American Journal of ORTHODONTICS

and DENTOFACIAL ORTHOPEDICS

Founded in 1915 Volume 92 Number 3 September 1987

Copyright 0 1987 by The C. V. Mosby Company

ORIGINAL ARTICLES

The influence of functional appliance therapy on

glenoid fossa remodeling
D. G. Woodslde,* A. Metaxas,** and G. Altuna***
Toronto, Ontario, Canada

This study investigates the remodeling changes in the condyle and glenoid fossa following a period
of progressively activated and continuously maintained mandibular advancement using the Herbst
appliance. Progressive mandibular advancement was achieved by adding stops to the telescopic arms
of the appliance, with the total activation reaching 7.0 to 10.0 mm, dependent upon the length of
the treatment phase. This mandibular advancement produced extensive remodeling and anterior
relocation of the glenoid fossa, which contributed to anterior mandibular positioning and altered
jaw relationships. (AM J ORTHOD DENTOFAC ORTHOP 1987;92:181-98.)

R emovable functional orthodontic appli-

ances have been used for nearly 85 years in an attempt
to induce mandibular growth by changing muscle func-
tion and condylar-glenoid fossa relationships. This type
of therapy has provided opportunities, both clinical and
experimental, to test bone and muscle relationships’”
in a setting of intermittently altered condylar position.
In contrast to removable functional appliances,
fixed functional appliances (eg, Herbst) maintain a con-
tinuous alteration in condylar relationships. At the Uni-
versity of Toronto, clinical studies of Class II treatment
using this appliance all showed abnormalities in con-
dylar position4-6 and two studies (Fig. 1) showed no
increase in mandibular length after treatment.5,6 Our
studies suggested that the final result reflected the op-
This article is based on research that received the Award of Special Merit in
the 1987 Mile Hellman Research competition of the American Association of
Orthodontists. It was based on a thesis by Angeles Metaxas conducted in the
Department of Orthodontics, Faculty of Dentistry, University of Toronto, in
partial fulfillment of the requirements for the degree of master of science.
Presented to the American Association of Orthodontists in Kansas City, May
1984, and the European Orthodontic Society in Madrid, June 1986.
*Professor and Chairman, Department of Orthodontics, University of Toronto.
**Assistant Professor, Department Orthodontics, University of Toronto.
***Associate Professor, Department of Orthodontics, University of Toronto.
eration of multiple factors described below; however,
these factors did not explain fully the results achieved.
We postulated that forward remodeling of the glenoid
fossa may also have contributed to the correction. Thus,
it was suggested that a nonhuman model using the
Herbst appliance might provide information about the
cellular and remodeling responses in the temporoman-
dibular joint to continuously altered, condyle-glenoid
fossa relationships.
REVIEW OF LITERATURE
In spite of considerable research and debate, the
precise mode of action of functional appliances remains
obscure. Of the many theories offered to explain this
action, the most common include one, or a combina-
tion, of the following.
1. Dentoalveolar changes
Harvold7-9 and others’@‘* have stressed the impor-
tance of a vertical manipulation of the functional oc-
clusal plane in achieving Class II corrections with re-
movable functional appliances. This occurs by pre-
venting the eruption of the maxillary buccal segments,
which is normally in a downward and mesial direction.
Removable functional appliances do not appear to move
181
 Am. J. Orthod. Dentofac. Orthop.
182 Woodside, Metaxas, and Altuna
September 1987

Fig. 1. This figure shows the occlusion and facial appearance of a growing 1Cyear old boy before
treatment (A and D) and following a 6-month treatment with a Herbst appliance (B and E), and the
relapse that occurred 6 months posttreatment (C and F).

the upper buccal teeth distally unless a headgear is
attached13; however, there may be undesirable tooth
movement in the mandibular dentition. 14-16Many have
reported both distal movement of maxillary teeth
and mandibular anchorage loss with the Herbst ap-
pliance.5~‘7~‘s
2. Midface restriction
It has been shown that an important factor in achiev-
ing Class II correction in both removable and fixed
functional appliances is restriction of forward maxillary
growth.W.‘W
3. Mandibular growth induction
A. Intermittent change in condylar position. Of the
two distinct schools of thought regarding therapeutic
induction of condylar growth, one group believes that
we cannot increase mandibular length to a clinically
useful degree by current methods of orthodontic treat-
ment. The other group maintains that the condyle re-
sponds to such treatment and the mandibular length can
be increased by changing the functional environment
of the craniofacial complex. The conflicting results in
this area may possibly depend on whether the treatment
is intermittent as with removable appliances, or truly
continuous, as in fixed functional appliances.
Activators are worn primarily during the evening
and at night, and thus produce intermittent changes in
condylar-glenoid fossa relationships. The best con-
trolled clinical studies of such treatment have been un-
able to show clinically useful increases in mandibular
length.‘6~‘9-22
Volume 92 Influence of functional appliance therapy on glenoid fossa remodeling 183
Number 3

Fig. 1 (Cont’d). G and H show the abnormal condylar position 1 week posttreatment; the tracing in I
shows the relapse in mandibular position. A subsequent study has shown lesser degrees of condylar
position abnormalities when the treatment time was extended to 9 to 11 months.6 In this study there
was no discernible difference in condylar position between subjects who had large initial protrusive
bite registrations (7.0 to 8.0 mm) and those who had small initial bite registrations (3.0 to 4.0 mm)
followed by small amounts of progressive protrusion.

