FORWARD ROTATION OF MANDIBLE DURING THE TRANSITION FROM LATE PRIMARY DENTITION TO EARLY MIXED DENTITION

Hiroshi Ueno, D.D.S.

An Abstract Presented to Graduate Faculty of Saint Louis University in Partial Fulfillment of the Requirements for the Degree of Master of Science in Dentistry (Research)

2012

Abstract Purpose: To determine whether dentoalveolar changes and/or the condylar growth are related to the true forward rotation of mandible that occurs during the transitional period between the late primary and early mixed dentition stages of development. Materials and Method: The sample included 50 subjects (25 males and 25 females) with Class I (N=25) and Class II (N=25) molar relationships. They were selected based on the availability of lateral cephalograms at two developmental stages: T1- last film with complete primary dentition (5.8 0.4 years) and T2- first film with permanent incisors and permanent molars erupted (8.0 0.2 years). Seventeen landmarks were identified and 22 measurements were calculated. The mandibles at T1 and T2 were superimposed using natural reference structures in order to measure true mandibular rotation. Results: The mandible underwent -2.4 2.6 degrees of true rotation, 1.9 2.4 degrees of remodeling and -0.6 1.8 degrees of apparent rotation between T1 and T2. There were no significant sex or Class differences in true rotation, remodeling and apparent rotation. There was a moderate correlation (r=0.76) between true rotation and remodeling, and a moderately low correlation (r=0.40) between true rotation and apparent rotation. There was a weak correlation between true rotation and SNA (r=0.28). True rotation showed a moderately low correlation (r=-0.34) with the increases in U1-SN, increases in U1-PP (r=-0.36), and with decreases in Id-Me (r=0.36). Conclusion: Independent of sex and Class, the true mandibular rotation that occurred between the late primary and early mixed dentition was mostly masked by angular remodeling, resulting in limited amounts of apparent rotation. True rotation was significantly related to anterior dentoalveolar changes, but not to the vertical growth changes that occurred.

FORWARD ROTATION OF MANDIBLE DURING THE TRANSITION FROM LATE PRIMARY DENTITION TO EARLY MIXED DENTITION

Hiroshi Ueno, D.D.S.

A Thesis Presented to the Graduate Faculty of Saint Louis University in Partial Fulfillment of the Requirements for the Degree of Master of Science in Dentistry (Research)

2012
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COMMITTEE IN CHARGE OF CANDIDACY: Adjunct Professor Peter H. Buschang, Chairperson and Advisor Professor Rolf G. Behrents Associate Clinical Professor Donald R. Oliver

ACKNOWLEDGEMENTS

The first important group of people that I would like to thank is my committee. Thanks to Dr. Peter H. Buschang for giving me the primary guidance I needed, and for reading my countless revisions. I am also grateful for the guidance and help of Dr. Rolf G. Behrents and Dr. Donald R. Oliver. I am also grateful for Dr. Mark. G. Hans, who gave me permission to use the Bolton archive to collect my sample. The last group is my family. I am grateful that they have given me support that I needed at the final stages of my education. Without their help and understanding, I could not finish the research successfully.

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TABLE OF CONTENTS

List of Tables............................................................................................................................. iv List of Figures ............................................................................................................................ v CHAPTER 1: INTRODUCTION ............................................................................................... 1 CHAPTER 2: REVIEW OF THE LITERATURE Class II Malocclusion ........................................................................................... 3 Class II Treatment ................................................................................................ 5 Rotational Control for Class II Correction .......................................................... 11 Growth and Rotation of Mandible ...................................................................... 12 Forward Rotation ......................................................................................... 12 Backward Rotation ...................................................................................... 14 Remodeling Pattern and Associated with Rotation.............................................. 15 Terminology for Rotational Changes of Mandible .............................................. 17 Dentoalveolar Changes and Growth ................................................................... 20 References ......................................................................................................... 23 CHAPTER 3: JOURNAL ARTICLE Abstract.............................................................................................................. 27 Introduction........................................................................................................ 28 Materials and Methods ....................................................................................... 30 Subjects ....................................................................................................... 30 Cephalometric Methods ............................................................................... 31 Statistical Methods ...................................................................................... 35 Results ............................................................................................................... 36 Discussion .......................................................................................................... 43 Conclusions........................................................................................................ 48 Literature Cited .................................................................................................. 49 Vita Auctoris ............................................................................................................................ 52

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LIST OF TABLES Table 2.1: Outcomes of Previous Headgear Studies Concerning Anterior-Posterior Changes ...................................................................................................................................... 6 Table 2.2: Characteristics of Activator Studies in Preadolescent Children and Their Outcomes in Anterior-Posterior Changes .................................................................................... 9 Table 2.3: Outcomes of Previous Studies Comparing Activators and Headgears Concerning Anterior-Posterior Changes .................................................................................... 10 Table 2.4: Summary for Treatment of Hyperdivergent Patients with Intrusion of Teeth ............ 11 Table 2.5: Terminology of Rotational Changes of the Jaws ....................................................... 19 Table 3.1: Mean Ages for Late Primary (T1) and Early Mixed Dentition (T2) .......................... 30 Table 3.2: Landmarks, Abbreviations and Definitions Used ...................................................... 32 Table 3.3: Planes, Abbreviations and Definitions Used ............................................................. 33 Table 3.4: Measurements, Abbreviations and Definitions Used and Error Analysis ................... 34 Table 3.5: Changes in Skeletal Variables from T1 to T2 ........................................................... 38 Table 3.6: Changes in Dental Variables from T1 to T2 ............................................................. 40 Table 3.7: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables ......... 41 Table 3.8: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables ......... 42

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LIST OF FIGURES Figure 2.1: Three Types of Forward Rotation of the Mandible .................................................. 13 Figure 2.2: Two Types of Backward Rotation of the Mandible ................................................. 14 Figure 2.3: Matrix Rotation and Intramatrix Rotation in Forward Rotating Cases ..................... 16 Figure 2.4: Matrix Rotation and Intramatrix Rotation in Backward Rotating Cases ................... 17 Figure 2.5: Percent Adult Status of Maxillary and Mandibular Heights ..................................... 22 Figure 3.1: Mean and Standard Deviation of Mandibular Rotation from T1 to T2 ..................... 36

CHAPTER 1: INTRODUCTION Significant amounts of true mandibular rotation takes place during childhood and adolescence.1 True rotation, which refers to the rotation of the core of mandibule relative to the anterior cranial base, is associated with greater inferior displacement of the posterior than the anterior mandible.2 It has been related directly to both the direction and the amount of condylar growth, with increasing amounts of true forward rotation associated with greater and more anterior condylar growth.2 In response to mandibular growth rotation, dentoalveolar compensatory changes usually occur.3 Remodeling on the lower border of the mandible can mask the true rotation.2 This explains why the mandible undergoes only limited amounts of change in the mandibular plane angle. True mandibular rotation provides important information for understanding facial growth changes, especially changes of the chin. Since most skeletal Class II patients have mandibular deficiencies, improvement in anterior-posterior chin position is crucial in their treatment. Greater true forward rotation of mandible has been related with more horizontal displacement of chin, and has been shown to be the primary determinant of AP chin position.4 Forward rotation of mandible has been recently incorporated in Class II treatment to improve AP chin position.4 Although significant amounts of true mandibular rotation occur both during childhood and adolescence, rotation is greatest during the transition from late primary to early mixed dentition.5 To date, it remains unknown why there is greater rotation during this transitional period than during other developmental stages. If the specific mechanisms associated with this rotation were known, they could be incorporated into treatment to further enhance the effects.

