Early Treatment of Vertical Skeletal Dysplasia: The Hyperdivergent Phenotype

Wayne Sankey, Peter Buschang, Jeryl English, and Albert Owen,

AJODO Sep 2000

Introduction
Growth modification of the hyperdivergent phenotype should be early and preventative
Favorable growth includes:
 Increase in posterior facial height/anterior facial height ratio
 Average or greater “true” forward mandibular rotation
 Enhanced condylar growth and in the anterior direction
 (most orthodontic therapy does the opposite of these)
Control of the vertical is critically important (High-pull headgear, extraction, bite-block, chin-cup)
Maxillary transverse constriction also common in the hyperdivergent phenotype
However, expansion can displace the maxilla and mandible inferiorly – increasing anterior facial
height (minimized by bonded expander)

Study Treatment:
1. Lip Seal Exercises –strengthen orbicularis oris and reduce mentalis strain
2. Lower Crozat/Lip Bumper – lower arch expansion. Initial 2-3 mm activation, additional 1
mm reactivation every 8 weeks
3. Bonded Palatal Expander (BPE) – upper arch expansion. 1 mm per month for ~6 months
4. High-pull Chincup – at least 14 hrs per day with 45º up and back pull relative to occlusal
plane.

Purpose: Determine whether this treatment would:

1. Change the amount and direction of “true” mandibular rotation
2. Alter the amount and direction of condylar growth
3. Control mandibular and maxillary molar eruption
4. Improve the vertical skeletal relationship

Materials and Methods

38 patients from Dr. Owen’s private practice
Selection:
1. Diagnosis of vertical skeletal dysplasia (mandibular plane angle > 35º)
2. Mixed dentition
3. Treatment ≥ 6 mo
4. High quality ceph records
38% of sample had open bites
Mean treatment duration = 1.3 ± 0.3 yrs
Control sample matched from Human Growth Research Center (Montreal, Quebec)
Pretreatment (T1) and Posttreatment (T2) lateral cephs traced and compared
Results
Significant changes in the treatment group:
 ANB decreased 0.8º and Gonial angle decreased 1.1º
 Anterior facial height increased 2.2 mm while Posterior Facial height increased 1.8 mm
 Upper/Lower anterior facial height ratio increased from 75.5% to 76.1%
 OB and OJ improved 1.3 and 0.8 mm respectively

Compared to the control group, the treatment group had significant changes of:
 SNB increased with treatment and decreased in the control group
 Gonial angle decreased and Articular angle increased
 OB/OJ improved
 The mandibular measures, except mandibular molar, displayed anterior displacement
 Gonion was displaced 0.6 mm more inferiorly with treatment (more posterior facial height
increases)
 Relative intrusion of upper molar, vertical control of lower molar and increased eruption
of lower incisor  increased overbite
 1.2 mm more vertical condylar growth than control
 True mandibular forward rotation was almost 3x greater (1.6º vs 0.6º)

Overbite vs Open bite treatment groups

 More ANB reduction in Open Bite group
 Upper incisor displaced more inferiorly in Open Bite

Discussion
 The treatment regimen led to increased condylar growth, altered direction of condylar
growth, increased true forward mandibular rotation, increased posterior facial height, and
decreased anterior facial height for openbite patients. It also controlled molar eruption,
increased overbite and decreased overjet.
 Therefore, this regimen seems effective for treating vertical skeletal dysplasia.
 Their results showed no increased vertical displacement of ANS or PNS and no increase
in MPA unlike other modes of expansion
 Increasing condylar growth helped improve the posterior facial height and anterior
displacement of the mandible
 Other studies have shown instability of intrusion after 4 months, so more work is needed
to investigate this regimen’s stability
 The improvements in OB/OJ was attributed to the posterior control and intrusion of molars
combined with increased soft tissue and facial muscular force

ABO Question
Which of the following is NOT a treatment goal for the Class II Hyperdivergent patient?
A. Increase in posterior facial height/anterior facial height ratio
B. Increase in the gonial angle
C. Forward mandibular rotation
D. Increase condylar growth in the anterior direction
B