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FORWARD ROTATION OF MANDIBLE DURING THE TRANSITION FROM LATE PRIMARY DENTITION TO EARLY MIXED DENTITION

Hiroshi Ueno, D.D.S.

An Abstract Presented to Graduate Faculty of Saint Louis University in Partial Fulfillment of the Requirements for the Degree of Master of Science in Dentistry (Research)

2012

Abstract Purpose: To determine whether dentoalveolar changes and/or the condylar growth are related to the true forward rotation of mandible that occurs during the transitional period between the late primary and early mixed dentition stages of development. Materials and Method: The sample included 50 subjects (25 males and 25 females) with Class I (N=25) and Class II (N=25) molar relationships. They were selected based on the availability of lateral cephalograms at two developmental stages: T1- last film with complete primary dentition (5.8 ±0.4 years) and T2- first film with permanent incisors and permanent molars erupted (8.0 ±0.2 years). Seventeen landmarks were identified and 22 measurements were calculated. The mandibles at T1 and T2 were superimposed using natural reference structures in order to measure true mandibular rotation. Results: The mandible underwent -2.4 ±2.6 degrees of true rotation, 1.9 ±2.4 degrees of remodeling and -0.6 ±1.8 degrees of apparent rotation between T1 and T2. There were no significant sex or Class differences in true rotation, remodeling and apparent rotation. There was a moderate correlation (r=0.76) between true rotation and remodeling, and a moderately low correlation (r=0.40) between true rotation and apparent rotation. There was a weak correlation between true rotation and SNA (r=0.28). True rotation showed a moderately low correlation (r=-0.34) with the increases in U1-SN, increases in U1-PP (r=-0.36), and with decreases in Id-Me (r=0.36). Conclusion: Independent of sex and Class, the true mandibular rotation that occurred between the late primary and early mixed dentition was mostly masked by angular remodeling, resulting in limited amounts of apparent rotation. True rotation was significantly related to anterior dentoalveolar changes, but not to the vertical growth changes that occurred.

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FORWARD ROTATION OF MANDIBLE DURING THE TRANSITION FROM LATE PRIMARY DENTITION TO EARLY MIXED DENTITION

Hiroshi Ueno, D.D.S.

A Thesis Presented to the Graduate Faculty of Saint Louis University in Partial Fulfillment of the Requirements for the Degree of Master of Science in Dentistry (Research)

2012
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Oliver i . Behrents Associate Clinical Professor Donald R.COMMITTEE IN CHARGE OF CANDIDACY: Adjunct Professor Peter H. Chairperson and Advisor Professor Rolf G. Buschang.

Hans. who gave me permission to use the Bolton archive to collect my sample.ACKNOWLEDGEMENTS The first important group of people that I would like to thank is my committee. Donald R. Rolf G. Mark. G. Peter H. Behrents and Dr. I could not finish the research successfully. Without their help and understanding. Thanks to Dr. Buschang for giving me the primary guidance I needed. The last group is my family. Oliver. I am grateful that they have given me support that I needed at the final stages of my education. I am also grateful for the guidance and help of Dr. and for reading my countless revisions. I am also grateful for Dr. ii .

........................ 17 Dentoalveolar Changes and Growth ..................................................................................................................................................................................................................................................................................................... 20 References ............................................................... iv List of Figures ...................................................................................................... 31 Statistical Methods ............................................................................ 12 Backward Rotation .............................................................................................................................................................. 49 Vita Auctoris .......................... 11 Growth and Rotation of Mandible .................................. 43 Conclusions............................................................................. 12 Forward Rotation ................................................................................................................................... 27 Introduction................................................................ v CHAPTER 1: INTRODUCTION .... 23 CHAPTER 3: JOURNAL ARTICLE Abstract.............................................................................................................................. 5 Rotational Control for Class II Correction ........................ 1 CHAPTER 2: REVIEW OF THE LITERATURE Class II Malocclusion ........... 3 Class II Treatment ............................................ 30 Subjects ..................................................................................... 14 Remodeling Pattern and Associated with Rotation................................................................................TABLE OF CONTENTS List of Tables.................................................................................................................................................................................................................... 30 Cephalometric Methods ........................................ 35 Results ................................ 36 Discussion ........................................................................................................................................ 15 Terminology for Rotational Changes of Mandible ................................................. 28 Materials and Methods ........................... 48 Literature Cited .......................................................................................................................................................... 52 iii ...........................................................................................................................................

........................... 33 Table 3........................6: Changes in Dental Variables from T1 to T2 ......7: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables ......... 19 Table 3............... 38 Table 3........... Abbreviations and Definitions Used and Error Analysis ............................................ Abbreviations and Definitions Used ...................................2: Characteristics of Activator Studies in Preadolescent Children and Their Outcomes in Anterior-Posterior Changes ...................................................1: Mean Ages for Late Primary (T1) and Early Mixed Dentition (T2) ......................... 9 Table 2..............3: Outcomes of Previous Studies Comparing Activators and Headgears Concerning Anterior-Posterior Changes ..........1: Outcomes of Previous Headgear Studies Concerning Anterior-Posterior Changes ............5: Terminology of Rotational Changes of the Jaws ............................. 6 Table 2..........................5: Changes in Skeletal Variables from T1 to T2 .......... 30 Table 3.3: Planes..................... 11 Table 2..... 41 Table 3..........................................LIST OF TABLES Table 2.........4: Measurements...................................................... 10 Table 2...8: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables ........... Abbreviations and Definitions Used ......................................4: Summary for Treatment of Hyperdivergent Patients with Intrusion of Teeth ............... 42 iv ................. 40 Table 3............2: Landmarks.................................................... 34 Table 3.................... 32 Table 3....................................

..................2: Two Types of Backward Rotation of the Mandible ....... 13 Figure 2... 36 v ..............................................4: Matrix Rotation and Intramatrix Rotation in Backward Rotating Cases ..3: Matrix Rotation and Intramatrix Rotation in Forward Rotating Cases ....1: Three Types of Forward Rotation of the Mandible ..............................LIST OF FIGURES Figure 2.. 22 Figure 3..................1: Mean and Standard Deviation of Mandibular Rotation from T1 to T2 .....5: Percent Adult Status of Maxillary and Mandibular Heights ............. 17 Figure 2.......................... 16 Figure 2.. 14 Figure 2............................

Greater true forward rotation of mandible has been related with more horizontal displacement of chin. rotation is greatest during the transition from late primary to early mixed dentition. is associated with greater inferior displacement of the posterior than the anterior mandible. True mandibular rotation provides important information for understanding facial growth changes. improvement in anterior-posterior chin position is crucial in their treatment.3 Remodeling on the lower border of the mandible can mask the true rotation. and has been shown to be the primary determinant of AP chin position.2 In response to mandibular growth rotation. which refers to the rotation of the core of mandibule relative to the anterior cranial base. it remains unknown why there is greater rotation during this transitional period than during other developmental stages.2 This explains why the mandible undergoes only limited amounts of change in the mandibular plane angle. If the specific mechanisms associated with this rotation were known.4 Although significant amounts of true mandibular rotation occur both during childhood and adolescence. with increasing amounts of true forward rotation associated with greater and more anterior condylar growth.4 Forward rotation of mandible has been recently incorporated in Class II treatment to improve AP chin position. 1 .2 It has been related directly to both the direction and the amount of condylar growth. especially changes of the chin.CHAPTER 1: INTRODUCTION Significant amounts of true mandibular rotation takes place during childhood and adolescence. they could be incorporated into treatment to further enhance the effects.1 True rotation. Since most skeletal Class II patients have mandibular deficiencies.5 To date. dentoalveolar compensatory changes usually occur.

This first section focuses on the definition.Based on timing. If significant relations are detected. no study has been specifically designed to closely evaluate the true forward rotation of mandible that occurs during the transition from late primary dentition to early mixed dentition. The increased rates of true rotation that occur during the transition from the primary to the permanent dentition could be associated with space created by the loss of the primary incisors. Thirdly. Next. followed by permanent incisors. the current choices for Class II treatment will be outlined to emphasize the advantages of focusing on the forward rotation. For instance. the first molars erupt at approximately 6 years of age. The purpose of the present study is to determine if the dentoalveolar changes and/or vertical growth are related to the true forward rotation of mandible during this transition period. the etiology and the problems associated with Class II malocclusion.5 years of age for both the lower and upper incisors. they will expand the possibilities of clinical interventions. In this literature review.6 It is also possible that changes in vertical growth are related to both forward and backward mandibular rotation. an overview of the current beliefs regarding Class II will first be provided. the causes. This possibility is supported by the fact that significant decreases in alveolar bone height have been reported between 5. mandibular growth and its rotation will be explained in detail to understand how this phenomenon can be taken advantage of and how it has been studied 2 . It also touches on the reason why forward rotation of mandible improves profiles of Class II patients and why forward rotation is so important in treating Class II malocclusions.5 and 7.1 To date. the forward rotation that occurs during the transition may be explained by dentoalveolar changes.

