Mandibular rotations

Submitted by-
Dr. Maitreye Priyadarshini
PG 1st YEAR
 Introduction to growth
rotations
• As the craniofacial region grows, many intricate events
occur within and outside the mandible to maintain its
structural integrity and function.
• As facial bones grow they cause downward and
backward rotation of the mandible.
• This is compensated by ramus growth and internal
remodelling within the corpus.
• A critical factor deciding the type of rotation and the
clinical effects thereof is the centre of rotation,which
may be located at the condyle the incisors or any place.
• in between.
• According to Bjork, 'from the standpoint of growth, the
mandible may be regarded as a more or less
unconstrained bone, for it may change its inclination in
several ways'.
• Rotation of the mandible occurs as a result of interaction
between growth at the condyles and surface remodelling
of the various areas of the mandible.
• Variation of up to 45 degrees has been documented.
• Arne Bjork, who through implant studies provided
significant insights into growth rotations of the mandible.
Lateral cephalometric radiograph from the archives of Björk's
implant studies, showing a subject with six maxillary and five
mandibular tantalum implants
 Implant Studies of Jaw Rotation
• This method of study was developed by Professor Arne Björk
and coworkers at the Royal Dental College in Copenhagen.
• In this technique, inert metal pins are placed in bones
anywhere in the skeleton, including the face and jaws.
• These metal pins are well tolerated by the skeleton, become
permanently incorporated into the bone without causing any
problems, and are easily visualized on a cephalogram with
considerable increase in the accuracy of a longitudinal
cephalometric analysis.
• It provided important new information about the growth
pattern of the jaws.
• Now, precise evaluation of dentofacial growth in humans
using implant cephalograms has largely been superseded by
3-D imaging via computed tomography (CT) or MRI.
Terminology: Rotational Changes of the Jaws
 Mechanism of mandibular rotations
• It is easier to visualize the internal and external rotation of the jaws by
considering the mandible first.
• The core of the mandible is the bone that surrounds the inferior alveolar
nerve.
• Rest parts are are the alveolar process (bone supporting the teeth and
providing for mastication), the muscular processes (the bone to which
muscles of mastication attach), and the condylar process, the function in
this case being the articulation of the jaw with the skull.
• In most individuals, the core of the mandible rotates during growth in a
way that would tend to decrease the mandibular plane angle (i.e., up
anteriorly and down posteriorly).
• By convention, the rotation of either jaw is considered “forward” and
given a negative sign if there is more growth posteriorly than anteriorly.
• The rotation is “backward” and given a positive direction if it lengthens
anterior dimensions more than posterior ones.
FIGURE- Mandibular anatomy determining
internal and external rotations
Types of mandibular rotations
• It can be of following types:
• Forward rotation.- is characterised by clockwise
rotation of the mandible. It can be of three types.
• Backward rotation.- is characterised by
downward and clockwise movement of the
mandible. It can be of two types.
 Forward rotations
• Type I-
The centre of rotation resides at the
temporomandibular joint.
With mandible rotation, the condyles and the lower
incisors move superiorly giving rise to deep bite with
concomitant under development of the lower anterior
face height.
Individuals with an extreme pattern of this type
have characteristic facial features such as reduced depth
of the antegonial notch, a brachycephalic head type,
anterior deep bite and strong muscular pattern of the
face.
• Type II-
The nature of the mandibular growth is such that the centre of
rotation gets located at the incisal edges of the lower anterior teeth.
This occurs when posterior face height increases
disproportionately in relation to anterior face height.
This may occur under following conditions:
(1) inferior relocation of the middle cranial fossa and
(2) disproportionate increase in the ramus height.
(3) May also be lack of tooth eruption like primary failure of
eruption may lead to cessation of posterior tooth
contact.
(4) Excessive loading of masticatory forces leads
to wearing away of the anterior teeth, thus resulting in
loss of anterior face height and forward rotation
• Type III -
Wherein the centre of rotation lies between the
condyle and incisor edge.
Subjects with large anterior overjet will fall in this
category.
In such cases, the centre of rotation is displaced
backwards to the level of the premolars presenting with
basal anterior deep bite.
In type II and III rotators, the mandibular symphysis
tlpically swings forward to reveal a characteristically
prominent chin.
Growth rotation in the mandible - FORWARD ROTATION
(A)Forward rotation with the centre located at the joints,
(B)Forward rotation with centre located at the incisors
(c) Forward rotation with the centre located at the premolars
Backward rotations
• Type I-
The centre of rotation lies at the
temporomandibular joint.
Such rotations may be seen when the
middle cranial fossa does not develop adequately or
when bite-raising appliances are given.
It results in increase in anterior face height.
The mandible is mostly normal in size.
• Type II
Here the centre of rotation lies at the most distal
occluding molars. Seen when condylar cartilage shows
less growth than the rest of the structures leading to
smaller vertical height of the ramus.
This pattern leads to rotation of the chin
downwards and backwards making it less prominent.
The soft tissues of the chin may not follow, resulting
in the characteristic double chin.
The lower incisors become retroclined over the
base.
Such cases are especially prone to development of
anterior open bite, which is difficult to correct
orthodontically.
(A ) Backward rotation with the centre located at the joints (B) Backward
rotation with the centre located at the last occlufing molars.
 Internal mandibular rotation
• The internal rotation is analogous to the rotation within
the body of the mandible.

