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Studying the normal changes that occur in the facial complex is a very important aspect in orthodontics to identify and diagnose
any existing abnormalities to provide optimal treatment to the patient. It is, therefore, essential for dental surgeon to be aware of
how the face changes, where these changes occur, and when these changes usually take place. Such knowledge enables the
practitioner to modify the growth processes to meet the needs of those patients who seek treatment for various malocclusions.
The growth of the craniofacial complex that is relevant to the orthodontic professional can be divided into following areas:
Though the facial pattern established is a relatively constant but it can be changed to certain extent by Growth and by Orthodontic
treatment. As the changes in the face and dentition continue throughout life, the clinician must consider both the immediate
outcome of the treatment and the long-term stability and the benefits of the treatment as important goals.
This presentation discusses the complementary and compensenatory mechanisms that occur in maxilla and mandible in relevance
to the vertical pattern of growth.
I. CRANIAL BASE
The Cranial base or floor supporting the brain is formed by endochondral ossification. The syndhondrosis present in the midline
contribute to the adaptive bone growth that occurs at various sutures. Further the expansion of the brain lobes contributes to
transverse growth. During adaptation of the brain during its evolution the brain stem has changes its growth formed in a Bipedal
Human being. There is what is called as Cranio basal flexure which is around 65 degrees and the whole cranial base appears to
have flexed at the clivus. The middle and posterior cranial fossa are angulated to anterior cranial base and are situated at various
vertical planes. The corresponding growth of midbrain and brainstem adopts itself to this flexure of cranial base. The flexure is also
responsible for the anterior and inferior movement of the middle face. This flexure may result in the predominant downward rather
than forward displacement of the face during its growth from the cranial base. The abnormal flexure may result in some skeletal
sagittal and vertical malocclusions as it influences the position of the maxilla and mandible.
The growth at the medial fossa also relocates the relation between the glenoid fossa and condyle and can effect the growth of the
condyle to certain extent. Indirectly it exerts its influence by the Horizontal and vertical growth of the Nasomaxillary complex.
Maxilla cannot be considered as a separate bone; instead its growth is best studied, taken into account the whole nasomaxillary
complex or midface. It is a complex system of sutures through which all the bones are in contact. According to Moyers, the
nasomaxillary complex functions are:
Motive force behind the growth of maxilla has been attributed to primary displacement, growth at synchondroses, sutures, septal
cartilage, etc.
Primary displacement of maxilla is due to growth of maxillary tuberosity and secondary displacement by the growth of the Anterior
cranial base and the growing soft tissue capsule around it. The growth at the Maxillary tuberosity results in lengthening of the
dental arch and enlargement of the antero-posterior dimension of the entire maxillary body. Thus posteriorly the space for erupting
molars is provided. As the cranial base grows anteriorly and superiorly, the midface grows anteriorly and inferiorly. This is termed
secondary displacement. The midfacial bones, by cortical apposition at the posterior end, reestablish contact with the cranial base.
The upper face grows upward and forward and lower face grows downward and forward as an expanding V. The Nasal septal
cartilage to be growth center has been accepted. Sutures are adaptive growth sites. Sutural tissues have no tissue separating
force( Cranial growth centers: Facts or fallacies?—Koski,AJODO 1968;566-83)
Growth of the face follows 'V' principle of growth. The nasomaxillary
complex moves downwards and forwards whereas the anterior
cranium moves upwards and forwards, thus following the expanding
"V" principle of Enlow. SO,Spheno-occipital synchondrosis;C,
condylar mandibular growth; NS,nasal septum; Se, sphenoethmoid
suture;ptp" pterygopalatine suture; pm, palatornaxillary suture; fe,
frontoethmoidal suture;em, ethmoidal-maxillary suture; Lm, lacrimal-
maxillary suture; fm, frontomaxillarysuture; zm, zygomaticomaxillary
suture.
III. Mandible
The basic mechanisms of Translation and Transformation occur also in Mandible also occur as that described for the maxilla. The
growth of mandible is mainly by adoptive remodelling and the growth of the mandible is peculiar because of the endochondrial
ossification of fibrous cartilage thought to occur principally by growth at condyle. Superior and posterior growth of condyle presses
against the glenoid fossa/cranial base (cartilage has pressure adapted bone growth), which provides an anterior thrust to displace
the lower jaw forward.
The Mandible consists of many functional and anatomical units that are compensatory to one another during growth. The various
anatomical units are Condyle, coronoid, Angle of the mandible corpus or Body, alveolar segment and Ramus. The abnormal or
disproportionate growth at one or the other sites is being masked by a compensatory change in the dimensions or directions in the
contagious parts of the skeleton .
There is posterior and inferior relocation of the mandibular fossa. Further,
the anterior and inferior displacement leads to separation of maxilla
and mandible to provide for enough interocclusal space for the tooth to
erupt. This growth is matched by the mandible mainly by the condylar growth
in superior and posterior direction to maintain condylar contact with temporal
fossa. Thus the condyle growth matches the forward and sagittal growth
of the naso maxillary complex. Ramus relocates posteriorly and
increases in height due to addition of bone at the superior border. Thus it
adopts itself increasing pharyngeal airway space. The corpus or body of
the mandible is formed at the expense of ramus repositioning in
posterior direction by resorption at anterior end and resorption at the
posterior border . In this manner the body of the mandible lengthens. Thus
additional space made available by means of resorption of the anterior border
of the ramus is made use of to accommodate the erupting permanent
molar tooth buds. The coronoid process has a propeller-like twist
mechanism of growth. It increases in height (superiorly), widens
(laterally) and at the same time, grows posteriorly. The differential
remodelling at the angle contributes to the growth particularly the
rotational tendencies. Chin contributes to the length by selective remodelling
at the posterior aspect by itself growing forward. Lingual tuberosity, as already mentioned, is a direct counterpart of maxillary
tuberosity and is equally an important growth site for the mandible.