Histologic examination following intermittent for-

ward mandibular functioning in animals usually shows
proliferation of condylar cartilage after treatment23W33;
however, very few of these studies actually measured
mandibular length. Of those that did, some showed no
increased length, 32-34while others showed small in-
creases.*7-31,33The results achieved in some animal stud-
ies may be due to the extent of mandibular reposturing,
which varies considerably and in some instances is in
the extreme range of what could be tolerated physio-
logically and may be unlike any analogous human sit-
uation.
B. Continuous change in condylar position. Truly
continuous functional therapy requires that the appii-
antes be worn constantly and not removed for eating
or social purposes; this is essential if a constant alter-
ation in condylar-glenoid fossa relationships is to be
achieved. Because few appliances have been designed
for truly continuous wear, the literature contains a min-
imal number of studies on this aspect of functional jaw Fig. 2. Experimental animal with appliance inserted and bonded
orthopedics. Two Herbst appliance studies4’35reported in the mouth. ,One tube used to advance the bite can be seen
an increase in mandibular length when this was mea- in right telescope plunger (arrow).
184 Woodside, Metaxas, and Altuna Am. J. Orthod. Dentofac. Orthop.
September 1987

Flg. 3. A, The temporomandibular joint of a nonexperimental animal showing postglenoid spine (PGS),
superior portion of the glenoid fossa fF/, articular eminence (Af), mandibular condyle (C), and articular
disk (‘0). (Safranine 0 stain. Original magnification x 8, sagittal section.) B, Enlargement of the superior
area of the condyle of the same animal showing zones of condylar cartilage. A, Articular zone.
B, Prechondroblastic zone (proliferative zone). C, Chondroblastic zone (hypertrophic zone). 0, Zone
of endochondral bone formation (zone of calcification). (Safranine 0 stain. Original magnification x 100,
sagittal section.)

Fig. 4. A, Experimental animal before insertion of the Herbst appliance. Note the Class I buccal segment
relationship, the mesiodistal relationship of the occlusal amalgam fillings in the first permanent molars,
and the location of the metallic implants. B, Same animal at the end of the 12-week experimental
period. A severe Class Ill malocclusion is evident (note position of amalgam fillings). In addition, the
condyle appears to be forward, relative to the glenoid fossa, when one compares the distance between
the condylar head and the basi-sphenoid implants or the vertebral column in A and B.
Volume 92 Influence of functional appliance therapy on glenoid fossa remodeling 105
Number 3

Fig. 5. A, A modified standard coordinate system28,3awas used to assess the changes in the jaws with
respect to the cranial bone. Thus, a line was drawn from sella to nasal tip (NT) on the tracing of the
initial cephalogram; a perpendicular to this line from the sella point provided a coordinate system.
Successive tracings were superimposed on the cranial base implants in the sphenoid bone and on
the best fit of cranial base and endocranial contours. Implants in the occipital area of the cranial base
were lnot used because growth was taking place at the sphenocccipital synchondrosis. Then overall
horizontal changes in jaw position were measured parallel to the SNT plane, while the overall vertical
changes were measured parallel to the SNT perpendicular. increments of change between stages
were calculated by subtraction (12-week experimental animal). B and C, The same type of templates
were used to assess the bony and dental changes in the maxilla and mandible. Reference planes
were drawn on the occlusal surfaces of the maxillary and mandibular dentitions and perpendiculars
were dropped from this line. Then the successive tracings of the maxilla and mandible were super-
imposed on their respective implants. Horizontal and vertical changes within the bones were measured
parallel to these planes and the increments of change calculated by subtraction (12-week experimental
animal).

sured by means of midplane lateral cephalograms, while
two studies in which mandibular length was measured
on right and left 45” oblique cephalograms showed no
increase in length. 5.6
Animal studies using continuous Class II elas-
tics23,3a,37have shown no increased cartilage prolifera-
tion in juvenile and adult monkeys. However, our con-
tinuing studies of posterior occlusal bite-blocks3X-4”have
shown that varying degrees of continuous mandibular
opening with no forced protrusion induced extensive
proliferation of condylar cartilage and large increases
in mandibular length in both juvenile and adolescent
monkeys. 3
4. Redirection of condylar growth
Several studies5.4’33 suggest that functional appli-
ance treatment of Class II malocclusions may induce
favorable change in condylar growth direction. It is
likely that such changes represent remodeling of various
areas of the mandible to produce changes in form.@
5. Deflection of ramal form
Animal experiments in mandibular reposition-
ing3.32.3X.45.46.4X.49
and human functional appliance stud-
ies5.43.47
have reported changes in the gonial angle that
appear to be the result of remodeling in response to
altered activity and tone in the masseter-internal pter-
ygoid muscle sling.
6. Horizontal expression of mandibular growth
Our continuing serial studies of mandibular growth
direction have shown that removal of adverse environ-
mental influences, such as severe airway obstruction,
may be followed by a more horizontal mandibular
188 Woodside, Metaxas, and Altuna Am. J. Orthod. Dentofac. Orthop.
September 1987

