You are on page 1of 11

ORIGINAL ARTICLE

Transverse skeletal and dentoalveolar changes


during growth
Richard M. Hesby,a Steven D. Marshall,b Deborah V. Dawson,c Karin A. Southard,d John S. Casko,e
Robert G. Franciscus,f and Thomas E. Southardg
Iowa City, Iowa

Introduction: We previously reported that, on average, maxillary molars erupt with buccal crown torque and
upright with age, mandibular molars erupt with lingual crown torque and upright with age, and these molar
crown torque changes are accompanied by concurrent increases in maxillary and mandibular intermolar
widths. Our purpose in this study was to determine the transverse skeletal changes that accompany these
molar movements during growth. Methods: Thirteen maxillary and mandibular transverse measurements
were made by using casts and posteroanterior radiographs from 36 Class I untreated subjects from the Iowa
Facial Growth Study at approximately ages 7.6, 10.3, 12.9, 16.5, and 26.4 years. Intermolar arch widths,
maxillary basal bone widths (bijugale), and mandibular basal bone widths (bigonion, biantegonion) were
recorded for each subject. Also recorded were the maxillary and mandibular cross-arch alveolar process
widths measured at the molar gingival crest and the midalveolar level. Results: The results indicate a pattern
of width changes in the maxilla, the maxillary alveolar process, the maxillary first molars, the mandibular first
molars, and the mandibular alveolar process that occurs as a gradient in the vertical dimension. The greatest
width change occurs superiorly (jugale point). The smallest width change occurs inferiorly (midalveolar point
of the mandible). On average, the basal bone of the maxilla increased in width by 5.37 mm; maxillary
cross-arch midalveolar process width increased by 3.20 mm (left buccal surface to right buccal surface) and
4.94 mm (left palatal surface to right palatal surface); maxillary intermolar width increased by 3.08 mm;
mandibular intermolar width increased by 2.05 mm; and mandibular cross-arch crest level alveolar width
increased by 1.60 mm (left buccal surface to right buccal surface) and 1.02 mm (left lingual surface to right
lingual surface). The basal bone of the mandible increased in width by 14.54 mm. Conclusions: We
concluded that transverse molar movements during growth mirror transverse maxillary basal bone width
increases, maxillary cross-arch alveolar process width increases, and mandibular cross-arch alveolar
process width increases. Furthermore, there is a pattern of width changes in the maxilla, the maxillary
alveolar process, the maxillary first molars, the mandibular first molars, and the mandibular alveolar process
that occurs as a gradient in the vertical dimension. On the other hand, transverse mandibular basal bone
changes, measured as bigonion and biantegonion, do not fit this pattern. (Am J Orthod Dentofacial Orthop
2006;130:721-31)

G
rowth-related changes in size, shape, and po- has been crucial to our understanding of normal and
sition of the facial skeleton and the associated abnormal facial growth in the vertical and sagittal
growth of the dentition have been well docu- planes.5 However, facial growth changes in the coronal
mented by longitudinal lateral cephalometry.1-4 This plane (ie, changes in the transverse dimension) are less
From the University of Iowa, Iowa City.
well understood.
a
Former resident, Department of Orthodontics; private practice, Bedford, Mass. Transverse growth-related bony changes in maxil-
b

c
Adjunct associate professor, Department of Orthodontics. lary basal width and maxillary alveolar process cross-
Professor, Department of Preventive and Community Dentistry, Director of
Biostatistics.
arch width are thought to result from growth at the
d
Professor, Department of Orthodontics. median palatal suture and appositional remodeling
e
Professor, B. F. and Helen E. Dewel Endowed Chair, Department of along the lateral aspects of the posterior region of the
Orthodontics.
f
Associate professor, Department of Anthropology.
maxilla and the maxillary tuberosity.6-9 Median palatal
g
Professor and head, Department of Orthodontics. sutural growth is greatest in the posterior portion of the
Supported by the Dr George Andreasen Memorial Fund. suture and occurs well into the second decade of
Reprint requests to: Thomas E. Southard, Department of Orthodontics, College of
Dentistry, University of Iowa, Iowa City, IA 52242; e-mail, tom-southard@ life,7-10 with sutural fusion occurring in the mid-
uiowa.edu. 20s.10,11 Increases in maxillary skeletal width have
Submitted, August 2004; revised and accepted, March 2005. been measured longitudinally into the mid and late teen
0889-5406/$32.00
Copyright © 2006 by the American Association of Orthodontists. years.8,9,12-17 In the mandible, growth of the corpus
doi:10.1016/j.ajodo.2005.03.026 width is accomplished by apposition and resorption of
721
722 Hesby et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2006

