Cephalometric Evaluation of Skeletal Open- and Deep-Bite Tendencies ...

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JCO-Online Copyright 2012 Cephalometric Evaluation of Skeletal Open- and Deep-Bite Tendencies
VOLUME 26 : NUMBER 06 : PAGES (338-343) 1992 ANTHONY D. VIAZIS, DDS, MS
The influence of mandibular growth rotation in the development of deep or open bites before, during, or after orthodontic intervention has been the subject of extensive investigations over the past 40 years. 1-19 A number of diagnoses have attempted to predict abnormal rotational patterns in the growth and development of the facial skeleton, especially the mandible. 4,5,7,14-16,18 Although it has been well documented that the morphology of natural reference structures is accurate and effective as a basis for cephalometric research, 5,17 Baumrind and colleagues have shown that there is no measurement or set of measurements that can be used to predict growth rotation, even by experienced clinicians. 16 However, this does not mean an orthodontist cannot use some cephalometric measurements to assess an individual patient's facial growth. This article presents 10 such measurements (Table 1) that can indicate a rotational pattern tendency, thus increasing the likelihood of accurate growth prediction in a particular case. Some of these measurements are based on a sample of 15 male and 15 female patients who had Class I dental and skeletal relationships, orthognathic profiles, and good facial esthetics. 20 The Michigan growth studies were also used for some of the standards.8

1. Width of the Symphysis (PgTH)

The width is measured along a line parallel to the true horizontal (TH) at pogonion. The greater this measurement, the more forward growth rotation can be expected. A narrow symphysis corresponds to a backward growth rotation. 5

2. Angle of the Symphysis (BPg-MeTH)

This is the angle formed by the line connecting B point and pogonion and a line parallel to the true horizontal (TH) at menton. If the symphysis is inclined backward--that is, if the angle of the symphysis is acute--it indicates a forward growth rotational pattern. If it is inclined forward (obtuse angle), a backward rotation is indicated. 5,16

3. Mandibular Plane Angle (GoMe-TH)

One of the most widely used cephalometric measurements, this angle can sometimes mask the true growth tendencies of the mandible if there is extensive remodeling at the angle of the mandible and the symphysis. High values indicate a backward rotator, and low values a horizontal growth pattern. The angle will decrease about 2 2 between childhood and adulthood.

4. Sum of Posterior Angles (SNa-SAr + SAr-ArGo + ArGo-GoMe)

As listed by Bjork 1,5 and Jarabak, 7 the means SD of the individual angles are: cranial flexure angle or saddle angle (SNa-SAr), 123 5; articular angle (SAr-ArGo), 143 6; gonial angle (ArGo-GoMe), 130 7. The saddle and articular angles each increase about 1 between 12 and 20 years of age, but the gonial angle decreases 2 during this period, making the sum about the same. High values indicate a vertical growth pattern (clockwise, opening, or backward rotation); low values indicate a horizontal growth pattern (counterclockwise, closing, or forward rotation).

5. Gonial Angle (ArGoMe)

Bjork 5 and Jarabak 7 showed that an increased gonial angle indicates a backward growth rotator and a decreased angle a forward growth rotator.

6. Gonial Angle Ratio (ArGoNa:NaGoMe)

A line from gonion to nasion divides the gonial angle into upper and lower segments. If the ratio of the upper angle to the lower is more than 75% (high upper angle), it shows a horizontal growth pattern. 1 The opposite (high lower angle) indicates a vertical pattern.

7. Posterior Cranial Base to Ramus Height Ratio (SAr:ArGo)

The length of the posterior cranial base is compared to the mean for the patient's sex and age group. Providing that the length of Ar is within normal limits, a ratio of more than 75% would indicate a short ramus height, which contributes to a clockwise rotation pattern. A short posterior cranial base also indicates a backward growth rotator.

8. Posterior/Anterior Face Height Ratio (SGo:NaMe)

A value greater than 65% shows a forward growth pattern; a ratio of less than 65% indicates a backward growth rotator. 1

9. Posterior/Anterior Maxillary Height Ratio (EPNS:NaANS)

Values greater than 90% indicate an upward rotation of the anterior maxilla and a downward movement of the posterior maxilla, which would tend to produce an open bite. Lower values may indicate a rotational pattern contributing to a deep bite.

10. Lower to Total Anterior Face Height Ratio (ANSMe:NaMe)

A ratio greater than 60% (long lower face) is indicative of a backward growth rotator. Low ratios suggest a forward growth rotation.

Discussion
No cephalometric analysis is perfect. The clinician must rely on direct observation and experience, as well as on tools such as measurements and ratios, to achieve a correct diagnosis. The distinction between open- and deep-bite tendencies, especially in borderline cases, is important not only for the initial diagnosis, but also for planning treatment mechanics (Table 2). In borderline cases--those with slight increments of growth in one direction or another--the treatment can become complicated and the case difficult to finish. Not all the measurements presented here will be of equal value in every case, but a majority of them will usually give a good indication of a patient's growth tendency. The following two cases demonstrate the thinking process used with these measurements in evaluating and predicting growth rotation. These cases were not treated orthodontically, and therefore the changes shown are attributable solely to growth.

Case Reports
Case 1 shows a 12-year-old male who presented with a 1mm open bite (Fig. 1A). It is obvious that successful treatment of such a patient would depend greatly on controlling his open-bite tendency, especially during the pubertal growth spurt. Six of his 10 measurements were more than 1 SD from the means, indicating a backward growth rotational pattern--in other words, a strong open-bite tendency (Table 3). In fact, three years later the patient exhibited significant vertical growth that decreased his overbite by 4mm (Fig. 1B). This patient was treated surgically. Case 2 is a 10-year-old male who presented with a 1mm overbite (Fig. 2A). In his cephalometric evaluation, three of the 10 measurements indicated backward growth rotation and two indicated a forward growth pattern. The rest were close to the mean values (Table 4). The diagnosis was that the patient would continue to grow in the same manner, and that orthodontic mechanotherapy should limit extrusive side effects as much as possible. Five years later, without treatment, the patient demonstrated a similar occlusal relationship, with an overbite of 0mm (Fig. 2B). In both of these cases, clinical judgment, combined with a realistic evaluation of the cephalometric measurements, allowed a proper understanding of the individual patient's growth tendencies.

Figures

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Fig. 1 A. 12-year-old male with 1mm open bite. B. Significant vertical growth resulted in 3mm anterior open bite three years later.

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Fig. 2 A. 10-year-old male with 1mm overbite. B. Five years later, overbite is about the same.

Tables

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Fig. 1

Fig. 2

Fig. 3

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Fig. 4

References
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