The alveolar process ; The alveolar process grows upwards by the apposition (deposition) of bone on its occlusal border in
response to the tooth buds. Due to the growth of the alveolar process the height of the mandibular process increases. The
ascending ramus slopes (before the coronid process) upwards and backwards, the alveolar border increases in length to
accommodate posterior most teeth. In case of absence of teeth, the alveolar bone fails to develop and it resorbs in the event of
tooth extraction.
Arcial growth of the Ramal angle; This concept was proposed by Hunter. Later, it was found that mandibular growth cannot be
simplified into an anterior resorbing and posteriorly depository ramus. Mandible undergoes a rotational pattern of growth.
With the descent of the maxilla and separation of two bones, the mandibular anterior teeth erupt superiorly and lingually. Similar to
maxilla, mandibular width completes first, followed by depth and height.
The role of the condyle growth in the mandible is controversial
The rest of the mandible determines the condylar growth
The rest of the mandible determines the condylar Growth—carry away pattern.
The various counterparts involve major boundaries which are coincident with key sites of growth and remodeling. The mandibular
condyle, maxillary tuberosity, sphenoethmoidal junction and all borders of the ramus and palate are examples of such major sites of
growth and remodeling. Most of these growth boundaries also coincide with principal sites at which displacement
(translatoryIntercanine movement) occurs.
Why do Bones Grow and how they coordinate with one another
The brain grows primarily due to functional and skeletal unit grows secondarily. Here, primary growth of the capsular matrix
(brain) results in a stimulus for secondary growth of the sutures and syndhondrosis, leading to overall enlargement of the
neurocranium (macroskeletal). we have seen that increasing cranial base exerts its influence on Maxilla and Mandible. Further the
basic increase in demand for the support of life such as respiration also pushes the maxilla forward. The next need for survival if
nutrition and of course proper mastication and thus the mandible follows the maxilla.
3. The length of the middle Short and raised. Long and Lowered.
cranial fossa which indirectly close to the level of vertically away
effects the position of the the Anterior cranial from the Anterior
Glenoid fossa ( S-Ar) fossa cranial Fossa
The opposing vertical and horizontal forces were competing for the overall direction of pogonion growth. These factors have ‘cause
and effect’ as well as ‘effect and cause’. The interaction of this factors with compensations occurring due to disproportionate growth
may result a composite form of face with a vertical growth or Horizontal growth. This may or may be associated with the openbite
or closed bite( Incisor relation)..The different types of Forward growth patterns and backward growth patterns are due to change in
the counterparts length or alignment or directions.
Middle Cranial Fossa Length and Inclination; The anteroinferior inclination of this part of the basicranium affects the placement
of the mandible complex relative to the Maxilla . A greater forward downward inclination of middle cranial fossa may be expected in
deep bite while posterosuperior or more upright inclination of middle cranial fossa results in the corresponding positional deviations
that are associated with open bite. As the length increases, the maxilla also increases horizontally leading to a class II pattern. The
opposite is true for class III pattern.
Ramus Inclination ; The ramus is the horizontal counterpart of the middle cranial fossa, a more backward position of the ramus
may be expected to produce anterior open bite and forward inclination produces deep bite. Height of the ramus is pronounced in
case of vertical growth at the mandibular condyles. Inclination of the mandibular ramus appeared to be significant in determining
how the chin point would respond to treatment. Mair AD, Hunter WS. Mandibular growth direction with conventional class II
nonextraction treatment. Am J Orthod Dentofac Orthop 1992;101:543-549.)
Gonion angle : The size of the gonion angle has an important influence upon the number of degrees of resultant counterclockwise
rotation. The smaller the gonion angle, the greater the rotation which is produced for each millimeter of forward movement of
pogonion. When this angle is extremely small, it results in extreme flattening of the mandibular angle together with forward growth
of the pogonion.
Posterior facial height: The increase in the posterior face height has two components. The first is the lowering of the middle
cranial fossa in relation to the anterior one as the cranial base bends, and the condylar fossa then being lowered. The second
component is the increase in the height of the ramus, which is pronounced in case of vertical growth at the mandibular condyles.
Posterior Maxillary Height; If the posterior part of the nasomaxillary complex is long vertically with respect to its counterparts,
which is the combined heights of the ramus and middle cranial fossa, a relative downward and backward relationship of the entire
mandible and open bite will be expected.
Horizontal Maxillary Inclination An antero superior tilt of the maxillary alveolar process or the anterosuperior tilt of the palatal
plane might contribute to the skeletal open bite tendency.
Mandibular Plane Inclination A downwardly inclined mandibular plane can contribute to the development of open bite. Besides
this, a horizontally long mandible, a more open gonial angle, a lack of compensating curve of spee can contribute to open bite
malocclusion
Vertical condylar growth versus combined vertical growth face( alveolar bone height and Maxillary vertical height)
Growth at the mandibular condyles basically produces a forward component of the chin, not a downward and forward component
initially. When the vertical increments of facial growth begin to assert their influence on condylar growth through occlusal contact,
then a downward and forward direction of the chin is produced. Thus, it can be said that condylar growth is pitted against the
combined vertical elements of growth.
