GROWTH

MARKERS

DR. AYUSHI TOLEY

PG 1ST YEAR
GROWTH
MARKERS

DR. AYUSHI TOLEY

PG 1ST YEAR
Contents
Ideal requirements
Classification Frontal Sinus
Skeletal age assessment Tooth calcification methods
through Radiograph Skeletal age assessment
Bjork method
Hagg and Taranger method through Biomarkers
Julius Singer method
Fishman Index
CVMI
Mid palatal suture
Ideal Maturity Indicator
Should be safe and no-invasive
Require minimum radiation
Should be accurate
Stages should be well defined and easily
identifiable
Should be valid overtime and across age
groups
Classification of Maturity Indicators
● Chronologic age
● Biologic age
○ Morphologic age
○ Dental age
○ Circumpubertal age
○ Skeletal age
● Chronologic age: time from birth till date, poor
indicator of maturity.
● Biologic age-
○ Morphological age- based on height of patient-
compared with standards of same age groups.
○ Sexual age- refers to the age of development of
secondary sexual characters- corresponding to
the pubertal growth spurt
○ Skeletal age- refers to the degree of development
of ossification in bone
○ Dental age- assessed by 2 methods- tooth
eruption and tooth mineralization
 SKELETAL MATURITY
ASSESSMENT
ORTHODONTIC
TREATMENT PLANNING
How much skeletal growth is remaining?
 SKELETAL MATURITY
ASSESSMENT
ORTHODONTIC TREATMENT
PLANNING
Treatment timing for Planning surgical treatment of
myofunctional treatment skeletal malocclusion

Evaluation of
skeletal age is
needed
Skeletal Maturity
Indicators/Markers
Estimation of growth
potential requires
assessment of the
developmental age of the
individual.
 The Basic Concept
Assessment through Assessment through
Radiographs Biochemical markers

• Different ossification • The levels of certain

centres appear and
mature at different times
and in a predictable
sequence
• Or with cephalometrics
Hormones, Growth
factors, or enzymes
is assessed
Skeletal Age
Assessment-
Radiographic
• Hand wrist radiograph
• Cervical vertebrae evaluation
• Tooth mineralization
• Cephalometrics
 “
INDICATIONS
● Discrepancy between dental and chronologic age
● For treatment of Skeletal Class II and Class III
malocclusion
● Assess age in patients affected by infections,
neoplastic diseases or traumatic conditions
● Predict future skeletal maturation rate and status
● Predict pubertal growth spurt
● For assessment of orthognathic surgery and prior to
Hand wrist Radiographs
Anatomy of Hand and Wrist
● Carpals- 8 small, irregular
shaped; arranged in 2
rows
● Metacarpals- 5 miniature
long bones
● Phalanges- form the
fingers;3in each finger
except thumb which has 2
 Hand Wrist Bones ossification
● The bone ossify from
○ Primary centre – diaphysis
○ Secondary centre- epiphysis
● As secondary centre is progressively
ossified, cartilage is replaced by bone
until only a thin layer of cartilage,
separates the diaphysis from epiphysis.
This thin layer is called the epiphyseal
● Metaphysis represents the
growing end of the bone.
● As long as the epiphyseal cartilage
plate persists, both the diaphysis
and epiphysis continue to grow,
but, eventually the osteoblasts
ceases to multiply and the
epiphyseal plate is ossified.
● At that time, osseous structures of
the diaphysis and epiphysis are
fused and growth ceases.
Ossification of Phalanges
● The three phalanges in each finger are : Proximal, Middle and
Distal.
● Ossify in 3 stages:
○ STAGE 1: Width of Epiphysis = Width of Diaphysis

○ STAGE 2: Epiphysis Diaphysis

○ STAGE 3: Epiphysis + Diaphysis

Standardisation of the Hand-wrist R/G
● Source to subject
distance= 64cm
● 0 degree angulation
● r/g taken without grid
● Specs- 46Kv, 6.5 Amp, 0.4
sec
HISTORY

