European Journal of Orthodontics 5 (1983) 1-46 0141-5387/83/00500001 $02.

00
© 1983 European Orthodontic Society

Normal and abnormal growth of the

mandible. A synthesis of longitudinal
cephalometric implant studies over a
period of 25 years*

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Arne Bjork and Vibeke Skieller
Copenhagen, Denmark.

Summary. This paper examines the complex rotation processes that occur during growth in
normal and abnormal mandibular development. The bony mandibular corpus and its soft
tissue covering, the matrix, are considered as independent tissue systems capable of
independent rotation. Both forward and backward rotation can be divided into three com-
ponents: the total rotation, the matrix rotation, and the intramatrix rotation, showing
different individual interrelationships and a changing composition in each individual during
the entire period of development. Dividing the mandibular rotation into these components
permits measurement of the, often considerable, remodelling at the lower border of the
mandible.
Orthodontic treatment influences the components of mandibular rotation and thus induces
a change in the remodelling of the mandible.
The findings do not support the view that the matrix is a dominating factor and that bone
formation is secondary in mandibular growth, but point to considerable independence in
development of the two tissue systems.

From the first longitudinal cephalometric
analyses of profile radiographs it was evident
that facial shape is remarkably constant
during growth (Brodie, 1941) even in cases of
pathological craniofacial growth (Roberts
etal. 1975).
Since metallic implants were used as
reference marks in a longitudinal profile
radiographic study of the face it has been
known that the mandibular corpus rotates
during growth and that the shape is kept stable
•Presented in part by Professor Arne Bjork as the
Sheldon Friel Memorial Lecture, at the 56th Congress
of the European Orthodontic Society, Paris, 1980.
by the associated substantial surface re-
modelling (Bjork, 1955).
Rotation of the maxillary corpus within
the upper face during growth was also
documented by Bjork and Skieller (1972 and
1976). In most cases both jaws rotate forwards
in the face relative to the anterior cranial base
but metallic implant studies showed that there
is backward rotation in some subjects. These
facts were subsequently verified by the
implant studies of Kuroda et al, (1979).
The present paper will consider forward
rotating and backward rotating types
separately and will discuss how orthodontic
treatment may affect the growth and
remodelling processes.

Forward rotation
To help explain the complex rotation
processes of the mandible, the facial develop-
ment and mandibular remodelling previously
reported in our studies will be described and
illustrated by a case of forward growth
rotation.
The case to be described is a boy who was
examined annually from the age of 8 years to
adulthood. The facial development and
mandibular remodelling characteristic of
forward growth rotation of the mandibular
corpus in a more stable soft tissue covering
(matrix) are illustrated in Figures 1 and 2.
The facial tiacing (Figure 1) superimposed
on structures in the anterior cranial base
clearly shows the general tendency to a
parallel lowering of the lower border of the
mandible relative to the anterior cranial base
during growth, described by Brodie (1941). A
detailed description of this method of
superimposition is given in the appendix.
Figure 1 Facial growth tracing superimposed on
structures in the anterior cranial base, illustrating the
facial development in profile view of a case with distal
occlusion, extreme overjet and deep overbite, treated
at the age of 14 years (From Halborg and Rank, 1978).
GROWTH OF THE MANDIBLE
The rotation of the mandible and the paths
of the erupting teeth during the period from
8-18 years of age are illustrated in the
mandibular tracings (Figure 2) which are
superimposed on an implant line based on the
metallic implants in the mandibular corpus
(Bjork, 1968). The forward converging lines,
representing transferred nasion-sella line at
the different age stages, show that the
mandibular corpus has rotated forwards
(—14.0 degrees) relative to the anteiior
cranial base.
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The mandibular tracings show the re-
modelling pattern characteristic of forward
rotating mandibles (Figure 2) with ap-
position below the symphysis and the
anterior part of the lower border, and
resorption at the lower border of the angular
region. The symphysis increased in thickness
by apposition at its posterior surface; no
apposition occurred on the anterior surface of
the symphysis. The condylar growth was
directed forward relative to the posterior
14.0?
Figure 2 Mandibular growth tracing superimposed
by means of metallic implants, illustrating the yearly
growth and remodelling of the mandible and the
eruption of the teeth, as seen in profile view (From
Halborg and Rank, 1978).
GROWTH OF THE MANDIBLE
Figure 3 The mandibular line ML t is defined as a
tangent to the lower border of the mandible,
corresponding to the classical anthropological
method when a dry mandible was placed on a table or
in a goniometer. The conventional mandibular line,
denoted ML.,, drawn to the lower border of the
symphysis, is also shown.
border of the ramus in the first stage. The
marked periosteal activity of the mandible as
a whole was manifested by growth in height of
the muscular process and a remodelling of
the ramus, with a moderate resorption at the
anterior border and marked apposition at the
lower part of the posterior border.
The eruption paths of the teeth denoted a
marked growth in height of the alveolar
process. The direction of eruption of the
teeth was forward relative to the occlusal
plane in the first stage, indicating a forward
migration of the dentition as a whole relative
to the mandibular corpus, with proclination
of the incisors and an increase in the alveolar
prognathism.
The facial tracing in Figure 1 shows that
the shape of the mandible as a whole is
practically unchanged during growth, and so
too is the inclination of the lower border.
The mandibular tracing (Figure 2) however
shows marked forward rotation of the
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Figure 4 By forward rotation of the mandibular
corpus inside the matrix of the lower face the symphysis
is raised in relation to the tangential line MLj. This
raising may be more or less masked by apposition at
the lower border of the symphysis with an increase in
thickness of the compacta. The mean increase in the
angle MI^/ML., during growth is around 3.5 degrees.
mandibular corpus and remodelling at the
mandibular suifaces. The striking contrast
between these two figures deserves careful
consideration and this paper will give our
interpretation of this discrepancy.
Components of mandibular rotation
The different patterns of mandibular rotation
exhibited by different individuals during
growth can be more readily understood if the
rotation is divided into three components.
These are differently composed and show a
changing inter-relationship in each individual
throughout the entire growth period.
Total rotation is the rotation of the
mandibular corpus and is measured as change
in inclination of a reference line, or an
implant line, in the mandibular corpus
relative to the anterior cranial base; this is

REFj X
IMPLANT LINE REGISTRATION
Figure 5 The rotation of the mandibular corpus in
relation to the anterior cranial base, termed total
rotation, is designated negatively when the reference
line in the corpus rotates forward in relation to the
nasion-sella line.
MANDIBULAR BASE REGISTRATION
Figure 7 The matrix rotation, metrically defined as a
change in inclination of the tangential mandibular line
MLj in relation to the nasion-sella line, is designated
negatively when MLj rotates forward.
GROWTH OF THE MANDIBLE
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Figure 6 With superimposition on a reference line in
the mandibular corpus, the direction and the amount
of the total rotation are manifested by the converging
nasion-sella lines representing the different age stages.
MATRIX ROTATION
"PENDULUM MOVEMENT'
Figure 8 Changes in inclination of the lower border
of the mandible in the face during growth express a
rotation of the soft tissue matrix. The matrix rotation
often shows a pendulum movement with the centre at
the condyles.
GROWTH OF THE MANDIBLE
INTRAMATRIX ROTATION
FORWARD
1597^
\ 2V
Figure 9 The intramatrix rotation, metrically
defined as a change in inclination of a reference line in
the corpus relative to the tangential mandibular line
ML,, is designated negatively when the reference
line rotates forward.
illustrated in the facial tracing (Figure 5).
When the implant line or reference line
rotates forward relative to the nasion-sella
line during growth, the total rotation is
designated as negative. In the mandibular
tracing (Figure 6) superimposed on a reference
line in the corpus, the total forward rotation is
indicated by the converging nasion-sella lines.
Complex rotation processes are more
readily understood if the bony mandibular
corpus and its soft tissue covering—the
matrix—are regarded as two independent
systems capable of independent rotary
movements.
Matrix rotation expresses a rotation of the
soft tissue matrix of the mandible relative to
the anterior cranial base. On profile radio-
graphs (Figures 3 and 4) the soft tissue matrix
is defined by the tangential mandibular line
MLi (Bjork, 1947). The matrix rotation is
recorded as negative when the tangential
INTRAMATRIX ROTATION
"ROTATION"
FORWARD
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^ ^ -APPOSITION
Ukiiii -RESORPTION
Figure 10 The intramatrix rotation represents a
rotation of the mandibular corpus inside its matrix
with the centre somewhere in the corpus and not at
the condyles. The anterior part of the corpus is
lifted up from the matrix, leading to apposition below
the symphysis and the anterior part of the lower
border. The posterior part of the corpus is pressed
downward into the matrix, resulting in resorption.
mandibular line rotates forward relative to
the nasion-sella line (Figure 7). The matrix
sometimes rotates forwards and sometimes
backwards in the same subject during the
growth period, with the condyles as the
centre of rotation, and can be described as a
pendulum movement. This is schematically
illustrated in Figure 8.
In the facial tracing (Figure 7) the
inclination of the lower border of the
mandible is almost the same in the adult as in
the first stage. The pendulum movement of the
matrix during growth in this case is illustrated
in the rotation diagram in Figure 31, Case 1.
Intramatrix rotation There are distinct differ-
ences in the pattern and the amount of the
total and the matrix rotation. The corpus
of the mandible must rotate inside the
soft tissue matrix. The difference between the
total rotation and the matrix rotation, termed

