CONTINUING EDUCATION ARTICLE

Maxillary and mandibular width changes studied using metallic

implants

Luiz G. Gandini, Jr, DDS, PhD,a and Peter H. Buschang, PhDb

Araraquara, Brazil, and Dallas, Texas

The purpose of this implant study was to evaluate the transverse stability of the basal maxillary and
mandibular structures. The sample included 25 subjects between 12 and 18 years of age who were followed
for approximately 2.6 years. Metallic implants were placed bilaterally into the maxillary and mandibular corpora
before treatment. Once implant stability had been confirmed, treatment (4 first premolar extractions followed by
fixed appliance therapy) was initiated. Changes in the transverse maxillary and mandibular implants were
evaluated cephalometrically and two groups (GROW+ and GROW++; selection based on growth changes in
facial height and mandibular length) were compared. The GROW++ group showed significant width increases
of the posterior maxillary implants (P < .001) and the mandibular implants (P = .009); there was no significant
change for the anterior maxillary implants. The GROW+ group showed no significant width changes between
the maxillary and mandibular implants. We conclude that (1) there are significant width increases during late
adolescence of the basal mandibular and maxillary skeletal structures and (2) the width changes are related
with growth potential. (Am J Orthod Dentofacial Orthop 2000;117:75-80)

W ith metallic implants used as stable ref- Table I. Pretreatment

(T2) and posttreatment (T3) ages
erences, Korn and Baumrind1 reported maxillary and (years) and treatment duration
mandibular widening in normal subjects 8.5 to 15.5 T2 mean T3 mean T3-T2 mean
years of age. Their rates of maxillary widening com- Groups min-max min-max min-max
pared well with those reported for implants by Björk
GROW ++ 13.9 16.7 2.8
and Skieller.2 Together, these cephalometric studies n = 13 11.7-16.9 14.5-19.9 1.2-3.5
confirm that most of the maxillary widening2-8 is due to GROW + 14.8 18.2 2.2
transverse rotation of the basal maxillary structures n = 12 12.1-18.3 14.4-20.9 0.8-3.6
around the midpalatal suture. Although mandibular COMBINED 14.2 16.8 2.6
n = 25 11.7-18.3 14.4-20.9 0.8-3.6
widening has also been reported,3,4,8-10 width increases
for basal mandibular structures have not been con-
firmed using implants. Replication of the Korn and
Baumrind1 study is important because indirect methods increases of the basal skeletal structures could effect
were used to ascertain mandibular width changes. arch length, which might have important ramifications
Potential increases of mandibular width hold impor- for the treatment of crowded malocclusions.
tant clinical and biologic implications. Biologically, The purpose of this study was to evaluate longitu-
increases in the width of the mandibular basal struc- dinal changes in maxillary and mandibular arch width
tures imply true rotational changes and ontogenetic using metallic implants as stable references. Two sub-
modeling in the symphyseal region.1 Clinically, samples were formed on the basis of their growth
mandibular width increases challenge traditional potential and compared.
notions concerning its immutability.11-13 Width
MATERIAL AND METHODS
The sample was composed of 25 patients (12 males
This research was supported by FAPESP – Fundação de Amparo à Pesquisa do
Estado de São Paulo, Brazil. and 13 females) who started treatment between 11.7
aDepartment of Orthodontics, Araraquara School of Dentistry – UNESP,
and 18.3 years of age (Table I). They were treated and
Araraquara, SP – Brazil. followed longitudinally for 2.6 years (range, 0.8 to 3.6
bDepartment of Orthodontics, Baylor College of Dentistry, Texas A & M Uni-

versity System. years). The subjects presented with Class I crowded

Reprint requests to: Dr P. H. Buschang, Department of Orthodontics, Baylor
College of Dentistry, Texas A&M University System, 3302 Gaston Avenue, Dal-
las, Texas 75246; e-mail, phbuschang@tambcd.edu
Copyright © 2000 by the American Association of Orthodontists.
0889-5406/2000/$12.00 + 0 8/1/101257
malocclusions; they were treated with 4 first premolar
extractions followed by fixed appliance therapy.
With the use of the techniques described by Björk,14
each subject had 7 metallic implants placed in the max-
75
76 Gandini and Buschang American Journal of Orthodontics and Dentofacial Orthopedics
January 2000

