British Journal of Orthodontics/Vol 4/No 2;53-64 Printed in Great Britain /'.

Growth of the Maxilla in Three

Dimensions as Revealed
Radiographically by the Implant
Method*
A. Bjork, Professor, Odont. Or and V. Skieller, Assistant Professor, L.D.S.
Institute of Orthodontics, Royal Dental College, Copenhagen

Abstract. By use of the implant method the growth of the maxilla was analysed from profile and frontal
(postero-anterior) cephalometric radiographs in nine boys with normal primary occlusion who were followed
annually up to adult age without receiving any orthodontic treatment.
The proportion of sutural and appositional growth in height was determined from profile radiographs
With reference to implants in the infrazygomatic crest. The sutural lowering of the maxillary corpus was,
on average, about twice as big as the apposition at the floor of the orbits. The resorptive lowering of the
nasal floor amounted to about one-third of the appositional growth in height of the alveolar process.
Our study suggests that the contour of the anterior surface of the zygomatic process could be used as a
reference structure in growth analysis as this contour kept a constant relation to implants in the infrazygomatic
crest and closely followed the natural growth rotation of the maxilla.
In relation to the implants, the dentition as a whole drifted forward on the maxillary corpus, simultaneously
With a smaller decrease in arch length which was partly related to a differentiated development in width of
the maxilla.
Measurements between bilateral implants on frontal radiographs proved that the growth in the median
suture was greater posteriorly than anteriorly, whereby the two halves of the maxilla rotate in relation to each
other in the transverse plane. This was reflected in the development of the dental arch as the increase in the
hi-molar width showed a high correlation with the sutural growth posteriorly in the medium suture, while
the increase in the bi-canine width was lesser. The forward drift of the dental arch led to a reduction in incisor
spacing, which may give rise to an incisal secondary crowding.

The purpose of this presentation is to describe Sample

the co-ordinated growth of the maxilla in three
dimensions, as far as this is possible from longitu-
dinal cephalometric radiographic exposures in the
lateral and the frontal view with the use of the
metallic implant method. The presentation will give
a quantitative description of the growth in the
median suture of the maxilla and elucidate if the
growth activity is the same throughout the length
of the suture. It has been possible to make a three
dimensional estimate of the influence exerted by
the growth of the maxilla in all three planes on the
development of the maxillary dental arch. Also, the
possibility of finding natural reference structures in
the maxilla will be discussed.
0
29th Northcroft Memorial Lecture delivered at the County Meetinll of
the B.S.S.O. in Edinbur11h on 4th April 1975.
In 1957, a sample of 4-year-old boys was selected
who had normal temporary dentition and normal
or almost normal occlusion. This account of facial
and occlusal development is limited to nine of
these subjects who had not received any ortho-
dontic treatment. It proved possible to follow-up
these nine boys by means of annual examinations
to the age of 21 years or more, except two who were
followed-up to the age of 18 years.
Method
When applying the implant method, it is essential
to ensure a perfect radiographic technique and to
maintain a thorough control of the stability of the
metallic implants. The use of the method also pre-
supposes faultless instruments as well as perfectly