the intramatrix rotation, is an expression of
the remodelling at the lower border of the
mandible and is defined by the change in
inclination of an implant or reference line in
the mandibular corpus relative to the
tangential mandibular line MLX (Figure 9).
Forward rotation of the corpus relative to
the tangential line is recorded as negative.
The centre of intramatrix rotation is some-
where in the corpus and not at the condyles
(Figure 10). The location of the centre of
rotation depends not only on the rotation of
the corpus of the mandible but also on the
growth rotation of the maxilla and the
occlusion of the teeth.
There is usually considerable intramatrix
rotation, while the matrix rotation is moderate
and may even be in the opposite direction to
the total rotation.
When the direction of total rotation is
more forward than the matrix rotation,
pronounced remodelling is taking place at the
lower border of the mandible (Figure 2).
Forward intramatrix rotation lifts up the
anterior part of the corpus from the soft
tissue matrix and the stretching leads to
apposition below the symphysis and anteriorly
at the lower margin. The posterior part of the
corpus is simultaneously pressed down into
the matrix, resulting in resorption at the
lower border in the region of the angle of
the mandible.
The total rotation is the sum of the matrix
and the intramatrix rotation. The matrix
rotation has its centre at the condyles and the
intramatrix rotation has its centre somewhere
in the corpus: the position of the centre of
total rotation is thus dependent on the other
two centres of rotation.
An explanation of the complicated
mechanism of mandibular growth rotation
may primarily be found to be closely
associated with both the direction and the
amount of growth at the condyles (Bjork and
Skieller, 1972) which may be part of a
genetically determined growth pattern in the
development of the bone and muscle
systems. This complex topic however needs
clarification.
GROWTH OF THE MANDIBLE
Sample analyses
The variability in facial and mandibular
development in cases with forward rotating
mandibles will be discussed on the basis of a
sample of nine individuals with normal
occlusion of the deciduous teeth, followed,
without orthodontic treatment, from the age
of 4 years to adulthood. All the permanent
teeth were present except for a lower right
first premolar in Case 5 and both lower third
molars in Cases 3 and 7. To restrict the
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illustrations only three of the cases are dealt
with in detail but the summary is based on all
nine cases.
Case 7 (7017) The photographs at 4.0 and
21.0 years of age show harmonious facial
development (Figure 11). The facial profile
straightened during growth, primarily as a
consequence of marked forward rotation of
the mandible with consequent forward
swinging of the symphysis.
The development of the face is also
illustrated by the superimposed profile radio-
graphs (Figure 12) and by the facial tracing
(Figure 14). The yearly changes in total,
matrix and intramatrix rotation are shown in
Figure 17 which illustrates the accumulated
rotation of each component from the age of
4.0 Stages in the rate of condylar growth
(Figure 31) are used as an expression of
physical maturation (Bjork, 1972).
It is evident from the facial tracing
(Figure 14) that only minor matrix rotation
has occurred. The rotation diagram (Figure
17) shows a pendulum movement of the
matrix starting with a moderate backward
rotation in the juvenile period and then a
change of direction at puberty (Cx) to
forward rotation of the same moderate
degree. The total rotation was constantly
forward andmuch greater (—19.5°at21.0years
of age) than the matrix rotation (—3.0 °). A
close association between the total rotation
and the amount of condylar growth is
indicated by the increased slope of the curve
at the juvenile growth spurt of the condyles
(CjX), by a slowing down at the prepuberal
minimum (CO and by a subsequent increase
GROWTH OF THE MANDIBLE

at puberal maximum (CO- The total rotation The intramatrix rotation of —16.5°,
ceased with the completion of condylar approximately 85% of the total rotation,
growth (Cc) shortly after the union of the expressed the remodelling at the lower
distal epiphysis of the radius (R u ). border, which was characterized by a marked

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Figure 11 Case 7 (7017). Photographs at 4° and 21 ° years of age.

Figure 12 Case 7 (7017). Profile radiographs at Figure 13 Case 7 (7017). Profile radiographs at
4° and 2.1° years of age superimposed on structures in 4° and 21° years of age superimposed on structures
the anterior cranial base. in the mandibular corpus.
 GROWTH OF THE MANDIBLE

-19°

20°

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Figure 14 Case 7 (7017). Facial tracing at three age Figure 15 Case 7 (7017). Mandibular tracing at
stages superimposed on structures in the anterior three age stages superimposed on a reference line in
cranial base. the corpus with reference to natural structures.

Figure 16 Case 7 (7017). Dental casts at 4° and 21° years of age.

GROWTH OF THE MANDIBLE

+ 4°
DFRRFFR
+2

:
-2
\jr c«
\MATRIX ]5%

-4 11

: Ru Cc

v\\V
-6

-8
:
-10
:
V Figure 17 Case 7 (7017). Rotation diagram showing

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-12
\ the cumulative age changes in the matrix, the intra-
-14 matrix and the total rotation of the mandible from the
_ Q MANDIBULAR ROTATION
- 1 6 " | 7017 :! INTRAMATRIX g5% age of 4° years to adult age.
\ \
FORV

-18 V
^-^TOTAL 100%
'-

10 12 14 16 18 20 22 25
YRS

CM/YR
MF P
12 \ I DP3,,
BODY HEIGHT
BOYS 1 90V.
7017
\
1 \
10
\ /
\
V 95 V. \
1 A J
8
=
""*; \

6
50*/. \
N ^— —— r t/ \

----
5 V.
\ V 'A
><•'
\\ A Ru

90V.
2 \ \
\\ \ ^
s \
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0 3= u—-
57. 95 V.
10 12 U 20 22 25
AGE

Figure 18 Case 7 (7017). Growth rate in body height plotted on a mean curve for Danish boys
with 5 and 95 percentiles. The two ellipses represent 90 per cent of the two-dimensional distributions
of individual age and growth rate at prepuberal minimum and at puberal maximum. This boy
has late maturation: (S) ossification of ulnar sesamoid of the thumb. (MP3cap) capping of
diaphysis of middle phalanx of the third finger. (DP3U) epiphyseal union of distal phalanx of
the third finger. (Ru) union of distal epiphysis of radius. (M) distribution of age at completion
of growth, defined as growth rate less than 5 mm.
10
MM/YR CONDYLAR GROWTH
C» RUCC
DEGREES/YR TOTAL ROTATION
18 20
Figure 19 Case 7 (7017) (a) Curve for yearly rate of condylar growth, (b) Curve for yearly rate of total rotation
of the mandible, (c) Curve for yearly rate of matrix rotation, (d) Curve for yearly rate of intramatrix rotation.
apposition anteriorly and considerable
resorption at the lower border of the angular
region posteriorly (Figures 13 and 15).
The intramatrix rotation has to com-
pensate for the pendulum movement of the
matrix. Until puberty, the matrix rotation was
directed backward and the curve for the
intramatrix rotation (Figure 17) showed an
increased slope relative to the curve for the
total rotation in the juvenile period. At
puberty, the matrix rotation changed from a
backward to a forward direction and the
intramatrix rotation showed a consequent
decrease. The remodelling at the lower
border of the mandible showed an increase in
the first period and a decrease towards adult
age. The pattern and amount of remodelling
changed in the last period, with reduced
resorption, or even some apposition, below
the angular region.
The close relationship between the yearly
rate of condylar growth and total forward
rotation is clearly demonstrated in Figures 19
a and b where the curve for the latter is a
mirror image of the former. The curve for
the yearly rate of matrix rotation (Figure 19c)
has an entirely different course, quite
unrelated to condylar growth rate, and shows
a pendulum movement similar to that seen on
the cumulative curve in the rotation diagram
(Figure 17). The compensatory function of
the intramatrix rotation is seen in Figure 19d.
GROWTH OF THE MANDIBLE
DEGREES/YR MATRIX ROTATION
+2
+1
O
0° -oc —
7017 ' - 1 - oc
7017''
-2
c C«
+ 1 DEGREES/YR INTRAMATRIX ROTATION
0"
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-2
7017 • -3 7017<-'
22 25 20 22 25
Comparison of Figures 18 and 19a shows
that the puberal maximum for body height
was recorded one year earlier than that of
condylar growth.
Despite the marked total rotation of the
mandibular corpus, the development of the
occlusion and of the dental arches was
perfect (Figures 14 and 16), clearly illustrating
the compensatory capability of the erupting
teeth to maintain normal occlusion. There was
a considerable forward migration of the
dentition as a whole, with an increased
alveolar prognathism and proclination of the
lower incisors, although there was agenesis of
the lower third molars (Figure 15).
Case 6 (6635) In contrast to the harmonious
facial development in Case 7, this case
illustrates an extreme facial growth pattern
characterized by vigorous growth in size of
the mandible with marked protrusion and
forward rotation of the mandible relative to
the maxilla. A considerable forward rotation
of the face as a whole occurred from 4.0 to
21.4 years (Figures 20, 21). The facial tracing
(Figure 23) shows parallel descent of the
nasal floor during growth as a result of
compensatory remodelling while the maxillary
corpus rotated markedly forward in its
matrix, —5.0 ° from the age of 11 years,
determined from implants in the maxilla.
The rotation is evident from the increased
GROWTH OF THE MANDIBLE 11

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Figure 20 Case 6 (6635). Photographs at 4° and 214 years of age.

