THE MANDIBLE

The human mandible has no one design for life. Rather, it adapts
and remodels through the seven stages of life, from the slim arbiter of
things to come in the infant, through a powerful dentate machine and even
weapon in the full flesh of maturity, to the pencil-thin, porcelain-like
problem that we struggle to repair in the adversity of old age.
D.E. Poswillo.

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ANATOMY OF THE MANDIBLE

Mandible is largest, strongest and lowest bone in the face.

Body – Horse shoe shaped

2 Parts – Body

- Pair of Rami

Body – Outer aspect

- Inner aspect

- Upper border

- Lower border

Outer surface presents the following factors

- Symphysis menti

- Mental protreslerance

- Mental foramen

- Oblique line

- Incisive fossa
Condylar process
Coronoid
Temporalis
Masseter

Bullinator
Mental foramen Angle
Symphysis menti Platysma
Mentalis
Pressor Labii inferioris
Mental prtrusion
Depressor anguli oris

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 Inner surface

- Mylohyoid line

- Submandibular fossa – lodges submandibular gland.

- Sublingual fossa – sub lingual gland

- Genial tubercle

- Mylohyoid groove

Lateral pterygoid

Temporalis
Lingula
Pterygomandibular raphe Mandibular forament

Superior constrictor
Mylohyoid sroove
Medial pterygoid

Sub lingual fossa

Sub mandibular fossa
Genioglossus
Mylohyoid line
Geniohyoid
Digastric

Upper border

- Socket of teeth

Lower border

- Midline of base is digastric fossa

Ramus – quadilateral in shape

- Coronoid process

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 - Condylar process

- Mandibular foramen

- Lingula

- Mylohyoid groove

Attachments and relations of mandible

- Oblique line – buccinator muscle

- Oblique line below mental foramen – depressor labii

inferious, depressor anguli oris

- Incisive fossa – mentalis muscle

- Mylohyoid line – mylohyoid muscle

- Posterior end of mylohyoid line – superior constructor

muscle

- Genial tubucle – geniohyoid, genioglossus muscle

- Digastric fossa – anterior belly of digastric muscle

- Lateral side of ramus – masseter muscle

- Lower border – Platysma muscle

- Postero superior part of lateral surface – Parotid gland

muscle

- Lingula – sphenomandibular ligament muscle

- Medial aspect of ramus – medial pterygoid muscle

- Mid surface of coronoid - temporalis muscle

- Pterygoid fossa - lateral pterygoid muscle

- Lateral surface of neck – attachment to lateral ligament of

TMJ.

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Age Changes in Mandible

Infants

1) 2 halves of mandible fuse during 1st year of age.

2) At birth mental foramen open below sockets for 2 deci molar teeth

near lower border (therefore an alveolar part of bone is present).

3) Angle is obtuse (140°) because head is in lie with the body.

4) Coronoid process is large and projects upward above the level of

condyle.

In Adults

1) Mental for opens midway between upper and lower border.

Therefore alveolar and sub alveolar parts are equally developed.

2) Angle reduce to 110° to 120° because ramus becomes vertical.

Old Age

1) Teeth fall out and alveolar border is resorbed. Height of body is

reduced.

2) Mental foramen and mandible canal are close to alveolar border.

3) Angle becomes obtuse.

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Differences and the similarities of the morphology, function and
development of the mandble compared to the nasomaxillary complex.

Mandible Naso Maxillary complex

 Has a ramus at distal end of  Has a maxillary tuberosity with

arch the pterygoid plate`

 Movable articulation with  Fixed sutural connection with

cranium cranium

 TMJ lined with cartilage,  Sutures composed of collagen

pressure tolerant articular tissue connective tissue

 Involves, both  Maxilla ossifies entirely intra

intramembraneous and membraneous
endochondral ossification

 Masticatory muscle attached  Not functionally mobile

 Consist of a single bone  Elaborate group of many

separate bone

 Has a chin  Has a nasal spine

 Concerned with vertical  Concerned with orbital, nasal

architecture component and its development
and function.

 Has a coronoid process  Has a zygomatic process

 Lingual tuberosity present  Maxillary tuberosity present

 Positional change in due to  Adjustive capacity lies in the

adjustment in alignment and sutural growth potential
vertical height, anterior, posterior
breadth of ramus.

Both are first pharyngeal arch origin and innervated by fifth cranial
nerve.
Both remodels in a posterior manner and displaced in a
anteroinferior manner.

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 Secondary displacement effect by expansion of middle and temporal
edge is seen more in the mandible than the maxilla.

PRENATAL GROWTH OF MANDIBLE

The cartilage and bones of mandibular skeleton are derived due to

inductive activity of Rhombencephalic organizing center and resulting

from migration of Neural crest cells from its origin to ventrally which leads

to formation of mandibular arch from first branchial arch and this branchial

arch gives rise to two mandibular prominences. In this prominences neural

crest cells differentiate to form bones and connective tissue.

But the mandibular division of Vth cranial nerve (Trigeminal nerve)

is the first structure to develop in the region of lower jaw which occurs

earlier than condensation of neural crest cell resulting in 1st branchial arch.

Supporting concept - the prior presence of nerve, acts as a pre requisite for

inducing osteogenesis by producing Neurotrophic factors.

As the mandibular process develop a rod of cartilage appears on

each side and extends from the position of developing ear to the midline.

This is known as MECKEL’S CARTILAGE.

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 Meckel’s Cartilage

Inferior alveolar nerve

Initial site of osteogenesis

Mental branch

In the tympanic cavity, this Meckel’s cartilage along with otic

capsule form the malleus and incus bone of middle ear. These two bones

function in the articulation of the mandible in lower animals and are known

as the articular and quadrate.

Some evidences in “Man” shows that these bones i.e. mallus and

inces function to provide a movable joint until the mandibular condyle

develops the relation to glenoid fossa. Therefore this joint may function in

movement of jaw between 8th to 18th week.

Meckel’s cartilage is not the “True precursor” of the mandible

because it is not replaced by bone, as cartilage does in long bone. The

reason behind this is that Meckel’s cartilage lacks the enzyme phosphotase

which is usually found in ossifying cartilage and therefore it disappears by

24th week of intra-uterine life but it acts as a template for guiding the

growth of the mandible.

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 The mandible is derived from ossification of an osteogenic

membrane formed from condensation of ectomesenchyme at 36 – 38 days

of development. The ectomesenchyme interacts with epithelium of

mandibular arch. This results in development of mandible on lateral side of

Coronoid cartilage
Meckel’s cartilage as a thin flat rectangular bar of fibrous tissue.

Condylar cartilage

Meckel’s cartilage

Lingual nerve Mandibular nerve

Inferior alveolar nerve
Mandibular
ossification centre Angular cartilage
Mental nerve

Incisive nerve
Mental ossicle

Ossification: Mandible is the 1st bone to begin to ossify along with clavicle.

A single ossification center for each half of the mandible arises in 6 th week

of intra-uterine life in the region of bifurcation of inferior alveolar nerve

and artery into mental and incisive branches. Ossification is

Intramembranous.

The ossifying membrane which is present lateral to Meckel’s

cartilage is accompanied by Neurovascular bundle which is responsible for

formation of mandibular foramen, mandibular canal and mental foramen.

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 Ossification spread from the primary center below and around the

inferior alveolar nerve and its incisive branch and upwards to form a trough

for the developing teeth. This spread of ossification is in dorsal and ventral

direction form the body and ramus of mandible.

The ossification stops dorsally at the site that will become the

mandibular lingula, from here Meckel’s cartilage continues into middle ear.

Later, almost all Meckel’s cartilage disappear but some part of it

forms accessory endochondral ossicles, that are incorporated into chin

region of mandible and some part of transforms into the sphenomandibular

and anterior malleolar ligament.

The initial woven bone formed along Meckel’s cartilage is soon

replaced by lamellar bone.

Some typical haversian system are already present at the 5 th month

of intra-uterine life. This is because intense sucking and swallowing, which

will stress the mandible during breast feeding in early post-natal life.

Between 10th week – 14th week secondary accessory cartilage appears to

form.

1. Head of condyle

2. Part of coronoid process

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 3. Mental protuberance

a) Cartilage of coronoid process - it develops within the temporalis

muscle as its predecessor and this cartilage becomes incorporated

into expanding ramus and disappears before birth.

b) Cartilage of mental region - in 7th month of intra-uterine life two

small cartilages appear and ossify to form mental ossicles in fibrous

tissue of sympysis and later on gets incorporated into it.

c) Condylar cartilage - This appears during the 10th I.U. as a carrot /

cone shaped independent structure and is enclosed by developing

bone of posterior part of the mandible. This condylar cartilage is the

primordium of future condyle.

Cells of hyaline cartilage differentiate from its center and condylar

head increases by interstitial and appositional growth. By 14 th week first

evidence of endochondral bone appears in condyle region. The condylar

cartilage serves as an important center of growth for ramus and body of

mandible. Much of cartilage is replaced by bone by middle of fetal life but

its upper end persists into adulthood, acting as both growth cartilage and an

articular cartilage.

The two condylar head functions similarly to epiphysis of long

bones.

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The condylar growth rate

- Increases at puberty

- Peaks between 12½ to 14 years of age

- Ceases at about 25 years of life

Mandibular symphysis: The mandible originally is formed in two halves,

which are joined at the symphysis by fibrocartilage by about the 6 th month

of I.U. The symphyseal cartilage serves as growth site until the first year

after birth. The post-natal closure of mandibular symphysis has been

described by Letburg and Champagne when symphysis menti is converted

from syndesmosis to a synostis during 1st post-natal year.

Similarly like nasomaxillary complex mandible can be described

developmentally and functionally into several skeletal sub units and each

unit is influenced by a functional matrix of its own.

Skeletal Unit Functional Matrix

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Alveolar unit Teeth
Coronoid process Temporalis muscles
Angular process Masseter and medial pterygoid muscle
Condylar process Lateral pterygoid muscle
Chin Geniohyoid and genioglossus muscle

Tongue, peri-oral musculature, various cavities provide stimuli for

mandibular growth to reach its full potential.

GROWTH PATTERNS OF THE MANDIBLE: SOME

REFLECTIONS MANDIBULAR GROWTH MECHANISMS : A
HISTORY

Approximately 200 yrs ago, Hunter proposed that the mandible

grows by apposition on its posterior border, with resorption occurring on

the anterior border of the ramus which provided space for succeeding

permanent molars. Later in 1866 Humphrey supported this theory on the

basis of animal experimental studies. In 1924 Brash showed appositional

growth with alizarin red.

Then in 1940’s Weinman and Sicher with the help of longitudinal

cephalometrics and evidence from experiments of animals, focused

attention on the mandibular condyle as a major factor in growth of the

mandible.

Later Brodie believed that superior and posterior growth of the

condyle along with apposition of the posterior border of the ramus and

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alveolar border area of the tooth development resulted in development of

mandible.

In 1950 Ricketts by superimpositions on lower border of the

mandible showed that the condyle followed a superior and posterior

course. He also noted that the mandibular growth was not same and that the

relationship of the mandibular plane to the Frankfurt Horizontal plane was

changing about one degrees every 3 yrs in a typical facial pattern.

A logarithmic spiral can be drawn through foramen ovale,

mandibular foramen of an individual from fetal to adulthood, when

superimposed, the mandibular body seems to be changing its orientation.

At the same time Moss (1960) envisioned the growth of the

mandible as a logarithmic spiral constructed via the path of the mandibular

nerve.

