Bone is a highly specialized, dense connective tissue primarily functioning as a supportive framework and metabolic reservoir for the human body [Singh V ,2016]. The adult skeleton comprises 206 distinct bones divided into the axial and appendicular systems, which develop through separate intramembranous or endochondral ossification processes [Poddar et al,2019]. Structurally, the osseous matrix consists of water, organic materials (such as collagen fibers and ground substance), and inorganic components dominated by calcium and phosphate crystals [Singh V ,2016]. This structural framework is metabolically maintained on bone surfaces by the periosteum and endosteum through a dynamic equilibrium orchestrated by supportive osteoblasts, mature osteocytes, and remodeling osteoclasts [Singh V ,2016].

Craniofacial Embryology and Mandibular Morphology

The development of the human face occurs rapidly between the 4th and 8th weeks of embryonic life. Face formation relies on five specific mesenchymal primordia surrounding the primitive stomatodeum: an unpaired frontonasal process and paired maxillary and mandibular processes derived from the first pharyngeal arch [Singh IB et al,2018].

• The frontonasal processdifferentiates into the forehead, external nose, nasal cavity, nasal septum, and the philtrum of the upper lip [Singh IB et al,2018].
• The maxillary processforms the lateral portions of the upper lip and the superior aspects of the cheeks [Singh IB et al,2018].
• The mandibular processforms the lower lip, chin, and lower regions of the cheeks

The mandible, arising from the mandibular process, stands as the largest and strongest bone of the human face [Singh IB et al,2018]. It comprises a horse-shoe-shaped central body and two quadrilateral rami extending upward from its posterior borders [Standring et al,2015]. Crucially, the mandibular rami and the gonial region undergo predictable morphological adaptations throughout the human lifespan. The orientation of the ramus is nearly parallel to the body in foetal life, progresses to an oblique angle during youth, shifts to a nearly vertical position at a right angle during mature manhood, and reverts to an oblique path in senile old age following tooth loss. This ongoing remodeling correlates significantly with overall skeletal mineral status, structural stress transmission, and genetic variables [Motawei et al, 2020, Ishwarkumar et al, 2017, Baghdadi et al, 2011].

Bone Metabolism and the Impact of Diabetes Mellitus

Osseous tissue operates under strict regulatory control mechanism networks, serving as the primary repository for 99% of systemic calcium . Different groups of metabolic bone disorders, such as osteopenic diseases (defined by decreased bone mass like osteoporosis), osteosclerotic conditions, osteomalacic diseases, or complicated mixed deficiencies, are caused by disruptions in homeostatic mineralization pathways [Maheshwari et al,2022, ].The relationship between bone volume, porosity, and mineral density is a crucial factor in defining physical bone strength since it directly affects the skeleton's elastic modulus and structural fragility [Bajoria et al,2015, Cakur et al,2009].      

Diabetes mellitus is a fast spreading worldwide metabolic epidemic that is typified by persistent hyperglycemia brought on by either progressive peripheral insulin receptor resistance (Type 2) or autoimmune pancreatic beta-cell death (Type 1). Diabetes severely impairs bone quality in addition to its known microvascular and macrovascular problems [ Prakash et al,2017, Chawla et al,2016, Mastrandrea et al,2008]. In order to increase bone formation, the anabolic hormone insulin directly activates receptors on osteoblasts and osteoclasts. Thus, proper skeletal remodeling is hampered by low absolute levels or systemic insulin resistance. Long-term hyperglycemia causes a negative calcium balance, increases the excretion of calcium in the urine, and speeds up the buildup of advanced glycation end products (AGEs), which results in altered skeletal metabolism and diabetes osteoporosis [Tripathi et al,2019, Adil et al,2014, Mariah et al,2023].

Justification and Objectives

An automated, non-invasive method for expressing the size, proportions, and physical changes of the craniofacial skeleton in exact mathematical dimensions is facial anthropometry [Ranjana et al,2016, Carlos et al,2021, S Rogers et al,1987]. Localized effects on craniofacial topographies are still poorly understood, despite the extensive documentation of the detrimental effects of diabetes bone disease on the appendicular skeleton, such as high fracture incidence and delayed healing [Constantini et al,2019]. Monitoring minute changes in the bone index in the mandible and facial Bones can identify localized signs of systemic metabolic deterioration since these areas are subject to continuous occlusal stress and muscular remodeling [Bajoria et al,2015, Cakur et al,2009]. A comparative radiological evaluation of facial width and gonial index in people with and without diabetes is presented in this study. This work intends to provide light on how regional craniofacial architecture and skeletal density markers are affected by chronic metabolic stress and altered calcium dynamics using high-fidelity CBCT datasets.

