ORIGINAL ARTICLE

Maxillary width and hard palate thickness

in men and women with different vertical
and sagittal skeletal patterns
Ruoyu Ning,a Jing Guo,b Qiming Li,b and Domingo Martinc,d
Changsha, Hunan Province, and Jinan, Shandong, China, and Barcelona, Spain

Introduction: The objective of this research was to compare maxillary width and hard palate thickness in men
and women with different vertical and sagittal skeletal patterns. Methods: A total of 241 adults (93 men and 148
women aged from 18 to 25 years) were divided into male and female groups. Subjects were then separately
divided into 3 sagittal skeletal groups and 3 vertical skeletal groups. A lateral cephalogram and a cone-beam
computed tomography were taken for each subject. We measured the parameters to make statistical
analyses and compared them between the different groups. Results: Women had smaller craniomaxillofacial
bone width and palatal thickness than men. In sagittal groups, maxillary width, maxillary alveolar width, and
external temporomandibular joint fossa width in Class II and Class III malocclusion groups were smaller than
in the Class I group for both women and men. The internal temporomandibular joint fossa width was the
same results in men and women. In vertical groups, palate thickness, maxillary width, and maxillary alveolar
width of the high-angle group were smaller than those of the low-angle group, regardless of sex.
Conclusions: To an extent, maxillary width is correlated with vertical and sagittal skeletal patterns, and insuf-
ficient maxillary width would lead to unfavorable skeletal patterns. Differences exist in the morphology of cranio-
maxillofacial bone between men and women. Therefore, these findings can provide clinicians with references for
differential diagnosis and treatment plans. (Am J Orthod Dentofacial Orthop 2021;159:564-73)

M
alocclusions in 3 dimensions (3D) often occur
at the same time and usually interrelate with
each other. Growth follows the sequential
completion of the cranium followed by width (trans-
verse), then depth (sagittal), and finally, height (verti-
cal).1 Transverse growth was found to achieve near
completion by late adolescence. However, sagittal
and vertical growth continues well into adulthood.2
Therefore, lack of maxillary transverse width will affect
vertical and sagittal development of maxillofacial bone
in the early stages, which is hard to perceive. Malocclu-
sion usually occurs in mixed dentition or permanent
a
Lecturer, Department of Orthodontics, Hunan Xiangya Stomatological Hospital,
Central South University, Changsha, Hunan Province, China.
b
Department of Orthodontics, School & Hospital of Stomatology, Laboratory of
Oral Biomedicine of Shandong, Shandong University, Jinan, Shandong, China.
c
Private Practice, Barcelona, Spain.
d
Department of Orthodontics, Universidad Internacional de Catalu~
na, Barcelona,
Spain.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Jing Guo, Department of Orthodontics, School &
Hospital of Stomatology, Shandong University, 44-1 Wenhua West Rd, Jinan,
Shandong 250012, China; e-mail, guojing@sdu.edu.cn.
Submitted, February 2019; revised and accepted, December 2019.
0889-5406/$36.00
Ó 2021 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.12.023
dentition when the transverse development approaches
completion. For this situation, patients usually did not
report the insufficient transverse width but the sagittal
problem as their main complaint, so clinicians were
often more likely to pay attention to the sagittal
dimension. However, more recently, the contributions
of maxillary expansion have become well known by
many dental professionals. When making a decision
between nonextraction with maxillary expansion and
extraction treatment modalities in borderline patients,
clinicians should make differential diagnoses
cautiously and choose a treatment plan suiting the
maxillary width of the patient.
The attention to transverse width will be helpful in
malocclusion diagnosis, differential diagnosis, and the
formulation of treatment plans. In addition, maxillo-
mandibular coordinate width is crucial for a stable trans-
verse intercuspal relationship, stable mandible position,
comfortable condylar position, functional coordination
of maxillofacial nerve and muscle system, and a stable
long-term curative effect. In clinical practice, maxillary
skeletal expansions are usually used for insufficient
maxillary transverse width. Therefore, to guide screw
implantation and surgical design of expansion, we
measured the posterior portion of the hard palate, where