Ricketts proposed the racial growth theory according to which the

mandibular growth followed a curve. He constructed as arc using the

distance from a point at internal ramal eminence to protrusion mental point

as the radius of the circle.

Bjork in 1963 conducted a study with metallic implants and

suggested that

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 1) Growth in length of the mandible occurs essentially at the condyles.

2) The anterior aspect of chin is extremely stable.

3) The thickening of the symphysis takes place by appostion on its

posterior surface and the lower border which contributes to increase

in height of symphysis.

4) At the region of the condyles there is upward and forward curving

growth.

5) The mandibular canal is not remodeled and the trabaculae related to

the canal are stationary. Hence the curvature of the mandibular canal

generally reflects the earlier shape of the mandib.e

JRC Mew in 1986 put forward the tropic premise (tropic – turning

or change of direction) theory. Where he suggested that a delicate tropic

mechanism overlays the genetic control of facial growth to guide the teeth

and jaws into satisfactory occlusion. The mandible grows to suit the

position in which it is normally postured and both the jaws tilt to balance

the anterior and posterior contact forces. He also suggested that the control

of growth is likely to be embedded within the individual cells of the

mandible themselves through their individual ability to respond to

positional information from tissues around them.

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 If the position of the mandible is changed the peripheral cells

receive new positional information and in this situation, they might

recontour the bone towards its original position in relation to related

structures.

Note: the main sites of post-natal mandibular growth are at the condylar

cartilage, the posterior border of ramus and the alveolar ridges. These

areas of bone deposition account grossly for increase in length and width of

the mandible. However superimposed in this basic incremental growth are

functional influences that involve selective resorption and displacement of

the mandible.

POST-NATAL GROWTH OF THE MANDIBLE

At birth the two rami of the mandible are quite short. Condylar

development is minimal and there is practically no articular eminence in

the glenoid fossa. A thin line of fibrocartilage and connective tissue exists

at the midline of the symphysis to separate right and left mandibular

bodies. Between the four months of age and at the end of the first year the

symphyseal cartilage is replaced by bone. Although growth is quite general

during the first year of life, with all surfaces showing bone apposition,

there is apparently no significant growth between the two halves before

they unite. During the first year of life, appositional growth is especially

active at the alveolar border, at the distal and superior surface of the ramus,

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at the condyle, along the lower border of the mandible and on its lateral

surfaces.

After the first year of extra uterine life, mandibular growth becomes

more selective. The condyle shows considerable activity as the mandible

moves and grows downward and forward. Heavy appositional growth

occurs also on the posterior border of the ramus and on the alveolar border.

Significant increments of growth are still observed at the tip of the

coronoid process. Resorption is said to occur at anterior border of the

ramus thus lengthening the alveolar border and maintaining the antero-

posterior dimension of ramus. Cephalometric studies indicate that the body

of the mandible maintains a relatively constant angular relationship to the

ramus throughout life. The gonial angle changes little after muscle function

has become well defined with approaching senescence and a marked

reduction of muscle activity there is evidence that the gonial angle tends to

become more acute.

Width of the mandible generally shows a subtle change. Actually

after the first year of life, during which there is appositional growth on all

surfaces, the major width contribution of the mandible is growth at the

posterior border.

Literally the mandible is an “expanding V” additive growth at the

ends of “V” naturally increases the distance between the terminal points.

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The two rams also diverge outward from below to above so that additive

growth at the coronoid notch and process and condyle also increases the

superior inter-ramus dimension continued growth of the alveolar bone with

the developing dentition increases the height of the mandibular body. But

we are again dealing with a 3-dimensional object. The alveolar process of

the mandible grows upward and outward on an expanding arc. This permits

the dental arch to accommodate the larger permanent teeth. Relatively little

increase in mandibular body width is noted after cessation of lateral

surfaces appositional growth. Modelling deposition at the canine eminence

and along the lateral inferior border is seen.

Scott divides the mandible into 3 basic types of bone basal,

muscular and alveolar.

The basal portion is a tube-like central foundation running from the

condyle to the symphysis.

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 The musculature (the gonial angle and coronoid process) is under

the influence of the massetter, internal pterygoid and temporal muscles.

Muscles function determines the ultimate form of the mandible in these

areas.

The third portion, alveolar bone, exists to hold the teeth. When the

teeth are lost there is gradual resorption of the alveolar bone. Reduced

muscle activity accounts for the flattening of the gonial angle and reduced

coronoid process.

Regional Details of Post-Natal Growth of Mandible

Cartilage
Dense fibrous
connective tissue
Bone

The Ramus

It plays a key role in placing the corpus and dental arch into ever-

changing fit with the growing maxilla and the faces limitless structural

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variations. This is provided by critical remodeling and adjustments in

ramus alignment, vertical length and antero posterior breadth.

The posterior border of mandibular bony arch has to proceed into a

region already occupied by the ramus. This requires a remodeling

conversion from ramus to mandibular corpus i.e. the ramus becomes

relocated posteriorly.

Some of the key anatomic parts participate in the relocation and

remodeling process of the ramus and the corpus. One of them is the lingual

tuberosity.

Lingual Tuberosity

The lingual tuberosity is a major site of growth for the mandible.

a) It grows posteriorly by deposits on its posterior facing surface.

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 b) The lingual tuberosity protrudes in a lingual direction i.e. towards

the midline. The prominence of the tuberosity is increased by the

presence of larger resorptive field just below it i.e. the lingual fossa.

(the combination of the periosteal resorption in the fossa and

deposition on the medial facing surface of the tuberosity itself

greatly accentuates the contours of both regions.

c) As the posterior growth of the tuberosity occurs that part of the

ramus first behind tuberosity grows medially. This brings the ramus

into alignment with the axis of the arch (i.e. corpus) thus eventually

becomes a part of the corpus thus lengthening it.

Ramus to corpus remodeling conversion:

The bony arch length and corpus length has been increased by

1) Deposits on the lingual tuberosity and the contiguous lingual side of

the ramus

2) Resultant lingual shift of the anterior part of the ramus to become

added to the corpus.

The presence of resorption on the anterior border of the ramus not

only makes room for the last molar but it progressively relocates the entire

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ramus in posterior direction from tiny mandible of fetus to attainment of

adulthood.

The posterior movement of the ramus does not occur in a straight

line. This is because the remodeling activity does not occur only on the

anterior and posterior border but also on the surfaces between them.

Coronoid Process

It has a propeller like twist so that its lingual sides faces 3 directions

posteriorly superiorly and medially. The growth occurs superiorly thus

increasing the vertical dimension. It also brings about posterior direction of

growth movement. This is also an example of expanding V-principle in

horizontal direction. This also contributes to the width of the mandible.

Lingual deposits also carry the base of the coronoid in a medial direction to

22
add this part to the lengthening corpus which lies medial to the coronoid

process.

Buccal side of the coronoid process has a resorptive type of

periosteal surface.

On the inferior edge of the mandible at the ramus corpus junction, a

field of surface resorption is present. This forms the antegonial notch

(discussed later in detail).

Mandibular foramen- as the whole ramus grows posteriorly and superiorly

the mandibular foramen also drifts backward and upward to maintain a

constant position i.e. midway between the anterior and posterior border of

ramus.

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Mandibular Condyle

This is an anatomic part of special interest because it is a major site

of growth, having considerable clinical significance. Historically the

condyle has been regarded as a kind of cornucopia from which the

mandible pours forth. It has believed that condyle was a growth center and

which determined the rate of growth amount of growth, growth direction,

overall mandibular size and shape.

Condylar cartilage: condylar cartilage is a secondary type of cartilage

which develops because of the functional and developmental conditions

imposed upon the part of the mandible.

It is now believed that the condyle is a growth site and its role is to

provide regional adaptive growth i.e. it maintains the condylar region in

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proper anatomic relationship with the temporal bone as the whole mandible

is simultaneously been carried forward and downward.

Note: The condyle has however a unique multidirectional capacity for

growth and remodeling due to it special structure i.e. the random

arrangement of the chodroblast unlike the linear arrangement associated

with unidirectional growth as in long bones.

Histologically the condylar cartilage has the following zones.

a) Fibrous layer

b) Prechondrablastic layer (Proliferative zone)

c) Hyaline cartilage - Hypoplastic

- Erosive zone

d) Bone

Neck of the condyle

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 As the growth is taking place in the condyle the endosteum and

periosteam are actively producing the cortical bone that encloses the

medullary core of endochondral bone tissue. This occurs upto the neck of

the condyle on which both the anterior margin and posterior margin are

both depository unless if mandibular relations occurs where the posterior

edge can be resorptive.

The lingual and the buccal sides of the neck have resorptive surface.

This is because as the condyle moves superoposteriorly hence, what used

to be the condyle becomes the neck. This again following the V-principle.

Mandibular Corpus

Since the mandibular arch relates specially to the bony maxillary

arch, the mandibular corpus lengthens to match the growth of the maxilla

and it does this by remodeling conversion from the ramus.

a) Chin: Bone is added on the external surface

of the basal bone area including the mental

protuberance, a reversal occurs at a point

where the concave surface contour becomes

convex. This results in enlargement of the

chin. The process involves a mechanisms of endosteal cortical

growth on the lingual surface behind the chin, heavy periosteal

26
 growth occurs, with the dense lamellar bone merging and

overlapping on the labial side of the chin. The point of periosteal to

endosteal contact is variable but usually occurs at a level just

superior to the projecting apex of the clip.

b) Symphyseal region: There is periosteal

resorption on the labial side of the labial

bony cortex and deposition on the alveolar

surface of the labial cortex and resorption

on the labial side of the lingual cortex and

deposition on the lingual side of the lingual cortex. This occurs

when the teeth drift lingually and superiorly to bring the upper and

lower teeth into occlusion.

In the mandibular corpus, except for a resorptive zone on the lingual

side there is deposition. This enlarges the breadth on each side of the

corpus. But there is only slight increase in width during post-natal growth.

The gonial angle is determined largely by the growth direction of

the ramus and condyle, but a small extent of downward corpus alignment

can be produced by new bone deposition on its antero inferior surface.

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Force that Produces the Displacement of the Mandible

Earlier it was presumed that the thrust of the mandible against its

articular bearing surface in the glenoid fossa pushes the whole mandible

away. However proponents of the functional matrix theory claimed that

mandible lacking condyle does grow. They presumed that the expansion of

the soft tissue matrix carried the mandible downward and forward and the

space created is filled by secondary growth of the condyle.

The current thinking is that condylar cartilage does have an intrinsic

genetic programming which results in continued cellular proliferation. The

rate and direction of condylar growth is influenced by extracondylar agents

such as muscles, maxillary growth etc.

Effect of enlargement of middle cranial fossa anterior to the

condyle.

As the middle cranial fossa enlarges horizontally, the nasomaxillary

complex is displaced forward and the pharyngeal space is enlarged. The

ramus of the mandible which bridges the pharynx also correspondingly

increases to maintain the facial form. This is required to place the mandible

in a continually functional position relative to the maxillary arch.

The ramus becomes more upright during mandibular development.

This is achieved by greater amount of addition on the inferior part of the

28
posterior border than on the superior part and a greater amount of

resorption on the inferior part of the anterior border than in the superior

part. This is necessary because as the middle cranial fossa broadens the

ramus also enlarges horizontally and vertically and to accommodate this

vertical growth the gonial angle closes to prevent change in the occlusal

relationship. Vertical lengthening continues to take place after horizontal

growth ceases. This is to match the vertical growth of the midface. Here

reversal remodeling change occurs which is marked in the later periods of

childhood. There is deposition on the anterior border in the upper part of

coronoid process and resorption on the upper part of posterior border. This

results in upright alignment of the ramus without changes in the breadth.