Figure 22 Case 6 (6635). Dental casts at 4° and 21 * yctis oi age.

 GROWTH OF THE MANDIBLE

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Figure 21 Case 6 (6635). Profile radiographs at 4° and 214 years of age superimposed on structures in the anterior
cranial base.
GROWTH OF THE MANDIBLE
11°
21"
Figure 23 Case 6 (6635). Facial tracing at three age
stages superimposed on structures in the anterior
cranial base.
forward slope of the anterior contour of the
zygomatic process (Bjork and Skieller, 1976,
1977 a and b).
From the age of 4.0 years there was a total
forward rotation of the mandible of —18.5°
The cumulative curve for the total rotation
for case 6, shown in Figure 31, followed a
steady course, similar to that of case 7, with
variations in the rate closely related to the
growth activity of the condyles and to
marked acceleration at puberty. The matrix
rotation was forward and amounted to half of
the total rotation, also with an acceleration at
puberty. The intramatrix rotation accounted
for the other half of the total rotation. As the
intramatrix rotation was moderate, the
resorption below the angular region (Figure
24) was less marked than that in case 7.
Despite the extreme displacement of the
mandible relative to the maxilla, both
sagittally and vertically, during growth
(Figures 21, 22 and 23), dento-alveolar
13
21'-
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6635 d
Figure 24 Case 6 (6635). Mandibular tracing at
three age stages superimposed on a reference line in
the corpus with reference to natural structures.
compensation resulted in well formed dental
arches with only a moderate mandibular
overjet in the adult. There was no marked
forward migration of the lower molars, the
lower incisors were somewhat retruded and
the alveolar prognathism was reduced (Figure
24). Marked resorption of the anterior part of
the ramus, as part of the pronounced re-
modelling of the ramus as a whole,'gave
sufficient space for eruption of the lower
third molars.
Case 1 (1597) Like Case 7, this was
characterized by harmonious facial develop-
ment, with a straightening of the profile
between the ages of 4.3 and 21.3 -years
(Figure 25). Only minor differences in the
inclination, within the face, of the lower
border of the mandible are seen in Figures 26
and 27 but it is evident that a pronounced
pendulum movement of the matrix has
occurred (Figure 31), with an increasing
14 GROWTH OF THE MANDIBLE

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Figure 25 Case 1 (1597). Photographs at 4 s and 21 3 years of age.

backward rotation to 4-4.5 ° at puberty and a

change to —1.0 ° forward rotation in the
adult. The lower border of the mandible had
therefore practically the same inclination at
the beginning and at the end of the
observation period (Figure 27).
There was forward total rotation to —8.5 °
by adult age, at a rate closely associated with
the condylar growth rate. Because of the
marked change in direction of the matrix
relative to the total rotation, the intramatrix
rotation was at first greater than the total
rotation (reaching —11.0 °) and then the
direction of rotation changed, with a
reduction to —7.5 ° at the end of growth—less
than the total rotation. This represented a
marked change in the amount and direction
of remodelling at the lower border up to
adult age.
There was ample space for the lower third
molars, essentially resulting from marked
mesial migration of the dentition associated
with marked proclination of the lower
incisors (Figure 30, Case 1), whereas there was
very little anterior resorption at the ramus.
Figure 26 Case 1 (1597). Profile radiographs at 4'
Secondary crowding of the front teeth and 21 3 years of age superimposed on structures in the
developed in both jaws during puberty anterior cranial base.
GROWTH OF THE MANDIBLE II

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Figure 27 Case 1 (1597). Facial tracing at three age Figure 28 Case 1 (1597). Mandibular tracing and
stages superimposed on structures in the anterior occlusal diagram of the dentitional development at
cranial base. two age stages, superimposed on a reference line in
the corpus with reference to natural structures.

Figure 29 Case 1 (1597). Dental casts at 43, 10aand 21'years of age.

16
(Figures 28 and 29). The development of
crowding in the upper jaw in this case has
been previously described (Bjork and Skieller,
1976). The crowding of the lower front teeth
can be explained by forward migration of the
dentition on the narrowing alveolar process,
Figure 30 Case 1-9. Mandibular tracings of the nine cases with forward rotation of the mandible.
Case 1
Case 3
GROWTH OF THE MANDIBLE
with insufficient development of functional or
hereditary alveolar prognathism. This lack of
compensation is apparent from the extremely
short alveolar arch length relative to dental
arch length (Figure 30, Case 1). It is difficult
to determine whether or not the crowding
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Case 2
Case 4
 Downloaded from http://ejo.oxfordjournals.org/ at Stanford Medical Center on October 12, 2012
17

6635 d

21°

Case 8
Case 6
19'
GROWTH OF THE MANDIBLE

Case 7
Case5
18 GROWTH OF THE MANDIBLE

should be considered hereditary (Bjork and

Helm, 1969).

2 2 5

Survey of the sample

The three cases discussed above were selected

to illustrate the principles of analysis of
mandibular growth. All except Case 6 in the
sample of nine developed harmonious faces
with clinically normal dental occlusion.
The mandibular growth tracings for all nine

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cases are shown in Figure 30 and, except for
Case 9, where a few registrations were missing,
the rotation diagrams are shown in Figure 31.

Case 9

Figure 31 Case 1-8. Mandibular rotation diagrams for the eight cases followed yearly from 4 years of age to
adult age. Stages in condylar growth rate: (Cjx) juvenile growth spurt, (Cj) prepuberal minimum, ( d ) puberal
maximum, (Cc) completion of growth, (Ru) union of distal epiphysis of radius.

\ Ufi'tt i ROTATE)

MANttEULAR ROTATION

—y.
6 6 10 1? IB 20 22 24-rtAFS 6 8 10 12 H 16

Case 1 Case 2
GROWTH OF THE MANDIBLE 19

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MAMXBULAR ROTATION

4 6 10 12 14 16 18 20 22 25*RS 6 8 to 12 14 16 IS 20 22YRS

Case 3 Case 4

DEGHHS
0*
c,

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-4
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10 INTRAMATRIX

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12

14

16 " |
MANOIBULAR ROTATION
v
6635 tf
^ " - ^ T O T A l

18

20 yj 1—L—i—i.
'4 ' 6 8 ' 10 12 ' M 16 18 20 ' 22 24 26YKS '« 6 8 10 12 14 16 18 20 22VRS

CaseS Case 6
8
- 4

mctna

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-2

-4

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MAN0SULAR ROTATION

7017 cf
A ^^.—.—. . B5X

-18

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A 6 8 12 M
., ,16 18
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20
TOTAL

22 Z5YRS

Case 7
 20
Components of rotation Figure 32 shows the
average composition of the three components
of forward rotation from the age of 4 to adult
age. There is a moderate forward matrix
rotation (-4.1 °) which is 27% of the
total rotation(—15.4 °). A forward intramatrix
rotation (—11.3 °) constitutes the remaining
73 % of the total rotation. Total rotation is
clinically the most important and showed the
largest individual variation in the sample,
with a range of 12.5°.
The individual rotation diagrams of eight
cases (Figure 31) show steadily forward-
directed total rotation curves. Five of the
cases show a distinct variation in the growth
rate, most clearly seen in cases 3 and 6. The
curve for the matrix rotation swung up and
down in five cases, most pronounced in cases 1,
7 and 8. The curves for the intramatrix
rotation showed great changes in amount and
direction in these individuals indicating
compensation for the discrepancy between
the matrix and the total rotation. In cases 1
and 7, the intramatrix rotation showed a
o°
-2
MANDIBULAR
ROTATION
-6
I "10
o
I -12 IM
M MATRIX
-14
IM INTRAMATRIX
T TOTAL
-16
-18
-20 9 BOYS
FROM 4-20 YEARS
Figure 32 Mean values and ranges for the three
rotation components.
GROWTH OF THE MANDIBLE
postpuberal backward turn indicating that
the remodelling at the lower border was
reversed at the end of the growth period.
For a more complete understanding of
facial development consideration is also given
to the rotation of the maxillary corpus
relative to the anterior cranial base in these
nine cases, registered on implants (Bjork and
Skieller 1976). The mean value for the
growth rotation of the maxilla was —3.2 °
forward (range —1.5 to —5.0 °) from the age
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of ten to adult age. The mean value for the
total rotation of the mandible over the same
period was —8.6 ° forward. The correlation
coefficient between the growth rotation of the
upper and the lower jaw was r=0.72.
Maxillary rotation takes place by changes
in the sutural complex of the upper face.
Complete lack of sutural enlargement and
rotation of the maxilla was demonstrated in
cases with Crouzon syndrome by Kreiborg
(1981).
Condylar growth The condylar growth curves
are depicted from a common condylar point
in Figure 33 and are displayed separately in
Figure 34. The shape of the curves varied, with
an almost straight line in case 2, an increase in
the curvature towards the end of the growth
period in case 6, and an increase in curvature
during thefirstyears of observation in cases 1
and 7. The generalizations made in the
literature that condylar growth takes a
circular course (Ricketts, 1972) or has the
shape of a logarithmic spiral (Moss and
Salentijn, 1970) were not confirmed by our
material. Condylar growth curves were, on
the contrary, characterized by marked
individual variation which makes prediction
of their course almost impossible.
In each case the general condylar growth
direction was determined by the angle
between a line connecting the condylar point
at the first and last stage, and a tangential
ramus line at the first stage. The mean value
from the age of 4 years was —10.0 ° (the
negative sign indicating a forward slope) with
a range from —22.0 ° in case 7 to +2.5 ° in
case 3. The average amount of growth of the
 GROWTH OF THE MANDIBLE 21

