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American Journal of ORTHODONTICS

V&me 6 2 , iVunahe~ 4, O c t o b e r , 1 9 7 2

ORIGINAL ARTICLES

Fad development and tooth eruption


An implant study at the age of puberty

A. Bjiirk, O d o n t . D r . , a n d V . S k i e l l e r , D.D.S.
Copmhngen, Denmark

During the growth and development of the face, compensatory change:;


in the path of eruption of the teeth occur which tend to even out positional
changes between the jaws. If such compensation is insufficient or does not OCCIII
at all, defective occlusion and space anomalies will result. Demonstrating tile
compensatory mechanism by means of conventional longitudinal radiographic
methods is more difficult with respect to the vertical than to the sagittal
tlevelopment of the face, and it is here that the use of metallic implants as
reference points is a particularly valuable technique. In this article special
emphasis is therefore placed on the association of tooth eruption with the vertical
tlevelopment of the face, as demonstrated with the aid of t,hc implant technique.
It is our hope that this investigation will contribute to the understanding
of the development of occlusion and spacing of t,he teeth at the time of puberty.

Material
The method by which the metallic implants are inserted in the jawbonc to
serve as fixed reference points on t,he films, t,he radiographic and graphic methods
used, and the samples examined have been dcscribetl e1sewherc.l For the purpose
of the present analysis, twenty-one subjects were chosen-nine girls and twelrc
boys (Cases 1 to 9 and 10 to 21, respectively). The metallic implants were insertecl
in both jaws, except in Cases 1 and 9, where they were inserted only in the

From the Institute of Orthodontics, Royal Dentd College, Copenhagen, Denmark.


This growth study was supported by United States Public Health Service Xenr~wl~
Grant DE-2858 from the National Institute of Dental Research, National Tnstitutrs
of Health, Bethesda, Md.

339
340 Bjtirk and Skieller

AGE DISTRIBUTION

19 7165
I9 5 1 8 5
17 582
16 lL52
15 3261
14 x33
13 53L5
12 30L5
11 9516
10 2323

9 1999

I
I e LO75

Q I
, 8 7 9160
I 6 557L

1I
5 8071
L 836L
3 5869
2 7176
1 20:6

8 10 12 1L 16 18 20
AGE IN YEARS

Fig. 1. Age distribution of the subjects studied over a &year period around puberty. Three
stages were recorded: (B) the annual observation, after which maximum condylar growth
was observed; (A) 3 years previously, and (C) 3 years later. In five cases the observation
period was 5 years. The subjects were numbered in sequence according to the time for
maximum condylar growth.

mandible. The analysis was confined to the lateral view. In order to obtain
uniformity with regard to physical maturity, the study was limited to a period
of 6 years around puberty. The subjects were numbered in sequence according
to the time of maximum puberal condylar growth (Fig. 1). From the annual
records of the longitudinal series, profile radiographs were selected that related
to three stages: film B, recorded at the annual observation at which the
condylar growth was found to have attained the puberal maximum ; film A,
taken 3 years previously; and film C, 3 years later. In four girls observation A
was one year shorter, and in one of the boys observation C was one year shorter.
All the subjects were in normal physical and mental health. As the illustra-
tions show, several of them had severe malocclusions, but no orthodontic therapy
was given during the observation period ; where required, it was performed later,
in some cases in combination with surgical treatment. Only children with sym-
metric facial development were included in the series.
The following deciduous or permanent teeth were missing or lost in the
course of the investigation : In Case 1 there was congenital absence of both upper
second premolars, with persisting deciduous molars. In Case 8 there was
Volwme 62
Number 4
Facial development and tooth eruption 341

congenital absence of the lower left second premolar; the deciduous molars had
been extracted at an early age, and the gaps had closed as a result of migration ;
the upper left deciduous canine had also been removed prematurely, and this
had led to impaction of the permanent canine. In Case 11 the upper left second
deciduous molar had been extracted at the age of 4 years and the corresponding
premolar had been impacted and therefore removed at 13 years, resulting in
distal rotation of the first premolar and mesial migration of the molars on this
side. In Case 13, the upper left first molar was extracted at 8 years, with
resultant forward migration of second and third molars. In Case 20 the lower
right first deciduous molar had been extracted at 7 years. Otherwise, no
deciduous teeth had been lost prematurely. In three cases molars had been
extracted without affecting the occlusal development: In Case 17 the lower left
first molar was extracted 1 month before the last examination, in Case 7 the
upper right second molar, and in Case 10 both lower second molars were
extracted 1 year before the last examination. In all but two cases the third
molars were present: In Case 7 there was congenital absence of the upper right
third molar, and in Case 16 there was congenital absence of all four third molars.
Method
The twenty-one subjects comprising the series are presented in Plates 1 to 21.
The facial photographs show the first and last stages and were taken with the
head in natural balance with the eyes directed straight forward. On the left,
above and below, are seen dental casts from Series A, and in the middle of the
plates are casts from Series C.
The cephalometric growth tracings show all three stages. The one on the right
demonstrates the growth of the mandible with orientation according to an
implant line (IPLi), drawn through two principal implants in the mandible.
The method for placing the implant line is described below. The position of
point articulare at the three stages of growth of the mandible was marked with
a cross. These points were used in calculating the direction of condylar growth
which, for the purpose of illustration, was marked on the top of the condylar
head with an arrow. While the contours of the mandible could be reproduced
to a high level of accuracy, the shape of the condylar head was more difficult to
establish and was drawn schematically.
The middle growth tracing illustrates details in the growth of the maxilla and
the paths of eruption of the maxillary teeth, with orientation in relation to an
implant line (IPLs) drawn through two principal implants in the maxilla. In
Cases 1 and 9, however, there were no implants in the maxilla.
The tracing on the left shows the development of the face, with orientation
in relation to the nasion-sella line (NSL) and a perpendicular drawn through
the sella point. The nasion-sella line was transferred from film A to films B and
C in accordance with the structural method described earlier.13 The position of
the nasion point in the three stages is indicated by a short line intersecting the
nasion-sella line. The position of the articulare point (here, too, indicated by
a cross at each stage) reflects the downward and backward displacement of the
condyles in relation to the anterior cranial base during growth.
Volume 62 Ftrcial development and tooth eruption 3 4 3
Nm7zbe~~ 4
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Number4 Facial development and tooth eruption 345

:
I

/ :
Volume 62 Facial development and tooth eruption 349
Number 4
Volume 62
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Facial development and tooth eruption 351
352 Bjiirk a n d Xkieller Am. d. Orthod.
October 19i
, .
Voh.me 62 Facial development and tooth eruption 353
Number 4
3 5 4 Bjbrk mad Skieller Am. J. Orthod.
October 1972
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Number 4 Facial development and tooth eruption 355
356 Bjiirk a n d Skieller Am. d. Orthod.
October 1 9 7 2
?u~,?Zr4 Facial development and tooth eruption 357
35% Bjiirk and Skieller A 111, $7. Orthod.
October l!li:!
Voltbme 62
Number 4 Facial development and tooth eruption 359

II
I
II
II

I,
360 Bjiirk and Skieller Am. J. Orthod.
October 1972
Volume 62 Pa&d development and tooth eruption 361
Number 4
362 Bjtirk aqLd Xkieller . I nc. J. Orlhod.
I)ctober1972
Volume 62
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Facial development and tooth eruption 363

