Clinical implications of growth

CLINICAL
IMPLICATION
OF
GROWTH
www.indiandentalacademy.com

GROWTH
A friend or foewww.indiandentalacademy.com

CONTENTS
Factors affecting growth
Normal growth changes
Skeletal
Dental
Soft tissues
Clinical evaluation of patients
Growth problems & treatment plan
Implication of timing,direction & rotation in
treatment plan.www.indiandentalacademy.com

FACTORS
AFFECTING
GROWTHwww.indiandentalacademy.com

SEASONAL CHANGES
Growth is faster in spring & summer
than in winter
CULTURAL CHANGES
•In developing countries, city children
tend to mature faster than rural ones.
•Influence of external stimuli on the
gonadotropin –releasing factor.www.indiandentalacademy.com

GROWTH
CHANGES

CRANIOFACIAL GROWTH FROM INFANCY
THROUGH ADULTHOOD,Henry W.
Fields(Peadiatric clinics of North America oct
1991)
Growth of the cranial structures is far
advanced and near its ultimate
adult size during infancy and
childhood than any other body
parts because of the “Cephalocaudal
growth gradient.”www.indiandentalacademy.com

Cranial vault growth is
completed before
maxillary growth,&
maxillary growth is
completed before
mandibular growth.www.indiandentalacademy.com

SKELETAL
GROWTH

Dimensional differences
Regional differences

Growth in three
dimensionswww.indiandentalacademy.com

DIMENSIONAL DIFFERENCES.
1.Transverse dimension
2.Anteroposterior dimension
3.Vertical dimension

•Completed first.
•The midpalatal suture fuses before the
adolescent growth spurt,& is
affected if at all,by adolescent growth
changes.
TRANSVERSE FACIAL GROWTH
DIMENSION

•The mandibular symphysis also is
fused at birth or during the first
year.
•The bases of both the upper and
lower jaw are therefore well
established early.
•Hence palatal expansion should be
addressed relatively early.

ANTERO POSTERIOR FACIAL GROWTH
•Continues well into adolescense & adulthood.
•Significant changes occurs in 20-30 years of
age .
•It appears that boys are more likely to have
significant late adolescent and early adult
jaw growth that results in forward positioning
of the lower jaw than are girls.

VERTICAL DIMENSION
•Last dimension to be completed.
•Late vertical growth increments are
greater in girls than boys & occur in
maxilla.
•As this occurs mandible if not growing by
similar amounts, is forced to translate
down & often backward, which lead
to a more convex profile.www.indiandentalacademy.com

Treatment delivered when it is
more effective and efficient may
not be sufficient because the
face can continue to change well
past the conventional adolescent
treatment period.

REGIONAL
DIFFERENCES
•The most important region of the cranial
vault,in terms of impact on the face & profile, i
probably the frontal bone area.
•The appositional changes that take place on
the frontal bone & brow ridge tend to make tha
area more prominent throughout adolescence
& early adult life.

The midsaggital cranial base
is a primary cartilaginous
structure that undergoes
bone growth at the
synchondrosis .www.indiandentalacademy.com

The anterior cranial base
•The midsphenoidal synchondrosis fuses at birth.
•The sphenoethmoidal synchondrosis fuses before
the beginning of the mixed dentition
(approximately 6 years)
•The frontoethmoidal junction changes little after 2
to 3 years of age.
•Early fusion of the anterior cranial base
synchondroses can lead to a retrusive or
deficient maxilla. www.indiandentalacademy.com

The spheno-occipital synchondrosis is a
potential force in posterior & late cranial
base growth change.
•This synchondrosis is viable
until mid to late adolescence
when first bony bridging
occurs.
Posterior cranial base

Because a good deal of
change in the cranial base
takes place from surface
apposition on the sphenoid
bone( around the pituitary
fossa) & at the most anterior
& posterior extent of the
midline cranial base ( nasion
& basion) ,

The anterior
cranial base is
the most
acceptable
reference for
facial growth.

MAXILLA
• Enlarges in the transverse dimension-
apposition on its lateral surfaces &
growth of the midpalatal suture.
•Anterioinferiorly , relative to the cranial
base- apposition at the maxillary
tuberosity & along the oral palatal
surface. www.indiandentalacademy.com

•Simultaneously , the anterior surface
of the maxilla & the nasal surface
of the palate are resorptive.

