8oLaLlon of Maxllla

Core of Lhe maxllla above Lhe alveolar process

luncLlonal process alveolar process bones
surroundlng alr passages
lnLernal roLaLlon 1he cove of Lhe maxllla undergoes a
small and varlable degree of roLaLlon forward or backward
AL Lhe same Llme resorpLlon of bone on Lhe nasal slde and
apposlLlon of bone on Lhe palaLal slde ln Lhe anLerlor and
posLerlor parL of palaLe occurs
LrupLlon of molars and lnclsors occurs
1he above Lwo facLors accounL for Lhe exLernal roLaLlon
lor mosL paLlenLs Lhe exLernal roLaLlon ls opposlLe ln
dlrecLlon and equal ln magnlLude Lo lnLernal roLaLlon
1he Lwo roLaLlons Lhus cancel each oLher and Lhe neL change
ln [aw orlenLaLlon (palaLal plane) ls zero
varlaLlon from Lhls average paLLern ls common and resulL ln
moderaLe varlaLlon ln !aw orlenLaLlon



oo 017
8C1A1lCn Cl MAxlLLA
98LulC1lCn Cl MAnul8uLA8 C8CW1P 8C1A1lCn
lf an aLLempL ls made Lo assess Lhe growLh Lrend aL an
early sLage Lhls lnformaLlon can be used ln deslgnlng Lhe
LreaLmenL of evaluaLlng Lhe problems LhaL may arlse before
growLh ls compleLe
ln splLe of several aLLempLs ln recenL years Lhere ls sLlll
doubL as Lo Lhe exLenL Lo whlch growLh of Lhe face as a whole
can be predlcLed from a slngle proflle radlograph
ln an aLLempL Lo analyse Lhe posslblllLy of predlcLlng
growLh of slngle faclal dlmenslon 8[ork and palllng correlaLed
llnear and angular measuremenLs aL puberLal age wlLh resldual
growLh of Lhese dlmenslons up Lo adulLhood 1hese
correlaLlons were however found Lo be low
Plxon suggesLed LhaL Lhe besL esLlmaLe of an adulL faclal
dlmenslon for a glven chlld ls Lo use Lhe dlmenslon presenLed
by Lhe chlld and add Lo LhaL Lhe remalnlng average growLh for
Lhe group 1hls meLhod was adopLed by several auLhors
Powever Lhls esLlmaLe would flL an average buL noL an
exLreme growLh paLLern where predlcLlon from a cllnlcal polnL
ls more lmporLanL
Lavergne Lrled Lo lndlvlduallze Lhe predlcLlon by a
subdlvlslon accordlng Lo Lhe morphogeneLlc Lypes
8lckeLLs arclal meLhod of long range growLh predlcLlon
uses geomeLrlc procedures Lo galn lnformaLlon abouL Lhe
growLh paLLern of Lhe mandlble
A compuLerlzed sysLem for shorL range faclal growLh
predlcLlon and LreaLmenL slmulaLlon based on longlLudlnal
observaLlons of lndlvldual growLh raLe and dlrecLlon has been
developed by 8[ork!orgensen
A growLh analysls conslsLs of essenLlally 3 lLems