564
Ning et al 565

Table I. Detailed definitions of each measurement

Measurements Definition
CBCT (mm)
Bizygomatic width (ZZ) (Fig 2) ZZ, transverse width between the lateral pterygoid plates; Za, zygomatic arch
landmarks
Maxillary alveolar widths (BAC and LAC) (Fig 2) BAC, maxillary width at the level of the buccal alveolar crest; LAC, maxillary
width between the lingual alveolar crests
Maxillary widths (NF and HP) (Fig 2) NF, maxillary width parallel to the lower border of the CBCT image and
tangent to the nasal floor at its most superior level; HP, maxillary width
parallel to the lower border of the CBCT image and tangent to the hard
palate
TMJ fossa widths17,18 (Fig 3) External and internal TMJ fossa width (determined in the plane where
condyle had the largest length in coronal views)
LSF, latero-superior TMJ fossa landmarks; LIF, latero-inferior TMJ fossa
landmarks; CC, center of the condyles
Hard palatal thickness19 (Fig 5) Hard palatal thickness at second premolar and first molar levels; 5 palatal
thickness, midpoint of bilateral second premolar and palate middle seam;
6 palatal thickness, midpoint of bilateral first molar and palate middle
seam
Pterygoid width (PW)20 (Fig 4) Transverse width between the lateral pterygoid plates
Cephalometric
APDI ( ) APDI 5 :FH-NPog 6 :AB-NPog 6 :PP-FH
ANB ( ) ANB 5 :A-N-S :B-N-S
Sum ( ) Sum 5 :N-S-Ar 1 :S-Ar-Go 1 :Ar-Go-Me
Anterior cranial base length (SN) (mm) Line distance between sella point and nasion point
Posterior cranial base length (SAr) (mm) Line distance between sella point and articulare point
Sella angle ( ) :N-S-Ar
Articulare angle ( ) :S-Ar-Go

it was often the position of screw implantation in maxil- exclusions: (1) craniofacial anomalies, syndromes, severe
lary skeletal expansions clinically. asymmetries, and clefts; (2) crossbites and history of or-
In previous studies, scholars paid more attention to thodontic treatment; (3) degenerative diseases of
the issues of sagittal direction and vertical orientation. temporomandibular joint (TMJs); and (4) other systemic
However, concerns about the transverse problem were diseases and clinical history.
relatively insufficient. Because of race, sample sizes,
reference points, measurement parameters, and other
inconsistencies, the results of transverse width studies
by different scholars were diverse.3-16 Table II. Comparison of craniomaxillofacial bone di-
The purpose of this study was to investigate the dif- mensions in sagittal patterns of female subjects
ferences in transverse width and hard palate thickness in Class I Class II Class III
men and women with different sagittal and vertical pat- CBCT group group group
terns, which will provide references for our clinicians for measurements (n 5 66) (n 5 41) (n 5 41) F P
ZZ 118.17 117.85 116.60 0.766 0.467
diagnosis and treatment plan options for various sagittal
BAC 55.91 54.85 54.44 0.840 0.434
skeletal patterns, and vertical skeletal patterns as well. LAC 37.96 36.31 35.14 3.186 0.040
This study looked at Chinese Northerners, and the results NF 73.13 71.11 70.67 3.457 0.023
might not apply to people of other regions. HP 67.94 64.59 63.81 3.336 0.027
External TMJ 117.64 113.18 112.50 3.572 0.031
fossa width
MATERIAL AND METHODS
Internal TMJ 80.86 80.40 78.85 2.678 0.082
The research was done at the Stomatological Hospital fossa width
of Shandong University, from which information on 5 Palatal 4.21 4.12 4.78 1.144 0.322
thickness
consecutive records of 93 men and 148 women were ob-
6 Palatal 2.11 2.31 2.53 1.519 0.222
tained. Patients aged 18 to 25 years with permanent thickness
dentition were selected as experimental objects, PW 56.86 56.86 59.08 2.310 0.103
excluding the effects of growth and development. All Note. Analyzed using analysis of variance (P \0.05). Grouping prin-
subjects were Chinese Northerners with the following ciple: Class II, APDI \76; Class I, APDI 76-86; Class III, APDI .86.