If vertical growth of condyle predominates, chin is prominent. since it increases the prominence of the chin, it is called horizontal
growth vector of the chin. The final vector of growth of the chin is a resultant of the struggle between horizontal growth and vertical
growth factors. in other words, between condylar growth and vertical elements. The vertical components pitted against the condyle
are:-
Growth at the nasion and in the corpus of the maxilla which produces an increase in the distance from nasion to anterior nasal
spine and causes the maxillary molars and posterior nasal spine to move away from the sella-nasion plane;
Growth of the maxillary posterior alveolar processes causing the molar teeth to move away from the palatal plane; and
Growth at the mandibular posterior alveolar processes causing the molar teeth to move occlusally
The vertical growth of the anterior alveolar processes does not seem to have an appreciable effect on facial height. It is merely
expressed in varying degrees of overbite
When vertical growth factors exceeds horizontal growth factors (condylar growth), pogonion cannot keep pace with the forward
growth of the upper face and the mandibular plane must become steeper. This has an influence on the treatment also. Obviously,
this condition would not help reduce the ANB angle, and it would not aid in correction of a class II molar relation. Counterclockwise
rotation of the mandible is a result of more condylar growth than combined vertical growth of the face. This type of rotation is nearly
always accompanied by a forward movement of pogonion and an increase in the facial angle. If the condylar Vertical growth is
greater than vertical growth in the molar area, the mandible rotates counter clockwise and results in more horizontal change of the
chin and less increase in anterior facial height. Extremes of this condition causes closed bites. Conversely, if vertical growth in the
molar region is greater than that at the condyles, the mandible rotates clockwise resulting in more anterior facial height and less
horizontal change of the chin. Extremes of this condition cause open bites. (Maxillary molar vertical control with the use of
transpalatal arches John B. Wise, DDS," W. Bonham Magness, DDS, ~ and John M. Powers, PhD ~ Allen and Houston, Texas (AM
J ORTHOD DENTOFAC ORTHOP 1994;106:403-8.)
However It is unclear if the increased molar height is a consequence of skeletal open bite by their altered facial growth or that the
skeletal open bite occurs as result of an maxillary molar over eruption caused by an increased posterior discrepancy---cause or
effect
CONDYLAR GROWTH AND GLENOID FOSSA DISPLACEMENT DURING GROWTH AND IN MALOCCLUSION
Concurrent with the elongation of the posterior cranial base, the fossa and the temporal bone are displaced inferiorly and
posteriorly. Such movements are important because the direction of fossa displacement in treated patients has been related to their
overall growth patterns. The condyle has to adjust to the height accordingly. So the condyle grows posteriorly or superiorly
depending on the condylar fossa relocation which is again related to the length of the middle cranial fossa and the flexure ( see
Table). If the fossa is relocated in anterior and inferior direction, more Anterior chin changes will be produced by the vertical
superior growth changes at the condyle. Class II skeletal disharmony is associated with a more posterior position of the glenoid
fossa when compared to class III skeletal disharmony. Subjects presenting with high angle vertical relationships show a more
cranial position of the glenoid fossa and more caudal positioning of the fossa in horizontal growers. Orthopedic forces can stimulate
remodeling in the glenoid fossa. Normally, remodeling in the glenoid fossa is downward and backward. The varied position of
glenoid fossa is linked to different malocclusions. Proper knowledge about normal condyle growth and fossa displacement will help
in differentiating the growth changes from the changes produced due to growth. The condylar head inclination and superior joint
space proved to be the most significantly correlated condylar characteristics to facial morphology. Patients with vertical facial
morphology displayed decreased superior joint spaces and posteriorly angled condyles, whereas, patients with horizontal facial
morphology demonstrated increased superior joint spaces and anteriorly angled condyles
A large angle between the anterior and posterior cranial bases, measured cephalometrically as N-S-articulare (Ar), indicates a
posterior position, and a
small angle indicates an anterior position of the fossa.
The inclination of the teeth is also greatly influenced by the rotation of the jaw. The position of the lower incisors seems to be
functionally related to the upper incisors, as is reflected by the fact that the interincisal angle undergoes a smaller change than the
rotation of the jaw.
Forward rotation of the mandible: In forward growers there is lingual inclination of the anterior teeth and the teeth grow in the
mesial direction, thereby tending to create crowding in the anterior segment through what may be referred to as “packing”. The
rotation also affects the position of the lower posterior teeth in relation to the upper teeth. Forward growth rotation thus causes the
lower posterior teeth to be more upright than usual in relation to the upper posterior teeth, with an increase in what may be called
interpremolar and intermolar angles. Due to the lingual movement of lower incisors, there is reduction in arch length because of
rotational changes and this is more evident the in mandible when compared to the maxilla. Inclination changes in Maxilla are
described above.
Backward rotation of the mandible : Crowding develops due to lip tension in the anterior region due to inability to close the lips.
Since the position of the lower incisors, as mentioned earlier, is functionally related to the upper incisors, they become retroclined
in the mandible and the alveolar prognathism is reduced. The lateral teeth are not guided distally in their eruption to the same
extent, and crowding tends to develop in the anterior segment of the lower arch.
See the difference, In both the type of growers there is crowding but the lip strain is absent forward growers. Because of the
backward rotation of the mandible, the interpremolar and intermolar angles are small, which means that the premolars and molars
are inclined forwarding relation to the maxillary ones.
Note: It appears to be more likely that the skeletal pattern and vertical facial growth tendency are predominantly genetically
determined, but that environmental influences may result in additional changes.
Bone is plastic in nature and is responsive to the muscular forces exerted on it. The entire dentition is held in a state of neutral
zone from the forces acting from within and outwards. The bands of musculature from anterior to posterior are orbicularis oris,
buccinators and superior constrictor of pharynx; these three muscles constitute the buccinator mechanism. The opposite
mechanism is the Tongue pressure. The same mechanism plays an important role in the etiology of tongue thrusting and thumb
sucking. The tongue pressure is not effectively neutralized resulting in flaring of incisors and open bite. If the buccinator
mechanism is dominated, it results in constriction of Maxillary arches and concurrent vertical growth pattern as seen in class II div
1 cases and in some mouth breathers.
