ONLINE ONLY

Longitudinal alteration of the occlusal plane

and development of different dentoskeletal
frames during growth
Eliana Midori Tanakaa and Sadao Satob
Yokosuka, Japan

Introduction: Valuable information about growth and development in different types of occlusions and
skeletal frames can be obtained by analyzing longitudinal data, particularly the functional significance of the
occlusal plane; this information is important for understanding the etiology, diagnosis, and treatment of
malocclusion. The purpose of this study was to investigate the relationship between the cant of the occlusal
plane and mandibular position to establish a functional determinant in the development of different
dentoskeletal frames in longitudinal growth samples. Methods: Several measurements were analyzed and
compared in a total sample of 406 lateral cephalograms of 102 orthodontically untreated white patients taken
at different ages of the growing period from the Burlington Growth Centre, Toronto, Ontario, Canada.
Results: Regarding changes related to the cant of the occlusal plane, a progressive tendency was seen
through the years for consistency (significance and correlation) between maxillary posterior occlusal plane
inclination (FH-OP[P] and Mx-OP[P] angles) and mandibular position (SNB angle) reflected in the appearance
of a certain type of dentoskeletal frame (APDI and ANB angles). Statistically significant correlations (P
0.0000) were found between the angle of the Frankfort plane-maxillary posterior occlusal plane and the
anteroposterior dysplasia indicator, the maxillary posterior occlusal plane angle and the anteroposterior
dysplasia indicator, the maxillary posterior occlusal plane angle and the angle of the palatal plane-mandibular
plane, the angle of the Frankfort plane-maxillary posterior occlusal plane and the SNB angle, and the
maxillary posterior occlusal plane angle and the SNB angle. Conclusions: There is a possible relationship
between the inclination of the maxillary posterior occlusal plane and mandibular position, consistent with the
etiology of different dentoskeletal frames. Thus, a more comprehensive etiologic approach based on the
inclination of the maxillary posterior occlusal plane should be considered in the correction of malocclusion.
(Am J Orthod Dentofacial Orthop 2008;134:602.e1-602.e11)

C
raniofacial growth prediction is an ultimate
goal in craniofacial biology and is a major
concern in orthodontics, because it is the key
point in the diagnosis, prevention, interception, and
From the Department of Craniofacial Growth and Developmental Dentistry,
Division of Orthodontics, Kanagawa Dental College, Yokosuka, Japan.
a
Orthodontist PhD and visiting research fellow.
b
Professor, chairman, and research associate, Research Institute of Occlusion
Medicine, Research Center of Brain and Oral Science.
Made possible with material from the Burlington Growth Centre, Faculty of
Dentistry, University of Toronto, Toronto, Ontario, Canada, which was
supported by funds provided by National Health Grant 605-7-299 (Canada)
(data collection); grant PR 33 (Province of Ontario) (duplicating); the Varsity
Fund (housing and collection). Research supported by a grant-in-aid for open
research from the Japanese Ministry of Education, Culture, Sports, Science and
Technology; and a research grant from Dr. Young H. Kim and the Kim
Foundation of the MEAW (Multiloop Edgewise Arch Wire), Kenkyukai
(Japan).
Reprint requests to: Eliana Midori Tanaka, Department of Craniofacial Growth
and Developmental Dentistry, Research Institute of Occlusion Medicine,
Research Center of Brain and Oral Science, Division of Orthodontics, Kana-
gawa Dental College, 82 Inaoka-Cho, Yokosuka, Kanagawa 238-8580, Japan;
e-mail, emtanaka@gmail.com.
Submitted, November 2007; revised and accepted, February 2008.
0889-5406/$34.00
Copyright 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2008.02.017
treatment of malocclusions. It is still not completely
clear how abnormal growth occurs in the different
dentoskeletal frames, largely because the various fac-
tors that seem to be involved (cranial base flexion,
eruption, vertical dimension, occlusal plane, intrinsic
maxillary and mandibular growth, genetics, environ-
ment, and so on) and their interactions, particularly the
significance of the occlusal plane inclination as a
primary determinant in establishing the mandibular
position, are not totally understood.
Many experiments and theories have addressed
craniofacial growth-related dentoskeletal problems. It
has been stated many times in the literature that the
mandible moves forward the exact amount of the
posterior horizontal condylar growth, if no autorotation
occurs.1-4 In addition, Schudy5 pointed out that the
relationship between effective vertical condylar growth
(horizontal growth) and vertical growth of the molars,
determines whether the mandible rotates backward or
forward, or whether it does not rotate. The occlusal
plane is the effect, not the cause, of anatomic relation-
ships attributing condylar growth (related to vertical
602.e1
602.e2 Tanaka and Sato American Journal of Orthodontics and Dentofacial Orthopedics
November 2008