15% of youths. These different underlying facial patterns are believed to develop with facial rotation. In Division 1. Class II malocclusion occurs in 23% of children. while dolicofacial patterns are associated with backward rotation of mandible. II and III.1 Brachyfacial patterns are often seen with forward rotation of mandible. while Division 2 individuals tend to have brachyfacial growth patterns. Division 1 individuals typically have mesofacial. accounting for about 20% to 30% of all orthodontic patients. On the other hand. brachyfacial or dolichofacial growth patterns. but approximately 15% to 30% of American children have Class II malocclusions. usually with a deep overbite. the dental changes related to the rotation of mandible will be reviewed in order to better understand the effects of rotation on the dentition and occlusion. While genetics plays an important role in the level of the basal structures.8 According to National Health and Nutrition Estimates Survey III. the maxillary incisors are in close relation to the lowers. Both Divisions 1 and 2 can be related to various types of vertical facial patterns. especially mandibular rotation. in which the lower first molar is positioned distally relative to the upper molar. 3 . can be subdivided into Division 1 and 2. in Division 2. Finally. CHAPTER 2: REVIEW OF THE LITERATURE Class II Malocclusion Edward Angle classified malocclusions into Class I. resulting in marked overjet.7 Class I malocclusions as the most prevalent. and 13% of adults. there is no evidence that AP skeletal patterns. based on the relationship between the upper and lower permanent first molars. the maxillary incisors are positioned forward in relation to the lower teeth.in the past. which regarded the overjet of 5 mm or more as Class II. Class II malocclusions.

subjects with Class II malocclusions are referred to orthodontists mainly for esthetic improvement. However. because the soft tissue changes in profile can enhance esthetics significantly. and it has been shown. he also argued the growth axis indicated a wide range of possibilities. In 1981. however. In fact. mandibular skeletal retrusion has been shown to be the most important component.16-17 Abnormalities in vertical development of the mandible are also important components of Class II malocclusion. subjective patient desires as well as objective treatment goals need to be met for successful Class II treatments.17 Buschang and Martins showed that londitudinal growth changes of the mandible were primarily responsible for producing anteroposterior and vertical discrepancies. that pre-treatment signs of TMD of muscular origin can benefit functionally from orthodontic treatments.17 In addition.10 Thus.9 This fact suggests that there is a possibility of early intervention in the Class II skeletal development. While patients seek orthodontic treatments to improve their oral functions and esthetics. straighter profiles and more prominent chins are generally accepted as more esthetic than retruded chin positions. was toward vertical direction of the sample. McNamara pointed out that almost half of his 277 Class II sample exhibited excessive vertical development. for instance.especially for subdivisions. it is important to improve their profiles by modifying chin position. 11 For these patients. Class II maleocclusion has been shown to exert a negative effect on masticatory performance.15 Even though Class II malocclusions can be caused by numerous combinations of dental and skeletal components. 14 In addition. are genetically determined. the effects of functional and environmental factors are unquestionable.17 The general tendency. 12-13 It has also been suggested that Class II patients might be more susceptible to functional problems.18 They also showed 4 .

particularly for cases with high mandibular plane angles.7. In general.22 English-language articles evaluating headgear treatments are listed in Table 2. depending on the vertical corrections required. which tends to make the chin less prominent. due to the unfavorable backward rotation of the mandible. 21 To date. straight along the occlusal plane. Class II malocclusion is typically treated with headgear or functional appliances to correct anterioposterior positions of the maxilla and mandible. the development of the intermaxillary relationship must be fully understood in order to be modified efficiently and effectively during Class II treatments.22 Both can pull either upwards and backwards. or downwards and backwards from the occlusal plane. In fact. It is based on the premise that the maxilla can be therapeutically controlled more easily and more predictably than the mandible.19 Class II Treatment Due to the substantial growth changes that occur during childhood and adolescence. However.less anterior and more posterior movements of pogonion and gonion. a large number of different directions of headgear pull have been used.22 There are two major types. the Class II problem has traditionally been regarded as problems in maxillary protrusion. cervical headgears are known to negatively affect the mandible. while the maxilla showed no difference between individuals.20 Headgear treatment aims to reduce or redirect maxillary growth. 5 .1. respectively. which explains why treatments have focused on upper arch retraction. J hook headgear and face bow headgear. for individuals developing anterior-posterior discrepancies.23 Headgears have usually been shown to favorably affect the maxilla in Class II correction.

4/9.9 10. 0. prospective. treated/no.3/8.1: Outcomes of Previous Headgear Studies Concerning Anterior-Posterior Changes23 Author Design No. Ben. Mandible *Data from control subjects were obtained from a historical database.5/8. Maxilla. not measured. controls Control type* Age of treated patients/control Max Mand A B C H U6 L6 U1 L1 U 1/ L1 Meach.4 9. retrospective.Table 2. NA. more retrognathic Max.4 10.5 9/9 11.Retro Bassat et al. 1974 Mills et al. 1986 Retro Tulloch et al.6/10.4 10. no change. from a previously unreported cohort of selected subjects.4/10. 1978 Retro RCT Retro Retro 30/46 19/19 28/28 51/20 84/13 74/50 53/50 52/61 Historical Random Selected Historical Selected Selected Random 9-14/8-11 8.4 NA + + + 0 0 - NA NA NA NA NA NA NA NA NA NA NA + + + + + NA NA NA NA + + Baumrind et al. from subjects randomly assigned to control status before the start of the study.0/8. 1996 RCT ++ + 0 0 NA NA 0 NA NA 0 + NA NA NA NA NA NA NA NA NA NA + Retro. 1983. Mand. Class II correction. pro. -. +. 1967 Wieslander. 1966 Jakobsson. and from subjects serving as their own controls 6 .

23 Headgears have been shown to affect the maxilla more than functional appliance. and both affect the maxilla and mandible. produced with Activators and Bionator appliances.3.24 Functional appliances assume that mandibular growth can be enhanced.4 They evaluated the pretreatment and post-treatment lateral cephalograms of 67 hyper-divergent patients (25 extraction headgear and Class II elastics.7 Functional appliances have been used for this purpose since the 1930s. more and more attention has been paid to the retruded mandible.Over the years. functional appliances affect the mandible more than headgear. It was recently shown by LaHaye and coworkers that true mandibular rotation is the primary determinant of the AP changes during treatment.2 lists the articles that have evaluated functional appliances. who were compared with 29 matched untreated Class II controls.4 Half of the patients showed improvements and half showed increasing amounts of retrusion. Flores-Mir reported substantial controversy regarding the changes in the chin position. With regard to soft tissue changes.20 Even though some believe that functional appliance therapy results in increased mandibular length and limited tooth movement.16-17 and more current treatments aim to increase mandibular prominence.28-29 This suggests new and different approaches must be considered for the effective correction. 23 non-extraction headgear. and no significant changes in chin position with Twin blocks. The differences in effect between headgear and activator are shown in the Table 2.25-27 there is a lack of consensus regarding the relative orthodontic/orthopedic correction.24 Table 2.23 It is worth noting that functional appliances have sometimes been shown to have a headgear effect on the maxilla. 4 They showed that none of the treatments had a positive effect on chin position. both of which were 7 . and 19 Herbst).

and condylar growth could not reliably predict the anterior-posterior changes in chin position that occurred. but true mandibular rotation could. 4 8 .4 Changes in vertical positions of the maxilla. mandibular molars.growth related. maxillary molars.

Table 2.2: Characteristics of Activator Studies in Preadolescent Children and Their Outcomes in Anterior-Posterior Changes23
Author Meach, 1966 Jakobsson, 1967 Trayfoot and Richardson, 1968 Harvold and Vargervik, 1971 Wieslander and Lagerstrom, 1979 Forsberg and Odenrick, 1981 Luder, 1981 Calvert, 1982 Baumrind et al, 1983; Ben-Bassat et al, 1986 Johnston, 1985 Vargervik and Harvold, 1985 Looi and Mills, 1986 Jakobsson and Paulin, 1990 Nelson et al, 1993; Courtney et al, 1996 Tulloch et al, 1996 Design Retro RCT Retro Pro Retro Retro Retro Retro Retro Retro Pro Retro Retro RCT RCT No. treated/no. Control 30/34 19/19 17/17 20/20 30/30 47/31 25/39 29/19 61/50 47/44 52/variable 30/22 53/60 17/12 53/61 Control type* Historical Random Selected Selected Historical Selected Selected Selected Selected Historical Self Historical Selected Random Random Age of Max patients/control 10-13/8-11 8.5/8.5 8-13/NA 9.7/8.4 8-11/NA 10.8/10.4 8.6/9.2 11.9/11.7 10.0/8.4 10.8/11 10-5/NA 11.5/11.7 NA + + + 0 + + + 0 + + 0 0 + 0 (5) + Mand 0 0 0 0 0 0 + + + + ABCH NA NA + NA + + NA NA NA + + + + NA + U6 NA NA NA 0 0 NA + + + + 0 NA NA 0 NA L6 NA NA NA 0 0 NA 0 0 0 0 0 NA NA NA NA U1 NA NA + NA + NA + + NA NA NA + NA + NA L1 NA NA 0 NA 0 NA + + NA NA NA 0 NA + NA U1/L1 NA + NA + NA + NA NA NA NA + + NA + +