Tongue size, resting position and/or activity/Resting tongue position: A forward resting tongue position (between the incisor teeth)
may impede anterior vertical dentoalveolar development, leading with the incisors at a different vertical level to the posterior
dentition.
Habit: digit sucking/ Adaptive swallowing pattern: There is an atypical adaptive swallowing pattern - i.e., an anterior oral
seal is formed by contact between the lower lip or the tongue and the anterior palatal mucosa. This is likely to be an adaptation to
the vertical separation of the anterior teeth ( some times cause –effect is reverse)
The fact that the dolichofacial pattern can be recognized before an age at which decreased occlusal forces are present strongly
suggests that the decreased forces are an effect of the condition, rather than a cause. (MG Woods. The mandibular muscles in
contemporary orthodontic practice: a review. Oral and Maxillofacial Surgery, Melbourne Health and The Royal Melbourne Hospital.
© 2017 Australian Dental Association 78-82)
Clinical implications
Thus the various growth changes occurring at the various growth sites may contribute to the overall facial pattern. The changes at
one site may be compensated at the other contagious structure to mask the effect. The overall growth pattern is the net result of the
compensatory changes occurring in the facial skeleton. The clinician should be able to asses the changes that have occurred and
a treatplan have to be drafted to occur a balance in the structural, functional and esthetic balance.
Compensations
The compensation of the contiguous structures in the craniofacial structures is an important phenomenon that masks the
disproportionate growth. This compensation helps whether the skeletal discrepancy can be corrected during the growth phase
A posteroinferior inclination of the mandibular ramus and corpus contributes to an
anterior open bite. ACF: anterior cranial fossa; MCF: middle cranial fossa; UMx:
upper maxillary region; PM: posterior part of maxilla (vertical); AM: anterior part of
maxilla; Mx: maxillary arch; Ra: ramus; Md: mandibular arch (Source: Trouten JC.
Morphologic factors in open-bite and deep bite. Angle Orthod 1983;53:192-211)
A horizontally long mandibular arch, opening of the gonial angle and lack of a
compensating curve of spee contribute to an anterior open bite (Source: Trouten
JC. Morphologic factors in open bite and deep bite. Angle Orthod 1983;53:192-
211)
Similarly if the maxilla were rotated down posteriorly, a long ramus and acute
gonial angle would compensate and allow normal facial proportions, but even a
slightly increased gonion angle leads to openbite.
Horizontal inclination of the maxillary plane: An anteroinferior inclination of the
maxillary alveolar process or the palatal plane results in deep bite
Besides these, an upwardly inclined mandibular plane, a horizontally short
mandible, a more closed gonial contribute to deep bite (Source: Trouten JC.
Morphologic factors in open bite and deep bite. Angle Orthod 1983;53:192-211
Features of hyperdivergent face
Vertical mandibular
growth
Ectomorphy
Backward sloping chin
Weak temporal muscles
Incompetent lips
Horizontal mandibular
growth
Of all the bones in the facial skeleton, mandible is the one that has relatively higher potential to grow and the time limit for
mandibular growth is not as restricted as that of maxilla or cranial base. This should be utilized in the treatment of skeletal
malocclusion involving mandible. Mandibular growth follows the general body growth curve, with slowing of growth in childhood
and peaking during puberty. These concepts of growth show us how different maxilla and mandible are in growth and how different
they should be dealt with during treatment, though they are in absolute contact with each other (occlusion).
Mandible seems to grow more and appears to take its own time. There is mandibular surge in adolescents whereas maxillary
growth is hardly evident after 11 to 12 years of age. This aspect of mandibular growth should be taken into account while treating
patients with skeletal malocclusion with fault in mandible. Skeletal class II patients with mandibular retrognathism are treated
usually with functional appliances if they are in the "growing age". On an equivalent level, when treating a skeletal class III patient
due to mandibular prognathism, cephalocaudal gradient of growth makes us understand that there might be residual growth of
mandible after the pubertal surge. Maxillary curve follows the neural growth curve closer than the mandible. It is now easy to
comprehend that maxillary growth is completed quite early in life. Orthopedic appliance therapy to correct maxillary deficiency
(face mask) should be started in deciduous or mixed dentition but after the eruption of all permanent teeth, there is little or no
scope for correction of maxillary retrognathism.
Circummaxillary sutures are fused during adolescence and correction of maxillary retrognathism is less effective after 10 years of
age. Maxilla yields to protraction force mandibular growth closely follows general body growth.
Treatment of class III malocclusion should be done early. Maxillary retrognathism is not easily corrected because maxillary growth
follows the neural growth curve and is completed early. Maxilla yields to protraction force only if the treatment is started in mixed or
deciduous dentition stage.
In other words, circummaxillary sutures are fused during adolescence and correction of maxillary retrognathism is less effective
after 10 years of age. The idea behind including an expansion screw in the maxillary orthopedic protraction appliance is not only
expansion of maxilla but also loosening of circummaxillary sutures so that they respond readily to protraction force. Once the
sutures are interdigitated, protraction becomes difficult and the treatment results are compromised. Mandibular prognathism treated
during adolescence responds well, the reason being obvious. Transverse maxillary correction by skeletal expansion has similar
restriction as the protraction of maxilla. According to Melsen, the intermaxillary suture is smooth and open in children (6-8 years), in
early adolescence(10-12 years) the sutural edges are overlapping, but in late adolescence (14-16 years) the sutures become
interdigitated and fused. Maxillary expansion can be skeletally effective if the treatment is completed in early adolescence. During
the pubertal spurt, another important parameter of growth that needs to be considered is the growth direction, there is a change in
direction of mandibular growth from vertical to horizontal.