● TODD TW 1931
Longitudinal study by
● RANKE 1896 ● ROTCH 1910 starting series of hand
First to study skeletal Weight, Height and wrist radiographs of
development progress tooth eruption were only children in Cleveland,
by means of wrist X- rough estimates of Ohio.
rays. physical maturity But he died in 1938 after
the publication of his 1st
report.
His study was continued
by William Greulich and
Idell Pyle
GREULICH & PYLE’s RADIOGRAPHIC
ASSESSMENT
● Book- Radiographic Atlas of Skeletal
Development of Hand and Wrist (1950)
● Atlas- standards – developed on the basis of
skeletal age as opposed to chronologic age
● Two Specific Steps were involved:
○ Atlas method
○ Bone Specific methods
● Atlas Method- the film is compared to the standard
of same age and sex acc. to chronologic age- then
the film is compared to older and younger standards.
Finally the standard most closely resembling the
film in question is chosen

● Bone Specific Method- after selection of app.

standard- detailed comparison of individual
bones and epiphyses visible in them is done. The
bones should be considered in regular order.
 Individual bones-
● CARPALS
Proximal Row- Scaphoid, Lunate, Triquetral, Pisiform
● Distal Row- Trapezium, Trapezoid, Capitate, Hamate

Mnemonic- She Looks Too Pretty Try To Catch Her

 TANNER & WHITEHOUSE METHOD

● 3 methods of scoring maturity of individual bones to

determine skeletal age
● (RUS) Radius, Ulna and Short bones score- radius,
ulna, metacarpals of digits 1,3,5, middle phalanges
of digits 3,5 and distal phalanges of digits 3,5.
● Carpal bone method score- C, H, Tri, L, S, T, and T
● TW2 method- recognizes 20 regions of interest
(ROI) in the main bones-
● each ROI divided into discreet stages
(A,B,C….,H,I)-
● numerical score associated with each stage for each
bone-
● Overall maturity= addition of all ROI scores
 Regions of Interest
(20)
Discreet developmental stages of TW2
method

Bjork, Grave and Brown Method
● 9 developmental
stages assessed
acc. to the
relation between
epiphyses and
diaphyses
First stage of maturation-
PP2
Index finger- width of
epiphysis of proximal
phalanx= width of
diaphysis
3 years before puberty
Second stage – MP3
Third finger- width of
epiphysis of middle
phalanx= width of
diaphysis
Third stage
Pisi stage- visible
ossification of pisiform
H1 stage- oss. of hamular
process of hamate
R stage- Radius- width
of epipysis= width of
diaphysis
Distinct oss sites but
appear at same time
Fourth stage
S stage- 1st mineralization of
the ulnar sesamoid bone of
metacarpophalangeal joint of
thumb.
H2 stage- progressive oss. of
hamular process of hamate
Shortly before or at the
beginning of the pubertal
growth spurt.
Fifth stage
MP3cap- capping of
diaphysis at middle phalanx
of 3rd finger
PP1cap- capping of diaphysis
at proximal phalanx of thumb
R stage- capping of diaphysis
at radius
Peak of pubertal growth
spurt.
Sixth stage
DP3u- middle finger- distal
phalanx- union of epiphysis
and diaphysis.
End of pubertal growth.
Seventh stage
PP3u- little finger- proximal
phalanx- union of epiphysis
and diaphysis.
Eighth stage
MP3u- middle finger- middle
phalanx- union of epiphysis
and diaphysis.
Nineth stage
RU- complete union of
epiphysis and diaphysis of
Radius
Singer’s Method- Julius Singer (1980)
6 stages

Stage 1
● Absence of Pisiform
● Absence of hook of
Hamate
● Index finger- proximal
phalanx narrower than
diaphysis
Stage 2 Pre-pubertal Prior to adolescent growth
• Initial oss. of hook spurt
Significant amounts of
of hamate mandibular growth possible.

