Growth patterns in subjects with long and short faces

Surender K. Nanda, DMD, MS Ann Arbor, Michigan The purpose of this study was to assess skeletal factors associated with the development of vertical facial disproportions. Angular measurements based on longitudinal lateral cephalometric radiographs of 16 male and 16 female subjects, from the ages of 4 through 18 years, were used. Subjects were selected on the basis of lower face height (ANS-Me) as a percentage of morphologic face height (N-Me). A single x-ray photograph at age 15 for the boys and 13.5 for the girls was used to classify each subject's occlusion as either open-bite or deep-bite. Sella-nasion/palatal plane, selia-nasion/mandibular plane, sella-nasion/anatomic occlusal plane, palatal plane/mandibular plane, and cranial base angle were analyzed statistically and graphically. It was found that (1) with the exception of sella-nasion/palatal plane and cranial base angles, all angular measurements demonstrated a progressive reduction throughout development in both open bites and deep bites; (2) the palatomandibular angle discriminated between open bites and deep bites throughout the developmental phase; (3) within each sex, typologic differences were evident in all angular measurements, with the exception of cranial base and occlusal plane; and (4) the cranial base angle demonstrated clear sexual dimorphism, and its magnitude was not associated with vertical dysplasia. The progressive reduction of angles in skeletal open bite reduced or maintained the magnitude of the imbalances, while the reduction of angles accentuated the skeletal deep bite with age. The inclination of the palatal plane and its constancy suggested that downward and backward rotation of the mandible in open bite subjects is precommitted in response to dentoalveolar compensatory changes with the center of rotation at the molars. The magnitude of the mandibular plane angle is not adequate for assessment of diagnostic or prognostic predictive value in determining the pattern of growth. (AMJ ORTHODDENTOFACORTHOP 1990;98:247-58.)

T h e two most common types of vertical facial dysplasia are generally defined as hyperdivergent and hypodivergent, t'2 SchendeP described the former as "long face syndrome"; Opdebeeck4 named the latter "short face syndrome." As the names suggest, the hyperdivergent "long face" is characterized by a tendency toward a relatively large lower face, compared with the hypodivergent "short face." An earlier study,5 established that the components of anterior facial height have divergent patterns of skeletal development in open bite (long-face) and deep bite (short-face), while those of posterior facial height do not. The differences between these two extremes of facial height raise the possibility that there also may be recognizable relationships between the positions of the four basic horizontal craniofacial planes (cranial base, palatal plane, occlusal plane, and mandibular plane) in open-bite and deep-bite faces. As noted by several investigators, the horizontal facial planes tend to be steeper and more divergent in persons with large lower face height (open bite) than
From the Department of On!hodontics and Pediatric Dentistry, University of Michigan School of Dentistry 8l 1/ 15265

in deep-bite subjects with small lower face height whose facial planes are more parallel .6-,0 Several investigations have confirmed that the increased angle of the mandibular plane commonly found in persons with long faces is associated with a backward rotational growth pattern that can affect the vertical proportions of the anterior component of the face. 3.4.n'2z Indeed, it has been assumed by many investigators that extreme values of the mandibular plane angle are prognostic criteria for predicting the dimensions, proportions, and direction of facial growthJ However, Baumrind et al. 2~ and Skieller and Bjrrk 24 suggested that a high mandibular plane angle is not a good predictor of facial growth and that persons with high mandibular plane angles can have both backward and forward mandibular growth patterns. Numerous investigators have also indicated that an obtuse gonial angle is associated with skeletal open bite, while a relatively small angle is associated with deep b i t e . 3`4"8.n'16.tg"2:'z5"29 However, Bjrrk 6 did not find the gonial angle to be a discriminating factor between the two vertical extremes of facial type. Enlow3'3~ arrived at a different conclusion concerning the relationship of gonial angle to upper face and cranial base; he contended that the gonial angle undergoes a counterrotation
247

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Nanda

Am. J. Orthod.Dentofac.Orthop. September1990

Table IA. Comparison of lower face height as a percentage of total anterior face height for open-bite and deep-bite subjects (mean age: females, 13 years 6 months; males, 15 years)

LFHITAFH* (Males)
Facial lTpe
Open bite Deep bite

LFHITAFH (Females) I Range(%)

59.48-63.24 52.34-54.92

Mean(%)
60.65 53.61 height;

SD (%1
1.2 1.3

Mean(%)
59.67 53.27

SD (%)
2.4 1.2

Range(%)
57.62-62.03 48.27-55.45

*LPH, Lower facial

TAFH, total

anterior facial height.