•The nasal septum moves in synchrony
with the maxilla & may provide some
guidance of growth & mechanical
support.

MANDIBLE
•Small changes in the chin area
accompanied by minimum
apposition on the lateral aspects of
the mandibular body.
•Apposition on the posterior surfaces
of the ramus .

•Resorption on the inner surface of the
mandibular body & the anterior surface
of the ramus.
•Little change in the size of
the anterior mandible,but
certainly makes space for
the erupting molars , as it
lengthens the mandibular
body.

•Transverse growth ceases early in
both the jaws.
•The width of the anterior portion of
both jaws changes by only 2 to
3mm.& occurs during eruption of
the permanent incisors.

•Some additional width increase
occurs when perm. canines
erupt.
•Some arch width also is gained when
the premolars erupt between 10 & 12
years www.indiandentalacademy.com

•Crowded front teeth do not spontaneously
straighten as the face grows because the
space increase on the dentoalveolar
ridges is small & not in the area most
affected by crowding .
•Facial growth & the obvious increase in the
size of the jaws really takes place
posteriorly & is most useful in creating space
for the molars.

SEVERE SKELETAL DISCREPANCIES
•Existing pattern will prevail in most of
the cases
•Orthopedic correction should include the
use of extraoral high pull force to
the molars or any other appropriate
appliance

AVERAGE SKETAL DISCREPANCIES
Assume the “worst case scenario”
For the milder version of the case
described the assumption is that
growth is going to proceed in an
unfavourable direction relative to the
needed correction

DENTAL
GROWTH

Facial & dental changes in
adolescents & their clinical
implications(Samir E.Bishara
AO,2000)
Terminal plane relationship in the
primary dentition and its
clinical implicationwww.indiandentalacademy.com

THE INITIAL OCCLUSION OF
PERMANENT 1ST
MOLARS IS
DEPENDENT ON THE TERMINAL
PLANE RELATIONSHIP OF THE
PRIMARY SECOND MOLARS.

TERMINAL PLANE RELATIONSHIP

MESIAL STEP
61.1% of individuals.

1mm.MESIAL STEP
76% CLASS I 23% CLASS II 18 % CLASS III

2mm.MESIAL STEP
68% CLASS I 13% CLASS II 19 % CLASS III
The greater the mesial step the greater
the probability for the molar
relationship to develop into a class
III occlusion.

DISTAL STEP
9.5% of individuals

Disto occlusion in the primary
or mixed dentitions will not
self – correct with growth

FLUSH TERMINAL PLANE
29.4% of individuals

FLUSH TERMINAL PLANE
56% - CLASS I 44% - CLASS II
Closely observe these cases and
initiate treatment when needed
at the appropriate time

“LEEWAY SPACE” OF
NANCE
The combined width of the
deciduous cuspid,first
deciduous & second deciduous
molars www.indiandentalacademy.com

is on the average 1.7mm greater
than the permanent successors in
the mandibular arch and 0.9mm
greater in the maxillary arch.

If the clinician finds that the loss of the
deciduous first molar is indeed a sign of lack
of space, we know that ordinary growth
procedures will not make up that space.
Though the leeway space of nance is present
adjustive changes following the loss of a tooth
can quickly dissipate this advantage.
Thereafter the clinician may plan to maintain the
space by placing a lower lingual arch or any
other space maintainerwww.indiandentalacademy.com

In the 56.4% of individuals
with a flush terminal
plane,placing a lower lingual
arch to maintain the space
may have the adverse affect.

End to end molar
relationship – lingual
arch is placed, consider
using headgear or other
appliances to obtain a
class I occlusion.

EXCESSIVE OVERBITE IN
DECIDUOUS DENTITION
Many deciduous dentitions present with
excessive overbite
In the deciduous dentition, the teeth are
more vertical & the angle formed by the
intersection of the long axis is greater
In the permanent dentition the long axis of
the upper & lower incisors form a more
acute angle.www.indiandentalacademy.com

The more upright the incisors the
greater the likelihood of excessive
overbite
A combination of the more acute axial
inclination of the permanent incisors
as they erupt & simultaneous vertical
alveolar growth often reduces the
temporarily excessive overbite

The mandibular intercanine dimension is
completed
at 9 years- girls
at 10 years- boys
The maxillary arch,intercanine dimension is
completed
at 12 years-girls
at 18 years- boys
INTERCANINE DIMENSION

In both male & female the maxillary
intercanine dimension serves as a
“safety valve”for pubertal growth
spurts,where there is a basal horizontal
mandibular growth,partly unmatched by
the maxilla,as the mandible grows
downward & forward.
“Safety valve mechanism”

UGLY DUCKLING PATTERN
•The maxillary lateral incisors erupt into
the oral cavity with a strong
inclination of their crowns
•This tends to force the apices of these
teeth toward the midline,while the
crowns tend to flare laterally.