• Initial oss. of
pisiform
• Index finger-
Proximal phalanx-
epiphysis=diaphysi
s
Stage 3 Pubertal Onset
• Ulnar sesamoid
calcification start
• Increased oss. of all the
bones assessed in stage
 Stage 4 Pubertal
• Calcified ulnar
sesamoid
• Middle finger-
middle phalanx-
capping of
diaphysis

Stage 5 Pubertal deceleration

Orthodontic treatment
• Ulnar sesamoid calcifiedcompleted.
Period of Retention
• Middle finger- middle phalanx- fusion of epi
and diaphysis
• Radius Ulna epiphyseal fusion not completed
Fishman Skeletal Maturity Indicator
● Leonard S Fishman 1982
● Anatomical sites located on thumb, III finger, V
finger and Radius
● 11 discreet developmental stages covering the entire
period of adolescent development.
● Interpretation uses 4 stages of bone maturation
○ Epiphysis width= diaphysis width
○ Adductor sesamoid of thumb appearance
○ Capping of epiphysis
○ Fusion of epiphysis
Fishman’s 11-grade scheme
4. Adductor sesamoid
ossification

1. Width of Proximal 8. Fusion of distal

phalanx III phalanx of III

2. Width of middle 5. Capping of distal 9. Fusion of proximal

phalanx III phalanx of III phalanx III

6. Capping of middle 10. Fusion of phalanx

phalanx of III of III
3. Width of middle
phalanx V
7. Capping of middle
11. Fusion of Radius
phalanx of V
Hagg and Taranger Method

• Ossification of ulnar sesamoid of metacarpophalangeal

joint of 1st finger
• Middle and Distal phalanges of IIIrd finger
• Distal epiphysis of Radius
• Radiographs used were taken from 6-18 yrs of age.

Appearance of Sesamoid- Stage S

Acceleration period of pubertal growth
spurt
86% girls and 92% boys.
 IIIrd finger-
Distal Phalanx
DP3 I- Fusion
of epiphysis
and diaphysis
completed.

IIIrd finger- Middle Phalanx

MP3 F- Epiphysis= Metaphysis
MP3 FG- Distinct medial/lateral border
of epi forming right angle to distal border
MP3 G- Sides of epiphysis thickened and
cap the metaphysis
MP3 H- Fusion of epiphysis and
diaphysis
MP3 I- Fusion of epiphysis and diaphysis
Distal Epiphysis of Radius
Stage I- Fusion of epi and metaphy has
begun- attained before or at end of
pubertal growth spurt.
Stage IJ- Fusion almost completed
Stage J- Fusion completed
Modified Hagg and Taranger by
Rajagopal et al (2002)
Additional bone stage between MP3-H and MP3-I
has been added.
MP3-H – corresponds to deceleration of pubertal
growth curve
MP3-I corresponds to end of pubertal growth spurt
• Additional stage- MP3- HI introduced:
Epiphysis superior surface- smooth concave
• Metaphysis- smooth convex with no undulation
• No radiolucent gap significant.
Cervical Vertebrae Maturity Indicator
Hassel & Farman (1995)
Based on shapes of cervical vertebrae at different
levels of skeletal development.

INITIATION
Inferior border of 2nd, 3rd, 4th CV Flat
3rd vertebra wedge shaped
Superior border tapered from posterior to
anterior
100% pubertal growth remaining.
ACCELERATION
Inferior border 2nd and 3rd CV show slight
concavity, 4th CV flat
Bodies of 3rd and 4th nearly rectangular
65-85% pubertal growth remains

TRANSITION
Inferior border of 2nd, 3rd CV show distinct
concavity, slight concavity with 4th CV
Bodies of 3rd and 4th nearly rectangular
25-65% growth remains
DECELERATION
Inferior border 2nd, 3rd, 4th –distinct
concavity
Body 2nd and 3rd begin to look more square
10-25% growth remaining

MATURATION
Inferior borders 2nd, 3rd, 4th- marked
concavity
Body 2nd and 3rd almost square
5-10% growth remaining