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566 Ning et al

Table III. Comparison of craniomaxillofacial bone di- Table V. Comparison of cranial and maxillofacial
mensions in sagittal patterns of male subjects bone dimensions in vertical patterns for female
subjects
Class I Class II Class III
CBCT group group group Low-angle Average- High-angle
measurements (n 5 31) (n 5 27) (n 5 35) F P CBCT group angle group group
ZZ 122.47 125.18 124.01 0.991 0.375 measurements (n 5 40) (n 5 63) (n 5 45) F P
BAC 58.45 59.56 56.85 1.512 0.226 ZZ 118.75 116.12 117.91 0.196 0.822
LAC 39.74 36.50 36.78 4.479 0.014 BAC 56.43 55.45 53.58 3.389 0.024
NF 76.27 73.21 73.69 3.368 0.025 LAC 36.43 35.87 34.64 5.277 0.006
HP 68.19 65.17 64.98 3.385 0.024 NF 72.92 71.76 69.72 4.357 0.014
External TMJ 126.26 124.36 123.81 3.276 0.031 HP 67.59 66.93 64.81 4.179 0.017
fossa width External TMJ 116.01 115.33 114.4 0.311 0.734
Internal TMJ 86.22 83.92 83.30 9.580 0.001 fossa width
fossa width Internal TMJ 81.16 80.98 79.52 0.452 0.638
5 Palatal 5.87 5.06 5.38 0.615 0.543 fossa width
thickness 5 Palatal 4.85 4.41 4.02 3.571 0.021
6 Palatal 2.51 2.93 2.29 2.061 0.133 thickness
thickness 6 Palatal 2.28 2.44 2.76 2.808 0.066
PW 59.47 59.63 60.81 0.311 0.734 thickness
Note. Analyzed using analysis of variance (P \0.05). Grouping prin- PW 56.66 57.72 56.45 1.304 0.276
ciple: Class II, APDI \76; Class I, APDI 76-86; Class III, APDI .86. Note. Analyzed using analysis of variance (P \0.05). Grouping prin-
ciple (sum): low-angle, \392; average-angle, 392-400; high-
angle, .400.