Figs. 6 and 7. For legends, see opposite page

Volume 92 Influence of functional appliance therapy on glenoid fossa remodeling 187
Number 3

growth direction. 5o-54In addition, we have used pos-
terior occlusal bite-blocks and functional appliances to
inhibit buccal segment eruption in both arches, and thus
produced horizontal mandibular growth directions in
children with excess lower anterior facial height.‘8-40.53
This horizontal expression of mandibular growth either
through actual mandibular autorotation, as in ortho-
gnathic surgery, or relative mandibular rotation through
buccal segment intrusion in growing children is one of
the more powerful tools available for the correction of
Class II malocclusions associated with excess lower
anterior facial height. While others have also achieved
similar results with different appliances,55-57unfortu-
nately, the functional appliance literature has largely
ignored this highly effective method for improving
mandibular position.
7. Changes in neuromuscular anatomy
and function
Abundant evidence suggests that functional appli-
ances modify the neuromuscular environment of the
dentition and associated bones. However, the interac-
tion between bone and muscle cannot be explained
solely on a pressure-tension basis.J8-a Even though the
mechanism of neuromuscular adaptation to functional
appliance therapy is complex and difficult to explain,
extensive research in this area suggests several adap-
tive processes-for example, elongation of muscle
fibers6’,62 or tendons,63 migration of muscle attach-
ments along bony surfaces,6’.64-66and changes in mus-
cle dimensions due to bone displacements and ro-
tations.3840,6’
Petrovic and co-workers33.67-69concluded that in-
creased lateral pterygoid activity stimulates increased
proliferation of condylar tissue; others have been unable
to demonstrate this response.” Experiments at the Uni-
versity of Toronto using chronically implanted elec-
trodes have shown that lateral pterygoid muscle activity,
induced by the placement of functional appliances, is
depressed for up to 18 weeks.7’-74In addition, we have
shown that, with the use of posterior occlusal bite-
blocks, certain muscles of mastication can adapt by
changing the proportion of specific muscle fiber types
and fiber diameters.”
Obviously, studies of neuromuscular activity are
important to the clinician who designs functional ap-
pliances. For example, the observation that induced
neuromuscular change is depressed for some weeks af-
ter appliance placement suggests that we should design
appliances to utilize inherent tissue tension and lip ac-
tivity.
8. Adaptive changes in glendoid fossa location
The adaptive capacity of the glenoid fossa has been
demonstrated in human studies of condylar fractures,75
permanent tooth 10ss,‘~and occlusal equilibration” not
related to orthodontic therapy. Animal experiments
with tooth extraction,78 condylectomy,79-8’ and sur-
gical repositioning of the glenoid fossas show adap-
tive changes in the glenoid fossa similar to those

Fig. 6. A, Section of the temporomandibular joint of a g-week experimental adolescent animal. Note
extensive bone formation along the anterior border of the glenoid fossa and postglenoid spine (arrows),
despite the short experimental period. The response of condylar cartilage seems to be within normal
limits. (Hematoxylin and eosin stain. Original magnification x8.) B, Under higher magnification, the
periosteum of the anterior border of the spine appeared to be thicker than normal. A highly cellular
inner layer contained numerous osteogenic cells differentiating into osteoblasts, which, in turn, appeared
to be forming osteoid and bone at a rapid rate. This osteoid and new bone (arrows) were not as bright
and dense as the adjacent adequately calcified mature bone when examined under normal or polarizing
light. In addition, the new bone lacked the typical morphology of mature haversian-type compact bone
and showed irregularly organized fibrous elements with large osteocytes and thick, coarse, and ir-
regular collagen fibers; it resembled woven bone in the process of being rapidly remodeled to
form mature, lamellar bone. R shows areas of bone resorption along the posterior border of the
spine. (Hematoxylin and eosin stain, section photographed with polarized light. Original magnifica-
tion x42.)
Fig. 7. A, Section of the temporomandibular joint of the 12-week experimental adolescent animal. Note
extensive bone formation along the anterior border of the postglenoid spine (circle, arrow) and increased
thickness of posterior part of the disk. The condyle is clearly in an anterior position in relation to the
glenoid fossa and does not show evidence of significant proliferation of cartilage. (Hematoxylin and
eosin stain. Original magnification x8.) B, High-power view of the postglenoid spine of the same
animal. Arrows demonstrate location of newly formed bone along the anterior border of the spine. Note
increased cellular activity in the inner (osteogenic) layer of periosteum (pe) and rows of osteoblasts
(ob) along the lower border of the spine. (Hematoxylin and eosin stain. Original magnification x 42.)
 Am. J. Orthod. Dent&c. Orthop.
188 Woodside, Metaxas, and Altuna
September 1987

