CONTENT

• Growth rotations of mandible.

• Direction of growth.
• Structural signs.
• Results of implants studies.
• Type of rotations.
a) Bjork and Skieller.
b) Proffit.
c) F.F. Schudy.
• Maxillary rotation
• Clinical implication
• Conclusion
• Rotation is the term used to describe the angular movement
of one rigid body relative to another.

• Until longitudinal studies of growth using metallic implants

in jaws were carried out, primarily by Bjork, the extent to
which both maxilla and mandible rotate during growth was
not appreciated.

• The term growth rotation was coined by Dr Arne Bjork in

1955
• Bjork did his study in 1951.

• He had sample size of 100 children between 4 -24

years.

• Used metal implants to find the site of growth and

resorption in individual jaws.
•Insertion of metallic implants (small pointed tantalum pins of 0.5x
1.5mm)under local anesthesia, with the help of a placement
instrument.

Instruments used for implant placement Tantalum pin

 Sites of implant placement
Mandibular implant placement:
[Link] pin in Anterior aspect of symphysis.
[Link] is placed under the first premolar, on the right‐hand
side beneath the root tips.
[Link] under the second premolar, on the right‐hand side be
neath the root tips.
4.A fourth pin is placed on the external aspect of
the ramus, on a level with the occlusal surfaces of the m
olars
Sites of implant placement
Based on superimpositions, Bjork identified primary and
secondary structures that do not change over time.

Primary Structures:
 Contour of the chin just below the pogonion.
 The inner contour of the cortical plate at the lower
border of the symphysis.
 Posteriorly, the contours of the inferior alveolar nerve
canals are stable throughout growth.

Secondary Structures: Before root development begins,

the lower contour of a mineralized tooth germ provides a
secondary structure.
 Mandibular growth rotation
• Mandibular growth rotations are more common
than maxillary rotations and thus are more
important.

• It affects facial morphology, treatment planning and

treatment outcome.
According to the type of rotation and the centre of
rotation the growth of the mandible can be divided into:

•Forward rotation
 Type I
 Type II
 Type III

•Backward rotation (less common)

Type I
Type II
Forward rotation:
Type - I
•Centre of rotation is in the
joint.
•Deep bite is seen.
•Decreased lower anterior facial
height.
•Powerful musculature is
usually seen
•May lead to occlusal imbalance
loss of teeth.
Forward rotation: Type - II
•Centre of rotation is at the incisal edges of the lower incisors.
•Increased posterior facial height with normal lower anterior facial
height.
•Mandibular symphysis swings forward.

Posterior facial height has 2

components:

•Lowering of middle cranial fossa

•Increase in height of ramus in

vertical growers
Forward rotation: Type - III
•In cases of increased overjet the centre of rotation is displaced to
the premolars.
•There is decreased lower facial height.
•Increased posterior facial height.
•Skeletal deep bite is seen.
•Mandibular symphysis swings forward.
Backward rotation: Type – I
•Centre of rotation at the joint.
•Seen in cases of:
Bite is raised by orthodontic treatment increasing the lower
anterior facial height.
Growth of cranial base occurs such that the cranial base
flexure flattens leading to the mandible being raised
posteriorly.
 Backward rotation: Type – II
•Centre of resistance is at the most distally occluding molar.
•Growth at the condyles is in the sagital direction.
•Mandible increases in length but is carried forward more due to
its muscles and ligaments attachments.

•Symphysis is swung backward,

chin goes below the face. The soft
tissues may not follow this leading
to a double chin.

•Skeletal open bite is seen.

•Incompetent lips.
Components of mandibular rotation
(Björk & Skieller 1983)

•The different patterns of mandibular rotation exhibited

by different individuals during growth can be more
readily understood if the rotation is divided into three
components.

 Total Rotation

Matrix Rotation

Intramatrix Rotation
Total Rotation
Total rotation is the rotation of the mandibular corpus and is
measured as change in inclination of a reference line, or an implant
line, in the mandibular corpus relative to the anterior cranial base.

When the implant line or reference line rotates forward relative

to the nasion‐sella line during growth, the total rotation is
designated as negative.
Matrix rotation
Matrix rotation expresses a rotation of the soft tissue matrix of the
mandible relative to the anterior cranial base.