COMPLETION
Inferior border 2nd, 3rd, 4th- deep concavities
Body- Vertical > Horizontal
Pubertal growth completed.
Modified CVMI- McNamara, Bacetti,
Franchi (2005)
Modified CVMI- McNamara, Bacetti,
Franchi (2005)
• Lower borders • Concavity at
of C2-C4 flat. lower border of
• C3,C4 trapezoid C2
shaped, superior • Lower borders
border tapered of C2-C4 flat.
post. to ant. • C3,C4 trapezoid
• Peak in shaped, superior
mandibular border tapered
growth occurs post. to ant.
on average 2yrs • Peak in
after this stage. mandibular
growth occurs
Class III treatment with maxillary expansion and protraction is on average 1yr
effective in the maxilla only when performed before the peak after this stage.
(CS1 and CS2 and in the mandible during both prepubertal and
pubertal stages.
• Concavity at • Concavity at
lower border of lower border of
C2, C3 C2, C3, C4.
• C3,C4 trapezoid • C3,C4
shaped or rectangular
rectangular horizontal
horizontal. shaped.
• Peak in • Peak in
mandibular mandibular
growth occurs growth ends on
on average average in the
within the same same year or 1yr
year at this before this
stage. stage.
• Ideal stage to
begin functional
• Concavity at • Concavity at
lower border of lower border of
C2, C3, C4. C2, C3, C4.
• C3,C4 • C3,C4
rectangular rectangular
horizontal horizontal
shaped or atleast shaped or atleast
one of them is one of them is
square shaped. rectangular and
• Peak in vertical shaped.
mandibular • Peak in
growth ends on mandibular
average 1yr growth ends on
before this average 2yrs
stage. before this
Tooth Mineralization/ Calcification

1
Mandibular Canine Calcification

Coultinho, Buschang, Miranda

Association between Stages of mandibular
canine calcification and epiphyseal-
diaphyseal stages of ossification for 3rd
proximal, middle and distal phalanges and 5th
proximal phalanx.
Simple 1st level diagnostic test- cannot be used as sole criterion to
predict developmental landmarks.
Determine whether additional, more sensitive measures of maturity
are warranted.
Crown formation completed down to CEJ
Beginning of root formation seen as a spicule

Walls of pulp chamber straight

Pulp horn present
Root length < Crown height

Walls of pulp chamber form isosceles triangle

Apex ends in funnel shape Initiation of puberty
Early stage
Root length =/> Crown height of Pubertal
Capping of 3 middle and 5
rd th growth
Walls of root canal now parallel spurt
proximal phalanges.
Apical end partially open +nce of adductor sesamoid

Apical end of root canal completely closed

Periodontal membrane has uniform width around the root and
the apex
Tooth Mineralization/ Calcification

2
Mandibular Third Molar Development

Engstrom et al 1983
Correlating the Stages of mandibular 3rd
molar development with skeletal age assessed
by hand wrist R/Gs.
Engstrom et al 1983

Developmental stages of mandibular 3rd

molar:
A: Tooth germ- rounded radiolucency
B: Cusp mineralization complete
C: Crown formation complete
D: Root half completed A B C D E
E: Root formation complete but apex open.
Concurrent stages
Skeletal dvlmt in Hand wrist R/G PP2= Stage B/C
PP2: 2nd finger proximal phalanx- epiphysis= MP3 cap= Stage C
diaphysis DP3 U= Stage C/D
MP3 cap: 3rd finger Middle phalanx- epiphysis RU= 1/3rd Stage C, 1/3rd
caps diaphysis Stage D, rest Stage E.
DP3 U: 3rd finger distal phalanx- fusion of epi
Mid- Palatal Suture
● If conventional RME is intended in young adults,
status of mid palatal suture is most frequently
evaluated on occlusal films
● In a R/G study, Revelo and Fishman (1994)
compared the status of the mid palatal suture on
occlusal films with the Fishman’s maturity index in
patients ranging from 8-18 years.
● Melsen 1975, analysed palatal growth and mid-
palatal suture morphology in humans from 0-18 yrs
of age.
● The morphological development was divided into 3
stages
● 1st stage- suture was short, broad, Y shaped
● 2nd stage- suture was more sinuous
● 3rd stage- heavy interdigitation occurred.
● 58.2 of midpalatine suture ossification is completed at
completion of the skeletal maturation stage- CVMI 5/
MP3 HI stage
● Total amount of ossification at the age of 25 years is
found to be 40.78
● Ideal time for RME based on midpalatine suture
ossification is at stage MP3F or CVM1.
● RME should be carried out before CVMI4 /MP3H stage
Frontal Sinus as SMI
Ruf and Pancherz- 1996
• The size of the frontal sinus was
measured at yearly intervals.
• R/G oriented along SN plane
• The peripheral border of frontal
sinus was traced, Highest point Sh
and lowest point S1 were makrked.
A line perpendicular to the the line
Sh- S1 line was used to assess the
maximum width.
The following conclusions were drawn:
• Frontal sinus growth velocity at puberty is closely related to body
height growth velocity.
• FSG shows a well defined pubertal peak (Sp), which, on the
average, occurs 1.4 years after the pubertal body height peak.
• In one year observation interval, PGV in frontal sinus of at least
1.3mm/yr is attained by 84% of subjects.
• In two year observation, PGV of atleast 1.2mm/yr was attained by
almost 70% of subjects.
• These specific frontal sinus growth velocities were assigned as
threshold values (T1, T2), for growth prediction.
 Prediction Procedure

