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An investigation of maxillary superimposition

techniques using metallic implants


Diane M. Doppel, DDS, MSD," Ward M. Damon, DDS, MSD, Donald R. Joondeph, DDS, MS, b
and Robert M. Little, DDS, MSD, PhD c
Seattle, Wash.

The purpose of this study was to determine if there are discernable, stable, anatomic landmarks in
ttie maxilla that may reliably be used for maxillary superimposition. It was hypothesized that, through
the evaluation of cephalometric radiographs of patients with metallic implants, such anatomic
landmarks could be identified. The material for this study consisted of pairs of cephalometdc
radiographs from 50 subjects, 23 males and 27 females ages 8.7 to 20.3 years. All films were taken
at least 3 years apart. The mean age at the time of the first film was 11.9 -'- 1.4 years, and the
mean age at the time of the second film was 16.0 --- 1.7 years. The two serial tracings from each
subject were superimposed on the implants and evaluated for best fit of anatomic structures. The
maximum distance that the structures varied from perfect superimposition was measured. Rotational
changes of the maxilla relative to the cranial base and of the palatal plane relative to the maxilla
were evaluated. In the vertical plane, the floor of the orbit raised more than the palatal plane lowered
by an average ratio of 1.5 to 1 mm. The maxilla demonstrated varying degrees and directions of
rotation relative to the cranial base. The palatal plane demonstrated varying degrees and directions
of rotation within the maxilla. Internal structure of the palate was of limited value as a stable area of
registration. Infraorbital foramen, PTM, ANS, PNS, A point, and superior and inferior borders of the
palate were not found to be stable landmarks for maxillary superimposition. The posterior and
anterior portions of the zygomatic process of the maxilla were found to be the most reliable anatomic
landmarks for cephalometric superimposition. (AMJ ORTHOO DENTOFACORTHOP 1994;105:161-8.)

Superimposition of serial cephalometric ra- medial to the first molar. Bj/Srk felt that complete su-
diographs has been an invaluable tool for the ortho- perimposition of two or three implants in the maxilla
dontist in evaluating growth and the interaction of would provide a stable registration for superimposi-
mechanotherapy. The determination of the best method tion. t In studies that used these implants as registration
for maxillary superimposition has been problematic be- points, Bjrrk and Skieller4 found that during growth
cause of the difficulty in identifying stable anatomic there is an apparent shortening of the distance between
landmarks. Bjrrk's technique of implanting tantalum the anterior and lateral implants. They attributed this
markers in the human maxilla and mandible for accurate change to the two maxillae rotating in relation to each
serial superimposition has helped elucidate the dynam- other in the transverse plane secondary to apposition at
ics occurring within the facial skeleton.~3 the midpalatal suture. They found more transverse
The sites that Bj~rk ~ recommended for placement movement at the posterior portion of the palate than at
of maxillary implants include: (1) inferior to anterior the anterior portion.
nasal spine (anterior implant), (2) in the zygomatic pro- Several methods of maxillary superimposition have
cess of the maxilla (lateral implant), and (3) at the been described in the literature. The most common tech-
border between the hard palate and the alveolar process nique has been superimposition on palatal plane reg-
istered at a variety of sites, including anterior nasal
spine (ANS), posterior nasal spine (PNS), pterygo-
This article is based on research by Diane M. Doppel and Ward M. Damon maxillary fissure (PTM), and internal palatal struc-
in partial fulfillment of the requirements for the degree of Master of Science tures. 59 Superimposition has also been performed using
in Dentistry. Supported in part by the University of Washington Orthodontic
Alunmi Association.
nasopalatal and oropalatal surfaces as references. I'n
'In private practice, Seattle, Wash. Until 1974, RiedeP z in his postretention studies used
t'Associate Professor, University of Washington Department of Orthodontics. the outline of the infratemporal fossa and posterior hard
"Professor, University of Washington Department of Orthodontics.
Copyright 1994 by the American Association of Orthodontists.
palate. This method was abandoned because of findings
0889-5406194151.00 + 0.10 8t1/38650 that indicated that there is increase in the length of the
161
162 Doppel et al. American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