Fig. 8. Enlargement of the superior and anterior area of the condyle in the 12-week experimental
adolescent animal. Note reduced thickness of chondroblastic zone with cell-free areas (arrows) and
no evidence of excessive remodeling in zone of endochondral bone formation. (Safranine 0 stain.
Original magnification x 160.)
Fig. 9. A, Decalcified section of the temporomandibular joint of the experimental adult animal. Note
absence of condylar cartilage, bone apposition along the anterior border of glenoid fossa and post-
glenoid spine (arrows), increased thickness of posterior part of articular disk, and anterior repositioning
of the mandibular condyle in relation to the fossa. (Hematoxylin and eosin stain. Original magnification
x 8.) B, High-power view of superior area of the glenoid fossa showing extensive new bone formation
and increased cellular activity of inner (osteogenic) layer of periosteum foe). (Hematoxylin and eosin
stain. Original magnification x 100.)
Volumr 92 InJIuence qf functional appliance therapy on glenoid fossa remodeling 189
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Fig. 10. Condyle and glenoid fossa of the juvenile pilot study animal. Note extensive bone formation
(s) along the anterior border of the postglenoid spine and the posterior border of the condyle. Also
note increased proliferation of condylar cartilage (arrow). M, Lateral pterygoid muscle attachment.
(Hematoxylin and eosin stain. Original magnification x 10.)

Fig. 11. The figure shows the pretreatment occlusion (A through C) and the occlusion following
6 months’ treatment (D through F) with a Herbst appliance in a 12-year old growing girl.

seen in humans. Few human studies have demon-
strated changes in the glenoid fossa following activator
treatment43.“3 or explored the possibility that glenoid
fossa relocation contributes to the correction of skeletal
dysplasia.16 Animal studies showing glenoid fossa re-
modeling and relocation fall into two groups: those that
show temporal bone adaptation to protrusive man-
dibular function23~26~30-32*37~W~86~87
and those that show
changes after retrusive mandibular forces.23,“7,45.46.84.85,8x
Thus, one can make a strong argument that altered
function induces temporal bone adaptive remodeling.
The contribution of this response to the correction
190 Woodside, Metaxas, and Altuna Am. J. Orthod. Dentofac. Orthop.
September 1987

Table I. Measured changes in the condyle obtained from mandibular metallic implant superimpositions during
control, sham control, and experimental periods
Sample Control period

Condyle extension (mm)

Duration . co. to co. Co. to AMI
Serial No. Sex Age (weeks) Horizontal Vertical (mm) fmm)

913 Cyno P Adolescent 61 3 4.95 5.15 4.5

915 Cyno P Adolescent 50 5.75 4.2 7.5 7.3
979 Cyno P Adolescent 61 2.9 5.9 6.5 6.1
926 Cyno 6 Adult 46 0 0 0 0
951 Sham Cyno 0 Adolescent 46 2.1 1.4 2.4 2.3
914 Sham Cyno 0 Adolescent 61 4.2 3.8 5.3 5.0
978 Cyno P Juvenile 45 4.0 2.0 4.4 4.2
(Pilot)

*Positive indicates forward movement; negative indicates backward movement = horizontal measurement.
**Positive indicates downward movement; negative indicates upward movement = vertical measurement.

Table II. Measured changes in tooth position obtained from maxillary and mandibular metallic implant
superimpositions during the experimental period

Serial No. Sex Age Duration Activation

973 Cyno P Adolescent 6 weeks I mm

915 Cyno P Adolescent 6 weeks 7mm
979 Cyno P Adolescent 12 weeks 10 mm
926 Cyno 6 Adult 12 weeks 8 mm
957 Sham Cyno 0 Adolescent 12 weeks -
974 Sham Cyno P Adolescent 12 weeks -
978 Cyno P Juvenile 13 weeks 10 mm
(Pilot)

*Positive indicates forward movement; negative indicates backward movement = horizontal measurement.
**Positive indicates downward movement; negative indicates upward movement = vertical measurement.