The position and inclination of the teeth have been correctly reproduced,
whereas the shape has been drawn schematically by means of a template. On
the tracing of the facial development the position and inclination of the first
molar have been indicated by means of a longitudinal axis through the midpoint
of the occlusal surface. From these axes the changes in the sagittal molar oc-
clusion can also be read off.
The jaws have been drawn as midcontours, as have the teeth. In Cases 8, 11,
13, and 17, where some teeth were missing, the first molar on the unaffected side
was drawn. The photographs of the casts, like the cephalometric tracings, are
reproduced to half scale, and are therefore comparable in size, the radiographic
projective enlargement not being taken into account.
The tongue and lip function was analyzed radiographically with the help of
an image intensifier and a television monitor with video tape recording.13
Implant lines. With the method applied, the insertion of the implants and
their stability present no major problems. Differences in the position of the head
in the cephalostat from year to year could not be avoided completely. This
discrepancy does not affect the analysis based on implants placed in the midline,
that is, in the mandibular symphysis or between the roots of the upper central
incisors, but the analysis based on implants located laterally in the jaws may
be so influenced. An attempt to correct for this was made in the following way:
From each original negative radiograph, a positive logetronic film was made.
An implant line in each jaw was marked on each film by means of a cellophane
strip bearing a printed line, placed so as to pass through two selected principal
implants. Short transverse lines served to mark the center or tip of the implants.
Where implants were placed on both sides of the jaws, the correction of the
positional error was relatively easy. The point midway between similarly placed
implants on the right and left sides will have a practically constant position,
irrespective of a difference in position of the head, inherent in the radiographic
method. This procedure could be used for the maxilla, and in some subjects also
for the mandible.
In some cases in which implants were placed only on the side of the mandible
nearest the film, the correction was more difficult. Where, in an exposure, the
mandible was displaced to the right or left in relation to the other films of the
series, the posterior implant was projected further backward or forward. This
shift was corrected for by keeping the length of the implant line constant in
relation to the anterior implant. In the case of a vertical displacement of the
mandible to one side, a vertical correction of the position of the posterior implant
was made, amounting to one half the difference in the vertical divergence from
the average distance between the lower borders of the mandible in the successive
films. In all cases these corrections were relatively small.
Other reference lines used were also marked on the logetronic positive films
by means of lines printed on cellophane strips. As the last procedure, a negative
logetronic film was made from the positive logetronic film bearing the lines ; this
negative film was used for the measurements and tracings. The position of the
reference lines was recorded on punch cards by means of an X-Y recorder,
and the required angles and statistical data were calculated by eomputer.31
3 6 4 Bjbrk and Skieller Am. J. Orthod.
October 1972

10mm
t 4

Fig. 2. Illustrations of the variability in growth at the mandibular condyles over the
6-year period in relation to the ramus line (RL) at Stage A. The subjects were numbered
according to Fig. 1.

Measurements. Growth changes in thirty-two variables were determined,


twenty-eight of them angles and four linear distances (Tables IA and IB) . The
variables represented the following: No. l-the change in the direction of
condylar growth between the first and last observation periods, CDaB,-CDBc
(Fig. 2) ; Nos. 2 to 5-the direction of condylar growth from the first to the last
stages, CDA~, in relation to four reference lines at the first stage, A (Fig. 3) ;
No. 6-the direction of the lowering of the maxilla at its posterior border,
NSL*-PMAc (Fig. 4) ; Nos. 7 to 29the growth changes for other angles, from
Stages A to C ; Nos. 29 to H-the changes in occlusion ; and No. 32-the intensity
of the condylar growth. The data for each subject are given in Table IA and IB,
with the means and standard deviations for each variable. Tables IIA and IIB
present the correlations between all thirty-two measurements. In the statistical
calculations both sexes were combined. Since this study was confined to a growth
analysis, no metric account of the facial morphology at the various stages has
been included here, but the reader may gain an impression of this from the
tracings.
Volume 62
Number 4 Facial development and tooth eruption 365

PMAC

Fig. 3. Method for determining the direction of growth at the mandibular condyles with
orientation with respect to the implants from the first to last stage (CD,,), to four different
reference lines at Stage A: ramus line (RL), mandibular line (Ml), lower occlusal line
(Oli), and nasion-sella line (NSL).
Fig. 4. Method for determining the direction of the lowering of the maxilla posteriorly
from the first to last stage with orientation with respect to the nasion-sella line at the
first stage (NSL,PM,c). Method for determining the change in sagittal jaw relation from
the first to last stage (IP,-IPc) where the line IP was drawn through the most anterior
implant in the two jaws.

The sample was small and clearly contained a greater number of extreme
variants than would be expected in a random sample. The statistical account
has therefore been confined to what was considered most relevant to the discus-
sion. An attempt has been made to interpret the individual development and to
offer the reader himself the opportunity of studying each case by reference to
the tables and plates.
The following reference lines and measurements will be defined here. A, B,
and C denote the stages. Angular measurements are given in degrees and linear
measurements in millimeters.
Reference lines for angular measurements of growth changes from Stages
A to c:
NSL -Nasion-sella line; defined on film A and superimposed on films B and C.
IPLs -Upper implant line.
Oh -Upper occlusal line.
OLi -Lower occlusal line.
IPLi -Lower implant line.
ML -Mandibular line.
RL -Ramus line.
Table IA
Individual growth directions (variables 1-5) and individual growth changes (variables 6-16) from stage A to C
Mean (X). Standard deviation (s)

CL%%
114.2 IoQ.8 87.1 84.0 -5.6 -4.7 -10.7 -6.9 -2.7 3.2 8.4 0.2 7.7
: -14.5 14.5 -9.9 34.8 162.8 141.2 115.3 1Old 0.4 -5.9 2.9 5.3 3.6 3.7 -1.0 0 0.4 3.8
3 -4.2 -20.2 100.8 89.0 78.3 89.0 -3.7 -5.0 -4.4 -11.0 -7.7 -3.0 ;:: 12.1 -0.3 7.1
4 12.9 44.8 180.6 151.8 128.0 109.7 0.5 -5.4 -0.9 1.4 -1.8 -1.9 -4.1 4.2 4.1
5 -21.8 17.0 141.3 120.1 988 103.7 -4.6 -5.1 4.9 4.7 -3.6 6.4 -1.8 8.0 3.1 1.5
6 -9.6 4.0 129.9 105.2 101.3 81.5 -1.9 -6.0 1.3 -6.0 -1.8 2.7 4.3 13.0 7.5 7.7
7 1.1 . -a.5 135.2 117.6 97.4 4.3 4.9 -0.7 -6.6 4.0 -0.7 3.2 7.0 a.7 5.7
8 -5.7 -8.0 131.9 111.5 98.3 2; 0.9 -2.2 0.8 -2.5 -1.3 -1.7 -1.5 6.3 8.6 12.1
9 -16.8 4.7 128.4 110.2 94.3 90.5 -1.9 -3.6 -3.2 -1.5 0 4.1 4.8 0.4 4.1

10 4.9 -1.1 130.1 108.3 93.6 93.7 -0.8 -3.4 -7.4 -7.9 -3.8 -2.2 3.4 7.8 10.6 5.3
11 A.6 -7.2 119.0 101.3 88.4 89.2 -3.2 -2.7 -3.7 -6.6 -3.5 2.1 2.9 7.2 8.9 6.1
12 -2.0 -16.9 106.6 81.6 75.5 100.0 -8.8 -5.9 -3.4 -7.0 -4.2 0.9 8.0 7.7 1.9 8.5
13 -11.5 -3.4 127.2 106.2 88.5 87.4 4.1 -12.9 -11.8 6.6 -1.8 -0.9 3.9 7.9 5.7 8.3
14 -13.4 -19.3 91.3 80.5 72.4 95.5 -6.6 -7.7 -17.0 -16.4 -9.1 -1.3 -3.9 11.2 10.8 12.0
15 -12.1 -5.7 114.0 92.2 82.7 89.2 -5.4 -8.5 -6.6 -11.0 -5.2 -5.0 1.7 13.7 6.5 15.5
16 0.5 10.5 140.9 123.0 105.4 94.2 -2.0 -5.5 -2.9 -4.6 -1.5 0.4 8.4 4.4 2.7 1.3
17 -1.; -3.0 124.1 104.9 83.2 93.8 -2.0 -2.7 -3.5 -5.0 -1.3 3.1 -2.1 1.5 1.1 5.6
18 -12.6 14.3 146.2 122.7 100.8 -3.4 -2.6 -1.7 -5.2 -4.7 4.7 5.1 5.4 5.0
19 0.1 13.5 141.5 114.7 106.6 ii?: -1.0 -3.4 -3.8 4.4 -5.1 -3.4 -0.4 7:; 0.9 4.3
20 -1.5 -8.2 125.8 102.8 84.1 103.1 -1.8 -7.0 4.3 -7.3 -4.3 0.2 8.5 11.7 3.3 12.5
21 -14.8 1.0 136.0 114.6 94.1 95.4 -2.9 4.6 -1.8 -5.3 -1.5 0.2 -0.2 5.1 2.8 5.1

2 4.0 1.1 130.0 109.5 94.0 93.7 -2.5 -5.3 4.2 -6.0 -3.4 -1.0 2.3 7.1 4.5 6.4
s 9.1 16.5 20.0 17.3 133 7.1 2.1 2.5 4.4 4.5 2.7 2.7 3.9 4.3 3.6 4.4

Measurements to the reference line IPLS are based on 19 cases. All other mesurements are based on 21 cases.
Table IB
Individual growth changes (variables 17-32) from stage A to C
Mean (X). Standard deviation (s)