Table lB. Comparison of mean values for lower face height as a percentage of total anterior face height in

studies by other researchers

I Facial type
Open bite Normal Deep bite

Fields and associates (%)

58.0 56.0 54.0

Subte/ny and Sakuda (%)

58.5 55.1 --

[ [

Hapak (%)
58.0 ---

during facial growth to compensate for the backward rotation of the mandible, resulting in a reduction of the gonial angle with age. On the other hand, Bjfrk and Skieller32 reported that ramal inclination does not change but maintains a constant relationship with the mandibular corpus during growth. With regard to the palatal plane, several investigators have noted that the posterior half of the palate tends to be tipped downward in persons with open bite, 3.4.7,9.t9 carrying the molars downward. With posterior teeth acting as a fulcrum, there is a backward rotation of the mandible and, consequently, the lower anterior face height and the palatomandibular angle increase. However, Subtelny and Sakuda, t~ Ellis and McNamara, 29 and CangialosF found that the palatal plane angle is comparable in open-bite and deep-bite faces. Large palatomandibular angles are often associated with open bite and with excessive lower anterior face height. 9'~'~6"22"33"34 In an earlier study, however, Nahoum ~5 reported normal palatomandibular angles in subjects with open-bite. With respect to the occlusal plane, Fish et al., ~s Schendel et al., 3 and Ellis and McNamara, 29 reported steeper occlusal planes in individuals with open bite, while no demonstrable differences in the maxillary occlusal plane were observed by Nahoum and Horowitz, 28 Ellis and McNamara, 29 and Cangialosif Several investigators have suggested that larger cranial base angles and the corresponding positional deviations of the mandible 6,8,9.3 are associated with open bite. These studies contended that the cranial base angle

is a key factor in influencing facial type. However, Subtelny and Sakuda ~4 reported no significant difference in the cranial base angle between the normal and open-bite group. It is evident from the previous studies that some of the morphologic characteristics of the face may be dependent on the inclination of the four horizontal planes. All of the previously reported studies are cross-sectional and deal with preadolescent or postadolescent age groups. There are still insufficient data concerning the basic differences between "open-bite" and "deep-bite" patterns of development. The purpose of this study is to examine the displacement of the maxilla and the mandible relative to the cranial base during growth of patients with extreme vertical facial proportions. By looking at four horizontal planes in a cephalometric study of two carefully selected samples of both long face and short face syndrome, we were able to identify measurable differences between the two extreme vertical facial types. We believe the analysis of changing form and proportions could have clinical implications for orthodontic diagnosis, treatment planning, prognosis, and the stability of treatment results with respect to changes in vertical facial form.
MATERIAL AND METHODS

Longitudinal cephalograms of growing children were gathered under the auspices of the Child Research Council in Denver, Colorado. 8 All subjects were white and had received no orthodontic treatment. From a sam-

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Growth patterns hi subjects with long and short faces

249

~alatal Plane

lomical
,,sol Plane

Cephalometric

ar Plane

Measure Six,
Fig. 1. Cephalometric landmarks and planes used to construct six angular measurements analyzed in study.

ple of 250 young persons, only 32 subjects were selected--sixteen male and sixteen female. The data used in this study covered a period from age 3 through 20 years. Most of these subjects had to be eliminated because of missing annual lateral radiographs or records covering an age range of less than 4 to 18 years. The resulting subsample was, in turn, partitioned into four groups according to gender and open-bite and deep-bite facial forms. The selection of these subjects was based on skeletal relationships, without reference to clinical evaluation of their occlusions. Differentiation between open bite and deep bite was based on relative lower face height (ANS-Me) as a percentage of morphologic face height (Na-Me). The lower face height proportions of the subjects were determined at approximately 15 years of age for boys and 13 years 6 months of age for girls. The use of these ages for sample selection was based on the recognized sexual dimorphism in the timing of development. 3537 The purpose of this selection process was to maximize the selection of subjects from the ends of the continuum of facial heights to better contrast and inspect differences and similarities between faces with skeletal open bite and deep bite. The percentage of lower face height values for the subjects in this study exceeds the values determined by several investigators for characterizing subjects with skeletal open bite and deep bite (Tables IA and

I B ) . 13"14'21

Serial cephalometric roentgenograms from the selected individuals were traced, and landmarks and planes were then obtained according to the description by Krogman and Sassouni) s From an analysis of the literature, it was ascertained that six specific cephalometric angular measurements were the best criteria for identifying subjects with vertical dysplasia. Six angular measurements (Fig. 1) were recorded: 1. Sella-nasion to palatal plane angle (S-N to ANS-PNS) 2. Sella-nasion to mandibular plane angle (S-N to mandibular plane) 3. Gonial angle (articulare-gonion-menton) (The position of gonion was determined through bisection of the angle formed by the tangents to the lower border of the mandible or mandibular plane and the posterior border of the ramus or ramal plane.) 4. Palatomandibular angle (ANS-PNS to mandibular plane) 5. Sella-nasion to anatomic occlusal plane angle (S-N to a line bisecting the overbite of the incisors and the intercuspation of molars) 6. Cranial base angle (N-S-Ba) Data analysis Graphic and statistical methods were used to characterize each sample. Absolute curves of growth were

250

Nanda 130 Ideg.|

Am. J. Orthod. Dentofac. Ortbop. September 1990

I0

deg 8

o~Deep ~ Deep

\\\
"~. ~ ,.~.~ ~.-,%....._

n. 6

.z t,.O
4 / 2
4

"-./"
~ .I 6

"-,.~,~-~._<~-~ ~ /- -~~ ,,..... =

~ I I I I0 12 14 age in years

....
"-- ~ - ' I

~ Open
o~Open

o Izc1 1
I

""--- ~/ I 8

5
I

~
]

D
I

16

18

I
I10

e "N
16
I

p \6-0=
18
I

Fig. 2. Comparison of mean absolute curves of growth for palatal plane inclination for four groups, segregated by facial type.