Sv > T : Bp passed by approx. 1.4 yrs

Sv < T and Age <15.1 yrs: Bp not reached or reached less than 1.4 yrs
before the end of the observation interval.
Sv < T and Age >15.1 yrs: Bp passed by more than 1.4 yrs wrt the
beginning of the obs interval.

To test the accuracy of the prediction the average yearly body

height growth velocity was calculated.
The max body growth velocity at puberty was assigned as
body height peak (Bp).
Therefore, the age of the subject is also needed to predict
somatic maturity stage.
Skeletal Age
Assessment-
Biochemical Markers
Any substance, structure or
process (or its products) that can
be measured in the body and
influence or predict the incidence
of outcome or disease.
Assessed using ELISA,
Radioimmunoassays and
immunoradiometric assays.
 Biochemical Markers
• Growth hormone
• Insulin like growth factor- I
• Parathyroid Hormone- related Protein and Indian
Hedgehog Protein
• Dehydroepiandrosterone/ Dehydroepiandrosterone
Sulphate
• Testosterone, androgens and Estrogens
• Cortisol
• Alkaline Phosphatase
• Osteocalcin
• Gingival crevicular fluid
• Creatinine
Growth hormone
• GH is an anterior pituitary hormone which was first
isolated in 1956 by Li and Papkoff.
• It chiefly functions in the growth and development
of craniofacial structures.
• GH receptors in the mandibular condyle have both
direct and indirect effects on tissues with indirect
effects mediated by insulin like growth factor-I,
generated in the liver in response to GH.
● After infancy, frequency and amplitude of GH decrease

● At puberty, amplitude of GH release increases and it was

found to be the highest at this stage of life

● After puberty, Gh secretion decreases with age by around

14% per decade.

● Maximum GH concentrations are reached in early

puberty in girls and late puberty in boys.
Insulin- like Growth Factor- I
● IGF- I is an effective growth stimulating factor which mediates
many GH functions.
● Liver is the principal source of circulating IGF-I though it is
produced locally by many tissues.
● IGF-I was first detected in serum but can be quantified in saliva
and urine.
● Salivary IGF-I levels reflect serum levels, but precise
quantification is difficult as salivary levels are <1% of serum
levels.
● Serum IGF-1 levels demonstrate GH status, high in acromegaly
and low in GH deficiency.
● Serum levels tend to peak whenever there is accelerated growth in
 ● Studies have been conducted to correlate biochemical markers
with skeletal growth status using the modified cervical
vertebral maturation method of Baccetti et al.
● It was observed that females have an earlier and shorter growth
spurt showing sharp spike up to cervical staging CS3 and rapid
decline in IGF-I levels upto CS6
● Males, on the other hand, experience a later and longer growth
spurt denoted by a steady increase in IGF-I levels from CS1 to
CS4 followed by a slow decline to CS6 with a relative plateau
phase extending from CS3 to CS5

GuptaS, Deoskar A, Gupta P, Jain S.Serum insulin-like growth factor-I levels in females
and males in different cervical vertebral maturation stages. Dental Press J Orthod
2015;20:68-75
Parathyroid Hormone- related Protein and
Indian Hedgehog Protein
● Parathyroid hormone- related protein (PTHrP) was
originally established as the primary mediator of
humoral hypercalcemia of malignancy.
● PTHrP is synthesized at the periarticular ends of
bones and affects adjacent chondrocytes carrying
PTHrP receptors to retain their proliferation potential
and slow down differentiation.
● Chondrocytes distant from the influence of PTHrP, however,
differentiate and secrete Indian hedgehog protein (Ihh), which
triggers further PTHrP release.