C&Se
1 -4.3 -2.9 -0.6 10.4 3.0 -5.9 3.7 -8.0 0 0 0 15.3
2 1.0 0 1.4 3.7 -0.6 0.4 -5.7 -9.1 -6.3 2.4 -1.8 1.8 3.5 -4.0 0 9.8
3 -5.5 -4.6 -3.4 -5.1 -0.6 8.5 11.3 3.9 -1.3 -6.6 3.3 -8.0 -0.5 0 0.5 14.8
4 -3.5 0.2 -3.5 -0.1 8.2 -3.6 -5.6 2.6 -6.0 2.3 -3.2 3.3 1.0 -1.5 -2.5 9.2
5 -6.0 2.8 4.9 -6.4 -6.3 3.7 1.7 3.2 -0.5 0.2 1.1 1.7 -2.0 0 -2.0 7.6 q
6 -7.0 -4.6 3.1 -5.3 2.4 11.1 -1.4 -1.7 -4.2 -7.3 4.2 -8.7 --2.0 -2.5 -1.0 18.8 8
7 6.5 -3.2 5.5 -1.3 -1.0 2.7 -2.0 0.9 -0.7 -5.9 2.7 -6.0 -3.0 -2.0 -3.5 13.7 S
8 -4.5 0.2 10.2 5.9 -0.6 7.2 -6.1 -9.6 -3.2 -3.3 1.2 -1.0 -2.0 -1.0 -1.0 10.6 N
9 -1.6 4.4 -0.8 2.8 -0.8 0.4 1.7 -3.3 -0.5 0 0 11.1 a
10 -8.0 -1.5 7.2 -2.4 2.5 6.9 -2.6 2.6 -2.6 -0.6 4.2 -5.8 -0.5 1.0 -1.5 14.5 s
11 -2.0 -5.8 5.8 -1.1 -0.3 4.0 -2.3 0.4 0.6 -2.9 3.0 -8.7 0.5 0.5 -0.5 17.0 8
13 -5.0 -0.9 1.8 0.2 -0.2 3.8 1.0 -1.6 -8.8 5.1 4.9 -5.7 1.0 -1.0 -1.0 15.8
14
12 -6.5
-2.5 -7.9
-5.1 14.7
-6.0 0.7
0.8 -10.5
7.2 4.6
6.9 5.6
5.0 - 14.4
.6 -1.1
-5.1 - 30.6
.6 7.3
2.8 -15.1
-7.9 .o
-13.0 4.0
-0.5 1.5 20.4
14.9 ij
15 -9.0 -0.1 4.8 1.8 -3.5 8.4 4.4 -4.5 -3.1 -4.4 5.9 4.0 -2.0 -1.0 0.5 19.2
16 -8.0 -1.9 -5.7 -3.1 6.4 rc
2.4 1.8 3.2 -3.5 -1.6 3.0 4.9 -2.5 -1.5 -5.5 17.2
17
18 -3.5
-8.5 -4.4
0.1 3.1
0.3 4.1
-3.7 -4.1
1.7 -0.5
5.3 3.9
-0.2 -0.6
0.3 -0.8 -1.5 3.6 -8.0 0.5 0 -1.5 17.8 s
0.8 2.6 0.6 -0.5 -1.0 2.0 -2.0 12.6
19 -2.5 -1.6 1.3 -3.1 -1.3 6.5 3.5 0 -2.6 -0.4 -0.8 -0.9 -1.0 1.0 -1.5 F4
13.6

21
20 -6.0
-5.5 -1.6
-4.6 3.0
-5.2 0.1
0.9 -3.3
6.8 2.1
9.9 2.6
3.9 0.2
-5.3 -3.7
-5.3 -3.5
-3.0 3.9
3.0 -5.5
-7.5 -0.50 -1.5 -2.0 14.5
-1.0 -0.5 15.6 2.
x -5.2 -2.4 2.1 -0.7 0.2 4.8 1.5 -0.5 -3.0 -1.8 2.6 -5.0 -0.4 s
-0.4 -1.1 14.5
s 2.6 2.6 5.3 3.1 4.8 3.7 4.7 3.9 2.5 3.4 2.5 4.4 1.7 1.7 1.6 3.4 s
g
Measurcmcnts to the refcrcnce line IPLs are basal on 19 cases. All other meswements are based on 21 CBSCF. =:
s
3 6 8 Bjiirk mad Skieller

Table IIA. Correlation Coefficients


Variables 1-5, growth directions, variables 6-32, growth changes from stage A to C

1 2 3 .a 5 6 7 8 9 10 II 12 13 14 15 16

C D ,,,-CD.,,. I 31 30 .4l ..50 .47 .68 .09 .48 .56 .42 .44 .36 --.58 m.14 -.34
51 .95 .94 .!I? .56 45 .lO .39 .79 37 --05 .lO -.71 --.20 -.74
so .95 .98 .96 .47 .56 .17 .43 .a7 .67 .03 .17 --.7? ~.I5 m.72
/i . . .49 .94 .98 .9s .42 .50 .19 .51 235 66 .03 .lO .i5 -m.16 -.75
CD \, -NSL,, 5 .50 .92 .96 .95 .36 .57 .22 .56 32 .61 .02 .13 -.66 --.ll -.73

NSL,-PM.,c 6 .47 .56 .47 .42 36 35 .oo .11 .42 .20 -.04 .lO -.52 -.24 -.42
NSL-IPLs 7 A8 A5 .56 50 .57 .35 .41 .68 .75 .62 .37 .25 -.58 mm.27 -.35
SSL-OLS 8 .09 .lO .17 .19 22 .oo .41 .41 .28 .oa .03 m.23 -.26 -.08 -.31
NSL-OLi 9 .48 .39 .53 .51 .56 .11 .68 .41 .71 .64 .39 .13 -.I1 --.33 -.33
ITSI..IPLi 10 .56 .79 37 .85 .a? .42 .is .28 .71 .88 .32 .o2 -.77 -.32 -.61

NSL-ML 11 .42 .57 .67 .66 51 .20 .62 .oa .64 .88 .56 -.05 -.65 -.18 -.39
NSI,.RI> 12 .44 -.05 .03 .03 .02 -.04 .37 .03 .39 .32 .56 .04 -.33 -.06 -.a4
NST..ILs 13 .36 .I0 .17 .lO .13 .lO .25 -23 .13 .02 -.05 .04 .I)4 .oo -.12
.usL-I\ioLs 1 4 -.5a -.71 -.72 -.75 -.66 --.52 m.58 -.26 -.41 -.77 -.65 -.33 .a4 29 .74
NSL-1L.i 15 --. 1 4 m.20 m.15 m.16 -.ll -.24 --27 -.08 -33 -.32 --.ia -.06 -.oo 29 .3?

SSI,-MOLi 1 6 -.34 --.i4 -.72 -.75 -.73 -.42 -.35 -31 -.33 - .61 --.39 -.04 -.12 .74 .32
IP,-IF,- 17 .58 .33 .24 .23 .22 .42 31 .14 .3P 27 .45 .51 -.18 -.54 m.42 -.24
KI..I\IL 18 -.oo .67 59 .67 .63 .27 .25 .04 .27 .60 .47 -.47 -.09 -.3+ -.14 -.3a
IL\-ILi 19 -.36 --.21 -23 --.18 -.17 --24 --.35 .12 -.32 -.24 -.09 -.oa -.74 .16 .68 .31
X101,\-MOLi 20 .32 -.05 -.Ol -.Ol -.lO .12 .32 -.06 .11 21 .3s .39 -.23 -.35 .OS .38

IPI.\-II.5 21 .54 .24 .39 .30 .36 .22 53 .07 .41 .40 .28 .22 .91 -25 -.20 -.3o
IPLS-MOLS 2 2 -.42 -.66 -.57 -.64 --.49 -.47 -.16 -.06 --.I? -.52 -.45 --.20 .13 .RO .20 .69
IPI,i-ILi 23 -.43 -.59 -.iO --.67 -.69 -21 -35 --.20 -.42 -.70 -.69 -26 -.03 .50 -.46 32
1PI.I.hJOLi 24 -.28 -.08 -.19 --.13 -.13 -.02 -.46 .o3 -.45 -A7 -.57 -.33 .lO .06 .Ol -.42
IPI.\-OLI 25 -.37 -.28 -.28 -.?l -.2-L -25 -.-1l .66 -.lt -.37 -.48 -.29 -.34 .24 -22 -.OO

