THE TREATMENT EFFECT OF MANDIBULAR

PROTRUSIVE APPLIANCES ON THE GLENOID

FOSSA FOR CLASS II CORRECTION

Elias G. Katsavrias and John C. Voudouris; Presented by: Dr. Arnab Agasty
Angle Orthodontist, Vol 74, No 1, 2004
ANATOMY OF THE GLENOID FOSSA
The mandibular condyle articulates at the
base of the cranium with the concave
mandibular fossa - squamous portion of
temporal bone.
 Posterior to this is the squamotympanic fissure,
extending mediolaterally. The post glenoid process
demarcates the border of the Glenoid fossa
 Anteriorly bound by Articular Eminence.

Posterior roof of the fossa is quite thin

indicating it is not designed to withstand
heavy forces. The articular eminence on
the contrary is composed of thick, dense
bone.
Management of TMJ disorders and occlusion
-J.P. Okeson
HISTOLOGY OF THE GLENOID
FOSSA
1. Articular zone- Most superficial,
made up of dense fibrous
connective tissue instead of
hyaline cartilage.
2. Proliferative zone- Made up of
undifferentiated mesenchymal
cells.
3. Fibrocartilaginous zone
4. Calcified Cartilage zone-
Chondrocytes and chondroblasts.

Management of TMJ disorders and occlusion

-J.P. Okeson
NECESSITY OF THIS STUDY
Clinical studies have used laminograms, cephalograms, cephalograms and
tomograms, and magnetic resonance imaging.
However, the findings of these studies are contradictory and confusing.
In an effort to clarify the mode of action of mandibular protrusive (functional)
appliances, it is imperative to clarify the role of the glenoid fossa.
OBJECTIVE
•The purpose of this study was to explore the effect of mandibular protrusive
appliances on the glenoid fossa morphology using corrected lateral tomograms.
•To study the role of glenoid fossa modification in the correction of skeletal class II
malocclusion.
INTRODUCTION
•Human studies on the remodeling processes in the temporomandibular joint have
shown that the joint is capable of significant modelling.
•Ruf and Pancherz, DG Woodside and other investigators suggest that glenoid fossa
remodelling plays a major part in the correction of skeletal Class II malocclusion
with functional appliances.
•The articular eminence appears to show the greatest adaptability of all the glenoid
fossa components.
•Woodside et al, Voudouris et al, Rabie et al have shown that mandibular protrusion
triggers bone deposition in the posterior region of glenoid fossa.
MATERIALS AND METHODS
Corrected lateral tomograms taken from both joints of 35 children who were
diagnosed as being suitable for treatment and were treated with functional
appliance (activator) by one of the investigators (Dr Katsavrias).
•Subjects: 35
Boys: 18 | Girls: 17
•Age (at start of treatment): 7.96 to 15.06 years | Mean: 11.63 ± 1.86 years
Duration of treatment: 0.72 to 2.0 years | Mean: 1.33 years
Starting Age Duration of treatment with activator
•The bite registration was taken by bringing the incisors edge-to-edge
with a vertical opening of 3 mm,
regardless of the initial overbite and overjet.
•Before the start of activator treatment, the ability for free mandibular protrusion
was evaluated, and in some patients where this was not possible, the necessary
adjustments were made.
•These adjustments included maxillary expansion, maxillary or mandibular incisor
leveling, and lower incisor uprighting.
•The activator used was a modification of Harvold type, and lower molars and
premolars were free to erupt.
•The lower incisors were capped with acrylic, and no acrylic trimming was performed
on the maxillary arch portion of the appliance.
•Patients were instructed to use the appliance for 12–14 hours per day, during sleep
and for part of the daytime.
•A written report of the number of hours per day the appliance was used was turned
in by all patients during their office visits.
•The tomograms were taken on a pretreatment and posttreatment basis.
•Before taking the tomograms, a submentovertex projection was taken to orient the
condylar heads with respect to the midsagittal plane and to calculate the depth of
