Growth Considerations
in Stability of
16 Orthodontic Treatment
CHAPTER OUTLINE
• Changes Related to Growth
– Growth Changes in Forward Rotating Mandible
Library of School of Dentistry, TUMS
– Growth Changes in Posterior Rotation of the
Mandible
For Personal Use Only
– Maxillary Growth Rotation and Stability
– Changes in Arch Width and Arch Length
– Growth Considerations in Stability of Extraction
and Non-extraction Treatment
– Growth Considerations in Retention Period after
Treatment in Various Types of Malocclusion
– Retention after Class II Correction
– Retention after Class III Malocclusion
Retention is defined as the process of holding teeth in
their optimal esthetic and functional position long enough
to aid in their stabilization. Success in orthodontic
treatment is achieved not only by correct diagnosis,
logical treatment planning and accurate treatment timing,
but also by planning of retention. The results achieved
after active orthodontic treatment are maintained by
retention appliances to prevent relapse. One of the main
problems in orthodontics is failure to maintain the
corrected relationships. The improvement achieved by
long duration treatment is lost in varying degrees after
the removal of the retention appliance. Studies on long
term assessment of post treatment results have proved
that relapse occurs in most cases. There has always been
a question about the achievement of long-term stability.
Relapse of corrected position of teeth after successful
orthodontic treatment is a source of annoyance to the
orthodontist. Nanda has stated that the change related
to growth, maturation, and aging of the dentition and
occlusion is one of the important reasons for the instability
of occlusion following orthodontic treatment. Relapse
is mainly due to the skeletal changes as a result of the
patient’s growth pattern. Despite considerations being
given to skeletal relationships at the initiation of and
during the orthodontic treatment, very meagre
consideration is given to the skeletal relationship during
retention. There are two reasons for this:
1. It is assumed that skeletal supervision is considered
secondary to dental relationship during orthodontic
treatment. Importance is given to the proper
interdigitation of the posterior teeth.
2. It is assumed that nothing can be done to control
the growth pattern of the patient.
The truth is that most of the patients whose
orthodontic treatment is completed are still going through
their pubertal growth spurt, which is more important
in boys than in girls, as they mature at a later period.
The failure to recognize the effects of dentofacial growth
after orthodontic treatment and its effect on the
morphology of the jaws might have an unfavorable effect
on the stability of orthodontic treatment. Therefore,
retention appliances should be selected based on the
dentofacial morphology and the expected magnitude
and direction of growth.
CHANGES RELATED TO GROWTH
Facial growth does not generally stop with puberty, and
the growth of the jaws continues till adulthood. This
progressive growth of the face results in a less convex
face, a less protrusive dentition with more upright incisors
and a more prognathic mandible. The amount of
changes produced varies both in males and females. In
males, these effects appear later, continue longer and
produce more marked changes. In a study by Bishara
 Growth Considerations in Stability of Orthodontic Treatment
about the changes in the face in adulthood, he concluded
that in male and female subjects, skeletal anteroposterior
and vertical linear dimensions continue to change
between 26 and 46 years of age.
In both male and female subjects, the lips became
more retruded relative to the nose and chin. The
implication is that orthodontic treatment at earlier ages
should not result in an overly straight soft tissue profile
and overly retrusive lips, since the expected changes in
the relative positions of the lips, nose, and chin may
exaggerate these characteristics.
In both male and female subjects, interincisor and
intercanine arch widths decreased, total arch lengths
decreased, and anterior crowding increased. Clearly,
these findings have important clinical implications
regarding the long range stability and retention of the
treatment results.
Library of School of Dentistry, TUMS
Generally, there is high variability in facial growth.
This was demonstrated by the Bjork implant studies. The
For Personal Use Only
variation is seen in the direction of facial growth as well
as in the growth of maxilla and mandible, and in the
eruption of teeth in the jaws. Bjork, from his implant
study for mandibular growth, concluded that the range
of variation of condylar growth in untreated normal
subjects may be as much as 42º, with a slight upward
and forward growth direction being most common, while
some people showed posterior condylar growth which
eventually showed distinct variations in the eruption of
teeth.
Growth Changes in Forward
Rotating Mandible
• In a pronounced forwardly rotating mandible, the
mandible teeth erupt and migrate mesially.
• The lower incisors are prevented from moving
forward—thereby increasing the crowding in the
lower arch and producing deep bite.
• For an anterior rotating mandible with a stable
occlusion, the fulcrum is at the incisors.
The goal of orthodontic treatment is to establish and
maintain normal, overjet and overbite relationships by
creating a solid fulcrum point at the incisors. By
positioning so that the interincisal angle is not too obtuse
and the lower incisors are not too upright, with the
required amount of torque in the upper incisors, the
anterior occlusion will be stable in an upward and forward
rotating mandible. Keeping the lower incisors too upright
263
in forward rotating mandible will cause further uprighting
of the incisors and eventually crowding will be the result.