● This feedback system thus determines the width of the zone of

chondrocyte proliferation.
● Ihh is secreted by prehypertrophic and hypertrophic
chondrocytes after cessation of chondrocyte
proliferation potential.

● Although stimulation of PTHrP and Ihh releases

sustain growth during adolescence, varying results
have been obtained in regard to correlation of
PTHrP levels with skeletal maturation during
puberty and hence using PTHrP to predict skeletal
growth accurately is not substantiated by sufficient
Dehydroepiandrosterone/ DHEA-Sulphate
● These are steroid hormones secreted from adrenal
gland during adrenarche, 3years before puberty.
● They stimulate pituitary and hypothalamus to initiate
puberty.
● They speed up growth and proliferation of
epiphyseal cartilage and increase the GH activity
● DHEAS salivary levels are high enough to be
measurable. Its salivary levels decrease with increase
in salivary flow rate.

● Serum DHEAS levels peak around 20-30years of age

then decrease to reach 20-30% of peak level by the
age of 70-80.

● Serum DHEAS levels are high in newborn, after

● First peak in DHEAS concentration – 6-8yrs of age in
both sexes

● Second peak – 11yrs for females and 13yrs for males.

● Srinivasan and Premkumar reported gradual rise in

serum concentration at initiation of maturation and
reached peak values after complete fusion of epiphysis
and diaphysis of radius.
Testosterone, Androgens, Estrogens
● Testosterone (T) and estradiol (E2) are the main
circulating sex steroids acting on human male bone
tissue.
● Estrogens reduce bone resorption by means of both
direct and indirect effects on osteoclasts and act on
osteoblasts, by inhibiting their apoptosis.
● Effective Threshold value of serum estrogen – 15-
25pg/ml
● Sex steroids prepare the immature bone to develop
in terms of size, structure, bone mineral density,
proportions

● Estrogens continue bone remodeling in adulthood

with decline associated with bone loss from adult to
ageing life.
● Serum E2 increases simultaneously with T levels
during puberty where estrogen in early puberty is
associated with growth plate lengthening and during
late puberty induces progressive ossification of
growth plate and its final disappearance.
Cortisol
● Major glucocorticoid released from the adrenal
cortex and is controlled by HPA axis.
● Stimulates GH production and secretion.
● Follows a circadian rhythm, reaches peak in early
morning and lowest levels at night.
● Cortisol levels show sharp rise at pubertal spurt and
gradual postpubertal increase with ageing.
Alkaline Phosphatase
● Membrane bound enzyme attached to
glycosylphosphatidylinositol moieties located on the
outer cell surface.
● To accurately predict skeletal growth, detection of
bone-specific ALP is required.
● Increases upto age of 14 yrs in boys and 11 yrs in
girls and rapid falls after that in botjh sexes to reach
adult levels by 20 years in boys and 18 yrs in girls.
● Tarvade et al. found a significant correlation of
salivary ALP with MP3 skeletal maturation stages.
They reported peak levels of salivary ALP in girls
as well as in boys correlated with G stage of MP3 at
the age of 13.
Osteocalcin
● Also known as bone gamma-carboxyglutamic acid
(Gla) protein, produced by osteobalsts, odontoblasts
and hypertrophic chondrocytes and binds to
hydroxyapatite.
● Its level increase significantly with age, body
weight, height, bone age until 12-13yrs in girls and
14-15yrs in boys
● According to Kirmani et al., serum osteocalcin
increased early in puberty and peaked at 14 yrs of
age but declined after the age of 14 yrs.
● Osteocalcin is a potential biomarker, which can
predict growth status with development of more
sensitive assays.
Creatinine
● Ratio of creatine to creatinine in the urine, this ratio
is thought to fall progressively with age after about
the age of 14yrs, probably under hormonal
influences.
● Girls maturing early have a lower ratio than those of
the same chronological age maturing late.
Bone Turnover Mechanism

76
OPG/RANK/RANKL system
● RANKL- Receptor activator of nuclear factor kappa
B ligand
Transmembrane protein
Produced by T-cells- in response to mechanical stress-
expressed on osteoblasts by factors that stimulate
osteoclast formation and activity.

