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Growth of mandibular prognathism after pubertal

growth peak
Hideo Mitani, DDS, MS, DDSc," Koshi Sato, DDS, DDSc, b and Junji Sugawara, DDS, DDSc =
Miyagi, Japan

This study deals with the growth changes of the Japanese face associated with mandibular
prognathism during 3 years after the pubertal growth peak. The investigation was based on the
serial lateral cephalometric roentgenograms of prognathic and normal males and females,
respectively. Maturational stages of the pubertal growth were determined individually by the
ossification events taken from hand-wrist radiographs. Results indicate that the morphologic
characteristics of the mandibular prognathism, which are established before the pubertal growth
peak, are strongly maintained during the period studied. However, mandibular prcgnathism seems to
show a manner of growth change fairly similar to that of the normal after the pubertal growth peak.
(AM J ORTHODDENTOFACORTHOP 1993;104:330-6.)

Normal occlusion is generally character- have been done regarding the manner of growth during
ized with a balanced facial skeleton accompanied with the late stage of facial growth. 9 "
harmony in growth between mandible and maxilla in This study was undertaken to gain information from
size, form, and position within a certain limit. A true the serial records of untreated samples as to how the
skeletal Class III malocclusion is, however, character- skeletal form of the prognathic mandible contributes to
ized with a facial dysplasia produced by excessive the face and whether the remaining growth of the prog-
growth disharmony of the mandible in size, form, and nathic face differs from that of the normal face after
position with respect to the maxilla and/or the cranial the pubertal growth peak.
base. L2 This may imply that the Class III malocclusion
is associated with a different manner of craniofacial MATERIALS AND METHODS
growth when compared with normal occlusion. 3 The materials used in this study consisted of normal and
Until now, several longitudinal studies have been Class III groups of serial lateral cephalometric roentgeno-
conducted to verify the manner of growth of the Class grams of Japanese male and female subjects. Each group
consisted of a 3-year interval set of lateral head films, which
III face.*VThose studies were, however, mostly con-
were taken at the ages of 15 and 18 years for the male subjects
cerned tothe growth changes before and/or during the
and 14 and 17 years for the female subjects. The normal
pubertal growth period. In reviewing the literature, var- group exhibited excellent or mild Class I malocclusion. None
ious results have been reported on the incremental underwent either orthodontic or any growth-related orthopedic
changes of the Class III maxillae, as well as mandibles, therapy. The normal group was used as a control in this study.
but the studies generally agree that fundamental dis- The Class III group exhibited severe crossbite relation of the
harmony of Class III structure is established in early anterior teeth, but none underwent either orthodontic or any
life. It is also indicated that the growth changes of the growth-related orthopedic therapy before or during the period
Class III mandible are fairly similar to those of the studied. All subjects of the Class III group were obtained
normal before the pubertal growth peak. 4.8 However, from a list of patients waiting for orthognathic surgery.
those studies were done on relatively short-term serial No attempt was made to distinguish a particular form of
the mandible, but subjects suspected to have some pathosis
samples and of too short a duration to determine the
were excluded. However, prognathism is a relative condition
total growth behavior. Although it is essential for the
because the relationship of the mandible to the maxilla not
treatment and retention of Class III cases to verify the only varies with the total size attainment of the mandible but
total growth behavior of the prognathic face, few studies also with anterior positioning of the mandible functionally to
the maxilla. The purpose of this study was to determine the
manner of growth of the face in a true skeletal Class III
From the Department of Orthodontics, School of Dentistry, Tohoku University. disharmony. Therefore the Class Ill group was first screened
'Professor and Chairperson.
qnstructor.
to exclude samples with anterior positioning of the mandible
*Associate Professor. functionally to the maxilla. To restrict Class III samples to
Copyright 9 1993 by the American Association of Orthodontists. those with a distinct anteroposterior skeletal disharmony be-
0889-5406/93/$1.00 + 0.I0 811137006 tween the two jaws, the values of the angle formed by point
330
American Journal of Orthodontics and Dentofaclal Orthopedics Mitani, Sato, and Sugawara 331
Volume 104, No. 4