Based on timing, the forward rotation that occurs during the transition may be explained by dentoalveolar changes. For instance, the first molars erupt at approximately 6 years of age, followed by permanent incisors. The increased rates of true rotation that occur during the transition from the primary to the permanent dentition could be associated with space created by the loss of the primary incisors. This possibility is supported by the fact that significant decreases in alveolar bone height have been reported between 5.5 and 7.5 years of age for both the lower and upper incisors.6 It is also possible that changes in vertical growth are related to both forward and backward mandibular rotation.1 To date, no study has been specifically designed to closely evaluate the true forward rotation of mandible that occurs during the transition from late primary dentition to early mixed dentition. The purpose of the present study is to determine if the dentoalveolar changes and/or vertical growth are related to the true forward rotation of mandible during this transition period. If significant relations are detected, they will expand the possibilities of clinical interventions. In this literature review, an overview of the current beliefs regarding Class II will first be provided. This first section focuses on the definition, the causes, the etiology and the problems associated with Class II malocclusion. It also touches on the reason why forward rotation of mandible improves profiles of Class II patients and why forward rotation is so important in treating Class II malocclusions. Next, the current choices for Class II treatment will be outlined to emphasize the advantages of focusing on the forward rotation. Thirdly, mandibular growth and its rotation will be explained in detail to understand how this phenomenon can be taken advantage of and how it has been studied

in the past. Finally, the dental changes related to the rotation of mandible will be reviewed in order to better understand the effects of rotation on the dentition and occlusion. CHAPTER 2: REVIEW OF THE LITERATURE Class II Malocclusion Edward Angle classified malocclusions into Class I, II and III, based on the relationship between the upper and lower permanent first molars. Class II malocclusions, in which the lower first molar is positioned distally relative to the upper molar, can be subdivided into Division 1 and 2. In Division 1, the maxillary incisors are positioned forward in relation to the lower teeth, resulting in marked overjet. On the other hand, in Division 2, the maxillary incisors are in close relation to the lowers, usually with a deep overbite. Both Divisions 1 and 2 can be related to various types of vertical facial patterns. Division 1 individuals typically have mesofacial, brachyfacial or dolichofacial growth patterns, while Division 2 individuals tend to have brachyfacial growth patterns. These different underlying facial patterns are believed to develop with facial rotation, especially mandibular rotation.1 Brachyfacial patterns are often seen with forward rotation of mandible, while dolicofacial patterns are associated with backward rotation of mandible.7 Class I malocclusions as the most prevalent, but approximately 15% to 30% of American children have Class II malocclusions, accounting for about 20% to 30% of all orthodontic patients.8 According to National Health and Nutrition Estimates Survey III, which regarded the overjet of 5 mm or more as Class II, Class II malocclusion occurs in 23% of children, 15% of youths, and 13% of adults. While genetics plays an important role in the level of the basal structures, there is no evidence that AP skeletal patterns,

especially for subdivisions, are genetically determined. However, the effects of functional and environmental factors are unquestionable.9 This fact suggests that there is a possibility of early intervention in the Class II skeletal development. While patients seek orthodontic treatments to improve their oral functions and esthetics, subjects with Class II malocclusions are referred to orthodontists mainly for esthetic improvement.10 Thus, subjective patient desires as well as objective treatment goals need to be met for successful Class II treatments. 11 For these patients, it is important to improve their profiles by modifying chin position, because the soft tissue changes in profile can enhance esthetics significantly. In fact, straighter profiles and more prominent chins are generally accepted as more esthetic than retruded chin positions. 12-13 It has also been suggested that Class II patients might be more susceptible to functional problems, and it has been shown, for instance, that pre-treatment signs of TMD of muscular origin can benefit functionally from orthodontic treatments. 14 In addition, Class II maleocclusion has been shown to exert a negative effect on masticatory performance.15 Even though Class II malocclusions can be caused by numerous combinations of dental and skeletal components, mandibular skeletal retrusion has been shown to be the most important component.16-17 Abnormalities in vertical development of the mandible are also important components of Class II malocclusion. In 1981, McNamara pointed out that almost half of his 277 Class II sample exhibited excessive vertical development.17 In addition, he also argued the growth axis indicated a wide range of possibilities.17 The general tendency, however, was toward vertical direction of the sample.17 Buschang and Martins showed that londitudinal growth changes of the mandible were primarily responsible for producing anteroposterior and vertical discrepancies.18 They also showed

less anterior and more posterior movements of pogonion and gonion, respectively, for individuals developing anterior-posterior discrepancies, while the maxilla showed no difference between individuals.19 Class II Treatment Due to the substantial growth changes that occur during childhood and adolescence, the development of the intermaxillary relationship must be fully understood in order to be modified efficiently and effectively during Class II treatments. In general, Class II malocclusion is typically treated with headgear or functional appliances to correct anterioposterior positions of the maxilla and mandible.20 Headgear treatment aims to reduce or redirect maxillary growth. It is based on the premise that the maxilla can be therapeutically controlled more easily and more predictably than the mandible. In fact, the Class II problem has traditionally been regarded as problems in maxillary protrusion, which explains why treatments have focused on upper arch retraction.7, 21 To date, a large number of different directions of headgear pull have been used.22 There are two major types, J hook headgear and face bow headgear.22 Both can pull either upwards and backwards, straight along the occlusal plane, or downwards and backwards from the occlusal plane, depending on the vertical corrections required.22 English-language articles evaluating headgear treatments are listed in Table 2.1.23 Headgears have usually been shown to favorably affect the maxilla in Class II correction. However, cervical headgears are known to negatively affect the mandible, particularly for cases with high mandibular plane angles, due to the unfavorable backward rotation of the mandible, which tends to make the chin less prominent.

Table 2.1: Outcomes of Previous Headgear Studies Concerning Anterior-Posterior Changes23

Author

Design

No. treated/no. controls

Control type*

Age of treated patients/control

Max

Mand

A B C H

U6

L6

U1

L1

U 1/ L1

Meach, 1966 Jakobsson, 1967 Wieslander, 1974 Mills et al, 1978

Retro RCT Retro Retro

30/46 19/19 28/28 51/20 84/13 74/50 53/50 52/61

Historical Random Selected Historical Selected Selected Random

9-14/8-11 8.5/8.5 9/9 11.6/10.9 10.4/10.4 10.3/8.4 10.0/8.4 9.4/9.4

NA + + +

0 0 -

NA NA NA NA NA NA NA NA NA NA NA + + + + + NA NA NA NA + +

Baumrind et al, 1983; Ben- Retro Bassat et al, 1986 Retro Tulloch et al, 1996 RCT

++ +

0 0

NA NA 0 NA NA 0 +

NA NA NA NA NA NA

NA NA NA NA +

Retro, retrospective; pro, prospective; NA, not measured; +, Class II correction; 0, no change; -, more retrognathic Max, Maxilla; Mand, Mandible *Data from control subjects were obtained from a historical database, from a previously unreported cohort of selected subjects, from subjects randomly assigned to control status before the start of the study, and from subjects serving as their own controls

Over the years, more and more attention has been paid to the retruded mandible,16-17 and more current treatments aim to increase mandibular prominence.7 Functional appliances have been used for this purpose since the 1930s.24 Functional appliances assume that mandibular growth can be enhanced.20 Even though some believe that functional appliance therapy results in increased mandibular length and limited tooth movement,25-27 there is a lack of consensus regarding the relative orthodontic/orthopedic correction.24 Table 2.2 lists the articles that have evaluated functional appliances.23 It is worth noting that functional appliances have sometimes been shown to have a headgear effect on the maxilla. The differences in effect between headgear and activator are shown in the Table 2.3.23 Headgears have been shown to affect the maxilla more than functional appliance; functional appliances affect the mandible more than headgear; and both affect the maxilla and mandible. With regard to soft tissue changes, Flores-Mir reported substantial controversy regarding the changes in the chin position, produced with Activators and Bionator appliances, and no significant changes in chin position with Twin blocks.28-29 This suggests new and different approaches must be considered for the effective correction. It was recently shown by LaHaye and coworkers that true mandibular rotation is the primary determinant of the AP changes during treatment.4 They evaluated the pretreatment and post-treatment lateral cephalograms of 67 hyper-divergent patients (25 extraction headgear and Class II elastics, 23 non-extraction headgear, and 19 Herbst), who were compared with 29 matched untreated Class II controls. 4 They showed that none of the treatments had a positive effect on chin position.4 Half of the patients showed improvements and half showed increasing amounts of retrusion, both of which were

growth related.4 Changes in vertical positions of the maxilla, maxillary molars, mandibular molars, and condylar growth could not reliably predict the anterior-posterior changes in chin position that occurred, but true mandibular rotation could. 4