53
A. Bji:irk and V. Skieller
MEAN GROWTH CHANGES
9 CASES, 4 TO 20 YRS
Fig. 1. Mean growth changes from 4 years until adult
age in nine boys, measured from the lateral implants.
Su= sutural lowering of the maxilla; 0= apposition at
the floor of the orbit; A= appositional increase in height
of the alveolar process; Re= resorptive lowering of the
nasal floor; C= apposition at the infrazygomatic crest.
INCREASE, MM
11
3 TO 17 11 YRS
3231 cf
Fig. 2. Growth in width of the maxilla at the level of the
lateral implants, Case 3231.
formed and accurately fitting pins, together with a
meticulous technique of insertion ( Bjork, 1955,
1968*).
At 4 years of age tantalum pins were inserted in
the zygomatic process of the maxilla, two on each
side. The pins were inserted slightly anteriorly on
the lower margin and relatively far laterally on the
crest. We have called these pins lateral implants. The
• The instrument and pins are supplied by Bangsdal Dental Ltd. Adelgrade
17, DK-1304, Copenhagen K Denmark.
54
increase in distance between one of the lateral im-
plants on each side, measured on the frontal
(postero-anterior) films, indicates the increase in
width in the median suture at the level of the first
molars. After full eruption of the permanent in-
cisors, pins were also inserted into the anterior
aspect of the maxilla, below the anterior nasal
spine, one on each side of the median suture at a
level with the apices of the central incisors. These
pins, designated anterior implants, were inserted at
the age of 10-11 years. The increased distance
between these anterior implants, measured on the
frontal films, indicates the growth in width in the
median suture anteriorly, at the level of the incisors
From the age of 10-11 years, when implants also
were inserted on the anterior aspect of the maxilla,
a line was drawn by pencil on the profile radio-
graphs from the tip of one of the anterior implants
to the marked midpoint between one of the lateral
implants on each side. A change in the inclination
of this implant line at different age stages in relation
to the nasion-sella line (NSL) indicates a vertical
rotation of the maxilla in relation to the anterior
cranial base (Fig. 6). By superimposing the various
radiographs on the implant line, on the other hand,
it is possible to analyse the remodelling of the
maxilla (Fig. 7).
The nasion-sella line can only be used in growth
analysis after adjustments have been made. In con-
nection with apposition in the glabella region, the
nasion point (n) moves forward throughout the
entire growth period and during this may be dis-
placed upward or downward. The eccentric re-
modelling of the sella turcica during growth has the
result that the position of the midpoint(s) of the
sella turcica is displaced backward and possibly
upward or downward. In the procedure of super-
imposition used, an attempt was made to reduce
these sources of error by transferring the nasion-
sella line, as defined on the first film in the series,
to the subsequent films by use of the structural
method. A detailed description of this structural
method of orientation is published elsewhere
(Bjork, 1968). The practical procedure consists in
placing a sheet of cellophane, with printed cross-
lines on the top of the first film of a series, passing
through the nasion and with the centre of the cross-
lines at the sella point. The subsequent films of the
series are then superimposed according to the struc-
tures on the first film, and then the orientated cross-
lines from the first film are transferred to the sub-
sequent films. All our facial growth tracings refer
to these transferred crosslines and accordingly to
the anterior cranial base (Figs 6-9).
Growth of the Maxilla in Three Dimensions

Fig. 3. Photographs at the age of 43 and 203, Case 1597.

Fig. 4. Photographs of dental casts at the age of 43, 103 and 2P years, Case 1597.

55
A. Bj6rk and V. Skieller

GROWTH AT MIDPALATAL SUTURE

.~..._----------------------------- ---- -------- - -- --- ---- - -- -- ---- - - - -- --:..._.....

1597c! ANTERIOR IMPLANTS: 0.8 mm

---10 3
-20 3 LATERAL IMPLANTS: 2.7 mm
Fig. 5. A triangle constructed in the transverse plane illustrating the mutual rotation of the two maxillae during growth,
Case 1597. The growth in the median suture, measured between the lateral implants was greater than between the
anterior implants, indicating that the two maxillae have rotated in relation to each other in the transverse plane.
As a consequence, the length of the maxilla in the mid-sagittal plane has decreased.

The magnification for the profile exposure was

5·6 per cent. For the frontal exposure the magnifi·
cation in the ear plane was 8·3 per cent. The mag·
nification in the frontal plane through the anterior
as well as through the lateral implants differed
individually, as both planes were at a varying dis·
tance from the ear plane. Moreover they moved
closer to the film during facial growth (Bjork and
Skieller, 1974). Correction for radiographic mag·
nification, however, did not seem necessary in this
presentation.

Growth of the Maxilla as Analysed by Means of

Lateral Implants from the Age of 4 Years
Maxillary height
Previous implant studies ( Bjork, 1955, 1966) have
confirmed that the increase in the maxillary height
takes place by growth at its processes; suturally
toward the frontal and zygomatic bones and appo·
sitionally on the lower aspect of the alveolar process
1597 c! in association with eruption of the teeth. Apposition
4J also occurs at the floor of the orbits with resorptive
6J remodelling of the lower surface. Simultaneously,
3 the nasal floor is lowered by resorption and an
10
13
1 apposition takes place at the hard palate.
21' Although these general principles of growth in
height of the maxilla have been clarified earlier, it
Fig. 6. Growth tracing representing five stages in the is of interest to obtain an idea of the mutual magni·
facial development in Case 1597 with orientation to the
anterior cranial base. An arrow indicates the change in tudes of these different growth factors, which at
position of nasion. present are unknown. The mean growth changes

