Variations in the Growth Pattern of the Human

Mandible: Longitudinal Radiographic Study by the

Implant Method
ARNE BJORK
Department of Orthodontics, Royal Dental College, Copenhagen, Denmark

Having been invited to speak on a subject related to growth and development, I

should like to give the first fairly detailed report of a longitudinal radiographic
cephalometric study of facial growth in children where metallic implants are used as
fixed reference points in the jaws. Although this report relates to a limited part of the
material and the data refer only to the mandible, I feel it is necessary by way of intro-
duction to outline the design of the study as a whole.
It was begun in 1951 as a series of experiments on a small group of children, but, as
the method proved to be satisfactory, the number of subjects was gradually increased
over the years, until now the material comprises 110 Danish children of both sexes.
Annual observations are being made, including somatometric registrations, and it is
intended to continue these until growth is complete or as long as the subjects are
available. As a rule, longitudinal studies of growth are planned to represent a normal
sample of the population and to cover certain ages. However, because of the experi-
mental nature of this study, a different method of selection had to be used. The sample
consists of children that have attended the Department of Orthodontics for various
reasons and who have expressed their willingness to take part in this special type of
growth examination.
The sample mainly comprises normal, healthy children with different types of mal-
occlusions, from slight rotation of individual teeth to severe occlusal disharmony, but
there are also cases of various types of cranial and facial deformities. In some cases
orthodontic treatment has been performed. All the children were summoned for annual
checks on the date of enrolment-not on their birthdays. Provided that the sample is
large enough, this procedure gives a fairly good differentiation of the time for growth
spurts. On the basis of profile radiographs, the greater part of the sample was analyzed
for sagittal and vertical growth of the face, for which purpose markers had been in-
serted in the right side of the maxilla and mandible-that is to say, the side closer to
the film.' For another group, the growth in width of the upper face was analyzed with
the aid of frontal radiographs, where the markers had been inserted in both sides of the
maxilla.4 In order to keep the X-ray dose to a minimum, the body was screened during
exposures, and the two types of study were carried out on different children.
MATERIALS AND METHODS
General technique.-The method involving the insertion -of metallic implants (small
pointed pins) under local anesthesia was described in 1955,1 and some eleven years of
This investigation was supported by U.S.P.H.S. research grant D-843 from the National Institute
of Dental Research, National Institutes of Health, Bethesda, Maryland.
400

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Vol. 42, 1963 GROWTH OF THE MANDIBLE: RADIOGRAPHIC STUDY 401

experience have proved it to be highly satisfactory.2 The procedure is painless, apart

from slight tenderness around the sites of insertion for the first day or so. Risk of in-
fection is practically negligible. In two early cases, mild periostitis was noted a few
days after the pins were placed, but since a clean instrument has been used for each
pin, no such complication has been observed. Altogether, some 900 pins have been
inserted.
In some cases a displacement of one of the 3 or 4 pins in each jaw was noticed at
the annual control, and a new pin was then inserted. One of the reasons for the shift in
position of the pins is that they lay in the path of eruption of a tooth or on a bone sur-
face undergoing resorption. Pins located in the tooth-bearing part of the alveolar process
may be displaced as a result of orthodontic tooth movements. These sources of error
can be avoided by careful choice of sites for the pins.
Another reason for displacement of the pins is that they were hammered in obliquely
or were bent against the bone, so that they did not go deep enough beneath the
periosteum and hence could be pulled by the periosteum during growth of the jaws. A
movement of several millimeters can result from this. It should be mentioned, how-
ever, that those pins in contact with the periosteum that were placed in bone surfaces
with periostal apposition, as on the outer surface of the mandible, often showed a
stabilization of their position after some years, as the pins gradually became imbedded
in the bone.
To insure that the pins will be guided straight into the bone, they must fit the instru-
ment accurately. The instrument is made of stainless steel, of an alloy which does not
splinter and thus incur a risk of chips remaining in the bone (Fig. 1). The tip might be
deformed by hard bone and is therefore made replaceable. With this limitation, the
design of the instrument is satisfactory. It is important that the tip project I mm. be-
yond the pin, so that the tip can be pressed through the periosteum to secure a stable
support before the pin is hammered in. It is also important that in the "ejected" posi-
tion the moving part-the piston project I mm. beyond the tip of the instrument, so
that the pin goes farther into the bone than the tip of the instrument (Fig. 2).
To reduce the risk of the pins' entering the bone obliquely, they must be of uniform
diameter and hard enough to resist bending. They were first made from wire, which was
cast from prosthetic chrome-cobalt alloy,* but these pins varied in thickness and hard-
ness. Tests have also been carried out with pins ground to the desired diameter from
0.9 commercial Kirschner wire of surgical chrome-cobalt alloy.t These pins can be uni-
form in size, but, because of the extreme hardness of this material, the heat generated
during the grinding may impair the electrolytic properties of the alloy. Tantalum pins
were therefore tested. These can be cut from commercial surgical tantalum wire, but,
as this material is soft, it is not very suitable for use on hard bone surfaces. The wire
therefore has to be hardened.; The tantalum pins are more radiopaque than those of
chrome-cobalt alloy, and they can, therefore, be made smaller. For reliable guidance,
the length of the pin needs to be three times its diameter. A suitable size for chrome-
cobalt pins has been found to be 0.65 X 2.0 mm., whereas the tantalum pins can be
as small as 0.5 X 1.5 mm. (Fig. 3).
* Vitallium
Laboratory, Copenhagen, Denmark.
t Vitallium, Austenal Company, New York.
+ Hardened tantalum wire has been produced for this purpose by the Ethicon Corporation, Somer-
yille? New Jersey.
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402 BJ(ORK J. de/l. Res. Supplevieni 1o Na. 1