IP1.i.OLi 2 6 .12 .54 .46 .46 .3fi .A2 .08 --.16 -.36 .39 .32 -.09 -.14 -.48 -.Ol -.3i
IPL->lL 27 --. 57 -.a1 --.82 --.a0 -~.a1 -.5+ -.67 -.42 -.59 -.84 -.t8 .O? -.09 .68 .39 .67
lPI.i.KI> 28 .31 .a4 .86 .a4 .R? .46 .52 25 .48 .a2 35 -.28 -.OO --.5R -.30 -3
O\I?RJET 29 .4o .19 .ll .08 .Ol .35 .A0 -.15 .oa .36 .34 .45 .oa -.45 -.39 -.I6
OW,RBITE 3 0 --.47 -.38 -.49 -.48 -.47 -.(I7 .A.5 .I9 -.79 -.64 .-.73 --.44 -.26 33 27 .la

MOLAR
OCCL. 31 -21 A0 -.60 -.63 -.59 .09 --.i6 -..16 -.30 -.37 -.34 .04 -.29 .39 -.04 29
CONDYL.
GROiVTH 3 2 -.18 -.62 -.67 -.68 -.62 -.48 -.47 -.34 -.43 -.70 -..41 .26 .12 .54 .30 .57

Measurements to the reference line IPLs are based on 19 cases. Significance levels: PCrO.05, r= 0.46 and PsO.01, r=0.58.
All other mesurements are based on 21 cases. Significance levels: PsO.05, r= 0.43 and P<O.Ol, r= 0.55.

IL5 -Upper in&al line; the axis of the upper central incisor.
YOLs-Upper molar line; the axis of the upper first molar.
ILi -Lower incisal line; the axis of the lower central incisor.
MOLi-Lower molar line; the axis of the lower first molar.
IP -A line through the most anterior implant in the upper and lower jaws.
CD -A condylar line, drawn through the articulare point at two stages with the mandible
oriented with respect to the lower implant line. For the purpose of illustration, this
line was transferred to the top of the condylar heads at the two stages (Figs. 2
and 3).

Angular growth chaTages:


CondyZar growth direction--The direction of condylar growth measured from the condylar
line CD,, to a reference line on Stage A (Fig. 3).
CD,,-CD,, -Curved path of condylar growth. The angle between the condylar lines
from Stages A to B and from B to C (Fig. 2).
P&O -A line through pterygomaxillare at Stages A and C, giving the direction
of the lowering of the maxilla at its posterior border. A change in the
8acial development and tooth eruption 369

Table II 6. Correlation Coefficients


Variables 1-5, growth directions, variables 6-32, growth changes from stage A to C
17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32

.58 -.OO -.36 .32 .54 -.42 -.43 -.28 -.37 .I2 -.57 .31 .40 -.47 -.21 -.18 1 Chr.%c
.33 67 -.21 -.05 .24 -.66 -.59 -.08 -.28 .54 -.81 .84 .19 -.38 -.50 -.62 2 CD,,-RL,
.24 .69 -.23 -.Ol .39 -.57 -.70 -.19 -.28 .46 -.82 .86 .il -.49 -.60 -.67 3 CD,,..ML \
.23 67 -.18 -.Ol .30 -.64 -.67 -.13 -.21 .46 -.80 .84 .08 -.48 -.63 -.68 4 CD,,,.OLi ,
.22 .63 -.17 -.lO .36 -.49 -.69 -.13 -.24 .36 -.81 .82 .Ol -.47 -.59 -.62 5 CD,,-NSL,
.42 .27 -.24 .12 .22 -.47 -.21 -.02 -.25 .42 -.54 .46 .35 -.07 -.09 -.48 6 NSL,,-PM,,.
.51 .25 -.35 .32 .63 -.16 -.55 -.46 -.41 .08 -.67 .52 .40 -.45 -.16 -.47 7 1uSL.IPLI
.14 .04 .12 -.06 .07 -.06 -.20 .03 66 -.16 -.42 .25 -.15 .19 -.I6 -.34 8 NSL-OLs
.39 .27 -.32 .11 .41 -.12 -.42 -.45 -.14 -.36 -.59 .48 .08 -.79 -.30 -.43 9 NSL-OLi
.57 .60 -.24 .21 .40 -.52 -.70 -.47 -.37 .39 -.84 .82 .36 -.64 -.37 -.70 10 NSL-IPLi

,45 .47 -.09 .35 28 -.45 -.69 -.57 -.48 .32 -.48 .55 .34 -.73 -.34 -.41 11 NSL-ML
.51 -.47 -.08 .39 .22 -.20 -.26 -.33 -.29 -.09 .O? -.28 .45 -.44 .04 .26 12 NSL-RL
-.18 -.09 -.74 -.23 .91 .13 -.03 .lO -.34 -.14 -.09 -.oo .08 -.26 -.29 .12 13 NSL-ILS
-.54 -.34 .I6 -.35 -.25 .90 .50 .06 .24 -.48 .68 -.58 -.45 .33 .39 .54 14 NSL-MOLa
-.4:! -.I4 .68 .05 -.20 .20 -.46 .Ol .22 -.Ol .39 -.30 -.39 .27 -.04 .30 15 KSL-ILi

-.24 -.38 .31 .38 -.30 .69 .32 -.42 ~00 -.37 .67 -39 -.16 .18 .59 .57 16 NSL-MOLi
-.08 -.15 .40 .08 -.37 -.24 -.37 -.28 .22 -.54 .25 .74 -.29 .29 -.35 17 IP,-IP,
-.OB -.02 -.05 .05 -26 -.45 -.25 -.18 .44 -.54 .89 -.I1 -.33 -.41 -.72 18 RL-ML
-.15 -.02 .21 -.77 .04 -.29 -.07 .38 .lO .34 -.20 -.32 .37 .19 .ll 19 ILS-ILi
.40 -.05 .21 -.07 -.26 -.24 -.66 -.32 .13 .oo -.03 .38 -.20 .28 .04 20 MOLs-MOLi

.08 .05 -.77 -.07 .04 -.25 -.12 -.45 -.04 -.40 .25 .23 -.40 -.28 -.17 21 IPLS-ILS
-.37 -.26 .04 -.26 .04 .36 -.20 .07 -.53 .44 -.40 -.34 .16 .41 .37 22 IPLs-MOLs
-.24 -.45 -.29 -.24 -.25 .36 .44 .19 -.36 .50 -.54 -.05 .39 .38 .43 23 IPLi-ILi
-.37 -.25 -.07 -.66 -.12 -.20 .44 .42 -.03 .22 -.27 -.23 .52 -.23 .17 24 IPLi-MOLi
-.28 -.18 .38 --.32 -.45 .07 .19 .42 -.29 .14 -.18 -.47 .56 -.09 .lO 25 IPLs-OLs

.22 .44 .I0 .13 -.04 -.53 -.36 -.03 -.29 -.35 .46 .36 .19 -.lO -.37 2 6 IPLi-OLi
-.54 -.54 .34 .oo -.40 .44 .50 .22 .14 -.35 -.87 -.28 .34 .29 .81 27 IPLi-ML
.25 .89 -.20 -.03 .25 -.40 -.54 -.27 -.18 .46 -.87 .lO -.38 -.40 -.87 28 IPLi-RL
.74 -.ll -.32 .38 .23 -.34 -.05 -.23 -.47 .36 -.28 .I0 -.18 .45 -.17 29 OVERJET
-.29 -.33 .37 -.20 -.40 .16 .39 .52 .56 .I9 .34 -.38 -.18 .28 .26 30 OVERBITE

MOLAR
.29 -.41 .19 .28 -.28 .41 .38 -.23 -.09 -.lO .29 -.40 .45 .28 .21 31 OCCL.
CONDYL.
-.35 -.72 .ll .04 -.17 .37 .43 .17 .lO -.37 .81 -.87 -.17 .26 .21 32 GROWTH

Measurements to the reference line IPLs are based on 19 cases. Significance levels: PsO.05, r= 0.46 and PsO.01, r=0.58.
All other mesurements are based on 21 cases. Significance levels: P<O.O5, r= 0.43 and P<O.Ol, r=0.55.

angle between PM and NSL indicates a forward or backward shift of


the maxilla (Fig. 4).
IP*-IP, -A change in the angle between IP at Stages A and C represents a gmwth
change in sagittal jaw relation; the sign is negative when the prognathism
increases more in the lower jaw than in the upper (Fig. 4).

Linear growth changes:


Condylar growth-Condylar growth intensity, measured in relation to the lower implant line
(Fig. 2).
Molar occl~.~ion -A change is negative when the lower molars move forward in relation to
the upper.
Overjet -A change is negative when the lower incisors move forward in relation
to the upper.
Overbite -A change is negative when the lower incisors move upward in relation to
the upper.