Table I. Variables measured from lateral cephalograms

Variable Description

Denture frame ()
FH-MP Angle formed by FH and MP
PP-MP Angle formed by PP and MP
OP-MP Angle formed by OP and MP
AB-MP Angle formed by AB and MP
Kim ()
APDI Sum of facial plane, AB plane angle,
and FH-PP angle
ODI Sum of AB-MP plane and FH-PP angle
Downs-Graber ()
SNA Angle formed by SN and NA planes
SNB Angle formed by SN and NB planes
ANB Angle between SNA and SNB planes
Occlusal plane ()
FH-OP(C) Angle between the FH plane and OP(C)
FH-OP(A) Angle between the FH plane and OP(A)
FH-OP(P) Angle between the FH plane and OP(P)
Mx-OP(C) Angle of OP(C) to the PP perpendicular
Mx-OP(A) Angle of OP(A) to the PP perpendicular
Mx-OP(P) Angle of OP(P) to the PP perpendicular
OP difference Angle between OP(A) and OP(P)
Fig 1. Reference landmarks and planes used for ceph-
(A P) alometric measurements.

dylar region a functional capacity to adapt to changes in

growth) as the key to the changes of the occlusal plane.
Nevertheless, some authors have proposed that the
vertical dimension of the posterior part of the dentition
might affect the cant of the maxillary posterior occlusal
plane and the functional positioning of the mandible,
and, consequently, the condyle adapts (secondarily) to
the new adopted position of the mandible during
growth.6 According to Moss7 and Moss and Salentijn,8
the mandibular condylar cartilages are only the sites, or
loci, of secondary and compensatory growth that fol-
lows the spatial repositioning of the mandible by other
factors. Thus, the morphology and growth of the lower
face are influenced and guided by the function of the
dentition. In a growing facial skeleton, the adaptability
is primarily located in the function of dentition, whereas it
is secondarily located in the sutures and at the condyles.
Furthermore, the cybernetic model introduced by Petrovic
and Stutzman9,10 emphasizes that occlusal function is the
functional factor that regulates mandibular growth. The
mandible can functionally adapt to the spatial position of
the maxillary occlusal surfaces and the maxillary dental
arch, making the temporomandibular joint adjust to the
new mandibular position; this leads to mandibular remod-
eling or growth.
Preliminary studies with nonhuman primates dem-
onstrated the relationship between mandibular devia-
tion induced by occlusal alteration and jaw growth,
attributing to the temporomandibular joint in the con-
mandibular position.11-13 Therefore, the dentofacial
complex is obviously adaptable to the functional de-
mands in the occlusal configuration.14,15 The spatial
position and inclination of the occlusal plane in the
lower face influences the functional position of the
mandible.16 The adaptation of skeletal and dentoalve-
olar elements of the face after functional displacement
of the mandible leads to reestablishment of structural and
functional balance of the orofacial region.17-19 Several
human studies have also suggested that occlusal devi-
ations are related to facial growth in patients with
mandibular asymmetry with transverse inclination of
the occlusal plane and different muscle activity on both
sides because of disparities between the left and right
occlusal vertical dimensions.20-22 Specifically, the ver-
tical height of the occlusion can affect the cant of the
posterior occlusal plane and, subsequently, mandibular
position and function in different skeletal malocclusion
types.23,24 This agrees with Dawson,25 who stated that
mandibular position is influenced by the vertical rela-
tionship of the dentition in the buccal segments, and the
relationship between the cant of the occlusal plane of
the maxillary dentition related to the sagittal inclination
of the condylar path and the guidance of lingual
concavity of the maxillary incisor, is another aspect to
consider in terms of functionality.
Furthermore, the impact of orthodontic treatment
on skeletal patterns is evident, indicating that craniofa-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 134, Number 5
