between 5 and 30 years of age, who had no systemic or local pathology, with no disorder at the craniofacial level, and for whom good quality panoramic radiographic studies (orthopantomographies) (i.e. that were well-centered to avoid distortion of any of the structures, that had high image definition, and that did not present overlapping of anatomical details) were available. Exclusion criteria comprised subjects with any local or systemic pathology that could alter the results of the study (for example, patients with congenital anomalies, connective tissue diseases, disorders of a local or general nature that could affect the tooth maturation process or cause tooth disorders regarding number, oligodontia, patients with growth disorders, etc.), patients undergoing orthodontic treatment or having undergone such treatment, patients who had had permanent molars removed, and poor quality panoramic radiographs. To ensure consistency, one investigator was responsible for the selection of radiographs based on the inclusion and exclusion criteria (Leversha et al., 2016). From an initial sample of 300 orthopantomographies of 300 subjects (100%), 34 (11.3%) were excluded from the study after applying the inclusion and exclusion criteria: one orthopantomography study of a Down Syndrome patient (0.3%), 25 orthopantomographies of subjects with ongoing orthodontic treatment or who had undergone such treatment (8.33%), six orthopantomographies (2.0%) of subjects who had had permanent molars removed, and two orthopantomographies (0.66%) with poor image quality. Finally, the sample analyzed in the study numbered 266 panoramic radiographs of 266 subjects (266 left and 266 right gonial angles were measured) with an age range from 5 to 30 years (mean ± SD, 17.3 ± 7.4 years) from an initial sample of 300 subjects (88.7%). One hundred and fifty-six were male (58.6%) and 110 female (41.4%). The 266 subjects were subdivided into five age subgroups: 5–10 year-olds (62 subjects with 124 gonial angles measured), 11–15 year-olds (59 subjects with 118 gonial angles measured), 16–20 year-olds (53 subjects with 106 gonial angles measured), 21–25 year-olds (47 subjects with 94 gonial angles measured), and 26–30 year-olds (45 subjects with 90 gonial angles measured). 2.2. Gonial angle measurements All panoramic radiographs were taken by the same radiographer for standardization purposes (Leversha et al., 2016) and on ® ® the same panoramic unit (Cranex Novus , XMIND Novus Soredex, France). The mean of five consecutive measurements of each gonial angle was performed by another experienced physician who was unaware of the gender and age of the subjects. Gonial angle measurements were performed by measuring between two tangents from the gonion (Fig. 1); the first running superiorly along
Fig. 1. Measurement of the gonial angle in a digital panoramic radiograph used in this study.
the posterior border of the mandibular ramus and the other anteriorly along the inferior border of the body of the mandible (Leversha et al., 2016). 2.3. Statistics The statistical study was carried out by another physician who did not participate in the selection or gonial angle measurements of the patients. G*Power 3 (version 3.0.10) was used to calculate the statistical power of the current study (Faul et al., 2007). We studied a total sample size of n = 532 gonial angles with 266 subjects included in the study and a value of ␣ error probability = 0.05 (corresponding to ␣ level of 5%); the statistical power reached was 0.76. Normality of the data distribution was determined using the Kolmogorov–Smirnov test. As all quantitative variables were normally distributed, the paired t-test and Anova test were used to assess differences between the groups. Pearson’s correlation was used to assess a possible relationship between age and the gonial angle values. A p-value <0.05 was considered statistically significant. All statistical analyses were performed using SigmaPlot v12 software (Systat Software, Inc., San Jose, CA, USA). Data are reported as mean ± standard deviation (SD). 3. Results Table 1 presents the gonial angle values obtained in the entire analyzed sample. The differences when analyzing all values beween females and males were not significant, neither were they when comparing the left and right gonial angle values between females and males. Nevertheless, the difference between the left and right gonial angle values were significant within the female and male groups. Detailed gonial angle values according to age subgroups and gender are presented in Tables 2 and 3. There were statistically significant differences between age subgroups (p < 0.001; Anova test).
Table 1 Gonial angle values obtained in the whole sample analyzed (mean◦ ± SD).
Female Male p-Valuea † a
n (%)
All
Left
Right
p-Valuea
220 (41,4%) 312 (58.6%) –
122.7 ± 6.7 122.8 ± 7.0 0.902
121.4 ± 7.1 121.6 ± 6.8 0.851
123.9 ± 6.1 123.9 ± 7.1 0.987
0.004† 0.006† –
Statistically significant. Student’s t test.