Fig 1. Cephalometric landmarks and implants: (1) nasion, (2) menton, (3) articulare, (4) pronasale,
(5) left posterior maxillary implant, (6) right posterior maxillary implant, (7) left anterior maxillary
implant, (8) right anterior maxillary implant, (9) left mandibular implant, (10) right mandibular implant,
and (11) symphyseal implant.

Table II.Changes (mm) of mandibular length (Ar-Me), tional radiographs were taken every 6 months until
facial height (N-Me), and horizontal nose growth (Pr) the end of treatment (T3). Transverse growth changes
Measure Mean SD SE t Probability were assessed with the radiographs taken at beginning
(T2) and end (T3) of treatment.
GROW ++ The lateral cephalograms were taken with the head
Ar-Me 6.31 3.52 0.97 6.46 <.0001*
N-Me 6.77 3.70 1.02 6.59 <.0001*
positioned in FH at standardized source-subject and
Pr (hor) 2.09 1.83 0.51 4.11 .001* subject-film distances. The PA radiographs were also
GROW + taken with the head positioned in FH at a standard
Ar-Me 1.47 1.18 0.34 4.29 .001* source-subject distance, and the film was placed to
N-Me 1.64 1.24 0.36 4.57 .001* make light contact with the nose. The distance
Pr (hor) 0.35 0.74 0.21 1.62 .132
between the anterior implants and the tip of the nose
could have increased due to growth, which would pro-
duce different magnification for the PA films taken at
illa and mandible before treatment. Informed consent T2 and T3. By measuring the distances between the
was obtained from all subjects. Four maxillary anterior maxillary implants and the pronasale, as seen
implants were placed bilaterally in the zygomatic on the lateral radiographs, we were able to adjust the
process (posteriorly) and on either side of the ante- PA films for each individual’s growth changes (aver-
rior nasal spine (anteriority). The zygomatic implants age correction factor was 0.235%).
were placed in close proximity to the key ridge. The A total of 11 anatomic and implant landmarks were
3 mandibular implants included an anterior implant identified and digitized (Fig 1). Four cephalometric
in the midline of the symphysis and 2 posterior landmarks were identified to (1) measure growth
implants placed as far as possible inferior to the first changes and (2) correct magnification due to changes
permanent molar. in the subject-film distance. The growth changes in
Cephalometric (lateral, PA) and panorex radio- total facial height (N-Me) and mandibular length (Ar-
graphs were taken to evaluate the stability of the Me) were computed. Transverse distances between
implants before treatment and to assess growth implants, as seen on the PA radiograph, were used to
changes. Radiographs taken immediately after quantify growth changes. The linear distances between
implant placement (T1) were compared with radi- the 2 mandibular implants, the 2 anterior maxillary
ographs taken 3 to 6 months later (T2) to assess implants, and the 2 posterior maxillary landmarks were
implant stability. Once it was determined that the evaluated. Transverse rotational changes were mea-
implants were stable, treatment was initiated. Addi- sured as the angular change between right and left cor-
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 117, Number 1
Table III. Width changes (mm) and rotation of the mandibular and maxillary implants
GROW ++
Mean SD SE
Mandibular 0.55 0.63 0.17
Maxillary post 0.80 0.44 0.12
Maxillary ant –.24 0.53 0.15
Maxillary rotation 4.64 5.51 1.59
Mandibular rotation 4.07 4.43 1.27
*P < .05.
pora. The anterior implant served as the vertex for
mandibular rotation; the 2 anterior and 2 posterior
maxillary implants were used to calculate maxillary
transverse rotation. Error analyses of 16 replicates
showed no systematic error and method error ranging
between 0.13 to 0.20 mm.
To evaluate the effects of age, the larger sample was
arbitrarily subdivided based on growth changes in
facial height (N-Me) and mandibular length (Ar-Me).
First, we computed the standard or z-scores for the
growth changes of each measure. Each patient’s 2 z-
scores were then summed and ranked. The 13 patients
who showed the greatest growth changes comprised the
GROW++ group and the remaining 12 patients com-
prised the GROW+ group (Table I).
The distribution of each variable was evaluated