56
Growth of the Maxilla in Three Dimensions

from the age of 4 years until adult age in the nine

cases are given in Figure I.
With the lateral implants as fixed reference points
in the maxilla, the vertical component of the sutural
growth was in the nine cases calculated at right
angles to the nasion-sella line (NSL). The sutural
lowering of the maxilla, calculated in this way, was
on an average 11·2 mm, with a range from 9·5-
13·5 mm. The orbits do not increase in height from
childhood through adolescence to the same degree
as the nasal cavity. The sutural lowering of the di'
maxillary corpus was, therefore, to some extent
compensated for by apposition at the floor of the
orbits, on an average by 6·4 mm, range 5-8 mm.
The lowering of the floor of the orbits from the age
of 4 years was thus somewhat less than half the 1597 d'
sutural lowering of the maxillary corpus. The 3
height of the nasal cavity up through puberty also 10
3
increased as a result of the resorptive lowering of 13
3
its floor. With the lateral implants as guidance, this 21
lowering was on an average 4·6 mm, i.e. about one- Fig. 7. Three stages in the remodelling of the maxilla
third of the increase in sutural height of the nasal with orientation to the implant line, registered on the
cavity, with a range of 1·5-7·5 mm. lateral implants, Case 1597.
An estimate of the magnitude of the development
in height of the alveolar process is clinically essential
as this is a measure of the degree of eruptive activity
of the teeth. The mean appositional growth in
height of the alveolar process, calculated in relation
to the lateral implants, at right angles to the nasion-
sella line, amounted to 14·6 mm, with a range from
9·5-21·0 mm. The appositional growth in height of
the alveolar process was thus on an average about
one-third greater than the increase in height of the
alveolar process as seen in relation to the nasal
floor which was lowered 4·6 mm by resorption.
Maxillary widtb
The discussion on growth in width of the maxilla
has mainly been concerned with to what extent
sutural growth in the median suture contributes to
this growth in width, and to what degree appo-
sitional remodelling of the outer aspects of the
maxilla contributes. Keith and Campion as early as
1922 attempted to evaluate this problem by com-
paring crania in children and adults. They took the 159? d'
view that the median suture must be an active factor
41
in the growth in width of the hard palate. The oppo-
site point of view, that the suture does not contribute si
1
to the growth in width of the maxilla to any great 10
1
extent, at any rate not after the first few years of 13
life, was later advocated by several authors. Scott 21 1
0956, 1967) described the median suture as a site Fig. 8. Five stages in dental arch development in relation
of active growth during fetal life, but claimed that to the infrazygomatic crest, with orientation to the
it was uncertain whether growth occurred in this anterior cranial base, Case 1597.

57
A. Bjork and V. Skicller

-2.5°

0 L s -3° p
I I ~ 1.5
2.5 5 1597 cf
1
10
1
21
Fig. 9. Two stages in dental arch development, and
tooth inclination with orientation to the implant line,
registered on the anterior implant, Case 1597. OL,=
bisectrix of the occlusal lines, 103 and 213. lP~,= line
through the anterior implant perpendicular to OL.
P= posterior point of the incisive papilla at the two
stages.

suture after birth. Also Enlow and Bang (1965)

