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Skeletal Growth and Maturation in Children Afflicted with Major Endocrine Disorders

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Skeletal Growth and Maturation in Children Afflicted with Major Endocrine Disorders DOI: 10.1051/odfen/2016031 J Dentofacial Anom Orthod 2017;20:106 Original Article © The authors Skeletal growth and maturation in children afflicted with major endocrine disorders F. Duhamel1, M. de Kerdanet2 1 Pediatric Endocrinologist, Specialist Assistant, Department of Pediatric Endocrinology and Diabetology, CHU Rennes 2 Pediatric Endocrinologist, Hospital Practitioner, Head of the Department of Pediatric Endocrinology and Diabetology, CHU Rennes SUMMARY Orthodontic and dentofacial orthopedic strategies depend on both skeletal growth and maturation stages. In children, various parameters such as growth curves shown in the child’s health record, puber- tal changes, or skeletal maturation (using the vertebral maturation method) need to be evaluated. These elements allow the practitioner to choose the optimal moment to start treatment or to discontinue it. Endocrine disorders such as growth hormone variations, thyroid disorders, and pubertal issues could modify skeletal growth and maturation. Diagnoses and treatment of these pathologies affect maxillofa- cial growth and development. Thus, these pathologies should be taken into consideration during ortho- dontic and dentofacial orthopedic treatment in children. KEYWORDS Growth, skeletal maturation, CVM, orthodontics, dentofacial orthopedics, endocrine disorders, growth hormone INTRODUCTION Pediatric care differs from adult treat- growth, both in its direction and its poten- ment because children show ongoing bone tial. For example, orthopedic therapies are growth along with continuous changes in aimed at redirecting condylar growth to cartilage growth and the accompanying treat a skeletal class II. However, there are bone maturation. individual, physiological, or pathological var- In DFO, most of the patients are children iations in bone growth and maturation. En- or adolescents. They are therefore expe- docrine disorders modify these parameters riencing a growth phase. As such, most and must therefore be considered while orthodontic treatments aim to modify this planning orthodontic treatments. Address for correspondence: Fanny Duhamel – CHU Rennes 16, boulevard de Bulgarie – 35200 Rennes Article received: 08-07-2016. E-mail: [email protected] Accepted for publication: 10-09-2016. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Article available at https://www.jdao-journal.org or https://doi.org/10.1051/odfen/2016031 F. DUHAMEL, M. DE KERDANET EVALUATING GROWTH AND BONE MATURATION Growth • To analyze these circumferences, they must be plotted on curves. In There are different measurement France, these curves are present- parameters to assess the growth of ed on health cards. In instances of children. These are systematically ob- complex orthodontic treatment, it served by the attending physicians and may be advisable to note these el- pediatricians who monitor the children ements in the health record to as- during follow-up. Any deviations from sess the overall growth potential of the norm is, at the very least, cause the child. for concern, and these should be ad- • In France, the weight, height, and dressed by a specialist (pediatrician or cranial circumference are analyzed pediatric endocrinologist) if required. at birth using the curves by Usher • Height: up to 4 years (or 100 cm), and Mac Lean. More recently the height can be measured using a AUDIPOG curves were introduced measuring tape with the child lying and can be used from 0 to 22 years down; however, beyond 100 cm, the of age. There are also curves devel- child’s height will be measured in oped by Sempé and Pédron (Fig. 1). the standing position with the head These curves differ according to the turned to one side and with a meas- sex of the patient. uring tape attached to the wall. • In France, BMI is assessed using • The growth rate is calculated by the the Rolland–Cachera curves (Fig. 2), increase in height in centimeters which also differ according to sex. per year. • Target height is calculated by calcu- Bone Maturation lating the average height of the par- ents and adding 6.5 cm for boys and In DFO, cervical vertebrae matura- subtracting 6.5 cm for girls. tion (CVM) is currently used. This tech- • Weight: measured with a measuring nique is easily accessible because it scale after the child is undressed. can be performed on any profile radi- • The body mass index or BMI (weight ograph. The cervical spine is observed in kg/the square of height in me- by analyzing cervical vertebrae C2, C3, ters). and C4. Its main benefit is not having • The cranial circumference: meas- to add wrist X-rays, thereby avoiding ured with a measuring tape at the radiation. Cervical spine radiographs largest cephalic circumference. are already being used when making • Additional measurements include diagnoses