Figure-Internal rotation of
the mandible (i.e., rotation of
the core relative
to the cranial base) has two
components: A, Rotation
around the condyle, or
matrix rotation. B, Rotations
centered within the body of
the mandible, or
intramatrix rotation.
External mandibular rotation

FIGURE-
External rotation
compensates for and
conceals the extent of the
internal rotation.

Figure-
Matrix versus intra-matrix
rotation
• Relocation of the mandible occurs to maintain occlusion
and harmony with the growing upper face.
• In order to compensate the demand of the growth,
descent of the upper face and dentition, the mandible
undergoes several changes.
• Rotation of the mandible at its condyles is called matrix
rotation
• Rotation within the mandible itself is termed as
intrmatrix rotation.
• The overall effect being total rotation of the mandible as
a whole.
There are areas of reference around which rotations occur.
A few locations or areas within the mandible that are
relatively stable include
a) the mandibular canal,
b) inferior margins of developing third molar
tooth buds before initiation of root formation,
c) of the inferior surface of the symphysis.
d) The anterior aspect of the chin (the
radiographic pogonion area) is considered extremely
stable, with surface changes seen at the bony contours
both above and below it.
• Matrix rotation

occurs when the whole mandible rotates

with the condyle as the centre.
This rotation takes place in the form of an arc.
Is seen when bite opening is facilitated by
dental eruption or when excessive vertical maxillary
growth rotates the mandible downwards.
• lntra-matrix rotation
Intra-matrix rotation occurs within the mandibular
corpus (i.e. the body of the mandible) leading to surface
remodelling of the corpus.
It contributes to development of the angle of the
ramus, prominence of the chin and development of the
antegonial notch.
This type of remodelling may be extremely evident
in cases where posterior teeth fail to erupt and the
centre of rotation shifts to the incisor region.
In such cases,the inferior border of the ramus
becomes convex and prominent with loss of the
antegonial notch.
Total rotation of mandible
• Total rotation of the mandible is the sum of matrix
and intra-matrix rotation, which occur in varying
intensity and amount.
• The two types of rotations may occur in the same
direction complementing each other or may occur
in opposite directions negating each other's effect.
• In most instances, intra-matrix rotation accounts for
most of total rotation, although there is great
variability.
Effect of mandibular rotation on occlusion

