Assessment of cephalometric characteristics in the elderly

Wilson Guilherme Nunes ROSA Ricardo de Lima NAVARRO Ana Cláudia de Castro Ferreira CONTI Marcio Rodrigues de ALMEIDA Paula Vanessa Pedron OLTRAMARI-NAVARRO About the authors

Abstract

This cross-sectional study aimed at assessing the cephalometric characteristics in the elderly, taking into account differences between genders, age ranges, ethnic groups and dental aspects. The sample consisted of 250 elderly subjects of both genders (163 female, mean age: 68 yr.; 87 male: 70.4 yr.). Conventional lateral cephalograms for cephalometric analysis were scanned and analyzed by Dolphin Imaging software 11.5. The statistical treatment of the data evaluated the influence of gender and age range variables (independent ttest), as well as ethnic group, facial profile, and dental characteristics (one-way ANOVA), on cephalometric measurements. A confidence interval of 95% and level of significance of 5% were considered for all the tests performed. The results revealed: 1) The cephalometric measurements evaluated showed significantly lower values for the female gender; 2) a significant decrease in the cephalometric values was observed in relation to the growth pattern, with the advancement of age; 3) significant cephalometric differences were observed between the ethnic groups and the facial profiles; 3) dentulous patients had greater absolute values for all the components evaluated, followed by the individuals with partial dental losses and by those who were edentulous. It may be concluded that the cephalometric alterations observed in this study are inherent to facial maturity, and that they represent specific characteristics regarding each of the variables evaluated. These modifications must be taken into account when planning the treatment for younger patients, to minimize the modifications arising from the natural aging process.

Orthodontics; Aged; Cephalometry


Introduction

Although aging is a natural process, it causes several modifications in the body. Knowing what changes individuals will experience with the advancement of age is an avenue of investigation that has taken on a relevant role in caring for the elderly, whether these changes are systemic, physiological or anatomical, or of health-related factors arising from lifestyle.1Watt RG. Strategies and approaches in oral disease prevention and health promotion. Bull World Health Organ. 2005 Sep;83(9):711-8. , 2Padilha DM, Hilgert JB, Hugo FN, Bos AJ, Ferrucci L. Number of teeth and mortality risk in the Baltimore Longitudinal Study of Aging. J Gerontol A Biol Sci Med Sci. 2008 Jul;63(7):739-44.

Dentistry is concerned about promoting a better quality of life for the elderly, and pursues aesthetical and functional results to reestablish dental occlusion, and favor social interaction. Dental services for these patients aim at restoring oral health, according to characteristics particular to this age group, such as absence of teeth, periodontal problems, and malocclusions.3Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod. 1996 Mar;2(1):21-30. , 4Melsen B. Preprosthetic movement of anterior teeth. Rev Belge Med Dent. 1982 May;37(3):111-4. , 5Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop. 1989 Sep;96(3):232-41. , 6Ogihara S, Marks MH. Alveolar bone upper growth in furcation area using a combined orthodontic-regenerative therapy: a case report. J Periodontol. 2002 Dec;73(12):1522-7. Viewed within this perspective, the number of elderly people who need dental treatment has been growing, and requires that professionals undergo adequate training, so that they can assist these individuals.