FACTORS CONTROLLING GROWTH OF MANDIBLE

The growth process in mandible proceeds in quite a complicated

way involving extensive remodeling and resorption of bone as well as

displacement of the entire mandible in an antero-inferior direction.

But what controls the growth?

How does the growth ceaze?

1. These questions were very easy to answer not a long ago, when all

growth was thought to be pre-programmed (i.e. genetically

29
 controlled) and growth ceazed once the adult size of the particular

bone was achieved.

2. As years past by because of extensive research the control seemed to

shift from the bones to the soft tissues surrounding the bones and

finally research brought to light the growth taking place at the

cellular level and the role of c Amp, Ca++ etc in growth.

Thus growth control is a cascade of graded feedback chains from the

systemic down to the local tissues, cellular and molecular level and back

again.

Several working theories have evolved over the period and these

factors do try to explain in parts, their role in the development and growth

of an individual.

a) Genetic Blue print

b) Biomechanical forces

A different line of reasoning emerged since the genetic theory

couldn’t explain everything (eg. The differences seen even in homozygous-

twins). According to this theory physical forces were thought to be of

primary importance in regulating the growth, development, morphology

and histology of the bone.

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 Thus Wolf’s law in late 1800’s introduced the concept of

form  function. Several experiments were conducted to test the validity

of this equation.

As seen in mandible it would mean that stress in any form on the

body, ramus or condyle would trigger the deposition reaction and that

would lead to growth (increase in size) of the mandible.

However, in all their experiments, they failed to prove an actual

cause and effect relationship. It could have (i.e. loss of growth in animals

where the muscle attachments were served) been because of vascular /

neural interruption, temperature changes, alterations in pH and oxygen

tension etc.

Nonetheless, there is no doubt that the mechanical forces, are one of

the factors in the control of growth.

c) Role of control messengers

The growth is essentially a localized affair with the systemic support

playing a background effect complementing the process.

These systemic agents are the messengers. First messengers are the

extracellular signals e.g: Hormonal inbalance, O2 and CO2 tension etc.

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These triggers on a cascade involving the second messengers eg. Increase

production of proteoglycans or acid / alkaline phosphatase etc.

The important 2nd messenger is adenyl cyclase and cAmp. It is primarily

concern with cytoplasmic and nuclear DNA – RNA transfers

E.C. on Membrane 2nd messenger

Osteoblast its receptor
Signal
Mobilization of Adenyle cyclase
ionic Ca++

Bone deposition or c(Amp)  ATP

resorption
Increase synthesis
of enzymes

Enzymes

1) Alkaline phosphatase  Bone formation

2) Acid phosphatase  Bone resorption

cAmp + Ca++  increase the permeability of mitochondria and lysosomes

Leads to increase flux of different Releases the lysosomal contents

ions required for synthesis and which include acid hydrolases,
discharge of different products lactate, citrates etc.

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d) Bioelectric signals

The bioelectric signals are being explained as the Peizo factor. It

attempts in explaining just how the biomech forces and other forces are

translated and interpreted in the remodeling process.

The peizo effect is because of distortions collagen crystals in bone

because of biomechanical stimulus.

This piezo effect results in zones of deposition or resorption and is

because of differing / altered electric potentials.

There are 2 separate target categories where the muscles exibit their

actions.

a) Cellular component of osteogenic connective tissue which covers

the bone.

b) Calcified part of the bone itself.

e) Neurotrophic factor

It involves the network of various nerves (sensory and motor)

concerned with the mandible and the muscle / soft tissue around it. These

nerves play an important role in providing a pathway for stimuli that

trigger certain bone however, remodeling is process. This believed to be

because of certain neurosecretory substances. Thus the feedback between

the nervous tissue and the periphery is established.

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f) Another important factor in craniofacial growth (which is under study) is

the role of substances as the cascade of prostaglandins, somatomedins,

osteonecrotines, leukotrimes neutrotrophic balancing agents and inter

cellular communications involving “G” proteins.

Anamolies of development

Lot of different congenital anomalies affect the growth of mandible.

They will be discussed in great detail later.

1) Agnathia 2) Aplasia 3) microganthia as seen in Pierre Robin Syndrome,

Treacher Collins syndrome, Progeria, Down’s syndrome etc 4) Hemifacial

microsomia 5) hemifacial hypertrophy etc.

g) Influece of masticatory muscles

- Animal studies have shown that a low masticatory function induces

decreased condylar growth.

- Human studies have shown that increased level of masticatory

muscle activity shows a low incidence of malocclusion a short face

small gonial angle etc.

34
h) Effect of physical environment on growth of mandible

- Respiratory obstructions could give rise to an opening movement of

the mandible in which the condyle is displaced forwards (eg:

Adenoid face).

- Constant opening of the mouth because of pain in teeth could result

in forward positioning of the mandible as a result of stretch of

suprahyoid muscles.

- Traumatic condition like bruxism could cause excessive regional

destruction of cartilaginous cells covering the condyle and resulting

in a distortion of the mandible.

STRESS TRAJECTORIES OF THE MANDIBLE

The mandible being a unit by itself and a movable bone has

different trabecular pattern or alignment from that of maxilla.

35
Trabecular columns radiate from:

i) From beneath the teeth in the alveolar process and join together in

a common stress pillar or trajectory system that terminates in the

mandibular condyle. (The mandibular canal and nerve are

protected at the same time by concentration of trabeculae,

demonstrating the unloaded nerve concept).

ii) The other trajectories are seen at symphysis

iii) At the gonial angle

iv) And leading downward from coronoid process into the ramus and
body of the mandible

[ii, iii, iv (accessory trajectories)] probably are due mainly to the direct

effect of attachment of muscles of mastications.

The thick, cortical layer of compact bone along the lower border of

the mandible offers the greatest resistance to the bending forces.

CLINICAL IMPLICATIONS

I. Developmental Anamolies

a) Agnathia - mandible may be grossly deficient or absent which

reflects deficiency of neural crest cell tissue in lower part of the

face.

36
 b) First arch and second arch syndrome – Aplasia of mandible and

hyoid bone.

c) Micrognathia - a diminutive mandible, occurs in

i) Pierre Robin’s syndrome

ii) Cat cry syndrome

iii) Mandibulofacial dysostosis

iv) Progeria

v) Down’s syndrome

vi) Occulomandibulodycephaly

vii) Turner’s syndrome

Pierre Robin’s syndrome – the underdeveloped mandible usually

demonstrates catch up growth in the child.

Mandibulo facial dysostosis – it is a condition in which both maxilla and

mandible are under developed as a result of generalized lack of

mesenchymal tissue and also due to diminished neural crest cell migration.

Hemifacial microsomia (Goldehar’s syndrome) – this is a condition

which is unilateral and is characterized by lack of tissue on the affected

side.

37
 In this condition typically, the external ear is deformed and ramus of

mandible and associated soft tissue are deficient or missing. This arises

from early loss of neural crest cells.

II. Defects due to failure of fusion of the various processes

Mandibular cleft - Rare condition due to persistence of furrow between 2

mandibular process.

Microstomia / Macrostomia - determined by fusion of maxillary and

mandibular process at their lateral extent

III. Muscle dysfunction

Facial muscles can affect the jaw growth in two ways:

i)Formation of bone at the point of muscle attachments depends on

the muscle activity.

ii) The musculature is an important part of total soft tissue matrix

whose growth normally carries the jaws downward and forward.

Loss of part of the musculature as a result of motor nerve damage –

results in under development of that part of face.

38
 Excessive muscle contraction can restrict growth example

Torticollis a twisting of the head caused by excessive tonic contraction of

neck muscles on one side results in facial asymmetry.

Conversely the decrease in muscle tonicity occurs in muscular

dystrophy which allows excessive displacement of the jaws resulting in

excess vertical growth and excessive eruption of posterior teeth and severe

anterior open bite.

Mandibular Hypertrophy

1) Acromegaly – an anterior pituitary tumor that secrets excessive

amounts of growth hormone, excessive growth of mandible may

occur creating skeletal class III malocclusion in adult life.

This excessive growth stops when the tumor is removed or

irradiated, but skeletal deformity persists.

2) Hemimandibular hypertrophy – unilateral excessive growth of

mandible occurs and previously it was as condylar hyperplasia as

condylar proliferation is a prominent aspect. The excessive growth

may stop spontaneously but in severe cases may require removal of

affected condyle. Condylar hyperplasia causes mandibular and

facial asymmetry.

39
Asymmetric mandibular deficiency

It is likely to result if mandibular condyles are affected by either a

congenital condition or birth injury.

In hemifacial microsomia there is absence of tissue in the region of

mandibular condyle and in more severe cases entire distal portion of

mandible may be missing along with associated soft tissues.

In hemifacial microsomia the problem is lack of tissue, so normal

growth potential is not present whereas in post injury problems there is

potential for normal growth.

II. Importance of pubertal growth spurt in mandibular growth (Arthur

Lewis, Alex Roche and Bett Wagner, Angle Ortho Oct. 1982).

Bambha reported that pubertal growth spurts occur earlier in girls

than boys.

Growth spurt as defined by Woodside as an annual increment exceeding

the immediate preceeding annual increment by atleast 1mm.

Consideration of growth spurt is of great importance in carrying out

treatment aimed at growth modification. This present study was undertaken

to analyze the relationship between the magnitude and timing of pubertal

spurts in mandible.

40
 (i) Annual increment in length from condylion and pogonion have

found to increase in pubescence at 13.5 yrs in boys (3.3 mm) and

11.9 yrs in girls (2.9mm).

(ii) There was pubertal increase in ramus height at 12 yrs in girls

(2.4mm) and 13 yrs in boys (3.2mm).

(iii) Increment in body length from gonion to pogonion also increases

at pubescence at 12 yrs in girls (2.3mm) and 14 yrs in boys

(2.8mm).

Mean annual increments (mm/year) before, during and after pubertal

spurts.

One year before During One year after

Boys Girls Boys Girls Boys Girls
Ar-Go 0.2 0.4 3.2 2.4 1.8 1.0
Ar-Gn 0.5 0.9 3.3 2.9 2.6 2.3
Go-Gn 0.5 0.6 2.8 2.3 1.2 1.1

Role of muscles in mandibular growth

The mandible though often thought to function as a Cl III lever is

actually a force couple system with Cl I lever operating off the coronoid

and condylar head via the external pterygoid acting as fulcrum.

The force exerted against the coronoid process from the temporalis

complex has a mean upward and backward direction. This tends to counter

41
balance the force on the condylar head. The massetric complex causes a

mean upward and forward pull. The external pterygoid is the most

important muscle. It shows a downward and forward inclination.

The role of the muscle is to open the mouth and move the mandible

contralaterally. It also acts as a stabilizer for the retraction of mandible and

keeps the condyle in juxtaposition with the articular eminence during

movements of mandible. The attachment of external pterygoid to the

mandibular condyle actually serves as a fulcrum against which the

temporalis and masseter act.

The heads of external pterygoid muscle hold the head of condyle

forward and downward. Hence loss of growth of condyle produces

downward and backward drift of chin and open bite and failure of external

pterygoid to hold the condyle downward and forward result in upward and

backward rotation of the gonial angle as the downward and backward pull

of the digastric is unopposed. This is seen in congenital mandibulofacial

dysostosis and in microsomia with condylar agenesis.

Opposite is the effect in patients with mandibular hypertrophy.

42
Role of functional appliances in the growth of mandible

A jaw discrepancy can be corrected in preadolescence by modifying

growth and this can be done either by functional appliance or extra oral

forces.