of skeletal dysplasia following orthodontic treatment MATERIALS AND METHODS

needs further investigation.
STATEMENT OF PROBLEM
This study was designed to assess the remodeling
that took place in the condyle and particularly the gle-
noid fossa of adolescent and adult primates in response
to a progressively reactivated and continuously main-
tained mandibular advancement. The present study en-
larges an earlier pilot study in which the Herbst appli-
ance was used to achieve progressive and continuous
mandibular protrusion.3 It was designed to test whether
temporomandibular joint changes following continuous
functional appliance therapy make an important con-
tribution to the correction of disproportionate jaw re-
lationships. In addition, this study might show whether
the changes observed represent healthy or degenerative
adaptations.
The sample consisted of 6 female and one male
cynomolgus (Macaca fascicularis) monkeys; one was
juvenile (24 to 36 months), five were adolescent (36 to
48 months), and one was adult (male 70 to 80
months).89,W Activated Herbst appliances (Fig. 2)
were placed in five experimental animals; two adoles-
cents wore inactivated appliances (sham controls).
Tables I, II, and III show the duration of the control,
sham control, and experimental periods.
The joints of four additional animals were examined
histologically to provide a basis for study of normal
joint histology (Fig. 3, A and B). Metallic implants and
occlusal amalgams were inserted by standard meth-
ods28,9’in the left side of the jaws, the skull, the cranial
base, and the first permanent molar to facilitate the
measurement and superimposition of the cephalograms
(Fig. 4, A). Fiberglass masks were prepared to allow
 Volume 92 Injluence of functional appliance therapy on glenoid fossa remodeling 191
Number 3

Experimental period

Con&le extension (mm)

Duration Activation co. to co. Co. to AMI
(weeks) (mm) Horizontal* Vertical** (mm) (mm)

6 I 0.5 0 0.5 0.5

6 7 1.2 I 1.33 1.25
12 10 0 0 0 0
12 8 0 0 II 0
12 - 1.65 0.9 1.3 I .45
12 - 0.8 I .22 1.23 0.84
13 10 -0.4 1.9 2.0 IO

Maxilla Mandible

First molar (mm) Incisor (mm) First molar (mm) Incisor (mm)

Horizontal* Vertical** Horizontal Vertical Horizontal Vertical Horizontal Vertical

0 0 0.2 0 0.7.5 0 1.3 0.3

- 1.3 -0.5 - 0.63 2.1 0.52 -0.65 1.5 0.61
- 1.4 -0.65 0.8 I I - 1.1 2 1.5
- 1.14 -0.2 0.7 -0.4 1.12 0.35 1.2 0.7
0.5 -0.5 0.75 I 0.2 0 1.25 0.7
0.32 0.1 -0.42 0.6 0.38 -0.29 0.3 0
-2.1 - 1.9 -0.5 0 1.5 -0.5 1.5 3.0