•As the lateral erupt, the canines higher up in the
alveolar process are also erupting but are literally
sliding down the developing roots of lateral
incisors.

•As the canine continues to erupt however,
there is an autonomous straightening
up of the lateral incisors.
•The temporary spacing that often occurs
between the central incisors & the
lateral incisors is usually closed as the
canines erupt into complete occlusion.
•Hence it would be most hazardous to place
appliances at this critical stage.

SOFT TISSUE
CHANGES

Soft tissue changes
Growth in the length of the face is
significant & can greatly
influence the balance between the
nose, lips,& the chin.
There is a tendency for the lips to
thin & become more retrusive with
age in the absence of treatment.www.indiandentalacademy.com

This means that more children have
lips that approximate at rest simply
because of normal growth changes.
This natural process makes the
nose & chin more prominent in
relative terms.

These changes combined with the
average forward mandibular rotation in
boys,produce considerable flattening of
the profile.
For girls, the profile flattening is less
dramatic becoz, although all the changes in
the soft tissue are similar, they are less
magnitude than those in boys & the average
backward rotation mitigates the flattening.

CLINICAL
EVALUATION

CLINICAL EVALUATION BY
THE CLINICIAN.
•Anterior posterior
•Vertical
•Transverse
•Problems occur simultaneously.

Look at them from
the side.

Seat the patient ,& ask them to look at
a distant object
One tries to visualize the anterior
extent of the cranial base, the maxilla,
& the mandible-relationship between
the three can be evaluated
The soft tissue landmarks overlying
these skeletal points are connected
mentally www.indiandentalacademy.com

Two line segments describe
the facial profile
The bridge of the nose to the
base of the nose to the
point of the chin

ANTERO- POSTERIOR
RELATIONSHIP

Patients who have no convexity, in other
words ,a straight facial profile where the
bridge of the nose,& the chin point are in
straight line are of concern in the preschool &
early childhood years.
Ideally the base of the nose & the chin
point should begin to approximate a
vertical line dropped from the bridge of
the nose as a child nears adolescence.

Young children up to school age usually
have some facial convexity in their profiles
It continues into the early childhood years
and upto adolescence in girls.
Boys may have slightly straighter facial
profiles,but minor convexity even at
maturity is normal.
Either excess convexity or concavity is an
indication of a jaw problem

CONCAVE
PROFILE

CONVEX
PROFILE

Most well balanced face have half the
face below the base of the nose.
These individuals normally have a
overbite of 1-5mm.
Patients with increased lower facial
height often have a open-bite occlusion.
VERTICAL FACIAL RELATIONS

Anterior open-bite is often seen as a normal
transition from the primary to early mixed
dentition years and does not always confirm a
skeletal problem .
Patients with decreased lower facial height often
have excessive overbite of more than 6mm.
Again these dental relationships do not always
confirm a skeletal problem but certainly are
suggestive of a discrepancy.

NORMAL FACIAL
HEIGHT
INTRA ORAL
VIEW

INCREASED
FACIAL
HEIGHT

DECREASED
FACIAL
HEIGHT

INCREASED AFH
DESCRESED AFH

FACIAL ASYMMETRY
Examine the patient from
posterosuperior view

Determine if the center of the chin
point lies on the facial midline.
Should be accomplished when the
patient is biting the teeth together.
Minor facial asymmetry is common
More than 2- 3mm of asymmetry or
facial asymmetry with a history of
trauma, is of concern.www.indiandentalacademy.com

MAXILLARY SKELETAL
CONSTRICTION
Observed by the presence of posterior
cross-bite when the patient is biting
the teeth together.

GROWTH
PROBLEMS

Excess facial convexity or concavity,
significantly increased or
decreased lower face height, facial
asymmetry & posterior crossbite
need to be referred for further
evaluation.