the cut of each tomogram. To achieve this objective,all tomograms were taken at
the middle of the condyles and with the teeth in maximum intercuspation.
•The sections were 2.5 mm thick. The tomograms were digitized on screen using a
commercial software program (Viewbox 3, Halazonetes, Athens, Greece)
Following points were located:
1. Articular eminence midpoint, AE50 (the middle point between roof of the fossa and the
height of the articular eminence).
2. Fossa posterior, Fp (the top of postglenoid process and when it was absent the most
anterior point of the squamo-tympanic suture).
3.Pt (top of the pterygomaxillary fissure) and the Ptm (the bottom point of the
pterygomaxillary fissure).
4. Porion, Po
5. Roof of the fossa, Fr
6. Height of the articular eminence, Aetop.
Following distances were measured:
1. FossaPosterior-FossaRoof (Fp-Fr).
2. FossaPosterior-Articular Eminence midpoint
(Fp-Em50).
3. FossaPosterior-Articular Eminence Top (Fp-
AEtop).
4. FossaRoof-Articular Eminence Top (Fr-AEtop).
5. FossaRoof-Pterygomaxillary Fissure Top (Fr-
Pt).
6. Articular Eminence Top-Pterygomaxillary
Fissure Top (EMtop-Pt).
7. Porio-FossaRoof (Po-Fr).
8. Porio-FossaPosterior (Po-Fp).
9. Porio-Articular Eminence Top (Po-AEtop).
10. Porio-Pterygomaxillary Fissure Top (Po-Pt).
STATISTICS
Paired t-tests were applied between pre- and posttreatment measurements,
separately for left and right sides to test for any statistical significance between them.
Paired t-test was also applied to the pretreatment as well as the posttreatment left
and right sides to test for any asymmetrical responses.
ERROR STUDY
For the error study, 14 pretreatment randomly selected tomograms (seven left and
seven right, not necessarily belonging to the same person) and their posttreatment
correspondings were evaluated. Thus, a total of 28 tomograms were selected and
the entire procedure was reapplied.
The initial measurements (set I) and the repeated measurements (set II) of these 28
tomograms were compared using a paired t-test to check for any systematic error.
Random errors were checked using the Dahlberg formula.
The t-test at the .05 level did not show any significance. The random error for the
measurements varied between 0.49 and 0.58.
RESULTS
All subjects were treated to a Class I dental arch
relationship and the posttreatment records were
taken two to three months after the Class I molar
relationship was established. All 10 linear variables
used in this study did not show any statistically
significant difference between initial and after-
treatment measurements. Similarly, no statistically
significant differences were recorded when the left
and right measurements were compared.
REVIEW OF LITERATURE
TEMPOROMANDIBULAR JOINT
REMODELING IN ADOLESCENTS AND
YOUNG ADULTS DURING HERBST
TREATMENT:
A PROSPECTIVE LONGITUDINAL MAGNETIC RESONANCE IMAGING
AND CEPHALOMETRIC RADIOGRAPHIC INVESTIGATION
Sabine Ruf and Hans Pancherz
Am J Orthod Dentofacial Orthop 1999;115:607-18
OBJECTIVE
The aim of this study was to analyze and compare the temporomandibular joint
adaptive mechanisms in Class II malocclusions treated with the Herbst appliance.
Temporomandibular joint remodeling was analyzed
by magnetic resonance imaging.
METHODS AND MATERIALS
Of all Class II patients applying for treatment at the Department of Orthodontics,
University of Giessen, since 1995, the first 25 adolescents (12 girls and 13 boys) and
the first 14 young adults (10 girls and 4 boys) were selected for Herbst treatment.
In each subject, 4 magnetic resonance images of both temporomandibular joints were
available:
before treatment, (T0)
at the start of treatment (when the Herbst appliance was placed), (T1)
during treatment (6 to 12 weeks after appliance placement), (T2) and
after treatment (when the appliance was removed). (T3)
Furthermore, effective temporomandibular joint changes (the sum of condylar
remodeling, fossa remodeling, and condyle-fossa relationship changes) were analyzed
with the aid of lateral cephalometric radiographs from before and after treatment.