Fig 2. Cephalometric measurements of the OPs.
cial growth can be influenced by occlusal changes.
Thus, it is extremely important to obtain a better
understanding of the anatomic and physiologic modu-
lation of the occlusal plane during growth and devel-
opment to determine the contributing factors and use an
adequate clinical approach to treat the various maloc-
clusions.
The purpose of this study was to estimate the
possible relationship between the cant of the occlusal
plane and mandibular position to establish a functional
determinant in the development of different dentoskel-
etal frames in longitudinal growth samples of white
subjects.
MATERIAL AND METHODS
This study was performed at the Research Institute
of Occlusion Medicine and Research Center of Brain
and Oral Science, Kanagawa Dental College, Yoko-
suka, Japan.
The total sample comprised 406 lateral cephalo-
grams of 102 subjects (46 female, 56 male), taken at
different age periods (range, 3-20 years) from the
representative population of the Burlington Growth
Centre, University of Toronto, Ontario, Canada; their
predominant racial origin was white, and the major
ethnic background was Anglo-Saxon.
Orthodontic records from the data bank of the
Burlington Growth Centre were initially selected based
on the availability of lateral cephalograms under the
following inclusion criteria: natural growth, orthodon-
tically untreated, no congenitally missing teeth (except
for the third molars), no extracted teeth, and sequential
records with at least 3 cephalograms including 1 at the
beginning and 1 at the end of the growing period. In
addition to these inclusion criteria, the final sample was
classified according to the dentoskeletal frame into
Class I, Class II, and Class III, based solely on the
anteroposterior dysplasia indicator (APDI), the follow-
ing criteria: Class II 81.37 3.79 (Class I) Class were defined as follows.
Tanaka and Sato 602.e3
III.26 Because APDI reflects both skeletal and dentoal-
veolar characteristics that cannot be shown by single
measurements and has proved to have the best diagnos-
tic performance in determining anteroposterior discrep-
ancy of the skeletal pattern according to the receiver
operating characteristic analysis,27 it was preferred over
the more commonly used ANB angle. Six age interval
groups (3-4, 6-7, 8-10, 12-14, 16-17, and 18-20 years)
were identified, and cephalometric data at these ages
were compared among the 3 dentoskeletal frames.
Cephalometric analysis
All cephalograms were hand traced on acetate
paper, and their landmarks were digitized by the same
investigator (E.M.T.). After data collection, the cepha-
lometric tracings were scanned at high resolution and
digitized by using computer software for digital anatom-
ical markers and cephalometric analysis (CADIAS,
GAMMA Dental Software for Windows, version 5.1.1.0
with SP10, Vienna, Austria). The analyzed variables of
the lateral cephalograms are shown in Table I.
The variables related to skeletal morphology were
analyzed by using the Downs-Graber analysis (SNA,
SNB, and ANB angles),28,29 the Kim analysis (anterior
dysplasia indicator [APDI] and overbite deep indicator
[ODI]),26,30 and Satos denture-frame analysis.31
Briefly, the denture frame consists of 5 planes: Frank-
fort horizontal (FH), palatal plane (PP), mandibular
plane (MP), maxillary occlusal plane (OP), and AB
plane (AB), and the angles formed by these planes were
measured (Fig 1). In this study, additional measure-
ments regarding the occlusal plane were made, namely,
FH-OP(C), FH-OP(A), FH-OP(P), Mx-OP(C), Mx-
OP(A), and Mx-OP(P), to examine the relationship
between the measurements regarding the skeletal frame
and the occlusal plane configurations (Fig 2).
The FH plane was determined by using anatomic
porion and orbitale as reference points,32 and the OPs
602.e4 Tanaka and Sato American Journal of Orthodontics and Dentofacial Orthopedics
November 2008