Table 2.2: Characteristics of Activator Studies in Preadolescent Children and Their Outcomes in Anterior-Posterior Changes23
Author Meach, 1966 Jakobsson, 1967 Trayfoot and Richardson, 1968 Harvold and Vargervik, 1971 Wieslander and Lagerstrom, 1979 Forsberg and Odenrick, 1981 Luder, 1981 Calvert, 1982 Baumrind et al, 1983; Ben-Bassat et al, 1986 Johnston, 1985 Vargervik and Harvold, 1985 Looi and Mills, 1986 Jakobsson and Paulin, 1990 Nelson et al, 1993; Courtney et al, 1996 Tulloch et al, 1996 Design Retro RCT Retro Pro Retro Retro Retro Retro Retro Retro Pro Retro Retro RCT RCT No. treated/no. Control 30/34 19/19 17/17 20/20 30/30 47/31 25/39 29/19 61/50 47/44 52/variable 30/22 53/60 17/12 53/61 Control type* Historical Random Selected Selected Historical Selected Selected Selected Selected Historical Self Historical Selected Random Random Age of Max patients/control 10-13/8-11 8.5/8.5 8-13/NA 9.7/8.4 8-11/NA 10.8/10.4 8.6/9.2 11.9/11.7 10.0/8.4 10.8/11 10-5/NA 11.5/11.7 NA + + + 0 + + + 0 + + 0 0 + 0 (5) + Mand 0 0 0 0 0 0 + + + + ABCH NA NA + NA + + NA NA NA + + + + NA + U6 NA NA NA 0 0 NA + + + + 0 NA NA 0 NA L6 NA NA NA 0 0 NA 0 0 0 0 0 NA NA NA NA U1 NA NA + NA + NA + + NA NA NA + NA + NA L1 NA NA 0 NA 0 NA + + NA NA NA 0 NA + NA U1/L1 NA + NA + NA + NA NA NA NA + + NA + +

10.9/10.411.6/10.5 + 11.7/11.5 9.4/9.4 0 0

Retro, retrospective; pro, prospective; NA, not measured; +, Class II correction; 0, no change; -, more Class II Max, Maxilla; Mand, Mandible *Data from control subjects were obtained from a historical database, from a previously unreported cohort of selected subjects, from subjects randomly assigned to control status before the start of the study, and from subjects serving as their own controls

Table 2.3: Outcomes of Previous Studies Comparing Activators and Headgears Concerning Anterior-Posterior Changes23

Author Meach, 1966 Jakobsson, 1967 Baumrind et al, 1983; Ben-Bassat et al, 1986 Tullock et al, 1996

Maxilla NA HG > A HG > A HG > A HG > A

Mandible A > HG 0 A > HG A > HG A > HG

ABCH NA NA NA NA 0

U6 NA NA 0 HG > A NA

L6 NA NA 0 0 NA

U1 NA NA NA NA NA

L1 NA NA NA NA NA

U1/L1 NA A > HG NA NA A > HG

NA, not measured; A, Activator; HG, headgear; 0, no difference

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Rotational Control for Class II Correction Rotational control of the mandible is considered to be a new approach for Class II correction because counterclockwise or forward rotation of mandible has been shown to improve anterior-posterior chin position.4 For example, the existing studies using miniscrew implants to intrude posterior teeth have shown 1.7 to 3.3 decreases in the mandibular plane angle and 1.5 to 1.8 increases in the SNB angle in adult patients.30-33 In growing children, a 3.9 decrease in the mandibular plane angle, and a 2.1 increase in the SNB angle has been reported in adolescent patients (Table 2.4).34 The data suggest that intrusion mechanics produce forward rotation of the mandible, which helps Class II correction by swinging the chin forward and producing better soft tissue profiles. The effects may be more pronounced in growing individuals than adults.

Table 2.4: Summary for Treatment of Hyperdivergent Patients with Intrusion of Teeth
N MPA () -1.7 -3.3 -2.3 -3.0 -3.9 SNB () +1.8 +1.5 +1.6 +1.6 +2.1 U6PP (mm) -2.6 -2.3 -1.8 -3.4 L6MP (mm) -0.1 -1.3 -1.2 Gonial Angle () -0.3 -1.0 -2.4 ANSMe (mm) -1.6 -3.7 Hard Tissue Convexity () -3.2

Erverdi et al, 2004 Kuroda et al, 2007 Xun et al, 2007 Akay et al, 2009 Buschang et al, 2011

10 10 12 10 9

Based on the foregoing, the rotation of mandible must be fully understood and the mechanics to produce the forward rotation of mandible should be incorporated in Class II treatment to successfully improve AP chin position.

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Growth and Rotation of Mandible Ever since Bjrk introduced mandibular growth rotation as a feature of normal facial growth in 1955,1 numerous studies have been conducted and the concept of mandibular rotation is now widely accepted. Bjrk was able to demonstrate that most of the mandibular rotation that occur is masked by periosteal remodeling at the lower border of mandible.1 In 1969, Bjrk published an article, discussing the rotation of mandible in relation to the cranial base, specifying the directions and the types of the mandibular rotation. 1 Bjrk noted that the mandible should be considered to be a more or less unconstrained bone from the standpoint of growth. As such, the center of rotation (COR) can be located anywhere between the posterior or anterior ends of the bone. Depending on where the COR is located, the mandible can swing in different directions.1 There are 3 centers of forward rotation and 2 centers of backward rotation. Forward Rotation Type I (Fig. 2.1)1: The center of rotation is located in the temporomandibular joint area. With this COR, a deep bite will develop, the lower dental arch is pressed into the upper, and there is an underdevelopment of anterior face height. Occlusal imbalance, such as loss of teeth and powerful muscular pressure, may be the cause. This type of rotation is thought to occur at any age, but mostly in adults. Type II (Fig. 2.1)1: The center of rotation is located at the incisal edges of lower anterior teeth. It is associated with marked development of posterior face height and a normal increase of anterior face height, which results in the rotation of the posterior part of the mandible away from the maxilla. The increase in posterior face height can be

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caused by two factors. First, the lowering of the middle cranial fossa in relation to the anterior cranial fossa can lower the condylar fossae. Secondly, the increase in the height of ramus, associated with vertical growth at the mandibular condyle, can also lead to an increase in posterior face height. The eruption of the molars is thought to keep pace with this rotation. With Type II growth rotation, the mandibular symphysis swings forward to make the chin more prominent. Type III (Fig. 2.1)1: The center of rotation is located in the premolar area. This is thought to occur when overjet is large, which displaces the center of rotation backward in the dental arch. Type III rotation also makes the chin more prominent than Type II rotation. The rotation displaces the paths of eruption of all the teeth in a mesial direction and also causes the mandibular posterior teeth to be more upright in relation to maxillary posterior teeth.

Center at the joints

Center at the incisal edges of the lower incisors

Center at the premolars

Figure 2.1: Three Types of Forward Rotation of the Mandible1

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Backward rotation Type I (Fig. 2.2)1: The center of rotation is located in the temporomandibular joint area. This type of rotation is thought to be related to changes in intercuspation that can increase anterior facial height, or growth of the cranial base, such as flattening of the cranial base, which leads to underdevelopment of the posterior face height and backward rotation of mandible. Type II (Fig. 2.2)1: The type II center of rotation is located in the most distal occluding molars. This type of rotation occurs in relation to the backward growth of the condyles. The cause is probably not due to the overeruption of lower molars, because Bjrk indicated that the eruption of the lower molars was hindered with this type of rotation. The lower incisors become retroclined. This induces crowding of the lower anterior teeth because the lateral teeth are not guided distally during their eruption. The premolars and molars are inclined forward in relation to the maxillary teeth because of their close proximity to the center of rotation.