the animals free movement while protecting the ap- period, and at the end of the posttreatment period after
pliances.” removal of the appliances. Radiographs were made in
Herbst appliances were bonded to the teeth of all centric occlusion and with the teeth separated at a stan-
experimental animals and activated to give an initial dard distance of 25.0 mm so that the cond,yles could
2.0-mm mandibular advancement. Progressive mandib- be seen clearly.
ular advancement was achieved by adding tube stops,
1.O to 2.0 mm thick, to the telescopic arms of the Herbst CEPHALOMETRIC ANALYSIS
appliance approximately every 2 weeks (Fig. 2). The A standard coordinate system’8.38was used to mea-
total activation was 7.0 to 10.0 mm, dependent upon sure changes in the position of the jaws relative to the
the length of the experimental period (Table I). cranial bones and changes within the maxilla and man-
Obviously, there was no activation for the sham dible. This is described in the legend of Fig. 5, A
controls. through C. Many measurements of bony and dental
A custom head positioner prepared for each monkey changes were made,” but this study reports only the
secured a reproducible head position during serial following obtained at the beginning and end of the
cephalometry. Fine-grained no-screen film (Kodak experiment:
XAR-2), used at 80 kvp and 15 mA with exposure time Horizontal condylar extension: the distance between the
of 10 seconds, produced the finest radiographic reso- perpendiculars drawn from the horizontal axis to the
lution possible (Fig. 4, A and@. Radiographs and study most posterior points of the condylar outlines from
models were made of all animals at the start of the the mandibular superimpositions (Fig. 5, C)
control period, the start and end of the experimental Vertical condylar extension: the distance between the
192 Woodside, Metaxas, and Altuna
Table III. Mandibular displacement during the experimental period obtained from overall superimpositions
on cranial base structures
Serial No. Sex Age
973 Cyno P Adolescent
975 Cyno 0 Adolescent
979 Cyno P Adolescent
926 Cyno 6 Adult
957 Sham Cyno P Adolescent
974 Sham Cyno 0 Adolescent
978 Cyno 0 Juvenile
(Pilot)
horizontal lines drawn from the vertical axis to the
uppermost portion of the condylar outlines
Condylion to condyfion: the distance between the most
posterior and superior points of the condyles
Condylion to the anterior metallic implant (AMI): the
distance between the most posterior and superior
points of the condyle and the most anterior point of
the anterior metallic implant
Ramus to ramus: the distance between the perpendic-
ulars drawn from the horizontal axis to the most
posterior point of the condyles from the overall su-
perimpositions on cranial base structures ( Fig. 5, A).
This distance was used to identify possible anterior
mandibular displacement.
Table IV shows that an acceptable level of accuracy
was achieved in superimposing successive tracings and
in the subsequent measurements of horizontal and ver-
tical changes between and within individuals.
HISTOLOGIC ASSESSMENT
Decalcified sections from the mandibular condyles
and the glenoid fossa were examined histologically. The
right temporomandibular joints of all the animals were
stored in 10% neutral buffered formalin and then de-
calcified in a 1: 1 solution of 45” formic acid and 20%
sodium citrate, changed every second day for 21 days.
The tissue was sectioned at 6 pm, stained with he-
matoxylin and eosin (to show osteoblasts, osteoid,
woven bone, resorption, resting line, inflammation),
safranine 0 (to show cartilage, stained red; bone, stained
green), toluidine blue (to show cartilage, stained dark
blue; bone, stained light blue), and Masson trichrome
(to show nuclei, stained black; collagen, stained blue).
The sections were examined under a Leitz Orthomat
microscope and photographed on Kodachrome 25 day-
light film with correction filters. Polarizing light was
added to some of the slides to emphasize areas of new
bone formation and bring out the difference in density
and organization between mature and young bone.
Am. .I. Orthod. Dentofac. Orthop.
September 1987
Duration Activation Ramus co ramus (mm)
6 weeks I mm 0.9
6 weeks 7mm 0
12 weeks 10 mm 4
12 weeks 8 mm 1
12 weeks - 0
12 weeks - 0.7
13 weeks 10 mm 1.5
RESULTS
1. Occlusal changes
All of the experimental animals had normal occlu-
sion at the beginning of the experiment. Progressive
appliance activation produced mandibular prognath-
ism with a Class III malocclusion in the buccal seg-
ments and an anterior open bite. These changes were
more pronounced in the 12-week experimental animal
(Fig. 4, B) than in the 6-week animals. After the ap-
pliances were removed, there was a minor abatement
of the Class III malocclusion. However, 5 to 7 days
after the end of treatment, the Class III malocclusion
was stabilized and the mandible could not be manip-
ulated posteriorly under general anesthesia. The sham
controls wearing unactivated Herbst appliances main-
tained a Class I buccal relationship and normal incisal
relationship during the 12-week sham control period.
2. Cephalometric evaluation and
coordinate analysis
The overall superimposition of tracings showed a
downward and forward translation of the mandible
(Fig. 5, A). The ramus-to-ramus measurement and the
forward displacement of the mandibular metallic im-
plants showed that there had been a forward displace-
ment of the mandible relative to the cranial base in all
experimental animals except one 6-week animal (Ta-
ble III). The maxilla was displaced down and back in
the incisor area and up and back in the molar area. This
brought the molars into a more distal position relative
to the cranial base (Fig. 5, A). The sham controls
showed a normal forward translation of the maxillary
and mandibular complex with horizontal displacement
of the implants greater than vertical displacement.
The maxillary superimpositions showed that three
of four experimental animals had distal movement of
the maxillary first molars (Fig. 5, B), while the lingual
and inferior displacement of the incisors was minimal
(Table II). Thus, the combination of maxillary trans-
Volume 92
Injluence of firnctional appliance therapy on glenoid fossa remodeling 193
Number 3

Table IV. Replications of condylar extension measurements obtained by superimposition of mandibles

on metallic implants

I Operator I (A.M.),
Replication I I
Operator I (A.M.),
Replication 2 Operator II (D.G.W.)

Condyle extension Condyle extension Condyle extemon

Serial No. Horizontal Vertical Horizontal Vertical Horizontal Vertical

973 0.5 0 0.6 0.2 0.8 0.1

975 1.2 1 1.1 I I.25 1.0
979 0 0 0 0 0 0
926 0 0 0 0 0 0
951 Sham 1.65 0.9 1.60 0.85 I .4 I.2
974 Sham 0.8 1.22 0.75 1.2 0.6 I.0

