Study Background
Constitutively active mutations (CAMs) in the thyrotropin receptor (TSHR) represent a predominant cause of nonautoimmune hyperthyroidism. These mutations lead to a continuous activation of the receptor independent of thyroid-stimulating hormone (TSH) binding, resulting in excessive thyroid hormone production. Thyroid hormones are critical regulators of skeletal formation, bone turnover, and craniofacial development. Beyond the canonical role of TSHR in thyroid hormone synthesis, emerging evidence suggests that TSH and its receptor may exert direct effects on bone metabolism, influencing both bone formation and resorption.
Despite the recognized importance of TSHR signaling in skeletal physiology, the impact of constitutively active TSHR mutations on cranial and skeletal development remains unclear. Previous studies rarely investigated these effects in vivo using models that mimic human gain-of-function mutations. Evaluating these effects has significant clinical relevance given the complications related to bone health and craniofacial abnormalities observed in patients with hyperthyroidism.
Study Design
This investigation employed established TSHR knock-in mouse models expressing patient-derived constitutively active mutations, specifically the D633H and M453T variants. The D633H homozygous mice exhibit mild and transient hyperthyroidism predominantly at 2 months of age, with more pronounced effects observed in females. In contrast, M453T homozygous mice develop a more severe hyperthyroid phenotype, which is dependent on iodine availability.
Comprehensive phenotypic characterization included quantitative cranial morphometric analysis, micro-computed tomography (µCT) to evaluate bone microarchitecture, and biomechanical assessment via three-point bending tests to determine bone strength properties. Comparisons were made between homozygous and heterozygous mutants and wild-type controls, across sexes and ages.
Key Findings
The study revealed significant alterations in craniofacial morphology in both TSHR D633H and M453T CAM mouse lines. Notably, a reduction in nasal bone dimensions contributed to a shortened snout relative to wild-type controls. Importantly, the incidence of dental malocclusion was markedly increased in both homozygous and heterozygous mutants, independent of sex, suggesting that TSHR CAMs disrupt normal craniofacial development beyond thyroid hormone effects alone.
Regarding bone morphology, the TSHR D633H mice exhibited no significant deviations in femoral or tibial bone structure or biomechanical properties compared to controls. In contrast, the M453T mutation was associated with hyperthyroidism-dependent alterations in trabecular bone mineral density (BMD) and architecture. Trabecular bone parameters, which critically influence bone strength and remodeling, were compromised in accordance with the severity of the hyperthyroid state. Interestingly, cortical bone properties remained unaffected in M453T mice.
Further phenotypic observations included stable body and tail lengths in D633H homozygotes, whereas M453T homozygous mice demonstrated a transiently reduced tail length at weaning, moderated by iodine status and normalizing with maturation.
Expert Commentary
These results underscore the complex role of TSHR signaling in skeletal biology, demonstrating that CAM-induced hyperthyroidism extends beyond systemic hormonal effects to influence craniofacial and skeletal morphology directly. The heightened malocclusion incidence aligns with the observed craniofacial structural changes, emphasizing potential clinical implications for orthodontic and maxillofacial management in hyperthyroid patients with TSHR mutations.
The differential skeletal phenotypes between the two mutations suggest a dose- or severity-dependent effect of hyperthyroidism on bone microarchitecture, particularly impacting trabecular bone integrity. The preservation of cortical bone in M453T mice might indicate tissue-specific sensitivity or compensatory mechanisms that warrant further investigation.
Limitations of the study include the exclusive use of murine models, which, while genetically relevant, may not fully recapitulate human skeletal and craniofacial complexity. Moreover, the mechanistic pathways linking constitutive TSHR activation to bone remodeling deficits remain incompletely understood. Future research exploring molecular intermediates such as osteoblast and osteoclast activity, as well as local TSHR expression in bone tissue, could provide valuable insights.
Conclusion
This in vivo study provides compelling evidence that constitutively active TSHR mutations causing hyperthyroidism result in altered craniofacial morphology and increased malocclusion risk, alongside trabecular bone compromise linked to hyperthyroid severity. These findings highlight the integral role of TSHR signaling and thyroid hormone homeostasis in bone and craniofacial development. The data advocate for comprehensive skeletal monitoring and tailored clinical management for patients with TSHR CAM-induced hyperthyroidism.
Further translational studies are necessary to elucidate underlying mechanisms and to optimize therapeutic strategies aimed at mitigating skeletal complications in this patient population.
Funding and Additional Information
This study was supported by institutional funding and grants referenced in the original publication. Clinical trial registration was not applicable as this is a preclinical investigation.
References
1. Makkonen K, Määttä J, Ivaska KK, et al. Altered Craniofacial and Bone Morphology in Hyperthyroid Knock-In Mice Carrying TSHR D633H and M453T Mutations. Thyroid. 2026 Jun 23; [Epub ahead of print]. PMID: 42333523.
2. Zaidi M. Skeletal remodeling in hyperthyroidism: mechanisms and clinical implications. J Cell Biochem. 2007;101(6):1338-1346.
3. Abe E, Marians RC, Yu W, et al. TSH is a negative regulator of skeletal remodeling. Cell. 2003 Oct 31;115(2):151-162.
4. Williams GR. Thyroid hormone regulation of bone remodeling. Ann N Y Acad Sci. 2010 May;1192:346-354.