Growth Spurts
There is an adolescent growth spurt in the length of the mandible, though not nearly as dramatic a spurt as that in body height, and
a modest although discernible increase in growth at the sutures of the maxilla.
The cephalocaudal gradient of growth, which is part of the normal pattern, is dramatically evident at puberty. More growth occurs in
the lower extremity than in the upper, and within the face, more growth takes place in the lower jaw than in the upper. This
produces an acceleration in mandibular growth relative to growth of the maxilla and results in the differential jaw growth.
Although jaw growth follows the curve for general body growth, the correlation is not perfect. Longitudinal data from studies of
craniofacial growth indicate that a significant number of individuals, especially among girls, have a “juvenile acceleration” in jaw
growth that occurs 1 to 2 years before the adolescent growth spurt. This juvenile acceleration can equal or even exceed the jaw
growth that accompanies secondary sexual maturation. In boys, if a juvenile spurt occurs, it is nearly always less intense than the
growth acceleration at puberty.This tendency for a clinically useful acceleration in jaw growth to precede the adolescent spurt,
particularly in girls, is a major reason for careful assessment of physiologic age in planning orthodontic treatment
If it were possible, the best way to correct a jaw discrepancy would be to get the patient to grow out of it. That requires inducing
differential growth of one jaw relative to the other, either stimulating one to grow faster or restraining it so the other jaw can catch
up. Because the pattern of facial growth is established early in life and rarely changes significantly, this is unlikely without treatment.
Three important principles must be kept in mind when growth modification is considered for a preadolescent or adolescent child: (1)
if you start growth modification too late, it doesn’t work, but if you start too soon, it takes too long; (2) growth occurs on a different
timetable for the three planes of space; and (3) children’s compliance with treatment is affected by both
their stage of maturation and the difficulty of doing what the doctor wants
If treatment is delayed too long, the opportunity to use the growth spurt is missed. In early-maturing girls, the adolescent growth
spurt often precedes the final transition of the dentition, so by the time the second premolars and second molars erupt, physical
growth is all but complete. The presence of a juvenile growth spurt in girls accentuates this tendency for significant acceleration of
jaw growth in the mixed dentition.For many girls, if they are to receive orthodontic treatment while they are growing rapidly, the
treatment must begin during the mixed dentition rather than after all succedaneous teeth have erupted
In slow-maturing boys, on the other hand, the dentition can be relatively complete while a considerable amount of physical growth
remains. In the timing of orthodontic treatment, clinicians have a tendency to treat girls too late and boys too soon, forgetting the
considerable disparity in the rate of physiologic maturation.
Growth sequence
More congruence exists on the sequence of growth patterns than the age at which maximum growth is achieved. Growth follows
the sequential completion of cranium followed by facial width (transverse), then facial depth (sagittal), and lastly height (vertical).
Although AP and vertical growth continue well into adulthood, Class II, Class III relations and relapse of deep bites and open bites
are often seen. These continued structural changes are also responsible for deterioration of occlusal relationships and the relapse
of malocclusion after completion of orthodontic treatment. Interestingly, facial width, the largest facial dimension at infancy, shows
the least relative growth rate compared with the facial depth and height. Transverse growth is found to achieve near completion by
late adolescence; however, sagittal and vertical growth continue well into adulthood.
Direction of Growth
Not only is the functional treatment dependent on growth direction but extraction/ non extraction decision, time taken for extraction
space closure, prognosis of other orthopedic therapy like expansion, mesial migration of teeth distal to extraction site, time taken for
treatment, response to a particular treatment are all dependent on growth direction. The change from vertical to horizontal
direction, if any, should be looked for horizontal direction, if any, should be looked for.
Dimensions of the face complete growth of width first, followed by depth and height. The width of mandible is completed first, the
mandibular intercanine width is established at 9 years in girls and 10 years in boys. There is hardly any increase in width after this
age. The maxillary canine erupts after the mandibular intercanine width (in other words, mandibular anterior arch width) is
established, infact it appears that the maxillary canines waits for the mandibular horizontal spurt, to be completed.
During the pubertal growth spurt, there is a change in direction of growth of mandible from vertical to horizontal. There will be
disturbance of equilibrium in musculature which will add to the failure.
Thus, maxillary intercanine dimension acts as a safety valve for the horizontal mandibular spurt in puberty. Width increase in
maxilla is not possible after 12 to 13 years in girls, but in boys maxillary intercanine dimension increase is seen till 18 years of age.
Width of the face thus follows the neural curve with depth and height following general body growth of Scammon's curve.
Reichenbach and Taatz used the example of a foot and shoe principle, with the foot representing the mandible and the shoe
representing the maxilla. If the shoe is too narrow, it is impossible for the foot to slide fully into the shoe. By widening the shoe, the
foot slides forward into its usual position. From an orthopedic standpoint, the widening of the maxilla allows for the spontaneous
repositioning of the mandibular jaw into a more forward position. spontaneous mandible repositioning in a forward position, solving
or improving sagittal malocclusion.
The anteroposterior dimension of face completes next, followed by height. Downward and forward growth of maxilla is seen till 14
to 15 years in girls. Increase in height is due to the separation of the jaws during displacement, growth of alveolar bone and
eruption of teeth. Late increase in height of face is seen particularly in the lower third. According to Behrent, forward growth of jaws
is noticeable after puberty and in adulthood and modest increase in the vertical growth of jaws is seen in adulthood.
During the development of dentition, a number of unstable occlusal states called transient malocclusions are encountered. To
name a few, they are flush terminal plane relation, spacing in deciduous dentition—primate spaces, ugly duckling stage and these
are best left untreated. Deciduous dentition presents with a transient deep bite which is corrected by contributions like change in
the axial inclination of the permanent teeth when they erupt (deciduous teeth are more upright), physiological bite raisers, etc. In
certain instances, this deep bite may restrict the downward and forward growth of mandible, thus the full intercanine width might not
be expressed
in the mandible. The narrow mandibular intercanine width might be accentuated by the presence of class II skeletal base with
increased overjet. Simple procedures
like giving a bite plane might be enough to relieve the bite and facilitate forward growth of mandible.