considered that the widening of the hard palate and
the upper dental arch were mainly the result of a
remodelling process. Latham ( 1971) found no histo-
logical evidence of active growth in the median
suture after 2-3 years of age. Recent histological
studies, however, have confirmed that growth in the
median suture takes place up to adolescence
(Persson, 1973; Melsen, 1975). The implant method
has been shown specially suitable to elucidate the
problems of the postnatal growth of the maxilla
and to permit a quantitative evaluation ( Bjork and
Skieller, 1974). Already from our early implant
studies it was clearly demonstrated that growth in
the median suture continues until puberty (Krebs,
1964; Skieller, 1964).
The growth in width of the maxilla at the level of
the first molars will first be exemplified by one of
our cases. followed from the age of 3 11 to the age
of 17 11 • As illustrated by Figure 2 the growth in the
median suture measured between the lateral im-
plants amounted to 6·7 mm. The measured distance
between the outer aspects of the maxilla increased
somewhat more, 9·5 mm. We can, therefore, estab-
lish that the sutural growth has been the most im-
portant factor in the development in width of the
maxilla. The extent of a remodelling of the outer
u
2.5
1597 cf
3
10
3
21
Fig. 10. Drawing of photographs of the dental arch in
occlusal view illustrating the changes in arch form and
the forward displacement of the arch on the maxillary
base from the age of 103 , Case 1597./ncisor segments:
midpoint of the central incisors to the mesial point of the
canines. Lateral segments: mesial contact point of the
canines to the mesial contact point of the first molars.
P= posterior point of the incisive papilla.
aspects at the same level as the implants cannot be
evaluated exactly by this method because the dis-
tance between the outer contours of the two sides
of the maxilla on the frontal radiographs is also
increased in connection with the increase in length
of the maxilla. The true increase in width of the
maxilla at the level of the first molars must, there-
fore, be reckoned as less than the above value. The
same growth pattern of the maxilla was seen in all
nine cases.