I0 12 14 age in years

Fig. 4. Comparison of mean absolute curves for gonial angle by sex and facial type. The gonial angle progressively decreased in all four groups. The four curves are segregated by

38 deg. 36 34 - ~ - ~ 32
30 i
28 ~'-'--~ ~ . . . .

sex until the adolescent spurt eliminates sexually related differences.

9 Open '~- ~ "'0"0 pen degl- ~ 32[.- ~ . ~ . F 16 -~ I 18 Deep ~-~'~" ~"---~ ~ ,---- 0 ''Open

~
I 4

O
I 6

'
I 8

p
I

I I I0 12 I4 age in yeors

~ 24
20
/I I I _

Fig. 3. Comparison of mean absolute curves of growth for mandibular plane angle for sex and facial types. The mandibular plane angle decreased steadily with age in all the four groups. Graphically, there is a suggestion of differencein facial form between open-bite and deep-bite groups, with the angle of the mandibular plane smaller in deep-bite groups.

I0 12 14 age in yeors

16

18

derived for each of the six angular measurements for each of the four groups. For those subjects on whom data at a particular age was missing, a polynomial regression was calculated for each of the six measurements to obtain interpolated annual increments. Yearly absolute values for each of the six angular measurements were calculated for each group at each age between 4 and 17 years. Analyses of variance were performed to test for the overall effects o f age, vertical proportions (open bite or deep bite), sex, and the interaction of these factors. Statistical comparisons were made between open-bite and deep-bite groups for samples from both male and female patients. The orthogonal contrasts between open bites and deep bites in males and females were determined. The level of significance for each comparison was determined at an alpha level of 0.05. The F test, with the Bonferroni procedure for pairwise comparison of each sample at

Fig. 5. The mean absolute curves of growth of the palatomandibular plane angle for open bite and deep bite are clearly segregated by facial type, eliminating sexual dimorphism.

each age (4 to 17 years), was applied to determine the significance of difference between the mean values.

RESULTS
Absolute mean growth curves for each angular measurement were plotted for the ages of 4 to 18 years to evaluate the association between age and patterns of facial growth in subjects with open bite and those with deep bite (Figs. 2 to 7). This approach revealed substantial variation among the four groups, demonstrating that certain angles were consistently larger or smaller, based on sex and facial type.

Sella-nasion to palatal plane angle (Table II, Fig. 2)

Differences in mean palatal plane angle were clearly evident between the two facial types, irrespective of

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Growth patterns in subjects with long atzd short f a c e s

251

134 - - _ ~ .
deg. 132 cO
o

~Deep

2 2 dg e. 2 O
o
12. IZ)

13C 128 -

~ ep De /
l

18

f--~"'
I

~ pn Oe
I I I

16
14

~ ~
I

~
6
I

.
8
I

D
t

e
I

~
16
I

~
18
I

Oe pn

126 1 4

I0 12 age in years

14

16

18

12 I 4

IO 12 age in years

14

Fig. 6. Comparison of mean absolute curves of growth for open bite and deep bite by sex and facial type. The four curves are clustered, and the concordance indicates that the inclination of occlusal plane is similar and nondiscriminatory.

Fig. 7. Comparison of mean absolute curves of cranial base angle by sex and facial type. The curves are segregated by sex. it is interesting to note that the female groups have higher values than males, and suggesting that there are no differences in facial form within each sex.

Table

II. Descriptive statistics on the absolute values (in degrees) o f palatal plane inclination in subjects from 4 to 17 years o f age for four g r o u p s - - B o n f e r r o n i test of differences in significance ( p values) between open-bite and deep-bite groups

Male Open bite O'r) Mean SD Mean Deep bite SD p values Open bite Mean SD

Female Deep bite Mean SD p ralues

4 5 6 7 8 9 10 11 12 13 14 15 16 17 *p < 0.05.

2.62 3.65 4.18 4.16 3.91 3,89 4.98 4.66 4.45 4.66 4.59 4.14 3.93 3.88

2.81 2.61 3.74 3.64 3.73 4.0 4.33 3.94 3.99 4.07 4.60 4.58 4.97 4.73

8.15 9.08 8.47 8.97 8.47 9.06 8.73 8.92 8.87 8.57 8.90 9.04 9.50 9.06

2.67 4.11 2.19 2.76 1.28 2.02 1.16 1.23 ! .43 1.40 1.55 2.30 2.13 2.06

0.002* 0.005* 0.014' 0.009* 0.008* 0.005* 0.038* 0.018* 0.011" 0.026* 0.017" 0.009* 0.005" 0.006*