This study was conducted in the Department of Anatomy at MPTMC, Siddharth Nagar in collaboration with Integral institute of medical sciences & research, Integral University, Lucknow, Uttar Pradesh. The study design received approval from the IIMS&R Institutional Research Committee and Ethical Committee . A total sample size of 152 individuals was randomly selected from the population of Uttar Pradesh. (76 diabetic patients and 76 non-diabetic control subjects). Written informed consent was obtained from all participating individuals before performing any radiographic measurements. Inclusion Criteria • Healthy individuals showing no history of chronic illness. • Subjects clinically diagnosed with either Type 1 or Type 2 Diabetes Mellitus. • Male and female individuals aged between 18 and 58 years. Exclusion Criteria • Individuals presenting with historical traumatic injuries to the craniofacial bones • Patients who have undergone prior orthodontic or maxillofacial surgeries. • Subjects presenting with any active jaw bone pathology. • Patients who have undergone radiotherapy to the head and neck region. • Individuals with other systemic illnesses known to affect bone metabolism. • Pregnant females & Post-menopausal women • Individuals who expressed a refusal to participate in the research study. Measurements (Linear and Index Anthropometric) Each of the measurements was taken in an isolated setting with an attendant during an axial computed tomography scan (Siemens 32-slice CT scanner). Radiological software was used to measure facial parameters required. 1. Measurement of Facial Width (Bigonial Width) • Measured horizontally from the right Gonion (Point C) to the left Gonion (Point D). • Traced by drawing a straight horizontal baseline connecting Point C to Point D . • Gonion (Go): Defined explicitly as the location marking the definitive angle of the mandible.[Datta et al, 2017] FIG.1. Measurement of Facial Width (Bigonial Width) 3. Measurement of Gonial Index (GI): The assessment of mandibular cortical thickness involves measuring along the bisectrix of the angle formed by the tangent lines to the posterior border of the ramus and the inferior margin of the mandible [David et al,2017] FIG 2.1: MEASUREMENT OF RIGHT GONIAL INDEX FIG. 2.2: MEASUREMENT OF LEFT GONIAL INDEX Age Categorisation and Statistical Analysis Depending on age, the entire sample size was categorized into five distinct age groups. Data was analysed statistically. p-value less than 0.05 considered to be is significant. • Group I: 18–25 years of age. • Group II: 26–33 years of age. • Group III: 34–41 years of age. • Group IV: 42–49 years of age. • Group V: 50–58 years of age.

Table. 1 Comparison of Facial width of Diabetic and Non-Diabetic Males (mm)

Table. 2 Comparision of Gonial Index on Right Side of Diabetic and Non-Diabetic Males (mm)

Table. 3. Comparision of Gonial Index on Left Side of Diabetic and Non-Diabetic Males (mm)

Table. 4 Comparision of Facial width of Diabetic and Non-Diabetic Females (mm)

Table. 5 Comparision of Gonial Index on Right Side of Diabetic and Non-Diabetic Females (mm)

Table. 6 Comparision of Gonial Index on Left Side of Diabetic and Non-Diabetic Females (mm)

Mean Facial Width was 98.75 mm in the diabetic males with maximum value of 108.2 mm and minimum of 89.7 mm, while the mean facial Width was 96.32 mm in the non-diabetic males with maximum value of 103.3 mm and minimum of 88.2 mm (Table 1). In Group I, the mean facial width was 100.77 mm in the diabetic males with maximum value of 103 mm and minimum of 98.5 mm, while the mean facial Width was 97.24 mm in the non-diabetic males with maximum value of 99 mm and minimum of 95.7 mm. In group II, mean facial Width was 92.89 mm in the diabetic males with maximum value of 96.9 mm and minimum of 89.7 mm, while mean facial width was 89.96 mm in the non-diabetic males with maximum value of 91.4 mm and minimum of 88.2 mm. In group III, mean facial Width was 98.03 mm in the diabetic males with maximum value of 100.4 mm and minimum of 95.6 mm, while mean facial width was 95.23 mm in the non-diabetic males with maximum value of 96.4 mm and minimum of 93.8 mm. 

    In group IV, mean facial Width was 94.28 mm in the diabetic males with maximum value of 97.6 mm and minimum of 92.1 mm, while mean facial Width was 92.53 mm in the non-diabetic males with maximum value of 103.3 mm and minimum of 98 mm. In group V, mean facial Width was 106.02 mm in the diabetic males with maximum value of 108.2 mm and minimum of 103 mm, while mean facial Width was 100.97 mm in the non-diabetic males with maximum value of 103.3 mm and minimum of 98 mm.