58
Growth of the Maxilla in Three Dimensions
TABLE I
Mean and Range of Age Changes (mm) Until Adult Age In Nine Boys
From 4 years 6-7 years
Between anterior implants
Between lateral implants 6·9 4·8
(5·5 to 8·2) (2·4 to 6·1)
Bi-canine width* 3·1 1 ·1
(-1·0 to 6·0) (-2·5 to 4·5)
Bi-molar widtht 3·1
(0·1 to 7·0)
* Measured between mesial contact points of canines
t Measured between mesial contact points of first molars.
In order to obtain a relationship of the sutural
growth to the general physical development and the
skeletal maturation, the increase in body height was
recorded and in addition special stages in the ossi-
fication of the bones of the hand (Helm et al., 1971,
Bjork, 1972). This relationship was exemplified for
another of our cases, 1597, whose facial photo-
graphs in half profile are shown in Figure 3. The
curves for the cumulative growth in width in the
median suture, measured between the lateral im-
Plants from year to year, followed the same pattern
as the curves for the growth in body height. The
curves also showed that the time of the puberal
growth spurt coincided, but that the sutural growth
terminated earlier than the growth in body height
(Bjork and Skieller, 1974).
The time for puberal growth maximum in the
median suture coincided in all nine cases with the
time for the growth maximum in the facial sutures
in the sagittal plane measured on profile radio-
graphs. The time for completed sutural growth in
the transverse and in the sagittal plane also coincided
in all cases, occurring on an average at about 17
years of age ( Bjork, 1966). The transverse growth in
the median suture, measured between the lateral
implants, was, on an average, 6·9 mm from the
age of 43 years until adult age, with a range from
5·5-8·2 mm in the nine cases (Table 1).
Bi-molar "·ldth
A question of clinical interest, which has not yet
been clarified, is how far the increase in width of the
dental arch of the upper jaw is related to the sutural
development in width of the maxilla. The increase
in width of the maxillary dental arch was determined
from dental casts between the first molars. The hi-
molar width in Case 1597 (Fig. 4) showed a puberal
increase, followed by a smaller decrease, so that at
10-11 years
0·9
(0·3 to 1·5)
3·0
(1·7 to 4·2)
-0·1
(-2·0 to 1·0)
1·8
(-0·2 to 3·4)
the age of 21 3 years the width was only I mm
greater than at the time of eruption of the first
molars at the age of 63 years.
The manner in which the increase in width of the
upper dental arch was associated with the growth in
the median suture can be illustrated from the data
from all nine cases (Table 1). From the times of
complete eruption of the first molars at about the
age of 6-7 years until adult age, the growth in the
median suture measured between the lateral im-
plants was, on an average, 4·8 mm. During this
time interval, the increase in width of the dental
arch between the first molars was, on an average,
3·1 mm. Thus the increase in sutural growth between
the lateral implants was greater than the increase
in width of the dental arch between the first molars.
The variability of the increase in the hi-molar width
was about twice as big as the variability of the
increase in the maxillary width in the median suture,
indicating a greater influence of compensatory or
dysplastic nature on the development of the dental
arch. However, these two increases in width were
nevertheless associated, as can be shown by the fact
that the correlation coefficient was 0·67. The reason
for this difference in the growth in width will be
discussed in the later section on the co-ordinated
growth of the maxilla in all three planes.
Hi-canine wide
The development in width of the dental arch between
the canines was also measured from dental casts.
This development showed quite another pattern
than the increase in width between the first molars
(Fig. 4) corresponding to the description by
Moorrees et al. ( 1969). In the nine cases the width
between the mesial contact points of the canines
was, on an average, increased by 3·1 mm from the
age of 4 years to adult age, individually varying
59
A. Bjork and V. Skiellcr
from -I to 6 mm. From the time of eruption of
the first molars the hi-canine width in the nine cases
increased only by 1·1 mm in contrast to the increase
of 3·1 mm between the molars (Table I). This will
be discussed in the next section.
Co-ordinated Growth of the Maxilla in Three
Dimensions as Analysed by Means of Anterior and
Lateral Implants from the Age of 10-11 Years
Maxillary length
Growth in length of the maxilla is known to occur
suturally towards the palatine bone and by appo-
sition on the maxillary tuberosities. Appositional
growth at the anterior surface of the maxillary cor-
pus was by Scott ( 1967) supposed to contribute to
the length of the maxilla, while Enlow ( 1968)
reported this area to be resorptive. Earlier implant
studies, however, proved this anterior surface to be
rather stable sagittaly ( Bjork, 1955, 1966, Bjork
and Skieller, 1972).
Profile radiographs from our nine cases have
confirmed that the anterior surface of the maxilla
retained its close relation to the anterior implants
from the age of I0-11 years. Observations from
earlier age groups indicate a similar condition. The
anterior surface of the maxillary corpus may,
therefore, be described as an area under continuous
remodelling in connection with the resorptive
lowering of the nasal floor, especially marked in
cases of extreme forward growth rotation of the
maxilla.
Transverse mutual rotation of the two maxillae
The analysis of the sutural growth in width of the
maxilla would be incomplete without elucidating
whether the growth in the median suture is of the
same degree throughout its entire length. We, there-
fore, compare the increase in width between the
anterior and the lateral implants. Since right and
left maxillae are two separate bones, joined along
the median suture, there is an anterior and a lateral