10.9/10.411.6/10.5 + 11.7/11.5 9.4/9.4 0 0

Retro, retrospective; pro, prospective; NA, not measured; +, Class II correction; 0, no change; -, more Class II Max, Maxilla; Mand, Mandible *Data from control subjects were obtained from a historical database, from a previously unreported cohort of selected subjects, from subjects randomly assigned to control status before the start of the study, and from subjects serving as their own controls

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Table 2.3: Outcomes of Previous Studies Comparing Activators and Headgears Concerning Anterior-Posterior Changes23

Author Meach, 1966 Jakobsson, 1967 Baumrind et al, 1983; Ben-Bassat et al, 1986 Tullock et al, 1996

Maxilla NA HG > A HG > A HG > A HG > A

Mandible A > HG 0 A > HG A > HG A > HG

ABCH NA NA NA NA 0

U6 NA NA 0 HG > A NA

L6 NA NA 0 0 NA

U1 NA NA NA NA NA

L1 NA NA NA NA NA

U1/L1 NA A > HG NA NA A > HG

NA, not measured; A, Activator; HG, headgear; 0, no difference

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Rotational Control for Class II Correction Rotational control of the mandible is considered to be a new approach for Class II correction because counterclockwise or forward rotation of mandible has been shown to improve anterior-posterior chin position.4 For example, the existing studies using miniscrew implants to intrude posterior teeth have shown 1.7° to 3.3° decreases in the mandibular plane angle and 1.5° to 1.8° increases in the SNB angle in adult patients.30-33 In growing children, a 3.9° decrease in the mandibular plane angle, and a 2.1° increase in the SNB angle has been reported in adolescent patients (Table 2.4).34 The data suggest that intrusion mechanics produce forward rotation of the mandible, which helps Class II correction by swinging the chin forward and producing better soft tissue profiles. The effects may be more pronounced in growing individuals than adults.

Table 2.4: Summary for Treatment of Hyperdivergent Patients with Intrusion of Teeth
N MPA (°) -1.7 -3.3 -2.3 -3.0 -3.9 SNB (°) +1.8 +1.5 +1.6 +1.6 +2.1 U6PP (mm) -2.6 -2.3 -1.8 -3.4 L6MP (mm) -0.1 -1.3 -1.2 Gonial Angle (°) -0.3 -1.0 -2.4 ANSMe (mm) -1.6 -3.7 Hard Tissue Convexity (°) -3.2

Erverdi et al, 2004 Kuroda et al, 2007 Xun et al, 2007 Akay et al, 2009 Buschang et al, 2011

10 10 12 10 9

Based on the foregoing, the rotation of mandible must be fully understood and the mechanics to produce the forward rotation of mandible should be incorporated in Class II treatment to successfully improve AP chin position.

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1 In 1969. but mostly in adults. which results in the rotation of the posterior part of the mandible away from the maxilla. This type of rotation is thought to occur at any age. may be the cause. It is associated with marked development of posterior face height and a normal increase of anterior face height. The increase in posterior face height can be 12 . Depending on where the COR is located.1 numerous studies have been conducted and the concept of mandibular rotation is now widely accepted.1)1: The center of rotation is located in the temporomandibular joint area. specifying the directions and the types of the mandibular rotation. a deep bite will develop. such as loss of teeth and powerful muscular pressure. Type II (Fig.Growth and Rotation of Mandible Ever since Björk introduced mandibular growth rotation as a feature of normal facial growth in 1955.1 There are 3 centers of forward rotation and 2 centers of backward rotation. 1 Björk noted that the mandible should be considered to be a more or less unconstrained bone from the standpoint of growth. the mandible can swing in different directions. discussing the rotation of mandible in relation to the cranial base. Björk published an article. the center of rotation (COR) can be located anywhere between the posterior or anterior ends of the bone. With this COR. Forward Rotation Type I (Fig. the lower dental arch is pressed into the upper. Occlusal imbalance. and there is an underdevelopment of anterior face height. 2. 2. Björk was able to demonstrate that most of the mandibular rotation that occur is masked by periosteal remodeling at the lower border of mandible. As such.1)1: The center of rotation is located at the incisal edges of lower anterior teeth.

the increase in the height of ramus. The rotation displaces the paths of eruption of all the teeth in a mesial direction and also causes the mandibular posterior teeth to be more upright in relation to maxillary posterior teeth.caused by two factors.1)1: The center of rotation is located in the premolar area. This is thought to occur when overjet is large. The eruption of the molars is thought to keep pace with this rotation. 2. First. which displaces the center of rotation backward in the dental arch. With Type II growth rotation. Center at the joints Center at the incisal edges of the lower incisors Center at the premolars Figure 2. Type III rotation also makes the chin more prominent than Type II rotation. the mandibular symphysis swings forward to make the chin more prominent. associated with vertical growth at the mandibular condyle. Secondly. Type III (Fig. can also lead to an increase in posterior face height. the lowering of the middle cranial fossa in relation to the anterior cranial fossa can lower the condylar fossae.1: Three Types of Forward Rotation of the Mandible1 13 .

2)1: The center of rotation is located in the temporomandibular joint area. which leads to underdevelopment of the posterior face height and backward rotation of mandible. Center at the joints Center at the last occluding teeth Figure 2. 2. The cause is probably not due to the overeruption of lower molars. This type of rotation is thought to be related to changes in intercuspation that can increase anterior facial height. This type of rotation occurs in relation to the backward growth of the condyles. because Björk indicated that the eruption of the lower molars was hindered with this type of rotation. 2. such as flattening of the cranial base. The lower incisors become retroclined. The premolars and molars are inclined forward in relation to the maxillary teeth because of their close proximity to the center of rotation.2)1: The type II center of rotation is located in the most distal occluding molars.2: Two Types of Backward Rotation of the Mandible1 14 . Type II (Fig. This induces crowding of the lower anterior teeth because the lateral teeth are not guided distally during their eruption. or growth of the cranial base.Backward rotation Type I (Fig.

males with deep bites showed significantly larger palatal plane angles at age 10. he showed that more forward rotation is associated with larger amounts of vertical condylar growth. Lavergne and Gasson argued that the rotational pattern affected the mandibular ramus and the gonial angle.35 According to Björk. 36 In females.1 Nanda.37 The larger the mandibular plane angle. with the COR located around the lower incisors. with the center of rotation at the molars. 36 With posterior rotation. Ødegaard demonstrated in his implant study that the degree of the rotation is associated to the direction and the magnitude of condylar growth.36 In fact.36 On the other hand. the lower anterior face height and the palatomandibular angle increase. carrying the molars downward.35 Importantly. the 15 . In 1977. gender and mandibular rotation. the palatal plane angles were approximately the same for the deep bite and the open bite groups at age 4. in 1990. large amounts of prominent condylar growth increase posterior face height and can lead to Type II forward rotation of mandible. as the teeth act as a fulcrum. in comparison with the open bite male group.36 He also showed the growth changes in mandibular rotation.36 He found that the posterior half of the palate tends to be tipped down in patients with openbite. 36 This suggests that deep bite caused by rotation of mandible can affect the palatal plane angle.Remodeling Pattern Associated with Rotation In 1970. he suggested that the downward and backward rotation of the mandible in open bite subjects was a response to the dentoalveolar compensatory changes. but the deep bite group showed a significant increase in this angle between 4 and 7 years of age. evaluated the relationships between the lower face height.

steeper the mandible tends to become. resulting in resorption. intramatrix rotation causes the anterior part of corpus to be lifted up from the matrix. the flatter the mandible becomes. leading to resorption below the symphysis and apposition at the chin (Fig. Figure 2. On the other hand.38 In forward rotating cases.3: Matrix Rotation and Intramatrix Rotation in Forward Rotating Cases38 16 . this remodeling masks most of mandibular rotation that occurs during growth. and a decreased gonial angle.38 The posterior part of the corpus is pressed downward into the matrix.3 and Fig. 2.4). 2. 2. where rotation of the mandibular corpus occurs inside the soft tissue matrix.38 In backward rotating cases. and the chin grows forward. the smaller the angle.3 and Fig. leading to apposition below the symphysis and the anterior part of the lower border (Fig. 2.38 As a result. and the more backward the chin relocates. the anterior part of corpus is lifted up from the matrix.3 and Fig.38 This is compared with matrix rotation.4). 2. 2. which they defined as the rotation of the soft tissue matrix of the mandible relative to the anterior cranial base (Fig.4).38 It was referred to by Björk and Skieller as intramatrix rotation. the gonial angle tends to increase. As Björk and Skieller later showed in their paper.

especially during adolescence.30-34 This suggests that rotational changes can cause remodeling of mandible. Skieller and Björk conducted a study designed to predict the direction and amount of growth rotation of the mandible.4. affecting the gonial angle. intermolar angle.Figure 2. the gonial angle decreases with the molar intrusion mechanics. Lavergne and Gasson also introduced a new term called ‘morphogenetic rotations’ to 17 . Lavergne and Gasson coined the term ‘positional rotations’ to describe changes in the orientation of the mandible relative to the cranial base.4: Matrix Rotation and Intramatrix Rotation in Backward Rotating Cases38 In 1984. 39 They showed that the combination of four variables (mandibular inclination.39 This result also suggests that there is strong relation between rotation and remodeling. Terminology for Rotational Changes of Mandible In 1977.37 In the paper. shape of lower border and inclination of symphysis) gave the best prognostic estimate (86%) of mandibular growth rotation. As shown previously in Table 2.