Center at the joints

Center at the last occluding teeth

Figure 2.2: Two Types of Backward Rotation of the Mandible1

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Remodeling Pattern Associated with Rotation In 1970, degaard demonstrated in his implant study that the degree of the rotation is associated to the direction and the magnitude of condylar growth.35 Importantly, he showed that more forward rotation is associated with larger amounts of vertical condylar growth.35 According to Bjrk, large amounts of prominent condylar growth increase posterior face height and can lead to Type II forward rotation of mandible, with the COR located around the lower incisors.1 Nanda, in 1990, evaluated the relationships between the lower face height, gender and mandibular rotation.36 He found that the posterior half of the palate tends to be tipped down in patients with openbite, carrying the molars downward. 36 With posterior rotation, as the teeth act as a fulcrum, the lower anterior face height and the palatomandibular angle increase.36 In fact, he suggested that the downward and backward rotation of the mandible in open bite subjects was a response to the dentoalveolar compensatory changes, with the center of rotation at the molars.36 He also showed the growth changes in mandibular rotation. 36 In females, the palatal plane angles were approximately the same for the deep bite and the open bite groups at age 4, but the deep bite group showed a significant increase in this angle between 4 and 7 years of age.36 On the other hand, males with deep bites showed significantly larger palatal plane angles at age 10, in comparison with the open bite male group. 36 This suggests that deep bite caused by rotation of mandible can affect the palatal plane angle. In 1977, Lavergne and Gasson argued that the rotational pattern affected the mandibular ramus and the gonial angle.37 The larger the mandibular plane angle, the

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steeper the mandible tends to become, and the more backward the chin relocates. On the other hand, the smaller the angle, the flatter the mandible becomes, and the chin grows forward. As Bjrk and Skieller later showed in their paper, this remodeling masks most of mandibular rotation that occurs during growth.38 It was referred to by Bjrk and Skieller as intramatrix rotation, where rotation of the mandibular corpus occurs inside the soft tissue matrix.38 This is compared with matrix rotation, which they defined as the rotation of the soft tissue matrix of the mandible relative to the anterior cranial base (Fig. 2.3 and Fig. 2.4).38 In forward rotating cases, the anterior part of corpus is lifted up from the matrix, leading to apposition below the symphysis and the anterior part of the lower border (Fig. 2.3 and Fig. 2.4).38 The posterior part of the corpus is pressed downward into the matrix, resulting in resorption, and a decreased gonial angle.38 In backward rotating cases, intramatrix rotation causes the anterior part of corpus to be lifted up from the matrix, leading to resorption below the symphysis and apposition at the chin (Fig. 2.3 and Fig. 2.4).38 As a result, the gonial angle tends to increase.

Figure 2.3: Matrix Rotation and Intramatrix Rotation in Forward Rotating Cases38

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Figure 2.4: Matrix Rotation and Intramatrix Rotation in Backward Rotating Cases38

In 1984, Skieller and Bjrk conducted a study designed to predict the direction and amount of growth rotation of the mandible. 39 They showed that the combination of four variables (mandibular inclination, intermolar angle, shape of lower border and inclination of symphysis) gave the best prognostic estimate (86%) of mandibular growth rotation.39 This result also suggests that there is strong relation between rotation and remodeling. As shown previously in Table 2.4, the gonial angle decreases with the molar intrusion mechanics, especially during adolescence.30-34 This suggests that rotational changes can cause remodeling of mandible, affecting the gonial angle.

Terminology for Rotational Changes of Mandible In 1977, Lavergne and Gasson coined the term positional rotations to describe changes in the orientation of the mandible relative to the cranial base.37 In the paper, Lavergne and Gasson also introduced a new term called morphogenetic rotations to
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describe the changes in the shape.37 This was derived from the concept of mandibular rotation described by Bjrk in 1963,6 and Odegaard in 1970.35 In 1983, new terminology was introduced by Bjrk and Skieller to describe forward and backward rotation of mandible.38 Total rotation was used to describe the rotational changes in the inclination of a stable reference line, or an implant line, in the mandibular corpus relative to the anterior cranial base.38 Matrix rotation, on the other hand, as previously touched on, was used to describe the rotation of the soft tissue matrix of the mandible relative to the anterior cranial base (Fig. 2.3 and Fig. 2.4).38 Finally, intramatrix rotation was used to describe rotation of the mandibular corpus inside the soft tissue matrix (Fig 2.3 and Fig. 2.4).38 In this article, the independence in development of the bony mandibular corpus and its soft tissue covering was emphasized. 38 Solow and Houston, in 1988, simplified the terminology.2 They used the term true mandibular rotation to describe rotation of the mandibular body as represented by implants or stable trabecular reference structures, relative to the anterior cranial base. 2 Apparent rotation was defined as the angular change of the mandibular line relative to the anterior cranial base.2 Finally, angular remodeling of the mandibular border was defined as the angular change of the mandibular line when the mandible is registered on implants or stable trabecular structures. 2 All the different terms described above are listed in the Table 2.5. For the purpose of this study, the terms that were introduced by Solow and Houston will be used.

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Table 2.5: Terminology of Rotational Changes of the Jaws Lavergne and Gasson37 Rotation of the core of mandible relative to the cranial base Positional rotation Bjrk and Skieller38 Total rotation Solow and Houston2 True rotation

Rotation of the mandibular plane relative to cranial base

Morphogenetic rotation

Matrix rotation

Apparent rotation

Rotation of mandibular plane relative to the core of mandible

Intramatrix rotation

Angular remodeling

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Dentoalveolar Changes and Growth It has been shown that dental compensations can maintain the occlusion even though individuals show different facial growth patterns and rotational changes of the mandible.3 In fact, Bjrk and Skeiller claimed that these compensatory mechanisms tend to even out positional changes between the jaws, and problems in occlusion will result if there is no compensation.3 They reported that in Type I forward rotation the lower dental arch is pressed into the upper arch so that anterior facial height develops less than usual, resulting in a deep bite.3 On the other hand, in Type II forward rotation, the molars keep pace as the posterior part of the mandible is lowered, giving rise to more eruption of molars than incisors.3, 40 The occlusal plane tips down posteriorly so that there is no increase in overbite.3 There is also a forward shift of the entire dentitions relative to the jaw bases, with forward tipping of both incisors and molars. 3 Finally, in Type III forward rotation, the upper and the lower dental arches are pressed into each other so that anterior facial height develops less than usual, resulting in a deep bite.3 The deciduous dentition ends with the eruption of second deciduous molars. In the deciduous dentition, the occlusal traits of Class II occlusion comprise large overjet, large overbite, distal terminal plane of the second deciduous molars and a distal canine relation.41 Any narrow upper dental arch, a narrow maxillary base and poor anterior spacing are also considered as characteristic of Class II.41 During the early mixed dentition, first molars erupt approximately at age 6, followed by permanent incisors. Actually, the increased rates of true rotation during the transition actually could be associated with space created by the loss of the primary incisors, because this enables the Type III forward rotation of mandible. In 1983, Buschang et al. demonstrated substantial

20

relative decreases in alveolar bone height between 5.5 and 7.5 years of age for the lower incisors (up to 5%) and especially for the upper incisors (up to 20%).42 Anterior maxillary (anterior nasal spine-prosthion) and mandibular heights (infradentale-menton) significantly decreased in relative size with the replacement of deciduous by permanent dentition (Fig. 2.5).42 Even though there are some characteristic occlusal traits in Class II primary dentitions, Class II children are skeletally similar to normal children during the deciduous dentition. In fact, Class II skeletal characteristics become prominent during growth. For example, when Class II individuals show backward rotation of mandible, it tends to make chin more retrusive. Recently, Wang and coworkers evaluated the mandibular rotation during the transition from late primary dentition to early mixed dentition, which can be related to Class II skeletal characteristcs. She demonstrated that, although significant amounts of true mandibular rotation occur during childhood and adolescence, there is a greatest rate of true rotation during the transition from late primary to early mixed dentition.5 Other studies have previously showed that greater amounts of true rotation occurs between 5 to 10 years of age,43 and between 6 to 11 years of age than late during adolescence.44 Together, the available literature suggests that the alveolar changes that occur during the transition may play an important role in true forward rotation of mandible, but no study has been specifically designed to evaluate the factors responsible for true forward mandibular rotation that occurs during transition from late primary to early mixed dentition.

21

Fig. 2.5: Percent Adult Status of Maxillary and Mandibular Heights for Males and Females
22

References

1. 2.