Mandibular deficiency: A skeletal Class II relationship due to mandibular

deficiency could be either due to a small mandible or a normal mandible in

posterior position.

i) One possibility of treatment is to restrain the growth of maxilla

with extra oral force and let the mandible continue to grow more

or less normally i.e. with the headgear the mandible expresses its

regular growth and catches up with maxilla which has been

prevented from growing forward as it normally would.

ii) More obvious treatment is enhancement of mandibular skeletal

growth and this is done with the help of functional appliance

which hold the mandible forward from its retruded position and

enhances growth.

In theory, additional growth occurs in response to the movement of

mandibular condyle out of the fossa mediated by altered muscle tension of

condyle.

43
 For most mandibular deficient patients: a bionator or activator

appliance is used as it is a simple, durable and readily acceptable appliance.

If transverse expansion is needed buccal shield attached to activator

or bionator or as a part of frankel appliance is best.

Frankel is less bulky, easier to speak, more acceptable, also delicate

and easily broken and has potential for soft tissue irritation.

The Herbst appliance if cemented and bonded into place has the

advantage of full time wear.

Mandibular excess

Class III malocclusion because of excessive growth of mandible are

extremely difficult to treat. The treatment of choice would be to inhibit the

growth of mandible or atleast prevent it from increasing in size. Many

patients ultimately need surgery if they have severe problems.

For growth modification, treatment of mandibular excess both

functional appliance and chin cup have been used before and throughout

the adolescent growth spurt.

i) Class III functional appliance (Bionatar) was designed to rotate the

mandible down and back and produce proper occlusal relation by

44
 allowing posterior teeth to erupt down and forward while restraining

eruption of mandibular teeth.

These appliances also tip the mandibular teeth (incisors) lingually

and maxillary incisors facially.

ii) Extra oral force: Chin cup treatment

Chin cup is attached to head gear for anchorage. In theory extra oral

force directed against the mandibular condyle would restrain growth

at that location. Chin cup therapy does accomplish lingual tipping of

lower incisors as a result of pressure of the appliance on the lower

lip and dentition and a change in direction of mandibular growth,

rotating the chin down and back.

Different surgical procedures

(I) Mandibular advancement

(i) Bilateral sagittal split osteotomy: can be used to set back or

advance the mandible

(ii) Inverted L. osteotomy

(iii) C Osteotomy

(iv) Sub apical surgery

45
(II) Mandibular set back

(i) BSSO

(ii) Trans oral vertical oblique ramus osteotomy (TOVRO)

(iii) Body ostectomy

(iv) Segmental surgery

Antegonial notch and its significance

Presence of prominent antegonial notch is commonly seen with

(i) Disturbed or arrested growth of mandibular condyles as in

mandibulo-facial dystosis.

(ii) Unilateral condylar hypoplasia – where mandibular notching is

seen on affected side.

(iii) In backward pattern of mandibular rotation

(iv) Frontometaphyseal dysplasia

(v) Mandibulolacraldysplasia

Clinical findings in deep notching

i) Mandible was more retrusively placed relative to the anterior

cranial base.

ii) They had a short body length

iii) Smaller ramus height

iv) Greater gonial angle (Obtuse)

46
 v) Steeper mandibular plane angle

vi) Smaller facial axis

vii) Less forward displacement of chin.

The most clinical significant feature of deep antegonial notches is

the reduced amount of mandibular growth.

An explanation for association between pronounced AGN and

diminished mandibular growth has been advanced by Becker, Coccaro

and Conversc – “when the growth of the mandibular condyle fails to

contribute to the lowering of the mandible, the masseter and medial

pterygoid by their continued growth cause the bone in the region of the

angle to grow downward, producing antegonial notching”. In otherwords

resorption that normally occurs below the gonial angle does not occur.

Rather a relative tension is generated below the angle and muscle

sling in which it is suspended such that bone deposition occurs in the area

under the angle posterior to the notch.

Isaacson and associates suggested that the amount of condylar

growth indirectly affects the direction of mandibular rotation i.e. reduced

condylar growth exhibits backward rotational growth pattern and

demonstrate a pattern of remodeling whereby anterior part of body is

pressed down resulting in resorption at the lower surface of symphysis,

47
while posterior part of the body is lifted up from soft tissues matrix,

stretching the periosteum – apposition taking place below the angle.

Dibbets, Vanderweele, Boering and Nahoum have reported

pronounced notching in conjunction with steep mandibular plane angle and

larger gonial angle.

Enlow postulated that an obtuse gonial angle counteracts the effect

of short mandibular body and ramus i.e. effective increase in length of the

mandible compensated for retrusive mandible. Enlow stated that gonial

angle opens, the antegonial notch is accentuated.

So it is clinically significant for a orthodontist as

(i) Deep notched subjects have retrusive mandible with shorter

corpus, less ramus height and increase gonial angle.

(ii) Mandibular growth directions in deep notched patients were

more vertically directed as measured by facial axis and the

mandibular plane angle.

(iii) Deep notched subjects had longer total facial height and longer

lower facial height.

(iv) Deep notched subjects had smaller saddle angle.

48
 (v) Deep notch patients required a longer duration of orthodontic

treatment.

In mandibulofacial dysostosis

i) Condyle is malformed and neck is short

ii) Antegonial notching

iii) Obtuse angle and ramus is deficient

iv) Coronoid and condyloid processes are flat or aplastic

In frontometaphyseal dysplasia

i) Short maxilla

ii) Antegonial notching of mandible

iii) Hypoplasia of the angle

In mandibulolacral dysplasia

i) Hypoplasia of mandible

ii) Micrognathia

iii) Delayed cranial suture closure

iv) Inability to open the mouth

49
 GROWTH AND DEVELOPMENT OF THE TONGUE

Prenatal development – The tongue arises in the ventral wall of the

primitive oropharynx from the inner lining of the first four branchial
arches.
Lateral lingual swelling
Body of Tongue

Copula
Root of Tongue

Tuberculum
Epiglottis Impar

The body of the tongue is mainly ectodermal in origin whereas the

mucosa of the root is derived from the endoderm.

- Development of the tongue begins during 4th week of intrauterine

life, Paired lateral thickenings of the mesechyme appear on the
internal aspect of the 1st branchial arches. These are termed as the
lateral lingual swellings.

Tongue Divisions

Palatine Tonsil
Root of Tongue
Foramen caecum
Sulcus Terminalis

Circumvalate papilla
Body of Tongue

50
 - Between and behind these swellings, a median eminence appears,

termed the tuberculum impar. The caudal end of this eminence

forms the foramen caecum (blind pit), which marks the origin site of

the thyroid diverticulum. This thyroid diverticulum is a duct, which

at later stages shall migrate downward to form the thyroid gland.

- The lingual swellings grow and fuse with each other, encompassing

the tuberculum impar, to provide the ectodermally derived mucosa

of the body of the tongue. Around the periphery of these fused

lingual swellings, epithelial proliferation occurs into the underlying

mesenchyme and the degeneration of the central cells of this horse

shoe shaped lamina forms a sulcus – the linguogingival groove,

which frees the tongue from the floor of the mouth except at the

lingual frenulum.

The ventral bases of the second, third and fourth branchial arches

elevate into a united, single prominence, termed as the copula. A posterior

subdivision of this prominence is termed the hypobranchial eminence. The

endodermally derived mucosa of the second to the fourth branchial arches

and the copula provide the covering of the root of the tongue.

The junction of the body of the tongue and its root is seen as a ‘V’

shaped sulcus terminalis in the adult tongue. This sulcus is marked by 8-12

large circumvallate papillae which form at 2-5 months i-u.

51
 In contrast, the mucosa of the dorsal surface of the body of the

tongue develop fungiform papilla at 11 weeks i.u.. The filiform papillae

develop later and are not complete until postnatally.

The taste buds arise by inductive interaction between the epithelial

cells (both ectodermal and endodermal) and the invading gustatory nerve

cells from the chorda tympani, glossopharyngeal and vagus nerves. The

gustatory cells start to form as early as the 7th week i.u. but taste buds are

not recognizable until 13-15 weeks i.u. Initially, only single taste buds are

present in fungiform papillae, but these multiply branching in later fetal

life.

All of the taste buds in the fungiform papillae are present at birth,

but some circumvallate papillae taste buds develop post natally.

The muscles of the tongue are derived from the occipital somites.

They arise in the floor of the pharynx opposite the origin of the

hypoglossal nerve. The muscle mass pushes forward as the hypoglossal

cord beneath the mucous layer of the tongue, carrying the hypoglossal

nerve along with it.

Because the tongue originates from various arches, its innervation is

accordingly complex.

52
 The lingual nerve supplies the mucosa of the body of the tongue

(sensory supply from the first arch nerve V-nerve).

The second arch nerve (facial – via the chorda tympani nerve)

accounts for the gustatory sensation from the body of the tongue.

The third and fourth arch contributions are readily made out by the

mixed tactile and gustatory glossopharyngeal and vagal nerve innervation

of the mucosa of the root of the tongue.

The motor innervation of the muscles except the palatoglossus, is by

the hypoglossal nerve, which depicts its occipital somite origin.

The palatoglossus is supplied by the pharyngeal plexus; whose

fibres are derived from the glossopharyngeal, vagus and accessory nerves.

The rapid enlargement of the tongue initially occupies almost the

whole of the stomodeal chamber and as a result, the initial partition of the

stomodeal chamber by the lateral palatal shelves is delayed.

Only after the later enlargement of the stomodeal chamber, the

tongue descends down and allows the fusion of the palatal shelves.

At birth, the root mucosa is deep pitted by crypts which develop into

the lingual tonsil, which later gets filled up by lymphocytic infiltration.

53
 The entire tongue is within the mouth at birth; the root descends into

the pharynx at the age of four years.

In the early stages, growth of the tongue is very rapid in relation to

the mouth size. This may perhaps depict its active role in suckling. Also,

the presence of a large tongue in a small mouth accounts for the peculiar

tongue thrusting nature during swallowing in an infant.

In this case the tongue encompasses the entire space between the

separated jaws. In contrast, the tongue tip is seen to tie at the tip of the

maxillary incisor teeth.

The tongue normally doubles in size between birth and adolescence

reaching adult size by around 8 yrs of age. In some individuals, it continues

to grow till adulthood.

Functions:

a) Swallowing

b) Speech

c) Suckling in infancy

d) Taste

e) Respiration

54
Clinical significance: In normal individuals, the forces generated by the

tongue musculature efficiently balance the anterior lip forces and the lateral

check forces.

This feature is incorporated in functional appliances like the

Frankel, where in the tongue pressure is utilized for expansion of the

arches after the cheek pressures are relieved by using buccal shields.

Also the freedom of the tongue permits it to deform the dental

arches when there is an abnormal function.

The commonest example of this is in cases of tongue thrust habit,

which many believe to be a retained infantile swallow, resulting in an

anterior open bite.

The other notable condition is in cases of macroglossia (large

tongue) in which the lower incisors flare out and are spaced abnormally

due to the tongue forces.

Other developmental anomalies of the tongue are

- Microglossia

- Tongue tie ankyloglossia

- Aglossia

- Lingual thyroid

55
GROWTH ROTATIONS

Concepts and terminology

The phrase growth rotation was first introduced in year 1955 by

Bjork, which can be understood as the overall changes in the orientation of

each jaw during growth.