5.34 5.53 5.27 4.78 5.50 4.87 4.72 4.71 5.11 4.94 4.80 5.10 4.90 5.00

4.8 3.97 3.81 4.10 4.37 4.58 4.76 4.86 4.43 4.65 4.38 4.45 4.55 4.15

5.71 6.22 6.59 7.31 8.16 7.98 8.63 8.51 8.87 8.68 8.93 8.73 8.70 8.70

3.74 3.35 3.16 3.22 2.55 2.55 2.23 2.28 2.17 2.01 2.02 1.89 2.00 2.32

0.829 0.700 0.427 0.155 0.109 0.082 0.031" 0.033* 0.028* 0.032* 0.022* 0.049* 0,048* 0.044*

sex. Deep-bite subjects o f both sexes had larger angles at each chronologic age, with the values for the female open-bite subjects actually exceeding those for the male open-bite subjects at 4 years of age. By 10 years o f age, the male open-bite curve approximated the female open-bite curve. Although the sella-nasion to palatal plane angles o f the two female groups were approximately equal at age 4, the deep-bite group showed a significant increase ( p < 0.03) in this angle at age 7. The palatal plane

angle increased significantly (p < 0.02) in the male deep-bite group in comparison with that of the male open-bite subjects at 10 years o f age. The palatal plane angle did not show any further significant differences across age between open-bite and deep-bite groups across the age range or between sexes after 10 years o f age. This lack o f difference suggests that there were minimal changes in the inclination of the palatal plane. The Bonferroni test further supported the interpretations of the graphic data that differences between facial types

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Nanda

Am. J. Orthod. Dentofac. Orthop. September 1990

Table Ill. Descriptive statistics on the absolute values (in degrees) of the mandibular plane in subjects from
4 to 17 years of age for four groups. Bonferroni test of differences in significance (p values) between open-bite and deep-bite groups
Male Open bite Age O'r)
4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female Deep bite Open bite

p vahtes

Deep bite SD
Mean

Mean
35.56 35.92 35.75 34.93 35.04 34.52 34.77 34.70 34.09 34.41 34.29 33.51 32.75 33.04

SD

Mean

SD
2.31 2.38 2.65 2.91 2.93 2.76 3.00 3.23 2.83 2.74 3.13 3.32 3.32 3.62

Mean
36.28 35.77 35.76 35.41 35.23 34.87 34.70 34.25 34.01 34.00 34.02 33.69 33.51 33.34

SD
5.52 5.59 5.52 5.86 5.86 5.86 5.80 5.60 5.47 6.03 5.49 5.54 5.41 5.32

p vahtes
0.015" 0.0315" 0.030* 0.047* 0.056* 0.087 0.083 0.165 0.127 0.186 0.099 0.085 0.087 0.060

3.79 4.21 4.42 4.84 4.62 4.50 4.11 4.56 4.23 4.93 5.91 4.93 5.29 5.22

34.59 33.37 33.35 32.17 31.97 31.50 30.78 30.98 30.59 30.60 29.70 29.77 29.37 28.75

0.634 0.236 0.262 0.232 0.179 0.174 0.075 0.104 0.115 O. 1I0 0.059 0.112 0.162 0.074

3.92 4.03 3.61 3.93 3.86 3.60 3.84 3.99 4.25 4. i 2 4.28 4.19 4.50 4.13

31.05 31.00 30.98 30.72 30.81 31.02 30.83 31.10 30.63 30.87 30.03 29.62 29.35 28.84

*p < 0.05.

within each sex (male skeletal open-bite versus male skeletal deep-bite, female skeletal open-bite versus female skeletal deep-bite) were significant from 4 to 17 years of age for the male groups and from 10 to 17 years for the female subjects.

(p < 0.01), 10 years (p < 0.02), and 15 years of age (p < 0.04).

Gonial angle (Table IV, Fig. 4)

Both open and deep-bite groups demonstrated a tendency toward progressive decrease in mean gonial angle from 4 to 18 years of age, with a resultant uprighting of the remus. The difference in the decrease in the gonial angle between deep-bite and open-bite male subjects was significant at 5 years (p < 0.02) and 7 years of age (p < 0.04).

Sella-nasion to mandibular plane angle (Table Ill, Fig. 3)

The relative positions of the four curves for the mean mandibular plane angle represent a direct reversal from the order for the mean palatal plane angle. The curves are clearly segregated according to facial type from 4 to 18 years of age, with the magnitude of the mandibular plane angle being larger in both open-bite groups in comparison with that of the deep-bite groups. However, the change in the mandibular plane angle did not show any significant difference in either the male or the female samples except that the female deep-bite group was significantly different from the open-bite group at 4 to 8 years of age (Table III). The mandibular plane angle decreased progressively throughout the period of study; however, the male deepbite group exhibited an accelerated rate of decrease from 4 to 10 years. Thereafter, the decrease was comparable with that for the female deep-bite subjects. The reduction in the mandibular plane angle was significantly different for the male deep-bite subjects at 5 years

Palatomandibular angle (Table V, Fig. 5)

The mean curves for the palatomandibular angle revealed clear-cut and highly significant differences between facial types in both male and female samples throughout the entire study period. These differences were so pronounced that the female open-bite values exceeded the corresponding values for male deep-bite subjects and revealed a sexual dimorphism in the palatomandibular angle. The magnitude of decrease in the palatomandibular angle was remarkably consistent between skeletal open-bite and deep-bite curves from 4 to 18 years. The changes in the palatomandibular angle were significant for both facial types within each sex (male p < 0.02, female p < 0.01) at 14 years of age.