maxilla at PNS. 4 Brodie ~ also noted that PNS is of and vertical relocation of the infraorbital foramen, and
limited value as an area of registration as it is often (4) downward and backward rotation and lowering
obscured by the developing second molars. through remodeling of the palatal plane approximately
Moss and Greenberg ~3 noted a constancy in the re- 3 at its anterior extent.
lationship of the infraorbital canal and foramen on the Baumrind et al. ~8 evaluated ANS, PNS, and point
basis of a study of 47 Eskimo skulls. They advocated A relative to implants in 31 subjects and found down-
superimposing the maxilla by drawing a line along the ward displacement of PNS, elongation o f the palate
mean anterior cranial base and constructing a perpen- posteriorly, variability in the rotation of the ANS-PNS
dicular at the infraorbital foramen with registration at line, and differences in the remodeling pattern among
the infraorbital foramen. Bjrrk and Skieller, 4 however, treated and untreated subjects. They also found that
disputed this conclusion finding instead that these struc- superimposition on the ANS-PNS line masked the
tures follow the same changes as the floor of the orbit downward remodeling of both the superior surface of
and may also be altered by orthodontic forces. the maxilla and the palate. ]9
Bjrrk and Skieller4 found that the anterior surface Nielsen 2 compared superimposition along the pal-
of the zygomatic process was strikingly stable in the atal plane registered at ANS with superimposition on
sagittal direction for all nine cases they evaluated. They implants in 18 subjects. He found this method of su-
also noted appositional remodeling of the floors of the perimposition significantly underestimates the eruption
orbits and resorptive lowering of the nasal floor with of the maxillary dentition by 30% to 50%. In comparing
an apposition to resorption ratio of 3 2. The posterior implant superimpositioning with the method introduced
surface of the zygomatic process was found to be ap- by Bjrrk and Skieller, 4''6 Nielson found that Bj/Srk and
positional with the greatest apposition at the most in- Skieller's method demonstrated significant differences
ferior portion. ~4 in the horizontal plane with tess displacement of ref-
Kurihara, Enlow, and RangeP 5 found that there is erence points and no significant differences in the ver-
a time related reversal from deposition to the formation tical plane. Nielsen's application of Bjrrk and Skieller's
of resorptive fields on the anterior surface of the max- method consisted of superimposing on the anterior sur-
illary arch and the anterior surface of the zygomatic face of the zygomatie process of the maxilla with the
process. They found that the maxillary resorptive pat- second radiograph oriented so that the resorptive low-
tern is established in the deciduous dentition and con- ering of the nasal floor is equal to the apposition on the
tinues in the mixed dentition. The distribution, config- orbital floor.
uration, and size of the resorptive fields was found to The diversity in the findings of many of the re-
vary with the person. searchers indicates a need for further evaluation of the
On the basis of the findings of previous studies, 4.~4 stability of landmarks within the maxilla. The current
Bj&k and Skieller ~6 described a method of maxillary study will attempt to accomplish what other studies
superimposition. A common reference line (nasion- have not achieved by evaluating a larger sample of
sella) was suggested for evaluation of the degree and growing, implanted patients with control of such factors
direction of maxillary rotation. Changes in position of as accurate implant superimposition and stability.
nasion and sella with growth can be eliminated by draw- The purpose of this study was to determine if there
ing the nasion-sella line on the first radiograph and were discernable, stable, anatomic landmarks in the
transferring this line to subsequent radiographs after maxilla that may be reliably used for maxillary super-
direct superimposition on structures in the anterior cra- imposition. It was hypothesized that through the eval-
nial fossa and on the anterior wall of the sella turcica. uation of cephalometric radiographs of implanted pa-
The anterior contour of the zygomatic process is then tients, such anatomic landmarks could be identified.
superimposed. They stated that this method demon-
MATERIALS AND METHODS
strates well whether rotation has taken place, but that
the amount of growth in height at the alveolar process The material for this study consisted of pairs of cepha-
is difficult to evaluate because of the absence of a struc- lometric radiographs from 50 subjects, 23 males and 27 fe-
ture for registration in the vertical dimension. males as described in Table I. The majority of the subjects
Julius t7 performed a clinical study on 21 untreated selected were treated with mechanotherapy including standard
edgewide appliances, headgear, Class II or HI elastics, or
subjects with implants and found: (1) parallelism and
combinations thereof. The sample included subjects treated
approximate location of the posterior and key ridge with nonextraction or with a variety of extraction choices.
surfaces of the maxillary zygomatic process, (2) parallel The serial cephalometric radiographs were obtained from
relationships of the outlines of the anterior cranial base implanted adolescent patients at the University of Washington
and cribiform plate of the ethmoid bone, (3) anterior Department of Orthodontics from 1967 to 1975. There was
American Journal of Orthodontics and Dentofacial Orthopedics Doppel et al. 163
Volume 105, No. 2