The electrolytic effect is the third reason why the pins might shift their position in
the jaw, since it stimulates fibroblastic activity with a consequent increase in the
thickness of the connective tissue layer formed in the bone around the pin. This effect
can be observed on the radiographs and is manifested as a rotation of the pin in its
position, without, however, its necessarily being displaced in the bone. To check the
tissue reaction, a comparison was made of the effect of pins of cast chrome-cobalt and

FIG. 1. Instrument for inserting metallic implants. A and B the components; C the assembled
instrument.

Fi(;. 2. Diagram illustrating method of inserting metallic implants. A = For stability, the instru-
ment is pressed against the bone; this requires the implant to be located a short distance back from
the tip of the instrument before it is hammered in. B = In its final position, the piston projects be-
yond the tip of the instrument, so that the implant is driven deeper into the bone,

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Vol. 42, 1963 GROWTH'l OF TIHE MAlNDIBLE: RADIOGRAPHIC STUDVY 403

tantalum pins over a 6-year period. It was found that, whereas quite a number of
chrome-cobalt pins had rotated in their position in the jaw, practically all the tantalum
ones remained in their original position. This difference was striking and points to a
better tissue tolerance of tantalum. Pins of hardened tantalum wire are now used
exclusively. Pins of different materials should not, of course, be used for the same
subject.
The indicator method is sensitive to the positional adjustment of the cephalostat,
which should be carefully checked. This applies especially to the profile view, for
which the pins are placed in one half of the face only. To take account of any such
discrepancies, the films must be compared with earlier ones and, if necessary, be re-
taken. Development of facial asymmetry may complicate the interpretation of the
profile radiographs.

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tantalum~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..wire...

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Mandibular~~~~~~~
tehiqeB for th pin aE:insreda impessio oftefomo
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mtheli deplntal gersteishobtogained fom proileteradoruepaphs. One=
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symhysiscoastfardown as possibleo iadnted

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ofvethe mentally imuslento
destrnotl change its posiiongwithi grothde of thfaw.a oThe pindicanhwvrbrexposened
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byoresorptionvifdtispaed
oott iudm highnthlae spra-mental
rnegitond. We netn t
fingerisbplace belowithe. ti oefor the chin, andte instrument ismpaessedo through the
temusuaturbe unti poiticanbefetwh the finalger.s The
obtheainirnisred ono rigoaht
theil n
sidene is placed unde thefitrstpemlr
andec onoude sech
the a a owndapreolarbleineathe

thirngermis rce reoot tip.Here

tipoo, the plchingofdthe instrument is cheked witouh one

finger under the mandibular border. The pins are not so easy to insert farther back,

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404A BvJ¢ORK .1J dentRiet S ppletuent to Na. /
under the molars, since the masseter muscle must be penetrated. The pins at the pre-
molars and molars are sometimes displaced, owing, apparently, to the afore-mentioned
pull from the periosteum. It is therefore necessary to place them. deep and at a right
angle to the surface. A fourth pin is placed on the external aspect of the ramus, on a
level with the occlusal surfaces of the molars. The instrument is inserted as far in over
the oblique line as possible, and account is taken of the position of the third molar
germ. This pin may be gradually exposed by resorption of the bone, and a new one
may be needed. Notwithstanding this, it is valuable, when orienting the radiographs, to
have a pin so far back in the jaxx.
Displacement of metal markers by periosteal traction has been mentioned as early