Table II. Descriptive statistics and comparisons in different skeletal occlusion types at subsequent age periods for
white subjects*
3-4 years 6-7 years

Mean SD Significance Mean SD Significance

I vs I vs II vs I vs I vs II vs
Class I (n 15) II (n 4) III (n 9) II III III I (n 29) II (n 16) III (n 19) II III III

Denture frame ()
FH-MP 27.1 3.5 24.8 4.5 28.4 4.9 NS NS NS 23.7 4.1 23.8 3.6 26.0 4.3 NS NS NS
PP-MP 30.1 3.7 30.2 5.4 29.7 4.3 NS NS NS 27.4 3.6 28.1 4.3 28.9 5.1 NS NS NS
OP-MP NA NA NA NA NA NA 12.5 3.1 11.0 2.5 17.9 14.6 NS NS NS
AB-MP 73.6 4.1 76.8 7.1 72.0 4.9 NS NS NS 76.5 4.3 76.7 5.3 72.2 5.1 NS

Kim ()
APDI 76.3 3.1 73.1 2.0 78.4 4.4 NS NS NS 76.1 4.0 75.3 3.9 78.9 3.9 NS NS

ODI 70.7 5.4 71.3 8.0 70.8 5.2 NS NS NS 72.7 4.9 72.4 7.3 69.3 6.7 NS NS NS
Steiner ()
SNA 80.1 4.2 79.6 5.0 81.4 3.8 NS NS NS 80.7 3.4 80.7 3.5 81.0 3.9 NS NS NS
SNB 75.7 3.8 74.3 4.1 76.7 2.4 NS NS NS 76.2 3.1 75.9 3.7 76.8 2.9 NS NS NS
ANB 4.4 1.4 5.3 1.6 4.7 2.2 NS NS NS 4.4 1.7 4.8 1.3 4.2 1.8 NS NS NS
Occlusal plane ()
FH-OP(C) 12.9 3.6 10.5 2.8 14.5 2.2 NS NS NS 10.5 3.9 9.7 4.8 11.3 3.4 NS NS NS
FH-OP(A) NA NA NA NA NA NA 6.1 5.7 8.1 2.7 8.5 5.1 NS NS NS
FH-OP(P) NA NA NA NA NA NA 12.6 2.8 17.0 4.3 14.4 7.2 NS NS NS
Mx-OP(C) 74.2 4.0 74.0 1.9 74.3 3.6 NS NS NS 75.7 2.6 75.9 3.9 75.8 3.9 NS NS NS
Mx-OP(A) NA NA NA NA NA NA 78.5 5.2 78.1 1.0 76.9 6.8 NS NS NS
Mx-OP(P) NA NA NA NA NA NA 72.0 3.2 69.3 4.4 71.0 7.0 NS NS NS
OP difference NA NA NA NA NA NA 6.4 6.9 8.8 4.9 5.9 5.5 NS NS NS
(A P)

NA, not applicable; NS, not significant.

*Post hoc test.
Statistically significant at P 0.05, P 0.01, P 0.001.

1. OPs in the permanent dentition.
OP(C): maxillary OP conventional, a line drawn
from the incisal edge of the maxillary central
incisor to the midpoint of the maxillary first molar
at the occlusal surface.
OP(A): maxillary OP anterior, a line drawn from
the incisal edge of the maxillary central incisor to
the cusp tip of the maxillary second premolar.
OP(P): maxillary OP posterior, a line drawn from
the cusp tip of the maxillary second premolar to the
midpoint of the maxillary second molar or third molar
(if it has erupted) at the occlusal surface.
2. OPs in mixed the dentition.
OP(C): maxillary OP conventional, a line drawn
from the incisal edge of the maxillary central
permanent incisor to the midpoint of the maxillary
first permanent molar at the occlusal surface.
OP(A): maxillary OP anterior, a line drawn from
the incisal edge of the maxillary central permanent
incisor to the cusp tips of the maxillary second
deciduous molar.
OP(P): maxillary OP posterior, a line drawn
from the cusp tips of the maxillary second decidu-
ous molar to the midpoint of the maxillary first
permanent molar at the occlusal surface.
3. OP in the deciduous dentition.
OP(C): maxillary OP conventional, a line drawn
from the incisal edge of the maxillary central
deciduous incisor to the distobuccal cusp tip of the
maxillary second deciduous molar.
Statistical analysis
Statistical analyses were performed with the SPSS
program for Windows program (version 13.0J, SPSS
Japan, Tokyo, Japan). In addition to standard descrip-
tive statistical calculations (means and standard devia-
tions), the ANOVA test was used to evaluate differ-
ences among the 3 groups. When ANOVA yielded
significant results indicating that at least 1 group was
significantly different from the others, post-hoc analy-
ses (Tukey, Bonferroni, Scheff tests) were also per-
formed for multiple group comparisons to determine
which group significantly differed. The statistically
significant levels were predetermined at P 0.05, P
0.01, and P 0.001. Additionally, to report intra-
group longitudinal changes in OP inclination, the Stu-
American Journal of Orthodontics and Dentofacial Orthopedics Tanaka and Sato 602.e5
Volume 134, Number 5

Table II. Continued

8-10 years 12-14 years

Mean SD Significance Mean SD Significance

I vs I vs II vs I vs I vs II vs
Class I (n 34) II (n 32) III (n 20) II III III I (n 39) II (n 27) III (n 22) II III III

Denture frame ()
FH-MP 22.8 3.8 23.6 4.9 24.8 4.5 NS NS NS 22.3 4.2 23.3 4.8 24.1 5.4 NS NS NS
PP-MP 26.1 3.9 27.6 4.9 27.5 6.1 NS NS NS 25.2 4.4 25.7 3.9 26.3 5.5 NS NS NS
OP-MP 11.6 3.1 12.7 4.9 13.4 4.6 NS NS NS 12.5 3.3 11.0 2.5 13.9 5.0 NS NS NS
AB-MP 75.6 4.3 76.8 7.1 70.9 5.9 NS
75.2 4.5 76.7 5.3 69.3 6.8 NS