For the purpose of this study. relative to the anterior cranial base.6 and Odegaard in 1970.2 They used the term ‘true mandibular rotation’ to describe rotation of the mandibular body as represented by implants or stable trabecular reference structures. 38 Solow and Houston. new terminology was introduced by Björk and Skieller to describe forward and backward rotation of mandible.4).37 This was derived from the concept of mandibular rotation described by Björk in 1963. was used to describe the rotation of the soft tissue matrix of the mandible relative to the anterior cranial base (Fig.4).5. ‘angular remodeling of the mandibular border’ was defined as the angular change of the mandibular line when the mandible is registered on implants or stable trabecular structures. as previously touched on.38 Matrix rotation.35 In 1983. 2 ‘Apparent rotation’ was defined as the angular change of the mandibular line relative to the anterior cranial base. 18 .describe the changes in the shape.38 Total rotation was used to describe the rotational changes in the inclination of a stable reference line. on the other hand.38 In this article. 2. 2 All the different terms described above are listed in the Table 2. simplified the terminology.3 and Fig. intramatrix rotation was used to describe rotation of the mandibular corpus inside the soft tissue matrix (Fig 2.38 Finally. or an implant line. in 1988. 2.2 Finally.3 and Fig. the terms that were introduced by Solow and Houston will be used. the independence in development of the bony mandibular corpus and its soft tissue covering was emphasized. in the mandibular corpus relative to the anterior cranial base. 2.

Table 2.5: Terminology of Rotational Changes of the Jaws Lavergne and Gasson37 Rotation of the core of mandible relative to the cranial base Positional rotation Björk and Skieller38 Total rotation Solow and Houston2 True rotation Rotation of the mandibular plane relative to cranial base Morphogenetic rotation Matrix rotation Apparent rotation Rotation of mandibular plane relative to the core of mandible Intramatrix rotation Angular remodeling 19 .

40 The occlusal plane tips down posteriorly so that there is no increase in overbite. the increased rates of true rotation during the transition actually could be associated with space created by the loss of the primary incisors.3 In fact.3 The deciduous dentition ends with the eruption of second deciduous molars. with forward tipping of both incisors and molars. resulting in a deep bite. In the deciduous dentition. In 1983. Björk and Skeiller claimed that these compensatory mechanisms tend to even out positional changes between the jaws.3 On the other hand. resulting in a deep bite. the occlusal traits of Class II occlusion comprise large overjet.3 They reported that in Type I forward rotation the lower dental arch is pressed into the upper arch so that anterior facial height develops less than usual. 3 Finally. the molars keep pace as the posterior part of the mandible is lowered. followed by permanent incisors.3 There is also a forward shift of the entire dentitions relative to the jaw bases. in Type III forward rotation.Dentoalveolar Changes and Growth It has been shown that dental compensations can maintain the occlusion even though individuals show different facial growth patterns and rotational changes of the mandible. the upper and the lower dental arches are pressed into each other so that anterior facial height develops less than usual. giving rise to more eruption of molars than incisors. Actually. demonstrated substantial 20 . because this enables the Type III forward rotation of mandible.41 Any narrow upper dental arch. in Type II forward rotation. Buschang et al. first molars erupt approximately at age 6. and problems in occlusion will result if there is no compensation. a narrow maxillary base and poor anterior spacing are also considered as characteristic of Class II.3.41 During the early mixed dentition. distal terminal plane of the second deciduous molars and a distal canine relation. large overbite.

She demonstrated that.5 and 7. Class II children are skeletally similar to normal children during the deciduous dentition. 21 .44 Together.5 years of age for the lower incisors (up to 5%) and especially for the upper incisors (up to 20%). For example.42 Even though there are some characteristic occlusal traits in Class II primary dentitions. when Class II individuals show backward rotation of mandible.43 and between 6 to 11 years of age than late during adolescence.5). In fact. Class II skeletal characteristics become prominent during growth. but no study has been specifically designed to evaluate the factors responsible for true forward mandibular rotation that occurs during transition from late primary to early mixed dentition. 2.relative decreases in alveolar bone height between 5. it tends to make chin more retrusive. Wang and coworkers evaluated the mandibular rotation during the transition from late primary dentition to early mixed dentition. although significant amounts of true mandibular rotation occur during childhood and adolescence. which can be related to Class II skeletal characteristcs.5 Other studies have previously showed that greater amounts of true rotation occurs between 5 to 10 years of age.42 Anterior maxillary (anterior nasal spine-prosthion) and mandibular heights (infradentale-menton) significantly decreased in relative size with the replacement of deciduous by permanent dentition (Fig. there is a greatest rate of true rotation during the transition from late primary to early mixed dentition. Recently. the available literature suggests that the alveolar changes that occur during the transition may play an important role in true forward rotation of mandible.

2.Fig.5: Percent Adult Status of Maxillary and Mandibular Heights for Males and Females 22 .

1969. 14. 1967. Boley JC. 23 3. prospective and longitudinal study. Jr. Buschang PH. Lip posture and its significance in treatment planning. Am J Orthod Dentofacial Orthop. Mandibular rotation and remodeling changes during early childhood. Class II malocclusion. Am J Orthod Dentofacial Orthop.References 1.55:585-99. Dann Ct.134:1-144.13:97-106. 2001. Int J Adult Orthodon Orthognath Surg. Björk A. Temporomandibular disorders and mandibular function in relation to Class II malocclusion and orthodontic treatment. Variations in the growth pattern of the human mandible: longitudinal radiographic study by the implant method.10(3):177-9. Prediction of mandibular growth rotation. 11. LaHaye MB. .1988 Aug. Orthodontic treatment changes of chin position in Class II Division 1 patients. Skieller V. 5. Halazonetis DJ.79:271-5. Alexander RG. 1972.. 13.104:180-7. Angle Orthod. 12. and early treatment. An implant study at the age of puberty. Am J Orthod. Genetics or environment? A twin-method study of malocclusions. Angle Orthod. Björk A. Currier GF. 9. Nanda RS. Perceptions of a balanced facial profile. Facial development and tooth eruption. 1963. Moray LJ. 6. Broder HL. Swed Dent J Suppl. 1993. 1995. Tadic N. Fields HW. Burstone CJ. Spyropoulos MN. Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. A controlled. Necka A. Contemporary Class II orthodontic and orthopaedic treatment: a review. Am J Orthod.52:168-74.42:400-11. Björk A. 2007.8:405-10.65:411-6. 2007. 8.53:262-84. Mandibular rotations: concepts and terminology. Self-concept. 1999.119:464-71.62:339-83. 7. 2006. 10. Eur J Orthod. World J Orthod. Kawala B.130:732-41. Buschang PH. 4. Woods M. Henrikson T. Am J Orthod Dentofacial Orthop. Proffit WR. Czarnecki ST. Solow B. Behrents R. Houston WJ. Significance of the soft tissue profile on facial esthetics. 1998. Antoszewska J. Tulloch JF. Am J Orthod. Wang MK. 2. 2009. J Dent Res. Phillips C. Aust Dent J.

Am J Orthod Dentofacial Orthop.76:876-81 16. Uysal T. Components of Class II malocclusion in children 8-10 years of age. 24 .68:199-206. McDowell F. 1979. et al. Martins LP. 2. Cabassa S. 2008. 21. English JD. 27. Int J Orthod. Wheeler TT.134:732-41.95:250-8. Soft tissue effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy.78:70-6. 22. Bowden DE. Eirew HL. 1967:13745. Eirew HL.113:40-50. Childhood and adolescent changes of skeletal relationships. Rep Congr Eur Orthod Soc. Buschang PH. Flores-Mir C.21:44-56. The bionator. 20. Buschang PH. 1978. Buschang PH. 2002. 17. 2011. Maxillary and mandibular dentoalveolar heights of French-Canadians 10 to 15 years of age. Martins J. McNamara JA.5:173-81. The function regulator of Frankel. Carrillo R. 24. Craig CE. Am J Orthod Dentofacial Orthop. Eur J Orthod. 2006. 1981. 19. da Rosa Martins JC. Theoretical considerations of headgear therapy: a literature review. Clinical response and usage. Division I malocclusions in norma lateralis. Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear. Angle Orthod. Skeletal and dental components of Class II correction with the bionator and removable headgear splint appliances. Demirjian A. Liu SS. 18. Br J Orthod. Baysal A. Throckmorton GS. 1951. A systematic review. Cohen DA. Functional appliances: a review. Garvan CW. Lager H. King GJ. Br J Orthod. 2008. Angle Orthod. 1998. Angle Orthod.17:12-8. Martins RP. Buschang PH. Am J Orthod Dentofacial Orthop. The individual growth pattern and stage of maturation as a basis for treatment of distal occlusion with overjet. Major PW.8:33-6. Cephalometric facial soft tissue changes with the twin block appliance in Class II division 1 malocclusion patients. 1981. Jr.51:177-202. Angle Orthod. Does malocclusion affect masticatory performance? Angle Orthod. Keeling SD. 1998. 23. Ziaja RR. 25.15. The skeletal patterns characteristic of Class I and Class II.72:21-7. Angle Orthod. 28. Bishara SE. 1989. Phillips JG. 26.