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RL 4YRS

4 5 6
CONDYLAR GROWTH
BOYS 4-20 YRS

CONDYLAR GROWTH
9 BOYS 4-20YRS Figure 34 The same condylar growth curves as in Fig. 33,
displayed separately.
Figure 33 Condylar growth curves,
depicted from a common condylar
point, related to the posterior tan-
gential line of the ramus at the first
stage (RL). A forward directed slope CHANGES IN INCISAL INCLINATION
is designated negatively.
9 BOYS 7-20 YEARS
•24 r

•20

•16

MESIAL MIGRATION
•12
LOWER TEETH

MM
•8
•8

-4

-8

-12
- 2 9 BOYS
FROM 7-20 YEARS
Figure 36 Mean values and ranges for age changes in
Figure 35 Mean values and ranges for the mesial inclination of lower central incisors: A, from a
migration of lower first molars (M I) [and of lower reference line in the mandibular corpus (IPLj). B, from
central incisors (II). the lower border of the mandible (MLi).
22
condyles from the age of 4 years was 41.3 mm
with only small variations, apart from case 6
(Figure 33).
In some individuals (e.g. case 7) the
puberal maximum in growth in body height
may be recorded one year earlier than the
maximum in condylar growth. The time of
completion of growth in body height can be
difficult to determine (Taranger and Hagg,
1980) due to late growth, as seen in Figure 18.
The cranial dimensions do not correlate
strongly with the length of the long bones or
with stature (Lindegard, 1953; Solow, 1966)
and, even if the timing of the growth rate for
head dimensions and body height is very
close, the amount of growth is not. For these
reasons stages in condylar growth rate were
chosen as an indicator of maturation in this
study.
Mesial migration of the dentition The classical
superimposition of mandibular tracings on
the lower border gives the impression that the
path of the erupting teeth is usually fairly
vertical. Superimposition on implants or
internal structure in the mandibular corpus
shows a more forward directed path of
eruption in cases of forward rotation, with a
considerable forward migration of the denti-
tion as a whole and marked proclination of
the lower incisors (Figures 35 and 36). Tn the
nine cases in this study, the mean forward
migration of the first molars, measured in the
midsagittal plane, from the age of 7 years was
5.2 mm, while the lower central incisors
showed a mean forward migration of 3.2 mm
from the same age. The shortening of the
dental arch by 2.0 mm is an expression of the
differentiated path of eruption of the teeth.
This shortening only amounted to about one
third of the mesial migration of the entire
dental arch. In association with this migration,
the mean forward inclination of the lower
central incisors relative to the implant line or
the reference line in the corpus increased by
8.5 ° but, relative to the lower border of the
mandible, there was on average practically no
change in incisor inclination (Figure 36). It is
clearly essential in orthodontic treatment that
the positioning and inclination of the lower
GROWTH OF THE MANDIBLE
incisors are in accordance with the individual
growth pattern.
Despite the small sample it is tempting to
try to associate some measureable variables in
the mesial migration of the teeth with some
variables in mandibular growth (Table 1).
All four variables of mesial migration were
significantly positively intercorrelated (Table
2) which stressed their strong inter-
dependence.
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Of the five mandibular growth variables,
there was significant positive correlation of
ramus resorption with condylar growth
direction, while the other correlations were
low.
The intercorrelation of the migration
variables and the mandibular growth variables
is of interest. Ramus resorption showed
significant negative correlations with all the
mesial migration variables, indicating a
reversed association. The condylar growth
direction also showed a significant negative
correlation with molar migration and thus a
relation to the development of the
dentition. The amount of eruption of the first
molars was moderately positively correlated
with all the mesial migration variables and
demonstrated the importance of growth in
height of the alveolar arch in the development
of the dentition. Despite the marked
variability in total rotation, this showed only
low correlation with the other variables,
suggesting a greater morphogenetic inde-
pendence. The amount of condylar growth
varied very little in this sample (Figure 33) and
did not show high correlations.
The marked individual development of the
dentition shown by the correlation analysis is
Table 1 Variables in mandibular development
Mesial Migration Mandibular Growth
1 Molar migration 5 Amount of molar eruption
2 Incisor migration 6 Ramus resorption
3 Incisor inclination 7 Total mandibular rotation
4 Alveolar prognathism 8 Amount of condylar
growth
9 Direction of condylar
growth
GROWTH OF THE MANDIBLE 23

Vi
further illustrated by the mandibular tracings
O
JD (Figure 30). There was considerable mesial
Q
C migration of the dentition in cases 1, 4 and 7
E
c O I I I I I where anterior resorption of the ramus was
Vi small. Molar eruption in these cases also
s contributed to posterior arch length. Marked
u
o o forward condylar growth was associated with
o
CN
oo Q
os this mesial migration. In contrast, there was
z I I I I little mesial migration in the dentition in
"o
o cases 3, 5 and 6 while the resorption on the
so u
a anterior surface of the ramus was marked.

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u
H The molars erupted practically vertically and
o
1 LUO

^ as the incisors erupted in a backward direction,

H I I I I I with a decrease in the alveolar prognathism.
iod

u
In case 3, marked ramus resorption and
a
o LU
backward condylar growth were associated
j=
with a small amount of mesial migration. In
ise i

"2 case 6, on the other hand, the relatively small

a i i i i i
< amount of mesial migration was associated
E oS
8 with marked forward condylar growth. In
a. case 8, a combination of several mandibular
so 3
c
a •^> W
growth factors influenced the marked mesial
JZ
^* J I I I migration of the dentition, extreme pro-
so
ca
o clination of the incisors and a pronounced
u
j= increase in the alveolar prognathism. Cases 1
_; o and 4 both showed marked mesial migration
<u
o
r/ X but the total rotation was small in case 1 and
JO
«0\00
P"; CM ~- so
a 1 marked in case 4 which illustrates the small
H _J i i i' f degree of dependence between total rotation
<
-
T3 and mesial migration in this sample.
les iiste

u
m
z The development of the dentition in every
J3
u case was the result of a unique combination of
ca z i i i i
a number of variables and could not be
explained by a single growth pattern. The
ofth

c great variability in mesial tooth migration

=5 CN ^
may explain the different migration tendencies
so
c after early loss of teeth and the different
ca u i i I i
1 z responses of tooth movement to orthodontic
bo
ra OS forces.
c
u
u
o Case 5, with early loss of both lower first
-2 temporary molars and absent lower right first
sbet

o i i i i premolar showed no mesial molar migration

c
_o
(Figure 30) and the space for the missing
tooth did not close (Figure 37).
rellat

o
Cases 3 and 7 had agenesis of both lower
U third molars. In case 3 there was little mesial
migration but marked ramus resorption.
ble:

q
while in case 7 there was marked mesial
a Vli migration but little ramus resorption. The
H a.
24 GROWTH OF THE MANDIBLE

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Figure 37 Case 5 (6474) Dental casts at 4' and 19' years of age. Both lower first temporary molars were extracted
early. The lower right first premolar was missing, and the small amount of space closure may be due to a mandibular
growth pattern with little mesial molar migration, (see Fig. 30, Case 5).