It is recorded as negative when the tangential mandibular line

rotates forward relative to the nasion‐sella line.
The matrix sometimes rotates forwards and sometimes
backwards during the growth period, with the condyles as the
centre of rotation, described as a pendulum movement
Intramatrix Rotation
The change in inclination of an implant or
reference line in the mandibular corpus
relative to the tangential mandibular line
ML
 Direction of Growth

Mandible can have a forward direction of growth (good

growing) or backward direction of growth (bad growing).

Bjork gave seven structural signs to find the direction

of mandibular growth.

These signs are not clearly developed before puberty.

Structural Signs

1) Condylar inclination.
2) Mandibular canal inclination.
3) Lower border of mandible (Antigonial notch).
4) Symphysis inclination.
5) Interincisal inclination.
6) Intermolar angle.
7) Lower face height.
 Condylar inclination
• Forward or backward inclination of the condylar head
is characteristic sign
• In forward growing mandible condyle is upright
compared to a backward growing mandible in which
it is inclined backward.
 Mandibular canal
• The mandibular canal curvature remains the same
throughout the life.
• In vertical growing mandible the curvature of the
canal is more than that of the mandibular contour.
• Where as in case of horizontal growers the canal may
be flat or may even be curved in opposite direction.
 Shape of lower border of mandible
• In vertical growers there is an increased deposition
below the symphysis, anterior part of the mandible
becomes thick along with this there is resorption at
the angle producing a characteristic concavity.

• In horizontal growers the anterior rounding is absent

so the concavity of the lower border is absent.
 INCLINATION OF THE SYMPHYSIS

•In horizontal growers chin swings forward to become

prominent.
•In vertical growers symphysis is swung backward
causing a receding chin.
 INTERINCISAL ANGLE
•Interincisal angle is almost constant showing that the
lower incisors is related functionally to the upper incisors
•In vertical growers angle in less.
•In horizontal growers there is an increased interincisal
angle.
 Intermolar angle
• In case of forward rotation the molars get more upright
increasing the intermolar and interpremolar angle.
• While in case of backward rotation the molars become
mesially tipped hence decreasing the intermolar and
interpremolar angle.
 LOWER FACE HEIGHT
It is increased in case of vertical growth pattern.
It is less in case of a horizontal growth pattern.
 PROFFIT
• Rotation occurring in the core of the jaw were called
INTERNAL ROTATION. Hence is the rotation which is
visualized by the implant line. (This is the rotation in the
mandibular core proper or total rotation according to
Bjork).
• Rotation caused by the surface changes and the
alteration in the rate of tooth eruption is called as
EXTERNAL ROTATION. (this is the remodeling that is
occurring in the mandible or intramatrix rotation
according to Bjork).
• Rotation occurring due to rotation around the condyle is
called as TOTAL ROTATION. (This is the rotation of
the mandible that is occurring around the condyles or
matrix rotation according to Bjork)
 CONDITION BJORK PROFFIT

Rotation of mandibular Total rotation Internal rotation

core relative to cranial
base
Rotation of mandibular Matrix rotation Total rotation
plane relative to cranial
base
Rotation of mandibular Intramatrix rotation External rotation
plane relative to core of
mandible

TOTAL ROTATION: internal rotation- external rotation

 F F Schudy
• Rotation of the mandible is a result of in-harmony
between vertical growth, antero-posterior growth and
horizontal growth.

• Clockwise rotation is a result of increased vertical growth

causing a decrease in bite.

• Counter-clockwise rotation is a result of decreased

vertical growth causing a deep bite.
•Growth increments causing downward movement of
chin is called as vertical growth, while growth
increments causing forward movement of chin are called
as horizontal growth.

•If growth at the condyles is more than molar eruption it

causes horizontal growth deepening the bite.

•If growth at the condyles is less then molar eruption is

leads to vertical growth and a decreased bite.
• There are four vertical growth elements which
increase the facial height, these are:-

 Anterior growth of nasion.

 Corpus of maxilla getting palatal plane down.

 Eruption of maxillary molars.

 Eruption of mandibular molars.

Growth rotation in maxilla
 Maxillary Implant placement

1. At 4 years of age tantalum pins were inserted in the

zygomatic process of the maxilla, two on each side.

2. After full eruption of the permanent incisors (10‐11 y),

pins were inserted into the anterior aspect of the
maxilla, below the anterior nasal spine, one on each
side of the median suture.

