Reaction of the pterygomaxillary fissure and the

condylar cartilage to intermaxillary Class III

magnetic mechanics
Alexander D. Vardimon, DMD, ~ T. M. Graber, PhD, DMD, b Jeanne Stutzmann, DSc, c
Lawrence Voss, DDS, b and Alexander G. Petrovic, MD, DSc c
Tel Aviv, Israel, Chicago, 111., and Strasbourg, France

The skeletal reaction to Class Ill intermaxillary magnetic mechanics was previously found to affect
two target areas, the pterygomaxillary fissure (PMF) and the condylar cartilage. The objectives of
this study were to analyze, radiographically and histologically, the response of these tissues to Class
Ill intermaxillary functional orthopedic magnetic appliance (FOMA III), and to postulate possible
models of their dichotomous biomechanism. Nine Macaca fascicularis monkeys received periodic
administration of vital bone procion dye and were treated for 4 months with FOMA Ill (6 subjects)
and sham appliance (3 subjects). The PMF (the target area of the midfacial complex) demonstrated
a decreased skeletal reaction in inferosuperior and lateromedial directions. Cephalometrically, the
lowermost PMF point was displaced inferiorly 1.98 _ 1.74 mm and 0.42 -+ 0.38 mm and anteriorly
1.42 _ 0.96 mm and 0.58 _+ 0.38 mm in the treated and control groups, respectively. The
displacement of the uppermost PMF point, compared with the lowermost point, was three to five
times lower. Histologically, two modes of response were found; first, a sutural response
(disarticulation and osteogenesis) of the palatomaxillary and pterygopalatine sutures, which was
distinctive of the lateral PMF aspect, and second, a dentosutural response, which was characteristic
of the medial PMF aspect (bony microfractures between the third molar germ and the maxillary
tuberosity in conjunction with mild sutural response). In the mandible, a discrepancy was found
between the histologic and the cephalometric findings. Radiographically, mandibular length was
unaffected after 4 months of treatment, and the distance condylion-pogonion was equally increased
in the treated (0.75 _ 0.78 mm) and the control animals (0.77 +_ 0.32 mm). Histologically, however,
the condylar cartilage demonstrated increased osteoclastic activity at the zone of endochondral
ossification and a decreased apposition rate at the adjacent bony trabeculae. Conceivably, the two
target areas (PMF sutures versus condylar cartilage) demonstrate two diverse time-related
responses that are either unrelated or interrelated to each other. An unrelated tissue response
suggests that tissue stimulation (sutural) is always superior to tissue suppression (condylar). Another
possible unrelated tissue reaction implies diverse response velocity (high sutural, low condylar). An
interrelated mechanism suggests that an applied force will dissipate initially at the less resistant
target area (sutures), and will subsequently affect the more resistant target area (condyle) once the
sutural resistance exceeds a certain threshold. The fact that no pathologic change was found in the
condylar cartilage encourages a long-term use of the FOMA III appliance, initiating treatment at an
early skeletal age. (AM J ORTHOO DENTOFACORTHOP 1994;105:401-13.)

I n the young rat, the retropulsion of the man-
dible induces a statistically significant decrease in the
n u m b e r of dividing prechondroblasts, i.e., a decrease
Study was supportedin part by the KenilworthDentalResearchFoundation
and the DeutscheForschungsgemeinschaft(DFG)grantSchm232/2-1.
'Section of Orthodontics,the Mauriceand GabrielaGoldschlegerSchoolof
DentalMedicine,Tel AvivUniversity,Tel Aviv,Israel.
bAmerieanDentalAssociationResearchInstitute,Chicago, I11.
'Departmentof Physiology,NationalInstituteof HealthandMedicalResearch,
Strasbourg, France.
Copyright9 1994by the AmericanAssociationof Orthodontists.
0889-5406194153.00 + 0 8/1139425
in the growth rate of the condylar cartilage, a closing
of the angle between the corpus and the ramus, a slow-
ing down of mandibular lengthening, and an increase
in the number of serial sarcomeres of the lateral pter-
ygoid muscle. ''2 However, in human beings and pri-
mates, the skeletal reaction of the facial complex to
orthodontic Class III mechanics is usually characterized
by a limited mandibular response and a moderate max-
illary response. Mandibular retrusive force produces
almost no pure growth deceleration of the condylion-
pogonion length, 3-~ but rather causes a change in the
condylar growth direction6"7 or influences regions not