For more detailed definitions, see the works of Bj6rk7 and So10w.~~
Findings

Botation of the face. From the plates and tables, it is evident that the facial
development is characterized by a rotation involving both jaws. Judged from
the position of the implant line in the mandible in relation to the nasion-sella
line (NSL-IPLi)*e, Cases 2 and 4 showed a backward rotation (positive), while
for the other nineteen subjects the rotation of the mandible was forward in
direction (negative). For the maxilla, a forward rotation was present in eighteen
of the cases (NSL-IPLs)~~. A forward rotation thus seemed to be a general
feature of the facial development. The mean forward rotation of the mandible
for the whole series was -6 degrees, or -7 degrees if Cases 2 and 4 were excluded.
For the maxilla, the corresponding means for the forward rotation were -2.5
and -2.8 degrees. Although strongly correlated (r = 0.75), the rotations were
thus more than twice as great for the mandible as for the maxilla and the range
more than 3 times as great-22 degrees against 7 degrees ; this is explicable on
anatomic and functional grounds.
In conventional cephalometry without the aid of implants, an assessment of
progressing rotation of the mandible is complicated by the compensatory
remodeling at the lower border. Since the mean forward rotation of this jaw
for the whole series, as measured in relation to the mandibular line, was
-3.4 degrees, with a range of 13 degrees (NSL-ML)ae, it is evident that about
one half the rotation was masked by the remodeling. Most correlations were
therefore weaker with ML than with IPLi as the reference line.
The remodeling at the lower border of the mandible (IPLi-ML)ao was, on
the average 2.6 degrees for all cases, with a range of 10.5 degrees. When Cases
2 and 4 were excluded, the mean was 3.1 degrees (Fig. 6).
The nature of the compensatory remodeling at the lower border of the man-
dible has been described in earlier publications. In forward rotation there is a
marked apposition below the symphysis and the anterior part of the lower
mandibular border,jl g leading to an increase in convexity in this area, while
resorption below the angle of the mandible leads to flattening. Examples are
seen in Cases 1, 3, 14, and 15, which showed the greatest forward rotation.
In Cases 2 and 4, with a backward rotation of the mandible, there is a remodeling
in the opposite direction, characterized by only slight apposition below the
symphysis and the anterior part of the lower border of the mandible. This area
is therefore flattened or almost straight. Marked apposition below the angle,
on the other hand, gives rise to increased convexity in this area. That the type
of remodeling provides an indication of the direction of rotation to be expected
has been stated earlier.14
As clearly seen from the tracings, the inclination of the ramus in relation
to the nasion-sella line (NSL-RL) *o, unlike that of the body of the mandible
(NSL-ML)Ac, was, on an average, practically unchanged over the observation
period. The mean change in the ramus inclination was -1 degree forward, with
a range of 10 degrees. The individual growth changes were not significantly
correlated with the mandibular rotation (NSL-1PLi)Ao. This constancy in the
ramus inclination must be ascribed to remodeling of the ramus in order to
maintain its functional relation to the neck muscles and the spinal column.
The compensatory remodeling at the posterior border of the ramus was, on
volums 62 Facial development and tooth eruption 371
Number 4

an average, -5 degrees, with a range of 18 degrees (IPLi-RL)ao. From the


tracings, it is seen that this remodeling was dependent on the condylar growth
direction and also on the degree of appositional growth behind the region of the
angle. Accordingly, there is a difference in direction of this remodeling in cases
of forward or backward rotation of the mandible, as illustrated by Cases 1 and 2.
The gonial angle, RL-ML, decreases by the apposition at the posterior border
of the ramus and increases by the resorption at the lower border of the mandible.
As the former was the largest, the gonial angle, on an average, decreased by only
-2.4 degrees.
The resorption at the anterior border of the ramus in most cases was small,
amounting to only a few millimeters. The devolpment in length of the lower
dental arch was more dependent on its growth in height against the sloping
ramal border. As described above, this development in height was associated
with the condylar growth direction. For illustration, compare Case 3 with Case
4, which also show that the space for erupting molars furthermore is dependent
on the direction of the erupting teeth, but a metric evaluation of these space
conditions has not been included.
The general pattern of growth of the maxilla in lateral view was described
in 1955, in the first article on the implant method,e and subsequently in greater
detaillo ; it was shown that the entire increase in length takes place posteriorly,
with little if any remodeling on the anterior surface. Apart from the sutural
growth, the development in height takes place by appositional growth of the
alveolar process in combination with a resorptive lowering of the nasal floor. This
growth pattern was recognizable in all of the present cases. Moreover, it was
found that the remodeling at the nasal floor varied according to the direction
and magnitude of the rotation of the maxilla. The remodeling was greatest
anteriorly or posteriorly according to whether the rotation was, respectively,
forward or backward, and was thus of compensatory nature. The inclination
of the nasal floor in the face therefore showed great stability, irrespective of the
direction and magnitude of the rotation of the maxilla. The greatest forward
rotation of the maxilla was noted for Cases 3, 5, 7, and 13 to 15; backward rota-
tion was found in Cases 2, 4, and 8. The remodeling at the nasal floor is clearly
illustrated by tracings, but no metric evaluation was made in this study.
Another finding of interest was the existence of a relationship between the
growth change in anteroposterior position of the maxilla as a whole, NSLA-PMAC
(Fig. 4) and the condylar growth; this will be discussed in the correlation analyses.
The causal factors in facial rotation remain to be fully explained. Attention
has previously been focused on condylar growth.g, 34 While this is no doubt an
essential factor, others are probably also involved ; one of these is development
of the cranial base,S where a marked lowering of its posterior part and the
mandibular fossae results in an increase in the posterior face height, as ex-
emplified by Cases 10 and 15 in contrast to, for instance, Case 2. The instability
of the incisal occlusion, as in Cases 10 and 14, may also have an influence and
likewise lip and tongue dysfunction, as in Case 12, and the interaction of the
jaw and neck musculature as a whole. In the puberal period with which we are
concerned here, however, the condyles are the center of the greatest growth in
the craniofacial complex, and this growth therefore merits special discussion.
Co~dyZar growth. The intc~sity of the condylar growth was determined 111
adding the growth from ,Stages A t o R a n d B t o C, with orientat.ion of the
mandible with respect t o t h e lower implant line (Fig. 2). Disregarding the
obvious sex difference, the intensity of the condylar growth was strongly co1*-
related with the rotation of the mandible and also significantly, but less
strongly, with the rotation of the maxilla.
The curved path of the condylar growth was determined by the angle
CDAB-CDBC (Fig. 2). The growth in most cases followed a path that curved
forward (negative) through a.17 angle of, on the average, -8 degrees with a
range of 22 degrees (Cases 2 and 4 excluded). In Case 4 there was a backward
curvature (positive) of 13 degrees, and in Case 2 of 15 degrees. The correlations
between the curvature and the rotation of both jaws were significant.
The directioyl. of condylar growth was determined by the angles that the
condylar line CDac formed with four reference lines in Stage A (Fig. 3). The
curved path of growth was thus disregarded. The four measurements are
numbered 2 to 5. Easiest to illustrate is the direction of condylar growth
measured in relation to the ramus line RLA (Fig. 2) ; when Cases 2 and 4 were
excluded, the mean direction was -3 degrees, the sign denoting a forward direc-
tion. Fig. 3 also shows the other reference lines used-the mandibular line, ML*,
the lower occlusal line, OLia, and the nasion-sella line, NSL*. The differences in
variability were striking, the range being smallest for measurements to NSLA
and greatest for measurements to ML*. The most reasonable explanation of these
differences would seem to lie in the variation of the reference lines themselves.
For practical reasons, the ramus line can be selected in clinical work.
There was a strong correlation between the condplar growth direction and
the rotation of the mandible. For all four reference lines, the correlations were
of the same strength. Similar correlations, though weaker, also existed between
the condylar growth directions and the rotation of the maxilla. The intensity
of the condylar growth was strongly correlated with the direction of condylar
growth but not with the curving. The correlation between the curvature and the
direction of growth, on the other hand, was of only moderate strength.
Tooth eruptio?z and growth of the face. It is essential to t.ake into consideration
that the rotation of the jaws during growth exerts an influence on the path of
eruption of the teeth and hence on the occlusion and tooth spacing. In addition
to the variation in direction, importance attaches also to the location of the
center of rotation. The fundamentally different ways in which the mandible can
rotate in relation to the maxilla during growth have been described in an earlier
article, to which the reader is referred. I4 Three types of growth rotation were
demonstrated in the present study, both for groups and for individual subjects
(Fig. 5).
Average growth changes in angular relations in the groups of nineteen cases
where there was a forward rotation of the mandible are illustrated schematically
in Fig. 6. That the center for this rotation was located in. the anterior part of
the dental arch is evident from the fact that the angle between the lower
implant line and the lower occlusal line, IPLi-OLi, was opened backward, thus
indicating that the eruption of the molars was greater than that of the incisors.
It should be observed that remodeling at the lower border completely masked
Volume 62
Number 4
Facial development and tooth eruption 373