bone.5,18 Width increases of the corpus measured at Class I) molar and canine occlusions. Subjects were
gonion (bigonial width) have been shown throughout chosen from this population for our study based on the
adolescence.15,16,19 Width increases measured along following criteria: (1) longitudinal study casts and
the lateral surface of the mandibular body anterior to posteroanterior radiographs available from ages 7 to 30
attachments of the masseter muscle have also been years, (2) untreated Class I occlusion, (3) lack of
reported through adolescence9 and into adulthood.20 distortion or abrasion of the tooth portion of the dental
Increases in mandibular width at the level of the casts, (4) lack of excessive enamel wear or restorations
alveolar process have not been reported. of the dental cusps of the measured teeth, (5) lack of
With respect to the dentition, many longitudinal missing or extracted permanent teeth, and (6) lack of
studies of dental arch width showed that intermolar gingival recession with time in the maxillary and
width increases occur during the first 2 decades of mandibular first molar regions. These criteria limited
life.8,9,12,15,21,22-30 During the transitional dentition, our sample to 36 subjects (18 female, 18 male). The
increases in width occur to a greater degree in the most common reasons for exclusion of a subject from
maxilla than in the mandible.8,9,12,15,21,23-29 Fol- the sample were cast distortion and restorations of teeth
lowed through adolescence into adulthood, intermo- at later ages.
lar width changes vary depending on the longitudinal
sample, with some investigators reporting in- Transverse measurements
creases,8,12,15,21-23,30 and others finding no significant The same subject population measured in this study
changes for males and females24,26,29,31,32 and de- was also measured in our previous study on transverse
creases for females.28,33,34 molar movements.21 Measurement time points for both
In our recent longitudinal study of untreated sub- studies were identical. The subjects were grouped to
jects, we identified transverse movements that first approximate 5 stages of dentition development: Early,
permanent molars undergo from ages 7 to 26 years.21 middle, and late mixed dentition; adolescent dentition;
As viewed in the coronal plane, maxillary molars were and adult dentition. The time points of measurement
found to erupt with buccal crown inclination and were the mean ages for the subject groups at these
upright lingually as maxillary intermolar width in- stages: 7.6, 10.3, 12.9, 16.5, and 26.4 years. The age
creased. Concomitantly, mandibular molars were found ranges and standard deviations for the groups are
to erupt with lingual crown inclination and upright reported in our previous study.21 Transverse maxillary
buccally as mandibular intermolar width increased. and mandibular dentoalveolar and skeletal widths were
These findings raise a number of questions. Why measured for each subject by using posteroanterior
did the maxillary molars erupt buccally but then later radiographs and dental casts as shown in Figure 1.
upright when the maxillary intermolar width was ex-
panding? In other words, as the maxillary molars were 1. Maxillary basilar width: width of the maxilla
uprighting, the intermolar width should have dimin- measured radiographically from bilateral points on
ished, not increased. Furthermore, why were the max- the jugale processes at the intersection of the
illary molars uprighting at all? Do the molar move- outline of the tuberosity of the maxilla and the
ments we found reflect transverse skeletal changes zygomatic buttresses.
during growth? Previous studies were inadequate in 2. Maxillary cross-arch width midalveolar buccal:
providing answers to these questions. The purpose of width of the maxilla measured on casts from
this study was to determine the relationship between bilateral points located 9.0 mm directly apical
transverse skeletal changes and transverse molar move- from the most occlusal point of the buccal devel-
ments during growth. opmental groove viewed from the buccal aspect of
the maxillary permanent first molar.
MATERIAL AND METHODS 3. Maxillary cross-arch width midalveolar palatal:
The material for this research project was obtained width of the palate measured on casts from bilat-
from the Iowa Facial Growth Study. Beginning in 1946, eral points located 9.0 mm directly apical from the
this sample consisted of 89 boys and 86 girls of most occlusal point of the lingual developmental
primarily northern European descent and above-aver- groove viewed from the lingual aspect of the
age socioeconomic status living near Iowa City, Iowa. maxillary permanent first molar.
Orthodontic records were taken semiannually from 4. Maxillary cross-arch width alveolar crest buccal:
ages 3 to 12 years, annually during adolescence, and width of the maxilla measured on casts from
once during early adulthood. All subjects were free of bilateral points located at the gingival margin
facial or skeletal disharmony and had normal (Angle directly apical from the most occlusal point of the
American Journal of Orthodontics and Dentofacial Orthopedics Hesby et al 723
Volume 130, Number 6

Fig 1. Transverse linear measurements recorded: 1, maxillary basilar width (bijugale); 2, maxillary
cross-arch width midalveolar buccal; 3, maxillary cross-arch width midalveolar palatal; 4, maxillary
cross-arch width alveolar crest buccal; 5, maxillary cross-arch width alveolar crest palatal; 6,
maxillary intermolar width; 7, mandibular intermolar width; 8, mandibular cross-arch width alveolar
crest buccal; 9, mandibular cross-arch width alveolar crest lingual; 10, mandibular cross-arch
width midalveolar buccal; 11, mandibular cross-arch width midalveolar lingual; 12, mandibular
basilar width (bigonion); 13, mandibular basilar width (biantegonion). Measurements 1, 12, and 13
were measured radiographically; measurements 2-11 were measured on study casts.

buccal developmental groove viewed from the buccal developmental groove viewed from the
buccal aspect of the maxillary permanent first buccal aspect of the mandibular permanent first
molar. molar.
5. Maxillary cross-arch width alveolar crest palatal: 9. Mandibular cross-arch width alveolar crest lingual:
width of the palate measured on casts from bilat- width of the mandible measured on casts from
eral points located at the gingival margin directly bilateral points located at the gingival margin di-
apical from the most occlusal point of the lingual rectly apical from the most occlusal point of the
developmental groove viewed from the lingual lingual developmental groove viewed from the lin-
aspect of the maxillary permanent first molar. gual aspect of the mandibular permanent first molar.
6. Maxillary intermolar width: width of the maxillary 10. Mandibular cross-arch width midalveolar buccal:
dental arch measured on casts from bilateral points width of the mandible measured on casts from
located at the most gingival point on the contour bilateral points located 9.0 mm directly apical
of the distal marginal ridge of the maxillary from the most occlusal point of the buccal devel-
permanent first molar. opmental groove viewed from the buccal aspect of
7. Mandibular intermolar width: width of the man- the mandibular permanent first molar.
dibular dental arch measured on casts from bilat- 11. Mandibular cross-arch width midalveolar lingual:
eral points located at the most gingival point on width of the mandible measured on casts from
the contour of the distal marginal ridge of the bilateral points located 9.0 mm directly apical
mandibular permanent first molar. from the most occlusal point of the lingual devel-
8. Mandibular cross-arch width alveolar crest buccal: opmental groove viewed from the lingual aspect
width of the mandible measured on casts from of the mandibular permanent first molar.
bilateral points located at the gingival margin 12. Mandibular basilar width bigonial: width of the
directly apical from the most occlusal point of the mandible measured radiographically from bilat-
724 Hesby et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2006