no regard to type of treatment or timing of treatment. The Table I. S u m m a r y o f the sample


implants were placed according to the methods described by [ Totalsample [ Mate I Femate
Bj/Srk~ in the following sites: (1) inferior to anterior nasal
spine (anterior implant), (2) in the zygomatie process of the Sets 50 23 27
maxilla (lateral implant), and (3) at the border between the Range at TI 8.7-16.0 8.7-16.0 10.3-15.2
hard palate and the alveolar process medial to the first molar. Range at T2 11.9-20.3 11.9-20.3 13.9-19.6
Approximately 700 subjects from these files were re- Mean age, T1 11.9 -'- 1.4 11.7 .4- 1.5 12.1 - 1.3
viewed from which only 50 subjects were chosen. Most of Mean age, T2 16.0 - 1.7 15.8 .4- !.8 16.3 --- 1.5
the 700 implanted patients showed loss or change in orien- Longest TI-T2 6.4 6.4 6.3
Shortest TI-T2 3.0 3.0 3.0
tation of one or more implants because of bone resorption or
Mean TI-T2 4.2 0.96 4.1 - 0.85 4.2 1.06
poor technique of implant placement. A select group of 50
patients had two films with perfect orientation of the three TI = beginning of serial interval.
maxillary implants and further met the following criteria: 72 = end of serial interval, mean shown with standard deviation.
Recorded in years and tenths of years.
1. Two serial films at least 3 years apart.
2. High film quality.
3. Films had to be taken with the same cephalostat, all
facing right.
4. Zygomatie process of the maxilla, anterior, and pos-
4. Films had to demonstrate the same head orientation,
terior aspects.
that is, the same head tilt and rotation.
5. Lateral border of the orbits.
The. importance of head position was made clear by 6. Orbital floors.
Masumoto al and Damon ~2 who found that significant error 7. Infraorbital foramen.
may be introduced in projection of a landmark lateral to the 8. Pterygomaxillary fissure (PTM).
sagittal plane by varying head position. Julius t7 found that 9. Palate, superior and inferior aspects.
the zygomatic implant varied as much as 3 nun secondary to I0. Internal structure of the palate.
rotational head movements. He also found that patients could 11. Central incisor.
rotate their head as much as 3" and tip their heads 5 while 12. First permanent molar.
positioned firmly in a cephalostat. The areas evaluated to 13. Anterior nasal spine (ANS).
determine head orientation were (I) inferior border of the 14. A p o i n t - - t h e innermost curvature from the maxillary
mandible, (2) posterior border of the mandible, (3) orbital anterior nasal spine to the crest of the maxillary al-
areas (same relative position), and (4) infratemporal fossa veolar process.
(equal distance apart in both films). 15. Posterior nasal spine (PNS).
Thurow 23 suggested that the accuracy of tracing is no 16. Nasion--the junction of the nasal and frontal bones
better than 0.5 mm. To minimize tracing error, one operator at the most posterior point on the curvature of the
alone performed all tracings for the current study. Two suc- bridge of the nose.
cessive tracings of 10 films were constructed at 2-week in- 17. Radiopacities that showed up serially.
tervals to establish an accuracy of +--0.25 mm that gives a
total tracing error of 0.5 mm, the same level of error noted The two serial tracings from each patient were super-
by Thurow. A 3H lead held in an architect's pencil (KOH-I- imposed with registration on the implants and evaluated for
NOOR Adapto 5611, Kohinoos, Mississauga, Ontario, Can- anatomic best fit of the previously mentioned structures. The
ada) and sharpened to a needle point with a lead sharpener maximum distance that the structures varied from perfect
(Alvin 5555, Alvin, Ranchero Cordoza, Calif.) was used to superimposition was measured with digital calipers accurate
mark the tracings. This pinpoint sharpness was maintained to 0.01 mm. For curved surfaces lacking definite landmarks,
throughout the tracings. When structures demonstrated an multiple points were measured, and the average was calcu-
anterior and posterior surface or a superior and inferior sur- lated. Rotational changes of a line constructed through sella
face, the posterior surface and the inferior surface were uni- and nasion (SN), and of a line constructed through ANS and
formly traced. The successive tracings were then superim- PNS (palatal plane) were evaluated relative to a line drawn
posed, and areas not matching were measured with digital from the lateral to the anterior implants. The SN from the
calipers (Fowler Ultra-Cal II, Newton, Mass.). The areas first film was transferred to the second film by superimposing
traced included: on the cranial base structures as described by Bjrrk. '6