RESULTS
All subjects were treated to Class I or
overcorrected Class I dental arch
relationships, and their mandibles
became significantly (P < .001) more
prognathic.
During treatment, mandibular
prognathism (SNPg-angle) was increased
(P < .001) by an average of 1.8° in the
adolescents and 1.3° in the young adults.
In comparison to the age-related Bolton control group, the amount of
effective TMJ changes in the adolescent patients treated with the Herbst
appliance was, on average, 6 times larger (P < .001) in the horizontal and
3 times larger (P < .001) in the vertical direction.
In the young adult patients with the Herbst appliance, the horizontal
effective TMJ changes were on average 11 times larger (P < .001), and
the vertical changes were 2 times larger (P < .01) than in the Bolton
group.
The comparison of the effective TMJ changes between the 2 Herbst
groups revealed that, on average, the horizontal and vertical changes
were twice as large (P < .01) in the adolescent than in the young adult
group.
Furthermore, in 19 of the 25 adolescent and in 13 of the 14 young adult
patients with the Herbst appliance, the direction of TMJ changes was
relatively more horizontal when compared with the Bolton Standards.
After 6 to 12 weeks of Herbst
treatment, signs of glenoid
fossa remodeling at the
anterior surface of the
postglenoid spine were noted
in 36 adolescent and 22 young
adult temporomandibular
joints.
Signs of fossa remodeling could
be visualized in 36 of the 50
TMJs of the adolescents and in
22 of the 28 TMJs of the young
adults.
In all subjects the adaptive processes were located at the anterior surface of the
postglenoid spine. The remodeling was most intensive at the inferior part of the
spine and decreased toward the top of the fossa, thus leading to a slight
anteclination of the postglenoid spine.
In some cases, a double contour of the anterior surface of the postglenoid spine
could be seen. In most subjects the amount of the glenoid fossa remodeling was
smaller than the amount of condylar remodeling and seemed to be more
pronounced in the young adult group.
CONCLUSION
Effective temporomandibular joint changes during treatment larger in both
adolescents and young adult patients treated with the Herbst appliance than in an
untreated group of subjects with ideal occlusion (Bolton standards).
The increase in mandibular prognathism accomplished by Herbst therapy in both
adolescents and young adults was attributed to condylar and glenoid fossa
remodeling.
Because the Herbst appliance is most successful in Class II patients also at the end
of the growth period, the treatment method could be an alternative to orthognathic
surgery in borderline skeletal Class II cases.
THE INFLUENCE OF FUNCTIONAL
APPLIANCE THERAPY ON GLENOID
FOSSA REMODELING
D. G. Woodside, A. Metaxas and G. Altuna
AM J ORTHOD DENTOFAC ORTHOP 1987;92:181-98.
OBJECTIVE
To investigate the remodelling changes in the condyle and glenoid fossa following a
period of progressively activated and continuously maintained mandibular advancement
using the Herbst appliance.
METHODS AND MATERIALS
The sample consisted of 6 female and one male cynomolgus (Macaca fascicularis)
monkeys; one was juvenile (24 to 36 months), five were adolescent (36 to 48
months), and one was adult (male 70 to 80 months).
Activated Herbst appliances were placed in five experimental animals; two
adolescents wore inactivated appliances (sham controls). The joints of four
additional animals were examined histologically to provide a basis for study of
normal joint histology
Progressive mandibular advancement was achieved by adding stops to the
telescopic arms of the appliance, with the total activation reaching 7.0 to 10.0 mm,
dependent upon the length of the treatment phase.
Metallic implants and occlusal amalgams were inserted in the left side of the jaws, the
skull, the cranial base, and the first permanent molar to facilitate the measurement and
superimposition of the cephalograms.