Kim ()
APDI 78.0 3.8 74.1 3.6 81.6 3.9 NS
74.1 3.6 76.2 4.5 84.4 4.6

ODI 72.3 5.7 74.3 6.9 68.2 7.7 NS

72.3 5.3 75.7 6.8 67.2 7.9 NS

Steiner ()
SNA 80.3 4.0 79.5 4.4 81.7 4.3 NS NS NS 80.6 4.0 80.4 4.0 81.3 4.1 NS NS NS
SNB 76.9 3.4 74.7 3.5 78.8 3.3
NS
77.5 3.0 75.9 3.7 79.4 3.0 NS NS

ANB 3.4 1.6 4.8 1.9 2.8 1.6

NS
3.1 1.6 4.5 2.1 2.0 2.2
NS

Occlusal plane ()
FH-OP(C) 11.6 4.4 10.4 4.7 11.1 2.6 NS NS NS 9.8 4.1 11.5 4.5 10.2 2.9 NS NS NS
FH-OP(A) 10.9 5.5 8.6 6.2 9.8 3.2 NS NS NS 9.0 5.2 10.4 5.0 10.1 3.2 NS NS NS
FH-OP(P) 12.9 3.5 14.4 3.3 13.0 2.9 NS NS NS 12.6 3.5 15.9 4.5 11.5 4.2
NS

Mx-OP(C) 75.0 3.8 75.6 3.7 76.2 2.6 NS NS NS 77.3 3.4 76.1 3.5 77.7 3.1 NS NS NS
Mx-OP(A) 75.7 4.9 77.4 5.1 77.2 3.0 NS NS NS 78.1 4.3 77.2 4.0 77.8 3.3 NS NS NS
Mx-OP(P) 73.6 2.9 71.5 3.7 74.0 3.9
NS
74.5 4.4 71.8 3.9 76.4 5.0
NS

OP difference 2.1 4.9 5.8 6.9 3.2 4.2

NS NS 3.5 6.3 5.4 5.1 1.4 2.4 NS NS NS
(A P)

dent t test was used to compare the change of the OPs
in each group (Class I, Class II, and Class III) over time
at the different age intervals (P 0.05). Pearson prod-
uct moment correlation coefficients were calculated to
estimate the relationship between the OP and the
dentoskeletal configurations.
Data analysis was performed in the total sample,
and no classification was made according to sex,
because there was no significant differences in vari-
ables related to the OP between the sexes.
To assess the cephalometric method error, dupli-
cate tracings and measurements of 30 randomly
selected lateral cephalograms were made by the same
investigator (E.M.T.) after 20 days. Dahlbergs cal-
culation33 and Houstons coefficient of reliability34
were used to determine sufficient reliability and
measurement accuracy. Random errors ranged from
0.15 to 0.65 for the angular measurements, and
Houstons reliability ranged from 0.87 to 0.99. No
systematic errors were detected at the 10% level of
significance.
RESULTS
Of the total sample of 102 subjects, 42 were
classified as Class I (41%), 38 as Class II (37%), and 22
as Class III (22%) based on the APDI.26 The results and
the statistical comparisons of the 3 dentoskeletal frame
groups at each age interval are shown in Table II.
There were no significant differences among the 3
groups in the measurements related to the denture-
frame analysis, although there was a notable tendency
for FH-MP and PP-MP to decrease through the years.
The values for OP-MP became close to normal (aver-
age, 12.1) after the growing period in all groups when
the OP(C) was considered. The AB-MP angle started to
show significance from 6 to 7 years; it was significantly
higher in Class I vs Class III and Class II vs Class III
from 8 to 14 years, and more significantly different in
Class I vs Class II and Class II vs Class III from 16 to
20 years. This might indicate the different mechanisms
of anteroposterior mandibular adaptation.
The ODI (mean SD, 74.50 6.07)30 did not
have statistical significance in the 3 to 7 age groups, but
it did change significantly in the 8 to 18 age groups,
showing no statistical significance and reaching normal
values for overbite among the 3 groups at the end of the
growing period. As we expected, the APDI was not
significant at earlier stages, but it became significantly
higher with growth and development in the 3 dentoskel-
etal groups. Similar behavior was observed for the
ANB angle, but no significant difference was found
between Class I and Class III.
602.e6 Tanaka and Sato American Journal of Orthodontics and Dentofacial Orthopedics
November 2008

Table II. Continued

16-17 years 18-20 years

Mean SD Significance Mean SD Significance

I vs I vs II vs I vs I vs II vs
Class I (n 31) II (n 29) III (n 16) II III III I (n 33) II (n 12) III (n 12) II III III