lation plus tooth movement produced a large occlusal
change relative to the cranial base. The sham controls
showed minimal dental changes.
Despite normal mandibular growth in the experi-
mental juvenile and adolescent animals during the con-
trol period, none of the measurements used to evaluate
condylar extension showed any significant additional
mandibular growth at the end of the experiment (Ta-
ble I). Both of the sham control adolescents showed
some horizontal and vertical growth of the condyles
(Table I).
Dentoalveolar changes in the mandible of the ex-
perimental animals consisted of a labial and inferior
movement of the incisors and a forward and slightly
superior movement of the first molars (Fig. 5, C, Ta-
ble II). The overall tooth movement was greater in the
12-week adolescent animal than in the two 6-week ad-
olescent monkeys. The dentoalveolar changes in the
experimental adult were similar to those in the ad-
olescents, while the sham controls showed minimal
changes.
3. Histologic study of the temporomandibular
On this examination the condylar cartilage in the
experimental adolescents showed a minimal remodeling
response and the prechondroblastic and chondroblastic
zones were thin in both the B-week and the 12-week
animals. Furthermore, no evidence was found of matrix
calcification or remodeling of the osseous trabeculae
(Figs. 6, A, and 7, A). The condylar cartilage of the
12-week adolescent showed cell-free areas in the su-
perior and anterior regions of the chondroblastic zone
(Fig. S), but no similar areas were seen in the 6-week
animals. The condylar head appeared to be flatter in
the experimental animals (Fig. 7, A) in contrast to the
normal round shape. The experimental adult condyles
had no cartilage and only a few scattered chondrocytcs
in the superior and posterior regions, and mature
cancellous bone adjacent to a thin articular zone
(Fig. 9, A). Histologic examination of the juvenile an-
imal showed a completely different condylar response
to the stimulus. There was extensive cartilage prolif-
eration at the end of 13 weeks (Fig. 10). This correlated
with the cephalometric examination, which showed a
small vertical condylar extension. The experimental ad-
olescents showed subperiosteal bone resorption along
the anterior border of the condyle under the insertion
of the lateral pterygoid muscle. This resorption ap-
peared to be more extensive in the 6-week animals than
in the 12-week animal.
4. Glenoid fossa-postglenoid spine
The most dramatic changes were seen in 1he glenoid
fossa, especially in the area of the postglenoid spine.
Study of the animals used to assess normal joint his-
tology showed bone deposition along the pos,terior bor-
der of the spine and bone resorption along the anterior
part of this area, in agreement with McNamara’s
finding? (Fig. 3, A). This contrasted sharply with the
joint histologic findings in all experimental animals. The ex-
perimental adolescents showed a dramatic remodeling
response of the glenoid fossa and especially the post-
glenoid spine. There was a reversal of the normal pat-
tern-namely, extensive bone formation along the an-
terior border followed by bone resorption along the
posterior border; this was greater in the 12-week ani-
mal than in the 6-week animals (Figs. 6, A and B,
and 7, A and B). The experimental adult showed a
similar response despite the total absence of any con-
dylar remodeling (Fig. 9, A and B). A juvenile pilot
study animal also showed extensive bone formation in
the same areas (Fig. 10).
Another important finding concerned the posterior
part of the articular disk; in all experimental animals,
194 Woodside, Metaxas, and Altunu Am. J. Orthod. Dentofac. Orthop.
September 1987

Fig. 11 (Co&t). Facial appearance at the beginning of treatment (G), after six months’ treatment (H),
and 7 months posttreatment (I). The tomographs show the very abnormal condylar position 1 week
following appliance removal (J and K) and the partial correction that occurred 7 months posttreatment
(L and M). This case required 2 additional years of orthodontic treatment to correct the dual bite that
was created by the appliance. A subsequent study has shown lesser degrees of condylar position
abnormalities ihen the treatment time was extended to 9 to 11 months.” In this study there was no
discernible difference in condylar position between subjects who had large initial protrusive bite reg-
istrations (7.0 to 8.0 mm) and those who had small initial bite registrations (3.0 to 4.0 mm) followed
by small amounts of progressive activation. It is assumed that these abnormalities would be further
minimized if treatment was extended even longer in growing children.