eral points at the most lateral margin of the angle tracing acetate and a 0.5-mm lead pencil. Distances
of the mandible. from the posteroanterior cephalogram landmarks to the
13. Mandibular basilar width biantegonial: width of midcoronal plane were measured on the lateral cepha-
the mandible measured radiographically from bi- logram to correct for enlargement of measurements on
lateral points at the most superior point of the the posteroanterior cephalogram.
antegonial notch.
Reliability of cast and radiographic measurements
For measurements on casts, midalveolar and gingi-
To assess the reliability of cast and radiographic
val points were located and marked with a 0.5-mm lead
measurements, 30 units (a unit is the cast or radiograph
pencil. A digital caliper was used to measure the linear from 1 visit for 1 subject) were randomly chosen, and
distance between bilateral points. The rationale for all cast or radiographic measures were duplicated by
choosing the midalveolar point 9.0 mm apical to the the investigator (R.M.H.) who made all the original
most occlusal point of the buccal and lingual grooves measurements. Selection of these units to assess reli-
was to ensure that the measurement point would be well ability was carried out separately for cast and radio-
within the alveolar process portion of the cast recorded graphic measures; this allowed for a greater distribution
by the impression and in the approximate root-trunk over the sample of subjects and the entire period of
area of the molar roots. observation. Intraclass correlation coefficients were
We assumed that interarch cast measurements made obtained for each width measure as measures of reli-
from the buccal, palatal, and lingual gingivae repre- ability. The intraclass correlation is typically used in
sented the underlying alveolar process bone measure- situations such as this, when it is of interest to obtain a
ments. That is, we assumed that the gingival soft tissue measure of intrarater agreement for quantitative out-
covering this bone maintained a relatively constant comes.37,38 Perfect agreement corresponds to an intra-
thickness throughout the age range studied. This was a class correlation coefficient of 1; intraclass correlations
reasonable assumption. Measurements of palatal gingi- of zero indicate lack of agreement between duplicate
val thickness near the first molar were reported to measures. All intraclass correlation coefficients were
change by only 0.1 mm over the ages of 14 to 59 greater than 0.99 and differed significantly from zero
years.35 Furthermore, no significant differences in buc- (with significance of P ⬍.00001 in each instance). This
cal gingival thickness of the first molar region were indicates almost perfect agreement between the dupli-
noted by ultrasonic measurement of the maxilla and the cate measurements with 1 rater.
mandible in subjects of widely differing ages.36 We
therefore assumed that our choice of measurement Statistical methods
points on casts represented the underlying alveolar To assess age trends, we used nonparametric
process bone. methods to analyze longitudinal data, using the
Passive eruption of the permanent molars with age approach of Ghosh et al39 and Dawson and Siegler.40
was noted for these subjects, and the gingival margin These statistical methods are useful when applied to
measurement point changed compared with the tooth modest subject numbers and when data are missing;
crown at the later ages of measurement. It is not they also apply in instances such as this one, when at
possible to have a fixed reference point on a study cast least some measurements of interest do not meet the
that is transferable to serial casts for the same subject. stringent distributional requirements of traditional
Thus, our gingival measurement point changed with parametric methods. Few distributional assumptions
time compared with the tooth crown in an indetermin- are required because they emphasize nonparametric
able way. We think, however, that the gingival margin approaches based on rank procedures. To assess age
point is a reference to the alveolar crest that is constant trends, the Spearman rank correlation of a given
with age, and we assumed that the width changes we radiographic or cast measurement and time of mea-
recorded were also accompanied by changes in other surement was computed as a summary measure of
dimensions that we could not record. each subject’s change in that measurement over time.
Corrections for radiographic enlargement of bilat- These independent summary reexpressions of the
eral linear measurements were made for each subject at data were used to address the null hypothesis of zero
each time point as previously reported for the Iowa correlation (no change over time). The Wilcoxon
Growth Study.19 The method was well documented for signed rank test was used to test the null hypothesis
the Iowa Growth Study. Lateral and posteroanterior that the median rank correlation is zero—ie, that
cephalograms were traced to include the landmarks there was no increasing or decreasing trend over
(jugale, gonion, and antegonion) with cephalometric time.41 This same approach was used to assess
American Journal of Orthodontics and Dentofacial Orthopedics Hesby et al 725
Volume 130, Number 6

Table I. Transverse skeletal and dentoalveolar width measurements (in mm) during growth
7.6 years 10.3 years 12.9 years 16.5 years 26.4 years