1 assessmenL of Lhe developmenL ln shape of Lhe face
2 assessmenL of wheLher Lhe lnLenslLy of Lhe faclal growLh ls
hlgh or low
3 evaluaLlon of Lhe lndlvldual raLe of maLuraLlon
ln Lhe assessmenL of shape Lhere are Lhree meLhods
l LonglLudlnal meLhod ConslsLs of followlng Lhe course of
developmenL ln annual cephalomeLrlc fllms
lL ls for Lhe sub[ecLs dlsplaylng Lhe mosL pronounced
changes ln faclal forms LhaL Lhe dlagnosls of growLh paLLern
ls lmporLanL
LlmlLaLlon
1 9aLLern of growLh ls noL consLanL and may be changed laLer
2 9ermlLs observaLlon of changes ln Lhe sagglLal [aw relaLlon
wlLh growLh and Lhose occurrlng ln Lhe verLlcal [aw relaLlon
are masked
Changes ln Lhe verLlcal poslLlons of Lhe [aw ln Lhe form
of roLaLlon appear Lo be smaller when assessed wlLh
convenLlonal longlLudlnal xray fllms by uslng Lhe base of
Lhe mandlble as Lhe reference Lhan when assessed wlLh Lhe
help of lmplanLs
Analysls of verLlcal developmenL of Lhe face may done
uslng naLural reference sLrucLures ln Lhe mandlble by
superlmposlng Lwo radlographs Laken aL dlfferenL ages and
orlenLlng reference Lo Lhese sLrucLures one may esLlmaLe
Lhe growLh paLLern of Lhe mandlble by readlng Lhe angle
beLween Lhe naslon sells llnes for Lhe Lwo ages
ll ML18lC ML1PCu
Alms aL a predlcLlon of faclal developmenL on Lhe basls
of faclal morphology deLermlned meLrlcally from a slngle x
ray fllm Powever predlcLlon of developmenL from slze and
shape aL chlldhood ls noL very accuraLe 1he growLh ln lengLh
of Lhe mandlble durlng adolescence could noL be [udged from
lLs slze before puberLy and also Lhe changes ln shape of Lhe
face durlng adolescence expressed ln Lerms of angular
measuremenLs also weekly correlaLed wlLh Lhe shape of Lhe
face aL 12 years whlch ls Lhe age aL whlch LreaLmenL ls
lnsLlLuLed
ll S18uC1u8AL ML1PCu
ls based on lnformaLlon concernlng Lhe remodelllng
process of Lhe mandlble durlng growLh galned from Lhe
lmplanL sLudles 1he prlnclple ls Lo recognlze speclflc
sLrucLural feaLures LhaL develop as a resulL of remodelllng ln a
parLlcular Lype of mandlbular roLaLlon A predlcLlon of Lhe
subsequenL course ls Lhen made on Lhe assumpLlon LhaL Lhe
Lrend wlll conLlnue
Conlal Angle and mandlbular roLaLlon
1he slze of Conlon angle lnfluence Lhe number of degree
of counLer clockwlse roLaLlon of mandlble
1he smaller Lhe gonlon angle Lhe greaLer Lhe roLaLlon ls
produced for each mm of forward movemenL of pogonlon