1. Clinoid process, anterior and posterior aspects. RESULTS


2. Anterior cranial base, represented by the sella-nasion
S u p e r i m p o s i n g each pair o f tracings on their per-
line.
fectly superimposed maxillary implants allowed for
3. Ethmoid triad, an oblique line composed of the lesser
wings of the sphenoid and the roof of the orbits m e a s u r e m e n t o f the distance each anatomic l a n d m a r k
bisected by the anterior border of the two greater varied from the first to the second film. The distance
wings of the sphenoid. measured represented reliability o f the anatomic land-
1 64 D o p p e l et al. American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

Table II. Summary of the maximum distance that structures varied after implant superimposition
S,ruc,l,re I N I ,eon I SO I Mioimu I
Clinoid process 50 2.64 1.43 0.58 7.50
Anterior cranial base 50 2.52 1.13 0.53 4.90
Ethmoid triad 50 2.52 2.01 0.23 11.99
Posterior key ridge 50 0.97 0.43 0.47 3.12
Anterior key ridge 40 0.95 0.57 0.15 2.56
Lateral border orbit 50 ! .27 0.72 0.41 4.29
Orbital floor 47 1.40 0.98 0.35 4.39
Infraorbital foramen 34 1.67 1.31 0.52 5.79
PTM-vertical 50 2.39 1.69 0.15 8.81
PTM-horizontal 50 1.52 0.99 0.30 4.10
Palate-superior border 50 1.05 0.52 0.43 2.90
Palate-inferior border 50 1.14 0.60 0.31 3.34
Palate-internal 50 0.85 0.43 0.28 2.45
ANS-vertical 50 1.29 0.86 0.15 4.82
ANS-horizontal 50 1.43 1.14 0.15 5.09
A point 50 2.13 1.63 0.15 6.55
PNS 27 2.27 1.75 0.32 9.10