77
● RANK- Receptor activator of nuclear factor kappa B
Transmembrane protein on osteoclast precursors.
Increase in RANK implies Increase in osteoclast
formation.

● Osteoprotegrin (OPG)
“BONE PROTECTOR”- limits osteoclast formation
OPG ligand is identical to RANK and hence competes
to bind with RANKL.
78
OPG/RANK/RANKL system

New bone formation Osteoclastogenesis

79
 Flow chart depicting the remodeling
process Exposure of mineralized
collagen to ECF and release of
inf. cytokines

RANKL expressed
on osteoblast surface
by T-cells

RANK on osteoclast OPG

precursor Mononuclear cells
coat the scalloped
border of
osteoclasts

80
Biochemical Markers of Bone Turnover

81
Markers of Bone Formation
● Serum Total Alkaline Phosphatase (AP)
● Osteocalcin (OC)
● Procollagen Type I Propeptides

Markers of Bone Resorption

● Hydroxyproline
● 3-Hydroxypyridinium Crosslinks of Collagen
Pyridinoline (PYD) and Deoxypyridinoline (DPD)
● Crosslinked Telopeptides of Type I Collagen
● Tartrate-Resistant Acid Phosphatase (TRAP, TRAcP)
● Cathepsin K
● Bone sialoprotein (BSP)

82
Serum Total Alkaline Phosphatase (AP)
● AP is a ubiquitous, membrane-bound tetrameric enzyme
attached to glycosyl-phosphatidylinositol moieties located on
the outer cell surface
● plays an important role in osteoid formation and
mineralization
● In adults with normal liver function, approximately 50% of the
total AP activity in serum is derived from the liver, whereas
50% arises from bone
●  in subjects with high liver AP, results of bone AP
measurements may be artificially high, leading to false positive
results
83
Osteocalcin (OC)

● hydroxyapatite-binding, protein exclusively synthesised by

osteoblast, odontoblasts and hypertrophic chondrocytes
● OC is involved in the bone remodelling process and may act
via a negative feed back mechanism.
● OC is considered a specific marker of osteoblast function.
● only one third of the total OC serum pool represents intact
OC, and due to the instability of OC in serum, rapid loss of
immunoreactivity is seen with these assays when samples
are left for more than 1 hour at room temperature.
84
 Procollagen Type I Propeptides
● The procollagen type I propeptides are derived from
collagen type I, the most abundant form of collagen found in
bone
● These precursor molecules are characterised by short
terminal extension-peptides: the amino (N-) terminal
propeptide (PINP) and the carboxy (C-) terminal
propeptide (PICP)
● PICP and PINP are generated from newly synthesised
collagen in a stoichiometric fashion, the propeptides are
considered quantitative measures of newly formed type I
collagen
85
 Hydroxyproline (OHP)
● OHP is formed intracellularly from the post-translational
hydroxylation of proline and constitutes 12–14% of the
total amino acid content of mature collagen
● Urinary OHP is usually considered to reflect bone
resorption. However, it should be noted that significant
amounts of urinary OHP are derived from the degradation
of newly synthesised collagen
● Urinary hydroxyproline is therefore considered an
unspecific index of collagen turnover and, consequently, has
been largely replaced by more specific techniques.