MP3-cap. MP3- fu s .MP3- uni

S; clear appearance

RAD-cap 9 RAD-I 9 RAD-IJ 9 RAD-J

Fig. 1. Ossification events of hand-wrist roentgenograms used in this study to evaluate maturational
stage of each sample in pubertal growth. MP3; middle phalanx of third finger, cap; epiphysis caps its
diaphysis, fus; epiphysis starts fusion to its diaphysis, uni; complete epiphyseal union to its diaphysis.
RAD: radius, cap; epiphysis caps its diaphysis, I; early stage of epiphyseal fusion, IJ; late stage of
epiphyseal fusion, J; complete epiphyseal union.

A, nasion, and point B (ANB angle) and the distance between jects. For the Class III group, it became 14 for the male
points A and B on the occlusal plane (Wits appraisal t2) were subjects and 20 for the female subjects. Fig. 2 shows the
used to examine whether each of the Class III samples was distribution of their maturational stages. Those of the Class
within two standard deviations of its normal mean at the initial III groups show a protruded mandible disharmonized with the
age. When a sample was within two standard deviations of maxilla anteroposteriorly with severe anterior crossbite, but
either of the measurement, it was excluded from the Class with no functional shift of the mandible, all passed the pu-
III group. bertal growth peak and in the decelerating phase of facial
Several ossification events of the hand-wrist roentgeno- growth.
grams were studied to determine the developmental stage of Lateral cephalometric films were traced. Fig. 3 illustrates
each subject. Those roentgenograms were taken at the same the points and planes and the diagrams for linear and angular
time as lateral cephalograms. According to studies by Grave" measurements used in this study. Measurements of the facial
and others, '4-~8the peak stage of the pubertal growth spurt depth and height were taken according to Coben's coordinate
was determined to occur shortly before the appearance of system19 in which the Frankfort horizontal plane was em-
epiphyseal capping on its diaphysis at the middle phalanx of ployed as a plane of orientation. Measurements of facial depth
the third finger and radius, and shortly before the epiphysis were taken parallel to the Frankfort plane; vertical height was
starts fusion to its diaphysis at the distal phalanges of the measured along lines perpendicular to the Frankfort. Other
fingers and radius. By this time, clear appearance of the ulnar measurements, however, were made directly between two
sesamoid at the metacarpophalangeal joint of the first finger points. This was done to avoid the effects of angular change
should be seen. All samples used in this study were carefully in length during growth when projected to the Frankfort plane.
examined for the above criteria. Samples evaluated to be For the measurements of the mandible, the top of the
before or in the peak stage of the growth spurt at the initial condyle (condylar) is the most appropriate point at which to
age were excluded from the normal and Class III groups. Fig. determine the actual size of the mandible when the image of
1 shows the ossification events used in this study to evaluate the condylar head is applicable for tracing. This image is
the stage of maturation. rather difficult to trace and often permits unavoidable errors
After all screenings, the sample size of the normal group in measurement. To avoid such errors, tracing of the condylar
became 16 for the male subjects and 20 for the female sub- head was aided by the headfilm taken during a wide open
332 Mitani, Salo, and Sugawara American Journal of Orthodontics and Dentofacial Orthopedics
October 1993

9 class III
O
O Normal O
O
O
QO O
QO OO
0 IO OO
0 QO 9 O
Q 0 O0 9 O
O0 OO oO
9 O 9 o
9. oo 88 |o 9 O oO 9 ,
M P 3 - c a p / M P 3 - f u s / MP3-uni / / ~D-cap/ RAD- I / RAD-IJ / RAD-J
0 O0 eo 0 9 0 OO OO
o oo 9 o 9 0 OO OO
o oo 9 0 OO
8 ~ 9 0 OO
o QO 9 0 O
QO 9 0 O
O0
8O 0 ~ 00
00
9 0
:8 00
:O80

Fig. 2. Distribution of samples on each maturational stage. All samples showed a clear appearance
of ulnar sesamoid at metacarpophalangeal joint of first finger. There was no statistical difference on
the proceeding stage of maturation between the Class III and the normal groups for male subjects
and female subjects.