3. Hard Palate: Behind canines: In front of the first molar

in the junction between alveolar process and palate.
Growth of maxilla occurs by two ways:
Passive displacement - In primary dentition period.
Active growth is by surface remodeling.
The maxilla can be divided into:

•It’s functional process

Alveolar process
Parts of bone surrounding the air passage
•Core of it’s bone
 Mechanism of rotations

Displacement type.

Remodeling type.

Maxillary Rotation

Displacement Remodelling
 Displacement
• Primary
The whole nasomaxillary complex is displaced
in conjunction with its own growth.

• Secondary
Result from growth of other bones and soft
tissues.
Primary displacement occurs in anterio-inferior
direction.
•Sutures are tension adapted-cannot grow by pushing-
apart.
•Stimulus for sutural remodeling is due to the
displacement.
Secondary displacement
•The balance between greater and lesser amounts of
remodeling in the posterior & anterior parts of the
maxilla is the response to clockwise/ counterclockwise
rotatory displacement of middle cranial fossa.

•Compensatory remodeling rotation of the

nasomaxillary complex- sustains its proper position
relative to the neutral orbital axis.

•Remodeling also occurs as bones assume new positions

with expansion of the soft tissue matrix.
•Implants placed on maxillary alveolar process show that
the core of the maxilla undergoes a small and variable
degree of rotation- forward and backward – INTERNAL
ROTATION.

•TOTAL ROTATION and MATRIX ROTATION not

possible in a maxilla (condyle).
•Varying degree of resorption on nasal side and
deposition on palatal side, also varying amount of
eruption of incisors and molars lead to EXTERNAL
ROTATION, INTRAMATRIX ROTATION.

•In most individuals the external and internal rotations

cancel each other.
 Bjork and Skeiller
They observed:
• Forward rotation
• Backward rotation
• Short face /forward rotation
• Increase in internal rotation and decrease in external
compensation.
• Horizontal palatal plane.
• Low mandibular plane angle.
• Deep bite.
• Crowded incisors.
• Long face\ backward rotation
• Excessive lower anterior facial height.
• Palatal plane rotates down posteriorly.
• Increase in mandibular plane angle.
• Open bite malocclusion and mandibular deficiency.
 Growth rotation and treatment outcome
• Patients with short lower face heights, the so-called
forward rotators, should be started with early treatment
and the anterior occlusion maintained with a bite plane.
• These patients are at risk for developing a deep
overbite and lower crowding.
• Avoid extractions in short lower facial height patients.
• Procline incisors and prevent the overbite from
deepening.
• Don’t base extraction decision solely on crowding.
• Maxillary premolar extraction treatment to resolve a
Class II malocclusion should never be done prior to
cessation of mandibular growth as determined by a hand
wrist radiograph.

• If mandibular growth continues it may be impossible to

close the extraction sites, and crowding of the lower
incisors during or after retention will follow.

• Long lower face patients with crowding often need four

premolar extractions to leave the incisors more upright
on the mandible. If treated non-extraction we will likely
see the lower anteriors tip lingually and crowd after
treatment.
• Patients with a strong backward rotation and open
bite should not be treated until growth has ceased.

• They will often require surgery to produce any

improvement in their skeletal balance, and treatment
during growth may compromise the benefits.

• Functional appliances lead to opening of mandibular

plane angle hence are contraindicated.
MUTUAL RELATIONSHIP BETWEEN ROTATING
JAW BASES
• Rotation of mandible decides the vertical proportions
of the face.
• Horizontal growers have a:
– Short lower anterior facial height.
– Predisposed to having a deep bite.
• Opposite of above for the vertical growers.
According to Lavergne and Gasson the mutual rotation
of the upper and lower jaw can be of following 4 types:

1. Convergent rotation.
oSevere deep bite.
oDifficult to treat with a functional therapy.

2. Divergent jaw bases.

oSevere open bite.
oIn severe cases orthognathic surgery is required.
3. Cranial rotation of both the bases
o Horizontal growth pattern.
o Maxillary cranial rotation compensates for mandibular
rotation.
o Normal overbite.

4. Caudal rotation of both the bases

o Vertical growth pattern.
o Maxillary caudal rotation compensates for mandibular
rotation.
o Normal overbite.
 CONCLUSION

• The ability of an orthodontist to predict future

mandibular growth would greatly aid in the diagnosis
and treatment planning.

• Better therapeutic decisions could be made regarding

timing and length of the treatment, appliance
selection, extraction pattern and possible need for
surgery.