• Both types of rotation patterns affect teeth

positioning in both the arches.-
a) In forward rotations
1. the inter-premolar and inter-molar angles are
larger, leading to posterior teeth being more
upright on the jaw base.
2. The lower anterior teeth are also guided
forward resulting in alveolar prognathism.
3. Since all mandibular teeth show mesial
migration of the mandibular base, the lower
incisors have a tendency to show crowding, which
is called 'packing.'
 b) Backward rotation,
1. the inter-premolar and inter-molar angles are small.
2. The premolars and molars are inclined forward in
relation to the maxillary bases,
3. The lower teeth also tend to become more upright
on the jaw bases,
4. leads to alveolar prognathism and
5. increased incisor crowding.
 Effect of mandibular rotations
on facial height development
• Differences in anterior facial height have been generalized to result
from two different types of mandibular rotation by Bjork and
Skeiller.
• The differences impact the vertical and sagittal dimensions.
• Forward mandibular rotation tends to allow more horizontal
expression of mandibular growth, thus
1. improving a Class II correction, and
2. results in a normal to decreased anterior vertical dimension.
• Backward mandibular rotation expresses mandibular growth in a
more vertical direction, thus
1. compromises Class II correction and
2. increases the chance of the patient developing a long face or
an open bite malocclusion.
Figure
Interaction Between Jaw Rotation and
Tooth Eruption
• Growth of the mandible away from the maxilla creates a space into
which the teeth erupt.
• The eruption path of mandibular teeth is upward and somewhat
forward.
• The normal internal rotation of the mandible carries the jaw
upward in front. This rotation alters the eruption path of the
incisors more posteriorly.
• Because the internal jaw rotation tends to upright the incisors, the
molars migrate further mesially during growth than do the incisors,
and this migration is reflected in the decrease in arch length that
normally occurs.
• Since the forward internal rotation of the mandible is greater than
that of the maxilla, the normal decrease in mandibular arch length
is somewhat greater than the decrease in maxillary arch length.
As the mandible rotates upward and forward, the vertical
overlap of the teeth tends to increase, creating a deep bite malocclusion.
Lingual displacement of incisors relative to the maxilla and mandible
increases the tendency toward crowding
Superimposition on mandibular implants shows the lingual
positioning of the mandibular incisors relative to the mandible
that often accompanies forward rotation during growth.
 Mandibular rotation during
adulthood
• The magnitude of the adult growth changes assessed on a
millimeters per year basis is quite small.
• Rotation of both jaws continues into adult life, in concert
with the vertical changes and eruption of teeth.
• The males show a net rotation of the jaws in a forward
direction, slightly decreasing the mandibular plane angle
• Whereas females have a tendency toward backward
rotation, with an increase in the mandibular plane angle.
• In both groups, compensatory changes occur in the
dentition, so that occlusal relationships largely are
maintained.
Late mandibular rotation and mandibular
incisor crowding.
• When the mandible grows forward relative to the maxilla
, as it usually does in the late teens, the mandibular incisor
teeth tend to be displaced lingually, particularly if forward
rotation is also present (as it would be in short face
individuals).

• This can be seen most clearly when the mandibular growth

is excessive.
Assessing rotational growth
• Rotational growth of the mandible can be assessed by
observing the following anatomic landmarks on a lateral
cephalogram:
• 1. Inclination of the condylar head
• 2. Cuwature of the mandibular canal
• 3. Shape of the lower border of the mandible
• 4. Inclination of the symphysis
• 5. Inter-incisal angle
• 5. Inter-premolar or inter-molar angles
• 7. Lower anterior face height.
Orthodontic problems due to excessive
mandibular growth rotations
Short face / deep bite
Skeletal vertical deficiency (short face),
An anterior deep bite
Degree of mandibular deficiency
Ofter accompanied with everted and prominent lips.
They tend to have a low mandibular plane angle (skeletal deep
bite) and a long mandibular ramus.
Growth is expressed in an anterior direction, with a tendency
toward upward and forward rotation of the mandible.
The challenge in correcting these problems is to increase
eruption of posterior teeth and influence the mandible to
rotate downward without decreasing chin prominence too
much.
 Short face pattern
Occurs due to excessive forward rotation of
mandible