ANTEROPOSTERIOR
PROBLEMS

•Caused by unfavourable
jaw size or position.
•Indicated as extreme
overjet

PROTRUSIVE MAXILLA
•If this is the predominant cause of the problem
headgear is used
•Headgear acts to restrain forward growth while
the lower jaw continues to grow.
•These compressive headgear forces are
transmitted to the sutures through appliances on
the teeth.
•Dental changes accompany headgear treatment.

There appears to be reasonable
evidence to indicate that maxillas that
are positioned posteriorly can be
successfully moved anteriorly in
young growing children between the
ages of 6 – 8 years.
RETRUSIVE MAXILLA

•Treatment aimed at the mandible – functional
appliance.
•They accentuate mandibular growth,possibly by
unloading the condyle & stretching the
associated mandibular muscles.
•Muscle forces transmitted to the maxilla have a
restraining effect or headgear effect on the maxilla.
•They also have a tooth moving effect & tip the
upper teeth backwards & the lower teeth forwards.
SMALL OR POSTERIORLY POSITIONED MANDIBLE

A LARGE MANDIBLE
•More difficult problem to treat
•The mandible undergoes accelerated growth
to a greater extent than the maxilla
during the adolescent growth spurt.
•Because growth modification for this type
of malocclusion is routinely unsuccessful,
camouflage treatment is often attempted

Headgears have more effect on the
maxilla & functional appliances have
more effect on the mandible.In both
types of treatment there are related
dental changes.
To achieve the kind of growth changes
that are most desirable,the patient
should be growing reasonably rapidly
& certainly not past the peak adolescent
growth spurt.

•Unfortunately comouflage is usually only
acceptable for male patients who can
tolerate a more prominent mandible.
•Ultimately many patients need to be
treated surgically to either move the
maxilla forward ,the mandible
backward, or a combination of the two
procedures.

VERTICAL PROBLEMS

•Patients with vertical facial problems comprise
less than 5% of all malocclusions.
•Those with excessive lower face height are difficult
to treat & often require surgical intervention.
•In all of these patients ,there is overdevelopment
of the lower face that is often accompanied by
exaggerated tooth eruption.
•The mandible appears to be rotated downward
and posteriorly.

•Treatment for this type of problem can include
headgears or functional appliances to
restrict downward growth of the upper jaw &
tooth eruption.
•The mandible then has a growth expressed in a
forward direction with limited increases in
the facial and dental height.
•But because of the long duration of vertical
facial growth, this type of treatment may
need to be continued into late
adolescence& may still prove unsuccessful.www.indiandentalacademy.com

•Hence this type of malocclusion should be
camouflaged or treated surgically
•The surgical treatment to correct this type
of malocclusion often involves superior
repositioning of the maxilla, forward &
upward autorotation of the mandible, as
well as repositioning of the mandible.
•This type of surgical treatment after the
completion of growth is usually
successful. www.indiandentalacademy.com

TRANSVERSE
PROBLEMS

•The most common transverse problem is
maxillary constriction.
•Posterior crossbite can occur in
approximately 5% of the population.
•Palatal expansion can be accomplished in
the primary or early mixed dentition years
•Appliances that apply moderate to high
forces to the teeth that are transmitted to
the maxilla & midpalatal sutures.

•Several forms of surgical intervention for
trasverse problems are possible for older
patients.
•Palate expansion combined with surgical
treatment or surgical treatment alone.
•Treatment for mandibular facial asymmetry
may initially include functional appliances to
modify or increase the growth on the deficient
side & adjust the eruption of the teeth or surgical
intervention.

TIMING
DIRECTION
ROTATION

GROWTH
TIMINGwww.indiandentalacademy.com

1st
peak – 3 year age level
2nd
peak – girls- 6 to 7 years
boys- 7to 9 years
3rd
peak - girls - 11 to 12 years
boys- 14 to 15 years
PUBERTAL SPURTS

Growth stages

1.Infancy to early childhood –birth to 6
years(the primary dentition years)
2.Late childhood or the preadolescent
period– 5 or 6 years to onset of
puberty(the mixed dentition years).

3.Adolescence – period of life when
sexual maturity is attained( early
permanent dentition years)
4.Adults.