401
402 Vardimon et al.
Fig. 1. Functional orthopedic magnetic appliance (FOMA) III
consisting of an upper plate with a translatory magnetic screw,
i.e., a retraction screw (RS) bearing a magnet (MU), and a lower
plate with a stationary magnet (ML). The two magnets are in
attractive force configuration and the upper magnet always re-
sumes a posterior position with respect to the lower magnet.
The maximal attractive vertical force (F,.,,~, = 3.72 N) devel-
oped in the system was three-fold greater than the maximal
attractive sagittal (horizontal) shearing force (Fh~, = 1.16 N).
directly involved in mandibular length reduction, such
as closure o f gonial angle 7~~ and an augmented appo-
sitional rate of the coronoid process. 8,it In contrast,
protrusive maxillary force causes a direct increase in
the maxillary length, as indicated by an advancement
o f point A 12-14 and a n increase in the S N A angle, t~'t6
Intramaxillary mechanics, such as a chin cap and re-
verse headgear, produces the described response in the
mandible 2"7"9''~ and midfacial complex, t'-,t4.~,'6.'8 re-
spectively, whereas intermaxillary mechanics, with a
force system equally transmitted to both jaws, produces
the described combined effect, tg2t In a previous study, 4
two target areas* were responsible for this combined
response: the pterygomaxillary fissure (PMF) in the
maxillofacial complex and the condyle in the man-
dible.
The objectives o f this study were to investigate the
histologie and radiographic changes in these target areas
on application o f intermaxillary Class III magnetically
induced mechanics and to postulate possible models o f
the dichotomous biomechanism.
MATERIALS AND METHODS
Nine female Macacafascicu/aris monkeys of mixed den-
tition age were divided into treated and untreated groups of
six and three animals, respectively. The treated group received
Class III intermaxillary mechanics in the form of functional
orthopedic magnetic appliances (FOMA) 1II for 4 months;
the control group received sham appliances. The FOMA 11I
*Target area refers to the bony zone v.'here a cascade skeletalresponseto
orthodontictreatmentis initiated.
American Journal of Orthodontics and Dentofacial Orthopedics
April 1994
Fig. 2. Schematic drawing of en block section of pterygomax-
il/ary fissure (PMF) as processed for histologic studies.
has been previously described.4 Briefly, FOMA III (Fig. 1)
consists of upper and lower Hawley-type retainers, with a
magnetic unit attached to each appliance. The two magnetic
units are in attractive force configuration and are made of
rare-earth permanent magnets, such as SmCos, Sm2Co,7, or
Nd2Fe~4B (Permag, Elk Grove, I11.). The lower magnet is
permanently linked to the Hawley-type appliance in maximal
proximity to the lingual surface of the mandibular central
incisors. The upper magnet is attached to a retraction screw
and affixed to the upper plate. The vertical attractive force
(F,) that develops between the magnets is on the order of
F, .... = 3.72 N.* A partial overlap is maintained between
the two magnets at maximal mouth closure position, i.e., the
upper magnet always resumes a posterior position with respect
to the lower magnet. The sagittal (horizontal) shearing force
(Fb) that develops between the magnets is on the order of
F,.,,~, = I. 16 N and produces an intermaxillary force system
consisting of a protractive force vector to the maxillary jaw
and a retractive force vector to the mandibular jaw. Reacti-
vation is accomplished by periodic posterior repositioning of
the upper magnet.
The animals received vital bone marker~2 in the form of
Procion red H-8B dye (chloro-s-triazine compound) (Poly-
sciences Inc., Warrington, Pa.), 80 mg/kg body weight, every
3 weeks. Standardized lateral radiographs were taken peri-
odically every 3 weeks. During euthanasia, animals were
heparinized and perfused with 10% neutral phosphate buff-
ered formalin. Blocks of the temporomandibular joint (TMJ)
were processed through routine histologic techniques for non-
decalcified tissues. Blocks of the pterygomaxillary region
(Fig. 2) were processed through routine histologic techniques
for decalcified tissues (because of the difficulties in sectioning
the crown of the maxillary third molar germ in nondecalcified
techniques). The blocks were cut parasaginally alternately at
8 I.tm and 12 ixm. Sections were harvested systematically.
*One Newton is the force required to accelerate a mass of 0.102 kg at
1 m/s2 (1 N = 102 gf).
American Journal of Orthodontics and Dentofacial Orthopedics Vt'lgdhnot! et al. 403
Voh,me 105, No. 4