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Growth patterns in subjects with long and short faces

253

Table IV. D e s c r i p t i v e statistics o n t h e a b s o l u t e v a l u e s (in d e g r e e s ) o f t h e g e n i a l a n g l e in s u b j e c t s f r o m 4 to

17 years o f a g e f o r f o u r g r o u p s : B o n f e r r o n i test o f d i f f e r e n c e s in s i g n i f i c a n c e ( p v a l u e s ) b e t w e e n o p e n - b i t e and deep-bite groups

Male Open bite Age (yr)

4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female Deep bite Open bite p values

4.73 4.09 3.98 4,73 4.16 4.47 5.34 4.73 3.83 5.16 5.13 5.13 5.36 5.35 0.513 0.176 0.213 0.075 0.201 0.085 0.221 0.223 0.253 0.273 0.291 0.357 0.415 0.365

Deep bite SD
4.39 4125 3.92 3.99 5.19 4.19 4.53 3.86 3.62 4.10 3.68 4.13 4.12 4.36

Mean
123.88 125.40 124.13 124.63 122.37 121.67 120.55 119.62 119.71 120.09 118.45 117.07 116.44 114.76

II

SD
4.61 5.71 5.79 6.54 6.59 7.02 7.38 7.25 7.37 2.83 7.88 7.71 7.04 8.60

Mean
122.02 121.61 120.75 119.34 118.44 116.44 116.55 115.79 116.11 116.30 114.92 114.04 113.69 111.44

Mean
125.32 124.56 124.41 122.89 121.88 122.06 121.80 121.05 119.80 119.41 118.83 118.04 117.77 117.37

Mean
123.07 122.09 120.61 119.81 118.28 117.41 116.90 115.81 114.79 114.50 114.44 114.84 114.66 114.96

I,o
7.93 7.21 6.88 7,08 7,49 7.09 7.72 7.79 8.36 7.87 8.31 8.08 9,05 9.35

p vahtes
0.429 0.375 0.163 0.290 0.240 0.123 0.136 0.090 0.115 0,158 0.190 0.333 0.357 0.510

Table V. D e s c r i p t i v e statistics o n the a b s o l u t e v a l u e s (in d e g r e e s ) o f the p a l a t o - m a n d i b u ! a r p l a n e a n g l e in

s u b j e c t s f r o m 4 to 17 y e a r s o f age f o r four g r o u p s : B o n f e r r o n i test o f d i f f e r e n c e s in s i g n i f i c a n c e ( p v a l u e s ) between open-bite and deep-bite groups

Male Open bite (yr)

4 5 6 7 8 9 10 11 12 13 14 15 16 17 *p < 0.05.

Female Deep bite Open bite p values

0.0000" 0.0001" 0.0003* 0.0005* 0.0002* 0.0004* 0.0007* 0.0004* 0.0007* 0.0009* 0.0003* 0.0010" 0.0006* 0.0001"

Deep bite SD Mean

25.33 24.79 24.37 23.40 22.64 23.03 22.07 22.58 21.51 22.18 21.09 20.88 20.63 20.14

Mean
32.93 32.27 31.56 30.77 31.12 30.62 29.78 30.03 29.63 29.75 29.70 29.22 28.56 29.15

SD
2.06 2.55 3.00 3.13 2.54 2.88 3.63 3,71 3.64 3.83 4.13 4.24 3,94 3.66

Mean
26.19 24.10 24.60 23.20 23.30 22.56 21.99 21.86 21.71 22.02 20.85 20.74 19.79 19.68

SD
1.48 4,23 2.61 3,10 3.16 3.43 3.84 3.88 3.95 3.53 4.39 5,24 5,03 4.79

I ]

Mean
30.98 20.21 30.38 30.59 29.85 30.00 29.97 29.53 28.85 29.02 29.15 28.62 28.69 29.39

SD
3.54 4,15 4.33 5.25 5.00 5.43 5.07 4.86 5.15 5.22 4.81 4.96 5.05 4.74

2.46 2.83 3.19 3.53 3.66 3.92 3.57 3.60 3.59 3.87 4.02 3.88 3.94 3.62

p values
0.0001" " 0.0040* 0.0013" 0.0009* 0.0006* 0.0018" 0.0006* 0.0019" 0.0014" 0.0028* 0.0009* 0.0023* 0.0013" 0.0006*

Sella-nasion to occlusal plane angle (Table VI, Fig. 6)

In c o n t r a s t to the g r o w t h c u r v e s for the palatal plane a n g l e , the m a n d i b u l a r p l a n e a n g l e , a n d the g e n i a l a n g l e ,

the g r o w t h c u r v e s f o r t h e o c c l u s a l p l a n e a n g l e w e r e c o n f l u e n t a n d c o u l d n o t b e d i s c r i m i n a t e d e i t h e r b y sex or facial type. F o r b o t h s e x e s , t h e o c c l u s a l p l a n e a n g l e s h o w e d n o s i g n i f i c a n t d i f f e r e n c e s (Table VI) t h r o u g h o u t

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Am. J. Orthod. Dentofac. Orthop. September 1990

Table Vl. Descriptive statistics on the absolute values (in degrees) of the occlusal plane in subjects from

4 to I7 years of age for four groups: Bonferroni test of differences in significance (p values) between open-bite and deep-bite groups
Male Open bite Age O'r)
4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female Open bite SD