laclal dlvergence and mandlbular roLaLlon

1he degree of faclal dlvergence (Sn M9) has a
slgnlflcanL bearlng on mandlbular roLaLlon
Larger SnM9 angle Lhe more Lhe mandlble Lends Lo
become sLeeper and Lhe chln moves more backward
1he smaller Lhe angle Lhe greaLer Lhe Lendency of Lhe
mandlble Lo become flaL and Lhe chln Lo grow forward



8LvlLW Cl Ll1L8A1u8L
8LvlLW Cl Ll1L8A1u8L
1Schudy sLudy
CrowLh was sLudled on 62 paLlenLs
29 11 14 years
33 8 11 years
1reaLed cases
30 11 14 years
Alm of Lhe sLudy 1o deLermlne Lhe cause of mandlbular
roLaLlon
Measurlng verLlcal growLh ln Lhe flrsL molar LeeLh and
relaLlng Lhls growLh Lo LhaL aL Lhe mandlbular condyles



8esulLs


8esulLs
unLreaLed 1reaLed
LffecLlve condyle growLh 72 mm 67mm
verLlcal growLh 63mm 71mm
73 of verLlcal growLh ln Lhe unLreaLed group
(46mm) was ln Lhe maxllla and 27 ln Lhe mandlble
1reaLed 68 maxllla 32 mandlble
1hus he concluded LhaL MAxlLLA ls responslble for
abouL 70 of LoLal verLlcal growLh and has an lmporLanL
effecL on Lhe 'LllL' of Lhe mandlble
2 Alf 1or karlsen 1997 Angle orLhodonLlsL
SLudy
Alm AssoclaLlon beLween verLlcal cranlofaclal growLh and
mandlbular growLh roLaLlon
SLudy group 1wo groups
(l) Low M9Sn angle
(ll) Plgh M9Sn angle
naLure LonglLudlnal sLudy from 6 13 years of age
8esulLs
-lncreased posLerlor 9oslLlvely correlaLed wlLh
lower faclal helghL lC8WA8u MA18lx 8C1A1lCn
lncrease ln ramus helghL lrrespecLlve of M9A / age
2 lncrease ln LAlP Weakly correlaLed wlLh
mandlbular roLaLlon (?)
SLrongly and poslLlvely
correlaLed wlLh lncreased ln
corpus lengLh



Cver developmenL of LAlP ln hlgh angle cases
occurred because Lhe sLeep mandlbular plane dlrecLed corpus
growLh more downward
3 1993 AC
1he same auLhor dld a longlLudlnal sLudy wlLh boys
havlng low and hlgh M9Sn angles
Alm Compare Lhe Lwo groups wlLh regard Lo dlmenslonal
changes and mandlbular growLh roLaLlon
8esulL SlgnlflcanL correlaLlons were almosL excluslvely
noLed beLween dlmenslonal change and LoLal roLaLlon and
dlmenslonal change and maLrlx roLaLlon
4 1984 nov 8[ork and Skleller A!C
Alm 1o esLlmaLe Lhe posslblllLy of predlcLlng Lhe dlrecLlon
and amounL of growLh roLaLlon of Lhe mandlble on Lhe basls
of morphologlc crlLerla observed on a slngle proflle
radlograph aL puberLal age
lorLy four morphologlc varlables were employed and
four among Lhem gave Lhe besL prognosLlc esLlmaLe (86) of
mandlbular growLh roLaLlon ln Lhe sample
1Mandlbular lncllnaLlon
a 9roporLlon beLween posLerlor and AlP (lndex l)
b Lower Conlal angle (CCL)
c Lower border lncllnaLlon (nSL ML1)





2 lnLer molar angle (MCLs MCLl)
3 Shape of lower border (ML1 ML2)
4 lncllnaLlon of symphysls (C1L nSL)
3 A!C uec 1998
ln response Lo 8[ork Skleller's arLlcle (1984 A!C)
Laurel 8 Leslle 9ubllshed a arLlcle assesslng Lhe rellablllLy of
Lhelr meLhod of predlcLlng growLh roLaLlon uslng Lhe four
varlables
1hey concluded LhaL only 9 of Lhe varlablllLy ln
mandlbular growLh roLaLlon could be accounLed for uslng Lhe
four varlables ln comblnaLlon ln conLrasL Lo 83 glven by
8[ork
1hus he sLaLed LhaL Lhe meLhod does noL permlL cllnlcally
useful predlcLlons of fuLure mandlbular growLh roLaLlon





Cllnlcal lmpllcaLlons
1uownward allgnmenL of Lhe whole mandlble aL Lhe
condylar plvoL has a mandlbular reLruslve effecL
Cnly Corpus mandlbular proLruslve effecL
upward allgnmenL of Lhe whole mandlble
Mandlbular proLruslve effecL
Cnly corpus Mandlbular reLruslve
2 1he more exLreme Lhe roLaLlon of Lhe mandlble durlng
growLh Lhe greaLer Lhe cllnlcal problems LhaL ls presenLs
LxLreme roLaLlon greaLly lnfluence Lhe paLh of erupLlon of
Lhe LeeLh magnlLude of LooLh erupLlon anLeroposLerlor
poslLlon of lnclsor LeeLh
9aLh of erupLlon of max LeeLh
uownward and somewhaL forward





ln normal growLh maxllla usually roLaLes a few degrees
forward
lL may be normal buL usually Lhe maxllla roLaLes sllghLly
backward


lorward 8oLaLlon of maxllla 1ends Lo Llp Lhe lnclsors
forward and lncrease
Lhelr promlnence