Mean SD Mean SD Mean SD Mean SD Mean SD P*

Transverse measurement
1. Maxillary basilar width bijugale 56.24 2.76 59.26 2.85 60.59 3.10 62.32 3.62 61.57 3.92 ⬍.0001
2. Maxillary cross-arch width midalveolar buccal 56.60 2.96 58.37 3.10 59.29 3.10 59.84 3.66 59.80 3.71 ⬍.0001
3. Maxillary cross-arch width midalveolar palatal 26.42 2.39 28.75 2.35 30.05 2.47 31.22 2.91 31.36 3.15 ⬍.0001
4. Maxillary cross-arch width alveolar crest buccal 54.22 2.82 55.70 2.77 56.59 2.86 57.31 3.67 57.60 3.59 ⬍.0001
5. Maxillary cross-arch width alveolar crest palatal 33.11 2.62 34.07 2.37 34.69 2.59 35.36 3.09 35.62 3.18 ⬍.0001
6. Maxillary intermolar width 46.50 2.18 48.24 2.48 48.78 2.62 49.25 3.04 49.58 2.98 ⬍.0001
7. Mandibular intermolar width 41.54 2.16 42.43 2.35 42.93 2.57 43.08 3.05 43.59 3.24 ⬍.0001
8. Mandibular cross-arch width alveolar crest buccal 51.95 2.47 52.78 2.59 53.27 2.70 53.46 3.01 53.55 2.85 ⬍.0001
9. Mandibular cross-arch width alveolar crest lingual 32.00 2.14 32.40 2.28 32.50 2.41 32.59 2.64 33.02 2.41 .0046
10. Mandibular cross-arch width midalveolar buccal 56.13 2.20 56.07 2.66 55.79 2.55 55.68 2.92 55.63 3.02 .0278
11. Mandibular cross-arch width midalveolar lingual 31.66 2.16 32.08 2.33 31.86 2.23 31.75 2.40 31.69 2.44 .9200
12. Mandibular basilar width bigonial 81.05 3.52 85.38 36.3 89.09 4.10 93.70 5.58 95.59 6.71 ⬍.0001
13. Mandibular basilar width biantegonial 72.03 3.26 75.95 3.15 78.80 3.35 81.90 3.79 83.04 4.42 ⬍.0001
Maxillary first molar torque‡ 10.30 3.64 7.62 4.49 7.10 4.18 5.94 3.90 4.83 4.35 ⬍.0001
Mandibular first molar torque‡ –10.18 5.20 –6.64 5.72 –3.30 5.17 –3.23 4.50 –2.27 5.25 ⬍.0001

*Significance probability associated with test for correlation between width change and time, using nonparametric approach of Ghosh et al39 for
longitudinal data.

Mean torque of paired right and left first molars in degrees from previous study.21

Fig 2. Mean transverse maxillary basilar, cross-arch alveolar, and intermolar changes with time.
Significance probability associated with Wilcoxon signed rank test of null hypothesis that median
correlation among subjects studied is equal to zero (ie, no correlation between width change and
time) is shown for significant changes in width with time as **P ⬍.0001. These results are significant
after adjustment for multiple comparisons. Measurement numbers are as described in Figure 1.

correlations between pairs of measurements within among the 6 maxillary measures, all pairwise com-
subjects over time. The Wilcoxon signed rank pro- parisons among the 7 mandibular measures, and
cedure for matched pairs was also used to evaluate additional comparisons contrasting the jugale-jugale
whether median net change over the time period width, the bigonial, and the biantegonial widths with
differed from zero for each of the 13 measures and to the other measures. All available pairwise data were
compare net change between a given pair of mea- used for these analyses. The modified Bonferroni
surements. The latter set of analyses included 53 method of Holm42 was used to adjust for multiple
comparisons, including all pairwise comparisons comparisons with an overall type I error level of .05.
726 Hesby et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2006

Fig 3. Mean transverse mandibular basilar, cross-arch alveolar, and intermolar changes with time.
Significance probability associated with Wilcoxon signed rank test of null hypothesis that median
correlation among subjects studied is equal to zero (ie, no correlation between width change and
time) is shown for significant changes in width with time as **P ⬍.0001 and *P ⬍.005. Results are
significant after adjustment for multiple comparisons. Measurement numbers are as described in
Figure 1.

RESULTS comparisons), which appeared to closely follow the


Mean transverse skeletal and dentoalveolar changes change in intermolar width. Maxillary basilar width
during growth are given in Table I. Figure 2 illustrates change is similar to palatal width change, and these
change with time for each transverse maxillary mea- changes are significantly different from all other
surement referenced to the first time point (mean age, maxillary and mandibular measures, after adjustment
7.6 years). Figure 3 illustrates change with time for for all pairwise comparisons of measures performed
each transverse mandibular measurement referenced to (Table II).
the first time point (mean age, 7.6 years). Table II As illustrated in Figure 3 and Table I, increases
illustrates the relationship between width changes at the with age in mandibular intermolar width and cross-
13 measurement points. The results in Table II include arch alveolar width at the buccal and lingual crests
adjustments made with the modified Bonferroni were highly significant (median P ⫽ .7, P ⬍.005).
method for multiple comparisons,42 with an overall .05 However, the cross-arch alveolar measurements
level of statistical significance. taken more apically (midalveolar buccal and lingual
Strong evidence for age-related increases in
measurements, 10 and 11) showed equivocal or no
width was identified at all 6 maxillary measurement
significant change in width with time. Mandibular
points with significant median Spearman rank corre-
basilar widths measured as bigonion and biantego-
lations (P ⫽ .8 to .9, P ⬍.0001). All 6 measurements
nion increased dramatically with age (P ⬍.0001).
had similar patterns of change during growth, appear-
ing to reach adult dimensions by age 16.5 years. As Mandibular basilar width change, measured as bigo-
shown in Figure 2, changes in maxillary basilar width nion and biantegonion, was 5 to 6 times greater than
(bijugale) and maxillary cross-arch width midalveolar width changes in the cross-arch alveolar buccal crest
palatal followed a similar pattern. On average, maxil- and lingual crest regions. Mandibular intermolar
lary basilar width appeared to decrease slightly after width change and mandibular cross-arch alveolar
age 16.5 years. Change in palatal cross-arch width at crest width change were similar, but both were
the midalveolar point appeared to be slightly less than significantly different from width change at antegonion
maxillary basilar change but significantly greater than and gonion (P ⬍.0001, remaining significant at the .05
the other 3 maxillary measurements (P ⬍.0001 by level after multiple comparisons adjustment). Bigonial
Wilcoxon signed rank test for the 3 comparisons, and biantegonial width changes differed significantly from
significant at the .05 level after adjustment for multiple those of all other measurements (Table II).
American Journal of Orthodontics and Dentofacial Orthopedics Hesby et al 727
Volume 130, Number 6