3.03 2.13 2.47 2.44 5.42 2.46 1.54 2,67 2.40 2,07 2.41 3.08 3.31 3.55

Deep bite SD Mean

19.68 18.79 18.70 18.63 20.78 19.25 17.03 17.97 17.68 17.68 16.74 16.90 15.51 15.50

Deep bite SD Mean

17.96 17.43 17.22 17.58 19.19 19.35 19.78 18.95 18.79 18.00 17.68 16.63 16.22 15.77

Mean
18.56 18.04 18.25 18.17 18.88 17.96 19.48 19.46 19.24 17,73 17.45 16.37 15.37 13.89

p values
0.702 0,755 0.820 0.822 0.406 0.471 0.167 0.380 0.410 0.977 0.703 0.774 0.937 0.417

Mean
19.75 19.60 19.46 19.34 19.48 18.93 19.12 18.78 18.19 18.17 17.26 17.19 16.31 16.24

SD

p values
0.543 0.369 0.272 0,393 0.899 0.813 0.704 0.917 0.754 0.918 0.824 0.761 0.960 0.810

3.62 3.04 3.52 4.01 4.20 3.60 3.23 3.33 4.61 4.35 4.80 4.52 4.53 4.79

3.73 4.69 4.09 3.97 4.46 3.84 3.67 3.52 4.08 3.28 3.56 3.11 3.40 2.97

9.90 7.40 5.35 5.32 3.81 4.01 4.14 3.72 3.54 3.77 3.73 3.72 3.16 4.04

the period of study. By the age of approximately 10 years the deceleration rates for the four curves were comparable. The changes in the occlusal plane angle were significant for the male open-bite and deep-bite groups at 10 years (p < 0.002), at 13 years (p < 0.04) and at 15 years (p < 0.05), but at 15 years of age the curves were tightly clustered, and they tended to level off at 18 years of age.

Cranial base angle (Table VII, Fig. 7)

The cranial base angle showed no significant difference between open-bite and deep-bite groups for either sex; however, the curves for male and female groups were significantly different at every age interval (Table VIII). The values for the female group exceeded the corresponding values for male subjects throughout the study period. A significant change in the cranial base angle was observed at 5 years (p < 0.003), as was a reduction in the angle at 17 years of age (p < 0.05) for the male open-bite group.

DISCUSSION
The parallel natures of longitudinal growth curves for the palatal plane inclination in the open-bite and deep-bite faces clearly demonstrate that anteroposterior inclination of the palatal plane is stable, despite significant vertical displacement, and that it is established at an early age. This finding is consistent with previously reported s t u d i e s . 31,32,39 This study also suggests that the inclination of the

palatal plane is significantly different between openbite and deep-bite faces throughout comparable phases of development, regardless of sex. Palatomandibular inclination in the skeletal open-bite and deep-bite groups was also significantly different between the two facial types throughout development and may have even masked any effects of sexual dimorphism. On the other hand, the magnitude of the gonial angle and the inclinations of the occlusal and mandibular planes were not significantly different between the two extreme vertical dysplasias in either sex. During the comparable phases of development however, the mandibular plane, the occlusal plane, and the gonial angle steadily decreased in both skeletal open-bite and deepbite subjects from 4 to 18 years of age. The decrease was least in the mandibular plane angle and greatest in the gonial angle, with the occlusal plane occupying an intermediate position. The results of this study indicate that the extent of influence of palatal plane inclination on lower anterior face height is determined by its geometric relationships with existing bones. For example, in open-bite subjects, the palatal plane is tipped down posteriody, resulting in the maxillary molars being located in a more inferior position. With this position, the molars may act as a fulcrum with the mandibular teeth, resulting in the positional rotation discussed by Lavergne and Gasson, 4 the matrix rotation studied by Bjrrk and Skieller,4t and the displacement rotation described by Enlow. 3~ This condition may also contribute considerably to lower

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Table VII. Descriptive statistics on the absolute values (in degrees) of the cranial base angle of subjects from 4 to 17 years of age in four groups: Bonferroni test of differences in significance (17 values) between open-bite and deep-bite groups
Male Open bite Age (yr)
4 5 6 7 8 9 10 11 12 13 14 15 16 17

Female Open bite SD

6.02 5.56 4.78 6.14 5,05 6.26 6.10 4.95 5.05 5,21 5.63 5.62 5.34 6.18

Deep bite SD Mean

129,21 129.19 129.66 129.49 128.75 129.38 129.37 129.42 129.43 129.58 129.42 129.89 129.93 130.19

Deep bite SD

Mean I
126.25 127.68 128.44 128.49 128.28 128.45 129.62 129.06 129.27 129.20 129.60 129.16 129.19 128.56

p values
0.224 0.504 0.549 0.672 0.822 0.702 0.926 0.873 0.947 0.870 0.943 0.760 0.759 0.526

Mean
133.64 133.60 133.23 133.28 133.04 132.63 133.03 132.82 133.48 133.18 132.88 133.17 132.90 132.67

Mean l SD
132.29 132.32 132.60 133.24 133.07 133.23 133.27 133.70 133.36 133.50 133.14 133.28 133.23 133.03 3.26 3.32 3.34 3.79 3.23 3.96 3.72 3.62 3.66 3.42 4.09 3.95 4.08 4,32

p values
0.576 0.570 0.757 0.986 0.986 0.802 0.928 0.699 0.955 0.807 0.916 0.962 0.894 0.889