Various terminologies have been used by different authors to explain

the rotation of jaw but these all terms have been used and explained

pertaining to mandible because.

a) it is less easy to divide muscle into core of bone like mandibular

b) maxilla do not have a series of functional processes.

c) There are no areas of muscle attachment analogues to mandibular.

In mandibular = Core of bone - bone surrounding inf. Alveolar nerve

= Function process - alveolar process, muscular process,

condylar process.

Terms used:

1) Total rotation - actual corpus rotation i.e. change in the inclination of

the implant line to SN)

56
2) Matrix rotation - visible rotation of the lower border of mandible to

SN.

Also described as Pendulum movement with center at condyles.

3) Intra matrix rotation - change of inclination of the lower border of

mandibular to the reference implant line.

This intra matrix rotation denotes remodeling changes and its alongs

keeps pare with matrix rotation.

 The total rotation is the sum of the matrix and intramatrix rotation

 Usually mild intra matrix rotation has its center at the condyles.

 The matrix rotation has its center at the condyles

 The intra matrix rotation has its center in the corpus

 The center of total rotation depends on above two centers.

The location of center of rotation depends on

 Rotation of corpus of mandible

 Rotation of maxilla
 Occlusion of teeth.

57
 The term “matrix” has purely osteogenic consideration and entirely

separate from Moss’s functional matrix (ML2).

Here soft tissue matrix can be defined by the tangential mandibular

line (ML1).

ML2
ML2 = Conventional mandibular line ML1
ML1 = Tangential mandibular line

4) Lateral rotation - rotation that occurs in core of each jaw.

5) External rotation - surface changes and alterations occurring in each

jaw.

6) Forward rotation - of growth face place more in than post region.

Dented by (- ve) sign also known as

7) Backward rotation - anterior dimension lengthen more than posterior

denoted by (+ ve) sign.

58
8) Counter balancing rotation - by Dibbets in 1985. circular condylar

growth accompanied by selective co-ordinated remodeling which does

not contribute to the incremental growth of mandible.

Before going to the individual jaw rotation in growth It is necessary

to understand the terms like rotation, angular change, matrix and

intramatrix rotation in detail.

Rotation - This term is used and showed be used only for the

displacements which brings out the angular movement of one rigid body

relative to another by Rune et al (1957) it is considered as a special case of

angular change.

Angular change - when a single body changes in form due to surface

opposition and removal there may be changes in orientation between

reference lines within that body. These are termed angular changes and not

rotations in short sense.

True rotation - rotation of the mandibular body as represented by implants

or stable trabecular reference structures relative to the cranial base (Total

rotation by Bjork and Skieller 1933).

Apparent rotation - the angular change of the mandibular line relative to

the anterior cranial base (by Lands in 1952) and (Matrix rotation by Bjork

and Skieller (1983).

59
Angular remodeling - the angular change of mandibular line when

mandible is registered on implants or stable trabecular structures.

This remodeling occurs when true rotation of the mandible force the

gonial region against the pterygomassetric muscular sling. This mechanism

led Bjork and Skeillar (1983) to give term “intra matrix rotation”.

Rotation and angular changes are designated

1) Negative or forward when 2) Positive or Backward when

changes are clockwise facing left changes are clockwise facing
or counter clockwise facing right or counter clockwise
right. facing left.

The intra matrix rotation can be described on popular terms as a

“Head Over Heels” turning of a bony element. But it is important to realize

that the external configuration of mandible do not change its form or

position within the head to allow intra matrix rotation of bony element to

occur. Infact, any depositional or resorptive activity as the periosteum

serves to preserve or maintain the original contours.

For Eg: If one consider periosteum two dimensionally like a frame

containing painting with the frame fixed to the wall the painting can be

rotated within the frame but the external outline, configuration and

dimension of frame does not change.

60
Matrix rotation - first defined by Bjork and Skieller and later an Schudy

and Jarabak and Fizzell contributed.

According To “Jarabak analysis” depending on position of

mandibular plane in relation to cranial base to be described or called

a) Clockwise growing faces

b) Counter clockwise growing faces

This phenomenon actually relates to the pattern of growth of head as

a whole.

Intra matrix rotation - first defined by Bjork and Skieller. Later on

contribution were given by Lavergne and Gasson and Dibbets but

Lavergne and Gasson called this as Morphogenetic rotation.

The concept of intramatrix rotation is based upon the local

behaviour of sites of deposition and resorption which a single bone during

the growth period and it actually relates to the pattern of growth to one

specific element of the head and not the head as a whole.

61
There views are clear from Bjork and Skieller concept

1) Mandible “Wiggles” within its matrix.

2) This wiggling is associated mainly with corpus but is caused by

growing condyle.

3) Rotation results to compensate for genetically predetermined

program.

GROWTH ROTATION IN MAXILLA

The rotation are a significant part of the developmental process of

the face and cranium and it is associated with simultaneous and continuous

modeling of bony surfaces that tends to mask the active growth changes.

The surfaces that faces toward the direction of movement is depository (+)

and the opposing surface facing away from the growth direction, is

resorptive (-). If the rates of deposition and resorption are equal. The

thickness of cortex remain constant and if deposition exceeds resorption,

over all size and cortical thickness gradually increase.

The pattern of growth fields which results in a rotation of skeletal

part is as follows.

62
According to Enlow there are two categories of rotations

1) Remodeling rotations

2) Displacement rotations

The whole nasomaxillary complex is rotated by displacement in

either a clockwise or counter clockwise direction. Growth activities taking

place is overlying basic cranium and or sutural system results in a canting

and misfit of palate and maxillary arch into open bite or deep bite

positions. Therefore modification take place is remodeling fields to provide

adjustment by producing a counter direction palatal remodeling rotation

(this occurs due to reversal of remodeling files along the nasal, oral sides of

palate to compensate for the direction and magnitude of whole maxilla

displacement rotation.

To study the growth rotations in the maxilla several studies and

investigation have been done using metallic implants and superimposition

63
technique and several methods and maxillary superimposition have been

described. The most common technique has been superimposition on

palatal plane registered at a variety of sites. Others are nasopalatal surface,

oropalatal surface.

The sites are

1. ANS (Anterior Nasal Spine)

2. PNS (Posterior Nasal Spine)

3. Pterygomaxillary tissue (Ptm)

4. Lateral palatal structures

But sites recommended by Bjork for placement of maxillary implants are

1. Inferior to ANS (anterior implants)

2. In zygomatic process (lateral implant)

3. At the border between the hard palate and alveolar process medial to

the first molar.

And their method of superimposition was as follows:

A common reference line (Nasion sella) was suggested for

evaluation of the degree and direction of maxillary rotation changes in

position of nasion and sella with growth can be eliminated by drawing N-S

line on 1st radiograph and transferring the line to subsequent radiographs

64
after direct superimposition on structures in the anterior cranial fossae and

anterior wall of sella turcica. The anterior contour of the zygomatic process

is then superimposed.

Findings:

a) During growth there is an apparent shortening of the distance

between the anterior and lateral implants.

b) Two maxilla rotating in relation to each other is transverse plane

secondary to opposition at midpalatal suture.

c) More transverse movement at the posterior portion of the palate

than at the anterior portion.

1) Study by Doppel and Damon and Joondeph in 1994

Results:

a) Palatal plane rotated between 8° downward and backward to –5°

upward and forward (angle between ANS-PNS line and line

connecting lateral and anterior implant).

b) Angle between anterior cranial base line S-N and line between

lateral and anterior implant.

Relation: 9° downward and backward to – 6° upward and forward.

65
2) Study by ISERI and Solow year 1995

Results:

a) Palatal plane rotated an average 2.5° backward in relation to the

implant line

b) Max body rotated about –1.5° forward in relation to the anterior

cranial base.

c) Average inclination of palatal plane to the anterior cranial base

increased by 1°.

MANDIBULAR ROTATION

Its is amazing to see how the face develops in a proportionate

manner from the infant stage to adulthood. The pattern of development

remaining constant over the period of time. However, the mandible and the

maxilla (as also the other components of facial skeleton) do undergo a lot

of translatory and remodeling changes. Eg. the bony mandibular corpus

and its soft tissues covering, the matrix, are considered independent tissue

systems capable of independent rotation. Until the use of metallic implants

(by Bjork and Skeiller) for longitudinal studies of growth became

popular, it was difficult to appreciate these rotations occurring during

growth.

66
 In the mandible (as in the maxilla) both forward and backward

rotation occur and they can be divided into 3 components which will be

dealt with a little later / missing.

One of the reasons the rotations cannot be appreciated is that the

internal rotation (total rotation – Bjork) around the core of the mandible is

often masked by surface remodeling changes i.e. external rotation

(intramatrix rotation by Bjork) seen at border of the mandible. Hence

coming to an inference, looking at the border is a improper way of

analyzing mandible rotation.

Normally if the total and intramatrix rotation and external rotation

were equal in magnitude and opposite in direction then no net effect would

occur. However mild to moderate variations do occur altering the extent to

which external rotation occurs and hence a net rotation is always seen. By

convention, when the cephalogram is extended facing to the left of the

operator, then a clockwise rotation is denoted as forward rotation (-ve sign)

and an anticlockwise rotation is called a backward rotation (+ve sign) in

case of forward rotation anterior growth is greater than posterior in case of

backward rotation, the reverse is true.

67
Components of mandibular rotation

The different patterns of mandibular rotation can be readily

understood when it is divided into 3 components. These components are

composed differently and show a changing inter-relationship throughout

growth of an individual.

1. Total rotation this term was coined by Bjork. Proffit referred to this

as the internal rotation.

It is the rotation of mandible corpus and is measured as change in

inclination of a reference line or an implant line in the mandible corpus

relative to the cranial base.

Refi TOTAL ROTATION

When the implant line / ref line rotates forward relative to Nasion –

sella line (NSL) the total rotation is designated as Negative. This is

possibly because of decreased anterior face height. If the cephalogram are

68
superimposed on the implant reference lines then the NSL is seen

converging indicating a forward rotation.

2. Matrix rotation termed by Bjork, Proffit used the term total rotation

for this.
ACB

Centre of condyles

PENDULUM MOVEMENT
ML1 MATRIX ROTATION

It expresses a rotation of the soft tissue matrix of the mandible

relative to cranial base.

On a lat ceph, the soft tissue matrix is defined by the mandibular

line (ML) which is a tangent to the border of mandible.

The matrix rotation is – ve when the ML rotates forward in relation

to NSL.

The matrix rotation is peculiar in a way that it can rotate forwards

and backwards in the same subject during different phases of growth (quite

69
similar to the pendulum movement with the center of rotation at the

condyles).

3. Intra matrix rotation by Bjork, Proffit use the term external rotation.

It was observed that there are distinct differences in the pattern and

amount of the total rotation and matrix rotation. It is this difference

between total and matrix rotation that is termed as intra matrix rotation.

This means that the mandibular corpus rotates within its soft tissues

matrix.

Intra matrix rotation is an expression of the remodeling changes

taking place at the lower border of mandible.

It is defined by the change in inclination of the implant line /

reference line relative to mandibular line.

Ref 1 & 2

Resorption

Apposition
ML1 INTRAMATRIX ROTATION (FORWARD)

70
 INTRAMATRIX ROTATION (BACKWARD)

Thus, if the 2 lines are converging it means that forward rotation

(-ve) has occurred. The center of this rotation lies within the corpus and it

depends not only on the mandibular rotation but also on the maxillary

rotation and the occlusion.

Normally the equation is :

Total rotation = Matrix + Intra matrix rotation.

It is intramatrix rotation which is the major contributor of total rotation

(almost 85%).