Thin sections of the pterygomaxillary block were stained with s-'q I I I i I /

hemotoxylin and eosin (H&E), and those of the TMJ block I PMF vertical displacement
were stained with H&E, modified Movat's pentachrome, 2~
and Goldner stain techniques. :4 Thick nonstained sections of
both blocks were studied on fluorescent microscopy.
i iJ I I ~ ~ ~ 9 io.er PMF point
RESULTS
Pterygomaxillary fissure (PMF)
Radiographically, the horizontal and vertical dis-
9 "ilill//p a i t
placements of the uppermost and lowermost points of
the pterygomaxillary fissure were measured from mag-
nified tracings of the before and after treatment lateral
cephalograms. Superimposition was performed on the
posterior clinoid process (PCP) to N line, with the PCP
point serving as a constant reference landmark. It was
found that the upper PMF point was displaced vertically
(inferiorly) 0.42 • 0.52 mm and 0 mm (Fig. 3, A),
and horizontally (anteriorly) 0.48 • 0.18 mm and s-(ll I I I I I I I i(i
0.58 • 0.36 mm (Fig. 3, B) in the treated and control

'H i'r~ H
groups, respectively. The lower PMF point changed
vertically (inferiorly) 1.98 _+ 1.74 mm and 0.42 -
0.38 mm (Fig. 3, A) and horizontally (anteriorly) [] upper PMF point
1.42 • 0.96 mm and 0.58 • 0.38 mm (Fig. 3, B) in |
the treated and control groups, respectively. g
Since the PMF is circumscribed by diverse sutures
along its three-dimensional boundaries, its tissue re-
action was studied histologically according to three re-
gions: the lateral upper aspect of the PMF, the lateral
i -

lower aspect of the PMF, and the medial aspect of the

PMF (Fig. 4). The lateral upper section of the PMF,
which is formed by a sutural juncture between the sphe-
noid, zygoma, and the maxilla bones (Fig. 4, A
and B), illustrated a dormant activity of the correspond-
ing sutures in the untreated animals (Fig. 5, A). In the
treated animals, sutures at the superior border of the
fissure, particularly the zygomaticomaxillary suture,
demonstrated a moderate appositional activity.
The lateral lower aspect of the pterygomaxillary
fissure is formed by a sutural juncture between the pos-
terior end of the maxillary alveolar process, the pyra-
midal process of the palatine bone, and the spheno-
maxillary surface of the pterygoid plate of the sphenoid
bone (Fig. 4, A and C). 25"26The two involved sutures,
the palatomaxillary and the sphenopalatine (pterygo-
palatine), demonstrated an inert remodeling condition
in the control group (Fig. 5, B and C).
In the FOMA IIl treated animals, two modes of
sutural reaction were found. In the first type (Fig. 6),
the palatomaxillary and pterygopalatine sutures disar-
ticulated. This type of expansion often occurred on the
lateral aspect of the fissure. The second type, the mixed
dentosutural reaction (Fig. 7) occurred more often on
the medial aspect of the fissure, where coherent artic-
I 2 3 4 5 6 7 6 9
CBS~
Fig. 3. Sagittal displacement of uppermost and lowermost
points of pterygomaxillary fissure (PMF) in treated and control
groups. A, Vertical (inferior) displacement; B, horizontal (an-
terior) displacement.
ulations are found between the pyramidal process and
horizontal plate of the palatine bone and the maxillary
tuber, anteriorly (Fig. 4, D and F) and, posteriorly,
between the vertical plate and orbital process of the
palatine bone and the medial pterygoid process and the
greater wing of the sphenoid bone, respectively (Figs,
4, D and E). 25'26 In this mode of response, the maxillary
third molar germ was partially dissociated from the
maxillary tuberosity in conjunction with a split in the
palatomaxillary suture. However, the sutural reaction
on the medial aspect was less prominent than on the
lateral aspect. The dental effect was delineated by a
surge in bony sequester along the juncture between the
404 Vardimon el al. American Journal of Orthodontics and Dentofacial Orthopedics
April 1994

Y
i" !