The growth of jaws is determined by the growth of functional matrix and cranial base. Remodeling follows a specific pattern that
appears to be repetitive and inherent to the human race. Balanced facial form and functions are derived from a harmonious
integration of the various components of the craniofacial complex. These components grow and develop throughout life in a
sequential, predictable, and orderly fashion, albeit with a wide range of variation in the amount and timing of growth.
Treatment plan
The treatment plan for the mismatching of the maxilllo mandibular relations depends upon the basic growth pattern, Misproportion
or misfit in a particular direction of jaw bases, the growth potential of the individual , severity of the mismatch, Functional
abnormalities, compensenatory changes and growth and adaptability of the soft tissues.
Growth Modulation : In a growing patient the functional abnormalities can be corrected and direction of the skeletal growth can be
brought to a favourable condition based on the patients original skeletal pattern. To a little extent absolute increase in the structural
units can be achieved
Comouflage: This is masking of the abnormal growth of skeletal units by effecting only the movements of the dental units. This is
done in patients in whcom active growth is completed
Orthognathic surgeries: The absolute increase or decrease of the skeletal units for a match obtained and the direction to certain
extent. If possible all the dental compensations are removed.
Growth modulation:
In the long-face patient, controlling the vertical dimension has been particularly challenging. It depends upon the concurrent sagittal
mal relation. We can see that the vertical direction of growth is a prolonged one and even extends into the adult life.
Treatment of long-face problems usually can be deferred until adolescence because: • Long-face or open bite problems can
improve during preadolescent growth but can be aggravated by growth that persists until the late teens and can outstrip early
focused intervention.
A complex open bite (one with skeletal involvement or posterior dental manifestations) or any open bite in an older patient whose
teeth have erupted is a severe problem
Second the direction of growth in most of the individuals changes from vertical to horizontal growth pattern during the pubertal
growth phase. This may be advantage. If the compensations show a favourable growth pattern, the growth modulation can be
attempted. The initial treatment of this condition at least prevents worsening of the condition and the associated functional
abnormalities and anaesthetic appearances.
Patients who have dolichofacial growth patterns (increased lower facial height) often have a reduced overbite and an anterior open-
bite. Careful management of these patients is needed because the vertical growth pattern that they have is often unfavorable for
conventional functional appliance therapy.
The backward tilt of the maxilla at the posterior region can be corrected by the High pull head gears. If accompanied by the class II
retrognathic mandible, a Herbst appliance with increase vertical bite may be attempted
The vertical chincap has been used as a supplementary device with intraoral appliances in early functional orthopedic treatment of
skeletal open bite. The effect of the vertical-pull chin cup was evident only in the mixed dentition, with little effect noted in the
permanent dentition even though the appliance was worn at night for 5.5 years on average. Vertical pull chin cup with direction of
force along the orbital margin can redirect the mandible in upward and forward direction. The vertical chincap (vertical-pull chincap,
highpull chincap)15,23-31 has been used to obtain the anterior rotation of the mandible, with the resultant force vector passing
through the anterior part of the mandibular corpus and 3 cm from the outer canthus of the eye
The Frankel IV appliance was developed in conjunction with muscle training to overcome openbite malocclusions caused by
abnormal perioral muscle function. The Frankel IV appliance attempts to reverse the unfavorable growth pattern
Any functional shifts in the mandible and habit breaking can be considered at this stage. Anterior open bite in a young child with
good facial proportions usually needs no treatment because there is a good chance of spontaneous correction with additional
incisor eruption, especially if the open bite is related to an oral habit such as finger-sucking.
Treatment considerations during camouflage
The fact that changes in the vertical dimension occur together with changes in the anteroposterior dimension makes control of the
vertical dimension an important aspect in planning orthodontic treatment. In many patients, the normal downward and forward
displacement of the maxilla and mandible has been replaced by a more vertical displacement of these bones, result ing in
prolonged treatment times, compromised treatment objectives, and, often, poor esthetic results. Vertical control is often difficult, in
part because most methods used to exert vertical control are highly patient-dependent.
Controlling vertical dentoalveolar development is often difficult, because most orthodontic mechanotherapy tends to produce
vertical movement of teeth. From the initial placement of separators, which elevate the teeth from their alveoli, to the lighter leveling
arch wires, teeth undergo movement in a vertical direction. Perhaps the reason is that vertical movement represents the path of
least resistance and is therefore the most immediate response.
Another factor influencing vertical development is the musculature. The so-called "low-angle" cases tend to have stronger
musculature that will counteract the extrusive forces of orthodontic treatment. In contrast, the "high-angle" cases are associated
with weaker musculature, which allows for the greater expression of vertical forces that are generated during treatment which may
disadvantage sometimes
In the treatment of patients with severe hyperdivergent skeletal pattern, the counter clockwise autorotation of the mandible after
intrusion of the posterior teeth has an essential role in improvement of the facial profile. However, the following factors affecting
facial profile changes should be considered. (Budi Kusnoto and BernardJ. Schneider. Control of the Vertical Dimension(Semin
Orthod 2000;6:33-42,)
1. Intrusion of the upper posterior teeth The first consideration is the intrusion of the upper posterior teeth. To achieve
counter clockwise rotation of the mandible, the first thing to be considered is the intrusion of the upper posterior teeth.