Direction and intensity of mandibular rotation in the sagittal adjustment during growth of the jaws. 32. Akyalcin S. EurJOrthod . Linde-Hansen T. Orthopedic correction of growing hyperdivergent. The use of skeletal anchorage in open bite treatment: a cephalometric evaluation. 40. Xun C. J Oral Maxillofac Surg. 31. Dentofacial maturation of untreated normals. Early developmental traits in Class II malocclusion. Nanda R. 1983. J Oral Maxillofac Surg. Carrillo R.98:247-58. Angle Orthod.29. Flores-Mir C. 1990. Enhanced effect of combined treatment with corticotomy and skeletal anchorage in open bite correction. Tamamura N. Am J Orthod. Microscrew anchorage in skeletal anterior open-bite treatment. Am J Orthod 1985. Skieller V. Akay MC.5:1-46. Wang X. 41. 25 . Bjork A. 37. Buschang PH. Zeng X. A systematic review of cephalometric facial soft tissue changes with the Activator and Bionator appliances in Class II division 1 subjects. 34.56:375-7. Erverdi N.67:563-9. Odegaard J. Skieller V. 39. Treatment of severe anterior open bite with skeletal anchorage in adults: comparison with orthognathic surgery outcomes. 1977. Kuroda S. 1984. Growth patterns in subjects with long and short faces. Acta Odontol Scand. Major PW. Sakai Y.132:599605. 35. Sinclair PM. Eur J Orthod.28:586-93. Lavergne J. Takano-Yamamoto T. 2007. Am J Orthod Dentofacial Orthop. Normal and abnormal growth of the mandible.57:145-57.85:193-6. Rossouw PE. Koyuncue BO. 2007. 38. Scand J Dent Res. Little RM. Bjork A.86:359-70. Gasson N. 30. Keles A. Angle Orthod. Aras A. Am J Orthod 1970. 2009. Deguchi T. 33.69:754-62. 1998.2006. Growth of the mandible studied with the aid of metal implant. 2011. Gunbay T. 36.77:47-56.74:381-90.88:146-56. Prediction of mandibular growth rotation evaluated from a longitudinal implant sample. Varrela J. retrognathic patients with miniscrew implants. Am J Orthod Dentofacial Orthop. 2004. Nanda SK. A synthesis of longitudinal cephalometric implant studies over a period of 25 years.

Craniofacial characteristics in children with Angle Class II div. 44. Baume RM. Miller S.14:95-8. Buschang PH. 1992. 1994. 2 malocclusion combined with extreme deep bite. 43. A craniofacial growth maturity gradient for malesand females between 4 and 16 years of age. Karlsen AT.64:123-30. 26 . Kerr WJ. Nass GG. Eur J Orthod. Am J Phys Anthropol.1983.6:373-81.42. Angle Orthod. A new look at mandibular growth--a preliminary report.

There were no significant sex or Class differences in true rotation.34) with the increases in U1-SN.9 ±2.4 degrees of remodeling and -0.4 ±2.6 ±1.2 years). Seventeen landmarks were identified and 22 measurements were calculated. 1.36).8 ±0.28).40) between true rotation and apparent rotation. Materials and Method: The sample included 50 subjects (25 males and 25 females) with Class I (N=25) and Class II (N=25) molar relationships. They were selected based on the availability of lateral cephalograms at two developmental stages: T1. and with decreases in Id-Me (r=0.0 ±0. and a moderately low correlation (r=0.last film with complete primary dentition (5. There was a weak correlation between true rotation and SNA (r=0. True rotation was significantly related to anterior 27 . True rotation showed a moderately low correlation (r=-0. Results: The mandible underwent -2. remodeling and apparent rotation.4 years) and T2.8 degrees of apparent rotation between T1 and T2. There was a moderate correlation (r=0.36).CHAPTER 3: JOURNAL ARTICLE Abstract Purpose: To determine whether dentoalveolar changes and/or the condylar growth are related to the true forward rotation of mandible that occurs during the transitional period between the late primary and early mixed dentition stages of development. The mandibles at T1 and T2 were superimposed using natural reference structures in order to measure true mandibular rotation.6 degrees of true rotation. Conclusion: Independent of sex and Class. increases in U1-PP (r=-0. resulting in limited amounts of apparent rotation. the true mandibular rotation that occurred between the late primary and early mixed dentition was mostly masked by angular remodeling.first film with permanent incisors and permanent molars erupted (8.76) between true rotation and remodeling.

which tends to make the chin less prominent. Introduction Significant amounts of true mandibular rotation take place during childhood and adolescence. but not to the vertical growth changes that occurred.6 Due to angular remodeling. there is only limited rotation of the mandiblar plane. which refers to the angular changes of the mandibular core relative to the anterior cranial base.12 and whether meaningful orthopedic improvement in chin position occur 28 .9 Class II malocclusion is typically treated with headgear or functional appliances to correct anterior-posterior positions of the maxilla and mandible. improvement in anterior-posterior chin position is crucial for their treatments. which is referred to as apparent rotation.6-8 True mandibular rotation provides important information for understanding facial growth changes. is typically in a forward and upward direction. Since most skeletal Class II patients have mandibular deficiencies. headgears have been shown to negatively affect mandibular position in Class II cases.dentoalveolar changes. especially changes of the chin. due to the unfavorable backward rotation of the mandible.10-11 However.6 Increasing amounts of true forward rotation and proclination of the lower incisors are associated with greater and more anterior condylar growth. 6 The true rotation that occurs is typically masked by the angular remodeling that takes place on the lower border of the mandible. Greater amounts of true forward rotation of mandible have been related with more horizontal displacement of chin. 10 While functional appliance therapy can alter the growth of mandible. true rotation has been shown to be the primary determinant of anterior-posterior chin position.1-5 True rotation. the orthopedic effects are limited and not predictable.

5 This suggests that true rotation may be related to the dentoalveolar changes that occur during the transitional dentition.12-15 Mechanics that cause the forward rotation of mandible have been recently incorporated in Class II treatment to improve anterior-posterior chin position of adults. More specifically.16-20 suggesting that a better understanding of rotation is necessary to improve orthopedic corrections in Class II patients.remains questionable.5 years of age. which would also explain the increases in true rotation observed. true rotation during the transition could be associated with temporary decreases in anterior alveolar bone height that occur between 5.1 It is also possible that greater posterior vertical growth occurs during this transitional period. space created anteriorly should result in greater rotation. no study has been specifically designed to explain why such relatively large amounts of mandibular rotation occur during the transition from late primary dentition to early mixed dentition. The purpose of this study is to evaluate if and how dentoalveolar changes and vertical growth are related to the true forward rotation of mandible during this transitional period. 29 . it was shown that there is greater true rotation during the transition from the late primary to early mixed dentition than at any time thereafter.5 and 7. It has been well established that greater amounts of true mandibular rotation occur during childhood than during adolescence.21 Assuming that the center of mandibular rotation is located at the premolars or the most distal occluding molars. Understanding the mechanism controlling true mandibular rotation holds great potential for facilitating the Class II treatments.1 To date.3-5 Most recently.

selected on the basis of recommendations by the family physicians and their overall good health.14 T2 SD 0.36 0.75 Mean 7.1).04 0.Materials and Methods Subjects The sample included 50 subjects (25 males and 25 females).80 5.2 yrs).83 5. and during the early mixed dentition after the first molars and incisors had erupted into functional occlusion (T2: 8.05 30 .98 7.1: Mean Ages for Late Primary (T1) and Early Mixed Dentition (T2) Class I T1 Male Female Mean 5.8 ±0.32 Mean 5.46 Mean 8. The subjects were selected based on the following criteria: a) Longitudinal cephalograms available during the late primary dentition (T1: 5. Table 3. b) Cephalograms had to be of sufficient quality to identify all of the structures necessary for landmark identification and regional superimposing.65 SD 0.24 0.35 0. followed longitudinally by the Bolton-Brush Growth study.08 8. c) Patients were rejected if they had received prior orthodontic treatment or had major craniofacial anomalies. The sample included untreated 50 subjects with Class I (N=25) and Class II (N=25) molar relationships (Table 3.4 yrs).91 T1 Class II T2 SD 0. The Bolton study population consists of individuals from the Cleveland.0 ±0.97 SD 0.