The mean gonial index of the right side was 5.27 mm with maximum value of 8.7 mm and   minimum of 3.7 mm in the diabetic males, while the mean gonial index of the right side was 6.48 with maximum value of 8.9 mm and minimum of 3.2 mm in the non-diabetic males (Table 2). In group I, the mean gonial index of the right side was 6.87 mm with maximum value of 7.7 mm and minimum of 6.2 mm in the diabetic males, while the mean gonial index of the right side was 7.18 mm with maximum value of 7.7 mm and minimum of 6.6 mm in the non- diabetic males. In group II, the mean gonial index of the right side was 5.05 mm with maximum value of 5.7 mm and minimum of 4.4 mm in the diabetic males, while the mean gonial index of the right side was 5.62 mm with maximum value of 5.9 mm and minimum of 4.4 mm in the non-diabetic males. In group III, the mean gonial index of the right side was 6.07 mm with maximum value of 6.5 mm and minimum of 5.5 mm in the diabetic males, while the mean gonial index of the right side was 6.54 mm with maximum value of 7.2 mm and minimum of 5.7 mm in the non-diabetic males.

In group IV, the mean gonial index of the right side was 4.69 mm with maximum value of 5.8 mm and minimum of 3.7 mm in the diabetic males, while the mean gonial index of the Right side was 3.85 mm with maximum value of 4.4 mm and minimum of 3.2 mm in the non-diabetic males. In group V, the mean gonial index of the right side was 8.0 mm with maximum value of 8.7 mm and minimum of 7.4 mm in the diabetic males, while the mean gonial index of the right side was 7.42 mm with maximum value of 8.9 mm and minimum of 6.2 mm in the non-diabetic males.

The mean gonial index of the left side was 4.83 mm with maximum value of 7.7 mm and minimum of 3.4 mm in the diabetic males, while the mean gonial index of the left sidewas 6.05 mm with maximum value of 7.6 mm and minimum of 3.2 mm in the non-diabetic males (Table 3). In group I, the mean gonial index of the left side was 5.85 mm with maximum value of 6.6 mm and minimum of 5.2 mm in the diabetic males, while the mean gonial index of the left side was 6.08 mm with maximum value of 6.5 mm and minimum of 5.6 mm in the non-diabetic males. In group II, the mean gonial index of the left side was 4.60 mm with maximum value of 5.3 mm and minimum of 3.6 mm in the diabetic males, while the mean gonial index of the left side was 4.14 mm with maximum value of 4.6 mm and minimum of 3.8 mm in the non-diabetic males. In group III, the mean gonial index of the left side was 5.26 mm with maximum value of 5.8 mm and minimum of 4.9 mm in the diabetic males, while the mean gonial index of the left side was 4.95 mm with maximum value of 5.4 mm and minimum of 4.5 mm in the non-diabetic males.

In group IV, the mean gonial index of the left side was 4.58 mm with maximum value of 5.4

mm and minimum of 3.4 mm in the diabetic males, while the mean gonial index of the left side was 3.70 mm with maximum value of 4.0 mm and minimum of 3.2 mm in the non-diabetic males. In group V, the mean gonial index of the left side was 7.05 mm with maximum value of 7.7 mm and minimum of 6.4 mm in the diabetic males, while the mean gonial index of the left side was 6.88 mm with maximum value of 7.6 mm and minimum of 6.5 mm in the non-diabetic males.

Mean Facial Width was 93.71 mm in the diabetic females with maximum value of 99.9 mm and minimum of 85.7 mm, while the mean facial Width was 92.74 mm in the non-diabetic females with maximum value of 96.2 mm and minimum of 86.2 mm (Table 4). In Group I, the mean facial width was 94.12 mm in the diabetic females with maximum value of 95.6 mm and minimum of 92.8 mm, while the mean facial Width was 93.31 mm in the non-diabetic females with maximum value of 96.2 mm and minimum of 90.4 mm. In group II, mean facial Width was 91.69 mm in the diabetic females with maximum value of 93.7 mm and minimum of 90.6 mm, while mean facial width was 90.52 mm in the non-diabetic females with maximum value of 92.4 mm and minimum of 88.6 mm. In group III, mean facial width was 89.22 mm in the diabetic females with maximum value of 90.6 mm and minimum of 88.1 mm, while mean facial width was 88.69 mm in the non-diabetic females with maximum value of 89.6 mm and minimum of 87.2 mm.