When the total forward rotation is more than the forward matrix

rotation then excessive remodeling changes occur at the lower border. The

forward rotation taking place lifts the anterior portion of border away from

the soft tissue matrix causing a stretch on the tissue leading to subperiosteal

deposition of bone. Similarly, since the posterior part is pressed down in he

matrix resorption occurs below the gonial angle.

Cause: The causal factor in facial rotation is not clear. However extreme

attention is being focused on the condylar growth, other causes could be

71
variations in development of cranial base eg. Marked lowering of middle

cranial fossa and along with it the mandibular fossae. The instability seen

in the incisor occlusion could also have an influence as could be the reason

of lip and tongue dysfunction or the interaction between jaw and neck

musculature.

Forward Rotation

Features of forward rotation in mandible

Negative (-ve) or (Clockwise rotation)

(Anterior growth is more than the post vertical growth)

Individuals with short face type, who have a characteristic short

anterior lower face height, have excessive forward rotation of mandible

during growth. It is because of increase in normal total rotation and

decreased in intra matrix rotation. They have a nearly horizontal palatal

plane and a ‘square jaw’ type with a low mandibular plane angle and a

deep bite with incisor crowding.

It is evident that the matrix rotation has a minor role in the total

rotation seen. The rotation diagram shows that the pendulum movement of

matrix rotation initially swings in the backward direction till puberty and

then swings back in a forward direction almost to the same magnitude. The

average matrix rotation was found to be –30° compared to the total rotation

72
which was much greater –19.5°. there was a close associate between total

rotation and condylar growth. The total rotation stopped after completion

of condylar growth, shortly after the union of distal epiphysis of radius

And about one year after increase in height of the individual during

pubertal growth spurt. The intra matrix rotation occurs to an extent of

approximate 85% of the total rotation (-16.5° as found in their study). This

was marked by greater apposition anteriorly and considerable resorption at

the post part of border.

Another feature observed in cases exhibiting a forward rotation of

mandible was the resorption occurring at the anterior border of the ramus

thus creating space for eruption of 3rd molars.

73
Forward rotation – may occur in 3 ways

Type I – This is the one most commonly considered.

 There is a forward rotation about centers in the joint.

 Gives rise to a deep bite (therefore of the arch pressing against the)

resulting in underdevelopment of anterior face height.

 Cause may be occlusal imbalance due to loss of teeth or powerful

muscular pressure.

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Type II – Center located at incisal edges of anterior.

 Due to combination of increase development of posterior face

height compared to normal increase in anterior face height.

 Posterior part of mandible rotates away from the maxilla.

Increase post face height may be because of

1) Lowering of middle cranial fossa in relation to anterior as the cranial

base bends and the condylar fossae being lowered as a result.

2) Increase in height of ramus because of increase vertical growth of

mandible condyles.

Because of increase vertical growth of condyles. The mandible is

lowered more than it is carried forwards. The mandible rotates forwards

because of the muscle and ligamentous attachments. There is a marked

resorption at the lower border below the gonial angle and hence the height

in this region may not increase to a given extent.

Type III – In cases of large maxillary overjet or mandible overjet the

center of rotation lies in the region of premolar.

 Anterior face height under developed posterior face height

increase.

75
  Dental arches are pressed into each other and basal deep bite

develops.

1. In type II and III, mandible symphysis signs forward and chin

becomes prominent.

2. The inclination of teeth is greatly influenced by rotation. The

position of incisors is functionally in relation to incisors which is

seen in the fact that the interincisal angle does not change to a

significance extent than the rotation of the jaw.

Hence, incisors are guided forwards during their eruption and

alveolar prognathism increase.

The rotation causes mesial displacement of paths of eruption of all

teeth creating a crowding in anterior segment referred to as packing.

Backward rotation

Features of backward rotation

Positive (+ ve) or (Anticlockwise rotation)

(Post growth more than anterior)

The backward rotation of the mandible is said to occur when the

mandibular plane angle opens up and the ML is diverging away from the

reference line / implant line or otherwise the NSL are diverging from each

other when the tracings are superimposed on the reference line.

76
 They can also be divided into 3 components. Similar to that in

forward rotation here the eg. Total rotation = matrix rotation + intra matrix

rotation

The backward rotation is seen typically in long face individual who

have an excessive lower anterior face height. The palatal plane rotates

downwards posteriorly as a result of which the mandibular plane angle

opens up. This is primarily because of a lack of normal forward rotation of

the mandible and in some cases an actual occurrence of backward rotation

is seen. The intramatrix rotation does not occur hence creating an anterior

openbite. In most cases, a skeletal open bite develops. This type of

backward rotation also occurs with pathologic condition affecting TMJ.

Components of backward rotation

The backward rotation occurs very rarely and is much less

understood as compared to forward rotation.

Total rotation: When the implant line / reference line rotates backwards as

compared to the NSL the total rotation in designated as positive.

In some cases the matrix and the intramatrix rotation may

supplement each other whereas in some others the matrix may rotate

forwards leading to increase compensatory remodeling at the border of

mandible.

77
 The center rotation is not fixed and depends upon the rotation

centers of matrix and intramatrix rotation.

Matrix rotation: when the ML rotates backwards relative to NSL, then it is

designated as positive.

It shows a similar pendulum movement with a gross effect in

backward direction.

Intra matrix rotation: when the implant line / reference line rotates

backwards relative to ML then it is designated as positive.

The center of rotation is studied in the corpus.

As the corpus rotates backward in the matrix, the anterior part of the

corpus is pressed down and hence resorption occurs at that point.

Conversely there is apposition of bone at the gonial angle.

78
Types of backward rotation

It is less frequent. 2 types are recognize

Type I – Center of rotation in TMJ

 Occurs for eg: when bite is raised by orthodontic means by

change in inter cuspal of teeth / bite blocks.

 Causes increase anterior face height

 It can also occur in conjunction with growth of cranial base.

 In case of flattening of cranial base middle cranial fossa raised

 condylar fossae raised  mandible rotates backwards

 In case of incomplete dev of height of middle cranial fossa (eg.

Oxycephaly) – under dev of post face height and increase

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 anterior face height - backward rotation of mandible and may

cause anterior open bite.

Type II – center situated at the most distally occluding molars.

 This occurs in connection with growth in sagittal direction at the

mandible condyles – curving backward.

 Because of this it is carried forward more than it is lowered in

the face and therefore of muscle and ligamentous attachment it

rotates backwards.

 The sympysis is swing backwards and chin is drawn back.

But the soft tissues may not follow and may give rise to a double

chin. Basal open bite may develop.

 Incisors being functionally related to incisors. They become

retroclined and alveolar proportion in decreased.

 Characteristic of condylar hypoplasia and severe in case of

condylar aplasia.

80
MANDIBULAR ROTATION RESULTING FROM GROWTH

By F.F. Schudy

The rotation of the mandible resulting from a disharmony between

vertical growth and anteroposterior or horizontal growth has important

implication in orthodontic treatment.

This study was initiated for the purpose of documenting the growth

changes which produce rotation of the mandible.

1) If the condylar growth is greater than vertical growth in the molar

area, the mandible rotates counter clockwise and results in more

horizontal change of the chin and less increase in anterior facial

height. Extremes of this condition cause closed bite.

2) If vertical growth in the molar region is greater than that at the

condyles, the mandible rotates clockwise, resulting in more anterior

– facial height and less horizontal changes of the chin extremes of

which cause open bites.

Growth of the mandibular condyle produce a forward component of

the chin, nor a downward non a downward and forward component. Only

when the vertical movements of facial growth begin to assert their

influence on condylar growth through occlusal contact that a downward

and forward direction of chin is produced.

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Vertical movements that produce increase in facial height

1) Growth at nasion and on the corpus of the maxilla produces an

increase in the distance from nasion to anterior nasal spine and

causes maxillary molar and posterior nasal spine to move away from

the sella-nasion plane.

2) Growth at the maxillary posterior alveolar process causes the molar

tooth to move away from the palatal plane.

3) Growth at the mandibular posterior alveolar processes causes the

molar teeth to move occlusally.

Clockwise rotation (forward rotation)

Is a result of more posterior vertical growth than condylar growth,

the point of rotation being the condyle. When vertical growth exceeds

horizontal growth, pogonion cannot keep pace with the forward growth of

the upper face and mandibular plane must become steeper. This helps to

correct vertical overbite of incisors.

Counter clockwise rotation:

Rotation of the mandible is a result of more condylar growth than

combined vertical growth. This type of rotation is really always

accomplished by a forward movement of pogonion and increase in the

82
facial angle. The point of rotation is at the most distal mandibular molar in

occlusal contact. The smaller the gonial angle, the greater relation is

produced for each mm of forward movement of pogonion. When the angle

is extremely small it is almost impossible for the chin to move forward

without flattening of the mandibular points. An obtuse gonion angle may

compensate for a short corpus. It may also compensate for a short ramus.

The correct gonian angle help to compensate for inharmony of fascial

proportions.

Mechanism of Growth

It is noted that as the molar height increases the chin swings

downwards and backward, the mandibular plane become steeper, gonial

angle moves posteriorly and fascial angle increases. Thus by varying the

molar height we are able to change facial angle. The molar height not only

controls the vertical portion of the chin, but also to a considerable extent

the anteroposterior position.

In the figure, the mechanism of growth of the jaw is illustrated.

These 5 growth increments are the principle ones with which the

orthodontists are concerned. The relationship of these increments control

the behaviour of the mandible. They determine whether gonion shall move

downward and forward or downward and backward and whether a Class II

condition will be easy or difficult to correct.

83
 When the pogonion and nasion grow forward at an equal rate,

increment A will equal the sum of increments I, II, III and IV. Growth at

the condyle must equal the antero-posterior growth at nasion plus vertical

growth of the corpus of the maxilla, plus the vertical growth of the

maxillary alveolar process plus the vertical growth of mandibular alveolar

process. Growth at the condyle is trying to carry the chin forward and

combined vertical growth is the molar area is buying to carry the chin

downward.

The result is usually downward and forward although downward

and backward is also seen. When the growth at A exceeds I, II, III and IV

mandibular plane become flatten with pogonion moving forward more than

nasion.

When the sum of I, II, III and IV appreciably exceeds A, pogonion

will usually move backward in relation to nasion and mandibular plane

well become steeper.

84
 When growth at A equals the sum of II, III and IV mandibular plane

moves downward in a parallel manner.

The ratio between the horizontal and vertical growth increment is

called the posterior growth analysis. It is by relationship between these

increments which controls the forward growth and rotation of the

mandible.

Growth of the mandible

Includes:

 Growth of condyle and ramus.

 Growth of corpus.

 Posterior alveolar process.

 Anterior alveolar process.

It grows in various ways. It may grow quite uniformly in all

directions or any one of its aspects may grow out of proportion to the rest

of the base. Sometimes, condyle may grow rapidly on the corpus and

condyle exhibiting little or no growth.

All these have a effect upon vertical overbite and overjet. It has been

said that the growth of the mandible is the primary determining factor of

facial morphology. However, vertical growth of the maxilla also plays a

major role.

85
Method

In order to determine the cause of mandibular rotation it is necessary

to measure total vertical growth in the region of the first molar teeth and to

rotate this growth to the condyles.

The effective growth of the condyle were measured over a period of

time by pinching holes on both tracings at the approximate site of the head

of the condyle. By superimposing on mandibular plane, registering on the

lingual cortical palate of symphisis and measuring between the 2 pin holes,

we can determine the increase in length of the mandible as well as

horizontal and vertical component of growth.