Cephalometric measurements used:

Horizontal condylar extension: the distance between the perpendiculars drawn from
the horizontal axis to the most posterior points of the condylar outlines from the
mandibular superimpositions.
Vertical condylar extension: the distance between thehorizontal lines drawn from the
vertical axis to the uppermost portion of the condylar outlines
Condylion to condyfion: the distance between the most posterior and superior points
of the condyles
Condylion to the anterior metallic implant (AMI): the distance between the most
posterior and superior points of the condyle and the most anterior point of the anterior
metallic implant
Ramus to ramus: the distance between the perpendiculars drawn from the horizontal
axis to the most posterior point of the condyles from the overall superimpositions on
cranial base structures
RESULTS
This mandibular advancement produced extensive
remodeling and anterior relocation of the glenoid fossa,
which contributed to anterior mandibular positioning and
altered jaw relationships.
The most dramatic changes were seen in the glenoid
fossa, especially in the area of the postglenoid spine.
Study of the animals used to assess normal joint histology
showed bone deposition along the posterior border of the
spine and bone resorption along the anterior part of this
area.
The experimental adolescents showed a dramatic
remodelling response of the glenoid fossa and especially
the postglenoid spine.
High-power view of superior area of the glenoid fossa
showing extensive new bone formation and increased
cellular activity of inner (osteogenic) layer of periosteum
CONCLUSION
Temporomandibular joint changes following continuous functional appliance
therapy were thought to assist in the correction of disproportionate jaw
relationships. Remodelling such as that seen in this study might create the
appearance of an increased mandibular length with or without a true increase.
CONDYLE-FOSSA MODIFICATIONS
AND MUSCLE INTERACTIONS
DURING HERBST TREATMENT
John C. Voudouris, Donald G. Woodside, Gurkan Altuna, Mladen M. Kuftinec,
Gerassimos Angelopoulos and Paul J. Bourque
Am J Orthod Dentofacial Orthop 2003;123:604-13
OBJECTIVE
To investigate the changes in the condyle, the glenoid fossa, and the muscles of
mastication in subjects undergoing continuous orthopedic advancement of the
mandible with a Herbst-block appliance.
METHODS AND MATERIALS
The total sample consisted of 56 subjects and included 15 nonhuman primates (in
the middle mixed, early permanent, and permanent dentitions), 17 human Herbst
patients in the early permanent dentition, and 24 human controls from the
Burlington Growth Center. The 8 nonhuman primates in the middle mixed dentition
were the focus of this study.
Mandibular advancement was obtained progressively in 5 animals by adding stops
to the telescopic arms of fixed functional Herbst appliances with occlusal coverage;
activations of 5.0 mm, 7.0 mm, and 8.0 mm were achieved. Two primates served as
controls, and the third was a sham control. Two experimental animals and the 2
controls also wore surgically implanted electromyographic electrodes in the
superior and inferior heads of the lateral pterygoid muscles and in the superficial
masseter and anterior digastric muscles.
Changes in condylar growth direction and amount were assessed with the Bjork
method from measurements made on serial cephalometric tracings superimposed
on metallic implants. Undercalcified sections, treated with intravenous tetracycline
vital staining, were viewed with fluorescence microscopy to examine histologic
changes in the condyle and the glenoid fossa.
RESULTS
New bone formation in the fossa associated with continuous mandibular protrusion
was quantified by using computerized histomorphometric analysis of decalcified
histological sections and polarized light. Approximately 1.2 mm of new bone
formation was found parallel to the occlusal plane in the 12-week experimental
animals.
Bone formation in the entire fossa was also observed up to the height of the
articular eminence. This new bone formation occurred a great distance away from
the insertion of the stretched retrodiskal tissues probably through force
transduction.
The growth modification measured in the glenoid fossa was in an inferior and
anterior direction.
All experimental subjects developed large super Class I
malocclusions, the result of many factors including posterior
movement of the maxilla and the maxillary teeth, an
increased horizontal component of condylar growth, and
anterior displacement of the mandible and the mandibular
teeth.
Differences in the area and maximum thickness of new bone
formation in the glenoid fossa and in condylar growth were
statistically significant. The bony changes in the condyle and
the glenoid fossa were correlated with decreased postural
electromyographic activity during the experimental period.