Denture frame ()
FH-MP 21.2 4.8 21.8 5.9 21.5 4.5 NS NS NS 20.2 3.9 19.4 7.2 18.8 3.7 NS NS NS
PP-MP 23.5 4.6 24.3 5.2 22.4 5.6 NS NS NS 22.3 4.1 22.5 6.8 19.5 6.3 NS NS NS
OP-MP 13.2 4.1 13.1 4.4 13.4 4.2 NS NS NS 12.2 4.0 12.3 6.2 12.0 4.0 NS NS NS
AB-MP 74.4 5.6 79.5 7.2 70.2 6.7
NS
75.3 4.6 81.8 8.2 72.6 5.9
NS

Kim ()
APDI 82.1 2.9 76.2 4.4 87.3 3.6
82.4 2.2 75.7 2.1 87.9 1.3

ODI 72.1 6.3 77.0 8.4 69.2 8.6

NS
73.2 5.5 78.7 9.6 71.9 9.0 NS NS NS
Steiner ()
SNA 81.1 3.9 79.9 4.3 84.4 4.4 NS
80.7 3.7 81.2 3.5 84.2 4.4 NS
NS
SNB 78.9 2.8 75.7 3.6 82.8 3.3
78.5 3.1 76.6 2.9 82.8 3.6 NS

ANB 2.3 1.9 4.2 2.1 1.6 2.3

NS
2.3 1.7 4.6 2.0 1.4 1.7
NS

Occlusal plane ()
FH-OP(C) 7.9 3.8 9.1 4.2 7.9 2.7 NS NS NS 8.0 3.5 8.3 4.9 7.0 2.6 NS NS NS
FH-OP(A) 7.5 4.6 8.3 5.7 7.7 3.1 NS NS NS 7.7 4.2 8.2 6.6 7.2 2.6 NS NS NS
FH-OP(P) 11.7 2.8 14.6 3.8 10.8 2.7
NS
11.3 2.7 13.8 3.3 8.7 2.9

Mx-OP(C) 79.7 3.5 78.4 2.5 81.1 3.6 NS NS

79.9 3.5 78.7 3.9 82.3 4.8 NS NS NS
Mx-OP(A) 80.2 4.3 79.2 3.9 81.3 4.0 NS NS NS 80.2 4.1 78.7 5.1 82.1 4.8 NS NS NS
Mx-OP(P) 76.0 3.4 72.9 4.6 78.2 4.0
NS
76.6 3.2 73.1 4.6 80.6 4.4

OP difference 4.2 4.6 5.4 5.1 3.1 2.4 NS NS NS 3.6 4.3 5.6 7.0 1.5 3.5 NS NS NS
(A P)

SNA angle was significant in Class I vs Class III
and Class II vs Class III, but only from 16 years
onward. The SNB values were significantly different
among the Class I, Class II, and Class III groups,
almost from the beginning of the growing period.
Measurements derived from the OP(C) and the
OP(A) did not show a statistically significant differ-
ence between any pairs in the groups. However,
measurements related to the maxillary posterior oc-
clusal plane, or more exactly, FH-OP(P) and Mx-
OP(P), showed a progressive tendency to increase
during the growing period, reaching statistical sig-
nificance at 12 to 14 years and 8 to 10 years,
respectively. This was especially observed in Class I
vs Class II and Class II vs Class III, but statistical
significance was also reached for Class I vs Class III
after the growing period (Figs 3 and 4). The Class II
group had steep posterior occlusal planes and the
Class III group had flat posterior occlusal planes in
the maxilla. Notably, these changes were also evi-
dent when analyzing the longitudinal behavior of this
parameter in each group. For the Class I group, there
was no significant difference over time for the cant of
the OP(P) from the beginning (12.6) to the end
(11.3) of the growing period (P 0.05). This might
explain why the cant of the OP has a tendency to decrease
but remains constant in a normal value during the growing
period while the mandible is adapting to obtain a Class I
position. In the Class II group, the OP(P) did not differ
significantly; it maintained an inclined (steep) plane from
the beginning (17.0) to the end (13.8) of the growing
period (P 0.05). But the Class III group showed a
significant change over time for the OP(P) from the
beginning (14.4) to the end (8.7) of the growing period,
more specifically between 16 and 20 years (P 0.05),
with marked flattening decreasing from 10.8 to 8.7.
Statistically significant correlations were found be-
tween FH-OP(P) and APDI (r 0.505, P 0.000);
Mx-OP(P) and APDI (r 0.548921, P 0.000);
Mx-OP(P) and PP-MP (r 0.50345, P 0.000),
FH-OP(P) and SNB (r 0.50419, P 0.000); and
Mx-OP(P) and SNB angle (r 0.4083, P 0.000).
These results indicate a progressive tendency
through the years for consistency (significance and
correlation) between the OP(P) inclination (FH-OP[P],
Mx-OP[P]) and mandibular position (SNB) reflected in
the appearance of a certain type of dentoskeletal frame
(APDI, ANB).
DISCUSSION
Many longitudinal growth studies have investigated
the changes in the skeletal pattern with age.35-43 There
American Journal of Orthodontics and Dentofacial Orthopedics Tanaka and Sato 602.e7
Volume 134, Number 5