A relevant aspect of orthodontics is the study of facial aging. This analysis is an important diagnostic resource for establishing references of normality and guiding professionals during orthodontic treatment. However, studies regarding growth have historically been centered on the first two decades of life,7Meng HP, Goorhuis J, Kapila S, Nanda RS. Growth changes in the nasal profile from 7 to 18 years of age. Am J Orthod Dentofacial Orthop. 1988 Oct;94(4):317-26. , 8Snodell SF, Nanda RS, Currier GF. A longitudinal cephalometric study of transverse and vertical craniofacial growth. Am J Orthod Dentofacial Orthop. 1993 Nov;104(5):471-83. since it was believed that growth ceased right after puberty.9Pecora NG, Baccetti T, McNamara JA Jr. The aging craniofacial complex: a longitudinal cephalometric study from late adolescence to late adulthood. Am J Orthod Dentofacial Orthop. 2008 Oct;134(4):496-505. Few studies9Pecora NG, Baccetti T, McNamara JA Jr. The aging craniofacial complex: a longitudinal cephalometric study from late adolescence to late adulthood. Am J Orthod Dentofacial Orthop. 2008 Oct;134(4):496-505. , 1010 Behrents RG. The biological basis for understanding craniofacial growth during adulthood. Prog Clin Biol Res. 1985;187:307-19. , 1Watt RG. Strategies and approaches in oral disease prevention and health promotion. Bull World Health Organ. 2005 Sep;83(9):711-8. 1Watt RG. Strategies and approaches in oral disease prevention and health promotion. Bull World Health Organ. 2005 Sep;83(9):711-8. , 1212 Bishara SE, Treder JE, Jakobsen JR. Facial and dental changes in adulthood. Am J Orthod Dentofacial Orthop. 1994 Aug;106(2):175-86. , 1313 Bjork A. Variations in the growth pattern of the human mandible: longitudinal radiographic study by the implant method. J Dent Res. 1963 Jan-Feb;42(1)Pt 2:400-11. , 1414 Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop. 1994 May;105(5):464-76. , 1515 Israel H. Recent knowledge concerning craniofacial aging. Angle Orthod. 1973 Apr;43(2):176-84. , 1616 West KS, McNamara JA Jr. Changes in the craniofacial complex from adolescence to midadulthood: a cephalometric study. Am J Orthod Dentofacial Orthop. 1999 May;115(5):521-32. have sought to understand and quantify the craniofacial alterations that occur as a consequence of aging.

Because of the scarce research with patients > 60 yr. of age, this study investigated the cephalometric characteristics in elderly individuals, taking into account differences between genders, age ranges, ethnic groups, and occlusion characteristics.

Methodology

This cross-sectional study was approved by the Human Ethics Committee of theUniversidade Norte do Paraná - UNOPAR (PP0070/09). The volunteers were informed about the procedures by means of a Written Free and Clarified Consent (WFCC) statement, duly explained by the researchers and signed by the elderly individuals.

The target population was comprised of independent elderly people, with no physical or mental disabilities, aged ≥ 60 yr., of both genders, recruited from 38 primary healthcare centers in the urban region of Londrina,PR, Brazil. Several health indicators were analyzed in the elderly population of this age from the city, as part of a broader investigation by a group conducting an Interdisciplinary Aging and Longevity Study. Note that 85% of the elderly population commonly uses the Brazilian public health system in this city.

The representative sample size was defined as 343 of those selected from a total of 43,610 elderly individuals from Londrina.

The inclusion criteria of the study was elderly subjects who had natural teeth, or teeth rehabilitated by prostheses. Edentulous individuals who were not rehabilitated by prostheses and those with clinically detectable facial asymmetry were excluded. The final study sample was reduced to 250 elderly subjects of both genders, in that 163 were women (mean age: 68 yr.) and 87 men (mean age: 70.4 yr.).

The lateral cephalograms were obtained from the same machine (Orthopantomograph OP 100 Instrumentarium Corp., Tuusula, Finland) (17.6 s, 77 KVP, and 12 to 14 mA), with a 10% rate of magnification and with patients placed at 1.52 m from the cephalostat. The cephalograms were digitalized on a scanner (HP G4050, Palo Alto, USA) (600 dpi) proper for radiographs, using the ruler for 100 mm calibrations, as recommended by the manufacturer of the Dolphin Imaging 11.5TM program (Dolphin Imaging, Chatsworth, USA). Prior to performing the measurements, the examiner was allowed to treat the images to improve brightness and contrast, and thus allow better identification of the structures. Once the images were treated, the measurements were made. One previously calibrated examiner analyzed all the images to assess the cephalometric variables related to skeletal and soft tissue facial characteristics (Table 1, Figure 1).

Table 1
Cephalometric variables assessed.