Photomicrographs of decalcified midsagittal section of glenoid fossa, showing postglenoid spines; haematoxylin and eosin stained, original magnification
10.5X. A, Control animal #273, arrows show natural backward and downward growth direction. B, 12-week experimental animal #271, arrows show forward (reverse
of natural growth direction) and downward growth. C, 12-week experimental animal #270, arrows show forward and downward growth. D, 18-week experimental
animal #269, arrows show forward and downward growth. Note that resting line (arrows) is toward posterior of postglenoid spine in control (A), indicating normal bone
formation on posterior aspect of postglenoid spine as fossa grows downward and backward. In contrast, resting lines are visible toward anterior of postglenoid spine in
12-week experimental animals (B and C), indicating start of new bone formation in anterior direction. Anterior resting line also found in 18-week experimental animal
(D). Note woven bone (W) in 12-week experimental animals. Lamellar bone (L) observed with increased time in 18-week experimental
CONCLUSION
Restriction of the downward and backward growth of the fossa observed in the
control subjects was thought to additionally contribute to the overall super Class I
malocclusion. Clinically, these combined effects could be significant at the fossa. The
restriction of local temporal bone (fossa) growth cannot be observed clinically; thus,
these results might also clarify some Class II correction effects that cannot be
explained with functional appliances.
Results from permanently implanted electromyographic sensors demonstrated that
lateral pterygoid muscle hyperactivity was not associated with condyleglenoid fossa
growth modification with functional appliances, and that other factors, such as
reciprocal stretch forces and subsequent transduction along the fibrocartilage
between the displaced condyle and fossa, might play a more significant role in new
bone formation.
GROWTH
-VOUDOURIS, 2000
RELATIVITY CONCEPT
Growth relativity states that – “with orthopaedically displaced condyle , the bone
architecture is influenced by the neuromusculature & the contiguous, non –
muscular , viscoelastic tissues anchored to the glenoid fossa & the altered dynamics
of the fluids enveloping bone”.
Growth relativity hypothesis 3 main foundations:-
1. Displacement
2. Viscoelasticity
3. Referred force (transduction) 
A HISTOCHEMICAL STUDY ON
CONDYLAR CARTILAGE AND GLENOID
FOSSA DURING MANDIBULAR
ADVANCEMENT
Payam Owtad; Zoe Potresa; Gang Shen; Peter Petocz; M. Ali Darendeliler
Angle Orthod. 2011;81:270–276.
OBJECTIVE
To evaluate cellular hypertrophic activities in the mandibular condylar cartilage
(MCC) and the glenoid fossa (GF) during mandibular advancement in the
temporomandibular joint (TMJ) of Sprague-Dawley rats, as evidenced by fibroblast
growth factor 8 (FGF8).
METHODS AND MATERIALS
Fifty-five female 24-day-old Sprague-Dawley rats were randomly divided into four
experimental and control groups, with a mandibular advancement appliance on the
experimental rats’ lower incisors. The rats were euthanized on days 3, 14, 21, and 30
of the study, and their TMJ was prepared for a immunohistochemical staining
procedure to detect FGF8.
RESULTS
FGF8 expression was significantly higher among the experimental rats (P 5 .002).
Patterns of ascension and descension of FGF8 expression were similar in
experimental and control samples. The results showed an overall enhanced
osteogenic transition occurring in both the MCC and the GF in experimental rats in
comparison with controls. The level of cellular changes in the MCC was remarkably
higher than in the GF.
In the MCC and the GF, cellular morphologic and hypertrophic differentiations
increase significantly during mandibular advancement.
Photomicrographs show immunostaining for FGF8 expressed in the glenoid fossa of another
experimental sample (27-day-old rat, wearing bite jumping appliance for 3 days)

experimental sample (38- day-old rat, wearing bite jumping appliance for 14 days)
CONCLUSION
It is also concluded that endochondral ossification in the MCC and
intramembranous ossification in the GF occur during adaptive remodeling.
VEGF AND BONE FORMATION IN THE
GLENOID FOSSA DURING FORWARD
MANDIBULAR POSITIONING