Vertical growth of the body of maxilla is measured from the

Frankfort plane to the palatal plane along a bone and to the Frankfort plane

through the distobuccal cusp of the maxillary first molar. The vertical

growth of the maxillary alveolar process is measured from the palatal plane

to the occlusal plane by a angular and to the Frankfort plane (Po-Or)

through the distobuccal surface of the first molar.

The vertical growth of the mandibular alveolar process is measured

from the occlusal plane at the site of distobuccal cusp of first molar.

Second measurement was taken at the same anteroposterior site as the first.

86
Enlow

According to Enlow, the surface that faces towards the direction of

movement is depository. The opposite surface facing away from the growth

direction is resorptive. If the rate of resorption and deposition are equal and

thickness of the cortex remains constant. If deposition exceeds resorption,

overall size and cortical thickness gradually increases. The figure shows

pattern of growth resulting in rotation.

Remoddling rotation

The function of the mandibular ramus in addition to muscle

insertion is to position the lower dental arch in occlusion. For this to occur

it usually becomes more upright in alignment as development proceeds

closing the gonial angle. It is the combination of remodeling fields that

caries out remodeling rotation of the ramus. As this growth change

proceeds, the outeric mandible can also become rotated move downward

and backward or upward or forward. This is a displacemental relation of

the mandible in a whole as its ramus simultaneously rotates to a more

closed position by adjunctive remodeling.

The nasomaxillary complex as rotated by displacement in either a

clockwise or control clockwise direction, depending on growth activities of

the overlying basocranium and also the extend of growth by sutural system

87
attaching the midface to the cranial, floor. This would result in open or

deep bite positions.

In the above diagram the mandible was placed in a retrusive position

owing to its downward and backward rotation resulting from more open

type of cranial base closure. The ramus can compensate by an increase in

its horizontal dimension. This places the whole mandibular arch more

anteriorly beneath the maxilla and positions both in Class I relation.

The alignment position of the whole mandible can be up or down at

the condylar point. The primary reason that this kind of developmental

rotation takes place is to adjust to whatever vertical size exists for the

midface and the alignment of middle cranial fossae. The mandible rotates

88
forward and upward to meet a short midface and as it rotates down and

back. This is a displacement type of rotation.

The angle between the ramus and the corpus also can become

increased or decreased as a separate kind of rotation. This not only refers to

the cranial angle but rather to the alignment between the whole of the

ramus and the corpus. This is in remodeling types of rotation in contrast to

displacement type.

89
 Condition Bjork Schudy

Anterior growth greater

Backward rotation Clockwise rotation
than posterior
Posterior growth greater
Forward rotation Counterclockwise rotation
than anterior
Bjork Solow, Houston Proffit
Rotation of mandibular
Internal
core relative to cranial Total rotation True rotation
rotation
base implant
Rotation of mandibular
Apparent
plane relative to cranial Matrix rotation Total rotation
rotation
base
Rotation of mandibular Angular
Intramatrix External
plane relative to core of remodeling of
rotation rotation
mandible lower border
Proffit = Internal rotation – external rotation
Bjork = total rotation – intramatrix rotation
Solow = true rotation – angular remodeling of lower border

Condylar growth and correlation with mandibular rotation

There was no doubt that there existed a close rotation between the

rate of condylar growth and total forward rotation. However Bjork and

Skieller found no correlation between the condylar growth and matrix

rotation.

The condylar growth can be visualized by looking at the condylar

growth curves depicted from a common condylar point in different cephs.

90
 The generalization seen in the literature that condylar growth takes a

circular course (Ricketts – 1972) or has the shape of a logarithmic spiral

(Moss 1970) was not confirmed in the study by Bjork and Skeiller (1983).

On the contrary, there was marked variation between the individuals and

hence prediction of condylar growth was difficult.

However it was observed that condylar growth ceazed along with

fusion of distal epiphysis of radius and followed the general growth curve

of the body and the pubertal maximum growth in body height occurred one

year before the maximum condylar height.

In the study by Bjork he found that the mean value for condylar

growth from age 4 to adulthood was –10° and the range was –22° the – ve

sign indicates a forward slope whereas the angle was measured by

connecting a line from the condylar pt in the 1st tracing to the condylar pt in

the last tracing and comparing it to a tangent drawn at the ramus and

condyle in the 1st ceph. The average amount of growth of the condyles was

about 41.3mm.

The intensity of condylar growth strongly correlated with the

rotation of mandible and less strongly with rotation of maxillary.

91
STRUCTURAL SIGNS OF GROWTH ROTATION

 From clinical point of view, it is imp to detect extreme types of

mandible rotation

 Structural signs will be considered in relation to condylar growth

direction.

More the number of signs present, more reliable the prediction.

(a) Inclination of the condylar head.

(b) Curvature of mandible canal

(c) Shape of border of the mandible

(d) Inclination of the symphysis

(e) Inter incisal angle

(f) Inter premolar or inter molar angles

(g) Anterior lower face height.

(a) A forward or backward inclination of the condylar

head is a characteristic sign of forward or backward rotation.

(b) Curving of the mandibular canal – In the vertical

type of condylar growth, the curvature of the canal tends to be greater

than that of the mandibular contour whereas in the saggital type the

opposite is true.

92
(c) Shape of the lower border of mandible – In forward

growth rotation there is apposition below the symphysis and anterior

part of the mandible producing anterior rounding, while resorption at

the angle produces a concavity. In backward growh rotation the

anterior rounding is absent resulting in a linear shape of anterior

lower border and the contour at the jaw angle is convex. The angle

between the two mandibular lines (MLI – MLZ) expresses the shape

of the mandible.

Shape of the Lower Border of the Mandible

Forward Rotation
Backward Rotation

ML1 - ML2

ML1
ML2
Inclination of the Symphysis

93
 NSL

CTL - NSL

CTL

(d) Inclination of the symphysis – This is measured as

the angle between the tangent to the anterior surface of the mandible

and the anterior cranial base. This is an important feature in

mandibular growth prediction because this surface is free from

remodeling.

(e) Inter molar angle – The inter molar angle tends to

increase in forward rotation of the mandible and decrease when the

rotation is directed backward.

(f) Lower face height – This is to some extent

dependent on the incisal occlusion.

Later in a study conducted by Skieller and Bjork to predict

mandibular growth rotation from a longitudinal implant sample, they

94
 used another variable i.e. the mandibular inclination which is

represented by 3 alternatives.

a) Proportion between anterior and posterior facial

height is calculated as S-Gox100/n-gn.

b) Lower gonial angle

c) Inclination of the lower border measured by the

angle NSL – ML.

However mandibular inclination in relation to the anterior cranial

base at a given developmental stage is a morphogenetic feature which only

to a moderate degree reflects the actual growth relation pattern of the

mandible.

PREDICTION OF MANDIBULAR GROWTH ROTATION

With an increased realization of the great individuality in

craniofacial growth and development the need for predictive system has

been imperative in orthodontic treatment planning.

Inspite of several attempts in recent years, there is still doubt as to

the extent to which growth of the face as a whole can be predicted from a

single profile radiograph.

95
 In an early attempt to analyse the possibility of predicting growth of

a single facial dimension Bjork and Palling correlated linear and angular

measurements at prepubertal age with the residual age growth of these

dimensions upto adulthood. These correlation however were found to be

very low.

Meredith confirmed that the variability of individual growth

changes between the two age levels were remarkably great between 50%

and 80% of the variability at prepurbertal age. He also found that single

morphologic dimension at an early stage will tell us little or nothing about

the amount and direction of the residual growth of this dimension.

Hixon suggested that the best estimate of an adult facial dimension

for a given child is to use the dimension presented by the child and add to

that the remaining average growth for the group. This method was adopted

by several authors and Johnson developed his grid method on these

premises as exemplified by Millo this estimate would fit an average but not

an extreme growth pattern where prediction from a clinical point of view is

most important Johnston in an earlier approach applied the multivariate

regression method to growth prediction.

Bhatia and associates outlined a prediction method based on a

duster analysis.

96
 Lavergne tried to individualize the prediction by a subdivision

according to morphologic types.

Ricketts racial method of long range growth prediction uses

geometric procedures to gain information about previous growth pattern of

mandible and project it to further development.

Bjorn-Jorgensen developed computerized system for short range

facial growth prediction and treatment simulation, based on longitudinal

observation of individual growth rate and direction over one or more years.

Cephalometric growth analysis - has been based on conventional

measurements of facial morphology without taking into account the

remodeling processes at the bony surfaces. The dynamics of the actual

growth pattern is therefore often concealed.

The present study by Skieller, Bjork and Lindehansen is limited to

an estimate of the possibilities of predicting the amount and direction of the

actual growth rotation of the mandible from pubertal age during the

subsequent growth period. A necessary condition was to analyze a sample,

followed longitudinally with meta implants upto adult age. Where the

mandibular growth relation could be exactly determined.

A growth analysis consists essentially of 3 items, each of which is

clinically significant

97
 (1) An assessment of the development in shape of the face which, in the

first place, implies changes in the intermaxillary relationship.

(2) An assessment of whether the intensity of the facial growth in

general is high or low.

(3) An evaluation of the individual rate of maturation. (important in

establishing whether puberty has been reached and when growth

may be expected to be completed.

In the assessment of shape there are 3 methods (i) longitudinal (ii)

metric (iii) structural.

(i) Prediction by longitudinal method: consists of following the

course of development in annual x-ray cephalometric films.

It is for the subjects displaying the most pronounced changes in

facial form from that the diagnosis of the growth pattern is of prime

clinical importance.

Limitation of longitudinal method

(i) Pattern of growth is not constant and pattern recorded at juvenile

age may well have changed by adolescence.

98
 (ii) Permits the observation of changes in suggital jaw relation with

growth and those occurring in the vertical jaw relation are

marked.

So implant method reveals this difference is due to the fact that

there is no major remodeling of the anterior surfaces and the jaws during

growth, where as the horizontal surfaces of references such as the nasal

floor and especially the lower border of the mandible under goes radical

interaction.

Changes in the vertical position of the jaws, in the form of rotation,

give the impression of being considerably smaller when judged by

conventional longitudinal x-ray analysis with the lower border of the

mandible as a reference than assessed with the aid of metallic implants.

Analysis of the vertical development of the face may be improved

by using what can be called natural reference structures in the mandible by

superimposing two radiographs taken at different ages and orienting then

with reference to these structures, one may estimate the growth pattern of

mandible by reading the angle between the Nasion sella lines for the two

ages.

99
(ii) Metric Method

The metric method aims at prediction of facial development on the

basis of the facial morphology determined metrically from a single x-ray

film. However, predicting the intensity or direction of subsequent

development from size or shape at childhood indicate that this is not

feasible. The growth in the length of the mandible during adolescence

could not be judged from its size before puberty and changes in shape

during adolescence expressed in terms of angular measurement, were also,

at most very weakly correlated with the shape of the face at 12 years of

age, which is an age at which treatment often is instituted or planned.

(iii) Structural method: It is based on information concerning the

remodeling processes of the mandible during growth, gains from

the implant studies. The principle is to recognize specific

structural features that develop as a result of the remodeling in a

particular type of mandibular rotation. A prediction of the

subsequent course is then made on the assumption that the trend

well continue.

100
GROWTH EQUIVALENCE

Growth is a differential process of progressive maturation whereas

development is a process working towards an ongoing state of aggregate,

composite, structural and functional equilibrium.