Bjrk A. Prediction of mandibular growth rotation. Am J Orthod. 1969;55:585-99. Solow B, Houston WJ. Mandibular rotations: concepts and terminology. Eur J Orthod.1988 Aug;10(3):177-9. Bjrk A, Skieller V. Facial development and tooth eruption. An implant study at the age of puberty. Am J Orthod. 1972;62:339-83. LaHaye MB, Buschang PH, Alexander RG, Boley JC. Orthodontic treatment changes of chin position in Class II Division 1 patients. Am J Orthod Dentofacial Orthop. 2006;130:732-41. Wang MK, Buschang PH, Behrents R. Mandibular rotation and remodeling changes during early childhood. Angle Orthod. 2009;79:271-5. Bjrk A. Variations in the growth pattern of the human mandible: longitudinal radiographic study by the implant method. J Dent Res. 1963;42:400-11. Tadic N, Woods M. Contemporary Class II orthodontic and orthopaedic treatment: a review. Aust Dent J. 2007;52:168-74. Proffit WR, Fields HW, Jr., Moray LJ. Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg. 1998;13:97-106. Kawala B, Antoszewska J, Necka A. Genetics or environment? A twin-method study of malocclusions. World J Orthod. 2007;8:405-10. Dann Ct, Phillips C, Broder HL, Tulloch JF. Self-concept, Class II malocclusion, and early treatment. Angle Orthod. 1995;65:411-6. Burstone CJ. Lip posture and its significance in treatment planning. Am J Orthod. 1967;53:262-84. Czarnecki ST, Nanda RS, Currier GF. Perceptions of a balanced facial profile. Am J Orthod Dentofacial Orthop. 1993;104:180-7. Spyropoulos MN, Halazonetis DJ. Significance of the soft tissue profile on facial esthetics. Am J Orthod Dentofacial Orthop. 2001;119:464-71. Henrikson T. Temporomandibular disorders and mandibular function in relation to Class II malocclusion and orthodontic treatment. A controlled, prospective and longitudinal study. Swed Dent J Suppl. 1999;134:1-144.
23

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English JD, Buschang PH, Throckmorton GS. Does malocclusion affect masticatory performance? Angle Orthod. 2002;72:21-7. Craig CE. The skeletal patterns characteristic of Class I and Class II, Division I malocclusions in norma lateralis. Angle Orthod. 1951;21:44-56. McNamara JA, Jr. Components of Class II malocclusion in children 8-10 years of age. Angle Orthod. 1981;51:177-202. Buschang PH, Martins J. Childhood and adolescent changes of skeletal relationships. Angle Orthod. 1998;68:199-206. Buschang PH, Carrillo R, Liu SS, Demirjian A. Maxillary and mandibular dentoalveolar heights of French-Canadians 10 to 15 years of age. Angle Orthod. 2008;78:70-6. Martins RP, da Rosa Martins JC, Martins LP, Buschang PH. Skeletal and dental components of Class II correction with the bionator and removable headgear splint appliances. Am J Orthod Dentofacial Orthop. 2008;134:732-41. Lager H. The individual growth pattern and stage of maturation as a basis for treatment of distal occlusion with overjet. Rep Congr Eur Orthod Soc. 1967:13745. Bowden DE. Theoretical considerations of headgear therapy: a literature review. 2. Clinical response and usage. Br J Orthod. 1978;5:173-81. Keeling SD, Wheeler TT, King GJ, Garvan CW, Cohen DA, Cabassa S, et al. Anteroposterior skeletal and dental changes after early Class II treatment with bionators and headgear. Am J Orthod Dentofacial Orthop. 1998;113:40-50. Bishara SE, Ziaja RR. Functional appliances: a review. Am J Orthod Dentofacial Orthop. 1989;95:250-8. Baysal A, Uysal T. Soft tissue effects of Twin Block and Herbst appliances in patients with Class II division 1 mandibular retrognathy. Eur J Orthod. 2011. Eirew HL. The bionator. Br J Orthod. 1981;8:33-6. Eirew HL, McDowell F, Phillips JG. The function regulator of Frankel. Int J Orthod. 1979;17:12-8. Flores-Mir C, Major PW. Cephalometric facial soft tissue changes with the twin block appliance in Class II division 1 malocclusion patients. A systematic review. Angle Orthod. 2006;76:876-81

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Flores-Mir C, Major PW. A systematic review of cephalometric facial soft tissue changes with the Activator and Bionator appliances in Class II division 1 subjects. EurJOrthod .2006;28:586-93. Akay MC, Aras A, Gunbay T, Akyalcin S, Koyuncue BO. Enhanced effect of combined treatment with corticotomy and skeletal anchorage in open bite correction. J Oral Maxillofac Surg. 2009;67:563-9. Erverdi N, Keles A, Nanda R. The use of skeletal anchorage in open bite treatment: a cephalometric evaluation. Angle Orthod. 2004;74:381-90. Kuroda S, Sakai Y, Tamamura N, Deguchi T, Takano-Yamamoto T. Treatment of severe anterior open bite with skeletal anchorage in adults: comparison with orthognathic surgery outcomes. Am J Orthod Dentofacial Orthop. 2007;132:599605. Xun C, Zeng X, Wang X. Microscrew anchorage in skeletal anterior open-bite treatment. Angle Orthod. 2007;77:47-56. Buschang PH, Carrillo R, Rossouw PE. Orthopedic correction of growing hyperdivergent, retrognathic patients with miniscrew implants. J Oral Maxillofac Surg. 2011;69:754-62. Odegaard J. Growth of the mandible studied with the aid of metal implant. Am J Orthod 1970;57:145-57. Nanda SK. Growth patterns in subjects with long and short faces. Am J Orthod Dentofacial Orthop. 1990;98:247-58. Lavergne J, Gasson N. Direction and intensity of mandibular rotation in the sagittal adjustment during growth of the jaws. Scand J Dent Res. 1977;85:193-6. Bjork A, Skieller V. Normal and abnormal growth of the mandible. A synthesis of longitudinal cephalometric implant studies over a period of 25 years. Eur J Orthod. 1983;5:1-46. Skieller V, Bjork A, Linde-Hansen T. Prediction of mandibular growth rotation evaluated from a longitudinal implant sample. Am J Orthod. 1984;86:359-70. Sinclair PM, Little RM. Dentofacial maturation of untreated normals. Am J Orthod 1985;88:146-56. Varrela J. Early developmental traits in Class II malocclusion. Acta Odontol Scand. 1998;56:375-7.

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Buschang PH, Baume RM, Nass GG. A craniofacial growth maturity gradient for malesand females between 4 and 16 years of age. Am J Phys Anthropol.1983;6:373-81. Miller S, Kerr WJ. A new look at mandibular growth--a preliminary report. Eur J Orthod. 1992;14:95-8. Karlsen AT. Craniofacial characteristics in children with Angle Class II div. 2 malocclusion combined with extreme deep bite. Angle Orthod. 1994;64:123-30.

43.

44.

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CHAPTER 3: JOURNAL ARTICLE Abstract Purpose: To determine whether dentoalveolar changes and/or the condylar growth are related to the true forward rotation of mandible that occurs during the transitional period between the late primary and early mixed dentition stages of development. Materials and Method: The sample included 50 subjects (25 males and 25 females) with Class I (N=25) and Class II (N=25) molar relationships. They were selected based on the availability of lateral cephalograms at two developmental stages: T1- last film with complete primary dentition (5.8 0.4 years) and T2- first film with permanent incisors and permanent molars erupted (8.0 0.2 years). Seventeen landmarks were identified and 22 measurements were calculated. The mandibles at T1 and T2 were superimposed using natural reference structures in order to measure true mandibular rotation. Results: The mandible underwent -2.4 2.6 degrees of true rotation, 1.9 2.4 degrees of remodeling and -0.6 1.8 degrees of apparent rotation between T1 and T2. There were no significant sex or Class differences in true rotation, remodeling and apparent rotation. There was a moderate correlation (r=0.76) between true rotation and remodeling, and a moderately low correlation (r=0.40) between true rotation and apparent rotation. There was a weak correlation between true rotation and SNA (r=0.28). True rotation showed a moderately low correlation (r=-0.34) with the increases in U1-SN, increases in U1-PP (r=-0.36), and with decreases in Id-Me (r=0.36). Conclusion: Independent of sex and Class, the true mandibular rotation that occurred between the late primary and early mixed dentition was mostly masked by angular remodeling, resulting in limited amounts of apparent rotation. True rotation was significantly related to anterior

27

dentoalveolar changes, but not to the vertical growth changes that occurred.