variation in mesial migration is evidently
determined by factors other than the presence
of the third molars.
In the remaining cases the lower third
molars erupted normally, irrespective of
varying growth patterns of the mandible.
Space for the lower third molars thus seems to
result from an individual combination of
several growth factors.
Prediction of normal eruption of the lower
third molars is difficult (Bjork et al, 1956).
Richardson (1977) surveyed recent concepts
of lower third molar impaction. A hitherto
overlooked consideration is the development
in width of the face, and the bi-ramal width
was found to be significantly greater relative
to the width between the lower second molars
in skulls with normally erupted lower third
molars than in skulls with impaction. A
broad mandible, relative to the dental arch,
gives more space for the third molars (Figure
38) by allowing the alveolar arch to elongate
posteriorly on the medial surface of the ramus
(Herskind and Bjorn-Jergensen, 1973).
Evaluation from frontal radiographs of the
bi-ramal width relative to dental aich width
was shown by Olive and Basford (1981) to be
of value in assessing the prognosis for third
molar eruption.
Effect of orthodontic treatment
As had been explained, the mandibular
GROWTH OF THE MANDIBLE
Figure 38 The importance of a large bi-ramal width
relative to dental arch width for third molar space.
Above: a mandible with fully erupted third molars.
Below: a mandible with impacted third molars (From
Herskind and Bjorn-Jorgensen, 1973).
corpus normally rotated steadily forward
relative to the anterior cranial base during
growth but the soft tissues showed a smaller
degree of rotation which could be forward as
well as backward—pendulum movement.
Equalization of the different rotations of
these two tissue systems is established by
periosteal remodelling of the corpus as well as
the ramus. Remodelling at the lower border
increased when the matrix rotation and the
total rotation were in opposite directions, and
was reduced when the rotations were in the
same direction.
25
The extent to which orthodontic forces
may affect the rotation of the corpus inside its
matrix, as reflected by a change in the
remodelling during the treatment period, may
be determined by analysis of the effect of bite
raising. Space does not permit an extensive
report of the orthodontic cases analysed so
far but a single case will be discussed to
exemplify the general findings.
Case 10 (4982)—a boy with distal occlusion,
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an extreme overjet and a deep overbite. Metal
implants were inserted in both jaws and he
was examined annually from the age of 8.0 to
adult age. The general growth pattern of the
face and of the mandible was discussed in the
introduction to this paper (Figures 1 and 2).
When orthodontic treatment was initiated
at 14 0 years of age facial appearance was
characterized by marked forward rotation
(Figure 39). Both upper first premolars were
extracted, fixed appliances and headgear were
used until the age of 16.0 years followed by an
upper retention plate and a lower canine to
canine retainer until 18-0 years of age. The
occlusion was stable at the re-examination at
20.0 and 25.0 years of age.
Discussion of the effect of treatment is
based on the rotation diagram in Figure 40.
Before treatment the rotation pattern was
characterized by a backward rotation of the
matrix and steady forward total rotation until
puberty (Cx). During this period the difference
in direction of rotation was compensated by
forward intramatrix rotation which was
greater than the total rotation. After puberty,
but before treatment, the matrix rotation
changed from a backward to a forward
rotation so that the intramatrix rotation de-
creased relative to the total rotation: thus the
remodelling was smaller than in the first
period. This pattern changed markedly during
the treatment period when the deep overbite
was eliminated. This process is illustrated in
the insertion in the diagram, where the curves
for the matrix and total rotation at the
beginning of treatment have the same zero
starting point. During the treatment period
from 14.0 to 16.0 years, the matrix rotated
backwards +2.5 °. Despite bite raising, the
Iff
Figure 39 Case 14 (4982). Photographs at 14° and 18° years of age, before and after orthodontic treatment.
\ ..
Figure 40 Case 14 (4982). Rotation diagram showing
increased intramatrix rotation in the treatment period
indicating an increased remodelling of the mandible:
(T) total rotation, (M) matrix rotation, (IM) intra-
matrix rotation.
total rotation was unchanged. The intramatrix
rotation increased correspondingly, indicating
a greater increase in remodelling during the
treatment period than would be expected
without treatment. It must be remembered
that the backward rotation of the matrix
during treatment had its centre at the
condyles, while the induced intramatrix
rotation, the rotation of the corpus inside the
GROWTH OF THE MANDIBLE
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matrix, had its centre somewhere in the
mandibular corpus, probably at the incisors.
This analysis shows that bite raising
affected the remodelling of the mandible as a
whole, in a way similar to the effect of
headgear inducing a rotation of the maxillary
corpus inside its matrix. In both instances
there may be a tendency to some relapse. The
findings concerning the effect on the mandible
during orthodontic treatment may involve a
need for revision of current methods of
treatment and retention.
Backward rotation
The distinction between forward and back-
ward rotation of the mandible during growth
is based on the direction of the previously
defined total rotation.
Backward rotation, like forward rotation
of the mandible, can be divided into three
components of which total rotation is the sum
of the matrix and intramatrix rotation. In
forward rotating cases, the total rotation is
characterized by the fact that the intramatrix
rotation is usually the dominant component.
In backward rotating cases, however, two
types of rotation can be distinguished, one in
which backward matrix rotation is the
dominant component and the other in which
the backward intramatrix rotation dominates.
GROWTH OF THE MANDIBLE
Components ofmandibular rotation
The general tendency of the mandibular
corpus to rotate forward in the face during
growth was described in the first report on
implant studies by Bjork (1955). The much
less common backward rotation is more
complex and was not understood until later
(Bjork, 1962). The components are as
follows:
Total rotation This was explained and defined
on page 4. When the mandibular implant or
reference line rotates backwards relative to
the nasion-sella line total rotation is
designated as positive.
Where total rotation of the mandible is
backwards, both matrix and intramatrix
rotation may also be directed backwards thus
supplementing each other. However in other
cases where total rotation is backwards, the
matrix may rotate forwards thus there is
greater backward rotation of the intramatrix
with increased remodelling at the lower
MATRIX ROTATION
"PENDULUM MOVEMENT"
Figure 41 In backward rotating cases the matrix
rotation may, as in forward rotation, show a pendulum
movement with the centre at the condyles.
27
border. Total rotation does not have a fixed
centre and is dependent on the combination
of the rotation centres of its two components
which may change during development.
Matrix rotation This was also explained on
page 4. When the tangential mandibular line
MLX rotates backwards relative to the nasion-
sella line, matrix rotation is designated as
positive. As with forward rotation, matrix
rotation may show a pendulum movement,
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forward and backwards in the same subject
during the growth period, with the centre of
rotation at the condyles (Figure 41).
Intramatrix rotation When the implant or
reference line in the mandibular corpus rotates
backwards relative to the tangential
mandibular line intramatrix rotation is
designated as positive (Figure 42).
The centre of the intramatrix rotation is
situated in the corpus and not at the condyles.
When the mandibular corpus rotates back-
ward in the matrix the anterior part of the
INTRAMATRIX ROTATION
BACKWARD
-APPOSITION
-RESORPTION
Figure 42 Backward intramatrix rotation resulting in
resorption below the symphysis and apposition below
the angle. Apposition may occur at the chin point.
The centre of rotation is situated in the corpus.
28
corpus is pressed down into the matrix
resulting in resorption at the lower surface of
the symphysis, especially marked in cases
with extreme backward intramatrix rotation.
As the centre of intramatrix rotation is
situated anterior to the angle, the posterior
part of the corpus is lifted up from the soft
tissue matrix, stretching the periosteum, and
apposition takes place below the angle.
Facial development in backward rotating cases
Backward growth rotation of the face has
been generally considered to be simply a
backward rotation of the mandible with the
centre of rotation at the condyles. In fact,
facial development in backward rotating
cases is not a single growth pattern but
consists of a combination of a wide variety of
maxillary and mandibular rotation. Two
distinct types of facial development will be
described in four selected cases.
Case 11 (7176) This girl represents what has
been called a high angle case, or a long face
syndrome (Figure 43). Metal implants were
inserted in both jaws at the age of 9.6 years.
Her facial development around puberty has
been described previously (Bjb'rk and Skieller,
Figure 43 Case 11 (7176). Photographs at 9° and 24° years of age.
GROWTH OF THE MANDIBLE
1972). Early finger sucking was followed by
tongue pressure. The profile radiographs
(Figure 44) show an increase in the anterior
open bite during the observation period to
the age of 17.6 years, when the distal epiphysis
of the radius had closed and facial growth was
complete. At this age orthodontic treatment
was instituted with extraction of all first
permanent molars. Treatment with fixed
appliances was finished at the age of 20.6 years
and was followed by one year of retention.
She was re-examined at 24.6 (Figure 48) and
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30.6 years of age.
The rotation diagram (Figure 47)
illustrates the complex rotation pattern of the
mandible. During the period of observation
from the age of 9.6 to 17.6 years the
mandibular corpus continuously rotated
backwards in the face by +6.0 °, as seen from
the total rotation curve. The dominant
component was backward matrix rotation,
amounting to +4.0 °, added to which the
corpus also rotated backwards inside its
matrix by +2.0 °. The further effect of
orthodontic treatment on the mandibular
rotation was that the matrix continued to
rotate backward to +5.0 ° but there was no
intramatrix rotation. The total rotation was
thus +7.0 ° at the end of treatment. The
GROWTH OF THE MANDIBLE

Figure 44 Case 11 (7176). Profile radiographs at

9C, 17°, and 30° years of age.

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Figure 45 Case 11 (7176). Facial tracing with the
implant line at three stages. Dots indicate the yearly
position of the implants.

•7°

Figure 46 Case 11 (7176). Mandibular tracing

superimposed on the implant line.