Figure 1
Less usual cephalometric variables: Gl’.Pr.Pog’ (°): Angle of total facial convexity including the nose, Gl’.Sn.Pog’ (°): Angle of facial convexity excluding the nose; N-B.Upper Lip-Pog’ (°): Holdaway’s soft tissue angle; Upper Lip-E(mm): Linear distance between the upper lip anterior point and line E (esthetic plane by Ricketts); Lower Lip-E (mm): Linear distance between the lower lip anterior point and line E.

Study error

Measurements of 40 randomly selected patients were repeated after a 30-day interval to evaluate the examiner’s calibration. This afforded the assessment of systematic (paired t test) and casual (error calculation as proposed by Dahlberg) errors. Just one angular variable (SN.GoGn) of the 22 measurements assessed had a statistically significant systematic error. The random errors ranged from 0.2 mm (Upper Lip-E) to 1.8 mm (Co-Gn), and from 0.4o (SNB) to 2.8o (Gl’.Pr.Pog’). This level of error is acceptable, and certified the calibration of the examiner for the study.

Statistical analysis

The data were tested regarding normal distribution, applying the Shapiro-Wilk test. Considering the normal distribution of main variables, the data were described by parameters of mean and standard deviation, and parametric tests were used (independent t test and ANOVA). Several parameters, such as gender, age, race and occlusion characteristics, were statistically tested to determine their influences on the cephalometric characteristics of the elderly, the main object of the current study. For comparison purposes, the 250 elderly subjects comprising the sample were divided according to the variable to be tested. The number of subjects included in each variable comparison was stated in Table 2. The independentt test was used to compare the influence of gender (male or female) and age range (60-70 yr. and > 70 yr.) on the cephalometric measurements. In addition, one way ANOVA (Post test: Bonferroni) was used to assess the influence of race (white, black and Japanese) and occlusion characteristics (dentulous, edentulous and partial dental losses) on the cephalometric variables. These tests made it possible to determine which of these variables (gender, age, race or occlusion characteristics) statistically influenced the cephalometric measurements made on the elderly.

Table 2
Characterization of the study population.

All statistical tests were carried out with the Statistical Package for Social Sciences (SPSS) software (SPSS Inc., Chicago, USA), version 15.0.

Results

The characterization of the population under study is shown in Table 2.

The comparisons between genders indicate statistically significant differences in the following measurements: Co-A, Co-Gn, LAFH, TAFH, Gl’.Pr.Pog’ (Table 3).

Table 3
Variables that showed significant differences in the comparison between different genders (female and male): Mean, Standard Deviation (SD), independent t test (p).

When the cephalometric variables were evaluated regarding age ranges, statistically significant differences were found for the following measurements: SNB, ANB, NAP, FMA, SN.GoGn, LAFH, Gl’.Sn.Pog’, N-B.Upper Lip-Pog’, Upper Lip-E, Lower Lip-E (Table 4).

Table 4
Variables that showed significant differences as to age range: Mean, Standard Deviation (SD), independent t test (p).

In verifying the cephalometric variables between ethnic groups, statistically significant differences were found for the following measurements: SNA, A-Nperp, ANB, NAP Convexity, N- N-B.Upper Lip-Pog’, Upper Lip-E, Lower Lip-E, 1-NB (Table 5).

Table 5
Comparison between the ethnic groups and the variables of maxillary component maxillomandibular relationship, and dentoalveolar component: Mean, Standard Deviation (SD), ANOVA (p).

When the cephalometric variables were compared regarding dental characteristics, statistically significant alterations were found for the following measurements: SNA, A-Nperp, Co-A, SNB, P-Nperp, Co-Gn, ANB, NAP Convexity, FMA, SN.GoGn, LAFH, TAFH, Gl’.Sn.Pog’, N-B.Upper Lip-Pog’, Upper Lip-E, Lower Lip-E (Table 6).

Table 6
Comparison between the occlusion pattern and the variables of maxillary component, mandibular component, and maxillomandibular relationship: Mean, Standard Deviation (SD), ANOVA (p).

Discussion

This cross-sectional study investigated the facial profile characteristics of elderly subjects, taking into account differences between genders (male and female), age ranges (60-70 and > 70 yr.), ethnic groups (white, black and Japanese) and dental characteristics.