Introduction Significant amounts of true mandibular rotation take place during childhood and adolescence.1-5 True rotation, which refers to the angular changes of the mandibular core relative to the anterior cranial base, is typically in a forward and upward direction.6 Increasing amounts of true forward rotation and proclination of the lower incisors are associated with greater and more anterior condylar growth. 6 The true rotation that occurs is typically masked by the angular remodeling that takes place on the lower border of the mandible.6 Due to angular remodeling, there is only limited rotation of the mandiblar plane, which is referred to as apparent rotation.6-8 True mandibular rotation provides important information for understanding facial growth changes, especially changes of the chin. Since most skeletal Class II patients have mandibular deficiencies, improvement in anterior-posterior chin position is crucial for their treatments. Greater amounts of true forward rotation of mandible have been related with more horizontal displacement of chin; true rotation has been shown to be the primary determinant of anterior-posterior chin position.9 Class II malocclusion is typically treated with headgear or functional appliances to correct anterior-posterior positions of the maxilla and mandible.10-11 However, headgears have been shown to negatively affect mandibular position in Class II cases, due to the unfavorable backward rotation of the mandible, which tends to make the chin less prominent. 10 While functional appliance therapy can alter the growth of mandible, the orthopedic effects are limited and not predictable,12 and whether meaningful orthopedic improvement in chin position occur

28

remains questionable.12-15 Mechanics that cause the forward rotation of mandible have been recently incorporated in Class II treatment to improve anterior-posterior chin position of adults,16-20 suggesting that a better understanding of rotation is necessary to improve orthopedic corrections in Class II patients. It has been well established that greater amounts of true mandibular rotation occur during childhood than during adolescence.3-5 Most recently, it was shown that there is greater true rotation during the transition from the late primary to early mixed dentition than at any time thereafter.5 This suggests that true rotation may be related to the dentoalveolar changes that occur during the transitional dentition. More specifically, true rotation during the transition could be associated with temporary decreases in anterior alveolar bone height that occur between 5.5 and 7.5 years of age.21 Assuming that the center of mandibular rotation is located at the premolars or the most distal occluding molars, space created anteriorly should result in greater rotation.1 It is also possible that greater posterior vertical growth occurs during this transitional period, which would also explain the increases in true rotation observed.1 To date, no study has been specifically designed to explain why such relatively large amounts of mandibular rotation occur during the transition from late primary dentition to early mixed dentition. The purpose of this study is to evaluate if and how dentoalveolar changes and vertical growth are related to the true forward rotation of mandible during this transitional period. Understanding the mechanism controlling true mandibular rotation holds great potential for facilitating the Class II treatments.

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Materials and Methods Subjects The sample included 50 subjects (25 males and 25 females), followed longitudinally by the Bolton-Brush Growth study. The Bolton study population consists of individuals from the Cleveland, selected on the basis of recommendations by the family physicians and their overall good health. The sample included untreated 50 subjects with Class I (N=25) and Class II (N=25) molar relationships (Table 3.1). The subjects were selected based on the following criteria: a) Longitudinal cephalograms available during the late primary dentition (T1: 5.8 0.4 yrs), and during the early mixed dentition after the first molars and incisors had erupted into functional occlusion (T2: 8.0 0.2 yrs). b) Cephalograms had to be of sufficient quality to identify all of the structures necessary for landmark identification and regional superimposing. c) Patients were rejected if they had received prior orthodontic treatment or had major craniofacial anomalies.

Table 3.1: Mean Ages for Late Primary (T1) and Early Mixed Dentition (T2)

Class I T1 Male Female Mean 5.83 5.65 SD 0.35 0.46 Mean 8.08 8.14 T2 SD 0.24 0.32 Mean 5.80 5.91 T1

Class II T2 SD 0.36 0.75 Mean 7.98 7.97 SD 0.04 0.05

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Cephalometric Methods Each cephalogram was traced and 17 landmarks were digitized with Dolphin software (Dolphin Imaging & Management Solutions & Patterson Technology, Lake Oswego, Oregon) (Table 3.2, 3.3). Traditional measurements were computed from the digitized data (Table 3.4).

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Table 3.2: Landmarks, Abbreviations and Definitions Used26 Landmarks Subspinale/A point Supramentale/B point Pogonion Nasion Sella Posterior nasal spine Anterior nasal spine Gonion (Anatomical) Gnathion Condylion Articulare (Bjrk) Prosthion Infradentale Incision superius Incision inferius Upper molar mesial cusp tip Lower molar mesial cusp tip Abbreviations A B Pg N S PNS ANS Go Gn Co, Cd Ar Pr In U1 L1 U6 L6 Operational definitions The most posterior midline point in the concavity between the anterior nasal spine and the prosthion (most inferior point on the alveolar bone overlying the maxillary incisors) The most posterior midline point in the concavity of the mandible between the most superior point on the alveolar bone overlying the lower incisors and pogonion The most prominent point on the symphysis of the mandible in the median plane, determined by a tangent through Nasion Most anterior on the frontonasal suture in the midsagittal plane Geometric center of of the pituitary fossa located by visual inspection. The posterior spine of the palatine bone constituting the hard plane The anterior tip of the sharp bony process of the maxilla at the lower margin of the anterior nasal opening A point on the curvature of the angle of the mandible located by bisecting the angle formed by the lines tangent to the posterior ramus and the inferior border of the mandible A point located by taking the midpoint between the anterior (pogonion) and inferior (menton) points of the bony chin The highest point on the curvature of the averaged condyles of the mandible The point of intersection of the inferior surface of the cranial base and the averaged anterior surfaces of the mandibular condyles Lowest point on the bony septum between the upper central incisors Highest point on the bony septum between the lower central incisors The incisal tip of the most anterior maxillary incisor The incisal tip of the most labial mandibular anterior incisor The anterior cusp tip of the maxillary first molar The anterior cusp tip of the mandibular first molar

*Primary central incisors and primary second molars were used at T1 instead of central incisors and first molars

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Table 3.3: Planes, Abbreviations and Definitions Used26 Planes Occlusal plane Mandibular plane (Steiner) Maxillary plane (Palatal plane) Sella-Nasion plane Reference Line Abbreviations OP MP PP SN RL Definitions A line passing through one-half of the cusp height of the first permanent molars and one-half of the overbite of the incisors A line joining gonion and gnathion A line connecting the tip of the anterior nasal plane with the tip of the posterior nasal spine A line connecting sella with nasion 7 degrees from SN (Horizontal reference line)

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Table 3.4: Measurements, Abbreviations, Definitions Used and Error Analysis26 Measurements AP Skeletal Abbreviations SNA () SNB () ANB () SN-MP () Na-Me (mm) ANS-Me (mm) S-Go (mm) Co-Go (mm) Ar-Go (mm) Gonial Angle () Definitions Dahlberg Error Analysis Maxillary protrusion/retrusion 0.973 Mandibular protrusion/retrusion 0.658 AP relationship between maxilla and mandible 0.566 Mandibular plane inclination 0.991 Anterior facial height 1.266 Lower face height 0.912 Posterior facial height 0.819 Ramus height 1.431 Mandibular height 1.130 The angle formed by the line connecting Condylion 1.735 and Gonion, and the line connecting Gonion and Menton Posterior facial height/Anterior facial height Maxillary incisor inclination 1.721 Maxillary incisor inclination 1.944 Mandibular incisor inclination 2.057 Horizontal measurement from facial surface of 0.487 lower central incisor to lingual surface of upper central incisor Vertical overlap of central incisor 0.582 Measurement of vertical alveolar height 0.476 Measurement of vertical alveolar height 0.808 Upper incisor distance from palatal plane 0.546 Lower incisor height from mandibular plane 0.789 Upper molar height from palatal plane 0.356 Lower molar height from mandibular plane 0.445

Vertical Skeletal

AP Dental

S-Go/Na-Me U1-SN () U1-PP () IMPA (L1-MP) () Overjet (mm)

Vertical Dental

Overbite (mm) ANS-Pr (mm) In-Me (mm) U1-PP (mm) L1-MP (mm) U6-PP (mm) L6-MP (mm)

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Mandibular rotation was measured using cranial base and mandibular superimpositions, as described by Bjrk and Skieller.1 Anterior and posterior fiducial landmarks were recorded on the first (T1) tracing, and transferred to the later (T2) tracing following superimpositions of the mandible. For superimposing the mandible, the radiographs were oriented sagitally by the anterior contour of the chin, which was made to coincide on the two radiographs.1 Anteriorly, the radiographs were oriented in a vertical direction by the inner contour of the cortical plate at the lower border of the symphysis, and by any distinct trabecular structure in the symphysis. 1 Posteriorly, the radiographs were vertically oriented by the contour of the mandiblar canal and the lower contour of a mineralized molar germ before root development begins, and possibly also of a premolar tooth germ.1 True rotation was the angular change between the two planes defined by the cranial base and mandibular fiducial landmarks. The angle between SN and the mandibular plane (Go-Gn) was used to describe apparent rotation. Angular remodeling was defined as the difference between true rotation and apparent rotation.