5.64 5.13 4.09 4.08 4.48 5.11 7.02 5.43 5.38 5.17 5.61 4.71 5.01 4.94

3.50 3,44 3.79 3.47 3.55 3.37 3.88 3.70 3.97 4.09 4.38 4.50 4,73 4.61

anterior face height and help increase the mandibular plane angle. Since the observed inclination of the palatal plane and its proportion remain constant with age, downward and backward rotation of the mandible in open-bite subjects may be precommitted in response to dentoalveolar compensatory changes. Bhatia, 42in his explanation of the reduction of mandibular plane and palatomandibular plane angles in a longitudinal study, arrives at a quite different conclusion concerning the relationship of the angle between the palatal and mandibular planes. He states that the palatal plane tips downward anteriorly, while the mandibular plane tips downward at the back. (It should be noted that the palatal plane angle was not specifically measured with respect to a reference plane.) Even equal dentoalveolar growth in both open-bite and deep-bite faces can have different implications for the final outcome of facial growth. The primary determinant of lower anterior face height is the spatial configuration of the palatal plane with its adjacent bones, while mandibular rotation is secondary to the existing inclination of the maxilla. It must be recognized that the maxillary complex is wedged between the cranial base and the mandible. Interposed between the bones of the upper and lower jaws are the alveolar bone and teeth. The molars are the first teeth to come in contact with each other and, as a result, the remaining anterior teeth erupt vertically to maintain contact with the opposing teeth, thus contributing to the change in the inclination of the occlusal plane. Any decrease in the

Table VIII. Orthogonal contrasts between the sexes with respect to cranial base angle
Age O'r) 4
5 6 7 8 9 10 II 12 13 14 15 16 17 *p < 0.05.

pvalues 0.004*
0.007* 0.011" 0.015' 0.004* 0.025* 0.064 0.017" 0.017' 0.020* 0.050* 0.035* 0.049* 0.062

gonial angle or increase in ramal height is probably compensation for dentoalveolar growth, a~ An alternative hypothesis offered here to explain the rotation of the mandible is that vertically divergent facial forms are the result of disproportionate displacement of the palatal plane in the vertical dimension and the resulting rotation of the mandible. The mechanism of adjustment in response to the rotation of the mandible is change in the gonial angle, differential dentoalveolar growth, a~ and positional rotation. 4

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The magnitude of the mandibular plane angle is often assumed to be a determinant in the rotation pattern (forward versus backward) observed during facial growth. However, the diagnostic and prognostic values of mandibular plane inclination are not adequate for assessment of the pattern of growth. These findings are consistent with those reported by Skieller and Bjrrk 24 and by Baumrind et al. 23 The larger values of the mandibular plane angle in open bite, as reported in this study, are probably secondary to the spatial orientation of the palatal plane. The mandibular plane is constantly remodeling, resulting in apposition of bone on the posterior-inferior part of the corpus, with or without remodeling at the lower border of the symphysis. After some time, the gonial angle is decreasing, compensating for the vertical increase of the ramus and for the direction of condylar growth. 4~ The interpretation by Enlow, 3.3t Bj/Srk and Skieller, 32 and Moss 43 is that the gonial angle is greater in posterior-inferior than superior-posterior rotations of the mandible. Further, it has been reported by Isaacson and coworkers, 2 Jensen and Palling, 27 Sassouni and Nanda, s Subtelny and Sakuda, 14 Enlow, 3~ and Trouten et al) 9 that in the case of open-bite, the gonial angle increases. Interestingly, this study reveals that the gonial angle does not differ between facial types; it continues to decrease proportionally from 4 to 18 years, irrespective of the facial form. However, the continued reduction of the gonial angle and inclination of the mandibular plane are unequal, and the magnitude of gonial angle reduction is roughly twice that of the mandibular plane, as observed by the slopes of their curves. The inclination of the occlusal plane is maintained until the age of 10 years in both open-bite and deep-bite groups. After the age of 10 years there is a sharp decrease in occlusal plane angle. The problem, then, is to explain the mechanism of downward inclination of the occlusal plane posteriorly. In the present context, it must be assumed that the differential apposition of bone at the angle of the mandible and the lower border of the symphysis, as shown by Bjrrk and Skieller, 32 results in a reduction of steepness of the mandibular plane and the gonial angle, while the condylar vertical growth accommodates extensive remodeling at the angle of the mandible. Along with the above-mentioned changes, dentoalveolar growth also responds to differential increases in the anterior and posterior segments of the dental arches as a necessary mechanism of adaptation regardless of facial configuration. The growth pattern of the cranial base angle in our subjects demonstrated no significant change with respect to either sex or typology between the ages of