FIG. 4.-For the radiographic profile analy sis of mandibular growth, one implant was inserted in
the mid-line of the symphysis, and three on the right side nearest the film: under the first and second
premolars, and in the external aspect of the ramus on a level with the occlusal lines.

as 1873 by Ollier,ti and it would seem to be consistent with the observation of Lacroix.
that the attachments of muscles that change their position with growth of the bone
are fixed to the periosteum, and not until growth is complete do deeper fibers grow
into the bone. That this is true of the masseter muscle can be confirmed by dissection of
young animals. In the newborn calf, for instance, the masseter and the internal pterygoid
muscles with the periosteum can easily be torn from the mandible. The masticatory
pressure is taken over mainly by the tendons from the masseter and internal pterygoid
muscles, which continue into each other to form a sling around the lower border of
the mandible. In the adult animal, however, there are strong fiber bundles attached to
the bone.
In an analysis of mandibular growth, the two profile radiographs to be compared
are oriented so that the implants in the mandible are superimposed.2 When measure
ments are performed lines should not be drawn directly on the radiographs, nor

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Vol. 42, 1963 GROWTH OF THE MANDIBLE: RADIOGRAPHIC STUDY 405
should tracings be used, as it has been found that these procedures complicate the
statistical computation of the data.3 The following technique was therefore used.
The direction of growth at the condyle is measured with the aid of clear sheets of
cellophane, on each of which has been printed a line that may be seen through both
radiographs. The line on a cellophane sheet is oriented so as to coincide with the dorsal
border of the condyle head on both radiographs and hence to represent the direction
of condylar growth. The direction of growth is taken as the angle between this line
and one of two reference lines: (1) the tangent to the posterior border of the ramus
on the first film, which is marked off by a line on another cellophane sheet, and (2)
the tangent to the lower border of the mandible on the first film, marked off in the
same way. The direction of growth is thus expressed in relation to the form of the
mandible at the lowest age level. In this study, it was measured only between the first
and the last film in each series and was therefore related to the entire growth period
for each series, irrespective of its length. A protractor graduated in halves of a degree
was used.
The intensity of condylar growth was recorded annually; this was performed directly
from the films after superimposition of the implants. The annual growth was repre-
sented by the distance between the condyles on the two superimposed films and was
measured from year to year in the direction of growth. The radiographs should there-
fore not be so dense that the implants and the contours from the condyles cannot be
seen through the two radiographs. The measurements were made with a ruler grad-
uated in halves of a millimeter. None of the curves presented is smoothed. No cor-
rection has been made for radiographic enlargement, which is 5.5 per cent in the mid-
sagittal plane.
RESULTS
Direction of condylar growth.-To obtain a preliminary impression of the direction
of the growth at the condyles by the method outlined above, the general tendency and
individual variations were calculated in 45 series for boys, excluding pathologic cases.
Measurements from the first and last radiographs of the series were used. The method
error in this registration was fairly large-estimated at ±30. The mean values and
extreme values for the direction of growth at the condyles are given in Figure 5.
The direction of growth in relation to the posterior tangent to the ramus on the
first radiograph was, on an average, 60. Related to the tangent to the lower border of
the mandible, also on the first radiograph, the mean direction of growth was 123°,
which was less than the mean jaw angle of 129° on the first radiograph. It was thus
evident that the mandibular base was generally curved with growth, which was ac-
companied by a reduction in the gonial angle. This decrease in the gonial angle was,
however, generally not pronounced, as it was compensated for by resorptive modeling
below the angulus of the mandible and periosteal growth below the symphysis. The
anterior aspect of the chin in most cases was unaffected. The symphysis increased in
thickness by periosteal growth on its posterior surface; in a few cases, however, re-
sorption or apposition on the anterior surface of the chin was observed.
The direction of condylar growth was not necessarily linear, and, in many cases,
there was a distinct curvature. An annual fluctuation may occur, but these variations
need closer examination. The individual variation in the direction of condylar growth

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 +1

I-

0D 0D

FIG. 5.-Diagram illustrating mean direction of growth at the condyles and extreme vertical and
sagittal directions for 45 subjects of the male sample. The direction of growth is measured with re-
spect to the tangent to the ramus and to the lower border of the mandible on the first radiograph in
each age series. The direction of growth is determined from the first to the last film of each series. A =
extreme vertical; B = mean; C = extreme saggital.

M-

5cm
FIG. 6.-A case from the boy sample representing mean direction of growth at the condyles. Broken
line = age 5 years 8 months; solid line = age 10 years 8 months.