In patients with severe class II malocclusions and deep
bite wherein treatment is completed early, the lower
incisors stability poses a serious problem. A fixed lingual
retainer banded to the second deciduous molar or first
permanent molar and a passive bite plane along with
a functional appliance worn at night could be given as
retentive devices. Although the continued facial growth
late in adolescence is outside the practitioner's control,
it is an important contributor to the stability of the
treatment results. In particular, the residual forward
growth of the mandible accommodates and largely masks
the tendency of the maxilla to grow forward and the crown
of the upper molar to drift mesially within the bone.
Growth Changes in Posterior
Rotation of the Mandible
In posterior condylar rotation, the amount of vertical
condylar growth determines the amount of increase in
posterior facial height. This type of rotation is less
common and here, the amount of increase in anterior
facial height exceeds that of the posterior facial height.
As the direction of eruption of incisors is more vertical,
the tendency towards retroclination and late incisor
crowding is also increased. Hence, long-term stabilization
of lower anterior teeth is absolutely necessary.
Maxillary Growth Rotation and Stability
Maxillary growth rotation is of less intensity than the
mandible. Due to the rotation of the maxilla, similar to
the mandible, the posterior teeth migrate mesially and
the anteriors show less forward movement, and hence,
more chance of incisor crowding. The lower lip plays
a major role the in development of upper incisor
crowding. Studies by Thuer have proved that the upper
lip is hypotonic in class II division 2 malocclusion and
that the lower lip is responsible for the upper crowding.
The same mechanism may be responsible for the relapse
of maxillary anterior crowding after treatment.
In patients with pronounced forward growth of the
jaws, there is more tendency towards class II molar
relation, due to more mesial inclination of upper molars
and distal inclination of mandibular molars due to growth
rotation. These changes are more or less pronounced,
depending on the intercuspidation and the function of
the soft tissue matrix.
 264 Textbook of Craniofacial Growth
Changes in Arch Width and Arch Length
Arch width and arch length changes with time. In a study
by Bishara about the changes in the arch width from
birth up to 45 years of age, he concluded the following:
• Between 6 weeks and 2 years of age, i.e. before the
complete eruption of the deciduous dentition, there
was significant increase in the maxillary and
mandibular anterior and posterior arch width in both
boys and girls.
• Intercanine and intermolar width significantly
increased between 3 and 13 years of age in both
the maxillary and mandibular arches. After the
complete eruption of the permanent dentition, there
was a slight decrease in the dental arch width, more
in the intercanine than in the intermolar width.
• Mandibular intercanine width, on the average, was
established by eight years of age, i.e. after the eruption
Library of School of Dentistry, TUMS
of the four incisors. After the eruption of the
permanent dentition, the clinician should either expect
For Personal Use Only
no change or a minimal decrease in arch width.
Changes in arch width continue even after the
cessation of growth. The changes in the arch width are
variable. There is a tendency towards decrease in the
arch width and length in early adulthood which is active
between the 20 to 30 year age span. Beyond 30 years
of age, the process continues and the constrictive trend
is very minimal. These unfavorable changes in arch width
and arch length result in crowding. The changes occur
regardless of whether the patient had orthodontic
treatment or not. Reidel has reported that even patients
who were atleast five years out of retention returned
to their original dimensions. Walter has reported that
slight increase in intercanine width can be maintained
after an adequate period of retention. This adequate
period was given as five years by Arnold.
Changes in post-treatment intercanine width were
also seen in patients, who had undergone extractions.
In Shapiro's study, he concluded that changes in
intercanine width were more stable in cases with class II
division 2 malocclusion and that the arch length reduction
in cases with class II division 2 was significantly less than
in cases with class I and II division 1 malocclusion.
Luiz G Gandini Jr and Peter H Buschang found that
the width of maxillary and mandibular basal structures
increased during late adolescence. Changes in the
maxillary width explained approximately 50 percent of
the variation among subjects with mandibular width
changes. Maxillary width increased more than mandibular
width, and the width changes were related with the
subjects' growth potential. Subjects with the greatest
growth potential showed the greatest width changes and
might be expected to tolerate the greatest amount of
therapeutic expansion.
Growth Considerations in Stability of
Extraction and Non-extraction Treatment
In patients with anterior growth rotation, extraction of
teeth in lower arch should be avoided and the potential
for sagittal and transverse expansion should be
considered before deciding on extraction. As a result of
extraction, an unstable occlusion is created and the front
teeth are too upright with an obtuse interincisal angle
which lacks an anterior fulcrum point. If extractions are
carried out, they should be done very early before the
growth spurt or before the growth pattern is clearly
expressed. Retention is more critical in these extraction
cases and must be maintained until the growth of the
condyles are completed.
When the condylar growth is directed posteriorly, the
natural tendency of the mandibular incisors to become
more crowded with time continues throughout the
growth period. Therefore, extraction decisions are not
made too early and in most instances, where posterior
rotation is anticipated, the extraction decision is delayed
until the completion of pubertal growth spurt. The degree
of growth rotation and the natural tooth migration is
unpredictable in this growth pattern. Hence, a permanent
lower lingual bonded retainer is recommended.