Table IV. Comparison of craniomaxillofacial bone

dimensions in sagittal patterns of female and male
subjects Table VI. Comparison of cranial and maxillofacial
bone dimensions in vertical patterns for male subjects
Male Female
Low-angle Average- High-angle
Class I Class I Class II Class I Class I Class II
CBCT group angle group group
vs vs vs vs vs vs
measurements (n 5 28) (n 5 41) (n 5 24) F P
Class Class Class Class Class Class
Measurements II III III II III III ZZ 125.18 122.46 124.01 0.196 0.822
LAC 0.029 0.018 0.415 0.018 0.039 0.699 BAC 59.97 57.98 55.51 8.391 0.001
External TMJ 0.025 0.041 0.692 0.033 0.032 0.531 LAC 38.83 38.23 34.52 12.89 0.001
fossa width NF 77.43 74.31 72.57 5.243 0.007
Internal TMJ 0.009 0.007 0.771 – – – HP 71.15 68.10 65.73 5.379 0.006
fossa width External TMJ 125.48 124.65 123.81 0.311 0.734
NF 0.022 0.031 0.506 0.022 0.021 0.573 fossa width
HP 0.234 0.042 0.345 0.034 0.036 0.632 Internal TMJ 86.92 84.23 84.30 0.452 0.638
fossa width
Note. Tukey least significant difference used for analysis of multiple 5 Palatal 5.75 5.33 5.04 9.529 0.001
comparisons in sagittal patterns (P \0.05). thickness
6 Palatal 2.90 2.51 2.19 1.516 0.225
thickness
For each subject, data including lateral cephalogram PW 59.63 59.85 60.71 1.304 0.276
and cone-beam computed tomography (CBCT) (ac- Note. Analyzed by analysis of variance (P\0.05). Grouping principle
quired by New Tom 5G CBCT scanner, QR system, Ver- (sum): low-angle, \392; average-angle, 392-400; high-
angle, .400.
ona, Italy, with exposure settings of 110 kV, 12-in
field of view, and 5.4-second exposure time) with the
teeth in centric occlusion (obtained at the same time) consent statements were acquired from all subjects.
were collected to make an exact diagnosis and acquire Subjects were on premises to ensure against systematic
information regarding the 3D configuration of maxillo- diseases and contraindications, and they were kept
facial bone. Every original image file of CBCT was recon- under strict protection when CBCTs were taken. This
structed in 3D with Dolphin Imaging software (version study was approved by the Medical Ethics Committee
11.8; Dolphin Imaging and Management Solutions, of the Stomatological Hospital of Shandong University.
Chatsworth, Calif). The grouping principle and sample Head positions were standardized according to the
distribution are shown in Tables II-VIII). Informed Frankfort plane, and coronal and sagittal planes were