, i

,j

Fig. 4. Pterygomaxillary fissure of Macaca fascicularis. A, Lateral view. B, Higher magnification of the
upper region of the lateral PMF aspect (area 1 in A) demonstrating complex junctional articuIation
between the maxillary (M), zygoma (Z), and sphenoid (S) bones forming the zygomaticomaxillary
suture (ZMS) and sphenozygomatic suture (SZS). C, Higher magnification of the lower region of the
lateral PMF aspect (area 2 in A) demonstrating short articulation between the pyramidal process (Py)
of the palatine bone and the maxillary tuber (T), forming the palatomaxillary suture (PMS), and between
the pyramidal process and the lateral pterygoid process (LPt) of the sphenoid bone forming the
pterygopalatine suture (PPS) (sphenopalatine suture). D, Medial view. E, Higher magnification (area
1 in D) displaying extended interface between the vertical plate (VP) and sphenoid process (SP) of
the palatine bone and the medial pterygoid process (MPt) of the sphenoid bone forming the ptery-
gopalatine suture (PPS) (sphenopalatine suture). F, Higher magnification (area 2 in D) demonstrating
tortuous articulation between the pyramidal process (Py) and horizontal plate (HP) of the palatine bone
and the maxillary tuber (T), forming the palatomaxillary suture (PMS).

alveolar socket of the third molar and the maxillary mental lines during elongation of the sutural processes
tuberosity (Fig. 7, B). confirms the extensive appositional activity of sutures
The fluorescent microscopy corroborates these find- at the inferior border of the fissure (Fig. 8, A and B).
ings. The distinguished separation of the bony incre- The incremental lines of the control animals were not
American Journal of Orthodontics and Dentofacial Orthopedics Vardimon et al. 405
Voh~me 105, No. 4

Fig. 5. Lateral PMF aspect of a control animal. A, Superior region with a dormant sphenozygomatic
suture (SZS) (H&E stain, x 14). B, Inferior region, both the palatomaxillary suture (PMS) and the
pterygopalatine suture (PPS) demonstrate an inert remodeling condition (H&E stain, x 12). C, Higher
magnification of the delineated area in B, illustrating a normal remodeling activity of resorption (R) and
apposition (A) in the pterygopalatine suture (H&E stain, x 63).

only less segregated, but interruption in their continuity
was clearly visible (Fig. 8, C). This apposition ces-
sation was the result of a compressed area that under-
went resorption during the eruption of the third molar
in a distoclusal direction.
Condylar cartilage
Radiographically, the distance condylion-pogonion
increased after 4 months by 0.75 __+ 0.78 mm in the
treated animals and by 0.77 • 0.32 mm in the control
group.
Histologically, the control group showed the well-
documented five layers of the condylar cartilage (Fig.
9).4"27 The reaction of the TMJ to FOMA III was char-
acterized by increased clastic activity at the zone of
endochondral ossification of the condylar cartilage and
the adjacent trabecular bone (Fig. 10, A and B). How-
ever, it should be emphasized that the four other layers
of the condylar cartilage, i.e., fibrous capsule, zone of
growth, zone of maturation, and zone of erosion, re-
mained intact (Fig. 10, B and C). Furthermore, the
extent of bone marrow space at the condylar neck in-
creased, especially at the area in close proximity to the
condylar cartilage (Fig. 10, A and B). The postglenoid
process showed no change in comparison with the con-
trol animal. However, an increase in osteoclastiC activ-
ity was also found at the uppermost region of the glenoid
fossa. The fluorescent microscopy of the treated group
showed a slight retardation in bony deposition along
the trabeculae at the condylar neck (Fig. 11), which
may explain the "pneumatization" effect (increased
bone marrow space) shown at the light microscopy
level.
DISCUSSION
Since the maxillary complex is confined, per side,
by six to seven bony attachments, the specifictarget
area at which the cascade osteogenic activity initiates
and propagates on application of protracting orthopedic
force depends on the point of force application (PFA). i~
Thus, Smalley et al. :8 demonstrated that when the PFA
was located extraorally, by means of osseointegrated
implants, at the primate's maxilla per se, an enlarge-
ment of the zygomaticomaxillary and palatomaxillary
406 Vardimon et al. American Journal of Orthodontics and Dentofacial Orthopedics
April 1994

Fig. 6. Sutural response found on lateral PMF aspect of treated animals. A, An integrated tuberosity
(-/') with no micro fractures and an expansion of the palatomaxillary suture (PMS)and pterygopalatine
(PPS) sutures that cause a sagittal increase in the PMF dimension (H&E stain, x6). B, Higher
magnification of the delineated area in A, illustrating disarticulated interdigitations of the palatomaxillary
suture (H&E stain, x 16).