Posterior cranial length (Ba-S)


Posterior cranial base angle to Frankfort plane (Ba-S/FH)
N Maxillary measurements:
Maxillary size (Ptm-A)
Maxillary position to anterior cranial base (SNA angle)
Maxillary position in total facial depth (Ba-Ptm)
Middle facial depth (Ba-A)
Upper anterior facial height (N-Arts)
Mandibular measurements:
Total mandibular length (Cd-Gni
Mandibular body length (Go-Pog)
Ba' ! " ~ ' : : : ~ ~ ~ A n s Mandibular ramal length (Cd-Go)
Lower facial depth (Ba-pog)
Lower anterior facial height (Ans-M)
Mandibular form (gonial angle)
Mandibular posture (mandibular plane angle)
Chin position to anterior cranial base (S-N-Pog angle)
Chin position to anterior maxillary base (A-N-Pog angle)
The means and standard deviations for each measurement
at each age were obtained in the norm.q, as well as in the
Class III groups. The means and standard deviations of the
total change of each measurement over the 3 years were also
obtained in both groups. Sexual dimorphism in the total
M growth increment of each measurement was examined during
the period studied.
Fig. 3. Tracing of lateral cephalometric roentgenograms show- For the evaluation of the significance of the mean differ-
ing points, planes, and diagram for linear and angular mea- ence of each measurement between.the two groups, a Student
surements used in this study. t test was used when F distribution indicated equal variance
of the samples. If not, a Welch t test was used.

RESULTS
mouth position at the same time as the lateral cephalograms
were take'n, This exhibited a clear image of the condylar head, The means and standarddeviations for each mea-
out of the articular fossa. surement of the Class III and the normal groups at the
The following measurements were used: initial age are shown in Table I. Those of the last age
Cranial base measurements: are shown in Table II. The means and standard devia-
Anterior cranial length (S-N) tions of the total changes of each measurement over
American Journal of Orthodonticsand Dentofacial Orthopedics Mitani, Sato, and Sugawara 333
Volume 104, No. 4

Table I. Results of measurements for Class III and normal groups at the initial age
Male Female

Class !11 Normal Class !11 Normal


I
Measurements Mean SD Mean [ SD Mean SD Mean SD

S-N (ram) 69.2 3.7 69.1 3.2 63.7 3.2 65.0 2.8
Ba-S 49.8 4.0 50.3 2.4 45.6 2.2 45.4 1.9
B a - S / R I angle 120.0 3.3 120.7 3.0 120.7 4.0 ** 123.9 3.4
Ptm-A (mm) 47.9 3.0 49.0 3.0 44.8 3.1 46.7 3.1
SNA angle 81.0 3.3 81.7 4.0 81.5 4.3 81.9 4.0
B.a-Ptm (mm) 45.2 3.7 44.9 2.8 41.7 3.4 * 44.0 3.2
Ba-A 93.0 5.7 93.8 3.7 86.5 4.3 ** 90.7 5.4
N-Ans 58.8 2.9 57.8 3.3 54.9 3.3 53.8 2.4
Cd-Gn 132.9 5.8 ** 120.9 4.5 120.1 7.8 ** 113.4 4.9
Go-Pog 84.6 4.2 ** 78.3 3.6 76.3 6.0 73.4 3.5
Cd-Go 62.3 4.7 59.5 4.5 56.0 3.6 55.3 5.3
Ba-Pog 99.6 8.9 ** 87.8 4.7 90.5 10.2 * 83.4 6.3
Ans-M 75.0 5.8 * 70.4 4.6 69.3 5.7 67.5 3.8
Gonial angle 130.4 5.7 * 123.8 8.8 132.3 6.2 ** 125.0 6.5
Mandibular plane angle 29.2 6.0 28.3 6.2 31.2 5.7 30.0 4.9
S-N-P~ angle 84.5 3.8 ** 79.3 3.7 83.6 5.4 ** - 77.9 4.3
A-N-Pog angle -3.5 3.0 ** 2.4 2.0 -2.2 3.6 ** 4.1 2.4
ANB angle -2.9 2.7 ** 3.0 1.8 -2.6 3.1 ** 4.5 1.9
A-B/Occlusal plane (mm) - 12.3 3.7 ** - 1.6 2.6 - 11.4 4.3 ** -0.6 2.6

*Significant at p < 0.05.