Fig. 5. Three types of rotation of the mandible during growth. A, Forward rotation with the
center at the incisal edges of the lower incisors. B, Forward rotation with the center at the
premolars. C, Backward rotation with the center at the occluding molars.

this differential eruption, the angle between the lower implant line and the
mandibular line, IPLi-ML, being increased. A clinical assessment of the molar
eruption should therefore be made on the basis, not of the lower border but,
rather, of the mandibular canal, which has been shown to be more stable.g
The adaptation of the upper occlusal line to the rotation of the face was
similar, with a more marked eruption of the molars than of the incisors ; the
angle IPLs-OLs thus also opened backward. It is clinically significant that a
differentiation between the rotation of the maxilla and the amount of tooth
eruption cannot be made on the basis of conventional radiographs.
In this group (Fig. 6)) the lower incisors were inclined backward in relation
to the nasion-sella line, NSL-ILi, to the extent of only two thirds of the man-
dibular rotation, and were thus tipped forward on the mandibular base,
IPLi-ILi. In the maxilla the incisors were inclined forward in relation to the
374 Bib& and Skieller

NSL
?
1
+4.7O + 2 2 + 7.101
,iR1

MOLI MOLs

\ $,/ -/ \+y, , /, i, , ,
IPLi

ML
G /I

IMPLANT
L
INCISORS
c, FIRST
LINES MOLARS

Fig. 6. Mean angular changes from the first to the last stages in the nineteen cases in
which the rotation of the mandible during growth was forward (Cases 2 and 4 thus
excludedl.

nasion-sella line, NSL-ILs, but were unchanged in relation to the maxillary


base, IPLs-ILs. That is to say, they followed the maxilla in its forward rotation.
The interincisal angle, ILs-ILi, was then opened slightly. It should be observed
that the molars in both jaws followed the mandible in its rotation. The intermolar
angle therefore remained, on average, unchanged. In the case of extreme rota-
tion, however, there may be a differentiation. The upper molars were inclined
forward in relation to the nasion-sella line, NSL-MOLs, three times as much
as the upper incisors, NSL-ILs. One third of this positional change was due to
rotation of the maxilla and two thirds to a forward tipping on the maxillary
base.
Marked rotation of the jaws during growth obviously places great demands
on compensatory adaptation in tooth eruption. Depending on the degree of
compensation, the subjects will display the most diverse development of the
occlusion and the spacing conditions, as will be illustrated by a description of
what may be regarded as typical cases.
Types of forward rotation during growth. Where the incisal occlusion is
stable, the forward rotation of the mandible toward the maxilla takes place about
a center at the incisors (Fig. 5, A). This type of rotation is the most suitable one
from the standpoint of a normal dentitional development, and it is most clearly
illustrated by Cases 1, 3, 11, 13, and 17. Taking Case 1 as a typical one, we see
from the tracings and tables that the lower molars erupted considerably farther
than the incisors, with the result that the angle between the lower implant line
and the lower occlusal line, IPLi-OLi, opened backward by -5.9 degrees, with
no increase in overbite. Here, as in other cases, there was a characteristic shorten-
ing of the dental arch, which was ascribed to a mesial migration of the posterior
teeth in relation to the anterior ones.
The essential feature of compensatory adaptation to forward rotation is,
Volume 62
Number 4
Facial development and tooth eruption 375

however, the forward shift of the dental arch as a whole in relation to the jaw
base, with forward tipping of both incisors and molars. The explanation of
the compensatory forward tipping, IPLi-ILi, of the lower incisors through 10.4
degrees on its jaw base is indicated by the growth pattern of the face ; it will be
seen that the inclination of the lower incisors in relation to the nasion-sella
line, NSL-ILi, remained unchanged at 0.2 degree, even though the mandible was
rotated forward through a large angle (-10.7 degrees). In other words, the lip
ancl tongue function tended to maintain the functional relationship of the
incisors, despite the rotation of the jaw. In response to the rotation of the
mandible, the lower molars also described a compensatory forward tipping
(3 degrees) on the jaw base, IPLi-MOLi, as a result of which the dental arch
as a whole moved forward. Such complete adaptation makes for a perfect dental
arch in spite of the rotation of the jaw. The characteristic forward tipping of
the lower anterior teeth is also seen in the dental casts.
A similar favorable development of the dentition is displayed by Case 17 ;
here, however, the lower molars moved forward without any tipping.
The development of crowding in the lower arch in a similar pattern of facial
development in Case 3 may be ascribed to collapse of the anterior part of the
dental arch as the result of an extreme compensation in inclination. Here the
lower incisors were tipped forward 11.3 degrees on the jaw base, IPLi-ILi, to
compensate for a rotation of the mandible of the same magnitude, NSL-IPLi
(-11.0 degrees). The development of crowding in the lower anterior segment in
Case 13, on the other hand, may be attributed to incomplete compensation, the
forward tipping of the incisors through 1 degree by no means keeping pace with
the jaw rotation of -6.6 degrees and forward migration of the molars.
When anterior occlusion is instable, the forward rotation of the mandible
can give rise to basal deep overbite (Fig. 5, B) . Such a development is illustrated
by Case 14, where there was an extreme forward rotation of -16.4 degrees. The
rotation of the mandible toward the maxilla did not take place at the incisors,
its center being located further back at the premolars. This is evident from the
fact that the depth of the bite increased by 4 mm. and that the inclination of
the occlusal line of the mandible decreased by as much as -17 degrees in relation
to the nasion-sella line, NSL-Oli, while the inclination of the maxillary occlusal
line, NSL-OLs, decreased by only -7.7 degrees. There was no differentiated
eruption at all in the mandible, the angle between the lower occlusal line and
the lower implant line, IPL-OLi, remaining unchanged (0.6 degree).
The deep overbite in Case 14 prevented a forward shift of the lower dental
arch which, as is evident from the cases discussed above, is an essential step in
the compensatory development of the dentition. The lower incisors were tipped
forward only 5.6 degrees on the jaw base, IPLi-ILi, but were inclined backward
10.8 degrees in the face, NSL-ILi. The position of the lower molars on their
base was not appreciably affected. This reduced the compensatory development
of both incisors and molars but left the spacing conditions in the mandible
unaffected.
If the pattern of facial growth in Case 14 is considered as a whole, it is seen
that the maxilla, too, was rotated forward through a fairly large angle, -6.6
degrees. The upper incisors did not follow this rotation but, on the contrary,
were inclined backward through -3.9 degrees in relation to the nasion-~sella lint,
NSL-Ills, and tipped -10.5 tlcgrecs backward in relation to the implant line,
IILs-Il,s; that is, to the base of the maxilla. Of the closure of the space for the
miincs SW~ on t hc casts, one third may thus 1~ tluc to backward inclination of
the upper incisors in the fact? and two thirds to forward rot,ation of the maxilla.
This is an entirely new aspect of the tlevclopment of Angles Class IT, Division 2
malocclusion.
Bacl~~n~d rotation of t3Le face. The backward rotation of the mandible is
illustrated diagrammatically in %ig. 5, 0. This t+pe of rotation results i n a
characteristic type of face, which has been described in earlier articl&, I?, I4 and
is illustrated by Cases 2 and 4; in both of these the development was associated
with an increasing backward direction of growth at the condylrs (Fig. 2). The
rotation of the mandible may be described as a rollin g of the mandible against
the maxilla about a center that moves back toward the post,erior occluding
molars; the chin then swings downward and backward, with an increase in the
anterior lower face height. The posterior face height, on the other hand, becomes
relatively 10~. The eentcr of rotation was thus not located at the temporo-
mandibular joint. In Casts 2 and 4 t.here was clearly differentiated eruption of
the lower teeth, the incisors erupting further than the molars, and the angle
brtwcen the occlusal line and implant line consequently opening forward.
The compensatory eruption of the incisors was to some extent prevented by
the position of the tongue, and in the two patients the open-bite increased
further. In both cases the loaner anterior teeth were tipped backward on the
jaw base, while there was simultaneous reduction in the alveolar prognathism.
This led to crowding in the anterior segment typical of this kind of growth
pattern. In Case 2 the inclination of the lower incisors to the nasion-sella line
was unchanged, despite a backward rotation of the mandible. The lower molars
were in this case tipped back in relation to the jaw base. However, since in this
type of rotation the eruption of the molars is diminished, this compensatory
movement of the molars will often be slight or, as in Case 4, nil.
The positional changes of the upper molars also seem to be characteristic
of the different types of rotation of the face. In the nineteen subjects the upper
molars followed the forward rotation of the face; in Case 2 their position was
unchanged, while in Case 4 they were inclined backward (-4.1 degrees), also
following the rotation of the face, NSL-MOLs.
Growth changes in sagittal jaw relation. The compensatory occlusal develop-
ment is, of course, also influenced by differences in prognathic development of
the two jaws. 3, *, 7, 24, 3o Here, too! functional factors are involved, as is illustrated
by some of the subjects composing the series. In order to assess the changes in
sagittal jam relation during growth, a line was drawn through the most anterior
implant in each jaw, II?, the change being measured in terms of the angle
IPA-IPo (Fig. 4). The mean change was -5.2 degrees ; the negative sign denotes
that the prognathism increased more in the mandible than in the maxilla.
Examples of mandibular overjet with increasing relative mandibular prog-
nathism but different occlusal development are provided by Cases 6 to 8, 10, and
Facial development and tooth eruption 377