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Vol. 42, 1963 GROWTH OF THE MANDIBLE: RA DTOGRAPHIC STUDY 407
was very great and fairly symmetrically distributed. In some cases it took place in a
vertical direction and then considerably increased the curvature of the mandibular
base, whereas in other cases it was directed sagittally, where the mandibular base was
flattened. The gonial angle decreased with the vertical condylar growth and increased
with the sagittal direction of growth. The compensatory resorption beneath the angulus
region was extremely great in the case of vertical condylar growth, whereas in the case
of sagittal growth it was moderate, or an apposition could even occur. The apposition
under the symphysis seemed to be greatest in the case of vertical condylar growth.
The range for the direction of growth in relation to the tangent to the ramus on the
first film was 42°; in relation to the mandibular border it was as large as 65°.
Figures 6, 7, and 8 show examples of the individual differences in the development
of the mandible. With the guidance of the radiographic tracing of the mandible,
tracings from the dental casts were incorporated on the growth diagram and hence
also oriented according to the indicators. Figure 7 shows that vertical condylar growth

3433i

FIG. 7.-Case illustrating extreme direction of vertical growth at the condyles in the boy sample.
Broken line = age 11 years 7 months; solid line = age 17 years 7 months.

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 _~
408 BJORK J. dent. Res. Supplement to No. I
was accompanied by forward eruption of all the teeth and Figure 8 that condylar
growth in the sagittal direction was followed by backward eruption of the anterior
teeth.
For accurate orientation of the mandible in the growth analysis, indicators are in-
dispensable. As has been shown, the lower border of the mandible is unsuitable as a
reference line for this purpose. For clinical purposes, the following method has been
worked out; it is a provisional measure, and no claim is made to perfection. The films

5cm
FIG. 8.-Case illustrating extreme direction of sagittal growth at the condyles in the female sample.
Broken line = age 10 years 6 months; solid line = age 15 years 6 months.

are superimposed so that the tip of the chin and the following three internal structures
are made to coincide as far as possible: (1) the inner cortical structure of the inferior
border of the symphysis, (2) detail structures from the mandibular canal, and (3)
the lower contour of the molar germ from the time that mineralization of the crown
is visible until the roots begin to form. These three structures were used for the follow-
ing reasons. In most of the cases there was a definite thickening of the cortical layer
of the lower border of the symphysis with growth-a process that occurs through
periosteal deposition on the inferior surface. The mandibular canal may change in
position but not to the same extent as the remodeling at the lower border of the

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Vol. 42, 1963 GROWTH OF THE MANDIBLE: RADIOGRAPHIC STUDY 409
mandible. The orientation of the radiographs in relation to the tooth germs is based
on the observation of specific tooth movements in three stages of eruption, namely:
(1) before mineralization of the crown is visible, movement of the germ (especially
that of the third molar) apparently can take place in different directions; (2) from
the onset of mineralization of the crown to the time when the roots start to develop, the
lower border of the germ is apparently stationary; (3) during the eruption and be-
cause of differentiated periodontal growth, which gives rise to growth of both the root
and the alveolar bone, the tooth as a whole is displaced occlusally, irrespective of
whether the development of the roots is still in progress or complete.
Condylar growth rate.-The annual fluctuation in the condylar growth rate for the
45 boys studied is shown in Figure 9, covering the period from five to twenty-two
years of age. Each of the 209 points on the diagram corresponds to an annual obser-
vation of growth increment and is placed in the middle of the year of observation.
The mean number of points in each series was 4.6. The accuracy with which the

XiD
10 -10

28 .8

2:6 . . . 6
56'\-l - * - t m -
-6

4~~~A
,.. 4. .-

2' ~. 2 ... ..._m

6 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 22B
AGE IN YEARS
FIG. 9.- Annual rate of growth at the mandibular condyles in the male sample, measured in the
direction of growth. The 209 points represent annual observations, marked at the middle of the year of
observation. The curve represents the mean annual growth.
annual growth was recorded, determined on the basis of repeated measurements, lies
within the limits ±0.5 mm. The mean annual condylar growth is represented in Figure
9 by a curve.
There is a clear difference between the mean growth rates for the juvenile and
puberal periods. A characteristic feature of the juvenile period was a fairly even
growth of about 3 mm. annually, with no pronounced maximum and with a slight
decrease to a well-defined prepuberal minimum at the age of eleven years and nine
months. At a mean age of fourteen and a half years, there was a puberal maximum,
with an average growth of about 5 mm. The mean curve, however, smooths the individ-
ual variations in periodic growth, as is apparent from Figure 10, which is based on
individual values for 25 of the cases.
As Figure 10 shows, during the juvenile period there was a marked fluctuation in
the rate of condylar growth from year to year, which gives the curves for this period
a zigzag course. Being apparently greater than the error of measurement, the fluctua-
tions would seem to be a biologic reality. In all cases, the puberal growth exceeded
the juvenile in intensity. The age for the maximum puberal growth varied widely, and
there were large variations in intensity. The puberal and postpuberal growth did not