Statistical Methods The skewness and kurtosis statistics showed that the distributions were approximately normal. Method error was evaluated based on 19 sets of duplicates, and the reliability was judged from the Dahlbergs statistic (Table 3.4). 22 The statistic is expressed in millimeters for linear dimensions and degrees for angular dimensions, and can be read as the average disparity between the measurement sessions. The errors in linear measurements were within 1 mm except for Ar-Go (1.13 mm), Na-Me (1.27 mm)

35

and Co-Go (1.43 mm). The errors in angular measurements were within 2 degrees except for IMPA (2.06 degrees). Group differences were calculated using independent t-tests. Paired t-tests were used to evaluate changes within subjects (i.e., changes over time). Pearson product-moment correlations were used to compute the relationship between true rotation and the other morphological measurements.

Results The mandible underwent -2.4 2.6 degrees of true rotation, 1.9 2.4 degrees of remodeling and -0.6 1.8 degrees of apparent rotation between T1 and T2 (Figure 3.1). There were no statistically significant difference between the genders or Classes in true rotation, remodeling and apparent rotation. There was a moderate correlation (r=0.76) between true rotation and angular remodeling, and a moderately low correlation (r=0.40) between true rotation and apparent rotation.

Degree (+: Backward, -: Forward)

6 4 2 0 -2 -4 -6 True Rotation Angular Remodeling Apparent Rotation

Figure 3.1: Mean and Standard Deviation of Mandibular Rotation from T1 to T2

Most of the skeletal measurements showed significant (p<.05) changes (Table 35). The ANB and SN-MP angles decreased 0.5 to 0.6. Anterior face height (N-Me) increased 5.5 mm, and lower face height (ANS-Me) increased 2.5 mm. Posterior face
36

height (S-Go), ramus height (Ar-Go) and Co-Go increased 4.3mm, 2.5mm and 3.0mm, respectively. The ratio of posterior and anterior facial height decreased slightly (2%); the gonial angle decreased 1.3.

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Table 3.5: Changes in Skeletal Variables from T1 to T2 T1 Mean AP Skeletal SNA () SNB () ANB () Vertical Skeletal MP-SN() N-Me (mm) ANS-Me (mm) S-Go (mm) Co-Go (mm) Ar-Go (mm) Gonial angle () S-Go/Na-Me 81.25 76.22 5.04 35.05 99.06 54.16 62.14 45.12 36.92 130.44 0.63 Std. Deviation 2.86 2.46 2.22 3.42 4.55 3.43 3.82 2.76 2.74 4.30 0.31 Mean 80.96 76.43 4.54 34.39 104.58 56.61 66.43 48.13 39.40 129.18 0.64 T2 Std. Deviation 2.98 2.64 2.21 3.51 4.95 3.93 4.25 3.44 3.44 4.33 0.34 Mean -0.30 0.22 -0.50* -0.62* 5.52** 2.46** 4.29** 3.01** 2.48** -1.26* 0.01** Difference Std. Deviation 1.49 1.60 1.41 1.78 2.63 1.72 1.96 3.24 2.44 0.48 0.01

** Paired t-test for equality of means was significant at the 0.01 level (2-tailed). * Paired t-test for equality of means was significant at the 0.05 level (2-tailed).

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Most dental measurements also changed significantly (Table 3.6). U1-SN, U1-PP and IMPA increased 10.8, 11.1 and 5.1 respectively. Overjet increased 0.8 mm. ANSPr decreased 4.8 mm and In-Me decreased 2.3 mm, resulting in a total dentoalveolar height (ANS-Pr+In-Me) decrease of 7.1mm. The linear distances of the lower incisor to the mandibular plane (L1-MP) increased 2.0 mm, and the distance of the upper molar to the palatal plane (U6-PP) decreased 1.1 mm. There were no statistically significant changes in the vertical distances between the upper incisor and the palatal plane (U1-PP) or between the lower molar and the mandibular plane (L6-MP). Other than the changes of the mandibular plane angle (SN-MP), the only skeletal measure related to true rotation was the change in SNA and S-Go/Na-Me (Table 3.7). Individuals with greater true rotation also showed greater increases in SNA (r=0.28). True rotation showed moderately low correlations with the increases in U1-SN (r=-0.34), and U1-PP (r=-0.36), indicating greater rotation for those individuals who had greater upper incisor proclination (Table 3.8). True rotation was most closely related to changes in dentoalveolar height. The greater the decreases in In-Me (r=0.36), and especially total dentoalveolar height (r=0.41), the greater the true rotation.

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Table 3.6: Changes in Dental Variables from T1 to T2 T1 Mean AP Dental U1-SN () U1-PP () IMPA () Overjet (mm) Vertical Dental Overbite (mm) ANS-Pr (mm) In-Me (mm) ANS-Pro + In-Me (mm) U1-PP (mm) L1-MP (mm) U6-PP (mm) L6-MP (mm) 88.56 96.05 86.80 3.03 1.79 17.21 28.11 45.32 24.44 30.27 18.50 25.38 Std. Deviation 6.40 6.77 7.09 1.47 1.61 1.79 2.39 3.73 1.88 2.27 1.51 1.83 Mean 99.39 106.90 91.91 3.85 2.11 12.56 26.03 38.59 24.80 32.23 17.37 25.27 T2 Std. Deviation 6.72 6.60 6.12 1.59 1.90 2.11 2.00 3.56 2.55 2.49 1.51 1.88 Mean 10.84** 11.08** 5.11** 0.81** 0.31 -4.75** -2.34** -6.72** 0.36 1.95** -1.13** -0.12 Difference Std. Deviation 7.26 7.12 5.86 1.79 2.30 1.83 1.44 3.15 2.10 1.79 -0.12 1.32

** Paired t-test for equality of means was significant at the 0.01 level (2-tailed). * Paired t-test for equality of means was significant at the 0.05 level (2tailed).

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Table 3.7: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables True Rotation Pearson Correlation AP Skeletal SNA () SNB () ANB () Vertical Skeletal SN-MP () Na-Me (mm) S-Go (mm) ANS-Me (mm) Co-Go (mm) Ar-Go (mm) Gonial Angle () S-Go/Na-Me -0.284* -0.233 -0.006 0.398** 0.244 -0.037 0.191 -0.095 -0.278 0.060 -0.289* Significance 0.046 0.103 0.966 0.004 0.088 0.8 0.184 0.51 0.051 0.681 0.042

** Correlation was significant at the 0.01 level (2-tailed). * Correlation was significant at the 0.05 level (2-tailed).

41

Table 3.8: Correlations between True Rotation and T1-T2 Changes in Skeletal Variables True Rotation Pearson Correlation AP Dental U1-SN () U1-PP () IMPA (L1-MP) () Overjet (mm) Vertical Dental Overbite (mm) ANS-Pr (mm) In-Me (mm) ANS-Pr + In-Me (mm) U1-PP (mm) L1-MP (mm) U6-PP (mm) L6-MP (mm) -0.339* -0.360* 0.042 0.043 0.213 0.264 0.360* -0.413** 0.241 0.219 0.136 -0.110 Significance 0.016 0.010 0.774 0.769 0.138 0.064 0.010 0.003 0.092 0.126 0.345 0.449