Table 2 Gonial angle values by age subgroup in all subjects analyzed (mean◦ ± SD).
n (%) Mean ± SD
5–10 years
11–15 years
16–20 years
21–25 years
26–30 years
124 (23.3%) 127.8 ± 4.0
118 (22.2%) 123.4 ± 6.7
106 (19.9%) 121.3 ± 7.1
94 (17.7%) 119.9 ± 6.9
90 (16.9%) 119.3 ± 5.9
Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004
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AANAT-51185; No. of Pages 4
C. Larrazabal-Moron, J.A. Sanchis-Gimeno / Annals of Anatomy xxx (2017) xxx–xxx Table 3 Gonial angle values by age subgroup and gender (mean◦ ± SD). Female (n = 220)
5-10 years 11-15 years 16-20 years 21-25 years 26-30 years † a
Male (n = 312)
n
Mean ± SD
n
Mean ± SD
p-valuea
68 48 36 38 30
128.6 ± 3.4 123.4 ± 5.2 119.1 ± 5.6 117.6 ± 5.2 117.5 ± 5.4
56 70 70 56 60
126.8 ± 4.5 123.5 ± 5.4 122.3 ± 7.7 120.8 ± 7.0 120.6 ± 5.4
0.017† 0.927 0.011† 0.016† 0.019†
Statistically significant. Student’s t test.
Fig. 2. Gonial angle values by gender and age.
The differences in gonial angle values were also significant between females and males in all age subgroups with the exception of the subgroups of males and females aged 11–15 years old. Fig. 2 presents the decrease in gonial angle values by gender and age. A significant negative correlation between age and gonial angle values was found (Pearson’s correlation coefficient, r = −0.365, p < 0.001). 4. Discussion We present the gonial angle values of a sample of young healthy subjects aged 5–30 years old in a study carried out by means of panoramic radiography (orthopantomography) which offers similar results to lateral radiography (Zangouei-Booshehri et al., 2012). The measurements were carried out in a masked fashion and our results were obtained from a sample of young subjects who had not undergone orthodontic treatment. Bilgic et al. (2015) revealed that nearly one-third of the evaluated population would have a mandatory need for orthodontic treatment. As orthodontic treatment is increasing worldwide it is possible that gonial angle values may be affected by these orthodontic treatments. Thus, our results are of particular importance for orthodontic treatment and surgeons in order to plan reconstructive surgery for mandibular hypoplasia. We found a significant negative correlation between age and gonial angle values with significant differences between the age subgroups analyzed: the younger subjects (5–10 years old) had higher values and the older subjects (26–30 years old), lower values. Our sample also showed that females have significantly higher values than males at the age of 5–10 years. The angle values decreased until the age of 11–15 years old when there were no significant differences between females and males. Thus, the males aged over 16 years old presented significantly higher values than the females. The decrease in
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gonial angle values seems to slow down or stop from 21 years onwards as the values that the subjects aged 21–25 and 26–30 years are almost the same in both females and males. On the other hand, the study carried out by Upadhyay et al. (2012) found no significant differences between gender in any age subgroups. When analyzing the gonial angle vaIues, Tarazona et al. (2010) found a significant decrease in values with increase in age. Ogawa and Osato (2013) found a significant decrease in gonial angle values with aging from an initial value of 129.5◦ to a final value of 122.78◦ . Bhardwaj et al. (2014) also found significant differences in the angle values in their 25–34 year-old, 35–44 year-old and 45–54 year-old subgroups. In their panoramic radiography study carried out on subjects aged from 13.5 to 19.5 years old, Haavikko et al. (1978) found a decrease of 2.6◦ in the gonial angle values. Altonen et al. (1977) carried out a study on subjects aged 5–19 and found that from the initial age the angle values decreased until the age of 15–18 years old. The gonial values decreased from 130.6◦ and 131.0◦ in males and females to 128.2◦ and 128.4◦ in both males and females. Upadhyay et al. (2012) found a decrease in the gonial angle values with mean values of 133.96◦ ± 8.15, 129.36◦ ± 7.58, and 127.29◦ ± 10.88 in their 6–16 year-old, 17–35 year-old, and 35–72 year-old subgroups, respectively. Nevertheless, Chole et al. (2013), Dutra et al. (2004), and Taleb and Beshlawy (2015) found no relationship between age and gonial angle values. We found no significant differences when comparing the gonial angle values of all female and male subjects (122.7 ± 6.7 and 122.8 ± 7.0, respectively, p = 0.902), our results being similar to