**Significant at p < 0.01.

the 3 years are shown in Table III. Sexual dimorphism that there was no distinctive disharmony of the maxilla
in the Class III group and the normal group is shown and the middle face in the present Class III samples.
in Table IV. Comparison of the mandibular measurements
showed that the total length (Cd-Gn) and the body
DISCUSSION length (Go-POg) were significantly greater than the nor-
Maturational stages /ff the ossification events em- mal, whereas the ramal length (Cd-Go) exhibited no
ployed in this study were compared between the Class significant difference between the two groups at the
III and the normal groups for the male subjects and the initial age. Gonial angle was significantly greater than
female subjects (Fig. 2). There was no significant dif- the normal but the mandibular plane angle was not.
ference between the two groups, although some vari- Consequently, those showed greater values of lower
ation in maturation exists within a group. It was thought facial depth (Ba-Pog) and lower anterior facial height
that there was no difference in the progress of matu- (Ans-Me), which caused excessive protrusion of the
rational stages between the Class III and the normal chin for the Class III group. This was supported by the
groups. Thus the samples of each group should be ad- greater values of the S-N-POg and A-N-Pog angles of
equate to compare for the purpose of this study, the Class III group.
Comparison of each measurement between the two
Facial characteristics of the Class III samples groups at the last age (18 years of age) indicated that
(Table I) the facial characteristics seen at the initial age (15 years
Male: Comparison of the cranial base measurements of age) in the Class III group were strongly maintained
showed that there was no significant difference in any during those 3 years. Results indicated that no new
measurement between the two groups at the initial age. significant difference took place in the measurements
Results indicated that there was no distinctive dishar- between the two groups during this period (Table II).
mony in size and form at the cranial base in the present Female: The posterior cranial base angle to Frank-
Class III samples. fort plane (Ba-S/FH angle) was significantly different
Comparison of the maxillary measurements showed between the two groups at the initial age. The posterior
that neither the size (Ptm-A) nor its position (SNA cranial base was more upright in relation to the Frank-
angle, Ba-Ptm) showed any significant difference be- fort plane in the Class III than the normal group. How-
tween the two groups at the initial age. Results indicated ever, the anterior cranial length (S-N) and the posterior
334 Mitani, Sato, and .~twawara American Journal of Orthodontics and Dentofacial Orthopedics
October 1993

Table II. Results of measurements for Class III and normal groups at the last age
Male Female

Class 111 Normal Class !11 Normal

Measurements Mean SD Mean [ SD Mean SD Mean [ SD

S-N (mm) 69.8 3.4 69.9 3.2 64.4 3.0 65.3 2.9
Ba-S 50.0 3.9 51.3 2.7 46.0 2.3 45.9 1.9
Ba-S/FH angle 120.9 3.4 120.4 3.0 120.0 3.8 ** 123.8 3.6
Ptm-A (mm) 49.0 2.9 50.4 3.3 45.2 2.9 47.2 3.3
SNA angle 81.3 3.0 81.8 4.1 81.3 4.3 82.0 4.2
Ba-Ptm (ram) 45.0 3.4 44.9 2.7 41.7 3.5 * 44.1 3.2
Ba-A 94.0 5.3 95.3 3.8 86.9 4.2 ** 91.3 5.5
N-Ans 59.7 3.2 ** 59. I 4.0 55.5 3.6 54.6 2.6
Cd-Gn 137.0 5.2 ** 124.9 5.1 123.0 8.6 ** 116.2 5.0
Go-Pog 86.5 4.5 80.4 4.1 77.9 6.0 74.9 3.7
Cd-Go 65.4 4.5 63.4 6.3 57.9 4.0 57.4 5.1
Ba-Pog 102.3 9.7 ** 90.2 6.0 92.9 10.2 ** 84.9 6.7
Ans-M 77.3 6.2 ** 72.2 4.3 70.4 6.3 69.2 4.0
Gonial angle 131.2 6.2 ** 122.7 9.2 132.2 5.8 ** 124.7 6.4
Mandibular plane angle 29.0 6.3 26.6 7.7 30.7 6.1 29.8 4.8
S-N-Pog angle 85.6 4.1 ** 80.1 3.9 84.5 5.9 ** 78.7 4.1
A-N-Pog angle -4.3 3.7 ** 1.8 2.6 -3.2 3.8 ** 3.3 2.0
ANB angle -3.8 3.3 ** 2.5 2.1 -3.2 3.2 ** 4.0 1.5
A-B/Occlusal plane (mm) - 13.8 4.9 ** -2.8 3.6 - 12.7 4.9 ** - 1.3 2.1