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Ning et al 567

recorded in CBCT. Cephalometric descriptions were de-

Table VII. Comparison of craniomaxillofacial bone
signed as anteroposterior dysplasia indicator (APDI),
dimensions in vertical patterns of female and male
sum angle, ANB angle, anterior cranial base length, pos-
subjects
terior cranial base length, saddle angle, and articular
Male Female angle. Detailed definitions19-22 of each measurement
High High vs Low vs High High vs Low vs
are shown in Table I, and the measurement of 8 trans-
Measurements vs low average average vs low average average verse dimensions and palatal thickness are shown in
BAC 0.001 0.099 0.054 0.016 0.140 0.512 Figures 2-6.
LAC 0.001 0.191 0.523 0.005 0.051 0.360
NF 0.006 0.472 0.421 0.012 0.089 0.675
HP 0.004 0.356 0.273 0.013 0.091 0.766 Statistical analysis
5 Palatal 0.006 0.257 0.198 0.021 0.235 0.475
To assess the reliability of these measurements, 50
thickness
subjects were randomly chosen. All measures were dupli-
Note. Tukey least significant difference used for analysis for multiple cated by the investigator (R.N) Casual and systematic er-
comparisons of vertical patterns (P \0.05). rors were calculated by comparing the first and second
measurements with the Dahlberg formula21 and depen-
dent t test at a significance level of 5%. All data were
Table VIII. Comparison of craniomaxillofacial bone analyzed with IBM SPSS statistical software (release
dimensions in male and female groups (P \0.05) 21.0; SPSS Inc, Chicago, Ill). Kolmogorov-Smirnov anal-
Female ysis and Fanchazzi test with P \0.05 were used for ho-
Male group group mogeneity of variance tests and normal distribution.
(n 5 148) (n 5 91) One-way or 2-way analysis of variance with Tukey tests
Measurements Mean SD Mean SD t P were used to explore the significance of differences be-
CBCT tween sagittal patterns, vertical patterns, and sexes. An a
ZZ 124.661 6.89 117.517 6.55 33.897 0.019 level of 0.05 was considered statistically significant.
BAC 58.789 3.76 55.172 4.03 31.507 0.020
LAC 38.020 3.25 36.267 3.83 42.377 0.015
RESULTS
NF 74.201 5.39 71.45 5.45 31.549 0.020
HP 67.339 4.97 66.54 4.26 31.378 0.020 The retrospective power was from 0.795 to 0.942.
External TMJ fossa 125.116 6.06 115.812 8.41 33.339 0.019 The intraobserver reliability of the measurements of all
width
descriptions using SPSS software was excellent, with in-
Internal TMJ fossa 85.305 5.14 80.337 6.47 25.895 0.025
width traclass correlation ranging from 0.812 to 0.933. The
5 Palatal thickness 5.594 1.59 4.406 1.48 14.118 0.045 Kolmogorov-Smirnov analysis and Fanchazzi test
6 Palatal thickness 2.815 0.65 2.438 0.76 13.939 0.046 showed that each data set conformed to the homogene-
PW 60.024 4.25 57.866 3.43 54.642 0.012 ity of variance tests and normal distribution. Two-way
Cephalometric
analysis of variance showed significant differences
APDI 83.422 10.25 81.456 8.55 83.864 0.008
Sum 394.258 7.94 395.920 8.77 475.318 0.001 between groups (Tables II, III, V, and VI). Therefore,
ANB 2.565 4.04 4.354 3.23 473.868 0.001 craniomaxillofacial bone dimensions were analyzed
SN 64.710 2.01 65.593 1.97 147.612 0.004 respectively for men and women (Tables IV and VII).
SAr 36.062 1.24 36.977 1.31 79.901 0.008 In women, significant differences in NF, HP, LAC, and
Saddle angle 124.495 5.33 123.558 5.06 264.679 0.002
external TMJ fossa width were observed between the 3
Articular angle 152.093 6.68 150.371 6.39 175.593 0.004
groups (Table II; P 5 0.023, 0.027, 0.040, 0.031). The
Class III group had the shortest NF, HP, LAC, and
standardized in CBCT. The Frankfort plane was oriented external TMJ fossa width; the Class II group had the