sutures occurred, whereas when the PFA was located
at the zygoma bone per se, an excitation was initiated
at the zygomaticotemporal, zygomaticofrontal, and
sphenozygomatic sutures. Likewise, the patent pre-
maxillary suture was the target area when a protraction
force was applied directly to the rat's snout. 29 In the
case of F O M A III, and most likely any other intraoral
appliance, with forces applied to an en-block maxillary
dental arch, 172' the target area was found to be localized
in the pterygomaxillary fissure. This is due to the in-
American Journal of Orthodontics and Dentofacial Orthopedics Vardimon et al. 407
Vohtme 105, No. 4

Fig. 7. Dentosutural response found on medial PMF aspect of treated animals. A, Dissociation of the
tuberosity (/-)-dental wall (DW) juncture (H&E stain, x6). B, Higher magnification illustrating bony
sequester (BS) at the tuberosity ('/')-dental wall (DIN)juncture (H&E stain, x 16).

terruption in the coherent ana integrateta attachment of
the maxillary complex with the cranial base and vault
at two loosened attachments, the first around the zy-
gomaticotemporal space (retrozygomatic space) and its
corresponding zygomaticotemporal and zygomatico-
maxillary sutures and the second around the pterygo-
maxillary fissure (pterygopalatine fossa) and its corre-
sponding sutures, the palatomaxillary and pterygopal-
atine (sphenopalatine) sutures. A protractive force
applied at the inferior level of the maxillofacial complex
dissipates at the nearby loosened region, namely, the
PMF. The specificity of the PMF as a target area found
401] Vardimon el al. American Journal of Orthodontics and Dentofacial Orthopedics
April 1994

Fig. 8. Fluorescent microscopy of palatomaxillary suture. A, Treated animal characterized by distin-

guished and continued bony incremental lines (fluorescent microscopy, x 100). B, Higher magnification
of a sutural process demonstrating substantial gaps between incremental lines, i.e., increased appo-
sition rate (fluorescent microscopy, x 150). C, Control animal defined by dense and interrupted bony
incremental lines, indicating apposition cessation and resorption activity (fluorescent microscopy,
x 100).

in the present study with intermaxillary midfacial pro-

traction, contradicts the previous hypothesis of mul-
tiregional response to Class III mechanics, that is, the
zygomaticotemporal suture, zygomaticofrontal suture,
frontomaxillary suture, and pterygomaxillary suture, 3~
i.e., a response that affects all maxillary growth centers
concomitantly. 26
Three dimensionally, the separation of the sutures
at the PMF was found to diminish in inferosuperior and
lateromedial directions. This reaction may indicate the
course in which the skeletal response propagated, the
spatial boundaries to which the response was confined,
or both, that is, the propagating course and its bound-
aries. The inferosuperior direction was inferred radio-
graphically and histologically. Radiographically, the
horizontal and vertical displacements of the lower PMF
point were three and five times greater than the cor-
responding displacements of the upper PMF point, re-
spectively. Histologically, disarticulation and osteogen-
esis were likewise more eccentuated at the inferior PME

Fig. 9. Condylar cartilage of an untreated animal with normal

distribution of its five layers, i.e., fibrous capsule (FC), zone of
growth (ZG), zone of maturation (ZM), zone of erosion (ZE),
and zone of endochondral ossification (ZEO) (Movat's pen-
tachrome stain, x250).
American Journal of Orthodontics and Dentofitcial Orthopedics Vordimot! et al. 409
Volume 105, No. 4

Fig. 10. Condylar cartilage of FOMA III treated animal. A, Increased clastic activity (Goldner stain,
• 63). B, Higher magnification of area I in A, demonstrating an abundance of osteoclasts (Ost) (arrows)
concentrated along the zone of endochondral ossification (ZEO), the other four layers of the condylar
cartilage, that is: fibrous capsule (FC), zone of growth (ZG), zone of maturation (ZM), and zone of
erosion (ZE) remained intact (Goldner stain, x 250). C, Higher magnification of area 2 in A, clastic
activity (Ost) (arrows) is also prevailed at adjacent trabecular bone causing an increase in bone marrow
space (Goldner stain, x 100).