In group IV, mean facial Width was 86.42 mm in the diabetic females with maximum value of 87.2 mm and minimum of 85.7 mm, while mean facial Width was 87.43 mm in the non-diabetic females with maximum value of 88.6 mm and minimum of 86.2 mm. In group V, mean facial Width was 96.67 mm in the diabetic females with maximum value of 99.9 mm and minimum of 95.6 mm, while mean facial Width was 94.85 mm in the non-diabetic females with maximum value of 96.2 mm and minimum of 93.9 mm.

The mean gonial index of the right side was 5.22 mm with maximum value of 6.6 mm and minimum of 4.1 mm in the diabetic females, while the mean gonial index of the right side was 6.92 mm with maximum value of 7.8 mm and minimum of 5.7 mm in the non-diabetic females (Table 5). In group I, the mean gonial index of the right side was 6.23 mm with maximum value of 6.6 mm and minimum of 5.9 mm in the diabetic females, while the mean gonial index of the right side was 6.90 mm with maximum value of 7.1 mm and minimum of 6.8 mm in the non-diabetic females. In group II, the mean gonial index of the right side was 5.02 mm with maximum value of 5.6 mm and minimum of 4.6 mm in the diabetic females, while the mean gonial index of the right side was 6.33 mm with maximum value of 6.7 mm and minimum of 6.0 mm in the non-diabetic females. In group III, the mean gonial index of the right side was 4.84 mm with maximum value of 5.2 mm and minimum of 4.4 mm in the diabetic females,while the mean gonial index of the right side was 6.68 mm with maximum value of 6.9 mm and minimum of 6.4 mm in the non-diabetic females.

In group IV, the mean gonial index of the right side was 4.45 mm with maximum value of 4.9 mm and minimum of 4.1 mm in the diabetic females, while the mean gonial index of the right side was 5.95 mm with maximum value of 6.2 mm and minimum of 5.7 mm in the non-diabetic females. In group V, the mean gonial index of the right side was 5.80 mm with maximum value of 6.4 mm and minimum of 5.2 mm in the diabetic females, while the mean gonial index of the right side was 7.40 mm with maximum value of 7.8 mm and minimum of 7.1 mm in the non-diabetic females.

The mean gonial index of the left side was 4.71 mm with maximum value of 5.6 mm and minimum of 4.1 mm in the diabetic females, while the mean gonial index of the left side was 6.20 mm with maximum value of 7.2 mm and minimum of 5.2 mm in the non-diabetic females (Table 6).In group I, the mean gonial index of the left side was 5.0 mm with maximum value of 5.6 mm and minimum of 4.5 mm in the diabetic females, while the mean gonial index of the left side was 6.27 mm with maximum value of 6.1 mm and minimum of 6.7 mm in the non-diabetic females. In group II, the mean gonial index of the left side was 4.50 mm with maximum value of 4.9 mm and minimum of 4.1 mm in the diabetic females, while the mean gonial index of the left side was 6.17 mm with maximum value of 6.2 mm and minimum of 6.1 mm in the non-diabetic females. In group III, the mean gonial index of the left side was 4.7 mm with maximum value of 4.9 mm and minimum of 4.5 mm in the diabetic females, while the mean gonial index of the left side was 6.58 mm with maximum value of 6.9 mm and minimum of 6.2 mm in the non-diabetic females.

In group IV, the mean gonial index of the left side was 4.5 mm with maximum value of 4.9 mm and minimum of 4.1 mm in the diabetic females, while the mean gonial index of the left side was 5.55 mm with maximum value of 5.9 mm and minimum of 5.2 mm in the non-diabetic females. In group V, the mean gonial index of the left side was 4.87 mm with maximum value of 5.2 mm and minimum of 4.4 mm in the diabetic females, while the mean gonial index of the left side was 6.97 mm with maximum value of 7.2 mm and minimum of 5.2 mm in the non-diabetic females.

In the present study, Facial height was obtained 115.43 mm and 111.96 mm in diabetic Males and non-diabetic males while Facial height was obtained 109.41 mm and 106.91mm in diabetic females and non-diabetic females. Facial width was obtained 98.75 mm and 96.32 mm in non-diabetic males while Facial width was obtained 93.17 mm and 92.74 mm in diabetic and non-diabetic females.

Limeira et al, (2017), studied the mandibular cortical index in patients with type-1 Diabetes mellitus in the Department of Dentistry, School of Dentistry, UEPB, Brazil, on 150 subjects, and they observed mental index 3.57±0.53 in females and mental index 3.53±0.78 in males.