3). Lake Oswego. 3. Oregon) (Table 3.4). 31 .2.Cephalometric Methods Each cephalogram was traced and 17 landmarks were digitized with Dolphin® software (Dolphin Imaging & Management Solutions & Patterson Technology. Traditional measurements were computed from the digitized data (Table 3.

The posterior spine of the palatine bone constituting the hard plane The anterior tip of the sharp bony process of the maxilla at the lower margin of the anterior nasal opening A point on the curvature of the angle of the mandible located by bisecting the angle formed by the lines tangent to the posterior ramus and the inferior border of the mandible A point located by taking the midpoint between the anterior (pogonion) and inferior (menton) points of the bony chin The highest point on the curvature of the averaged condyles of the mandible The point of intersection of the inferior surface of the cranial base and the averaged anterior surfaces of the mandibular condyles Lowest point on the bony septum between the upper central incisors Highest point on the bony septum between the lower central incisors The incisal tip of the most anterior maxillary incisor The incisal tip of the most labial mandibular anterior incisor The anterior cusp tip of the maxillary first molar The anterior cusp tip of the mandibular first molar *Primary central incisors and primary second molars were used at T1 instead of central incisors and first molars 32 . Cd Ar Pr In U1 L1 U6 L6 Operational definitions The most posterior midline point in the concavity between the anterior nasal spine and the prosthion (most inferior point on the alveolar bone overlying the maxillary incisors) The most posterior midline point in the concavity of the mandible between the most superior point on the alveolar bone overlying the lower incisors and pogonion The most prominent point on the symphysis of the mandible in the median plane.2: Landmarks. Abbreviations and Definitions Used26 Landmarks Subspinale/A point Supramentale/B point Pogonion Nasion Sella Posterior nasal spine Anterior nasal spine Gonion (Anatomical) Gnathion Condylion Articulare (Björk) Prosthion Infradentale Incision superius Incision inferius Upper molar mesial cusp tip Lower molar mesial cusp tip Abbreviations A B Pg N S PNS ANS Go Gn Co. determined by a tangent through Nasion Most anterior on the frontonasal suture in the midsagittal plane Geometric center of of the pituitary fossa located by visual inspection.Table 3.

3: Planes.Table 3. Abbreviations and Definitions Used26 Planes Occlusal plane Mandibular plane (Steiner) Maxillary plane (Palatal plane) Sella-Nasion plane Reference Line Abbreviations OP MP PP SN RL Definitions A line passing through one-half of the cusp height of the first permanent molars and one-half of the overbite of the incisors A line joining gonion and gnathion A line connecting the tip of the anterior nasal plane with the tip of the posterior nasal spine A line connecting sella with nasion 7 degrees from SN (Horizontal reference line) 33 .

4: Measurements. and the line connecting Gonion and Menton Posterior facial height/Anterior facial height Maxillary incisor inclination 1. Abbreviations.266 Lower face height 0.789 Upper molar height from palatal plane 0.944 Mandibular incisor inclination 2.991 Anterior facial height 1.546 Lower incisor height from mandibular plane 0. Definitions Used and Error Analysis26 Measurements AP Skeletal Abbreviations SNA (°) SNB (°) ANB (°) SN-MP (°) Na-Me (mm) ANS-Me (mm) S-Go (mm) Co-Go (mm) Ar-Go (mm) Gonial Angle (°) Definitions Dahlberg Error Analysis Maxillary protrusion/retrusion 0.912 Posterior facial height 0.445 Vertical Skeletal AP Dental S-Go/Na-Me U1-SN (°) U1-PP (°) IMPA (L1-MP) (°) Overjet (mm) Vertical Dental Overbite (mm) ANS-Pr (mm) In-Me (mm) U1-PP (mm) L1-MP (mm) U6-PP (mm) L6-MP (mm) 34 .476 Measurement of vertical alveolar height 0.057 Horizontal measurement from facial surface of 0.735 and Gonion.808 Upper incisor distance from palatal plane 0.658 AP relationship between maxilla and mandible 0.487 lower central incisor to lingual surface of upper central incisor Vertical overlap of central incisor 0.721 Maxillary incisor inclination 1.566 Mandibular plane inclination 0.973 Mandibular protrusion/retrusion 0.819 Ramus height 1.431 Mandibular height 1.582 Measurement of vertical alveolar height 0.356 Lower molar height from mandibular plane 0.Table 3.130 The angle formed by the line connecting Condylion 1.

27 mm) 35 . The errors in linear measurements were within 1 mm except for Ar-Go (1. The angle between SN and the mandibular plane (Go-Gn) was used to describe apparent rotation. the radiographs were oriented sagitally by the anterior contour of the chin. 22 The statistic is expressed in millimeters for linear dimensions and degrees for angular dimensions. Method error was evaluated based on 19 sets of duplicates.13 mm). the radiographs were vertically oriented by the contour of the mandiblar canal and the lower contour of a mineralized molar germ before root development begins.1 True rotation was the angular change between the two planes defined by the cranial base and mandibular fiducial landmarks.Mandibular rotation was measured using cranial base and mandibular superimpositions. Statistical Methods The skewness and kurtosis statistics showed that the distributions were approximately normal.1 Anteriorly. Na-Me (1.4). as described by Björk and Skieller. Angular remodeling was defined as the difference between true rotation and apparent rotation. and transferred to the later (T2) tracing following superimpositions of the mandible. and the reliability was judged from the Dahlberg’s statistic (Table 3. 1 Posteriorly. and by any distinct trabecular structure in the symphysis. and can be read as the average disparity between the measurement sessions. For superimposing the mandible. and possibly also of a premolar tooth germ.1 Anterior and posterior fiducial landmarks were recorded on the first (T1) tracing. the radiographs were oriented in a vertical direction by the inner contour of the cortical plate at the lower border of the symphysis. which was made to coincide on the two radiographs.

43 mm).1).5 mm.6 degrees of true rotation. There was a moderate correlation (r=0. and a moderately low correlation (r=0.6 ±1.9 ±2. Group differences were calculated using independent t-tests. The errors in angular measurements were within 2 degrees except for IMPA (2. Degree (+: Backward.1: Mean and Standard Deviation of Mandibular Rotation from T1 to T2 Most of the skeletal measurements showed significant (p<.6°. Results The mandible underwent -2. There were no statistically significant difference between the genders or Classes in true rotation.06 degrees). 1. Paired t-tests were used to evaluate changes within subjects (i.8 degrees of apparent rotation between T1 and T2 (Figure 3.40) between true rotation and apparent rotation.76) between true rotation and angular remodeling.. Pearson product-moment correlations were used to compute the relationship between true rotation and the other morphological measurements.and Co-Go (1.4 degrees of remodeling and -0. and lower face height (ANS-Me) increased 2.05) changes (Table 35). Posterior face 36 . remodeling and apparent rotation. Anterior face height (N-Me) increased 5. changes over time).e.4 ±2.5 mm.5° to 0. -: Forward) 6 4 2 0 -2 -4 -6 True Rotation Angular Remodeling Apparent Rotation Figure 3. The ANB and SN-MP angles decreased 0.

3°. 2. ramus height (Ar-Go) and Co-Go increased 4. The ratio of posterior and anterior facial height decreased slightly (2%). 37 .3mm.0mm.5mm and 3. respectively.height (S-Go). the gonial angle decreased 1.

22 3.82 2.44 3.46 2.05 level (2-tailed).22 5.54 34.43 48.16 62.25 76.55 3.26* 0.46** 4.21 3.41 1.78 2.39 104.72 1.92 130.50* -0.18 0.01 level (2-tailed).25 3.43 3.64 2.48 0.05 99.01** Difference Std.98 2.04 35. Deviation 1.44 0. * Paired t-test for equality of means was significant at the 0.76 2.14 45.22 -0.63 Std.48** -1.42 4.01 ** Paired t-test for equality of means was significant at the 0.13 39.49 1.Table 3.30 0. Deviation 2.31 Mean 80.29** 3.58 56.5: Changes in Skeletal Variables from T1 to T2 T1 Mean AP Skeletal SNA (°) SNB (°) ANB (°) Vertical Skeletal MP-SN(°) N-Me (mm) ANS-Me (mm) S-Go (mm) Co-Go (mm) Ar-Go (mm) Gonial angle (°) S-Go/Na-Me 81.74 4.12 36.96 3.43 4.60 1.96 76.24 2.34 Mean -0.64 T2 Std. Deviation 2. 38 .44 4.44 0.62* 5.01** 2.06 54.30 0.93 4.63 1.86 2.51 4.52** 2.40 129.95 3.33 0.61 66.