in DFO. Moreover, there the following: the brachial circumfer- is a good correlation between carpal ence and the relationship between bone age, mandibular growth, and the the brachial and cranial circumfer- pubertal growth peak6,7,11. There are six ences and the upper segment/lower stages of maturation. (Fig. 3). segment ratio and arm span-height • Stage 1 (CS1): the lower edges of difference. the vertebrae C2, C3, and C4 are 2 Duhamel F., de Kerdanet M. Skeletal growth and maturation in children afflicted with major endocrine disorders Skeletal growth AND maturatioN IN CHILDREN AFFLICTED with major ENdocriNE disorders Figure 1 Curves by Sempé and Pédron. flat, the upper edges are tapered • Stage 5 (CS5): concavities at from the back toward the front and the lower edges of the cervical to the trapezoidal vertebral bodies. vertebrae are more pronounced, the This stage takes place 2 months be- square vertebral bodies and the in- fore the peak in pubertal growth. tervertebral spaces are decreased. • Stage 2 (CS2): a concavity is formed This stage comes 1 year after the at the lower edge of C2, and the pubertal peak. anterior height of the vertebral • Body Mass Index (BMI) = Weight bodies increases. This stage gener- (kg)/Height (m). ally occurs 1 year before the puber- • Stage 6 (CS6): all the concavities tal peak. appear deeper; the vertebral bodies • Stage 3 (CS3): a concavity is formed are longer than they are wide. This at the lower edge of C3. The puber- stage occurs 2 years after the peak, tal peak occurs 1 year later. signaling the end of pubertal man- • Stage 4 (CS4): a concavity is formed dibular growth. Other methods of at the lower edge of C4. The ver- bone maturation analysis exist, but tebral bodies become rectangular. they are seldom used in DFO. There is a pubertal peak in mandibu- • Bone maturation can be evaluated lar growth between CS3 and CS4. by conducting a bone age analysis J Dentofacial Anom Orthod 2017;20:106 3 F. DUHAMEL, M. DE KERDANET Figure 2 BMI curves by Rolland–Cachera Figure 3 Location of the pubertal peak in mandibular growth over the six stages of cervical vertebral maturation according to Baccetti et al.3 (via radiographs of the hand, and average feature of the chronological the frontal side of the left wrist). age according to the sex1. Calcifica- These radiographs then analyzed by tion and hand bone cartilage growth comparing the X-ray with the Greu- are analyzed. lich and Pyle atlas, which is a series • When growth is complete, of hand and wrist models, each the Risser test can be used reproduction corresponding to an particularly within the context of 4 Duhamel F., de Kerdanet M. Skeletal growth and maturation in children afflicted with major endocrine disorders Skeletal growth AND maturatioN IN CHILDREN AFFLICTED with major ENdocriNE disorders scoliosis where the therapeutic indications depend on the degree iliac crests marks the end of bone of maturation. An X-ray of the maturation. frontal view of the pelvis analyz- • Tooth maturation, by quantitative es growth in the cartilage of the or qualitative radiological analysis, is iliac crests. The complete fusion poorly correlated with overall bone of the ossification nucleus of the maturation and is therefore a poor evaluation tool. NORMAL GROWTH IN CHILDREN Growth is deemed “normal” when The response to orthodontic treatment it is situated on the curves between is better in phases 2 and 3, especially −2 and +2 standard deviations (SD) or with respect to mandibular growth3,4. between the 3rd and the 97th percen- It is therefore necessary to analyze tile (BMI curves), without slowing or children’s growth phases both clinical- breaking this growth. ly and radiologically. Clinical analyses Antenatal growth is assessed by an- look for recent accelerations in growth tenatal ultrasound and neonatal meas- or signs of puberty such as breast de- urements. velopment and hair growth. Radiologi- There are three phases in normal cal assessments optimize the start of postnatal growth in childhood. orthodontic treatment. Growth has of- • Phase 1: early childhood (0-4 years): ficially ended when the growth rate is phase of rapid growth (+25 cm in <2cm per year and when the bone age the first year or 75 cm by age 1, is >15 years for girls and >16 years for years + 10 cm in the 2nd year, or 85 boys. cm by age 2 years). Growth is stunted when it measures • Phase 2: childhood (age 4 years to <−2 SD and severely retarded when it is pubertal period): growth rate slowed <−4 SD. to 5–6 cm per year. Any slowdowns or breaks in the • Phase 3: puberty: accelerated growth rate constitute cause for growth rate and bone maturation, alarm as well as deviations of >1.5 SD pubertal gain of about 20–25 cm for between the actual height of the patient girls and 25–30 cm for boys. and the average height. FEATURES OF THE MAJOR ENDOCRINE DISORDERS It should be noted that two-thirds nonpathological maturations; these are of the growth retardations or slow- sometimes familial.
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