** Correlation was significant at the 0.01 level (2-tailed). * Correlation was significant at the 0.05 level (2-tailed)

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Discussion The mandible underwent substantial true rotation during the transition from late primary to early mixed dentition. There was almost -2.5 degrees of true forward rotation between T1 and T2, which amounts to approximately -1.1 deg/yr. This is similar to the 1.3 deg/yr (age 5.7-8.4) reported by Wang et al,5 the -1.3 deg/yr (age 5-10) reported by Miller and Kerr4 and the -0.9 deg/yr (age 6-11) reported by Spady.23 The high rates of true rotation that occur during this transition explain why previous studies have reported greater amounts of true rotation during childhood than adolescence. 4-5, 23 The rates of the true rotation during adolescence were lower, as -0.8 deg/yr (age 8.4-15.4) by Wang,5 -0.8 deg/yr (age 10-15) by Miller and Kerr4 and -0.4 deg/yr (age 11-15) by Spady.22 True rotation occurred regardless of genders or Classes because the group differences seem to be too small to detect with the sample size of the current research. The remodeling that occurred along the lower mandible border "covered up" the true rotation that occurred, resulting in little change of the mandibular plane angle. The current study showed approximately 1.9 degrees of remodeling and -0.6 degrees of apparent rotation. Greater amounts of remodeling than apparent rotation have been previously reported, both during the transition from late primary to early mixed dentitions,
4-5

during childhood,4-5 and during adolescence.23 As described by Bjrk and Skieller,8

true forward rotation is associated with substantial amounts of resorption at the posterior aspect of the lower border of the mandible and deposition on the anterior aspect. True forward rotation indicates that there was more inferior displacement of the posterior than anterior mandible. In fact, there was a significant correlation between true mandibular rotation and S-Go/Na-Me. However, the absolute growth changes in anterior

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face height (Na-Me) were more than the increases in posterior facial height (S-Go). This discrepancy can be explained by the relatively large amounts of resorption that occurs at the gonial angle, which cause posterior facial height measurements based on landmarks such as a gonion (S-Go or Co-Go) to be underestimated. Using mandibular superimpositions, Buschang and Gandini showed that over 40% of the growth at condylion between 10-15 years of age was negated by resorption at gonion. 2 Moreover, the increase in anterior facial height was partially due to deposition at menton, suggesting that the distance N-Me overestimated the actual amount of displacements. The upper and lower permanent incisors were tipped significantly more labially than the deciduous incisors. U1-SN, U1-PP and IMPA all increased significantly over time. The proclination of the upper incisors, which was significantly greater than the lower incisors, was probably due to the size differences of the primary and permanent crowns, especially of central incisor, amounting to approximately 2 mm.24 They compensated for this size discrepancy by proclining, which explains the increases in arch depth that has been associated with the eruption of the permanent incisors. 25 Bjrk argued that the forward shift of the whole dental arch in relation to the jaw base occurs with forward tipping of incisors as the essential feature of compensatory adaptation to forward rotation.1, 7 Proclination of the lower incisors had been previously related to forward mandibular rotation,7 presumably as a compensation to its displacement with forward mandibular rotation. The proclination of the upper incisors that occurred during the transition was directly related to true forward rotation. The subjects who underwent the greatest rotation also showed the greatest proclination. Wang and coworkers also showed that true

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mandibular rotation during adolescence was associated with maxillary incisor proclination.26 Greater amounts of upper incisor proclination might be expected to eliminate contacts and create more space for the mandible to rotate forward. Apparently, the changes in overjet and overbite from T1 to T2 are masked by the larger size of permanent incisors so that they do not reflect the space required for the forward rotation. Anterior alveolar height decreased significantly during the transition between the late primary and early mixed dentition. ANS-Pr and In-Me decreased a total of 7.1 mm between 5.8 and 8.0 years of age. Buschang and coworkers showed that anterior upper alveolar height, which also showed a greater decrease during the transition of the dentition than lower alveolar height, attained over 100% of its adult size at 5.5 years of age, and decreased to approximately 80% of its adult size during the transition.21 This decrease in height is probably a compensation for the larger crown height of permanent incisors. Interestingly, there was no significant change in the distance U1-PP over the 2.2 years, indicating that the space created between the upper and lower jaws (ANS increased 2.5 mm) was partially occupied by large permanent crown. On the other hand, L1-MP actually increased significantly during the transition from T1 to T2. The overall increases in lower facial height were primarily accounted by the increases in lower incisors to mandibular plane (L1-MP) observed. Importantly, the decreases in anterior alveolar height were also directly correlated with true forward rotation. Of all the dental variables evaluated, the decreases in overall alveolar height, which included both upper and lower alveolar height, was most closely associated with true mandibular rotation. However, the decreases in upper alveolar heights were more closely associated with true rotation than decreases in lower alveolar

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height. Wang et al. reported a low, but significant correlation (r=0.250) between true forward mandibular rotation and the decrease in ANS-Pr.25 Bjrk argued that Type III rotation, the center of which is located at the most distally occluding molars, was related to large overjet,1 suggesting that existing or space created in the anterior segment allows the mandible to rotate forward. Between approximately 6 to 8 years of age, the upper and lower deciduous central and lateral incisors are lost and the permanent incisors erupt. Importantly, up to 4 years are required for the central incisors to attain 100 % of their clinical crown height.27 More specifically, it takes 3.0 to 3.5 months for the upper and lower permanent central incisors to erupt 50% of their respective intraoral heights, 6.0-7.5 months to erupt 70%, and 19 months to erupt 90%.27 This may provide more than enough time for forward rotation to occur while there are space in the anterior alveolar region. Vertical skeletal growth was not related to the true rotation that occurred. According to Bjrk, forward rotation takes place as a result of marked increase in ramus height and normal increase in anterior face height. 1 However, the present study showed that rotation was not significantly correlated with growth changes of S-Go, Co-Go, or ArGo. In other words, individuals with greater forward rotation did not exhibit greater amounts of posterior growth. Enlow suggested, as vertical growth continues, ramus remodeling takes place such as resorption along the posterior border of the mandible. 28 Later, Hans et al. called this remodeling pattern as vertical variation, which would result in closure of the gonial angle with an increase in vertical ramus height. 29 In addition, they mentioned another remodeling pattern named rotation variation which took place in 7 out of their 30 cases, also characterizing resorption along the inferior border of the ramus,

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with rotation of ramus in a pronounced superior-anterior direction.29 Interestingly enough, even though the sample size was not large enough, 4 out of the 7 cases of this rotation variation were observed at age six.29 Therefore, as previously suggested, it is possible that this resorption along the posterior border of the mandible negated some of the vertical growth that occurred during the transitional period. Finally, the forward growth of maxilla was also correlated with true forward rotation. The subjects who showed greater increases in SNA also showed greater increases in true rotation. Wang and coworkers also found a significant correlation (r=0.376) between true forward rotation and the increase in SNA between 8.4 and 15.4 years of age, but not during the transition.25 Importantly, the increases in SNA were not correlated to proclination of the upper incisors. This may suggest that the more that the maxilla was displaced anteriorly, the more true rotation takes place. In fact, as described earlier, Bjrk argued that forward rotation of the mandible takes place when space, exists in anterior region, which moves the center of rotation posteriorly towards the occluding molars.1 In other words, the space created by the forward displacement of the maxilla contributed to true rotation of mandible. The findings might suggest a few things clinically. First, true mandibular rotation was significantly correlated with the decrease in lower anterior alveolar height during the transition. It has been known that the curve of Spee is minimal in deciduous dentition, and its depth increases significantly corresponding to the eruption of the mandibular permanent first molars and central incisors.30 If the permanent lower incisors erupt more than usual and lower anterior alveolar height increases with the incisors, the curve of Spee will deepen. Therefore, it might be better to prevent excessive eruption of lower

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incisors in growing individuals, not only to avoid deep overbite, but also to enhance forward rotation of mandible. Second, the proclination of the upper incisors was correlated to true forward rotation during the transition. If the eruption path of permanent incisors is directed lingually, it might be better to tip them labially as they erupt in order to allow space for mandible to rotate forward.

Conclusions 1. Great amounts of true mandibular forward rotation of mandible took place during the transition from late primary to early mixed dentition, which was largely masked by remodeling along the lower border. 2. There were no significant differences in true mandibular rotation, remodeling and apparent rotation between males and females, or between subjects with Class I and Class II occlusion. 3. True mandibular rotation was significantly associated with the decrease in anterior alveolar height, increases in SNA, and proclination of the upper incisors, all of which could have created space for mandible to rotate forward. 4. True mandibular rotation was not significantly associated with the increases in posterior face height.

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VITA AUCTORIS Hiroshi Ueno was born on February 22, 1981 in Nishinomiya, Hyogo, Japan. At the age of six, he moved to Yokohama, Kanagawa, where his parents currently reside. He attended Tohoku University, Sendai, Miyagi, graduating in 2006. After he finished the mandatory residency at Nagoya University hospital, Nagoyo, and worked as general dentist in Japan, he started the orthodontic program at Saint Louis University.

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