Table II.Pairwise comparison of 13 maxillary and crest level (means, 4.94 and 2.51 mm, respectively),
mandibular transverse measurements with respect to suggesting that the lateral drift of the palatal surface
change over time away from the midsagittal plane is greater at the level
of the first molar roots than at the level of the first molar
Maxillary measurements Mandibular measurements
gingival crest. Along the buccal alveolar surface of the
Comparison P value* Comparison P value* maxilla, width increase in the region of the first molar
1 vs 2 .0002 7 vs 8 .3420
is similar at the midalveolar and alveolar crest (means,
1 vs 3 .4957 7 vs 9 .0026 3.38 and 3.20 mm, respectively), and both points
1 vs 4 .0004 7 vs 10 ⬍.0001 showed lateral drift greater than that of the maxillary
1 vs 5 ⬍.0001 7 vs 11 ⬍.0001 molar crowns (3.04 mm).
1 vs 6 ⬍.0001 7 vs 12 ⬍.0001 We also reported that mandibular molars upright
2 vs 3 ⬍.0001 7 vs 13 ⬍.0001
2 vs 4 .5116 8 vs 9 .0249
transversely with age by tipping buccally, but without
2 vs 5 .0346 8 vs 10 ⬍.0001 the lateral translation of the roots seen in the maxillary
2 vs 6 .5197 8 vs 11 ⬍.0001 molars.21 In this study, the alveolar crest measurement
3 vs 4 ⬍.0001 8 vs 12 ⬍.0001 points had mean increases in width of 1.60 mm (right
3 vs 5 ⬍.0001 8 vs 13 ⬍.0001 buccal surface to left buccal surface) and 1.02 mm
3 vs 6 ⬍.0001 9 vs 10 ⬍.0001
4 vs 5 .0111 9 vs 11 .0031
(right lingual surface to left lingual surface), carrying
4 vs 6 .3708 9 vs 12 ⬍.0001 the alveolar surfaces away from the midsagittal plane.
5 vs 6 .0727 9 vs 13 ⬍.0001 In contrast, the more apical measurement points at the
1 vs 7-13 ⬍.0001 10 vs 11 .0106 mandibular midalveolar process had no significant
10 vs 12 ⬍.0001 change in width. This pattern is consistent with the
10 vs 13 ⬍.0001
11 vs 12 ⬍.0001
mean change in mandibular first molar intermolar width
11 vs 13 ⬍.0001 (2.02 mm) and suggests transverse uprighting that
12 vs 13 ⬍.0001 occurs by rotation in the coronal plane around a point in
*P value ⬍.01163 indicates significant difference between measure-
the body of the tooth root. However, these mandibular
ments after adjustment for multiple comparisons, using overall .05 width increases in the dentoalveolar region, proximal to
level of significance. the first molars, were far less than the mean changes in
the basilar width measured at the angle of the mandible,
representing less than 15% of mean basilar width
DISCUSSION increase measured at antegonion (10.81 mm).
A composite illustration of the mean transverse If we reflect on the transverse changes in our study
basal skeletal, dentoalveolar, and molar changes from with respect to growth changes in bone that is proximal
ages 7.6 to 26.4 years is provided in Figure 4, which to the permanent first molars (ie, excluding changes at
summarizes our principal findings: Transverse maxil- gonion and antegonion), the pattern of width change
lary basal bone width increases, maxillary alveolar reflects the transverse molar movements occurring with
process width increases, and mandibular alveolar pro- growth for this sample. Thus, width changes in the
cess bone width increases are consistent with transverse basal maxilla (jugale), the maxillary alveolar process,
molar movements during growth. In contrast, trans- the maxillary first molars, the mandibular first molars,
verse mandibular basal bone width increases, measured and the mandibular alveolar process occur as a gradient
as either gonion-gonion or as antegonion-antegonion in the vertical dimension (jugale-mandibular alveolar
are considerably greater, and transverse mandibular process). The greatest width change occurred superi-
molar movements do not reflect this magnitude of orly (jugale point). The smallest change occurred infe-
basilar mandibular change during growth. riorly (midalveolar point of the mandible). In the
We previously reported that maxillary molars un- maxilla, transverse basilar drift and displacement ap-
dergo uprighting in the transverse dimension as their peared to highly influence transverse molar move-
crowns expand laterally with age and rotate in the ments, whereas the mandibular dentoalveolar complex
coronal plane to increase molar torque.21 The age- in the region of the first molars appeared to be restricted
related changes seen in maxillary basilar and alveolar in transverse growth compared with the mandibular
arch widths in this study are congruent with this basal bone in the region of gonion and antegonion,
maxillary transverse molar uprighting. Basilar maxil- which appeared to grow independently.
lary width underwent the greatest increase (mean, 5.37 How might this be explained? According to the
mm), followed by palatal width increase, which is twice equilibrium theory, the tongue, the muscles and the soft
as great at the midalveolar level than at the alveolar tissues of the cheeks, and occlusal function play roles in
728 Hesby et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2006

Fig 4. Composite illustration of mean transverse basilar, cross-arch alveolar, and intermolar
changes from ages 7.5 to 26.4 years. 1, maxillary basilar width; 2, maxillary cross-arch width
midalveolar buccal; 3, maxillary cross-arch width midalveolar palatal; 4, maxillary cross-arch width
alveolar crest buccal; 5, maxillary cross-arch width alveolar crest palatal; 6, maxillary intermolar
width; 7, mandibular intermolar width; 8, mandibular cross-arch width alveolar crest buccal;
9, mandibular cross-arch width alveolar crest lingual; 10, mandibular cross-arch width midalveolar
buccal; 11, mandibular cross-arch width midalveolar lingual; 12, mandibular basilar width bigonion;
13, mandibular basilar width biantegonial. Measurements 1, 12, and 13 were measured radiograph-
ically; measurements 2-11 were measured on study casts. Overall pattern of changes includes
changes in molar torque reported previously.21 Horizontal bars indicate average change in width
measured in millimeters from 7.5 to 26.4 years of age.