The comparisons regarding gender indicated statistically significant differences in measurements of the maxillary and mandibular components, and of the growth pattern (Table 3). In this study, lower values were found for the female gender in linear measurements, following the trend described in the literature9Pecora NG, Baccetti T, McNamara JA Jr. The aging craniofacial complex: a longitudinal cephalometric study from late adolescence to late adulthood. Am J Orthod Dentofacial Orthop. 2008 Oct;134(4):496-505. , 1010 Behrents RG. The biological basis for understanding craniofacial growth during adulthood. Prog Clin Biol Res. 1985;187:307-19. , 1111 Bishara SE, Jakobsen JR, Hession TJ, Treder JE. Soft tissue profile changes from 5 to 45 years of age. Am J Orthod Dentofacial Orthop. 1998 Dec;114(6):698-706. , 1212 Bishara SE, Treder JE, Jakobsen JR. Facial and dental changes in adulthood. Am J Orthod Dentofacial Orthop. 1994 Aug;106(2):175-86. , 1414 Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop. 1994 May;105(5):464-76.. Thilander et al.1717 Thilander B, Persson M, Adolfsson U. Roentgen-cephalometric standards for a Swedish population. A longitudinal study between the ages of 5 and 31 years. Eur J Orthod. 2005 Aug;27(4):370-89. observed linear measurements with absolute values that were higher in the male gender as compared with the female gender; however, their study was carried out with a younger sample (5 to 31 yr.). Studies by Behrents1010 Behrents RG. The biological basis for understanding craniofacial growth during adulthood. Prog Clin Biol Res. 1985;187:307-19. and by Pecoraet al.,9Pecora NG, Baccetti T, McNamara JA Jr. The aging craniofacial complex: a longitudinal cephalometric study from late adolescence to late adulthood. Am J Orthod Dentofacial Orthop. 2008 Oct;134(4):496-505.conducted with samples of older individuals, observed significantly higher mean values for Co-A and Co-Gn measurements for men in relation to women. Likewise, the LAFH and TAFH measurements were also observed with this same relationship between genders in studies by Behrents1010 Behrents RG. The biological basis for understanding craniofacial growth during adulthood. Prog Clin Biol Res. 1985;187:307-19.and Formby et al.1414 Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop. 1994 May;105(5):464-76. On the other hand, in this study, the measurement of the angle of the facial profile including the nose (Gl’.Pr.Pog’) showed a higher value for the female gender, in disagreement with the results by Formby et al.1414 Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop. 1994 May;105(5):464-76. and Bisharaet al.1111 Bishara SE, Jakobsen JR, Hession TJ, Treder JE. Soft tissue profile changes from 5 to 45 years of age. Am J Orthod Dentofacial Orthop. 1998 Dec;114(6):698-706.These results may be explained by the influence of the size of the nose, which tends to be larger for men as compared with women,1818 Genecov JS, Sinclair PM, Dechow PC. Development of the nose and soft tissue profile. Angle Orthod. 1990 Fall;60(3):191-8. leading to an angle of the facial profile including the nose that is smaller for males in relation to females.