sutures than at the superior PMF sutures. The latero-
medial direction was inferred histologically, that is, a
pure sutural (skeletal) response was found on the lateral
aspect of the PMF, whereas the medial PMF aspect
showed a mixed dentosutural reaction. These two
modes of response (sutural versus dentosutural) are the
result of a diverse bony interdigitation and, conse-
quently, diverse degrees of disarticulation. The exces-
sive change found on the lateral aspect of the PMF,
especially the inferior sutures, that is, the palatomax-
illary and pterygopalatine sutures (disarticulation and
osteogenesis) is due to the fissure being interposed be-
tween two bones with short articulated interface (max-
illary tuberosity anteriorly and the tip of the pyramidal
process of the palatine bone, posteriorly). The less pro-
found sutural change found on the medial PMF aspect
(microfractures with bony sequester) is due to increase
in bony structures and in articulated interfaces (the hor-
izontal plate and the pyramidal process of the palatine
bone conjoining the maxillary tuberosity, anteriorly,
410 Vardimon el al.
Fig. 11. Fluorescent microscopy of bony trabeculae adjacent to condylar cartilage. A, Control animal,
segregated bony incremental lines indicating normal trabecular growth rate (fluorescent microscopy,
x 100). B, Treated animal, confluent bony incremental lines indicating slight retardation in osteogenesis
(fluorescent microscopy, x 100).
and the vertical plate and orbital process of the palatine
bone articulating with the root of the pterygoid plates
of the sphenoid bone, posteriorly).
The issue of separating the maxillary complex from
the cranial base at the PMF was also studied thoroughly
from a surgical point of view. During LeFort I ad-
vancement osteotomy, a fracture must be introduced at
the level of the pterygomaxillary fissure. This region is
of particular interest because of the risk of surgically
damaging the internal maxillary artery, the jugular vein
and the greater palatine neurovascular bundle. In an
attempt to develop diverse surgical techniques to coun-
teract these potential iatrogenie problems, it was found
that on application of an osteotome (surgical chisel) at
the PMF, maximal strain was developed at the medial
pterygoid plate. This strain that is directly related to
the stress was three to eight times greater than the strain
developed at the lateral pterygoid plate. 31 This result
lends support to our finding of a decrease in PMF sep-
aration capability in the lateromedial direction because
of the increased articulated interface. In 17% of the
LeFort I treated cases, 32 a small cuff of the horizontal
plate of the palatine bone remained attached to the pter-
ygoid process of the sphenoid bone that corresponds to
the increase in anatomic structural complexity in the
medial direction. Our finding of a decrease in PMF
separation capability in the inferosuperior direction is
confirmed by the study of Robinson and Hendy33 on
cadavers. The authors defined three patterns of fortui-
tous fractures associated with surgical separation of the
PMF, i.e., high level fractures, low level fractures, and
American Journal of Orthodontics and Dentofacial Orthopedics
April 1994
fractures of the maxillary tuberosity. The most common
fracture was the high level one.
The decrease in sutural response in both directions
(superior and medial) also implies that maxillary pro-
traction treatment is directly related to Melsens' sutural
complexity index, .34 and consequently linked to the age
factor. Since the complexity index increases from in-
fancy to juvenile by fourfold for the palatomaxillary
suture and by twofold for the pterygopalatine s u t u r e , 34
it is strongly recommended to initiate Class III treatment
at a deciduous dental age to accomplish disarticulation
of this target area:
Two side effects have to be taken into treatment
consideration when using intermaxillary Cla.ss III me-
chanics. The first, the net vertical displacement (treated
minus control) of the lowermost PMF point (1.56 mm)
was greater than the net horizontal displacement (0.84
mm). This suggests that major improvement in interjaw
sagittal relationship is the result of anterior (upward and
forward) rotation of the maxillary complex, 14.16.35which
dictates a posterior (downard and backward) autorota-
tion of the mandible and thus bears the potential hazard
of increased bite clearance. The second side effect, the
lesser sutural response of the medial PMF wall in com-
parison with the lateral PMF wall may generate a trans-
versal convergence of the maxillary alveolar arch, with
progression of protraction treatment. Thus, a compen-
*For a given sutural interface, the complexity index refers to the ratio between
the actual length of the contact surface divided by the shortest distance between
the two extremities of this sutural interface.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 105, No. 4
effect
k threshold
f ~
stimulation of
sutural growth
reduction of