determining the buccolingual position of teeth.43 It has drift of the alveolus.44 Thus, under conditions of
been demonstrated that, when cheek pressure and reduced forces from occlusal function and cheek-
posterior occlusal function are reduced by a Fränkel muscle function, the area of least lateral drift is the
appliance, both the molar crowns and their buccal mandibular buccal midalveolar process. This suggests
alveolar bones drift farther laterally during growth than some limitation to lateral alveolar drift and lateral drift
if the appliance was not used.44 However, with a of the dentition in the mandible.
Fränkel, the lateral tipping of the molar crowns is If we assume that the mandibular dentoalveolar
greater than the lateral drift of the associated buccal complex is limited in growth-driven lateral drift, then
alveolar bone. In other words, transverse maxillary the transverse molar movements in our sample can be
molar uprighting (increased lingual crown torque), explained by occlusal function and cheek pressure
identified in our sample of untreated subjects, does not during development. Erupting maxillary molars move
occur in patients whose cheek and occlusal forces are laterally as the suture widens and encounter cheek
reduced. This suggests that these forces are important muscles that force the crowns lingually. In addition,
influences in transverse molar uprighting. In addition, occlusal function between the maxillary and mandibu-
application of a Fränkel appliance produces a change in lar molars could also act to upright the maxillary molars
the transverse relationship of the mandibular molars in the lingual direction while uprighting the mandibular
that mirrors the findings of our study. In subjects molars in the buccal direction. Because of the con-
treated with a Fränkel, the mandibular molars show straints suggested above, the mandibular molars are
lateral drift of the molar crowns greater than the lateral limited in lateral drift, and the maxillary molars re-
American Journal of Orthodontics and Dentofacial Orthopedics Hesby et al 729
Volume 130, Number 6

Table III. Comparison of maxillary and mandibular longitudinal change in transverse width

Authors Landmark for bilateral measurement Mean annual change*

Woods12 Most lateral aspect of zygomatic arch 1.91


Singh and Savara13 Zygomaticomaxillary suture 1.33
Savara and Singh14
Singh and Savara13 Pterygomaxillary fissure 0.88
Savara and Singh14
Present study Jugale 0.76
Cortella et al16 Jugale 0.76
Snodell et al15 Jugale 0.67
Korn and Baumrind9 Implant in zygomatic process of maxilla 0.43
Björk and Skieller8 Implant in zygomatic process of maxilla 0.42
Gandini and Buschang17 Implant in zygomatic process of maxilla 0.27
Present study Alveolar bone proximal to maxillary first molars 0.38
Various authors8,15,21,23-29 Maxillary first molars 0.30-0.48
Various authors15,21,23-29 Mandibular first molars 0.18-0.32
Present study Alveolar bone proximal to mandibular first molars 0.18
Gandini and Buschang17 Implant placed inferior to mandibular first molar 0.19
Cortella et al16 Antegonion 1.23
Present study Antegonion 1.24
Snodell et al15 Antegonion 1.41
Newman and Meredith19 Gonion 1.47
Woods12 Gonion 1.71

*Change in mm/year based on calculation directly from data provided for total mean change in bilateral width between right and left implants or
between right and left radiographic or study cast landmarks over age range of study.

Bilateral widths measured between right and left landmarks.

spond by uprighting as they increase their transverse those of other cephalometric studies.15,16,19 Implants
width due to continued maxillary basilar transverse measure bone displacement longitudinally, whereas
expansion. In other words, the transverse molar move- cephalometric landmarks measure drift (remodeling)
ments compensate for the differential transverse growth and displacement longitudinally.
of the maxillary and mandibular basilar structures near Our maxillary buccal midalveolar points grew in
the first permanent molars (not antegonion or gonion) that width at the rate of 0.40 mm per year over the first 10
directly influence alveolar process cross-arch width. Sim- years of measurement (ages 7.6 to 16.5 years); this is
ilar compensation in the anteroposterior dimension was similar to the rate of maxillary basilar transverse
shown during growth of untreated Class II subjects.45,46 displacement seen in implant studies when implants
Our transverse skeletal data agree with previous lon- were placed in the zygomatic process of the maxilla
gitudinal studies of skeletal width changes.8,9,12-17,19 Ta- proximate to the first molars.8,9
ble III compares these studies with our data by calcu- Our basal skeletal data agree with those of others
lation of annual rates of width changes for various who reported that mandibular basal bone, measured at
landmarks, including the permanent first molars. It is gonion or antegonion, increases in width approximately
interesting to note how the growth change in these twice as much as maxillary basal bone, measured at
structures compares with growth change in intermolar jugale, over the first 2 decades of life, growing approx-
width. Relative to maxillary intermolar width change, imately 20 mm wider in the transverse dimen-
width change from right to left jugale point is approx- sion.9,15,16,47 In some studies, with implants in the
imately 2-fold greater; width change from right to left buccal cortical plate of the mandibular body in the
pterygomaxillary fissure point is more than 2-fold region apical to the first molar, the authors reported
greater; width change from right to left zygomatico- lateral displacement of the right and left corpora of the
maxillary suture point is more that 3-fold greater; and mandible during growth.9,17 Our measurements, made
width change from the most lateral aspect of the right at a more occlusal level in the alveolar bone, do not
and left zygomatic process is approximately 5-fold support these findings.
greater (Table III). We are unaware of any other longitudinal growth
Width change of the basilar portion of the jaws studies reporting alveolar process transverse changes
measured by implant studies8,9,17 shows a smaller measured from either the lateral aspect of the alveolar
annualized rate of change compared with our data and process (buccal surface to buccal surface) or the medial
730 Hesby et al American Journal of Orthodontics and Dentofacial Orthopedics
December 2006