When the cephalometric variables were compared regarding age ranges, statistically significant differences were found for various measurements (Table 4). Most of the cephalometric measurements related to growth pattern (FMA, SN.GoGn, LAFH) had significantly lower mean values according to advancing age (> 70 yr.), thereby showing a vertical loss from aging. Moreover, a significant increase in the average value of the SNB measurement and a significant decrease in the ANB and NAP convexity measurements were observed in the > 70-yr. age range. This indicates a mandibular displacement in the anti-clockwise direction. This same tendency of increased facial concavity was observed for soft tissues (Gl’.Sn.Pog’, N-B.Upper Lip-Pog’, Upper Lip-E, Lower Lip-E). These results can be explained by the decrease in the vertical dimension due to progressive bone loss common to the elderly1919 Ulm CW, Solar P, Ulm MR, Matejka M. Sex-related changes in the bone mineral content of atrophic mandibles. Calcif Tissue Int. 1994 Mar;54(3):203-7. , 2020 Ulm C, Kneissel M, Schedle A, Solar P, Matejka M, Schneider B,et al. Characteristic features of trabecular bone in edentulous maxillae. Clin Oral Implants Res. 1999 Dec;10(6):459-67. , 2121 Kim ST, Won SY, Kim SH, Paik DJ, Song WC, Koh KS, et al. Variations in the trabecular bone ratio of the maxilla according to sex, age, and region using micro-computed tomography in Koreans. J Craniofac Surg. 2011 Mar;22(2):654-8. , 2222 von Wowern N, Stoltze K. Sex and age differences in bone morphology of mandibles. Scand J Dent Res. 1978 Dec;86(6):478-85., especially taking into account that most of the individuals analyzed in this sample had multiple dental losses. Bone reduction is a physiological process that generally starts in the third and fourth decades of life, that is more expressive in women than men2222 von Wowern N, Stoltze K. Sex and age differences in bone morphology of mandibles. Scand J Dent Res. 1978 Dec;86(6):478-85. , 2323 Gulsahi A, Yuzugullu B, Imirzalioglu P, Genc Y. Assessment of panoramic radiomorphometric indices in Turkish patients of different age groups, gender and dental status. Dentomaxillofac Radiol. 2008 Jul;37(5):288-92. and that is greatly influenced by the presence of teeth. Dental losses cause an irreversible vertical resorption of the alveolar bone.1919 Ulm CW, Solar P, Ulm MR, Matejka M. Sex-related changes in the bone mineral content of atrophic mandibles. Calcif Tissue Int. 1994 Mar;54(3):203-7. , 2020 Ulm C, Kneissel M, Schedle A, Solar P, Matejka M, Schneider B,et al. Characteristic features of trabecular bone in edentulous maxillae. Clin Oral Implants Res. 1999 Dec;10(6):459-67. These changes regarding dental losses are more readily and significantly observed in the maxilla, in relation to the mandible.2424 Glowacki J. Impact of postmenopausal osteoporosis on the oral and maxillofacial surgery patient. Oral Maxillofac Surg Clin North Am. 2007 May;19(2):187-98, vi. In this study, the probable bone loss in the maxilla and mandible due to aging and to the high degree of edentulism in this sample were determining factors for the reduction in the vertical dimension, and for the increase in facial concavity, in accordance with the measurements studied.

Considering the ethnic groups in the sample, some statistically significant differences were found. Freitas et al.2525 Freitas LM, Freitas KM, Pinzan A, Janson G, Freitas MR. A comparison of skeletal, dentoalveolar and soft tissue characteristics in white and black Brazilian subjects. J Appl Oral Sci. 2010 Mar-Apr;18(2):135-42. showed that the various cephalometric measurements evaluated had higher values for blacks, followed by Japanese and whites. Although the present study comprised a sample with a higher age range (> 60 yr.), the values found followed the same trend for young patients (Table 5).