SHORT ANTERIOR LOWER FACIAL HEIGHT

1. Horizontal palatal plane

2. Deep bite and crowding
[Link] jaw
4. Square gonial angle
Excessive forward rotation may be due to:
A. Increase in internal rotation
B. Decrease in external rotation
 Long face/ open bite

• If the maxilla moves downward, the mandible rotates

downward and backward.
• The effect is to prevent mandibular growth from being
expressed anteriorly.
 Long face pattern
Occurs due to excessive backward rotation of
mandible

INCREASED ANTERIOR LOWER FACIAL HEIGHT

1. Anterior open bite

2. Palatal plane rotates down posteriorly
3. Mandibular deficiency
4. Increased lower anterior facial height
Excessive backward rotation may be due to:
A. Lack of normal internal rotation
B. Backward internal rotation rotation
Effect of orthodontic treatments
on mandibular rotations
Acrylic splint used for treatment
of deep bite
• The acrylic splint placed on either the right or left
mandibular second premolar and first molar, leads
consistently to following changes in rotation
pattern:
• -In all treated cases there is frontal plane upward
rotation of the condyle contralateral to the
interference;
- In 58% of cases there horizontal plane backward
rotation of the condyle ipsilateral to the interference.
• Despite treatment of deepbite being difficult, placement of
a splint along with fixed orthodontic treatment can lead to
forward mandibular rotation.
• As a result the pretreatment deepbite gets reduced.
• In due time desired over jet can be achieved.
• This can help if the orthodontist and patient don't want
orthognathic surgery performed on the patient.
Figure: showing rotation of mandible due to splint
placed on left side of a patient during a study.
It was determined that wearing of splint leads to
forward rotation of mandible
Figure:Lateral cephalogram of patient before (left)
and after(right) orthodontic treatment including
usage of splint for treating deepbite.
 Molar extrusion
• In the case of short-faced patients, posterior
extrusion leads to opening rotation of the mandible
and, consequently, the lower facial height is
increased.
Figure: Post treatment mandibular rotation due to chin
cup application.
Myofunctional appliances for
correcting open bite
• In correcting skeletal open bite problems, intraoral
appliances, such as activators, bionators, Frankel
TM regulators (most with the inclusion of
posterior biteblocks), have been used to control
vertical maxillary growth of the mixed dentition.
• On the other hand, with functional appliances,
forward and upward rotation of the mandible was
noted with the center of rotation at the premolars.
• Due to forward and upward rotation of mandible in
relation to maxilla the molar relation becomes class I and
the existing open bite decreases.
• If used properly in the mixed dentition period along with
the bite planes it is seen that desirable over bite can be
achieved.
• Thus myofunctional appliances can be used intraorally to
attain reduced facial height due to backward rotation of
mandible.
Figure: showing forward rotation of mandible due to
myofunctional appliance use.
Figure: change in overjet and overbite to achieve desired
effect(red).
Figure: pre treatment and post treatment lateral
cephalogram showing change in mandibular rotation
pattern to attain desired treatment result after the use of
activator
• When are myofunctional appliances useful in treating
mandibular rotations:
-useful in treating patient with openbite.
- in treating patients with skeletal class III due to
backward rotation of mandible.
- must be used before skeletal growth is completed i.e.
during mixed dention period.
- to counteract negative affect of tongue thrusting habit.
Bimler functional appliance
• It stimulates a favourable mandibular rotation leading
to correction of skeletal open bite .
• There is seen a reduction in the values of the
GoGN/SN and the Inferior Gonial angles after the
treatment.
• The functional appliance can counteract that
negative effect by positioning the tip of the tongue
on the incisive papilla, permitting the dorsum of
the tongue to displace backward, relaxing the
hyoglossus muscle and reducing the traction on the
hyoid bone.
 Effect of habit breaking appliances
on mandibular rotations
• In open bite patients, the tongue at rest tends to
be positioned between the upper and lower incisors
and thrusting forward on swallowing.
• When the tongue’s tip is positioned between the
maxillary and mandibular incisors teeth, the dorsum
of the tongue is moved upward and forward.
• That pulls the hyoid bone upward and backward
because the hyoglossus muscle has to contract.
• A backward position of the hyoid bone stretches
the anterior digastrics and the geniohyoid muscles
pulling the mandibular symphysis down and
backward.
• That stimulates the mandibular body to rotate in a
clockwise direction thus helping in improving open
bite in patients with skeletal malocclusion.
• These appliances also tend to improve the duration of
treatment and retention of treatment over a longer
period of time.
Figure:
Active vertical corrector (AVC)
• A removable or fixed appliance that intrudes the
posterior teeth in both the maxilla and mandible by
reciprocal forces.
• This appliance reportedly corrects open bites by
actually reducing anterior facial height.
• Arat and Iseri compared fixed appliance treatment
with functional treatment to correct open bite. During
fixed appliance therapy, marked increases in the
maxillary and mandibular posterior dentoalveolar
height were observed, and the mandible rotated
backwards.
Figure: AVC can cause backward rotation of the
mandible thus leading to reduction of anterior facial
height thereby decreasing open bite.
Effect of extraoral appliances on
mandibular rotations
• Chin cup
The backward and downward rotation of the
mandible is correlated with an increase in the ANB
angle
The anterior facial height ,
The mandibular plane angle (SN-MP) and
The FMA were significantly increased,
Whereas the gonial angle was significantly
decreased.
• The tendency towards increase of the anterior face
height is further supported by the statistically
significant increase of the linear variable N-Me
according to the exploratory analysis performed.
• There is statistically significant reduction of the variable
SNB indicates a restriction effect on the mandibular
growth of growing patients and/or an intense clockwise
rotational effect
• Chin cup increases a tendency towards a backward
and downward rotation of the mandible.
Figure: chin cup
Conclusion
• It is very important to recognise the type of
mandibular rotation.
• This can help the orthodontists in providing an
early intervention to the developing jaws thus
preventing future skeletal and dental problems.
• Identifying appropriate mandibular growth
rotations can also help in determining proper
appliances needed for the treatment of
malocclusion.
References:
1. Graber TM: Orthodontics -current principles &
techniques , Elsevier , 6th edition.
2.
Profitt , contemporary orthodontics, Elsevier, 5th
edition.