MANDIBULAR ROTATION
BACKWARD
•8P
7176 9
o 1 -/-
106 126 146 16 6
Figure 47 Case 11 (7176). Rotation diagram showing cumulative age changes.
Figure 48 Case 11 (7176). Intraoral photographs at y° and 24° years of age.
position of the mandible in the face was
stabilised during the retention period and
remained stable in the follow-up period to the
age of 30.6 years.
In this case both the matrix and the
intramatrix rotation was backward in the
growth period to the age of 17.6 years. From a
clinical point of view it must be remembered
that, even if the total rotation of the mandible
is backward during growth, in some cases the
matrix may rotate in the opposite direction.
The classical method of determining total
rotation of the mandible, using the inclination
of the lower border of the mandible, is
therefore misleading.
GROWTH OF THE MANDIBLE
TREATMENT RETENTION
TOTAL 100%
MATRIX 71%
INTRAMATRIX 29%
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18° 2Cfi 24® 3O«YRS
In the facial tracing (Figure 45) the
inclination of the implant line at three stages
indicates a marked backward total rotation.
There is virtually no change in the position
of the temporomandibular fossae in the
cranial base. The symphysis moved forward
and was lowered in the face while condylar
growth was taking place, and subsequently
continued to be lowered during the treatment
period.
In the mandibular tracing (Figure 46) the
nasion-sella line at the three stages shows that
the total rotation was +7.0 ° backward up to
the age of 20.6 years and subsequently
unchanged. Considerable backward-directed
GROWTH OF THE MANDIBLE
growth took place at the condyles in associa-
tion with marked apposition along the entire
posterior border of the ramus and marked
resorption at the anterior border. The
apposition below the angular region is a
result of moderate backward intramatrix
rotation which lifted up the posterior part of
the corpus from its matrix. As is often the case
in backward rotating cases, the symphysis
was slender and of quite considerable height.
The alveolar prognathism decreased during
the growth period.
The facial growth in this case represents
an extreme example of normal variation in
facial physiognomy and illustrates facial
development in which the dominating factor
was backward matrix rotation, with only a
small amount of backward intramatrix
rotation.
Case 12 (1988) A different type of backward
rotating face, is seen in association with
hypoplastic growth at the mandibular
condyles in Stills' disease. The facial develop-
ment in a girl with juvenile rheumatoid
polyarthritis was followed annually from 8.3
to 17.3 years. Both mandibular condyles were
affected, with increasing restriction of jaw
movements. Assimilation of the atlas and
fusion of the upper vertebrae limited move-
ment of the head. The skeleton as a whole was
Figure 49 Case 12 (1988). Photographs at 8 3 and 173 years of age of a girl with juvenile rheumatoid
polyarthritis.
seriously affected, gradually making walking
impossible. No reliable indication of stages of
maturation could be used.
The face was malformed (Figure 49) and
the mandible was extremely retrognathic and
inclined backwards (Figure 50). Metal
implants were inserted in the maxilla and the
mandible. In the facial profile tracing (Figure
51) the implant line is shown at the first and
last stage. This tracing gives the impression
that only a minor positional change of the
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mandible took place. This relative stability,
however, only concerns the soft tissue matrix,
represented by the mandibular outline. As
determined from the implants, forward move-
ment of the mandible in the face was due only
to a small extent of growth, and mainly to
lowering of the condylar fossae in the cranial
base. The prominence of the symphysis in
the face increased further by apposition at the
chin point, which is not seen in normal cases.
Marked resorption of the condylar head
may occur in juvenile rheumatoid arthritis as
was shown on a skull by Alexandersen et al
(1979) and in longitudinal studies by Ronning
and Valiaho (1981). In the present case, only a
small amount of condylar growth took place
during the first half of the observation period,
followed by resorption at the condyles in the
second half. The symphysis changed its
forward course in the face during the later
 GROWTH OF THE MANDIBLE

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Figure 50 Case 12 (1988). Profile radiographs at 83and 173 years of age.

w
1988 9

Figure 51 Case 12 (1988). Facial tracing with the Figure 52 Case 12 (1988). Mandibular tracing
implant line at the first and last stage. Dots indicate superimposed on the implant line.
the yearly position of the implants.
GROWTH OF THE MANDIBLE

relative to the matrix. As the implant lines

MANOIBULAR ROTATION from the two stages intersect in the corpus the
1888 9 centre of total rotation cannot be in the
condyles: this centre is dependent on a
combination of the matrix and intramatrix
rotation centres.
The mandibular tracing, orientated on
the implant line, shows the remodelling of
the entire mandible during the rotation of the
corpus inside its matrix (Figure 52). The
intramatrix rotation evidently has its centre of

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83 103 123 I43 16 3 IS 3 2O3 YRS
Figure 53 Case 12 (1988). Rotation diagram showing
cumulative age changes.
Figure 54 Case 12 (1988). Intraoral photograph at
the age of 173 years.
observation period and was carried backwards
as can be seen from the implants in the facial
tracing (Figure 51).
The vertical development was even more
dramatic as is seen from the backward
rotation of the implant line in the facial
tracing. This backward total rotation raised
the posterior implant, indicating an upward
movement of the posterior part of the corpus
rotation in the corpus, at the occlusal surface
of the lower first molars and, later, of the
second molai s. The position of the intramatrix
rotation centre resulted in the symphysis
moving downwards into the soft tissue
matrix, with resorption at its lower border,
while the symphysis was drawn backwards
from its matrix at the chin point, with
resultant anterior apposition at the chin.
The photographs show that the rotation has
led to a soft tissue double chin typical of
backward intramatrix rotation. Also as a
result of the position of the intramatrix
rotation centre, the angular process is lifted
out of its matrix, leading to apposition at the
lower border in this area. There was con-
siderable remodelling of the ramus with
marked apposition along the entire posterior
border, including the neck of the condylar
process, and with extreme resorption
anteriorly at the ramus, including the
muscular process.
The eruption of the lower molars was
hindered by the abnormal growth pattern,
not allowing sufficient uprighting of the teeth
to compensate for the rotation. The inter-
molar angle was acute, characteristic of
backward rotation (Figure 50). There was
compensatory increased eruption of the lower
incisors and they became retroclined.
The yearly changes of the rotation
components during development are
illustrated in the rotation diagram (Figure 53).
Up to the age of 14 the matrix rotation was
somewhat forward (—3.0 °) returning to its
original inclination at adult age. Tn contrast,
the total rotation was directed continuously
backward to an extreme value of +16.0 °.
The intramatrix rotation during growth was

somewhat greater than the total rotation,
compensating for the forward rotation of
the matrix.
It is not known to what extent maxillary
growth is primarily affected in this disease.
The facial tracing shows a fairly normal
amount of forward growth of the maxilla,
more so than that of the mandible. It is
obvious however from the maxillary implants
and from the inclination of the anterior
surface of the zygomatic process that there
was increasing backward rotation of the
maxillary corpus, probably secondary to the
rotation of the mandibular corpus.
Despite the extreme rotation of the jaws, a
quite acceptable occlusion was maintained
due to favourable compensatory tooth
eruption, even though crowding of the teeth
developed (Figure 54). Orthodontic treatment
was not instituted because of the restricted
jaw movements and the general physical
condition.
Engel and Brodie (1947) pointed out the
characteristic shape of the lower border of the
mandible with angular notching in juvenile
rheumatoid polyarthritis. Odenrick (1977)
and other authors who have analysed the
facial shape in this disease noted the relatively
stabl? position of the mandible in the face.
Figure 55 Case 13 (2138). Photographs at 10' and 20' years of age of a boy with mandibulofacial
dysostosis.
GROWTH OF THE MANDIBLE
The extreme extent to which the mandibular
corpus could rotate backwards in its matrix
was first realised in a follow up study, using
metallic implants, of a case with juvenile
rheumatoid poylarthritis (Bjork, 1962). This
report clearly demonstrated that the centre of
rotation of the corpus inside its matrix was
not situated at the condyles but at the
occlusal level of the molars. Apposition at
the chin point was also observed in this first
case. This early implant study is of interest as
it reports a growth pattern exactly like that
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described in the present case.
It is obvious that orthodontic or surgical
treatment in a growing individual with this
deformity must be planned with due con-
sideration to the specific growth pattern.
Case 13 (2138) Mandibular hypoplasia in a
genetically transmitted craniofacial deformity
is now discussed. Facial development in a boy
with mandibulofacial dysostosis was followed
yearly from 10.7 to 20.7 years of age with
metallic implants in both jaws. Examination,
including radiographs, showed the physical
and skeletal symptoms characterizing this
disease. The physiognomy is shown in
Figure 55.
The mandibular condyles were small and
ball-shaped. In contrast to the mandibular
GROWTH OF THE MANDIBLE
Figure 56 Case (2138). Profile radiographs at 10' and 20' years of age.
hypoplasia in juvenile polyarthritis, the
condylar cartilage in this case retained its
growing capacity although to a somewhat
reduced degree. Movements of the mandible
were unrestricted.
The profile radiographs show that the face
is retrognathic with an extreme backward
inclined mandible (Figure 56). The implant
line at three stages is shown in the facial
tracing (Figure 57). It can be seen that there
was little change in the facial outline from the
age of 10.7 years. The mandible appears to
have been lowered in the face with little
change in inclination as assessed from its
lower border.
The protrusion of the mandible in the face
during growth was due to three factors:
lowering of the condylar fossae in the
markedly bent cranial base, growth at the
condyles, and marked apposition at the chin
point. The vertical development of the
mandible, as determined from the implant
line, was complicated and was characterized
by extieme backward total rotation of the
corpus relative to the anterior cranial base.
The anterior implant was continuously
lowered in the face in a somewhat backward
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direction. The lowering of the posterior
implant followed an s-shaped course, at first
forward, then forward and downward and
finally slightly upward. On the facial tracing
the implant lines from the three stages
intersect, indicating that the backward intra-
matrix rotation constituted the greatest part
of the total rotation, as in the case of juvenile
polyarthritis.
The rotation diagram (Figure 59) shows
that the intramatrix rotation was directed
backward by +13.5 °. The matrix rotation,
also backward-directed, was only +2.5 ° with
a maximum at puberty. This small change in
inclination of the lower border of the
mandible is apparent from the facial tracing.
The total rotation, the sum of these com-
ponents, increased to +16.0 ° backward,
with the curve following a steady course.
With the marked intramatrix rotation, a
considerable remodelling of the whole
mandible took place. The mandibular corpus
was rolled backward against the upper teeth
(Figure 58) thus the intramatrix rotation had
its centre at the occlusal surface of the lower
first molars and subsequently of the second
molars. Because of the short radius of
36 GROWTH OF THE MANDIBLE