86
3-Hydroxypyridinium Crosslinks of Collagen
Pyridinoline (PYD) and Deoxypyridinoline (DPD)
● PYD and DPD are formed during the extracellular maturation of
fibrillar collagens
● During bone resorption, crosslinked collagens are proteolytically
broken down and the crosslink components are released into the
circulation and the urine
● not influenced by the degradation of newly synthesised collagens
and their levels strictly reflect the degradation of mature i.e.
crosslinked collagens
● independent of dietary sources since neither PYD nor DPD are
taken up from food
● the pyridinium crosslinks are currently viewed the best indices for
assessing bone resorption 87
Crosslinked Telopeptides of Type I
Collagen
● The crosslinked telopeptides of type I collagen
are derived from specific regions of the collagen
type I molecule, namely the aminoterminal (NTP)
and the carboxyterminal (CTP) telopeptide.
● provide information on the age-dependent
changes of collagen in health and disease.

88
Bone Sialoprotein (BSP)
● BSP is a phosphorylated glycoprotein
● 5–10% of the non-collagenous matrix of bone.98,99 The
protein has been shown to be a major synthetic product of
active osteoblasts and odontoblasts
● BSP or its mRNA is detected mainly in mineralised tissue
such as bone, dentin and at the interface of calcifying
cartilage.
● he protein is therefore considered to play an important role
in cell-matrix-adhesion processes and in the
supramolecular organisation of the extracellular matrix of
mineralised tissues.

89
Tartrate-Resistant Acid Phosphatase
(TRAP, TRAcP)
● subforms, 5a and 5b are known, and recent research has
shown that TRAP-5b is characteristic of osteoclasts.
●  The origin of TRAP-5a is unknown, but may be expressed
by macrophages. The two isoforms 5a and 5b are different
in that 5a contains sialic acid, whereas 5b does not.
● More recently, specific immunoassays for TRAP 5b have
been described and clinical results indicate that this marker
may be useful to assess osteoclast activity

90
Cathepsin K
● Immunocytochemical studies have shown that cathepsin K is
located intracellularly in vesicles, granules and vacuoles
throughout the cytoplasm of osteoclasts and that it is secreted into
bone resorption lacunae for extracellular collagen degradation.
● Recently, a new enzyme-linked immunoassay for measurements of
cathepsin K in serum has been developed.
● Due to the fact that cathepsin K is expressed and secreted by
osteoclasts during active bone resorption, cathepsin K, and
specifically its circulating form, may be a useful and specific
biochemical marker of osteoclastic activity.
91
Conclusion
● Growth modification therapy needs evaluation of
each patients maturational profile individually.
● Both maxillary and mandibular growth can be
closely estimated relative to the timing, amount and
rate of development.
● Skeletal maturity indicators can improve the
diagnostic expertise of the orthodontist.
References
● Julian Singer “physiologic timing of orthodontic
treatment. Angle orthod 1980;50:320-333
● Hagg U, Taranger J. maturational indicators and the
pubertal growth spurt. AmJ Orthod 1982:299-309
● Fishman L.S: Radiographic evaluation of skeletal
maturation
● HasselB, Farman AG. Skeletal maturation and
evaluation using cervical vertebrae. Am J
● Baccetti T, Franchi L, McNamara Jr. An improved
version of the cervical vertebral maturation method
for assessment of mandibular growth. Angle orthod
2002.
● Ruf S, Pancherz H. Can frontal sinus development
be used for prediction of skeletal maturity at
puberty? Actaa Odontol Scand 1996; 54:229-34.
● Tripathi T, Gupta P, Rai P. Biochemical markers as
● Radiological indicators of bone age assessment in
cephalometric images. Review, Magdalena et al. pol
J Radiol, 2016;81:347-353
● Evaluation of skeletal maturity using maxillary
canine, mandibular second and third molar
calcification, Giedre et al. European journal of
orthodontics, 2016, 298-403
● Reliability of the frontal sinus index as a maturity
indicator, Ajinkya A Patil, Ameet V Revankar. Indian
journal of dental research.
● Midpalatal suture Ossificattion and skeletal
maturation: comparative Ctscan and
Roentgenographiic study, Thadani et al.Journal of
Indian Academy or Oral Medicine and Radiology,
April-June 2010, 81-87.
● Midpalatal suture in young adults. A radiological-
histological investigation, Heirich and Faruk.
European journal of orthodontics 2001, 105-114.
Thank
You!