this appeared to proliferate posteriorly to fill the space DISCUSSION

created by the condylar displacement. In this area the
fibrous tissue contained numerous, enlarged active fi-
broblasts; most of these appeared in areas where the
anterior displacement of the condyle had increased the
tension being exerted on the fibers (Figs. 6, A, 7, A,
and 9, A).
A number of factors contributed to the rapid creation
of the Class III malocclusion-eg, maxillary and man-
dibular tooth movement, changes in maxillary position,
anterior glenoid fossa relocation, condylar displace-
ment in the glenoid fossa, and proliferation of the pos-
terior part of the fibrous disk. Mandibular growth was
Volume 92 Irtjluence of functional
Number 3
a contributing factor in the juvenile animal only. Human
studieP also have shown anchorage loss changes and
condylar displacement, which in many cases are con-
sidered undesirable.
Condylar response
After continuous mandibular advancements, ceph-
alometric and histologic examinations of the adolescent
and adult animals did not demonstrate any useful in-
crease in mandibular length or increased proliferation
of the cellular elements in the cartilaginous zones of
the mandibular condyle. Although a number of factors
may be operating, this finding may be age- and sex-
related because the juvenile female animal responded
with increased mandibular length and proliferation of
condylar tissues.3 Further, it may be related to the fact
that the degree of mandibular protrusion used in some
experimental animals was extreme compared to the pro-
trusion achieved in clinical work. Experiments with a
sample of juvenile animals are in progress to clarify
this point. Further, experiments by Degroote95 have
shown that the presence or absence of posterior occlusal
contact during mandibular protrusion is related to pro-
liferation of condylar tissues. The cell-free zones noted
in the superior and anterior regions of the chondro-
blastic zone may represent either damage or a temporary
aberration; further investigation is necessary to clarify
this point. However, the condylar flattening observed
(Figs. 7, A, and 10) obviously represents an adaptation
to continuously altered condylar position and may be
undesirable.
Glenoid fossalpostglenoid spine
The most important findings in this study are the
changes in the glenoid fossa observed after continuous
anterior repositioning of the condyle. In all the ex-
perimental animals, including, most importantly, the
mature adult, a large volume of new bone had formed
in the glenoid fossa, especially along the anterior
border of the postglenoid spine. With this bone for-
mation and the resorption along the posterior border of
the postglenoid spine, the glenoid fossa appeared to be
remodeling anteriorly. Expert histopathologists have
agreed that the newly forming bone had a normal ap-
pearance .
The new bone formation appeared to be localized
in the primary attachment area of the posterior fibrous
tissue of the articular disk. The desposition of the finger-
like woven bone seemed to correspond to the direction
of tension exerted by the stretched fibers of the poste-
rior part of the disk. These findings were completely
opposite to those observed in our nonexperimental
growing animals in whom bone resorption occurred
along the anterior part and bone deposition along the
posterior part of the spine. This study, which sup-
appliance therapy on glenoid fossa remodeling 195
ports the work of Hinton and McNamara3’ and oth-
ers 23,26*30*37,84~86**7
demonstrates that fixed functional ap-
pliance therapy may exercise a strong influence on gle-
noid fossa remodeling.
The new bone was deposited rapidly on the anterior
border of the postglenoid spine in direct response to
the altered mandibular position. This deposition was
greater in the 1Zweek adolescent than the 6-week mon-
keys, indicating that the glenoid fossa was adapting
continuously to the continuous stimulus-specifically,
the progressive activation of the Herbst appliance. The
amount of newly formed bone was large considering
the size of the animals’ glenoid fossa. Morphometric
analysis to estimate the thickness and volume of new
bone is in progress.
The posterior part of the articular disk, between
the postglenoid spine and the posterior part of the
condyle, increased in thickness and showed active cel-
lular and connective tissue response associated with
numerous enlarged fibroblasts in active stage. The in-
creased fibrous tissue of the disk posterior to the
condyle, associated with the bone apposstion in the
glenoid fossa, appeared to stabilize the anterior con-
dylar displacement, which was demonstrated cephalo-
metrically, functionally, and histologically. This fi-
brous tissue overgrowth may explain why the mandible
could not be manipulated posteriorly under anesthesia
or after sacrifice and removal of the adjacent muscu-
lature. However, it is still possible that such fibrous
tissue may resorb after the stimulus is removed and
the mandible may partially return toward its original
position.
In a study of human material at the University of
Toronto, the mandible could not be manipulated pos-
teriorly after 6 months’ treatment with the Herbst ap-
pliance. However, tomographs of the temporomandib-
ular joints showed that the condyle was displaced an-
teriorly in relation to the glenoid fossa in some patients
and that at 8 months posttreatment the jaw position had
undergone a partial relapse (Fig. 11). Similar obser-
vations also have been noted during the early stages
of removable functional appliance therapy. A recent
study,16 using a longer treatment period, also showed
condylar displacement but not to the same degree. It
is possible that proliferation of fibrous connective
tissue similar to that observed in the animals might
have contributed to the above clinical findings in hu-
man subjects. These observations may aho indicate
that the condyle needs time to grow back into the gle-
noid fossa, or the fossa needs time to remodel anteri-
orly, or both.
In summary, all the glenoid fossa findings in adult,
adolescent, and juvenile animals support the view that
temporomandibular joint changes following continuous
functional appliance therapy may assist in the correction
196 Woodside, Metaxas, and Altuna
of disproportionate jaw relationships. Remodeling such
as that seen in this study may create the appearance of
an increased mandibular length with or without a true
increase.
Studies using larger samples of juvenile animals and
studies of the posttreatment stability of the altered jaw
relationships are in progress in our laboratory.
CONCLUSIONS
1. In adult, adolescent, and juvenile primates, con-
tinuous and progressive mandibular protrusion produces
extensive anterior remodeling of the glenoid fossa.
2. This glenoid fossa remodeling contributes to
anterior mandibular positioning and altered jaw rela-
tionships.
3. Proliferation of condylar tissues and increased
mandibular length following continuous and progres-
sive mandibular protrusion may be age- and sex-related,
and was seen only in the juvenile primate. Adolescent
primates in the permanent dentition prior to third molar
eruption did not show any condylar response.
4. After continuous protrusion, proliferation of the
posterior part of the fibrous articular disk splinted the
condylar head eccentrically in the glenoid fossa.
5. Skeletal jaw relationship may be altered by both
glenoid fossa remodeling and condylar extension in
young primates, thereafter by glenoid fossa relocation.
This result may be related to age, sex, and the amount
of mandibular protrusion.
The authors wish to express their sincere thanks to
Dr. G. Lie for his critical reading of the manuscript.
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Reprint requests to:
Dr. Donald G. Woodside
Faculty of Dentistry
University of Toronto
124 Edward St.
Toronto, Ontario, Canada
M5G lG6