H6°

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2138 6
107
157
20 7

Figure 57 Case 13 (2138). Facial tracing with the Figure 58 Case 13 (2138). Mandibular tracing
implant line at three stages. Dots indicate the yearly superimposed on the implant line.
position of the implants.

MANDIBULAR ROTATION

2133 <i

Figure 60 Case 13 (2138). lntraoral photograpn at

207 years of age.

25'YRS
Figure 59 Case 13 (2138). Rotation diagram showing
cumulative age changes. Stages in growth rate in
body height: (Hj) prepuberal minimum, (Hx) puberal
maximum, (Ru) union of distal epiphysis of radius,
(Hc) completion of growth.
rotation, the bony symphysis was pressed
downwards into the soft tissue matrix and
somewhat retracted from the matrix at the
chin point resulting in resorption at the lower
border and at the posterior surface of the
symphysis, while apposition took place at
the anterior surface of the chin. Change in
shape of the anterior surface of the symphysis
can be seen in the profile radiographs (Figure
56). When such apposition occurs at the chin
point in pathological cases the anterior
surface of the symphysis is not a reliable
contour in the determination of the inclination
of the symphysis.
GROWTH OF THE MANDIBLE
The backward intramatrix rotation of the
corpus lifted up the posterior part from its
matrix and there was apposition posteriorly
at the lower border, including the angular
process. It is evident in this type of growth
pattern with abnormal condylar growth, that
apposition at the angle results from the
angular process being lifted up from its
matrix and not from downward soft tissue
traction as suggested by Solow and Kreiborg
(1977) even though hyperextension of the
head may influence the development of the
facial height.
The ramus was rotated forward and
remodelled, with increased anterior resorption
and marked posterior apposition, by the
intramatrix rotation. It is important to note
that the remodelling affected the whole ramus,
including the hypoplastic condylar heads.
The limited cartilagenous growth at the
condyles could not account for the large
backward displacement seen in the mandi-
bular tracing (Figure 58). This observation
supports the view that if one growth factor is
inhibited it may be replaced by another
growth factor. When the condylar growth is
reduced the lack of cartilagenous growth may
be compensated by periosteal bone
production.
The facial tracing (Figure 57) shows that
the upper face was short sagittally with a large
anterior height. The anterior implant shows
that the sutural growth in sagittal length of
the maxilla was restricted and, as determined
from the change in inclination of the anterior
surface of the zygomatic process of the
maxilla, the maxillary corpus was rotated
markedly backwards. The nasal floor was
maintained parallel by compensatory re-
modelling. The typical shape of the nasal
floor can, as described by Delaire (1974) be
called a downward deflection of the maxillary
base, a shape which seems to characterize
the more pronounced backward growth
pattern.
Acceptable occlusion was maintained by
great compensatory eruption of the teeth
(Figure 60). It can be seen from the mandi-
bular tracing that the molars, secondary to
the rotation, were forced distally with some
37
uprighting. There was quite marked com-
pensatory eruption of the incisors and these
teeth were also directed distally. The curve of
Spee retained its characteristic reverse shape.
The abnormal condylar growth hindered the
eruption of the molars and their roots
consequently had to grow downward in the
bone, which is not seen in normal develop-
ment.
The anatomical aberration in mandibulo-
facial dysostosis has been further studied on
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dry adult skulls from our collection one of
which had all the characteristic symptoms of
this disease (Dahl et al., 1975), while two had
less pronounced symptoms (Dahl and Bjork,
1981). The constancy in the shape of the
lower border of the mandible during develop-
ment in this anomaly has been described by
Roberts et ah, (1975).
The present analysis however shows that
although the shape of the mandible was
constant, considerable remodelling occurred
on all surfaces. These aberrations could be
detected only by means of metal implants,
which justifies their use in pathological cases.
Case 14 (7255) Another aberration in
mandibular growth occurs in cases of bi-
condylar fracture. The displaced condyles are
normally resorbed and new condylar
heads develop (Lund, 1974). The influence of
the development of new condylar heads on
facial development and the subsequent growth
will be described.
This girl fractured both condylar processes
of the mandible at the age of 4.1 years. The
fractured and dislocated condylar heads and
the new developing condyles can be seen in
the frontal radiographs (Figure 62). Facial
development was followed at varying intervals
until the girl was 16.10 years old (Figure 61).
A monobloc was used for stabilization of the
occlusion in the first months after the fracture.
From the age of 4.6 to 13.6 an anterior open
bite developed. Orthodontic treatment, with
extraction of four premolars and fixed
appliances, was instituted after this age. The
bite continued to open anteriorly and the
appliances were removed at the age of 16.2
years. Development was subsequently

Figure 61 Case 14 (7255). Photographs at 4° and 1610 years of age of a girl with bi-condylar
fractures.
Figure 62 Case 14 (7255). Oblique frontal radiographs at 42 and 141 years of age illustrating development of
new condylar heads after fractures of both condyles.
observed to the age of 16.10 years when
growth had almost ceased.
An unusual type of growth and re-
modelling is seen in the mandibular tracing
(Figure 64). The growth at the condyles was
directed upward during the first years of
observation but then directed increasingly
backward. From the nasion-sella line, rep-
resenting the different age stages, it can be
seen that total rotation of the mandible
during the first years after the fracture was
directed forward and then gradually changed
to a backward direction. A similar pattern is
seen for the mandibular occlusal line. With
backward-directed condylar growth, the
angular process was beginning to increase in
size.
The changing growth pattern of the
GROWTH OF THE MANDIBLE
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mandible is reflected in the facial development
as a whole, determined from the outer
contours in the facial tracing (Figure 63).
During the first five years of observation the
inclination of the lower border of the
mandible decreased relative to the cranial
base and subsequently began to increase. At
first the lowering of the mandibular symphysis
was directed forward but from the age of 9.3
years the direction changed to downwards
and backwards. Tt is of interest that the
development of the maxilla, as seen from the
zygomatic process, showed a similar pattern,
possibly of a secondary nature, with a change
from a forward to a backward rotation.
The dramatic change in mandibular
rotation is easier to understand from the
annual changes in the composition of the
GROWTH OP THE MANDIBLE 39

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16"

Figure 63 Case 14 (7255). Facial tracing from seven Figure 64 Case 14 (7255). Mandibular tracing super-
age stages. imposed on a reference line in the corpus with
reference to natural structures.