horizontally; the coronal plane was positioned passing second-shortest (Table II). Significant differences in the
through the inferior border of the external acoustic 4 descriptions were found between the Class III group
meatus of both sides, and the sagittal plane was posi- and the Class I group and between the Class II group
tioned passing through the anterior nasal spine and in- and the Class I group (Table IV; P \0.05).
ternasal suture (Fig 1). In men, significant differences were found in NF, HP,
Landmarks of CBCT were designated on the recon- BAC, LAC, and external and internal TMJ fossa width
structed 3D surface model. Bizygomatic width, maxillary (Table III; P \0.05). Class II and Class III men had
width, maxillary cross-arch width, TMJ fossa width, significantly smaller descriptions than the Class I men
pterygoid width, and hard palatal thickness were (Tables III and IV).

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568
Fig 1. Standardized head positions.
Fig 2. Maxillary and maxillary alveolar widths. NF, maxil-
lary width parallel to the lower border of the computed to-
mography image and tangent to the nasal floor at its most
superior level; HP, maxillary width parallel to the lower
border of the computed tomography image and tangent
to the hard palate. BAC, maxillary width at the buccal
alveolar crest; LAC, maxillary width between the lingual
alveolar crests.
Descriptive statistics for vertical patterns in cranio-
maxillofacial bone width of female subjects are dis-
played in Tables V and VII, which shows that BAC,
LAC, NF, and HP were significantly shorter in the high-
angle group than in the low-angle group. Moreover,
the high-angle group had the smallest hard palatal
thickness at the second premolar level (Table V), which
was also significantly smaller than that of the low-
angle group (Table VII; P 5 0.021). The results of the
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Ning et al
male vertical patterns were similar to the female vertical
patterns (Table VI).
This study found that the skull base and maxilla
morphology for male and female groups were different
in 3D. Transverse differences showed in the width of ZZ,
NF, HP, BAC, LAC, Pterygoid width, and internal and
external TMJ fossa, which were longer in the men;
sagittal differences showed in anterior cranial base
length (SN), posterior cranial base length (SAr), saddle
angle, articular angle, ANB value, and APDI value. SN,
Sar, and APDI in male samples were greater than those
in female samples. However, saddle angle, articular
angle, and ANB angle from male samples were smaller
than those from female samples; vertical differences
showed in hard palatal thickness and sum value. Male
subjects had a significantly thicker hard palatal thick-
ness and smaller sum value than female subjects
(Table VIII; P \0.05).
DISCUSSION
This study focused on the differences in transverse
width and hard palate thickness in sagittal and vertical
patterns. Although our experiment was designed on
the basis of sex, we found that the transverse differences
recorded in vertical and sagittal groups for both men and
women were the same. When we further analyzed cra-
niomaxillofacial morphology between the sexes, 3D dif-
ferences were also found, which provides references in
treatment timing and prognosis of different skeletal pat-
terns between men and women.
It is worth noting that we chose APDI and sum to
group the patients instead of using MP-SN and ANB
like most previous research work. The reason is that
ANB may easily be affected by lower facial height (AB
distance) and the position of N point when expressing
Ning et al 569