aspect of the alveolar process (palatal surface to palatal uprighting that we found naturally occurring during
surface or lingual surface to lingual surface) for both normal growth supports the board’s criteria. As we
the maxilla and the mandible. Knott48 reported an noted in our earlier study,21 our findings justify the goal
increase in palatal width from ages 5 to 17 years in of achieving upright posterior teeth during orthodontic
untreated females. Our finding of 4.94 mm is similar, treatment.
considering that our study did not extend to an earlier Another implication of our investigation concerns
age when rapid growth in width occurs. studies of spontaneous mandibular arch expansion and
Authors have previously proposed comparing ef- transverse expansion stability. Because the posterior
fective maxillary width (right to left jugale width) with teeth are both uprighting and expanding (on average, 3
effective mandibular width (right to left antegonial mm in the maxilla and 2 mm in the mandible) during
width) to indicate the presence or absence of an normal growth, it should not be surprising to find
underlying transverse skeletal discrepancy.47,49 How- reports of spontaneous mandibular molar uprighting
ever, Newman and Meredith19 reported only a weak, after rapid maxillary expansion or reports of relative
clinically insignificant correlation between these long-term stability of small amounts of arch expansion
mandibular and maxillary basal bone measures. Our in childhood or adolescence.51
findings—that transverse molar movement with
growth generally reflects the corresponding alveolar CONCLUSIONS
process and maxillary basal but not mandibular basal ● Transverse molar movements during growth mirror
skeletal change—support the findings of Newman and transverse maxillary basal bone width increases,
Meredith.19 Simply put, gonion and antegonion appear maxillary cross-arch alveolar process width in-
to be too far removed from the maxillary or mandibular creases, and mandibular cross-arch alveolar process
alveolar process bone to be of much value in defining width increases.
transverse skeletal discrepancies. Gonion and antego- ● There is a pattern of width changes in the maxilla, the
nion positions might be more reflective of medial maxillary alveolar process, the maxillary first molars,
pterygoid and masseter muscle dynamics than the other the mandibular first molars, and the mandibular
landmarks studied. alveolar process that occurs as a gradient in the
How do our findings translate into clinical practice? vertical dimension (jugale-mandibular alveolar pro-
These results support the concept that the limiting cess). The greatest width change occurs more supe-
factor for either orthopedic or surgical expansion of the rior (jugale point). The smallest width change occurs
maxilla is the mandibular posterior dentition. Although inferiorly (midalveolar point of the mandible).
the mandibular basilar bone widens at the angle of the ● Transverse mandibular basal bone changes, mea-
mandible during growth, this region is essentially sured as bigonion and biantegonion, do not fit this
divorced from the maxillary basal bone, the maxillary pattern.
alveolar process bone, and the mandibular alveolar
process bone. Mandibular basal bone at the first molars REFERENCES
does not appear to widen substantially. An increase in 1. Björk A. Facial growth in man studied with the aid of metallic
mandibular intermolar width with age results from implants. Acta Odontol Scand 1955;13:9-34.
slight widening of the alveolar process bone and tipping 2. Björk A. Variations in the growth pattern of the human mandible:
of the molars buccally. In our opinion, the greatest longitudinal radiographic study by the implant method. J Dent
amount of expansion an orthodontist should attempt to Res 1963;42:400-11.
3. Björk A. The use of metallic implants in the study of facial
achieve in the mandibular molar region is the point at growth in children: method and application. Am J Phys An-
which the mandibular molars are upright. Short of a thropol 1968;29:243-54.
mandibular midline surgical procedure to widen the 4. Björk A, Skieller V. Normal and abnormal growth of the
mandible, this mandibular limit establishes a maxillary mandible: a synthesis of longitudinal cephalometric implant
expansion limit. studies over a period of 25 years. Eur J Orthod 1983;5:16-46.
5. Enlow DH. Handbook of facial growth. Philadelphia: Saunders:
The American Board of Orthodontics requires can- 1975.
didates for board certification to assess molar bucco- 6. Enlow DH, Bang S. Growth and remodeling of the human
lingual inclinations for finished cases. The board states maxilla. Am J Orthod 1965;51:446-56.
that, “In order to establish proper occlusion in maxi- 7. Krebs A. Midpalatal suture expansion studied by the implant
mum intercuspation and avoid balancing interferences, method over a 7-year period. Trans Eur Orthod Soc 1964;40:
131-42
there should not be a significant difference between 8. Björk A, Skieller V. Growth of the maxilla in three dimensions
heights of the buccal and lingual cusps of the maxillary as revealed radiographically by the implant method. Br J Orthod
and mandibular molars and premolars.”50 The molar 1977;4:53-64.
American Journal of Orthodontics and Dentofacial Orthopedics Hesby et al 731
Volume 130, Number 6