Table Ill. Summary of rotational changes seen with implant superimposition


s ,,c,ure I I Meo I so I Minimum ] Maximum

Palatal plane TI-T2 50 0.92 2.10 8o _5


S-N line T1-'1"2 50 - 0.56 2.19 9o _ 6o

mark as compared with metal implant superimposi- the palate (X = 1.14 - 0.60). All other landmarks
t i o n - t h e less the average distance, the greater the re- were considered to have too low a reliability for prac-
liability (Table II). tical clinical application. The infraorbital foramen could
The internal architecture of the anterior maxilla su- be accurately traced in only 32% of the cases and dem-
perior to the incisor area appeared to be the most re- onstrated a significant amount of change. The PTM
liable landmark (average distance between contours showed substantial change both vertically and horizon-
= 0.85 + 0.43 mm). However, the distances mea- tally. The PNS demonstrated increase in length, as well
sured were quite small, and exact superimposition of as change vertically and was visible in only 52% of the
these structures was difficult. cases.
The posterior and anterior portions of the zygomatie The line ANS-PNS is often used to evaluate rota-
process of the maxilla were the next most stable, dis- tional changes of the maxilla, but is this line a reliable
tances between landmarks from first to second films tool? To assess reliability, the angle formed by the line
demonstrating clinically acceptable reliability (posterior or "plane" ANS-PNS and the line connecting the lateral
zygomatic process X = 0.97 __+ 0.43 ram; anterior and anterior implant was measured. Theoretically, there
contour ofzygomaticprocess X = 0.95 + 0.57 mm). should be no angular change with time. However, the
The posterior portion of the zygomatic process could angle was found to be quite variable with a range of
be accurately traced in 100% of the cases, whereas the change from 8 downward and backward to - 5 up-
anterior portion could be accurately traced in 80%. The ward and forward. This further demonstrates the lack
anterior portion was variable in the direction of change of reliability of ANS and PNS as appropriate landmarks
with 27.5% of the cases appearing to show anterior for superimposition and interpretation of change.
change, 35% showing posterior change, and 37.5% The angle formed by the anterior cranial base line
showing no mean anterior or posterior change. The S-N and a line connecting the lateral and anterior im-
posterior portion of the zygomatie process demonstrated plants demonstrates'maxillary rotation with time. The
posterior direction of change in all cases. 50 treated cases in this sample showed considerable
Next in reliability were the superior border of the treatment variation with a range from 9 downward and
palate (X = 1.05 _+ 0.52 mm) and inferior border of backward rotation to - 6 upward and forward rotation.
American Journal of Orthodontics and Dentofacial Orthopedics D o p p e l et al. 165
Volume 105, No. 2

DISCUSSION \
Zygomatic process. The present study found vari- |

ability in the anteroposterior position of the anterior


portion of the zygomatic process. In some cases there
was no mean change. In other cases it appeared re-
sorptive, which would concur with the findings of this
age group of histologic studies by Kurihara, Enlow, and / r
Rangel. 15 In other cases there was apparent forward
movement, which would concur with Bjrrk and
Skieller's 4 finding that the maxillae rotate in relation to
each other in the transverse plane because of apposition
at the midpalatal suture with greater movement poste-
riorly than anteriorly. Variability found in the current
study may be due to differential amounts of resorption
and anterior rotation.
Bjrrk and Skieller stated that the anterior portion
of the zygomatic process of the maxilla was the area
of greatest reliability for superimposition and found this
area to match almost exactly in each of the nine cases
they reported. Variability in the present study of the
anteroposterior position of this area may be related to
a larger sample size, or to superimposing exactly on
Fig. 1. Superimposition on palatal plane registered at ANS.
all three implants. Bjrrk and Skieller superimposed by
using the implant line registered at the lateral implant
with the intent to compensate for any possible anterior
rotation of the two maxillae. tions. Bjrrk and Skieller 14 in evaluating 21 untreated
hzternal maxilla structure. At first glance the sta- parapubertal subjects at 6-year intervals found that in
tistics for the internal structure of the palate appear quite addition to sutural growth affecting maxillary height,
promising as an area of stability. Unfortunately, there there was appositional growth of the alveolar process
are significant limitations to using this area for regis- in combination with resorptive lowering of the nasal
tration. The measurement of the maximum distance that floor. This remodeling was found to vary according to
structures within the palate changed that used implant the direction and magnitude of the rotation of the max-
superimposition was quite small, but when empirically illa and was of a compensatory nature. Findings from
viewing these structures, it could be seen that they did the present study showed considerable variability in the
not superimpose well. It would be preferable to use relationship of rotation of the maxilla to rotation of the
larger anatomic structures that consistently demonstrate palatal plane. This may be a result of the treatment that
superior best fit. these persons received.
Other structures. There was considerable variability Clinical implications. The method of maxillary su-
in the positions of PNS, ANS, A point, and PTM. perimposition, which most closely approximates im-
Rotation of the palatal plane and remodeling changes plant superimposition, appears to be on the anterior and
influenced the positions of both PNS and ANS. Tooth posterior contours of the zygomatic arches allowing for
movement and the forces of treatment may be partially the floor of the orbit to raise more than the palatal plane
responsible for the variability in the position of A point. lowers in a ratio of 1:5 to 1 mm (Fig. 7). Clinical
This investigation found that PTM moves vertically as conclusions can be greatly affected by the superimpo-
well as horizontally and is very inaccurate as a reference sition method. The degree to which anatomic super-
point. The floor of the orbit was found to be appositional imposition methods vary from the implant method is
with the palatal plane lowering because of resorptive demonstrated.
remodeling with a ratio of about 1.5 to 1, a finding in Superimposition on palatal plane registered at ANS
agreement with Bjrrk and Skieller~ and Nielsen. -' (Fig. 1). Note that the implants appear to move pos-
Maxilla rotation. A parallel relationship between teriorly and superiorly. Incisors appear to move lin-
the cranial base and the lowering of the maxilla was gually while molars descend vertically. The occlusal
not found, which may be due to the maxilla rotating plane rotates upward and forward.
with time and treatment in variable degrees and direc- Superimposition on palatal plane registered at PTM
166 Doppel et al. American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