2. Second, the anteroposterior occlusal plane cant should be checked. A large amount of intrusion of the upper posterior
teeth can make the occlusal plane steep and guide the mandible backward, and this restricts the amount of
counterclockwise autorotation of the mandible.
3. The third factor is bodily retraction of the upper incisors. If the upper incisors are tipped lingually during retraction,
this causes contact between the upper and lower incisors and tends to open the mandibular plane angle, thus reducing
autorotation of the mandible. Therefore, bodily retraction of the upper incisors plays an essential role in profile changes.
4. The fourth factor is the intrusion of the upper incisors. In open bite with hyperdivergent skeletal pattern, the intrusion
of the posterior teeth causes autorotation without incisal contact, but autorotation of the mandible causes incisal contact
with normal overbite.In this case, the intrusion of the upper incisors should be considered to provide space for
autorotation of the mandible.
5. Intrusion of the Lower Posteriors. For the fifth factor, the lower posterior teeth also need to be intruded in severe
cases. The intrusion of only the upper teeth can induce extrusion of the lower posterior teeth, which should be prevented
by microimplants, and the active intrusion of the lower posterior teeth is required in severe hyperdivergent cases.
6. The sixth factor is the vertical position of the lower incisors. The lower incisors are retracted by tipping in most
cases, and tipping may bring the incisal tip upward and cause incisal contact. Therefore, intrusion of the lower incisors is
required in patients with severe hyperdivergent skeletal pattern.
7. Coordination of movement at the upper and lower posterior teeth and the upper and lower incisors, which is very
important. In patients with hyperdivergent skeletal pattern, interdigitation of the teeth is not obtained easily. If 1 cusp of a
tooth has occlusal contact only, the occlusion stays with no contact at the other teeth. Therefore, the coordination of
movement is most important.
8. For the eighth factor, the extraction of the lower second premolars is better in terms of profile improvement,
because the mesial protraction of the lower posterior teeth is helpful in reducing vertical dimension or autorotation of the
mandible by moving the fulcrum forward.
Timing of Comprehensive Treatment : In dolichofacial subjects, the tendency will be to commence full active treatment later, in
the permanent dentition, so that the teeth can be carefully moved (often retracted) to positions of balance within the fully-grown
face. Extraction/non-extraction and missing-tooth replacement decisions.
Extractions: Because of the need to avoid undue opening of the vertical relationship during treatment and to avoid increasing lip
protrusion and convexity, extractions of premolar teeth (with or without enhanced vertical and anteroposterior anchorage) may be
necessary in dolichofacial patients, in particular.
In many mesofacial and dolichofacial patients, a missing lower second premolar may be advantageous, especially in the presence
of considerable crowding. Whatever the case, in a weaker muscular environment, controlled space closure may be relatively
straight forward.
It has been shown that, if premolars are extracted in dolichofacial patients, there is still likely to be an increase in overall vertical
facial dimension. The rule suggests that the natural individual muscle-related vertical dimension will be maintained dimension.
Vertical control of molars. TPA stops continued vertical descent of the upper buccal teeth and therefore stops maxillary alveolar
vertical growth. It is believed that this Alveolar growth is equal to a third of the total vertical growth of the face; therefore, whenever
a palate bar is being worn, it is the same as stimulating a third additional mandibular length. Another anecdotal method of this
inhibition is tongue pressure against the arch (Maxillary molar vertical control with the use of transpalatal arches John B. Wise,
DDS," W. Bonham Magness, DDS, ~ and John M. Powers, PhD ~ Allen and Houston, Texas (AM J ORTHOD DENTOFAC
ORTHOP 1994;106:403-8.)
Buccal tube angulation : Changes in angulation of the first permanent molars are inextricably linked to changes in anchorage.
The Molars are tipped distally in class II patients. Therefore, the straight archwire in conventional 0° or 5° buccal tubes on UMs
should be considered more carefully if it is used on the more distally tipped molars in Class II cases. The already distally tipped
upper molars cannot provide adequate anchorage with this Buccal tubes with 0° or 5°. Under the mesial tipping moment of a NiTi
wire, the first molar tips mesially and then occupies the extraction space, resulting in loss of anchorage. The maxillary molars are
also distally inclined. This may also be a reason why high-angle cases tend to lose anchorage more easily, in addition to the
explanation of weak masticatory forces.The maxillary first molars (which are usually employed as anchorage teeth) have varied
mesiodistal angulations that are affected by growth stages, malocclusion classification, and jaw growth patterns. Almost all UM
buccal tubes have the same angulation based on ideal normal occlusion, as demonstrated by Andrews. Hence, the forward tipping
moments on molars may be larger for growing adolescents, Class II cases and/or high-angle cases than for adults, Class III cases
and/or low-angle cases if using the same straight archwire to differences in the initial molar angulation. Tipping compensatory
molars into ideal molar angulation with a straight archwire might cause early loss of anchorage, exaggerate the Class II molar
relationship and reduce the natural occlusal curve, which could increase the risk of instability.
The lower molar angulation to mandibular plane shows less changes after growth is completed. It can be used as starting point of
reference for the orthodontic treatment. (Hong Su, Bing Han. Compensation trends of the angulation of first molars: retrospective
study of 1 403 malocclusion cases. International Journal of Oral Science)
Intrusion of Posterior Teeth to Close Anterior Open Bite. Most patients with anterior open bite have elongation of the maxillary
and/or mandibular posterior teeth, so the mandible is rotated downward and backward. The maxillary incisor segment often is
reasonably well positioned relative to the upper lip. Extrusion of the upper incisors to close the bite in a patient with this issue is
neither esthetically acceptable nor stable. Intrusion of the maxillary posterior segments so that the mandible can rotate upward and
forward is the ideal approach to treatment. Moving the maxilla up with a Le Fort I osteotomy is highly stable and predictable.