4 and 18 years. A number of comparable findings regarding the stability of the pattern have been reported. 4449 Of particular significance is the fact that the cranial base angle in the two facial types clearly demonstrates sexual dimorphism. This is in contrast to the findings of Knott, 49 who found no statistically significant difference in cranial base angle between sexes. In another study Schulter: using dry skulls, observed population and sex differences in the cranial base angle. Bjrrk 47 demonstrated the influence of the cranial base angle and its associated effect in both sagittal and vertical dysplasias. It has been assumed that this angle reflects the position of the glenoid fossa and the temporomandibular joints. Thus, when the angle is acute, the mandible is assumed to be in a forward position; conversely, when the angle is obtuse, it is assumed that the mandible is in a retruded position. Similar interpretations were advanced by DeCoster H and Sassouni) suggesting an association between a large cranial base angle and open bite and, conversely, between smaller cranial bone angles and deep bite. Yet, the comparable patterns of growth in both open-bite and deep-bite faces of both sexes in the present study indicate that there is no interaction of magnitude of the cranial base angle in subjects with vertical dysplasia. Even the significantly larger magnitude of the angle in female subjects failed to show any effect of the cranial base angle on vertical dysplasia. These observations are comparable to those of Knowles, ~ who reported that subjects with excessive or deficient midfacial regions had no significant differences in cranial base angles. Bjrrk's 47 rationale of rotation is based on the sphenooccipital synchondrosis and its effect on the backward rotation of the glenoid fossa; for example, he maintains that the point basion shifts posteriorly, because of addition of bone at the sphenooccipital synchondrosis. His assertion is based on the assumption that the anterior limb of the cranial base is essentially complete at an earlier age. In contrast, Scott, 52 Baer and Nanda, 53 and Coben ~4'55implied that basion is a stable reference point that affects forward and upward growth of the anterior cranial base. Coben 54'55 concluded that the distance from basion to articulare is stable during the developmental process. Subsequently, Coben ss registered on basion, using the anterior cranial base (sella-nasion) for superpositioning to demonstrate different craniofacial patterns of growth during successive growth changes. Each of the above conceptions of the relationship of the cranial base to the configuration of the face is vulnerable to criticism, however, either on theoretical grounds or in terms of conflicting data. In opposition to Bjrrk's 47contention, Nanda s6 hypothesized the effect

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of the cranial base angle on the relative protrusion or retrusion of the mandible. The temporal bones are bilateral structures and the influence of the midline structures measured in the cranial base angle, Nanda maintained, may be dissipated before they impinge on the glenoid fossa. Further, it is possible that compensatory changes may take place in the form and positions of the temporal bone that negate the influence of the cranial base angle. Thus, the anteroposterior growth that poshions the lateral elements of the cranium may not operate in total synchrony with the midline. Even Enlow 3~ contended that the conventional cranial base angle is not a true reflection of the protrusive or retrusive position of the mandible. In summary, it is evident that no close correspondence exists between the cranial base angle and vertical dysplasias of the face; rather, there is a sexually related difference in the magnitude of the cranial base angle. The evidence suggests that there are significant differences in the inclination of the palatal p l a n e - palatomandibular angle throughout the growing period in open-bite and deep-bite faces. It further suggests that the intricate changing spatial relationships of the bones in the dentofacial structures are a function of different rates of growth and that they influence the ultimate facial form. The differences among conceptual explanations and conclusions regarding the mechanism of rotation ~m,4,41'43'576 may be traced to the selection of different superpositioning points and cross-sectional samples by the various researchers. Another problem frequently encountered in the literature is the lack of distinction between different facial forms, which may mask the basic pattern of rotation of the mandible. The effect of rotation patterns of the components of the face should be examined in homologous groups of similar face configurations. Therefore, a distinction between patients with open bite and those with deep bite should be made with respect to the spatial relationships of the different vertical segments of the face (i.e., lower anterior face heights).

face height to total face height, points to the fact that there are large individual variations in the positional relationships of the horizontal planes of the face during development, regardless of the nature of vertical dysplasia. The decrease in mandibular plane, palatomandibular plane, occlusal plane, and gonial angles will have specific clinical effects on facial configuration of patients who have severe vertical dysplasia. For example, in open-bite subjects, the magnitude of dysplasia will attenuate; on the other hand, in deep-bite subjects it will be intensified with the series of vertical changes. A static cephalometric analysis of an orthodontic patient with an adopted standard based on preadolescent or adolescent age groups is not adequate. Further, it is fallacious to assess an orthodontic patient's dentofacial structure by referring to particular norms of a structure. Rather, these parts should be evaluated by the manner in which each affects the morphologic unit tO which it belongs. Compensatory adjustments in other related parts of the dentofacial complex may reduce, maintain, or exaggerate the magnitude of dysplasia. Hence, in clinical studies aimed at establishing the efficacy of dentofacial orthopedic methods, the basis for comparison of treatment effects should also include a consideration of expected growth changes, based on the morphologic typology of both treated and untreated controls (matched for typology, age, and gender). Selection of successfully treated cases for posthoc analysis of treatment effects is methodologically unsound and liable to bias.

Clinical implications
The observations reported in this study on vertical facial extremes have disclosed fundamental positional relationships between dentofacial structures. The clinical implications of the study suggest that, despite the disparate initial morphologie characteristics, adjacent bones in the anatomic structure undergo progressive positional changes throughout different phases of development, regardless of sex or facial configuration. The evidence from this study, which classified individuals on the basis of extreme proportional values of lower

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Reprint Requests to" Dr. Surender K. Nanda The University of Michigan School of Dentistry Department of Orthodontics and Pediatric Dentistry Ann Arbor, MI 48109-1078