I I
l

i S~'" I

. . S~
" /

.... : i 5C ...... 4

4,"k
I Ii a4

Fig. 2. Superimposition on palatal plane registered at PTM. Fig. 4. Superimposition on best fit of internal palatal structures.

\ method results in downward and posterior movement


of the implants. Incisors appear to erupt substantially
down and lingually, whereas-molars erupt vertically.
The occlusal plane rotates markedly in downward and
backward direction.
Superimposition on the internal architecture of the pal-
ate (Fig. 4). This method is similar to superimposition
on palatal plane registered at ANS. Incisors move lin-
gually and molars move vertically. The occlusal plane
rotates upward and forward slightly.
Superimposition on the anterior portion of the zygo-
matic process registered at the most hzferior portion
(Fig. 5). This method results in a slight downward
movement of the implants. Incisors and molars descend
vertically, the molars showing slight mesial migration.
The occlusal plane shows very slight upward and for-
ward rotation.
Superimposition on the posterior portion of the zygo-
matic process registered on the bzternal structure of
the palate above the hzcisors. (Fig. 6). This method
It I
demonstrates slight superior and anterior movement of
the implants. There is more apparent forward movement
Fig. 3. Superimposition on infratemporal fossa registered at
posterior of palate. of the molars with vertical eruption. The incisors show
slight mesial movement with less eruption.
There is a possibility for a systematic error within
(Fig. 2). The implants appear to move anteriorly and this study. It is possible that some of the implants only
superiorly. Incisors and molars appear to move labially matched well in the present sample because of slight
with minimal vertical descent. The occlusal plane ro- alterations in the subject's head position in the trans-
tates somewhat upward and forward. verse plane. Since the amount of shortening Bjrrk and
Superimposition on the infratenlporal fossa registered Skieller4 found between the lateral and anterior implants
at the posterior portion of the palate (Fig. 3). This was very small, a slight alteration in head position could
American Journal of Orthodontics and Dentofacial Orthopedics Doppel et al. 167
Volume 1 0 5 , No. 2

\
I

/,
t

Fig. 5. Superimposition on anterior border of zygomatic process


Fig. 6. Superimposition on posterior portion of zygomatic pro-
of maxilla registered at most inferior portion.
cess registered on internal structure of palate.

affect the apparent distances between the implants. Al-


t
teration in head position could influence the relative t
I
position of the anterior portion of the zygomatic pro- I
cesses in the anteroposterior direction. Although not
done in this study, bilateral placement of implants may
have been able to reduce errors caused by differences
in head position between films. ,r .
Systematic error may also be introduced in the use
is - ..t
of relatively closely spaced implants as the "gold stan-
dard" for superimposing. Slight, unavoidable rotational
errors would make the apparent error of a given struc-
ture a function of its distance from the implants. The
statistical findings of this study are also dependent on
empirical observations of best fit because of the t f
limitations of evaluating curved surfaces with mea-
surements between the multiple points along these . . . . .