those obtained by Ohm and Silness (1999), Dutra et al. (2004), Uthman (2007) and Hassan (2011). Nevertheless, other authors found significant gender differences. Bhardwaj et al. (2014) obtained significant higher values in females than in males (122.10 ± 6.04 and 117.66 ± 6.54, respectively). Huumonen et al. (2010) also found higher gonial angle values in females than in males (127.3 ± 6.4 and 123.3 ± 7.4, respectively), and Abu Alhaija et al. (2011) found gonial angle values of 125.10 ± 7.06 in females and 123.43 ± 7.85 in males; the gender differences were also significant. Xie and Ainamo (2004) analyzed the gonial angle value differences between gender in one subgroup of subjects at a mean age of 27 years, in a second subgroup at a mean age of 64 years, and in a third subgroup of subjects aged over 80 years. They found significant differences between males and females in their first two subgroups, but no gender differences in older edentulous subjects. We found no significant differences when comparing the left (121.4 ± 7.1 and 121.6 ± 6.8, p = 0.851) and right (123.9 ± 6.1 and 123.9 ± 7.1, p = 0.987) gonial angle values of the entire sample of males and females. However, we found that the right gonial angle was significantly higher than the left in females (123.9 ± 6.1 versus 121.4 ± 7.1; p = 0.004) and males (121.6 ± 6.8 versus 123.9 ± 7.1; p = 0.006). Altonen et al. (1977) observed greater right gonial angle values, but the differences between left and right were not significant. Nevertheless, Chole et al. (2013) and Bhardwaj et al. (2014) found significantly greater left angle values. On the other hand, other authors found no significant differences between the left and right gonial angle values (Dutra et al., 2004; Uthman, 2007; Upadhyay et al., 2012; Zangouei-Booshehri et al., 2012). Finally, it must be taken into account that the sample of the present study was made up of young Caucasian Mediterranean subjects, thus different outcomes would be expected if another population were evaluated because the gonial angle varies in different human population groups (Taleb and Beshlawy, 2015).
Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004
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ARTICLE IN PRESS C. Larrazabal-Moron, J.A. Sanchis-Gimeno / Annals of Anatomy xxx (2017) xxx–xxx
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5. Conclusions In summary, our study has shown that Caucasian Mediterranean female subjects under 10 years of age have significantly higher values than males. The angle values decreased until the age of 11–15 years after which there were no significant gender differences. Thus, the males aged over 16 years presented significantly higher values than the females, and finally, the decrease in gonial angle values seems to slow or stop from 21 years onwards. Knowledge of the pattern differences will serve as a basis in age and gender determination when analyzing human remains. Role of the funding source None. References Abu Alhaija, E.S., AlBhairan, H.M., AlKhateeb, S.N., 2011. Mandibular third molar space in different antero-posterior skeletal patterns. Eur. J. Orthod. 33, 570–576. Altonen, M., Haavikko, K., Mattila, K., 1977. Developmental position of lower third molar in relation to gonial angle and lower second molar. Angle Orthod. 47, 249–255. Bhardwaj, D., Kumar, J.S., Mohan, V., 2014. Radiographic evaluation of mandible to predict the gender and age. J. Clin. Diagn. Res. 8, ZC66–ZC69. Bilgic, F., Gelgor, I.E., Celebi, A.A., 2015. Malocclusion prevalence and orthodontic treatment need in central Anatolian adolescents compared to European and other nations’ adolescents. Dent. Press J. Orthod. 20, 75–81. Chole, R.H., Patil, R.N., Balsaraf Chole, S., Gondivkar, S., Gadbail, A.R., Yuwanati, M.B., 2013. Association of mandible anatomy with age, gender, and dental status: a radiographic study. ISRN Radiol. 2013, 453763. Dutra, V., Yang, J., Devlin, H., Susin, C., 2004. Mandibular bone remodelling in adults: evaluation of panoramic radiographs. Dentomaxillofac. Radiol. 33, 323–328. Faul, F., Erdfelder, E., Lang, A.G., Buchner, A., 2007. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav. Res. Methods 39, 175–191. Gamba Tde, O., Alves, M.C., Haiter-Neto, F., 2016. Mandibular sexual dimorphism analysis in CBCT scans. J. Forensic Leg. Med. 38, 106–110.
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Please cite this article in press as: Larrazabal-Moron, C., Sanchis-Gimeno, J.A., Gonial angle growth patterns according to age and gender. Ann. Anatomy (2017), https://doi.org/10.1016/j.aanat.2017.09.004