8ackward 8oLaLlon of maxllla ulrecLs Lhe anLerlor LeeLh
more posLerlorly
relaLlvely up rlghLlng
Lhem and decreaslng
Lhelr promlnence

uurlng adolescence abouL half Lhe LoLal maxlllary LeeLh
movemenL ls due Lo roLaLlon of maxllla (1eeLh moved along
wlLh Lhe [aw 1ranslocaLlon)

oo 040
oo 040

Mandlble
Mandlble
9aLh of erupLlon of mandlbular upward and forward
1eeLh
lorward roLaLlon of growLh Llngual poslLlonlng of
mandlbular lnclsors
relaLlve Lo mandlble
Llngual poslLlonlng of mandlbular lnclsors
Molars mlgraLe furLher meslally durlng growLh Lhan Lhe
lnclsors
uecrease ln Lhe arch lengLh
1he forward roLaLlon progresslvely uprlghLs Lhe
lnclsors causlng a Lendency Loward crowdlng
oo 048
oo 043
LlnCuALL? 9LACLu lnClSC8S MLSlAL MCLA8 MlC8A1lCn
lncase of pronounced forward roLaLlon Lhere ls a ma[or
rlsk of deep blLe developlng
ln Lhe case of backward roLaLlon openlng of Lhe blLe ls
dlfflculL Lo prevenL durlng LreaLmenL so ln Lhe case of
exLreme forward roLaLlon a sLablllzlng appllance llke blLe
plane ls lnLroduced before puberLy and conLlnued unLll
growLh compleLlon
Accordlng Lo 8[ork lL ls advlsable Lo delay orLhodonLlc
exLracLlons unLll beglnnlng of puberLal growLh spurL



2 laclal paLLerns
SPC81 lACL 9A11L8n
Lxcesslve forward roLaLlon of mandlble durlng growLh
ShorL AnLerlor LlP
PorlzonLal palaLal
plane

Square [aw
(Mandlble)
Square gonlal
angle
Low M9A ueep blLe and
crowdlng
Lxcesslve forward roLaLlon may be due Lo
(l) lncrease ln lnLernal mandlbular roLaLlon
(ll) uecrease ln exLernal roLaLlon
LCnC lACL 9A11L8n (lnC8LASLu LAlP)
8ackward roLaLlon of mandlble
AnLerlor open
blLe
lncrease

M9A

9alaLal plane
roLaLes down
posLerlorly
Mandlbular
deflclency
Mandlbular backward roLaLlon resulL prlmarlly from
Lack of normal lnLernal roLaLlon
Cr even backward lnLernal roLaLlon
1he lnLernal roLaLlon ls prlmarlly maLrlx roLaLlon (Cor
condyle) and noL lnLramaLrlx roLaLlon
8ackward roLaLlon of mandlble also occur ln paLlenLs
wlLh abnormallLles or paLhologlc changes ln 1M!



3 Accordlng Lo schudy Clockwlse roLaLlon of mandlble (effecL
upon LreaLmenL)

Would noL help reduce An8 angle
noL ald ln correcLlon of class ll molar relaLlon
Would Lend Lo help connecL Lhe verLlcal overblLe of
lnclsors and malnLaln lL




CounLer clockwlse roLaLlon

1ends Lo lncrease Lhe verLlcal overblLe (deep blLe) and
renders verLlcal overblLe correcLlon and reLenLlon more
dlfflculL
Accordlng Lo schudy Lhe condylar growLh versus verLlcal
growLh deLermlnes Lhe mandlbular roLaLlon