Fig 3. Schematic representation of the average changes and comparison of the FH-OP(P) in the
different dentoskeletal frames (Class I, Class II, and Class III) during the growing period (6-20 years).
Statistical significance was reached at 12-14 years among the 3 classes.

Fig 4. Schematic representation of the average changes and comparison of the Mx-OP(P) in the
different dentoskeletal frames (Class I, Class II, and Class III) during the growing period (6-20 years).
Statistical significance was reached at 8-10 years among the 3 classes.
602.e8 Tanaka and Sato
Fig 5. Continuous horizontalization of the OP accom-
panied by simultaneous reduction of the FH-MP as the
mandible adapts more or less forward (AB-MP) during
growth and development.
is no doubt regarding the increase of mandibular
prognathism with age35-43 associated with decrease in
the angle of convexity and the angulation of the lower
border.37 Previous findings also showed that, as age
increased, growth at menton is related to the steepness
of the MP: a steep plane shows more vertical and less
horizontal growth than a flat or horizontal plane.38,39
On average, the MP and the OP tend to rotate forward
with age, denoting a relationship between OP alteration
and mandibular adaptation during growth and develop-
ment.40,41 Some studies have lent credibility to this
longitudinal clinical observation arising from normal
growth and have substantiated that the gradual flatten-
ing of the maxillary OP causes a decrease in the FH-MP
angle and concomitantly, a decrease in the PP-MP
angle, indicating anterior rotation of the mandible; this
seems to be closely related to AB-MP for the antero-
posterior relationship of both jaws.42,43
We evaluated the longitudinal OP alteration related to
the development of different dentoskeletal frames in white
subjects in the growing period. In our longitudinal sample
of 120 subjects, different maxillary OPs were measured
(conventional, anterior, and posterior) because of the
variability of each dentofacial morphology.
In effect, our findings also showed continuous hori-
zontalization of the OPs accompanied by simultaneous
reduction of the mandibular plane angle (FH-MP, PP-MP)
as the mandible adapts more or less forward (AB-MP)
American Journal of Orthodontics and Dentofacial Orthopedics
November 2008
during growth and development (Fig 5). However, no
significant differences were found in the OP(C) and
OP(A) among the groups. Instead, the OP(P) seemed to
be the key point responsible for the changes in man-
dibular position and the subsequent development of a
certain type of dentoskeletal frame.
The OP is the plane of displacement of the mandi-
ble in the anteroposterior direction during function and
growth, and in abnormality. Thus, the angle of this
plane with the direction of the resultant muscle pull on
the mandible has etiological and prognostic signifi-
cance.44 How then is the OP established during growth
and development?
As stated by Schudy,5 it is assumed that the position
of the OP is determined largely by the vertical growth
of the maxillary teeth, and the inclination of the OP is
determined largely by the growth of the dentoalveolar
bone. From this assumption, it makes sense to trigger a
specific point, the vertical dimension of occlusion.
The decrease in the cant of the OP related to the FH
plane, or the PP, also reflected that, on average, the
maxillary molar moves down to a greater extent than
the maxillary incisor during growth. Therefore, the face
as a whole appeared to decrease in its divergence
during normal growth, and this might support the
concept that many malocclusions can be associated
with discrepancies in the vertical dimension and result
in changes in the anteroposterior dental and jaw rela-
tionships.45,46 This is consistent with recent research
findings of larger values due to extrusion of the
maxillary molars in Class III patients47 and a steeper
OP(P) with insufficient vertical height of the maxillary
second molars in Class II patients.45,46
An outstanding and consistent outcome of our
research was the progressive tendency toward statistical
significance for the maxillary posterior occlusal plane
(FH-OP[P] and Mx-OP[P]) in accordance with mandib-
ular positioning (SNB) and the appearance of sagittal
intermaxillary discrepancy, as measured by both APDI
and ANB angles. Interestingly, statistical significance
was reached at 12 to 14 years among Class II vs Class
I and Class III, corresponding with the period in which
completion of the permanent dentition is expected with
the final eruption of the second molars and the estab-
lishment of the OP(P).48 This constitutes one more
significant fact to consider the OP(P) as a determinant
for malocclusion. Additionally, a significant difference
between Class I and Class III subjects was observed