      David et al, (2017), performed a study on radiomorphometric indices of the mandible in patients with diabetes mellitus in the department of oral and maxillofacial radiology at Amrita School of Dentistry, Kochi, Kerala, India, on 100 people, and they found that people with type 2 diabetes had a mental index of 2.82 ± 0.38; people with type 2 diabetes who were  taking calcium and vitamin D supplements had a mental index of 2.82 ± 0.47; and people with type 1diabetes had a mental index of 2.73 ± 0.38.

Jang et al, (2018), studied bone mineral density on patients with diabetes mellitus in the Korea National Health and Nutritional Survey, South Korea, on 37,753 subjects, and they observed males with diabetes and prediabetics had significantly higher mean BMD at all the measured sites than the control males, irrespective of diabetes mellitus duration. So finally, they concluded that diabetes mellitus was significantly associated with reduced femoral neck BMD.

Tuominen et al, (1999), did a study on bone mineral density in type 1 and type 2 diabetes mellitus patients, department of medicine, Turku University Central Hospital District, Finland, on 639 diabetic patients, and they concluded lower BMD in type 1 diabetic patients compared to type 2 and control group. There is rapid loss of bone after the onset of type 1 diabetes mellitus.

Mathkhor et al, (2023), performed a study on bone mineral density in type 2 diabetes Mellitus patients, Department of Rheumatology, Basrah Teaching Hospital, Iraq, on 300 individuals (150 diabetic patients and 150 normal individuals), and they found out of 150 diabetic patients, 11 had osteoporosis and 21 had osteopenia in the lumbar spine compared to the control group.

While 9 had osteoporosis and 17 had osteopenia in the left femoral neck region in Diabetic patients as compared to the control group.

     Ledgerton et al, (1999), performed a study on radio morphometric indices of the mandible in the British female population on 500 radiographs. They measured several indices, cortical width at the gonion (GI) and below the mental foramen of Mandible (MI), the panoramic indexof mandible (PMI), cortical index of mandible (MCI), and one new index (measurement of cortical width at the  antegonion; AI) and  they observed  all the  quantitative  indices  (GI, MI,PMI, AI), showed a  significant,  negative  correlation  with age.   MCI showed   an  age-related distribution. Some  variables were  significantly impacted by   mandibular   dentition, however socioeconomic class had no effect. MI, PMI, and AI had acceptable intra-observer repeatability (accuracy < 20%), whereas GI had poor intra-observer reproducibility.

   Our finding was similar to the finding of David et al., Limiera et al., they showed a decrease in the mental index and gonial index of diabetic patients. Mental index and gonial index were found to be lower in both diabetic males and diabetic females compared to healthy peers. Changes in the face in people with diabetes mellitus, prolonged hyperglycemia can lead to minor but noticeable alterations in the skeletal structure of the face. For instance, bone resorption or soft tissue alterations may cause the jawline to shift or the cheekbones to become more prominent.

Joint alterations and osteoarthritis, diabetes raises the risk of osteoarthritis, which can impact the temporomandibular joint (TMJ), which joins the jaw to the skull. This can result in a misaligned jaw, which could affect the look of the face as a whole.

This study suggests that the Mental Index (MI), Gonial Index (GI) and Facial Height may be a useful facial tool for measuring the quantitative changes in bone brought on by diabetes mellitus since it was lower in diabetic people.

The results of this study indicate that diabetes has a substantial effect on bone health and skeletal fragility. Both genders with type 1 diabetes are at higher risk of fractures than individuals with type 2 diabetes. Overall, the study shows that diabetes significantly affects the skeletal dimensions of the face and jaw growth in both men and women, albeit the effects may differ depending on gender. Males with diabetes frequently have wider faces, although their jaw angles are narrower. Although their faces are wider, diabetic women show similar changes to males in terms of jaw angles (Gonial Indices). ACKNOWLEDGEMENT I can never find adequate words to thank my professors and teachers for their valuable suggestion and support. I am thankful to Integral University, Lucknow for providing me this this opportunity. Additionally, deserving my gratitude are my teachers, Dr. Mumal Nagwani Mishra & Dr. Prerna Gupta and Dr Ashish Sharma for their moral support. I Couldn’t have completed this project without the kind assistance of my senior. I’m incredibly appreciative to my parents and spouse for their generous support. CONFLICT OF INTEREST No conflict of interest from all the authors INFORMED CONSENT Written consent was taken from the subjects before the measurements. ETHICAL CLEARANCE This research article has received ethical clearance approval from the IIMS&R Institutional Research and Ethical Committee.

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