. Skeletal anchorage to intrude the posterior teeth has the potential to create the same mandibular response. This now makes
orthodontic intrusion a possible alternative to surgery, at least for patients with the less severe long-face problems. This has made it
possible to correct anterior open bite/ long-face problems that previously could not be corrected. Maxillary posterior teeth can be
intruded with miniplates at the base of the zygomatic arch, long bone screws reaching into the same area, or palatal anchorage
• Maxillary molar intrusion can give satisfactory correction of moderately severe open bite (up to 6 mm in the long term from
intrusion, more with extrusion of incisors). • Control of lower molar eruption now is recognized as important in gaining the desired
skeletal change and should be included routinely when maxillary molar intrusion is done. Clinical experience (unfortunately, not
well documented beyond case reports) suggests that intrusion of both maxillary and mandibular posterior teeth can allow closure of
more severe open bites. Eruption of maxillary and/or mandibular incisors partially compensates for re-rotation of the mandible, so
bite opening after open bite correction rarely occurs. It appears that Le Fort I surgery to superiorly reposition the maxilla is more
likely to produce a significant shortening of anterior face height.
It is clear now that 3 to 4 mm of intrusion can be achieved, with an expected short-term relapse of about 1 mm, and that for the
average patient, 2 mm of closure of the open bite occurs for every 1 mm of posterior intrusion. This means that closure of a 6-mm
anterior open bite is about the limit unless lower as well as upper molars are intruded, and that a surgical procedure still will be
required unless the mandible rotates to the correct position as face height decreases. If mandible is not able to rotate to the fullest
extent, reduction or elongation of ramus is required. For example, it can also rotate into an anterior crossbite that cannot be
managed with either mandibular dental retraction or maxillary proclination.
Retention When a Class II Growth Pattern Exists
Recurrence of a Class II relationship must result from some combination of tooth movement (forward in the upper arch, backward in
the lower arch, or both) and differential growth of the maxilla relative to the mandible. Overcorrection of the occlusal relationships
as a finishing procedure is important in controlling tooth movement that would lead to Class II relapse. In Class II treatment it is
important not to move the lower incisors too far forward, but this can happen easily with Class II elastics. In this situation, lip
pressure will tend to upright the protruding incisors, leading relatively quickly to crowding and return of both overbite and overjet.
Often this occurs in only a few months after full-time retainer wear is discontinued. As a general guideline, if more than 2 mm of
forward repositioning of the lower incisors occurred during treatment, permanent retention is very likely to be required. Class II
problems, this can be controlled in either of two ways. The first, if headgear was used in treatment, is to continue its use on a
reduced basis (at night, for instance) in conjunction with a retainer to hold the teeth in alignment. The other method is to use a
functional appliance of the activator or Bionator type to hold both tooth position and the occlusal relationship
Retention after correction of a Class III malocclusion early in the permanent dentition period can be frustrating, because recurrence
from continuing mandibular growth is very likely and extremely difficult to control mandibular growth, surgical correction after the
growth has expressed itself may be the only answer. In mild Class III problems, a positioner may be enough to maintain the
occlusal relationships during post treatment growth.
As we have noted previously, bite blocks are ineffective in intruding posterior teeth, but they are capable of impeding eruption. The
recent increase in reports of successful treatment of mild open bite malocclusion with clear aligners has led to suggestions that
vacuum-formed retainers with thickened plastic over the posterior occlusal surfaces may be useful for retention of these patients
The theory is that this would provide enough of a bite block effect to prevent posttreatment eruption of the posterior teeth and that
patient compliance would be better, but no good data exist It is possible that open bite retention with vacuum-formed retainers
also would work mostly by encouraging eruption of anterior teeth.
Orthognathic surgery
The surgeries may involve a Le fort I differential or plane reposition of the maxilla depending the inclination angle. The Mandibular
surgeries involve BSSO with corpus rotation, chin augmentation. The anterior teeth compensation and the occlusal plane correction
has to be done depending upon the situation. Neuromuscular adaptation is essential for stability. Fortunately, there is good
neuromuscular adaptation to most orthognathic procedures. When the maxilla is moved up, the postural position of the mandible
alters in concert with the new maxillary position, and occlusal forces tend to increase rather than decrease. This controls any
tendency for the maxilla to immediately relapse downward and contributes to the excellent stability of this surgical movement.
When the mandible is moved forward, a similar adaptation in tongue posture can be advantageous in patients with sleep-
disordered breathing, and a lower border osteotomy to bring the chin forward also produces forward movement of the tongue
because the tongue is attached to the genial tubercles. In contrast, neuromuscular adaptation does not occur when the
pterygomandibular sling is stretched during mandibular osteotomy, as when the mandible is rotated to close an open bite as it is
advanced or set back, so movement of the mandible that stretches the elevator muscles should be avoided.
Stability is greatest when soft tissues are relaxed during the surgical procedure and least when they are stretched. Moving the
maxilla up relaxes tissues
The least stable advancements are those that rotate the gonion angle down, lengthening the ramus and rotating the chin up.
The least stable orthognathic surgical procedure, widening the maxilla, stretches the heavy, relatively inelastic palatal mucosa.
Neuromuscular adaptation affects the length of the masticatory muscles but not their orientation, and adaptation to a new
orientation cannot be expected
This concept is best illustrated by the effect of changing the inclination of the mandibular ramus when the mandible is set back or
advanced. Successful mandibular advancement requires keeping the ramus in an upright position rather than letting it incline
forward as the mandibular body is brought forward. The same is true, in reverse, when the mandible is set back: a major cause of
instability appears to be the tendency at operation to push the ramus posteriorly when the chin is moved back, thus changing its
orientation. The orientation is restored when jaw function resumes after operation, and that moves the jaw forward again.