only at 18 to 20 years, suggesting the possibility for the
development of a Class III malocclusion because of
some causal factor that could have altered the inclina-
tion of the OP after the growing period.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 134, Number 5
Fig 6. Correlation between the OP(P), measured by the FH-OP(P), and A, anteroposterior
maxillomandibular relationship (APDI); B, mandibular position (SNB).
It was postulated that the position of the OP in the
denture frame can be greatly influenced by a tooth-to-
denture base discrepancy posterior to the first molar
(posterior discrepancy) due to the squeezing out
effect that causes overeruption of the maxillary and
mandibular posterior teeth. Consequently, a less steep
OP develops and adversely affects the vertical dimen-
sion (elongation) of the dentition; this interferes with
the functional occlusion and induces malpositioning of
the mandible followed by abnormal mandibular condy-
lar growth in the developing skeletal Class III maloc-
clusion.49 Based on our findings, posterior discrepancy,
in addition to the eruption force of the third molars
(from 17-21 years)48 at the end of the growing period,
should be considered a probable causative factor for the
abrupt flattening of the OP in Class III development,
because this condition was seen in most patients (19 of
22; 86%) of our Class III sample, caused mainly by a
discrepancy in both maxillary and mandibular molars
(63%) or only in the maxillary molars (32%). In
comparison, Class I and Class II groups had a lower
prevalence of posterior discrepancy; 43% (18 of 42
patients) and 57% (22 of 38 patients), respectively, due
mainly to the discrepancy in the mandibular molars
(61% and 50%) or in both jaws (33% and 41%).
As for the ODI,30 the statistical significance ob-
served in the 8 to 17 age intervals might represent the
different skeletal adaptations to the changes in the
occlusal configuration during growth. Noteworthy is
the observation that, when there was statistical signif-
icance, higher values in Class II indicated a tendency
for a deep bite; lower values in Class III denoted a
tendency for open bite. However, no statistical signif-
icance and normal values for the ODI were found in the
Tanaka and Sato 602.e9
3 groups at the end of the growing period. This leads us
to consider the extraordinary functional capacity of the
mandible to adapt to the maxillary occlusal surfaces to
achieve function (optimum and maximum occlusal
relationship) in this study sample.
The correlation analysis also showed a relationship
between the magnitude of OP(P) inclination and man-
dibular position. The smaller the OP(P) angle measured
by the FH-OP(P), the more forward the mandibular
position in congruence with the dentoskeletal type, and
vice versa, as indicated by the SNB and APDI angles
(Fig 6). However, it is difficult to establish a cause-
and-effect relationship from these results, since other
factors could also be involved (eg, condylar growth)
and should be evaluated with our outcomes. But it
would be reasonable to assume, from these longitudinal
growth findings, that any change in the inclination of
the OP would alter the mandibular position relative to
the maxillary occlusal surfaces as well as the condylar
adaptive response to it. This, in turn, might influence
the skeletal pattern and type of malocclusion.
Nevertheless, our data suggest a link between the
cant of the OP and the development of dentoskeletal
frames caused by mandibular retrognathism or progn-
athism. This relationship was especially observed in
Class II subjects, in whom a steep OP was associated
with decreased mandibular prognathism, and Class III
subjects, in whom a flat OP was associated with
increased mandibular prognathism than that in the
Class I subjects.
It is likely that the inclination of the maxillary
posterior occlusal plane (OP[P]) during growth and
development is a factor corroborating with the contin-
uous adaptive capacity of the mandible.
602.e10 Tanaka and Sato
CONCLUSIONS
From this study, the following conclusions can be
drawn.
1. The cant of the OP(P) appears to play a pivotal role
in the establishment of different dentoskeletal frames.
2. The cant of the OP(P) is significantly different
in the dentoskeletal groups. The OP is steeper in
those with Class II malocclusions and flatter in
Class III subjects than that in the Class I occlusion
group.
The findings of this longitudinal investigation sub-
stantiate previous findings regarding the significance of
the OP and elucidate a different point of view for
evaluating malocclusions. Therefore, an etiologic ap-
proach based on the OP control might be an important
factor to consider in the treatment of malocclusion.
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