Infancy & early
childhood

Growth of brain case, gets completed by the
age of 6
Extra oral orthopedic forces can be used to
our advantage
 Rapid growth is exhibited during this period
(ie)4-6 years
Growth modification using
functional appliances for jaw
discrepancies should be successful at
this stage. www.indiandentalacademy.com

Unfortunately relapse
occurs because of continued
growth in the original
disproportionate pattern due
to a phenomenon known as
“predominance of
morphogenetic pattern”www.indiandentalacademy.com

Growth modification
therapy for skeletal
discrepancies is best attempted
until the preadolescent years
when growth modification
results are more stable

Juvenile period
or
preadolescent

“Juvenile acceleration” occurs 1- 2
years before the adolescent growth
spurt ,more particular in girls
•This juvenile acceleration can equal or exceed
the jaw growth that accompanies the
secondary sexual maturation.
•Careful assessment of physical growth is
clinically important
•If treatment is delayed too long in girls we
may miss this juvenile spurt.www.indiandentalacademy.com

Class II correction –
preadolescent period is
more effective

REASONS
The bones are less minerlized &
therefore more easily deformed
Sutures & ligaments are more cellular
resulting in more rapid biological
responses

Growing tissues are more responsive
to external forces
Best orthopaedic results are obtained
when growth is more active
The juvenile period has greater
growth on the average at its
beginning

Adolescent
period

In boys generally puberty begins later
& extends for a longer period
which is 5 years in boys as
compared to 3 & half in girls
Girls’ physical and facial growth
occurs before boys’and demonstrates
less intensity.

Girls – adolescent facial growth
spurt- between the ages of 9 to
11, or possibly 12.
Boys – accelerated facial growth
– between 11 to13,or possibly
14. www.indiandentalacademy.com

During the adolescent growth
spurt,growth modification &
definitive treatment can be
combined
Results are stable,unlike the
deciduous dentition period

DENTAL
TIMING

Early maturing girls
The adolescent growth spurt precedes
the final transition of the dentition
 if girls are to receive orthodontic
treatment it is best during the
mixed dentition rather than in the
permanent dentition

Slow maturing boys
A considerable amount of
physical growth remains
even after transition of the
dentition

TYPICAL TREATMENT PLAN FOR
JAW DISCREPANCIES
STAGE I – during mixed dentition
stage ,focus on skeletal problem( ie
1- 2 years before the peak of the
adolescent growth spurt)
STAGE II – comprehensive fixed
appliance treatment during the early
permanent for stability.

DIRECTIONS
OF
GROWTH

Factors affecting
the directions of
growth

MUSCLE DYSFUNCTION
HABITS
•Tongue thrust
•Mouth breathing
PIERRE-ROBIN SYNDROME

•The formation of bone at the muscle
attachments depends upon the activity of
the muscles.
•The musculature is important for the soft
tissue matrix,whose growth normally
carries the jaw downward & forward
•The loss of musculature could occur in
utero or due to birth injury as a damage
to the motor nerves

Excessive muscle contractions can cause
restriction of growth.this is seen in
Torticollis where growth is restricted
on the affected side,
Decrease in muscle activity in
conditions like cerebral palsy or
muscular dystrophy can cause
displacement of the jaws.this results in
a vertical rotation & even open bite

Ingerwall & Muller in their
studies have said that in high angle
cases , there is a weaker
musculature which supports the
supra eruption of the posteriors &
in low angle cases the musculature
is strong which prevents the supra
eruption of the posteriors.

HABITS
SUCKING
 the most common,non nutritive habit
In general habits during primary dentition have
little effect
If habit persists during permanent dentition this
could lead to malocclusions & also vertical
rotation of the mandible due to extrusion of
molars
If a child stops the habit by 3-4 years then
there would be no deletrious effect.www.indiandentalacademy.com

TONGUE THRUST
 the position of tongue in children &
adult varies
Tongue is interposed between lips in
infancy which is normal
If this persists , it may lead to an open
bite & vertical rotatin of the jaws &
cause malocclusion

MOUTH BREATHING
Partial obstrution of nasal airway is due to
enlarges adenoid & tonsils and may lead to mouth
breathing.
Solow & Kreiboig (1977) confirmed in several
studies that factors affecting adequacy of the nasal
airway can result in a posterior tilt of the head.
When the head tilted back,the face was
retrognathic & the mandibular plane angle as well
the total & anterior face heights were large.

PIERRE-ROBINS SYNDROME
This is a condition which is characterized
by a deficient mandible & cleft palate
due to the pressures that restrict growth
during intrauterine life.
After birth one can expect normal growth.
In some cases there has been a restriction
which is caused by the pressure that
have injured the TMJ.