implant in each maxilla, so that the distance between
these implants is constant throughout growth. In
the transverse plane, therefore, a triangle could be
constructed with sides of constant length (Fig. 5).
It then appeared that the increase in width from the
age of I0-11 years in the nine cases, measured
between the lateral implants, was, on an average,
three and a half times as great as that between the
anterior implants (3·0 mm against 0·9 mm) and
with a greater range (2·5 mm against 1·2 mm)
(Table 1). That the lateral implants separate more
than the anterior during the growth indicate that the
60
two maxillae rotate in relation to each other in
the transverse plane. Due to this transverse rota-
tion, the length of the maxilla when measured
in the mid-sagittal plane becomes reduced. Since
the anterior and the lateral implants lie at different
vertical levels, the magnitude of this shortening
becomes a three dimensional problem.
The mutual transverse rotation of the two maxi!·
lae during growth has the result that the lateral
segments of the dental arch also separate more
posteriorly than they do anteriorly. The distance
between the first molars thus increases more than
the distance between the canines, while at the same
time the length of the dental arch becomes reduced
in the mid-sagittal plane. The sutural factor in this
development of the dental arch has hitherto been
unknown. The shortening in length of the dental
arch in the mid-sagittal plane has been ascribed to
a shortening of the arch perimeter due to an
increased crowding of the teeth during the develop·
ment (Figs 4 and 10). We have, however, shown
that this shortening of the dental arch in the mid-
line is also related to the transverse growth of the
maxillae (Figs 5 and 9).
Vertical rotation of the maxillary complex
Superimposition of longitudinal profile radiographs
on the nasion-sella line shows generally an almost
parallel lowering of the nasal floor, as described by
Brodie in 1941. This observation led to the view
that during growth the maxilla is lowered without
rotation in the vertical plane. However, implant
studies (Bjork and Skieller, 1972) have shown that
the downward and forward displacement of the
maxilla during growth is associated with a varying
degree of vertical rotation, as a rule directed for·
ward. Despite the maxillary rotation in the vertical
plane, the inclination of the nasal floor to the
anterior cranial base is maintained as a result of a
compensatory differentiated resorption. In cases of
forward rotation of the maxilla, the resorption at
the nasal floor is greater anteriorly than posteriorly,
whereas cases of backward rotation are associated
with a more pronounced resorption posteriorly. As
a consequence of this differentiated remodelling, the
contour of the nasal floor cannot be used as a
reference structure in the radiographic cephalo-
metric analysis of the growth of the maxilla.
Forward rotation of the face occurs when the
facial growth is greater posteriorly than anteriorly.
In backward rotation, the situation is the reverse.
To understand the growth rotation of the face and
the growth forces which develop as a result, it is
necessary to the development of the posterior facial
Growth of the Maxilla in Three Dimensions
height to add not merely the growth in height of
the lower jaw, but also the development in height
of the cranial base and thus of the medial cranial
fossae (Bjork, 1947). As a rule, the growth rotation
of the lower jaw is greater than of the upper jaw,
With the result that the lower jaw also rotates in
relation to the upper jaw. As described previously,
the centre of the mandibular growth rotation does
not lie in the mandibular joint, but anteriorly in the
dental arch (Bjork, 1969). It should be pointed out
that the different types of mandibular rotation
associated with growth, as demonstrated with the
aid of the implant method, differ essentially from
an opening or closing movement of the mandible,
With a centre of rotation in the mandibular joint,
a type of rotation which may occur in case of over-
eruption of the molars, as can be seen in some
Patients with muscle dysfunction, or in connection
With orthodontic treatment.
Zygomatlc process
On the profile radiographs, the contour of the zygo-
rnatic process is a dominant structure in the
maxilla. The process has the form of a truncated
cone with three sides, an anterior, a posterior and
an upper side, the latter constituting the floor of
the orbit. The profile radiograph usually shows
double contours.
Characteristic in the development in length of
the face is the change in position of the dental arch
in the sagittal direction which occurs in relation to
the infrazygomatic crest during growth. In a child
the distal surface of the second temporary molar
lies behind the crest, while the mesial surface of the
first molar in the adult lies in front of the crest.
According to the classical view, this change in
position takes place as a result of remodelling of
the zygomatic process, with resorption at the
anterior surface and apposition on the posterior
surface, whereby the process as a whole gradually
moves backward on the body of the maxilla, an
interpretation illustrated by En low and Bang ( 1965).
Observations from the first years of our implant
studies, however, showed that an implant inserted
slightly anteriorly to the lower margin of the infra-
zygomatic crest retained its position in relation to
the anterior surface of the zygomatic process.
To illustrate the facial development, one case
will be analysed from profile radiographs at five
selected stages from 4 3 to 21 3 years of age. As
appears from the facial growth tracing in Figure 6,
with orientation to the anterior cranial base, only
an insignificant change in the sagittal jaw relation
had occurred. The facial photographs on Figure 3
show, on the other hand, a relatively great growth
rotation of the face as a whole in the forward direc-
tion. This rotation is not directly observable on the