condylar growth
lib_
A 9-- 4 months time
effect
,J
C - - 4 months
Fig. 12. Graphic presentation of sutural versus condylar response to intermaxillaryClass III treatment.
A, Unrelated response characterized by deficient condylar response. B, Unrelated response charac-
terized by delayed condylar response. C, Interrelated response characterized by catch-up condylar
response.
satory vertical intrusion and transversal expansion reg-
imen should be adjunctive to any midfacial protraction
mechanotherapy.
A discrepancy between the histologic and cepha-
lometfic findings was found with respect to the man-
dible. Histologically, a definitive suppression of en-
dochondral growth was detected, characterized by an
increase in osteoclastic activity at the zone of endo-
chondral ossification of the condylar cartilage, and a
decrease in bony apposition at the trabeculae in close
proximity to this zone. In contrast, cephalometrically,
no significant decrease in mandibular length (0.02 mm)
was observed between the treated (0.75 - 0.78 ram)
and untreated (0.77 -4- 0.32 mm) groups.
The cephalometric results per se suggest failure of
FOMA III to induce a growth reducing effect on the
mandible due to the light forces regimen of the appli-
ance (1 N) in comparison with previous applied Class
III forces (5 to 35 N), 7J2J6"18'36that is, the applied force
Vardimon et al. 411
effect
J
timulation Of
sutural growth
/
/
!i/ reduction of
" condylar growth
Ii,._
B lag ii--4 months time
stimulation of
sutural growth
y g
time
was below a desirable "orthopedic" threshold. How-
ever, in light of the histologic response of the condylar.
cartilage and the adjacent trabecular bone in the present
study, and because of numerous studies which also
demonstrate limited mandibular restraining effect and
more growth redirecting response even with heavy ("or-
thopedic") forces,3~ 5'8"9"36'37 it is difficult to accept the
concept that light versus heavy forces corresponds to
dental versus orthopedic response in the case of Class
III mechanics. It is more conceivable that the two target
tissues (PMF suture versus condylar cartilage) dem-
onstrate two diverse time related responses, which are
either interrelated or unrelated to each other.
An unrelated tissue response suggests that for any
growth site, a stimulation effect is always more effec-
tive than a suppression effect (Fig. 12, A). This is in
agreement with Petrovic et al. 2 who demonstrated that
excitation of the condylar cartilage by means of hy-
perpropulsion increased the number of labeled pre-
412 Vardimon el al.
chondroblasts by 54.8%, whereas its suppression by
means of a chincap decreased the number of labeled
cells by only 29.9%. Likewise, the sutural stimulation
was substantially more pronounced than the cartilagi-
nous suppression.
Another unrelated tissue response implies a diverse
response velocity for the two secondary growth sites
(Fig. 12, B) whereby a slow but steady increase in
condylar growth suppression requires an extended time
to reach an expression level, which was not accom-
plished after 4 months of treatment. This view is sup-
ported by the fact that even within the same tissue,
excitation velocity differs from suppression velocity.
Thus, the circummaxillary sutures with an initial lower
mitotic index than the condylar cartilage, 29 showed a
pronounced excitation (expansion) response 3s~ and a
weak suppression (compression) response. 4t43
It is also conceivable, that the Class III bio-
mechanism is an interrelated tissue response (Fig.
12, C). An applied force will dissipate initially at the
less resistant target area, such as the loosened articu-
lations of the pterygomaxillary fissure, and will sub-
sequently affect the condylar area only once the sutural
resistance to expansion exceeds a certain threshold. The
latter interpretation may suggest that in the present
study such a threshold was accomplished only shortly
before the end of the experiment.
The fact that no pathologic change was found in the
condylar cartilage encourages a long-term use of the
FOMA III appliance, initiating at an early skeletal age.
Moreover, a recent study by Petrovic and Stutzmann44
has demonstrated that hypomobility of the mandible is
more detrimental than the retractive force in Class III
correction. The threefold increase in the vertical at-
tractive force vector over the sagittal force vector in
FOMA III implies meeting the biomechanical require-
ments of the appliance.
We acknowledge R. Clayton, American Dental Associ-
ation Research Institute Animal Facility, for animal care, B.
Schulz, University of Bonn School of Dentistry, for histologic
preparation, and Ms. R. Lazar, scientific editor, and the
Maurice and Gabriela Goldschleger School of Dental Medi-
cine, Tel Aviv University, for editorial assistance.
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Reprint requests to:
Dr. Alexander D. Vardimon
Section of Orthodontics
The Maurice and Goldschleger School of Dental Medicine
Tel Aviv University
Tel Arty, Israel