3. E. Moyers, handbook of orthodontics, 4th

4. Graber
edition TM:book
, year Principles andpublishers
medical practice orthodontics,
, inc, 1988.
WB Saunders.
5. Bishara Textbook of orthodontics, WB Saunders.

6. O.P. Kharbanda Diagnosis and Management of

• Treatment of Anterior Open Bite with the Bimler Functional
Appliance: Report of Three Cases Ramirez-Yañez , Mahony
and Bimler
• Mandibular Rotation and Angular Remodeling During
Childhood and Adolescence M. SPADY,l P.H. BUSCHANG, A.
UEMIRJIAN, AND L. LAPALME
• Prediction of mandibular growth rotation: Assessment of the
Skieller, Björk, and Linde-Hansen method
• Molar occlusion and mandibular rotation: A longitudinal
study Ilana Brin, D.M.D.,* Mary Beth Kelley, D.M.D.,** James
L. Ackerman, D.D.S.,*** and Paul A. Green,
• Skeletal and dental changes after lower posterior tooth
extrusion in Class II Division 1 deep bite short-faced growing
patients Pornpan Jariyavithayakul, Chairat Charoemratrote
• Open bite: a review of etiology and managementPeter
Ngan, DMD Henry W. Fields, DDS, MS, MSD
• Class II Division 2 deep bite treatment using a combination
of fixed orthodontic appliances and an acrylic splint Johan
Christian Julyan1 and Marius Coetsee
• Experimental occlusal interferences. Part III. Mandibular «-
rotations induced by a rigid interference ^N.M. RASSOULI &
L.V. CHRISTENSEN Marquette University, School of Dentistry,
Milwaukee, Wisconsin
Thank you!