*Significant at p < 0.05.


**Significant at p < 0.01.

Table III. Total changes for Class III and normal groups during 3 years
Male Female

Class III Normal Class II1 Normal


Measurements Mean SD Mean [ SD Mean SD Mean [ SD

S-N (mm) 0.7 0.5 0.7 0.7 0.7 0.5 0.3 0.4
Ba-S 0.2 0.4 ** 1.0 0.9 0.4 0.5 0.5 0.5
Ba-S/FH angle 0.2 1.2 -0.3 1.3 -0.3 1.5 -0.1 1.0
Ptm-A (mm) 1.1 1.2 1.5 1.7 0.4 0.8 0.5 1.2
SNA angle 0.3 1.0 0.2 1.0 - O. 1 0.9 O. 1 1.0
Ba-Ptm (mm) -0.1 0.9 0 0.8 0.l 0.8 0.1 0.7
Ba-A 1.0 1.0 1.5 1.7 0.4 0.8 0.6 1.3
N-Arts 0.9 1.0 1.2 1.2 0.6 1.0 0.9 1.2
Cd-Gn 4.1 2.5 4.0 2.6 2.9 1.9 2.8 1.8
Go-Pog 1.8 2.1 2.0 2.2 1.6 0.9 1.5 1.4
Cd-Go 3.1 1.6 4.0 2.4 1.9 1.8 2.1 1.0
Ba-Pog 2.8 3.3 2.4 2.6 2.3 2.2 1.6 1.9
Ans-M 2.3 1.5 1.8 1.5 1.2 1.4 1.7 1.3
Gonial angle 0.8 1.7 ** - 1.1 2,0 0 1.6 -0.3 0.8
Mandibular plane angle -0.2 1.3 * - 1.8 1,9 -0.5 1.8 -0.3 1.5
S-N-Pog angle 1.1 1.3 0.8 1,2 0.9 1.4 0.8 0.8
A-N-Pog angle -0.9 1.3 -0.7 1.2 - 1.0 1.2 -0.8 1.1
ANB angle - 1.0 1.2 -0.5 0,9 -0.7 1.2 -0.5 0.9
A-B/Occlusal plane (mm) - 1.6 1.9 - 1.3 1.7 - 1.3 2.0 -0.7 1.3

*Significant at p < 0.05.


**Significant at p < 0.01.

cranial length (Ba-S) did not show any significant dif- anterior cranial base (SNA angle) showed any signifi-
ference between the two groups. cant difference between the two groups at the initial
Comparison of the maxillary measurements showed age. However, the maxillary position in the cranial base
that neither the size (Ptm-A) nor its position to the (Ba-Ptm) and the middle facial depth (Ba-A) were sig-
American Journal of Orthodontics and Dentofacial Orthopedics Mitani, Sato, a n d S u g a w a r e 335
Volume 104, No. 4

Table IV. Sexual dimorphism in the Class III and the normal face
Class HI Normal Total change

Init~l Last Initial Last


Measurements age age age age Class HI Normal

S-N (mm)
** ** ** **
Ba-S
Ba-S/FN angle
** * ** ** $ *
Ptm-A (mm)
SNA angle
Ba-Ptrn (mm)
** ** *
Ba-A
** *$ ** **
N-Ans
** *# ** **
Cd-Gn
** ** ** **
Go-Pog
** * ** **
Cd-Go
Ba-Pog
** * ** *
Ans-M
Gonial angle
Mandibular plane angle
S-N-Pog angle
A-N-Pog angle
ANB angle
A-B/Occlusal plane (nun)

*Significant at p < 0.05.