16. In Case 6 the lip and tongue function was normal and the intercuspation
of the lateral teeth good. The mandibular overjet and the mesial molar occlusion
increased only slightly because of a marked compensatory forward-guided
eruption of all the upper teeth and some backward-guided eruption of the lower
teeth, including the molars. A similar compensat,ory development in the maxilla
was seen in Cases 10 and 16; in the former, the lower incisors were tipped back-
ward without any major change in the alveolar prognathism, while in Case 16
the lower alveolar prognathism diminished simultaneously with the backward
tipping of the lower incisors. This illustrates the necessity for differentiating
between a change in alveolar prognathism and a change in inclination of the
incisors in the cephalometric analysis, as is observed in the system of diagnosis
applied at this Institute.3, 7
In Case 8, where there was marked tongue pressure and open-bite, there
was no compensation in the upper anterior segment but only in the mandible,
where the whole dental arch, including the molars, was guided distally during
eruption. In Case 7, where the interdental position of the tongue during
speech and swallowing interfered with normal intercuspation, there was no
compensation in either jaw.
The mandibular overjet in Case 19 was of a different type, arising as a
result of prolonged finger-sucking where two fingers were pressed down between
the dental arches. The prognathic development of the mandible in relation
to the maxilla was moderate. The inverted incisal occlusion, however, prevented
normalization of the occlusion, and the lower incisors tipped forward to an
ever greater extent.
Development of normal occlusion was seen in Cases 9, 11, and 17, where
there was only a moderate change in the sagittal jaw relation.
In Case 5 there was a tendency for the development of distal molar occlu-
sion, which was normalized with an improvement in the sagittal jaw relation.
As in Case 20, the crowding in the lower arch was due to mesial migration of
the posterior teeth.
An increase in the distal occlusion due to pressure of the lower lip after
finger-sucking was seen in Case 12. The sagittal jaw relation improved slightly
during the observation period, but the sagittal occlusion deteriorated ; the
maxillary overjet increased by 3 mm. and the distal molar occlusion by 1.5 mm.
On swallowing, the lower lip was pressed behind the upper incisors, which were
then tipped forward without any increase in the alveolar prognathism in the
maxilla.
Crowding of the teeth. Secondary crowding was seen in several of the sub-
jects ; some conceivable causes may be discussed briefly.
The effect of early loss of deciduous teeth on the paths of eruption of the
permanent teeth is well known. It is clearly illustrated in the upper jaw by
Case 8 and in the lower jaw by Cases 8, 11, and 20.
Secondary crowding may also occur around puberty or toward adulthood
and is clinically problematic because it is difficult to predict. The secondary
crowding in the lower arch in several of the subjects may be ascribed to the
37% Bjbrk and Slciello .lm. J. Orthod.
October 1972

complicated facial development, and likewise the crowding in t,he nlaxillary


arch in Case 14, which provet to be essentially due to the forward rotation of
the maxilla.
Secondary crowding is alten considered to be due to eruption of the third
molars, but no clear evidence of this was found in the sample. It is true that
in most cases there was a. shortening of both tlcntal arches, but this was of the
same magnitude in the two observation periods and was thus manifested beforc
the roots of the third molars had appreciably developed. More probably the
shortening of the arches is to some estent due to the pressure exerted by the
erupting second molars. The part played by t.he third molars in this connec-
tion, however, cannot be judged reliably7 until completion of jaw growth ant1
root development.
The crowding in the maxillary arch seen in Cases 4, 7, 10 and 20 may be
regarded as primary.
Correlations. The correlations between all 32 measurements of age changes
are presented in Tables IL4 and IIB. It should be remembered that the calcula-
tions are based on a fairly small sample of both sexes combined, which, more-
over, contained extreme cases. The analyses of the correlations may be divided
into three parts.
Concerning cha,nges in the face and their relation to condylar growth, the
conclusions are similar to those drawn on the basis of earlier implant studies61 9.
lo, I49 27, 33y 34 but here apply also to the maxilla. The rotation of the mandible
and maxilla as determined from the implant lines in relation to the cranial
base (NSL-IPLi) AC and ( NSL-IPLs) ho showed a strong intercorrelation, as
is evident from the tracings. The mandibular rotation was correlated strongly
with the intensity and direction of condylar growth and moderately with its
curvature. The maxillary rotation was moderately correlated with the same
condylar growth factors. The change in inclination of the lower border of the
mandible (NSL-ML)*o was significantly correlated with the rotation of the
mandible. In contrast, the change in inclination of the posterior border of the
ramus (NSL-RL)*o was not significantly correlated with the mandibular rota-
tion. The extent of compensatory remodeling at the lower border of the mandible
(IPLi-ML)ao was correlated with both the mandibular and the maxillary
rotation (more strongly with the former) and, therefore, with the factors bearing
on this rotation. A strong correlation also existed between the same growth
factors and the compensatory remodeling at the posterior border of the ramus
(IPLi-RL)*o. The change in the gonial angle (RL-ML)*o was correlated with
the remodeling at both areas and strongly corrclatcd with the intensity and
direction of condylar growth and, therefore, also with the rotation of the
mandible.
Another finding of interest was that the change in the anteroposterior posi-
tion of the maxilla, NSL*-PMac, was correlated, although moderately, with the
intensity, direction, and curvature of condylar growth. The anteroposterior
position of the maxilla was also correlated with the change in sagittal jaw
relation, II?*-IPc (almost significant). ,4s a,n effect of the rotation of the face,
the change in the inclination of the lower occlusal line (NSL-OLi)ao was
strongly correlated with the rotation of the two jaws. The change in the inclina-
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Facial development and tooth eruption 379