Comparing the cephalometric variables regarding dental characteristics, statistically significant alterations were found for the majority of the measurements assessed (Table 6). The cephalometric measurements obtained from dentulous patients showed greater absolute values for all the components evaluated, probably due to higher integrity of alveolar processes, resulting in retaining of the same vertical dimension. Individuals with partial dental losses had intermediate cephalometric values, whereas edentulous individuals had lower values. This is most likely explained by alveolar bone loss resulting from the dental loss.1919 Ulm CW, Solar P, Ulm MR, Matejka M. Sex-related changes in the bone mineral content of atrophic mandibles. Calcif Tissue Int. 1994 Mar;54(3):203-7. , 2020 Ulm C, Kneissel M, Schedle A, Solar P, Matejka M, Schneider B,et al. Characteristic features of trabecular bone in edentulous maxillae. Clin Oral Implants Res. 1999 Dec;10(6):459-67. , 2121 Kim ST, Won SY, Kim SH, Paik DJ, Song WC, Koh KS, et al. Variations in the trabecular bone ratio of the maxilla according to sex, age, and region using micro-computed tomography in Koreans. J Craniofac Surg. 2011 Mar;22(2):654-8. , 2222 von Wowern N, Stoltze K. Sex and age differences in bone morphology of mandibles. Scand J Dent Res. 1978 Dec;86(6):478-85. In this study, edentulism was detected in 38.8% of the sample, a datum similar to that of the study by Salonen et al.,2626 Salonen L, Hellden L, Carlsson GE. Prevalence of signs and symptoms of dysfunction in the masticatory system: an epidemiologic study in an adult Swedish population. J Craniomandib Disord. 1990 Fall;4(4):241-50. in which edentulism was observed in 35% of the individuals 60-69 yrs. old, 70% in the 70-79-year range, and 80% in elderly subjects > 80. This high dental loss was also observed in other studies with the elderly population,2626 Salonen L, Hellden L, Carlsson GE. Prevalence of signs and symptoms of dysfunction in the masticatory system: an epidemiologic study in an adult Swedish population. J Craniomandib Disord. 1990 Fall;4(4):241-50. , 2727 Schmitter M, Rammelsberg P, Hassel A. The prevalence of signs and symptoms of temporomandibular disorders in very old subjects. J Oral Rehabil. 2005 Jul;32(7):467-73. including developed countries such as Japan, where 50% of elderly individuals 65 yr. old make use of total prostheses; moreover, this percentage is even greater in elderly subjects >80 yr. of age.2828 Okubo M, Fujinami Y, Minakuchi S. Effect of complete dentures on body balance during standing and walking in elderly people. J Prosthodont Res. 2010 Jan;54(1):42-7.

Taking into account the cephalometric aspects observed in this study regarding elderly subjects, it is worth emphasizing that professionals should avoid orthodontic treatments that promote excessive retraction of the facial profile, especially in cases of individuals with a straight profile who require dental extractions. A better understanding of the alterations inherent to the aging process will contribute to establishing more conservative treatment protocols that will minimize the effects of aging on facial characteristics.

Conclusion

The cephalometric alterations shown in this study are inherent to facial maturity, and present specific characteristics for each of the variables assessed. These modifications must be taken into account when planning treatments for young patients, to minimize the modifications arising from the natural aging process.