surfaces.
It appears that there is no area in the maxilla that
is completely reliable as an anatomic area of cephalo-
metric superimposition. The best method of maxillary
superimposition appears to be on the anterior and pos-
terior contours of the zygomatic arches allowing for the
floor of the orbit to raise more than the palatal plane
lowers in a ratio of 1.5 to 1 mm (Fig. 7). Fig. 7. Illustration of individual case, closely representative of
mean findings, superimposed on implants.
CONCLUSIONS
Assuming that superimposition on metal implants 1. The posterior and anterior portions of the zy-
is the most accurate method for determining growth and gomatic process of the maxilla matched closely
treatment changes, the following conclusions may be with the implants. The anterior portion dem-
drawn from this investigation: onstrated a range of variation between films: no
168 D o p p e l et al. American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

mean difference, slight anterior change, or slight 12. Riedel RA. A postretention evaluation. Angle Orthod
posterior change. The posterior portion of the 1974;44:194-212.
zygomatic arch always demonstrated apposition. 13. Moss ML, Greenberg SN. Functional cranial analysis of the
human maxillary bone: I, basal bone. Angle Orthod
2. In the vertical plane, the floor of the orbit raised 1967;37:151.
more than the palatal plane lowered in a ratio of 14. Bjrrk A, Skieller V. Facial development and tooth eruption. An
1.5 to 1 mm. implant study at the age of puberty. AM J ORrUOD 1972;62:339-
3. The maxilla demonstrated varying degrees and 83.
directions of rotation relative to the cranial base. 15. Kurihara S, Enlow D, Rangel R. Remodeling reversals in anterior
parts of the human mandible and maxilla. Angle Orthod
4. The palatal plane demonstrated varying degrees 1980;50:98- i 06.
and directions of rotation within the maxilla. 16. Bjrrk A, Skieller V. Roentgencephalometric growth analysis of
5. Internal structure of the palate was of limited the maxilla. Trans Eur Orthod Soc 1977;53:51-5.
value as a stable area of registration. 17. Julius RB. A serial cephalometric study of the metallic implant
6. Infraorbital foramen, PTM, ANS, PNS, A point, technique and methods of maxillary and mandibular superim-
position. [Thesis.] Seattle: University of Washington, 1971.
and superior and inferior borders of the palate
18. Baumrind S, Korn E, Ben-Bassat Y, West E. Quantitation of
were not reliable landmarks for maxillary su- maxillary remodeling, 1. A description of osseous changes rel-
perimposition. ative to superimposition on metallic implants. AM J ORTHOD
DENTOFACORTHOP 1987;91:29-41.
REFERENCES 19. Baumrind S, Kom E, Ben-Bassat Y, West E. Quantitation of
I. Bjrrk A. Facial growth in man studied with the aid of metallic maxillary remodeling, 2. Masking of remodeling effects when
implants. Acta Odont Scand 1955;13:9-34. an "anatomical" method o(superimposition is used in the absence
2. Bjrrk A. Sutural growth of the upper face, studied by the implant of metallic implants. AM J ORTHOD DErCrOFAC ORTHOP
method. Eur Orthod Soc Report 40th Congr 1964;40:49-65. 1987;91:463-74.
3. Bjfrk A. The use of metallic implants in the study of facial 20. Nielsen I. Maxillary superimposition: a comparison of three
growth in children: method and application. Am J Phys Anthro- methods for cephalometdc evaluation of growth and treatment
pol 1968;29:243-54. change. AM J ORTHODDENTOFACORTHOP 1989;95:422-31.
4. Bjrrk A, Skieller V. Growth of the maxilla in three dimensions 21. Masumoto GT. An analysis of the use of the metallic implant
as revealed radiographically by the implant method. Br J Orthod method in superimpositioning of the maxilla. [Thesis.] Seattle:
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