Growth of course involves constant changes of size, shape and

relationships among all the separate parts and the regional components of

each parts. Any change in any given part must be proportionately matched

by appropriate growth changes and adjustments in many other parts,

nearby as well as distant, to sustain and progressively achieve functional

and structural balance of the whole. In short growth anywhere in any

region, local area, or part is not isolated. “Balance” is a developmental

aggregate involving close interplay throughout. For example, the shape and

size of ones external nose and facial airway are not determined solely, by

blue print just within these parts themselves, since many other parts

elsewhere establish regional developmental conditions.

The nature of anatomic fit among the different bones of the

craniofacial complex of one subject at any age and through time is

presented in two parts:

1) A ‘form analysis’ which deals with facial pattern, construction and

dimensions.

101
 2) A ‘growth analysis’ which is concerned with an interpretation of

incremental changes.

The above analysis are based on and basic morphologic concepts

which are summarized below:

(A) Concept of architectural equivalence:

In any functional assemblage of bones, such as the craniofacial

complex, certain key dimensions must necessarily correspond between

these bones in order to provide proper fit. A prescribed portion of each

bone represents a direct architectural (dimensional) counterpart of some

segments of another bone or (bones), even though their respective function

and other anatomic relationships are different. These dimensional

analogoues among bones are termed “equivalents”. If any two such

equivalents match a dimensional balance is thereby produced and

morphologic fit is thereby provided (continued growth can:

1) Sustain balanced or an imbalanced condition.

2) Improve an unbalanced situation.

3) Aggravate the original status of balance or imbalance)

(B) Concept of effective dimensions

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 In order to equate any two bony “equivalents” only those portion

that represent on actual structural and dimensional counterpart can be

considered. The entire length or width of bone is not ordinarily involved.

Rather that particular span that provides proper fit to a corresponding

segment of another bone is relevant.

E.g., the horizontal bony arch of the mandible is a direct structural

equivalent to the bony maxillary arch. The ramus portion of the mandible,

on the other hand is not directly involved since this segment of the

mandible provides structural equivalence to another entirely different part

of the skull, that is part of the cranial floor.

(C) Concept of aggregate balance

Somatic and genetic variations are regularly present in the structure

of the bones involved, a factor of reciprocal adjustments can occur in some

of these dimensions for their mutual accommodation of variation in size

and shape.

E.g., the sum of bony mandibular arch and ramus horizontal

dimensions should closely balance the sum of bony maxillary arch and

“effective” cranial floor dimensions.

A number of different combinations are possible to achieve a

composite balance among all of them. Thus, the cranial floor may be “long

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relative to it direct equivalent, the ramus. This regional dimensional

imbalance, however can be offset by a corresponding imbalance in another

set of equivalents thereby providing adjustment when aggregate balance

between the sum of all of them is considered.

(D) Concept of incremental balance

Aggregate balance can change through time by correcting (or

improving) or by aggravating on original dimensional balance or imbalance

between regional equivalent. Note that the “form analysis” reveals where

imbalance exists and to what extent. The “growth analysis” develop how

this original balance is either sustained or changed as a consequence of

continued growth (and/or treatment). Conclusion of the above four

concepts can be given in the following manner.

Thus the concept of “balance” applies to increments of growth as

well as to effective anatomic dimensions among the structural equivalents.

If any two now talk about the Hunter and Enlow growth equivalent

concepts.

The Developmental Sequence

The multiple growth process in all the various parts of the face can

be described separately as individual ‘regions’ or ‘stages’ sequence being

first the maxilla, mandible and then parts of cranium. Growth increases are

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shown in such a way that the same craniofacial pattern and form are

maintained throughout, that is the proportions, shape, relative sizes and

angles are essentially unaltered to the extent possible as each separate

region changes. Thus, the geometric form of the whole face for the 1 st and

last stage is the same only the overall size is changed.

Facial and cranial enlargement in which form and proportions

remain constant, constitutes “balanced” growth. However, a perfectly

balanced mode of growth in all the parts of the face and cranium never

occurs in real life because regional imbalances occur during actual

developmental processes. However, most of these imbalances are perfectly

normal.

The reason to study balanced growth is two fold:

1. To see what constitutes balanced growth.

2. To recognize and explain facial imbalances.

Note: The process of “compensation” is a feature of the developmental

process i.e. it provides for a certain latitude of imbalance in some areas

inorder to offset the effects of disproportions in other regions.

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 To state the counterpart principle of facial growth: It states simply

that the growth of any given facial or cranial part relates specifically to

other structural or geometric “counterparts” in the face and cranium.

e.g., Maxillary arch - mandibular arch.

Anterior cranial fossa - palate.

Middle cranial fossa, ramus of mandibular arch and zygomatic arch

are respective counterparts.

Each regional growth changes is presented as two separate processes:

1) Deposition and resorption (fine arrows).

2) Displacement (heavy arrows).

Regional change (Stage) 1:

1) Bony maxillary arch lengthen horizontally in a posterior direction.

This is schematized by showing post involvement of the

pterygomaxillary fissure (PTM).

2) Overall length of maxillary arch has increased by the same amount

that PTM moves posteriorly.

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 3) Bone deposited on posterior-facing cortical surface of maxillary

tuberosity.

Resorption occurs in the inside surface of the maxilla in the

maxillary sinus.

The above is termed “Remodelling”.

4) Class I molar relation seen.

Regional change (Stage) 2:

1) This part involves “displacement”.

2) As the maxillary tuberosity grows and lengthens posteriorly, the

whole maxilla is simultaneously carried anteriorly.

3) The amount of forward displacement = amount of post lengthening.

4) This is primary type of displacement.

5) Note the Class II molar position.

Regional Change (Stage) 3:

Now with the elongation of the maxilla, its counterpart must also

undergo equivalent changes in order to maintain structural balance.

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 1) The bony mandibular arch now lengthens (to match the elongation

of the maxilla).

2) In this the anterior part of the ramus remodels posteriorly.

3) Amount of elongation (posteriorly) and direction is the same on that

of the maxillary arch.

4) Note : A Class II type of molar relation still exists.

Regional Change (Stage) 4:

Remember remodeling and displacement occur at the same time:

1) The whole mandible is displaced anteriorly (just as the maxilla) as it

grows posteriorly.

2) The amount of anterior ramus resorption is equated by the amount

of posterior ramus addition. The purpose of this is to relocate it

posteriorly for lengthening the corpus.

Regional change (Stage) 5:

1) The anterior displacement of the whole mandible equals the amount

of anterior maxillary displacement assuming everything is perfectly

in balance.

2) Class I position of molars is returned.

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 3) Ramus remodeling also lengthens the vertical dimensions. This

separates the occlusion.

Regional change (stage) 6:

1) By now with the above stages, simultaneously the dimensions of the

temporal lobes of the cerebrum and the middle cranial fossae have

also been increasing at the same time.

2) Done by Resorbtion-endocranial side.

Deposition-ectocranial side.

Spheno-occipital synchondrosis-endochondral bone

growth.

3) Expansion of the middle fossae (Note in the diagram it moves

anterior to the reference line).

Regional change (Stage) 7:

1) All cranial and facial parts lying anterior to the middle cranial fossa

(infront of the vertical line) become displaced in a forward direction

as a result.

2) As the middle cranial fossa expands anteriorly in forward direction.

The fore head, anterior cranial fossa, cheek bone, palate and

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 maxillary arch all undergo protrusive displacement on an anterior

direction. This is a “secondary” type of displacement.

Regional change (stage) 8:

1) Expansion of middle cranial fossa also causes secondary

displacement effect on the mandible (secondary displacement).

2) This effect is less on the mandible than on the maxilla (this is

because greater part of MCF growth occurs in front of the condyle

and between the condyle and maxillary tuberosity.

3) Therefore, the upper incisor show overjet and molars one in a Class

II (this is due to maxillary protrusive displacement is greater than

mandibular protrusive displacement).

Regional Change (stage) 9:

1) MCF  places the maxillary arch anteriorly.

Similarly Ramus places the mandibular body.

The ramus is the specific structural counterpart of MCF both are

counterparts of the pharyngeal space.

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 2) The skeletal function of the ramus is to bridge the pharyngeal space

and the span of the MCF in order to place the mandibular arch in

proper anatomic position with maxilla.

3) The breath of ramus is critical (if too narrow or forward it places the

lower arch too retrusively or too protrusively respectively).

4) The horizontal dimension of the ramus now equals the horizontal

dimension of the MCF (in this stage the breadth of ramus actually

increases as compared to stage 4).

Regional Change (stage) 10:

1) The entire mandible is displaced anteriorly at the same time that it

remodels posteriorly.

2) Amount of anterior displacement equals.

a) Extent of renal and condylar growth posteriorly.

b) Amount of MCF enlargement anterior to the mandibular

condyle.

c) Extent of result anterior maxillary displacement.

3) Oblique growth of condyle ceases and upward and backward

projection of condyle with corresponding downward and forward

displacement of mandible.

Thus, the ramus growth vertically and horizontally.

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 This results in further descent of mandibular arch separation of

occlusion.

4) Extent of vertical growth must match the total vertical lengthening

of the nasomaxillary complex of the upward eruption of the

mandible dentoalveolar arch if same facial balance is to be achieved.

5) Maxillary protrusion has now been matched by equivalent amount

of mandibular protrusion.

6) Molars are once again in Class I and upper incisors have no overjet.

Regional change (stage) 11:

1) The posterior-anterior lengthening of the ACF is now in balance

with the horizontal lengthening by its structural counterpart, the

maxillary arch thus retaining the profile.

2) The enlarging brain displaces the bone of the calvaris outward (by

structural growth).

3) The upper part of face-the ethmomaxillary region, increases

horizontally to an extent that matches. MCF above and maxillary

arch and palate below it. These areas are counterparts to one

another.

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Regional change (stage) 12:

1) The vertical lengthening of nasomaxillary complex is brought about

by remodeling and primary displacement.

2) The combination of resorption on the nasal side of the palate and

deposition of the oral side produces a downward remodeling

movement of the whole palate.

3) This relocates the palate inferiorly this leading to vertical

enlargement of overlying nasal region (thus to keep pace with the

enlargement of the whole body and lungs).

Regional change (stage) 13:

1) Vertical growth by displacement is associated with bone deposition

at the many various sutures of the maxilla.

2) The total extent of downward movement of palate and maxillary

arch is by:

a) Downward displacement of the whole maxilla, carrying the

entire dentition passively with it (2 to 3).

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 b) Tooth is own movement as bone is added and resorbed on

appropriate lining surfaces of each socket. (This is vertical

difference of the tooth). (Maxillary relation).

Regional change (stage) 14:

1) The mandibular teeth and alveolar bone drift upward to attain full

occlusion.

Regional change (stage) 15:

1) Remodelling change also occur in incisor alveolar region, the chin,

and the corpus of the mandible.

2) Lower incisors undergo lingual tipping (a retroclination) to create a

overbite.

3) Resorption on the outside surface of alveolar region just above the

chin and deposition on the lingual side.

Regional change (stage) 16:

1) The forward part of the zygoma and molar region of the maxilla

remodel in conjunction with the contiguous maxillary complex.

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 2) Molar area remodels posteriorly by continued deposition of new

bone on its posterior side and resorption from its anterior side.

3) This remodeling process keeps this areas position in proper

relationship with the lengthening maxillary arch. They both

“relocate” backward.

4) The amount of deposition on the posterior side of molar process

however exceeds resorption on the anterior surface so that the whole

molar protuberance becomes larger.

5) The arch remodels laterally by bone deposition on the lateral side

together with resorption from the medial side with the temporal

fossa.

Regional change (stage) 17:

The molar area is thus moved anteriorly and inferiorly by primary

displacement as it enlarges by remodeling.

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