**Significant at p < 0.01.

nificantly shorter than those of the normal. This was for the female subjects indicated that there was basically
not due to retrusion of the maxilla but to the upright no difference between the Class III and the normal face.
posture of the Posterior cranial base. The upper anterior A few measurements, i.e., posterior cranial length
facial height (N-Ans) showed no significant difference (Ba-S), gonial angle, and mandibular plane angle for
between the two groups. Results indicated that there the male subjects and anterior cranial length (S-N) for
was no distinctive disha.rmony of the maxilla in size the female subjects showed a significant difference be-
and position to the anterior cranial base. tween the two groups, but the differences were minimal
Comparison of the mandibular measurements and negligible in growth variation.
showed that the total length (Cd-Gn) was significantly
9greater than the normal, whereas the body (Go-Pog) Sexual dimorphism in the Class Ill and the normal
and ramal (Cd-Go) length were not significantly greater face (Table IV)
at the initial age. The gonial angle was significantly Absolute values of the linear measurements in the
greater than the normal, but the mandibular plane angle male subjects were all significantly greater than the
was not. Those produced a greater value of the lower corresponding measurements in the female subjects for
facial depth (Ba-Pog), which caused excessive protru- both the Class III and the normal groups. However,
sion of chin indicated by the greater values of S-N-Pog those of the angular measurements showed no signifi-
and A-N-Pog angles. cant difference between male and female subjects for
Comparison of each measurement between the two both the Class III and the normal groups. This means
groups at the last age (17 years of age) indicated that that the spatial proportions of the various craniofacial
the facial characteristics seen at the initial age (14 years structures are fundamentally similar in both sexes. Al-
of age) in the Class III group were strongly maintained though the linear measurements were significantly
during those 3 years. Results indicated that no new greater in the male subjects, their total growth incre-
significant difference took place in the measurements ments during the 3 years showed a much lower degree
between the two groups (Table II). of significant sexual dimorphism. Sexual dimorphism
was seen in the mandibular ramal length (Cd-Go) and
Total changes of each measurement during 3 the maxillary length (Ptm-A) for both the Class III and
years (Table III) the normal face. Those two measurements showed
Comparison of the total changes of each measure- greater growth in the male subjects than in the female
ment during the three years from 15 to 18 years of age subjects over 3 years. In other measurements, the lower
for the male subjects and from 14 to 17 years of age facial height (Ans-M) of the male subjects showed
336 Mitani, Sato, and Sugawara American Journal of Orthodontics and Dentofacial Orthopedics
October 1993

greater change in the Class III face and so did the 2. Jacobson A, Evans WG, Preston CB, Sadowsky PL. Mandibular
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/ 7. Takeuchi U, Genba Y, Suzuki S, Nakamura S. Longitudinal
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CONCLUSIONS wrist films. Br J Orthod 1979;6:142-52.
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growth peak do not change fundamentally and
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are maintained thereafter. height, hand bones and cervical vertebrae during puberty. Jpn J
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o f the normal face. Neither excessive nor re- in the distal phalanx of the first digit--a longitudinal study. Jpn
J Orthod Soc 1991;50:293-302.
tarded growth occurs in any part o f the face after
19. Coben SE. The integration of facial variants. AM J OR'HtOD
the pubertal growth peak. 1955;41:407-34.
3. The Class III face, in which the mandible is
Reprint requests to:
oversized and prognathic but the maxilla is Dr. Hideo Mitani
within the normal range o f size and position, Department of Orthodontics
shows a manner o f growth change fairly similar School of Dentistry
to that o f the normal face after the pubertal Tohoku University
growth peak. Seiryo-cho 4-1, Aoba-ku
Sendal, Miyagi
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