Fig 3. External and internal TMJ fossa width (determined in the plane where condyle had the largest
length in coronal views). LSF, latero-superior TMJ fossa landmarks; LIF, latero-inferior TMJ fossa land-
marks; CC, center of the condyles.

Fig 4. Lateral pterygoid plate width. PW, transverse width between the lateral pterygoid plates.

sagittal skeletal types. However, APDI can not only

Fig 5. Bizygomatic width. Za, zygomatic arch landmarks.
describe the positions of the maxilla and mandible rela-
tive to the skull base but also take into account the
compensation effect of lower facial height and vertical
patterns. APDI not just accords with the characteristics
of 3D malocclusion, which appear simultaneously, inter-
acting with and compensating for each other, but also
coincides with the fact that the skeletal and facial shapes
camouflage each other clinically in 3D.22-24 Hence, we
considered that APDI is more sensitive and reasonable.
Sum considered the determination of congenital
skull base on skeletal patterns and the muscle and
TMJ compensation, which is guided by the central ner-
vous system and influenced by environmental factors
during the postnatal growth process. It reflects the

American Journal of Orthodontics and Dentofacial Orthopedics May 2021  Vol 159  Issue 5
570
Fig 6. Hard palatal thickness: hard palatal thickness at
second premolar and first molar levels.
influences of heredity, environment, and their interac-
tions on vertical patterns. Sum describes the etiologic
mechanism of vertical patterns and reflects its compen-
satory mechanism, which is a relatively dynamic in-
dex.25,26 Therefore, we thought the sum was more
credible than the static index MP-SN.
For many years, studies on maxillary transverse skel-
etal and dentoalveolar and arch width of Class I, II, and
III malocclusions have been controversial.7-12 Some
scholars believed that the transverse width of the
maxilla and maxillary arch in patients with Class II
malocclusion was often less than patients with a Class
I relationship.7-11 Meanwhile, other scholars, such as
Fr€ohlich, thought there was no difference in
dentoalveolar and arch width between Class II samples
and Class I normal samples.10,12 In addition, some
scholars4-6 reported that maxillary transverse skeletal
and dentoalveolar and arch width of Class III samples
were smaller than those of subjects with a Class I
relationship. However, Braun,16 reported that the arch
width of patients with Class III malocclusion was wider
than that of patients with a Class I relationship. Sample
size, race, grouping criteria, and selection of measure-
ment items, to a large extent, caused inconformity. In
this study, we found that men and women had the
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Ning et al
same results, so the following description does not
take sex into consideration.
We measured and analyzed the maxilla, temporal
bone, and sphenoid bone measurements of the un-
treated Class I, II, and III samples. The results showed
that maxillary width (NF, HP) and maxillary alveolar
width (LAC) in subjects with Class II and Class III maloc-
clusion were less than those in subjects with a Class I
relationship; however, there was no significant differ-
ence between the Class III and Class II groups. The results
were consistent with Slaj,4 Kuntz,5 and Uysal.6
The development of maxillary width is basically
completed before the onset of growth burst and ends
earlier than maxillary height, depth development, and
mandibular development. Insufficient maxillary width
would affect the development, location, and range of
motion of the mandible.11 Most patients with a Class
III malocclusion had maxillary hypoplasia and mandib-
ular hyperplasia,27 which showed not only a backward
position of maxilla relative to the mandible in antero-
posterior direction but also an insufficient width in a
transverse orientation. Functional factors are also crit-
ical. Patients with Class II malocclusion had a relatively
smaller maxilla, which might be associated with different
nasal resistance, finger habits, tongue thrust, low tongue
location, abnormal swallowing, and sucking behaviors.7
The results reveal that the transverse and sagittal devel-
opment of maxillofacial bone interacts with each other
and that coordinated maxillomandibular width is signif-
icant for anteroposterior development.
The results show that for both female and male
groups, NF, HP, BAC, and LAC of the low-angle group
were larger than those of the high-angle group, but
there were no significant differences between the
high-angle group and the average-angle group or be-
tween the low-angle group and the average-angle
group. These findings are consistent with previous
studies.13-15 It is probably because the mandibular
plane angle plays a more important role in the
transverse growth of the maxilla than the dental arch
transverse growth itself.28 As mentioned earlier, lacking
maxillary width would affect the development and loca-
tion of the mandible.17
In addition, zygomatic arches mainly affect the mid-
dle third of faces,29 and sphenoid bones are closely con-
nected to maxilla that influences the lower third of facial
shapes.20 Therefore, we selected markers on zygoma and
sphenoid bones to make a preliminary exploration into
their association with facial patterns. However, we found
that ZZ and pterygoid width were independent of the
vertical and sagittal maxillofacial patterns in both male
Ning et al
and female samples, which just explain the complexity
and variability of craniofacial development. Lacking
the former correlative research, we hypothesized that
zygoma and sphenoid bone have little impact on maxil-
lofacial sagittal and vertical development through teeth
and muscles, which need to be investigated further in
future studies.
Our study found that hard palate thickness at the sec-
ond premolar level of hyperdivergent samples was
smaller than that of brachycephalic samples. A number
of studies on the relationship between vertical skeletal
patterns and maxillary and mandibular bone mass re-
ported that the alveolar bone mass in the hyperdivergent
group was smaller than in the other 2 groups.30-33 Our
study showed that the differences of palatine bone in
different vertical patterns were similar to those of