Growth Considerations in Retention
Period after Treatment in Various
Types of Malocclusion
Short Face Syndrome
As vertical growth occurs several years after the pubertal
growth spurt, the individuals with short face syndrome
with deep bite require a maxillary removable retainer
with a bite plane for several years after fixed appliance
orthodontics. Failure to recognize the dominant horizontal
pattern of growth of the individual may result in a “dished
in face” with or without extraction. Additional growth
of soft tissues especially the nose would further increase
the concavity of the face.
 Growth Considerations in Stability of Orthodontic Treatment
Long Face Syndrome
A high pull face bow is required to hold the molar position
vertically and prevent further dentoalveolar growth and
worsening of the facial profile.
Retention after open bite correction: Control of erupting
molars is the key to retention in open bite patients. An
alternative to high pull head gear is a posterior bite block
that provides several millimeters of jaw separation, e.g.
open activator or bionator. The bite block produces the
stretch of the soft tissues thus preventing the eruption
of the molars.
Patients with severe open bite problems can be given
conventional maxillary and mandibular retainers for
daytime wear and an open bite bionator as a night time
retainer, from the beginning of the retention period.
Jean Driscoll-Gilliland et al, in their study on stability
Library of School of Dentistry, TUMS
of treatment due to growth, concluded the following:
• Significant growth, especially in the posterior and
For Personal Use Only
lower anterior facial height, occurred beyond the age
when orthodontic treatment is typically completed.
• Tooth Size Arch Length Discrepancy (TSALD)
increased more in the untreated subjects than in the
treated subjects, and the difference might be a result
of the combined effects of growth and treatment.
• The subjects who had greater growth in the vertical
dimension and lower incisor eruption had larger
increase in space irregularity.
Retention in Class II Correction
Relapse in Class II correction can occur as two processes:
(a) Short-term relapse occurring due to local periodontal
and gingival factors. (b) Long-term relapse due to altered
jaw position.
The short-term relapse can be controlled by over-
correction and by avoiding too much proclination of lower
incisors. The long-term relapse occurs due to differential
jaw growth. This can be controlled in two ways:
1. After the fixed appliance therapy, head gear is given
on a part time basis to control the molar position.
Compliance is the major problem with head gear.
However, patients who were wearing the head gear
during treatment show good cooperation in wearing
it during retention phase also.
2. A functional appliance (activator or bionator) to retain
the occlusal relationship and tooth position. The
patient is advised to wear the appliance on a part
265
time basis during the night and the conventional
retainers during the day time. The wear of functional
appliance is good for people with skeletal discrepancy.
Retention after Class III Malocclusion
Retention after class III correction is difficult due to the
continuous growth of the mandible. The chin cup, as
a restraining force to the mandible, is ineffective and
only causes downward and backward rotation of the
mandible leading to an increase in the vertical facial
height. Surgical treatment after growth completion is the
only option for patients with vertical growth pattern and
class III malocclusion. A functional appliance or a tooth
positioner is usually sufficient for a mild class III
malocclusion.
BIBLIOGRAPHY
1. Bjork A. Variations in growth pattern of the human mandible
longitudinal radiographic study by the implant method. J
Dent Res 1963;42:400-10.
2. Jean Driscoll-Gilliland, Peter H Buschang, MA, Rolf G
Behrents. An evaluation of growth and stability in untreated
and treated subjects. Am J Orthod Dentofacial Orthop
2001;120:588-97.
3. Little RM, Reidel, Arton J. An evaluation of changes in
mandibular anterior alignment from 10-20 years post-
retention. Am J Orthod 1988;93:423-28..
4. Luiz G Gandini Jr, Peter H Buschang. Maxillary and
mandibular width changes studied using metallic implants.
Am J Orthod Dentofacial Orthop 2000;117:75-80.
5. Nanda R, Charles J Burstone. Retention and stability in
Orthodontics. WB Saunders Company. A division of
Harcourt Brace and Company; 1993.
6. Nanda RS, Nanda SK. Considerations of dentofacial growth
in long-term retention and stability. Is active treatment
needed? Am J Orthod Dentofac Orthop 1992;101:297-302.
7. Nanda SK. Growth patterns in subjects with long and short
faces. Am J Orthod in press.
8. Nanda SK. Patterns of vertical growth in face. Am J Orthod
1988;93:103-16.
9. Reidel RA. Post pubertal occlusal changes. In: McNamara
JA Jr (ed). Factors affecting the growth series. Ann Arbor,
Michigan, Center for Human Growth and Development,
University of Michigan 1977;113-40.
10. Shapiro PA. Mandibular dental arch form and dimension
treatment and post treatment changes. Am J Orthod 66:58-
70,197id4.
11. Walter DC. Changes in form and dimensions of dental
arches resulting from orthodontic treatment. Angle Orthod.
1953;23:3-18.
12. William R Proffit. Contemporary orthodontics. 4th edn,
2007 by Mosby Inc.