tion of the upper occlusal line (NSL-OLs) *o, on the other hand, was not cor-
related with rotation of the mandible but almost significantly so with that of
the maxilla.
The second type of correlations relates to the changes in the occlusion of
the teeth. The change in overjet was correlated moderately strongly with the
change in the molar occlusion and strongly with the change in the sagittal jaw
relation, IPA-IPo. There was also a correlation with the inclination of the upper
molars in the face ( NSL-MOLS)~~ ; this indicated a greater forward inclination
of these molars as the overjet increased during growth. The change in overbite,
on the other hand, was significantly correlated with the rotation of both jaws,
most strongly with the lower, and therefore also with change in the inclination
of the lower occlusal line (NSL-OLi) do. Furthermore, the change in overbite
was correlated with the curvature and direction of condylar growth. The incli-
nation of the ramus in relation to the nasion-sella line (NSL-RL) AC increased
with the overjet and decreased with deep overbite.
The third type of correlations is concerned with compensatory changes in
tooth inclination. The change in the inclination of the upper and lower incisors
to the nasion-sella line (NSL-ILs) ho and (NSL-ILi) AC was not correlated
significantly with the rotation of either of the jaws ; nor was the change in the
interineisal angle ( ILs-ILi) Ao. Their positions were thus, on the average,
functionally stabilized. The change in the inclination of the lower molars in the
face (NSL-MOLi)Ao was moderately correlated with the rotation of the
mandible and thus followed, on an average, the rotation of this jaw. The change
in the inclination of the upper molars in the face (NSL-MOLs)Ac, on the other
hand, was correlated with the rotation of both jaws, more so with that of the
mandible. The change in their inclination, however, was due not only to the
rotation of the maxilla but also to a forward tipping on the maxillary base
(IPLs-MOLs)ac, for which the correlation was even stronger. That the compen-
satory tipping in the same direction of the lower incisors ( IPLi-ILi)Ao and
molars (IPLi-MOLi)Ao on the mandibular base, occurs to some extent is
demonstrated by a moderate correlation. There was no such correlation in the
upper jaw, where the correlation between the changes in (IPLs-ILs)Ao and
( IPLs-MOLs)ao was not significant. These results show that the direction of
eruption of the incisors and molars is more strongly differentiated in the upper
than in the lower jaw.
The correlation analyses, on the whole, confirm the results of the analyses
of the individual subjects.
Treatment. In studies of natural changes in the jaws and occlusion during
growth it is essential that, as here, no treatment should have been given during
the observation period. In Cases 1, 3, 9, 11, 13, and 17 no treatment was con-
sidered necessary. In Cases 2, 4, 10, and 14 orthodontic treatment was given
after the observation period; in Cases 6, 8, and 12 orthodontic treatment was
combined with surgery and in Case 7 with prosthetic measures. The patients in
Cases 15, 16, and 18 to 21 have still not expressed a willingness to be treated.
From our present knowledge of the growth of the face and the importance of
individual maturation, it would seem that in some cases, such as Cases 12, 14
and 19, treatment should have been started prior to puberty.
Discussion

The present st,utly is concerned with an analysis of observed facial grow-t11


changes and their intSeractions. Howcvcr, t,lic possible causal factors rcsponsiblc
for these growth changes, such as, for instance, the functional matrices of the
head and neck, are not included in the discussion., 21, =, 23
Detection of changes in the sagittal jaw relation wit,11 growth prescnt,s no
major problem, since these can be demonstrated with longitudinal profile radio-
graphs. Changes in the vertical jaw relation with growth, on the other hand,
present some diagnostic problems, since rotation of the jaws is partly, if not
completely, masked by remodeling. The rotation of the mandible can, however,
be judged clinically by superimposing longitudinal radiographs with respect
to characteristic internal structures in the mandible-what we call the struc-
tural mcthod.14
From structural features in the mandible and the type of remodeling, it is
also possible in more extreme cases to predict the direction of rotation on the
basis of a single profile radiograph. These structural features become particular-
ly evident during puberty. As the germs of the premolars are stationary in
the mandible before root development commences, they follow the rotation of
the jaw. A marked rotation of the mandible can therefore be detected even prior
to puberty from the inclination of the stationary tooth germs in relation to the
erupted tcth.
In the maxilla the situation is different. The remodeling of the nasal floor
makes it impossible to assess the rotation from longitudinal clinical series or
to judge the path of eruption of the teeth. A fairly large rotation of the man-
dible can, however, provide an indication of rotation also of the maxilla.
The demonstrated influence of the rotation of the face during growth on
the paths of eruption of the teeth, and hence on the occlusal development and
dental spacing, constitutes a new factor in the clinical discussion on the inclina-
tion of the teeth. The time seems to have come for a revision of the current
views on, particularly, the inclination of the anterior teeth, its relation to facial
morphology, and its role in trca,tment planning. We have seen that t,he posterior
teeth essentially follow the rotation of the two jaws. The inclination of the
anterior t&h, on the other hand, is determined to a considerably greater extent
by functional factors, in so far as their position in t,he face and in relation to
ea.& other tends to persist, irrespective of the rotation of the jaws. In treatment
planning it is necessary to take into account t,he developmental forces that are
acting.lY, 28
Case 1 is an example of the situation in which the lower incisors are con-
tinuously proclined on the jaw base as a result of compensatory forces, so as to
counteract the forward rotation of the mandible. Extraction of premolars in an
attempt to raise the incisors on the base would tend to interrupt this functional
pattern and result in collapse of the dental arch and possibly the development
of deep overbite. Where this anomaly exists, as in Case 14, this natural forward
guidance of the lower incisors does not occur. A logical step in the treatment of
basal deep overbite is to bring the lower incisors forward, possibly with increased
forward tipping, even though they are apparently standing upright on the jaw
Volume 62
Number 4
Facial development and tooth eruption 381

base. Extraction of lower premolars in such cases is therefore incompatible


with normal development. What is evidently required is an early normalization
of the anterior occlusion. Only then is any needed extraction of premolars per-
missible. Extraction while the deep overbite is still present can lead to difficulties
in finishing the treatment. A stabilization of the occlusion and a prevention of
further development of the deep overbite by means of some form of bite plate up
to adult age may be necessary.
In the treatment planning, the possibility of rotation of the maxilla should
be considered despite diagnostic difficulties. Extraoral traction would seem
to affect not only the sagittal position of the maxilla but also its rotation,9
and the same applies to intermaxillary traction.16, 26y *K 32 In Case 14, for
instance, it might have been possible to influence the rotation of the maxilla.
It is clear that tooth eruption not only follows an individual genetic pat-
tern but is strongly influenced by forces governing the occlusal development.
In most cases there is a shortening of the arches11 *O and at the same time the
arches shift bodily either forward (Case 3) or backward (Case 9). During their
eruption the teeth are therefore exposed to guiding forces that cannot be judged
from the shape of the arches. In the case of interceptive extraction of deciduous
teeth there is a great risk that the natural path of eruption will be interrupted
unpredictably. Where the development of the jaws is complex, with fairly
marked changes in intermaxillary relations, whether sagittal or vertical, such
extraction is strongly contraindicated. In the treatment of crowding, it would
seem important to examine the development of the face and jaws before any
extractions are undertaken, whether of deciduous or permanent teeth.
As orthodontic treatment should be planned in accordance with the indi-
vidual pattern of facial growth, it is essential to increase our knowledge in
this field. It is likewise of importance to time the treatment according to the
rate of maturation.11l I53 I7

Summary

By means of the implant method, the eruption paths of the teeth have been
analyzed in relation to facial development and growth of the jaws; growth
changes were followed in longitudinal series of profile radiographs of twenty-one
subjects. To ensure uniform conditions with respect to physical maturity, the
analysis was confined to the 6-year period around puberty. Various types of
malocclusion were represented. No orthodontic treatment was performed during
the observation period. The series is presented in the form of growth tracings,
photographs of casts and faces, with data on growth changes for each subject,
so that the reader is afforded the opportunity of making his own interpretation,
A general feature of the facial development was a more or less marked
forward rotation of the face, including the two jaws, but greater for the
mandible. There was a strong association between the facial rotation and the
condylar growth. At the lower border of the mandible about one half of the
rotation was masked by a compensatory remodeling in this area. At the posterior
border of the ramus about four fifths of the mandibular rotation was masked
by compensatory remodeling. The rotation of the maxilla was likewise masked
by remodeling of the nasal floor, which remained almost unchanged in incli-
nation. While the rotation of the mandible during growth can be judged clinical-
ly from internal structures, there is no similar orientation method for the
maxilla; the path and the degree of eruption of the upper teeth therefore
cannot be analyzed without the use of implants.
The rotation of the face necessitates compensatory adaptation of the paths
of eruption of the teeth. When there is full compensatory occlusal development,
the lower incisors retain their inclination in the face practically undisturbed,
irrespective of the rotation of the jaw, because of a forward tipping on t,he
jaw base. The posterior teeth in the lower jaw, too, are involved in this compen-
satory occlusal development and are likewise tipped forward. The lower dental
arch then shifts forward on the jaw base without undergoing any appreciable
change in shape. The intermolar inclination remains comparatively constant as
the lateral teeth in both jaws follow the rotation of the face. What clinically
has been regarded as an eruption of the upper molars appeared to be a combi-
nation of active eruption of the teeth in the jawbone and bodily rotation of the
maxilla. This is a new aspect of occlusal development which may have clinical
implications.
A general conclusion that may be drawn from the results is that malocclu-
sions are to a greater extent due to incomplete compensatory guidance of
eruption than to dysplastic deformation of the dental arches. Prophylactic and
interceptive measures should therefore be focused on the factors potentially
responsible for impairing the compensatory mechanism. In the planning of
orthodontic treatment the therapy should be designed to take into account the
action of such forces on the development of the occlusion.

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