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410 BJORK J. dent. Res. Supplement to No. .1
display the zigzag pattern that was characteristic of the juvenile period. The duration
of puberal growth also varied widely, but, as most of the subjects were still growing,
it was impossible to calculate the end of the puberal spurt. Similarly, it was impossible
to indicate variations in the time when growth ceased altogether. As the diagram shows,
the earliest recorded completion of growth was seventeen years and five months of
age, whereas in other cases increases were still being recorded after twenty years of age.
To obtain a metric impression of the individual variation in the time for the pre-
puberal minimum and maximum and of the variations in growth intensity at these
periods of development, analyses were performed for the 11 cases in which these
minimum and maximum values were reached (Fig. 11). Because of the limited num-
ber of cases and the fact that growth data are seldom normally distributed, the dis-
tributions are fairly skew.7-9 The prepuberal minimum occurred at an average age of
eleven and three-quarters years. The individual variations, however, were large, with
the earliest recorded minimum at nine years and four months and the latest at thirteen

FIG. 10.-Individual curves for the growth rate at the mandibular condyles, measured in the di-
rection of growth in 25 cases of the male sample.

LLJ
>8- -8
Of
LdJ -

-6
26 -

4- -4

2- -2

4.
B 9 10 11 12 13 14 1E5 16 17 18
AGE IN YEARS
FIG. 11.-Mean and range for age at which pre-puberal growth minimum and puberal growth
maximum were reached in 11 cases from the male sample, together with mean and range for the
growth rate at these stages of development,

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Vol. 42, 1963 GROWTH OF THE MANDIBLE: RADIOGRAPHIC STUDY 411
and one-half years of age-that is, with a range of about 4 years. The growth intensity
at the pre-puberal minimum stage was as low as between 0.5 and 2 mm., with a neg-
ative skewness, the mean value being 1.5 mm. The time when maximum puberal
growth occurred varied likewise and appeared earliest at twelve years and nine months
and latest at fifteen and one-half years of age, with a mean of fourteen and one-half
years. The range of variation was thus about 3 years. The annual growth during the
puberal maximum varied from 4.5 to 8 mm., with positive skewness, the mean being
5.5 mm.
Finally, I would mention that no correlation could be demonstrated between the
intensity and direction of growth in this material. All metric values given should be
regarded as preliminary and subject to revision in the light of results obtained on
further studies.
SUMMARY
Eleven years of experience have proved the value of the implant method in radio-
graphic studies of facial growth in man. An instrument for inserting the pin in the
jaw under local anesthesia was designed to give accurate guidance. Altogether, some
900 pins have been inserted in the jaws of 110 children. Tantalum pins have proved
to be better tolerated by the tissues than those of chrome-cobalt alloy. The prelim-
inary data relate to the growth of the mandible in a sample of 45 Danish boys. The
anterior aspect of the chin underwent, for the most part, no visible remodeling. Be-
neath the chin there was, in many cases, some periosteal growth, accentuated during
adolescence. The most pronounced remodeling occurred beneath the angulus region.
Here resorption was usual, but periosteal apposition was also seen. The direction of
growth at the condyles in the sagittal plane varied widely, with an average direction
slightly forward in relation to the posterior tangent to the ramus.
REFERENCES
1. BJ6RX, A. Facial Growth in Man, Studied with the Aid of Metallic Implants, Acta odont. scand.,
13:9, 1955.
2. . Cephalometric Growth Analysis by Radiographic and Implant Technique. Color film,
16 mm. Copenhagen: Royal Dental College, 1962.
3. BJ6RK, A., and SOLOW, B. Measurements on Radiographs, J. dent. Res., 41:672, 1962.
4. KREBs, A. Expansion of the Midpalatal Suture Studied by Means of Metallic Impants, Acta odont.
sandd, 17:491, 1959.
5. LACROIX, P. The Organization of Bones. London: Churchill, Ltd., 1951.
6. OLLIER, L. Recherches exp6rimentales sur le mode d'accroissement des os, Arch. physiol. (Paris),
1873.
7. SOLLBERGER, A. and STR6MBERG, U. The Biological Moving Variate, Acta anat., 29:20, 1957.
8. SOLLBERGER, A. Frequency Distributions Arising from Biological Movement, Acta morph. neerl.-
scand., 3:179, 1960.
9. TANNER, J. M. Boas' Contributions to Knowledge of Human Growth and Form, Amer. Anthro-
pologist, 61:76, 1959.

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