ROTATION
OF
JAWS

MANDIBULAR GROWTH
ROTATIONS:
Reflection or imbalance of differential
growth in anterior & posterior face
heights
Mandibular growth rotations – thier
mechanisms & importance
W.J.B.Houston EJO ,1988.

GROWTH IN POSTERIOR FACE HEIGHT:
Depends on vertical components of
growth at the middle cranial fossa& at the
condyle.
GROWTH IN ANTERIOR FACE HEIGHT:
Is greatly influenced by growth of the
cervical column & the resulting differential
growth of the muscles,fascia,& other soft
tissues, that pass between cranium,
mandible,hyoid bone & shoulder girdle.

(-ve) or forward
Counterclockwise(facing right)
Clockwise(facing left)
(+ve) or backward
Clockwise( facing right)
Counterclockwise(facing left)www.indiandentalacademy.com

Growth of the anterior & posterior face heights are
determined in different ways, & so it is not
surprising that there can be minor discrepancies in
the amount of their growth
Since growth in the AFH is determined primarily
by growth in the length of the cervical column
& the associated stretch of the cranio-cervical
fascia & musculature
Treatment induced changes in the AFH will be
unstable unless they are associated with adaptive
changes in head posture or in the musculo-fascial
balance of the mandible.www.indiandentalacademy.com

Clinical
significance of
growth rotation

FORWARD ROTATION/DECREASED
AFH
In forward rotation of jaws the fulcrum
point is located at the incisors
STABLE:the overbite remains unchanged
UNSTABLE:the fulcruming point is
located further back along the occlusal
plane, resulting in deepening of the bite
combined with greater increase of the
posterior facial height.www.indiandentalacademy.com

This deterioration of the occlusion is not
pronounced during puberty when growth
intensity is at its greatest, but continues
throughout the growth periods.
Therfore deep bite should be treated early &
the occlusion supported throughout the
growth period.
Retention should be maintained untill the
mandibular growth is completed.www.indiandentalacademy.com

POSTERIOR ROTATION OF
MANDIBLE/INCREASED AFH
The centre of growth rotation ( fulcrum
point) is located near the mandibular
condyles.
Here early interception is needed to
maximise the dentoalveolar compensation

REASONS:
a. After puberty there is less active growth
b. Potential for backward or posterior rotation is
reduced
c. Tendency to extrude the posterior teeth
decreases when there is less active growth.
d. Mesial migration & uprighting of the anterior
teeth are minimal.
In cases where extractions are necessary,
treatment should be postponed until
after puberty.

CONCLUSIONwww.indiandentalacademy.com

Problems with facial growth can result in
aesthetic & functional complaints.
Using a simple method of clinical
evaluation the orthodontist can identify
facial growth ploblems in the
anteroposterior,vertical & transverse
dimensions.
These problems can then be referred for
evaluation & treatment by a variety of
means. www.indiandentalacademy.com

By adopting a contemporary view that
facial growth is the result of genetic &
environmental factors,growth modification
becomes a real possibility.
Unfortunately some problems must be
camouflaged or treated by combined surgical
& orthodontic means
Continued growth in early childhood can
enhance or detract from treatment results
obtained in childhood or adolescence

These dynamic properties of
the face make management of
facial growth challenging but
generally rewarding & successful
because of substantial aesthetic &
functional improvements

Guided by:Dr.Uma

Facial & dental changes in adolescents
& their clinical implications
Samir Bishara(A.O.,2000)
Skieller,Bjork,and Linde hansen
Found that the combination of 4
variables gave the best prognostic
estimate of future mandibular growth
direction. www.indiandentalacademy.com

1.Mandibular plane inclination to
the anterior cranial base –(MP:Sn
angle) or the ratio of PFH/AFH.
2.Intermolar angle

3.Shape of the lower border of the
mandible measured as the angle –
Go–Me and a tangent to the lower
border of the mandible
4.The inclination of the symphysis
measured as the angle between
the tangent of the anterior surface
of the symphysis and SN

Steep MP
Obtuse gonial angle
Open bite tendency
Severly retrognathic or prognathic
mandible
Future growth will be unfavourable

MOLAR RELATIONSHIP IN
PERMANENT MOLARS

Clinical implications of growth

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