based on its skewness and kurtosis. Means and stan-
dard deviations (SDs)were used to describe central
tendencies and dispersion. Because of the limited
sample sizes available, more conservative nonpara-
metric tests were used to evaluate changes over time.
Growth and width changes between implants were
evaluated with Wilcoxon signed-rank tests. Spearman
rank-order correlations were used to evaluate the
associations between maxillary and mandibular
implant width changes.
RESULTS
Compared with pretreatment values, the GROW++
group showed a significant (P < .0001) 6.3 mm
increase in mandibular length and a significant (P <
.0001) 6.8 mm increase in facial height (Table II). Rel-
ative to the anterior maxillary implants, the nose of
patients in the GROW++ group grew forward 2.1 mm.
The GROW+ group showed a 1.5 mm increase (P =
.001) in mandibular length and a 1.6 mm increase (P =
.001) in facial height; they showed no significant
changes in nasal projection.
Maxillary and mandibular width changes were sig-
nificantly (P < .05) greater for the GROW++ group
than the GROW+ group. The mandibular and posterior
Gandini and Buschang 77
GROW +
Probability Mean SD SE Probability
.009* 0.10 0.40 0.11 .369
<.0001* 0.18 0.38 0.11 .125
.126 –.05 0.43 0.12 .678
.021* 3.26 6.06 3.02 .139
.010* 2.67 5.84 2.6 .168
maxillary implants of the GROW++ group showed sig-
nificant widening during treatment (Table III). The dis-
tances between the mandibular and maxillary implants
increased 0.6 mm and 0.8 mm, respectively (Fig 2).
The anterior maxillary implants showed a 0.2 mm
decrease, which was not significantly (P = 0.13) differ-
ent from zero. The angle of transverse rotation also
increased significantly in both the maxilla and
mandible. The Spearman rank-order correlation
between the mandibular and posterior maxillary
implant width changes was 0.72 (P = .006); there was
no significant association between anterior and poste-
rior maxillary implant width changes. The GROW+
group showed no significant linear or rotational
changes for the mandibular or maxillary implants.
Width changes were annualized to compare indi-
viduals. All of the GROW++ group showed maxillary
width increases ranging from 0.13 mm/year to 0.54
mm/year (Fig 3). Of the 13 patients in the GROW++
group, 12 (92%) showed increases between the
mandibular implants (Fig 4).
DISCUSSION
As expected, the increases in posterior maxillary
arch width were less than previously reported during
adolescence and later childhood. Björk and
Skieller2,15 showed that posterior maxillary implant
width increased 0.4 mm/year in adolescents between
4 and 20 years of age, which compares well with the
rates reported between 8.5 and 15.5 years by Korn
and Baumrind.1 Their estimates are approximately
0.1 mm/year greater than the maxillary width
increases observed for the GROW++ group, who
were approximately 14 years of age at the initiation
of treatment. The rate differences may be attributed
to the reduced growth potential of our GROW++
sample.16 Width increases between the anterior max-
illary implants, previously shown to be less than the
posterior implants,1,15 had essentially stopped by 14
years of age, whereas the posterior implant widths
continued to increase.
78 Gandini and Buschang
Fig 2. Average increases (mm) in maxillary and
mandibular interimplant distances.
The results of this study confirm width increases of
basal mandibular structures. Mandibular implant width
of the GROW++ group increased approximately 0.1
mm/year less than the width increases reported by Korn
and Baumrind.1 This difference might again be
explained by growth potential of their younger sample.
Our older GROW+ group showed no significant
changes in mandibular width, which might be expected
given their limited growth potential and advanced age.
To understand transverse mandibular development,
3 different types of width changes should be consid-
ered. The width increase of basal structures, as
observed with implants, appears to be less than the
width increases observed in cephalometric and anthro-
pometric studies.3-5,8-10 This suggests that surface bony
deposition17 augments the width increases of the basal
structures. Although the dental arch shows some
increases during childhood,18-20 stability or actual