U1-PP and IMPA increased 10. and the distance of the upper molar to the palatal plane (U6-PP) decreased 1.36).36).3 mm.1° respectively.8 mm.1mm. 11.8°. The linear distances of the lower incisor to the mandibular plane (L1-MP) increased 2.1° and 5.0 mm. Other than the changes of the mandibular plane angle (SN-MP). 39 . Individuals with greater true rotation also showed greater increases in SNA (r=0. U1-SN. resulting in a total dentoalveolar height (ANS-Pr+In-Me) decrease of 7. ANSPr decreased 4. the only skeletal measure related to true rotation was the change in SNA and S-Go/Na-Me (Table 3.6).8). True rotation showed moderately low correlations with the increases in U1-SN (r=-0.34). and especially total dentoalveolar height (r=0.7).28). Overjet increased 0. There were no statistically significant changes in the vertical distances between the upper incisor and the palatal plane (U1-PP) or between the lower molar and the mandibular plane (L6-MP). The greater the decreases in In-Me (r=0.41). True rotation was most closely related to changes in dentoalveolar height. indicating greater rotation for those individuals who had greater upper incisor proclination (Table 3.8 mm and In-Me decreased 2.1 mm. the greater the true rotation.Most dental measurements also changed significantly (Table 3. and U1-PP (r=-0.

83 Mean 99.34** -6.Table 3.55 2.80 3.73 1.79 2.88 2.39 3.32 24.11** 0.59 24. Deviation 7.31 -4.77 7.72 6.51 1.79 2.79 -0.90 91.56 26.75** -2.08** 5.91 3.12 5.40 6.30 1.49 1.13** -0.83 1.09 1.05 level (2tailed).90 2.39 106. Deviation 6.47 1.38 Std.56 96.12 1.44 3.26 7.11 2.88 Mean 10.15 2.79 17.23 17.03 38. Deviation 6.56 2. * Paired t-test for equality of means was significant at the 0.21 28.51 1.27 18.72** 0.36 1.80 32.6: Changes in Dental Variables from T1 to T2 T1 Mean AP Dental U1-SN (°) U1-PP (°) IMPA (°) Overjet (mm) Vertical Dental Overbite (mm) ANS-Pr (mm) In-Me (mm) ANS-Pro + In-Me (mm) U1-PP (mm) L1-MP (mm) U6-PP (mm) L6-MP (mm) 88.10 1.11 12.12 Difference Std. 40 .00 3.27 T2 Std.05 86.27 1.03 1.37 25.84** 11.81** 0.12 1.59 1.60 6.50 25.85 2.61 1.95** -1.32 ** Paired t-test for equality of means was significant at the 0.86 1.44 30.01 level (2-tailed).11 45.

289* Significance 0.966 0.01 level (2-tailed).051 0.191 -0.Table 3.042 ** Correlation was significant at the 0.095 -0.8 0.278 0.184 0.046 0.060 -0.103 0.05 level (2-tailed).037 0.284* -0.004 0.088 0.233 -0.244 -0.006 0.681 0.7: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables True Rotation Pearson Correlation AP Skeletal SNA (°) SNB (°) ANB (°) Vertical Skeletal SN-MP (°) Na-Me (mm) S-Go (mm) ANS-Me (mm) Co-Go (mm) Ar-Go (mm) Gonial Angle (°) S-Go/Na-Me -0. 41 . * Correlation was significant at the 0.398** 0.51 0.

003 0.264 0.339* -0.213 0.016 0.064 0.8: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables True Rotation Pearson Correlation AP Dental U1-SN (°) U1-PP (°) IMPA (L1-MP) (°) Overjet (mm) Vertical Dental Overbite (mm) ANS-Pr (mm) In-Me (mm) ANS-Pr + In-Me (mm) U1-PP (mm) L1-MP (mm) U6-PP (mm) L6-MP (mm) -0.360* -0.136 -0. * Correlation was significant at the 0.449 ** Correlation was significant at the 0.219 0.769 0.345 0.042 0.010 0.010 0.043 0.241 0.413** 0.774 0.126 0.360* 0.092 0.110 Significance 0.138 0.01 level (2-tailed).05 level (2-tailed) 42 .Table 3.

4 deg/yr (age 11-15) by Spady. which amounts to approximately -1.8 deg/yr (age 8.4) reported by Wang et al. There was almost -2.9 deg/yr (age 6-11) reported by Spady. there was a significant correlation between true mandibular rotation and S-Go/Na-Me.5 -0.Discussion The mandible underwent substantial true rotation during the transition from late primary to early mixed dentition.5 degrees of true forward rotation between T1 and T2. as -0.3 deg/yr (age 5.8 true forward rotation is associated with substantial amounts of resorption at the posterior aspect of the lower border of the mandible and deposition on the anterior aspect.8 deg/yr (age 10-15) by Miller and Kerr4 and -0. Greater amounts of remodeling than apparent rotation have been previously reported.4) by Wang. This is similar to the 1. both during the transition from late primary to early mixed dentitions. However. True forward rotation indicates that there was more inferior displacement of the posterior than anterior mandible. the absolute growth changes in anterior 43 .5 the -1. 23 The rates of the true rotation during adolescence were lower.23 As described by Björk and Skieller. resulting in little change of the mandibular plane angle. The remodeling that occurred along the lower mandible border "covered up" the true rotation that occurred.23 The high rates of true rotation that occur during this transition explain why previous studies have reported greater amounts of true rotation during childhood than adolescence.22 True rotation occurred regardless of genders or Classes because the group differences seem to be too small to detect with the sample size of the current research.3 deg/yr (age 5-10) reported by Miller and Kerr4 and the -0. 4-5. The current study showed approximately 1. 4-5 during childhood.9 degrees of remodeling and -0.6 degrees of apparent rotation.4-15.4-5 and during adolescence. In fact.1 deg/yr.7-8.

The proclination of the upper incisors that occurred during the transition was directly related to true forward rotation. Buschang and Gandini showed that over 40% of the growth at condylion between 10-15 years of age was negated by resorption at gonion.7 presumably as a compensation to its displacement with forward mandibular rotation. suggesting that the distance N-Me overestimated the actual amount of displacements. This discrepancy can be explained by the relatively large amounts of resorption that occurs at the gonial angle.24 They compensated for this size discrepancy by proclining. the increase in anterior facial height was partially due to deposition at menton. 7 Proclination of the lower incisors had been previously related to forward mandibular rotation. U1-PP and IMPA all increased significantly over time.face height (Na-Me) were more than the increases in posterior facial height (S-Go). The upper and lower permanent incisors were tipped significantly more labially than the deciduous incisors. 25 Björk argued that the forward shift of the whole dental arch in relation to the jaw base occurs with forward tipping of incisors as the essential feature of compensatory adaptation to forward rotation. which explains the increases in arch depth that has been associated with the eruption of the permanent incisors. Using mandibular superimpositions. was probably due to the size differences of the primary and permanent crowns. 2 Moreover.1. The subjects who underwent the greatest rotation also showed the greatest proclination. which was significantly greater than the lower incisors. Wang and coworkers also showed that true 44 . U1-SN. The proclination of the upper incisors. amounting to approximately 2 mm. which cause posterior facial height measurements based on landmarks such as a gonion (S-Go or Co-Go) to be underestimated. especially of central incisor.

2 years.5 mm) was partially occupied by large permanent crown. was most closely associated with true mandibular rotation. On the other hand. Anterior alveolar height decreased significantly during the transition between the late primary and early mixed dentition.5 years of age. Importantly.0 years of age. and decreased to approximately 80% of its adult size during the transition.8 and 8. attained over 100% of its adult size at 5. which also showed a greater decrease during the transition of the dentition than lower alveolar height. indicating that the space created between the upper and lower jaws (ANS increased 2. ANS-Pr and In-Me decreased a total of 7. However.26 Greater amounts of upper incisor proclination might be expected to eliminate contacts and create more space for the mandible to rotate forward. the decreases in anterior alveolar height were also directly correlated with true forward rotation. the decreases in upper alveolar heights were more closely associated with true rotation than decreases in lower alveolar 45 .1 mm between 5. Apparently.21 This decrease in height is probably a compensation for the larger crown height of permanent incisors. which included both upper and lower alveolar height. Interestingly.mandibular rotation during adolescence was associated with maxillary incisor proclination. the changes in overjet and overbite from T1 to T2 are masked by the larger size of permanent incisors so that they do not reflect the space required for the forward rotation. there was no significant change in the distance U1-PP over the 2. Buschang and coworkers showed that anterior upper alveolar height. L1-MP actually increased significantly during the transition from T1 to T2. The overall increases in lower facial height were primarily accounted by the increases in lower incisors to mandibular plane (L1-MP) observed. the decreases in overall alveolar height. Of all the dental variables evaluated.

called this remodeling pattern as vertical variation.0 to 3. Wang et al. which would result in closure of the gonial angle with an increase in vertical ramus height. According to Björk. Enlow suggested.0-7.5 months for the upper and lower permanent central incisors to erupt 50% of their respective intraoral heights. reported a low. individuals with greater forward rotation did not exhibit greater amounts of posterior growth. up to 4 years are required for the central incisors to attain 100 % of their clinical crown height.1 suggesting that existing or space created in the anterior segment allows the mandible to rotate forward. 1 However.5 months to erupt 70%. 29 In addition. forward rotation takes place as a result of marked increase in ramus height and normal increase in anterior face height. Co-Go. 6.250) between true forward mandibular rotation and the decrease in ANS-Pr. the upper and lower deciduous central and lateral incisors are lost and the permanent incisors erupt. and 19 months to erupt 90%. the center of which is located at the most distally occluding molars. also characterizing resorption along the inferior border of the ramus.25 Björk argued that Type III rotation. they mentioned another remodeling pattern named rotation variation which took place in 7 out of their 30 cases.27 This may provide more than enough time for forward rotation to occur while there are space in the anterior alveolar region. 46 . but significant correlation (r=0. Between approximately 6 to 8 years of age. Importantly.27 More specifically. ramus remodeling takes place such as resorption along the posterior border of the mandible. In other words. or ArGo. as vertical growth continues. was related to large overjet. 28 Later. it takes 3. Vertical skeletal growth was not related to the true rotation that occurred. Hans et al.height. the present study showed that rotation was not significantly correlated with growth changes of S-Go.