A. B. M. Rabie, Lily Shum, and Atinooch Chayanupatkul

OBJECTIVE
This study was designed to identify the relationship between vascularization and
bone formation in the glenoid fossa during natural growth and functional appliance
therapy. The temporal pattern of vascular endothelial growth factor (VEGF)
expression and bone formation in the glenoid fossa during natural growth was
identified and compared with that during forward mandibular positioning.
METHODS AND MATERIALS
150 female Sprague-Dawley rats, 35 days old, were randomly divided into 10
experimental and 10 control groups. Appliances were fitted to position the
mandible forward in the experimental groups. The rats were then killed at different
times.
Sections were cut and stained with anti-VEGF antibodies to evaluate VEGF
expression, and with periodic acid and Schiff’s reagent to evaluate new bone
formation.
Both VEGF expression and newly formed bone were measured by a computer-
assisted image analyzing system.
RESULTS
The results showed that, during natural growth and
forward mandibular positioning, VEGF expression and
new bone formation were highest in the posterior
region of the glenoid fossa. There were significant
increases of VEGF and new bone formation in the
experimental groups compared with the controls. The
highest amount of VEGF expression occurred before the
highest amount of bone formation was reached.
CONCLUSION
Forward mandibular positioning causes significant increases in vascularization and
new bone formation in the glenoid fossa. A close correlation exists between
vascularization and bone formation.
REPLICATING MESENCHYMAL CELLS IN
THE CONDYLE AND THE GLENOID
FOSSA DURING MANDIBULAR
FORWARD POSITIONING
A. B. M. Rabie, Louise Wong, and Marjorie Tsai
Am J Orthod Dentofacial Orthop 2002;122:202-9
OBJECTIVE
The purpose of this study was to identify and quantify the temporal sequence of
replicating mesenchymal cells during natural growth and mandibular advancement
in the condyle and the glenoid fossa.
METHODS AND MATERIALS
One hundred fifty 35-day-old female Sprague-Dawley rats were randomly divided
into 10 experimental groups (10 rats each) and 10 control groups (5 rats each). The
experimental groups were fitted with appliances that positioned the mandible
forward.
One hour before the rats were killed, bromodeoxyuridine (BrdU) was intravenously
injected into them. Sections were cut and stained with anti-BrdU antibody to
evaluate the number of replicating mesenchymal cells. Cellular uptake of BrdU was
quantified with the Leica Qwin (Leica Microsystem Imaging Solutions, Cambridge,
United Kingdom) system.
RESULTS
The results showed that the numbers of replicating mesenchymal cells during
natural growth were highest in the posterior region of the condyle and the anterior
region of the glenoid fossa.
In the experimental groups, the posterior region had the highest number of
replicating cells for both the condyle and the glenoid fossa, with the condyle having
2 to 3 times more replicating cells than the glenoid fossa.
CONCLUSION
The number of replicating mesenchymal cells, which is genetically controlled,
influences the growth potential of the condyle and the glenoid fossa. Mandibular
protrusion leads to an increase in the number of replicating cells in the
temporomandibular joint. Individual variations in the response to growth
modification therapy could be a result of the close correlation between
mesenchymal cell numbers and growth.
CONCLUSION
Although a lot of conflicting schools of thought exist, it might be concluded that the
anteroinferior resorption and subsequent remodelling of the glenoid fossa does play
a significant role in forward positioning of the mandible during orthopedic
treatment with a functional appliance (activator, herbst etc) as an adjunctive to
condylar remodelling.
REFERENCES
1. Graber T. Functional appliances. In: Graber TM, Vanarsdall RL,eds. Orthodontics:
Current Principles and Techniques. 3rd ed. St Louis, Mo: Mosby; 2000:473–520.
2. Ruf S, Pancherz H. Temporomandibular joint remodeling in adolescents and
young adults during Herbst treatment: a prospective longitudinal magnetic
resonance imaging and cephalometric radiographic investigation. Am J Orthod
Dentofacial Orthop. 1999; 115:607–618.
3. Woodside DG. Do functional appliances have an orthopedic effect? Am J Orthod
Dentofacial Orthop. 1998;113:11–14. 4. Ruf S, Pancherz H. Temporomandibular joint
growth adaptation in Herbst treatment. A prospective magnetic resonance imaging
and cephalometric roentgenographic study. Eur J Orthod. 1998; 20:375–388.
4. Rabie AB, She TT, Ha¨gg U. Functional appliance therapy accelerates and
enhances condylar growth. Am J Orthod Dentofacial Orthop. 2003;123:40–88.
5. Rabie AB, Xiong H, Ha¨gg U. Forward mandibular positioning enhances condylar
adaptation in adult rats. Eur J Orthod. 2004;26:353–358.
6. Shen G, Rabie AB, Zhao ZH, Kaluarachchi K. Forward deviation of the mandibular
condyle enhances endochondral ossification of condylar cartilage indicated by
increased expression of type X collagen. Arch Oral Biol. 2006;51: 315–324.
7. Voudouris JC, Kuftinec MM. Improved clinical use of Twin-block and Herbst as a
result of radiating viscoelastic tissue forces on the condyle and fossa in treatment
and long-term retention: growth relativity. Am J Orthod Dentofacial Orthop
2000;117:247-66.
8. Voudouris JC. Glenoid fossa and condylar remodeling following progressive
mandibular protrusion in the juvenile Macaca fascicularis: a computerized
histomorphometric, cephalometric and electromyographic investigation [thesis].
Toronto, Ontario, Canada: University of Toronto; 1988.