rotation components (Figure 65). As a

MANDiBULAR ROTATION . result of the fractures, the total rotation
•8 7255 9 during the first five years was less forward-
/
directed than that of the matrix and therefore
•0
a backward intramatrix rotation occurred.
• 4
. Bl :ON0YLAR
FR ACTURE
N From the age of 9.3 years the total rotation of
the mandible changed its direction from
• 2 fliTRAUATaix j S I J forward to backward and, as the matrix
/1 rotation was still the greater and in the same
direction, the intramatrix rotation continued
- 2 /A I to be backwards. Orthodontic treatment,
instituted at the age of 13.6 years, resulted in
• 4
- V ^ TOT**- ^ x * / TKATMIMT
the total rotation increasing even more
MATRIX/^ rapidly in a backward direction and the bite
- 6
continuing to open, which led to the removal
0" II3
of the appliance at 16.2 years. The rotation
Figure 65 Case 14 (7255). Rotation diagram showing diagram shows that the treatment had caused
cumulative age changes. Ossification stages: backward total rotation that was greater than
(MP3cap) capping of diaphysis of middle phalanx of
the third finger, (DP3U) epiphyseal union of distal that of the matrix. During treatment the
phalanx of the third finger, (Ru) union of distal direction of intramatrix rotation changed
epiphysis of radius. from backward to forward, indicating that the
40
remodelling was reversed. This pattern
continued during the following eight months
of observation at the end of which the
epiphysis of the distal radius united and the
condylar growth was almost complete.
It is important to note that the fractures
affected condylar growth during the entire
growth period and not only in the first period.
This has been observed in studies of condylar
fractures by Ull Jacobsen and Lund (1972)
and by Lund (1974).
From the present study it may be suggested
APPENDIX: Superimposition of profile
radiographs by the structural method
Anterior cranial base orientation
The nasion-sella line (NSL) is a well
established reference line in morphological
craniofacial analysis from profile radiographs
at a single stage or in cross-sectional studies.
However, in longitudinal growth studies, the
nasion point and the sella point have to be
adjusted for displacement due to growth.
As a consequence of apposition in the
glabella region the nasion point (n) may be
displaced upward or downward relative to its
initial position throughout the entire growth
period. Eccentric remodelling of the sella
turcica during growth results in a displace-
ment of the midpoint (s) which is moved
backward by resorption at the posterior wall
of the sella turcica and possibly downward by
resorption at the floor or upward by apposi-
tion at the tuberculum sellae (Figure 69).
The posterior contour of the dorsum sellae
moves backward with mineralization of the
covering cartilage. In the following procedure
an attempt has been made to reduce these
sources of error by transferring the nasion-
sella line, as registered on the first radiograph
in the series, to the subsequent radiographs
after superimposition on certain structures in
the anterior cranial base and in the cranial
vault.
GROWTH OF THE MANDIBLE
that condylar fractures could, in some cases,
be a primary factor in the so called long face
syndrome. The study also points to the risk of
aberrant effects on condylar growth resulting
from orthodontic treatment in such cases.
The case illustrates the complexity in the
facial development that may be induced by
condylar fracture. The aberrent growth
pattern underlines our findings that there is an
independence in the development of the two
tissue systems - the soft tissue covering (or
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matrix) and the living bone.
This method of superimposition of profile
radiographs on structures in the anterior
cranial base is principally based on the
observation by De Coster (1952) of 'The
immutability of the basicranial line'. In
craniometry, superimposition of tracings
from sectioned.dry skulls on the pituitary
fossa and the cribriform plate was described
in 1922 by Keith and Campion.
Practical procedure The nasion-sella line
(NSL) and a perpendicular line through the
sella point (NSP) are drawn in pencil directly
on the first radiograph (Figure 68). The
subsequent radiographs in the series are
superimposed according to the structures on
the first radiograph, as described below. The
sella point and the crosslines are then
transferred from the first to the subsequent
radiographs. When nasion is displaced
vertically during growth it is projected onto
the transferred nasion-sella line.
Natural reference structures The method used
in our longitudinal growth studies for
superimposition by means of natural
structures in the cranial base is as follows
(Figure 66):
Sagittally: Radiographs from different age
stages are orientated by superimposition on
(1) the contour of the anterior wall of the sella
turcica, which does not show great
remodelling (Melsen, 1974) and, from the end
GROWTH OF THE MANDIBLE
NSP
14 CONTROL TRACING
Figure 66 The principles of superimposition of
profile radiographs using structures in the anterior
cranial base as reference.
Figure 68 The sella point is marked on the first
profile radiograph in a series. It is found by bisecting
the sagittal diameter of the sella turcica and the
height from tuberculum sellae to the floor.
of the juvenile growth period, on (2) the
anterior contours of the middle cranial
fossae.
Vertically: At the sella region the radio-
graphs are orientated by use of (3) the mean
intersection point of the lower contours of the
anterior ciinoid processes and the contour of
the anterior wall of the sella, which point is
made to coincide, Fig. 59 (Walker, 1972). The
orientation is further facilitated vertically by
41
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Figure 67 Facial tracing, of all stages, as a control of
the logical sequence of facial growth changes, using
structures in the anterior cranial base for super-
imposition (cf. profile radiographs, Fig. 12).
Figure 69 During growth sella turcica increases in
size by apposition on tuberculum sellae and by
resorption at the posterior wall and at the floor.
Points (1) and (3) are the most stable.
the observation that towards the end of the
juvenile period (4) the inner surface of the
frontal bone is stable over a short period, in re-
lation to the anterior cranial base and to the
sella point (Figs. 70, 71 and 72). In the anterior
cranial base the radiographs are orientated
vertically by coincidence of (5) the contour of
the cribriform plate, by (6) the contours of the
bilateral fronto-ethmoidal crests and possibly
also by (7) the cerebral surfaces of the orbital
42 GROWTH OF THE MANDIBLE

7017^

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Figure 70 Case 7 (7017). In the juvenile period the Figure 71 Case 7 (7017). From prepuberal age the
frontal bone translates forward. Implant in the frontal bone is normally tilted somewhat backward
maxilla indicates a simultaneous sutural translation of until adult age.
the maxilla.

" MM

7017 ' Logical sequence of growth changes Note that

. /
(9) the frontoparietal suture from about
("TtRNAl
7-8 years of age lies more posteriorly on
\- subsequent radiographs, and that (10) the
• Xs—\ '"
INTERNAL occipital bone is continuously lowered, most
clearly seen from its inner contour (Fig. 67).
<il
20 22
t
am By superimposition of radiographs from three
Figure 72 Case 7 (7017). Age changes in height of the or more stages it should be noted that in
brain case measured from sella to the frontal bone, untreated cases the points (11) articulare.
(4 in Fig. 66). Internal height normally increases until (12) pterygomaxillare, (13) anterior nasal
about 6-7 years of age and then decreases somewhat spine and (14) tip of the chin have a logical
until adult age. In the present case the increase was positional relation at the different stages.
2.5 mm and the decrease 3.5 mm, cf. Figs. 70 and 71.
External height decreases less, due to thickening of Orthodontic treatment may, however, in-
the skull cap. fluence the position of these points, 11 to 14.

Control tracing The first step in the cephalo-

roofs. Details in the trabecular system in the metric growth analysis is to transfer the
anterior cranial base may also be a guide. crosslines from the first radiograph to all the
Further guidance is provided by irregularities subsequent radiographs in the series, as
in (8) the inner contour of the frontal bone. described above. As a control of the cranial
GROWTH OF THE MANDIBLE
base orientation, a tracing like that in
Fig. 67, including all stages, has to be made.
The final facial tracings are simplified to
selected stages.
Mandibular superimposition
Due to remodelling processes, mandibular
growth cannot be analysed from profile
radiographs using the mandibular outline,
such as the lower border, as a reference line.
However, the growth analysis can be made
with sufficient accuracy by superimposition on
stable natural reference structures without
the use of metallic implants (Bjork, 1969).
Practical procedure On the first radiograph in
a series a reference line in the mandible
(REFi) is drawn with pencil from the anterior
contour of the chin to the lower contour of a
molar germ or to the contour of the mandi-
bular canal (Fig. 73). The subsequent radio-
graphs are then superimposed on natural
reference structures which will be described,
and the constructed reference line is trans-
ferred with pencil to these radiographs. To
facilitate superimposition, the reference line is
given a fixed length.
Natural reference structures The radiographs
(Fig. 73) are orientated sagittally by (1) the
r by (5) the lower contour of a mineralized
Figure 73 The principles for mandibular super-
imposition of profile radiographs using natural
structures in the mandibular corpus as reference.
43
-19°
20°
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Figure 74 Mandibular tracing, at all stages, as a
control of the logical sequence of mandibular growth
changes using natural structures for superimposition
(cf.Fig. 13).
anterior contour of the chin which is made to
coincide on two radiographs. Anteriorly the
radiographs are orientated in a vertical
direction by (2) the inner contour of the
cortical plate at the lower border of the
symphysis, and by (3) any distinct trabecular
structure in the symphysis. Posteriorly the
radiographs are vertically orientated by
(4) the contour of the mandibular canal and
molar germ before root development begins,
and possibly also of a premolar germ.
Logical sequence of growth changes When root
development of a tooth has started (5) the
lower contour may be stationary in the bone
for a period before upward movement starts.
The root is normally not lowered below its
original level. Further (6) the anterior contour
of the ramus lies more posteriorly on sub-
sequent radiographs, not anteriorly.
Exceptions Tn backward rotating cases, and
especially in pathological cases, (I) apposition
may occur at the chin point and (2) resorption
can take place at the lower surface of the
44
symphysis with apposition at its inner surface.
When molar eruption is hindered by the
occlusion, as may occur in backward rotating
cases, (5) the roots of the molars might be
depressed into the alveolar sockets as in
Case 12 and 13.
Control tracing The mandibular orientation is
controlled by making a detailed tracing (as in
Fig. 74) including all stages. The final tracings
include only selected stages.
Acknowledgements
This study was supported in part by grants
from the Danish Medical Research
Foundation and the Danish Dental
Association (F.U.T.).
Address for correspondence
Arne Bjork,
Vibeke Skieller,
Institute of Orthodontics,
Royal Dental College,
Jagtvej 160,
DK-2100 Copenhagen,
Denmark.
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