The findings might suggest a few things clinically.29 Interestingly enough. 4 out of the 7 cases of this rotation variation were observed at age six.29 Therefore. the forward growth of maxilla was also correlated with true forward rotation.4 years of age. it is possible that this resorption along the posterior border of the mandible negated some of the vertical growth that occurred during the transitional period. the more true rotation takes place. the space created by the forward displacement of the maxilla contributed to true rotation of mandible. the curve of Spee will deepen. it might be better to prevent excessive eruption of lower 47 . but not during the transition. First.4 and 15. and its depth increases significantly corresponding to the eruption of the mandibular permanent first molars and central incisors. even though the sample size was not large enough. Björk argued that forward rotation of the mandible takes place when space. This may suggest that the more that the maxilla was displaced anteriorly. Wang and coworkers also found a significant correlation (r=0.1 In other words. exists in anterior region. In fact. as previously suggested. Finally. Therefore.30 If the permanent lower incisors erupt more than usual and lower anterior alveolar height increases with the incisors. The subjects who showed greater increases in SNA also showed greater increases in true rotation.with rotation of ramus in a pronounced superior-anterior direction. true mandibular rotation was significantly correlated with the decrease in lower anterior alveolar height during the transition.25 Importantly. which moves the center of rotation posteriorly towards the occluding molars. as described earlier.376) between true forward rotation and the increase in SNA between 8. the increases in SNA were not correlated to proclination of the upper incisors. It has been known that the curve of Spee is minimal in deciduous dentition.

48 . If the eruption path of permanent incisors is directed lingually. Great amounts of true mandibular forward rotation of mandible took place during the transition from late primary to early mixed dentition. all of which could have created space for mandible to rotate forward. True mandibular rotation was not significantly associated with the increases in posterior face height. Conclusions 1. increases in SNA. not only to avoid deep overbite.incisors in growing individuals. which was largely masked by remodeling along the lower border. 2. Second. True mandibular rotation was significantly associated with the decrease in anterior alveolar height. remodeling and apparent rotation between males and females. 4. There were no significant differences in true mandibular rotation. and proclination of the upper incisors. the proclination of the upper incisors was correlated to true forward rotation during the transition. but also to enhance forward rotation of mandible. it might be better to tip them labially as they erupt in order to allow space for mandible to rotate forward. or between subjects with Class I and Class II occlusion. 3.

Skeletal and dental components of Class II correction with the bionator and removable headgear splint appliances. Buschang PH. 4. Am J Orthod Dentofacial Orthop. Skieller V. Am J Orthod. Am J Orthod. Facial development and tooth eruption. An implant study at the age of puberty. Bjork A. Buschang PH. 2008.55:585-99.62:339-83.134:732-41. Eirew HL.64:123-30. 1988. Eur J Orthod. 9. Br J Orthod. Bishara SE. 1972. Miller S. Eur J Orthod. Am J Orthod Dentofacial Orthop.113:40-50. 1983. Mandibular rotations: concepts and terminology. 12. 1994. A synthesis of longitudinal cephalometric implant studies over a period of 25 years. Cabassa S.24:69-79. Angle Orthod. Prediction of mandibular growth rotation. 49 3.79:271-5. Bjork A. 14.10:177-9. 1989. Behrents R. Mandibular rotation and remodeling changes during early childhood.Literature Cited 1.1-11. Martins LP. Garvan CW. 2011. Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear. . 2009. Solow B. Buschang PH. Alexander RG.5:1-46. da Rosa Martins JC. Craniofacial characteristics in children with Angle Class II div. Am J Orthod Dentofacial Orthop. King GJ. Martins RP. Eur J Orthod. Wheeler TT. Eur J Orthod.130:732-41. 10. Wang MK. 1992. 2002. LaHaye MB.8:33-6. Baysal A. Normal and abnormal growth of the mandible. 5. 1981. 13. 7. Am J Orthod Dentofacial Orthop. et al. Bjork A. Uysal T. Keeling SD. Orthodontic treatment changes of chin position in Class II Division 1 patients. 6. Kerr WJ. Soft tissue effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy. The bionator. A new look at mandibular growth--a preliminary report. Houston WJ. 2. 1969. 11. Skieller V. Angle Orthod. Cohen DA. Ziaja RR. 2 malocclusion combined with extreme deep bite. Eur J Orthod. Buschang PH.14:95-8.95:250-8. Mandibular skeletal growth and modelling between 10 and 15 years of age. Karlsen AT. 8. Functional appliances: a review. 2006. Boley JC. Gandini Junior LG. 1998.

Aras A. Treatment of severe anterior open bite with skeletal anchorage in adults: comparison with orthognathic surgery outcomes. Phillips JG. 21. Erverdi N. 50 . McDowell F. The use of skeletal anchorage in open bite treatment: a cephalometric evaluation. 2009. 1997. Sakai Y. 1964. Xun C. Am J Phys Anthropol. Buschang PH.edu/Documents/cade/thesis/Wang_thesis.17:12-8. Deguchi T. Eirew HL. 2007. Zeng X. Angle Orthod. Eur J Orthod. J Oral Maxillofac Surg. Nass GG. 16. 17. Statistical methods for medical and biological students. Tamamura N. Orthopedic correction of growing hyperdivergent.67:563-9. Moorrees CF. 24. Master Thesis at Saint Louis University. 2007. 1940.61:373-81. Mandibular rotation and angular remodeling during childhood and adolescence. Am J Orthod Dentofacial Orthop.40:92-106. Enhanced effect of combined treatment with corticotomy and skeletal anchorage in open bite correction. Int J Orthod. 25. Takano-Yamamoto T. 26. 23. Akay MC.74:381-90. 2011.pdf. Dental development--a growth study based on tooth eruption as a measure of physiologic age. Kuroda S. 1992:683689. Tang EL. Wang X.77:47-56. The function regulator of Frankel.69:754-62. Buschang PH. Lapalme L. Koyuncue BO. Baume RM.15. Wang MN.19:721-31. Spady M.slu.132:599605. Mesiodistal crown diameters of the primary and permanent teeth in southern Chinese--a longitudinal study. 1979. Angle Orthod. Buschang PH. 22. 19. Am J Hum Bio. Rossouw PE. 20. 2004. London: Bradford and Dickens. Nanda R. Rep Congr Eur Orthod Soc. Yuen KK. 2007. Dahlberg G. Keles A. A craniofacial growth maturity gradient for males and females between 4 and 16 years of age. Gunbay T. Mandibular rotation during late primary and early mixed dentition. Akyalcin S. retrognathic patients with miniscrew implants. Demirjian A. 18. J Oral Maxillofac Surg. Microscrew anchorage in skeletal anterior open-bite treatment. So LL. Available from http://www. 1983. Carrillo R.

Marshall SD. 2008. 1963. The Angle Orthodontist. 51 . Franciscus RG.65:335-40. Southard TE. Hans MG. Meredith HV. Am J Orthod Dentofacial Orthop. Age-related differences in mandibular ramus growth: a histologic study. Louis: Mosby. Subjects. Aquilino SA. Development of the curve of Spee. Angle Orthod. Hardinger RR.27.33:195-206. Giles NB.134:344-52. Increase In Intraoral Height Of Selected Permanent Teeth During The Quadrennium Following Gingival Emergence*. Enlow DH. Noachtar R. St. 3rd ed. Knott VB. 29. Handbook of facial growth. Caspersen M.13(2):97106. 1995. 30. 1990. 28.

VITA AUCTORIS Hiroshi Ueno was born on February 22. and worked as general dentist in Japan. Miyagi. 52 . Sendai. After he finished the mandatory residency at Nagoya University hospital. graduating in 2006. He attended Tohoku University. he moved to Yokohama. Kanagawa. Hyogo. he started the orthodontic program at Saint Louis University. At the age of six. 1981 in Nishinomiya. Nagoyo. where his parents currently reside. Japan.