growth tracing, due to the remodelling of the lower
border of the mandible (Bjork, 1969).
The growth rotation of the maxilla could only be
analysed from the time the anterior implants were
inserted. ln the growth tracing of the face (Fig. 6)
the implant line for the maxilla is, therefore, shown
only for the ages of 103 , 13 3 and 2!3 years.
On the guidance of these implant lines, we can
establish that the maxilla has rotated forward in
relation to the anterior cranial base. From the facial
tracing it appears that the contour of the anterior
surface of the zygomatic process followed the for-
ward rotation of the maxilla to the same degree as
the changes in the inclination of the implant line
and was thus stable in relation to the maxillary
corpus. lt can also be observed that the rotation of
the maxilla did not result in a corresponding alter-
ation in the nasal floor, as the inclination of the
latter in relation to the anterior cranial base was
maintained due to a differentiated remodelling.
Likewise it can be seen from the facial tracing that
the floor of the orbit has also maintained its incli-
nation in relation to the anterior cranial base
irrespective of the rotation of the maxilla due to
remodelling. It should be noted that the posterior
surface of the maxilla, which forms the anterior
wall of the pterygo-palatine fossa, also retained its
inclination to the anterior cranial base more or less
unchanged during facial development. A differen-
tiated apposition at the maxillary tuberosity thus
compensated more or less completely for the vertical
rotation of the maxilla, illustrating once more the
complicated pattern of maxillary remodelling.
The remodelling of the zygomatic process clearly
appears when we orientate the films according to
the implant line (Fig. 7). The tracing reproduces
three stages up to adult age, so that we can follow
the course from the age of I 0 3 years.
We must bear in mind that the length of the
maxilla in the midline is shortened as a result of
the two maxillae rotating transversely in relation to
each other, whereby the projected implant line
also becomes shortened on the profile film. Here,
as it is a question of the remodelling of the zygo-
matic process, the superimposition of the three
stages was done on the implant line with the mid-
point of the lateral implants as register point. When
orientating the films in this manner. it is seen from
the tracing that no striking remodelling of the
anterior surface in the antero-posterior direction
61
A. Bjork and V. Skieller
has taken place. On the other hand, in relation to
the implant line and thus to the maxillary corpus, a
differentiated compensatory remodelling can be
observed of the nasal floor and also of the floor of
the orbits, which explains why these contours
retained their inclination to the cranial base. The
posterior surface of the zygomatic process is appo-
sitional, with the greatest apposition downward.
The infrazygomatic crest is also appositional,
whereby the crest is displaced somewhat downward
and backward on the maxillary corpus.
The conclusion of the above analysis is that the
anterior contour of the zygomatic process was found
to be strikingly stable on the profile radiographs in
the sagittal direction. This was characteristic for all
nine cases. It should, therefore, be possible to regard
the anterior contour of the zygomatic process as a
natural reference structure in the growth analysis
of the maxilla, where this contour can be identified
from film to film.
Alveolar process and dental arch
It now remains to discuss the alveolar process and
the development of the dental arch (Fig. 8). At the
age of 43 years in Case 1597, the distal surface of
the second temporary molar on the profile radio-
graphs lies behind the lateral implants and behind
the crest. With development this relation was
changed, as described above, so that the anterior
surface of the first molar at adult age was lying in
front of the lateral implants and the crest. Thus in
relation to the lateral implants and the maxillary
corpus the dental arch has been displaced in the
anterior direction. The visual impression of this
changed relation is strengthened by the downward
and backward directed apposition under the
crest.
It is now possible to carry out a co-ordinated
analysis of the influence of the growth of the
maxilla in all three planes on the development of
the upper dental arch from the age of 1()3 years. A
tracing of the maxilla from profile radiographs at
the age of I 0 3 and of 213 years of age with super-
imposition on the implant line (Fig. 9) shows both
the sagittal and the vertical development of the
alveolar process and the dental arch. As previously
mentioned, the implant line projected into the mid-
sagittal plane becomes shortened during develop-
ment and we have here chosen the anterior implant
as register point for the two films. In order to draw
a geometrically analysable figure in the mid-sagittal
plane of the face, we drop a line (IPA) through the
anterior implant at right angles to the occlusal line
of the upper jaw. The occlusal line (Ols) on the
62
drawing is placed as a bisectrix of the occlusal lines
of the two age stages. The illustration shows that
the dental arch as a whole is displaced forward in
relation to the anterior implant and thus on the
maxillary corpus, whereby the alveolar prognathism
is increased. The forward drift of the dental arch
as a whole measured at the first molars was 5 mm
and at the central incisors 2·5 mm. Of the shortening
of the dental arch in the midsagittal plane, I mm
was a result of the mutual rotation of the two
maxillae in the transverse plane and 1·5 mm was
thus a result of crowding due to the packing of the
teeth in the dental arch.
A special discussion is necessary to elicit the
development of crowding in the dental arch (Humer-
felt and Slagsvold, 1972, Kaplan, 1974). Such
crowding cannot solely be ascribed to the change