decrease has been reported during adolescence and
early adulthood.5,18,19,21-23 The discrepancy between
the width increases of the mandibular corpora and
decreases of the dental arch is probably due to the
decrease in arch length20,22,24 associated with mesial
movement of posterior teeth.22,24,25
Biologically, width increases of the maxillary and
mandibular basal structures imply transverse rotation
of the right and left corpora. The observed correlation
between maxillary and mandibular widths increases
suggests coordination between jaws (ie, subjects with
larger increases in posterior maxillary implant width
also showed larger mandibular implants width
increases). The maxillary transverse rotational
American Journal of Orthodontics and Dentofacial Orthopedics
January 2000
changes take place at the midpalatal suture around a
center located anterior to the incisors.1,2,15 The fact
that we found no significant width increases of the
anterior implants after 14 years of age suggests that
the center of maxillary transverse rotation moved pos-
teriorly with age. Our results suggest that the center
of transverse rotation for the mandibular basal struc-
tures is located in the symphyseal region. As indi-
cated by Korn and Baumrind,1 this implies modeling
of the symphyseal region.
Modeling of the human symphysis has been estab-
lished and may represent adaptation to mandibular
function. With the use of superimpositions on stable
mandibular reference structures, Buschang et al26
showed that the greatest sympheseal modeling changes
for growing children occur on the lingual surface.
Hylander27 associated such modeling changes with
masticatory stress on the mandible’s curved beam
structure. It has been well established with mandibular
width changes during dynamic jaw movements, such
as protrusion and opening.28,31 In addition, parasagittal
and transverse mandibular deformation and rotational
distortion occur with tooth clenching.32,33
Clinically, the results help to explain why ortho-
dontic treatment increases in posterior arch width
might be expected to remain stable over time. If the
width between the right and left corpora normally
increases, then there is no basis for maintaining the
width of the posterior arch segment throughout treat-
ment. It is important to emphasize that the observed
width changes were small and that little or no width
increase might be expected in the anterior region.
These notions are consistent with the stability of the
mandibular intercanine width18,34 and the possibility of
arch development in the molar region.35-37 It should be
emphasized that the stable mandibular widths observed
for most of the patients in the GROW+ group support
the maintenance of arch widths for older patients with
little or no growth potential.
The findings are limited by sample size and by
potential treatment bias. Although the sample size
was small, the highly significant probabilities
(<.001) obtained suggest that the growth changes
observed were real. Nevertheless, additional research
with larger numbers of subjects is required to provide
better estimates of variation in width increase that
take place throughout growth. There is also the pos-
sibility that the observed width changes were at least
partially related to the treatment performed. How-
ever, because no maxillary expansion was performed
and only fixed appliances were used to move teeth
into extraction spaces, little or no orthopedic effects
might be expected to have occurred.
American Journal of Orthodontics and Dentofacial Orthopedics Gandini and Buschang 79
Volume 117, Number 1

Fig 3. Changes (mm/year) of posterior maxillary implants width for the 13 GROW++ and 12 GROW+ patients.

Fig 4. Changes (mm/year) of mandibular implants width for the 13 GROW++ and 12 GROW+ patients.

CONCLUSION jects with the greatest growth potential showed the

In conclusion, the widths of maxillary and greatest width changes and might be expected to toler-
mandibular basal structures increase during late ado- ate the greatest amount of therapeutic expansion.
lescence. Changes in maxillary width explained
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Table IV. Annual changes (mm/year) in mandibular and maxillary implant widths
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