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Prediction of Mandibular

Prediction of Mandibular

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Published by Andrei Busmachiu

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Published by: Andrei Busmachiu on Apr 16, 2012
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mandibular growthrotation
A. BjSrk, Odont. Dr.
e introduction of cephalometric radiography 37 years ago initiatednew trends in orthodontics, as is witnessed by a wealth of articles in thisJOURNAL over the years. As a tribute to Dr. Pollock, editor of the
for half a century, I am pleased to have the opportunity of offering a contri-bution on this subject. It will take the form of an outline of some resultsof studies of craniofacial growth in children, in which metallic implants havebeen inserted in the jaws to serve as fixed reference points. Clinical applicationsarising from these studies will also be touched upon.The technique whereby metal implants are inserted in bone has been usedin animals for more than a century, but the application of the method incraniometric studies of growth in man is of more recent date. Our investigation,which wa,s begun in 1951, comprises a mixed longitudinal study of about 100children of each sex covering the age period from 4 to 24 years.6y Q~4 The sampleconsists of normal children with and without malocclusion and also childrenwit,h pathologic conditions. By means of the implant method, and within itsinherent limitations, it is possible to locate sites of growth and resorption inthe individual jaws and to examine individual variations in direction andintensity. The marker technique has also proved useful in the a,nalysis of themechanisms underlying changes in the intermaxillary relationship duringgrowth, an analysis that has led to a radical modification of previous views.This applies in particular to the vertical jaw relation, since the implant techniquedetects considerably greater rotation of the mandible during growth than maybe observed with conventional methods. Mandibular growth rotation willtherefore be the main topic of this presentation.
From the Orthodontic Department, Royal Dental College, Copenhagen, Denmark.This article is based on investigations supported by Research Grant HS 154 fromthe National Institute of Child Health and Human Development, National Institutesof Health, Bethesda, Md.
586 Bjiirk
Ant. J. OrthodonticsJune 1969
Since the information gained by the implant technique should be regardedas supplementary to that obtained from conventional x-ray examinations, theresults obtained by the two methods will be compared. As t,hc invitation topresent this article requested personal views on procedures and perspectivesin orthodontics and a survey of original contributions in t,hc field, the 1~4crcncesare essentially limited to reports from this J>cpartmcnt. The article is alsobased on experience with the implant method that cannot be documentetl here.
Average versus individual growth pattern
At the time when x-ray cephalometry was introduced, research was con-cerned primarily with the average growth changes in form of the head andface. Represented by measurements or by tracing, the facial form showedcomparatively small changes with age in such studies pcrformcd as far backas the early 1930’s.Jr I9 It is hardly surprising, thcrcforc, that the developmentin form of the face was conceived as being relatively static, except in pathologicor otherwise extreme cases. A given intermaxillary relation, for instance, wasthen considered as being static throughout the period of growth. The treat-mcnt of malocclusion, therefore, was thought to be essentially independent ofage, sex, or maturation rate. This view of the facial dcvelopmcnt is perhapsone of the main reasons that, in spite of the introduction of highly efficientappliance systems in treatment, due regard has not always been given to theindividual variability of growth. This applies t,o both fixed and removableappliances.As a result of longitudinal studies in which x-ray ccphalomet.ry wasapplied, it was recognized that there arc considerable individual clifferencesin the development of facial form and in intermaxillary relations. It was furtherrealized that these i?l&viclzcnZ growth changes in shape arc the rule rather thant,hc exception. The changes in form duringgrowth were found to follow aGaussian distribution and, as mcntionetl above, even though they are on theaverage quite small, they include extreme types which do not necessarilyhave a pathologic origin2It, is clearly important to have complete st,atistical data for the normal rangeof variation of facial changes throughout the whole period of growth, but atpresent such data arc available only for limited periods. 1 would like here torefer to a follow-up study of a random sample of 243 Swedish boys first esamincclby the lateral x-ray ccphalometric method at 12 years of age and again at 20years. In general, the range of the individual changes in both form and size ofthe facial skeleton that took place in this period was roughly half the rangeof form or size at adult ages.51 7 In the dentition, still greater individualgrowth changes were found; for overbite, these amounted to 78 per cent of thetotal range at adult ages3A ccphalometric radiograph from a single stage of development is undoubted-ly of great value in facilitating a morphologic analysis of the facial structures.It is evident, however, that the younger the child, t,hc more difficult it is toassess the final facial form from such a morphologic analysis. If the treatmentis delayed until the end of the growt,h period, it is obvious what morphologic
mandibular growth rotation 587problems are involved, but the possibility of introducing therapeutic measuresearlier, when they could have been more effective, has then been lost. If anattempt is made to assess the growth trend at an early stage, this informationcan be used in designing the treatment or evaluating the problems that mayarise before growth is completed. A growth analysis consists essentially of threeitems, each of which is clinically significant : (1) an assessment of the develop-ment in shape of the face which, in the first place, implies changes in theintermaxillary relationship,17 (2) an assessment of whether the intensityof the facial growth in general is high or 10w,~ and (3) an evaluationof the individual rate of maturation. This last item is important in establishingwhether puberty has been reached and when the growth may be expected to becomplcted.75Before discussing growth changes in shape of the face related to growthrotation of the mandible, I shall first outline what has been learned about thegrowth pattern of the mandible from our implant studies.Il~andibular growth pattern. It has been confirmed by the implant techniquethat growth in length of the mandible in man occurs essentially at thecondyles6, *I The anterior aspect of the chin is extremely stable, no growth hav-ing been found here except in a few cases of pathologic development. Thethickening of the symphysis, therefore, normally takes place by apposition onits posterior surface. On its lower border there is likewise apposition, whichcontributes to the increase in height of the symphysis. As the endosteal rcsorp-tion in this area does not occur at the same rate as the apposition on the outersurface, a pronounced apposition will be reflected in an increase in the thicknessof the cortical substance. The pcriosteal apposition below the symphysis isextended posteriorly, to the anterior part of the lower border of the mandibleand when it is marked this area is characteristically rounded. Below the angleof the mandible there is normally resorption, which may bc very pronounced.In some cases there is, instead, apposition on the lower border at the angle ofthe jaw. These appositional and rcsorptive processes result in an individualshaping of the lower border of the mandible, which characterizes the type ofgrowth.The growth at the condyles usually does not occur in the direction of theramus, as is commonly imagined, but slightly forward. Individual variationsin the dir&ion of growth at the condyles are large and, in the adolescentperiod, have been found to vary by almost 45 degrees, Growth is not alwayslinear in direction but usually curves slightly forward or occasionally evenbackward. The pattern of mandibular growth is thus generally characterizedby an upward- and forward-curving growth at the condyles, while at the sametime there is resorption on the lower aspect of the gonial angle and some apposi-tion below the symphysis. The mandibular canal is not remodeled to the sameextent as the outer surface of the jaw, and the trabeculae related to the canalare therefore relatively stationary. The curvature of the mandibular canal,t,herefore, reflects the earlier shape of the mandible.The lower border of a developing molar germ in the mandible appears tobe fairly stationary until the roots begin to form. This means that, for a period,

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