alveolar bone. The differences in the characteristics of
palate thickness among the groups may be attributed
to functional differences such as variations in muscle
position and forces.33 Perhaps patients with long faces
have lower masticatory muscle strength, which brings
about a weaker tension on the bone tissue, causing
less adaptive bone remodeling.19 So when the skeletal
arch is expanded with implant screws, clinicians should
focus on the thinner hard palate of hyperdivergent pa-
tients to prevent implant screws from penetrating nasal
mucosa and causing iatrogenic injury.
All of the transverse descriptions were longer in men
than in women, which was consistent with the results of
previous research.34-36 In sagittal dimensions, the small
saddle angle and articular angle of men resulted in
smaller ANB and larger APDI than in women. Thus, we
found a Class III tendency in men and a Class II
tendency in women. In vertical dimensions, the smaller
sum in the male group suggested a lower mandibular
angle, and the greater sum in the female group
indicated a higher mandibular angle.
Congenital and postnatal factors lead to those differ-
ences. The congenital skeletal and facial patterns are
determined by the shape of the skull base. The anterior
cranial base affects the position and width of the
maxilla, and the length and direction of the posterior
cranial base have more influence on the position of the
mandible.37,38 The SN and SAr of men are longer than
those of females, which indicates that men have a
more active anterior cranial base, and so develop a wider
maxilla. Men with a smaller saddle angle and articular
angle have a more forward mandible position, which
leads to a Class III tendency and counterclockwise
mandibular rotation positions.
Postnatal skeletal and facial patterns are related to
hormones and constitution and the time, rate, and incre-
ment of maxillofacial development.39 Maxillofacial
American Journal of Orthodontics and Dentofacial Orthopedics
571
muscles also have significant effects on vertical skeletal
patterns during the period of growth and develop-
ment.40,41 Men with smaller articular angles have greater
masticatory strength and more vertical muscle distribu-
tion, which leads to the mandible growing forward, re-
sulting in a low-angle, counterclockwise rotation
pattern trend. Women with larger articular angles and
whose smaller masticatory muscle force and inclined
muscle distribution cause the trend of a high-angle
pattern to have more clockwise mandibular rotation po-
sitions. Moreover, the mandible position is also impacted
by the stability of the TMJ disc. The stronger maxillofa-
cial muscle strength of men promotes a more stable soft
tissue in the TMJ area, whereas the weaker muscle
strength of young women tends to form a more flexible
TMJ disc and ligament, which leads to easier displace-
ment of the TMJ disc and articular cartilage damage.
When the disc displacement occurs in adults, pathologic
absorption or remodeling of the articular structure might
be caused to a certain extent, such as a short mandibular
ramus.42 When the disc displacement occurs during pu-
berty, the mandibular ramus and anteroposterior devel-
opment becomes restricted.43
This study suggests vertical or sagittal abnormalities
in patients might be traced back to whether those pa-
tients are essentially deficient in maxillary width, which
means that clinicians should be cautious when making
diagnoses and differential diagnoses. Dental arch
expansion is needed if there is a narrow width of the
dental arch, whereas skeletal arch expansion should be
considered if there is a narrow maxillary width.44,45
The findings also suggest that male and female pa-
tients might have different clinical considerations.
Because of the narrower maxillary width and Class II
malocclusion, and high-angle patterns, the rate of
maxillary arch expansion would be higher in women
than in men. It is beneficial to experience more mandible
growth in a relatively limited growth time, improving
their skeletal and facial shape in adulthood. The
adequate growth time and larger increment of the jaw
lead to greater unpredictability in the treatment of Class
III boys during adolescence. In contrast, clinicians could
make the best use of the growth potential of subjects
with Class II malocclusion to remedy the deficiency of
the Class II dental and facial type. The situation for Class
II women is just the opposite. Vertical control of poste-
rior teeth might be more difficult clinically for female pa-
tients. Because of the trend of brachycephalic pattern in
men, clinicians, when facing borderline brachycephalic
men, should carefully consider whether teeth extraction
would lead to slow space closure, excessive closure of the
face axis, teeth wear, and insufficient vertical height. In
addition, for male patients who have a deep bony
May 2021  Vol 159  Issue 5
572
overbite and muscular dysfunction, the symptoms are
hard to eliminate if the treatment relies on orthodontic
therapy because the strong mandibular muscle strength
of male patients would aggravate the bony closure. In
this case, clinicians should not ignore the importance
of orthognathic surgery, functional training, occlusion
plate, and botulinum toxin.
CONCLUSIONS
For both men and women, maxillary width, to some
extent, is correlated with vertical and sagittal skeletal
patterns. Insufficient maxillary width would lead to un-
favorable anteroposterior and vertical skeletal types.
There are differences in the morphology of cranio-
maxillofacial bone between the sexes. Women tend to-
ward a Class II and hyperdivergent pattern. The
conclusion proves to clinicians that vertical control and
risk assessment of temporomandibular disorder are
crucial in the treatment of women.
In contrast, men tend toward a Class III and brachy-
cephalic pattern. Therefore, because of their larger
growth increment and longer growth time of the
mandible, the decision-making of treatment strategies
and timing, prediction of camouflage treatment is
worthy of note for men with Class III malocclusion.
ACKNOWLEDGMENTS
The authors thank all the patients for their coopera-
tion and contributions to the study. We also thank the
School & Hospital of Stomatology, Shandong University,
for providing equipment.
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