9. Korn EL, Baumrind S. Transverse development of the human 30. Bondevik O. Changes in occlusion between 23 and 34 years.
jaws between the ages of 8.5 and 15.5 years, studied longitudi- Angle Orthod 1998;68:75-80.
nally with use of implants. J Dent Res 1990;69:1298-306. 31. Brown VP, Daugaard-Jensen I. Changes in the dentition from the
10. Melsen B. Palatal growth studied on human autopsy material: a early teens to the early twenties. Acta Odontol Scand 1951;9:
histologic microradiographic study. Am J Orthod 1975;68:42-54. 177-92.
11. Persson M, Thilander B. Palatal suture closing in man from 32. Lundstrom A. Changes in crowding and spacing of the teeth with
15-35 years of age. Am J Orthod 1977;72:42-52. age. Dent Practit 1969;19:218-24.
12. Woods GA Jr. Changes in width dimensions between certain 33. Carter GA, McNamara JA Jr. Longitudinal dental arch changes
teeth and facial points during human growth. Am J Orthod in adults. Am J Orthod Dentofacial Orthop 1998;114:88-99.
1950;36:676-700. 34. Sinclair PM, Little RM. Maturation of untreated normal occlu-
13. Singh IJ, Savara BS. Norms of size and annual increments of sions. Am J Orthod 1983;83:114-23.
seven anatomical measures of maxillae in girls from 3 to 16 years
35. Waraaswapati N, Pitiphat W, Chandrapho N, Rattanayatikul C,
of age. Angle Orthod 1966;36:312-24.
Karimbux N. Thickness of palatal masticatory mucosa associated
14. Savara BS, Singh IJ. Norms of size and annual increments of
with age. J Periodontol 2001;72:1407-12.
seven anatomical measures of maxillae in boys from 3 to 16
36. Eger T, Muller HP, Heinecke A. Ultrasonic determination of
years of age. Angle Orthod 1968;38:104-20.
gingival thickness. J Clin Periodontol 1996;23:839-45.
15. Snodell SF, Nanda FS, Currier GF. A longitudinal cephalometric
study of transverse and vertical craniofacial growth. Am J Orthod 37. Zar JH. 1984. Biostatistical analysis. 2nd ed. Englewood Cliffs,
Dentofacial Orthop 1993;104:471-83. NJ: Prentice-Hall; 1984. p. 323-5.
16. Cortella S, Shofer F, Ghafari J. Transverse development of the 38. Hunt RJ. Percent agreement, Pearson’s correlation, and kappa
jaws: norms for the posteroanterior cephalometric analysis. Am J as measures of inter-examiner reliability. J Dent Res 1986;
Orthod Dentofacial Orthop 1997;112:519-22. 65:128-30.
17. Gandini LG, Buschang PH. Maxillary and mandibular width 39. Ghosh M, Grizzle JE, Sen PK. Nonparametric methods in
changes studied using metallic implants. Am J Orthod Dentofa- longitudinal studies. J Am Stat Assoc 1973;68:29-36.
cial Orthop 2000;117:75-80. 40. Dawson DV, Siegler IC. 1996. Approaches to the nonparametric
18. Enlow DH, Harris DB. A study of the postnatal growth of the analysis of limited longitudinal data sets. Exp Aging Res 1996;
human mandible. Am J Orthod 1965;50:25-50. 22:33-57.
19. Newman K, Meredith H. Individual growth in skeletal bigonial 41. Conover WJ. Practical nonparametric statistics. 2nd ed. New
diameter during the childhood period from 5 to 11 years of age. York: Wiley; 1980.
Am J Anat 1956;99:157-88. 42. Holm S. A simple sequentially rejective multiple test procedure.
20. Israel H. Evidence for continued apposition of adult mandibular Scand J Stat 1979;6:65-70.
bone from skeletalized materials. J Prosthet Dent 1979;41:101-4. 43. Proffit WR. Equilibrium theory revisited, factors influencing
21. Marshall S, Dawson D, Southard KA, Lee AN, Casko JS, position of the teeth. Angle Orthod 1978;48:175-86.
Southard TE. Transverse molar movements during growth. Am J 44. McWade RA, Mamandras AH, Hunter WS. The effects of
Orthod Dentofacial Orthop 2003;124:615-24. Fränkel II treatment on arch width and arch perimeter. Am J
22. Harris EF. A longitudinal study of arch size and form in untreated Orthod Dentofacial Orthop 1987;92:313-20.
adults. Am J Orthod Dentofacial Orthop 1997;111:419-27. 45. You ZH, Fishman LS, Rosenblum RE, Subtelny JD. Dentoalve-
23. Moorrees CFA. The dentition of the growing child: a longitudi- olar changes related to mandibular forward growth in untreated
nal study of dental development between 3 and 18 years of age. Class II persons. Am J Orthod Dentofacial Orthop 2001;120:598-
Cambridge: Harvard University Press; 1959.
607.
24. Sillman JH. Dimensional changes of the dental arches: a
46. Lager H. The individual growth pattern and stage of maturation
longitudinal study from birth to 25 years. Am J Orthod
as a basis for treatment of distal occlusion with overjet. Trans Eur
1964;50:824-42.
Orthod Soc 1967;135-45.
25. Knott VB. Size and form of the dental arches in children with
47. Ricketts RM. Perspectives in the clinical application of cepha-
good occlusion: studied longitudinally from 9 years to late
adolescence. Am J Phys Anthropol 1961;19:263-84. lometrics, the first fifty years. Angle Orthod 1981;51:115-50.
26. DeKock WH. Dental arch depth and width studied longitudinally 48. Knott VB. Height and shape of the palate in girls; a longitudinal
from 12 years of age to adulthood. Am J Orthod 1972;62:56-66. study. Arch Oral Biol 1970;15:849-60.
27. Bishara SE, Treder JE, Damon P, Olsen M. Changes in the dental 49. Vanarsdall R. Transverse dimension and long-term stability.
arches and dentition between 25 and 45 years of age. Angle Semin Orthod 1999;5:171-80.
Orthod 1996;66:417-22. 50. The American Board of Orthodontics grading system for dental
28. Bishara SE, Jakobsen JR, Treder J, Nowak A. Arch width casts and panoramic radiographs. St Louis: American Board of
changes from 6 weeks to 45 years of age. Am J Orthod Orthodontics; 1999.
Dentofacial Orthop 1997;111:401-9. 51. Lima A, Lima A, Filho R, Oyen O. Spontaneous mandibular arch
29. Tsujino K, Machida Y. A longitudinal study of the growth and response after rapid palatal expansion: a long-term study on
development of the dental arch width from childhood to adoles- Class I malocclusion. Am J Orthod Dentofacial Orthop 2004;
cence in Japanese. Bull Tokyo Dent Coll 1998;39:75-89. 126:576-82.