CrLhodonLlc LreaLmenL does noL sLlmulaLe growLh aL Lhe
condyles lL ls only Lhe verLlcal lncremenLs LhaL we may
posslbly alLer wlLh orLhodonLlc LreaLmenL


lnhlblLlon of growLh of verLlcal lncremenLs wlll have
Lhe same effecL as sLlmulaLlng growLh aL Lhe condyle
So lf verLlcal growLh ls deflclenL we Lry Lo sLlmulaLe lL
(Cervlcal pull head gear class ll elasLlcs) lf verLlcal
growLh ls excesslve we Lry Lo lnhlblL lL (lnhlblL downward
growLh of maxlllary molar hlgh pull head gear)
4 lL ls also lmporLanL Lo ldenLlfy Lhe relaLlonshlp beLween [aw
base roLaLlons and occlusal flndlngs (eg lncllnaLlon of
upper anLerlors and lower anLerlors and over blLe) and
accordlngly plan Lhe LreaLmenL especlally lf Lhe paLlenL ls
ln growLh phase
6 ComblnaLlons of maxlllary and mandlbular roLaLlon and
lLs cllnlcal lmpllcaLlons (Lavergne and Casson 1982) 1he
comblnaLlons are very lmporLanL for occlusal relaLlonshlp

ConvergenL roLaLlon of [aws durlng growLh




A deep blLe whlch ls very dlfflculL Lo correcL even by
funcLlonal meLhods

ulvergenL roLaLlon skeleLal open blLe ofLen resulLs
Severe cases requlre orLhognaLhlc surgery
8oLaLlon ln Lhe same dlrecLlon




1he occlusal relaLlonshlp ls malnLalned normally ln
mosL slLuaLlons (eg deep blLe avolded ln cranlally
dlrecLed roLaLlon of boLh [aws)


oo 039
CCM8lnA1lCnS Cl 8C1A1lCnS Cl !AW 8ASLS
7 upward and forward Llpplng of anLerlor maxllla ls ofLen
observed ln conflrmed mouLh breaLhers

8 Mandlbular roLaLlon ls caused by boLh growLh dependenL
and funcLlonal lnfluences only funcLlonal lnfluences can
be alLered LherapeuLlcally whlle growLh can only be
gulded so Lhe roLaLlon of mandlble can be only
moderaLely lnfluenced LherapeuLlcally

Cenerally Lhe lncllnaLlon of maxlllary base ls sLable
and no growLh dependenL lnfluences seen Lhus Lhe
lncllnaLlon can be lnfluenced by boLh flxed orLhopedlc and
funcLlonal LherapeuLlc Lechnlques


CCnCLuSlCn
CCnCLuSlCn
1hough dlfferenL auLhors glve dlfferenL
mechanlsms and Lermlnologles for CrowLh roLaLlons Lhe
[aw should roLaLe elLher forward or backward lL ls upLo
Lhe orLhodonLlsLs Lo ldenLlfy Lhe roLaLlon early and lLs
cllnlcal presenLaLlon and apply lL ln LreaLmenL so LhaL
LreaLmenL can be sLarLed aL Lhe earllesL
8LlL8LnCLS
8LlL8LnCLS
1ConLemporary CrLhodonLlcs 9rofflL
2 Pandbook of laclal CrowLh Lnlow
3 CrLhodonLlc ulagnosls 8akosl
4uenLo faclal orLhopeadlcs wlLh funcLlonal appllances
9eLrovlc
39redlcLlon of Mandlbular growLh roLaLlon 8[ork (1969 !une
A!C)
61he roLaLlon of Lhe mandlble resulLlng from growLh lLs
lmpllcaLlons ln CrLhodonLlc LreaLmenL ll Schudy (1963
Angle CrLhodonLlsL
7 1he puzzle of growLh roLaLlon !MP ulbbeLs (A!C
!une 1993)
8 Mandlbular roLaLlon and enlargemenL !MP ulbbeLs
(A!C !une 1990)
9 8[ork (1972) A!C