References

  • 1
    Watt RG. Strategies and approaches in oral disease prevention and health promotion. Bull World Health Organ. 2005 Sep;83(9):711-8.
  • 2
    Padilha DM, Hilgert JB, Hugo FN, Bos AJ, Ferrucci L. Number of teeth and mortality risk in the Baltimore Longitudinal Study of Aging. J Gerontol A Biol Sci Med Sci. 2008 Jul;63(7):739-44.
  • 3
    Kokich VG. Esthetics: the orthodontic-periodontic restorative connection. Semin Orthod. 1996 Mar;2(1):21-30.
  • 4
    Melsen B. Preprosthetic movement of anterior teeth. Rev Belge Med Dent. 1982 May;37(3):111-4.
  • 5
    Melsen B, Agerbaek N, Markenstam G. Intrusion of incisors in adult patients with marginal bone loss. Am J Orthod Dentofacial Orthop. 1989 Sep;96(3):232-41.
  • 6
    Ogihara S, Marks MH. Alveolar bone upper growth in furcation area using a combined orthodontic-regenerative therapy: a case report. J Periodontol. 2002 Dec;73(12):1522-7.
  • 7
    Meng HP, Goorhuis J, Kapila S, Nanda RS. Growth changes in the nasal profile from 7 to 18 years of age. Am J Orthod Dentofacial Orthop. 1988 Oct;94(4):317-26.
  • 8
    Snodell SF, Nanda RS, Currier GF. A longitudinal cephalometric study of transverse and vertical craniofacial growth. Am J Orthod Dentofacial Orthop. 1993 Nov;104(5):471-83.
  • 9
    Pecora NG, Baccetti T, McNamara JA Jr. The aging craniofacial complex: a longitudinal cephalometric study from late adolescence to late adulthood. Am J Orthod Dentofacial Orthop. 2008 Oct;134(4):496-505.
  • 10
    Behrents RG. The biological basis for understanding craniofacial growth during adulthood. Prog Clin Biol Res. 1985;187:307-19.
  • 11
    Bishara SE, Jakobsen JR, Hession TJ, Treder JE. Soft tissue profile changes from 5 to 45 years of age. Am J Orthod Dentofacial Orthop. 1998 Dec;114(6):698-706.
  • 12
    Bishara SE, Treder JE, Jakobsen JR. Facial and dental changes in adulthood. Am J Orthod Dentofacial Orthop. 1994 Aug;106(2):175-86.
  • 13
    Bjork A. Variations in the growth pattern of the human mandible: longitudinal radiographic study by the implant method. J Dent Res. 1963 Jan-Feb;42(1)Pt 2:400-11.
  • 14
    Formby WA, Nanda RS, Currier GF. Longitudinal changes in the adult facial profile. Am J Orthod Dentofacial Orthop. 1994 May;105(5):464-76.
  • 15
    Israel H. Recent knowledge concerning craniofacial aging. Angle Orthod. 1973 Apr;43(2):176-84.
  • 16
    West KS, McNamara JA Jr. Changes in the craniofacial complex from adolescence to midadulthood: a cephalometric study. Am J Orthod Dentofacial Orthop. 1999 May;115(5):521-32.
  • 17
    Thilander B, Persson M, Adolfsson U. Roentgen-cephalometric standards for a Swedish population. A longitudinal study between the ages of 5 and 31 years. Eur J Orthod. 2005 Aug;27(4):370-89.
  • 18
    Genecov JS, Sinclair PM, Dechow PC. Development of the nose and soft tissue profile. Angle Orthod. 1990 Fall;60(3):191-8.
  • 19
    Ulm CW, Solar P, Ulm MR, Matejka M. Sex-related changes in the bone mineral content of atrophic mandibles. Calcif Tissue Int. 1994 Mar;54(3):203-7.
  • 20
    Ulm C, Kneissel M, Schedle A, Solar P, Matejka M, Schneider B,et al Characteristic features of trabecular bone in edentulous maxillae. Clin Oral Implants Res. 1999 Dec;10(6):459-67.
  • 21
    Kim ST, Won SY, Kim SH, Paik DJ, Song WC, Koh KS, et al Variations in the trabecular bone ratio of the maxilla according to sex, age, and region using micro-computed tomography in Koreans. J Craniofac Surg. 2011 Mar;22(2):654-8.
  • 22
    von Wowern N, Stoltze K. Sex and age differences in bone morphology of mandibles. Scand J Dent Res. 1978 Dec;86(6):478-85.
  • 23
    Gulsahi A, Yuzugullu B, Imirzalioglu P, Genc Y. Assessment of panoramic radiomorphometric indices in Turkish patients of different age groups, gender and dental status. Dentomaxillofac Radiol. 2008 Jul;37(5):288-92.
  • 24
    Glowacki J. Impact of postmenopausal osteoporosis on the oral and maxillofacial surgery patient. Oral Maxillofac Surg Clin North Am. 2007 May;19(2):187-98, vi.
  • 25
    Freitas LM, Freitas KM, Pinzan A, Janson G, Freitas MR. A comparison of skeletal, dentoalveolar and soft tissue characteristics in white and black Brazilian subjects. J Appl Oral Sci. 2010 Mar-Apr;18(2):135-42.
  • 26
    Salonen L, Hellden L, Carlsson GE. Prevalence of signs and symptoms of dysfunction in the masticatory system: an epidemiologic study in an adult Swedish population. J Craniomandib Disord. 1990 Fall;4(4):241-50.
  • 27
    Schmitter M, Rammelsberg P, Hassel A. The prevalence of signs and symptoms of temporomandibular disorders in very old subjects. J Oral Rehabil. 2005 Jul;32(7):467-73.
  • 28
    Okubo M, Fujinami Y, Minakuchi S. Effect of complete dentures on body balance during standing and walking in elderly people. J Prosthodont Res. 2010 Jan;54(1):42-7.

Publication Dates

  • Publication in this collection
    2015

History

  • Received
    26 May 2014
  • Accepted
    14 Nov 2014
  • Reviewed
    27 Jan 2015
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