of the temporary teeth. As will be seen, this crowd·
ing can essentially be regarded as the influence on
the dentition of forces developing in association
with the growth of the face in all dimensions (Fig. 4).
A drawing of the upper dental arch in occlusal
view from photographs in natural size (Fig. 10)
illustrates the marked sagittal shift since the age of
1()3 years of the lateral segments of the dental arch
on the jaw base amounting to 5 mm in relation to
the anterior implant, while the forward drift of the
incisor segments was 2·5 mm. The drawing shows
that the lateral segments were practically unchanged
in length while the two incisor segments were
shortened, resulting in crowding of the incisors.
That the crowding is localized to the incisor seg·
ments can be seen in relation to the fact that the
forward shift of the dental arch is checked by the
musculature of the lips and cheeks. A further
explanation of the disparity in the growth in width
of the dental arch at the canines and the molars
may lie in the circumstance that the growth in
width in the median suture is greater posteriorly
than anteriorly, which is a new aspect in the
development of the dentition.
We have reported the development of the upper
jaw as being associated with a forward shift of the
dental arch as an entity on the jaw base. The forces
underlying this shift cannot be regarded as fully
clarified.
Discussion
Sutural Contra Appositional Growth In Width
Implant studies have clearly shown that growth in
the median suture is the most important factor in
the growth in width of the maxilla. There also
appears to be some degree of appositional remodel-
Growth of the Maxilla in Three Dimensions
ling of the outer aspects of the maxilla, the extent
of which could not be evaluated (Bjork and Skieller,
1974).
Displacement of the Maxilla in Three Planes
A new factor in understanding the growth in width
of the maxilla is the transverse rotation we have
demonstrated between the two maxillae in relation
to each other as a result of the growth in the median
suture being greater posteriorly than anteriorly.
This mutual rotation results in a shortening of the
maxilla in the mid-line during growth. However, it
remains for further studies to clarify the amount of
the sutural growth activity at different vertical levels.
It can be shown that in general the two maxillae
rotate in relation to each other in the transverse
Plane during development, while at the same time
the maxilla as a whole shifts forward in the sagittal
Plane and rotates, forward or backward, in the
vertical plane. That this complicated displacement
of the maxilla in all three planes during growth is
Possible may be explained by the intricate shape of
the palatine bone. It does not seem likely that the
nasal septum should be the active factor in the
development mentioned above, in view of the
strongly differentiated growth pattern of the
maxilla. Nor does it seem likely that the facial
matrix should be the primary factor in the normal
growth rotation of the maxilla, as this rotation
takes place inside the soft tissue capsule, like the
normal growth rotation of the mandible, although
muscles, fascias and tendons may have an influence.
Growth in Height
With the lateral implants as fixed points, an attempt
has been made to quantify the unequal growth com-
ponents in the development in height of the maxilla.
If we compare the extent of the sutural lowering of
the maxillary corpus with the apposition at the
floor of the orbits from the age of 4 years, we find
that the apposition was only about half as great as
the sutural lowering. This does not support
Latham's hypothesis (Latham and Burston, 1966)
that the sutural growth in height is secondary to a
lowering of the maxilla as a result of apposition on
free surfaces. It would seem more natural to regard
the apposition at the floor of the orbits as a com-
pensation for the sutural lowering of the maxillary
corpus.
. The development in height of the alveolar process
Js of special clinical relevance from an orthodontic
point of view. The growth in height takes place as a
result of apposition on its occlusal surface, while
at the same time the process is reduced in height
as a result of resorption at the nasal floor. The
extent of the resorption in this sample was on an
average about one-third of the apposition on the
lower surface. The resorptive lowering at the nasal
floor is furthermore strongly differentiated and
usually greater anteriorly than posteriorly. As a
result of these circumstances, the contour of the
nasal floor on the radiographs is unsuited as a
reference line.
Reference Structures
It is desirable to find naturally stable reference
structures in the maxilla on profile radiographs.
Hitherto, the radiographic contour of the zygo-
matic process of the maxilla has not attracted any
interest, because of the current view of a con-
tinuous remodelling of this process in the posterior
direction. The striking stability we have demon-
strated in the contour of the anterior surface of the
zygomatic process in relation to the maxillary cor-
pus indicates the possible utilizing of this contour
as a natural reference structure.
The relation of the infraorbital canal to the floor
of the orbit is also worth consideration. As the
canal in normal growth follows the same compen-
tosary changes as the floor of the orbit, the canal
retains its inclination to the anterior cranial base
no matter the rotation of the maxilla and shifts
upward by the apposition in relation to the corpus
of the maxilla. This contrasts with the mandibular
canal, which retains its position in the corpus of
the mandible during growth and which in cases
with growth rotation of the mandible follows this
rotation in relation to the anterior cranial base.
The hypothesis put forward by Koski (1973) that
the infraorbital canal and the mandibular canal
retain a given mutual inclination during growth is,
therefore, contradicted by the present studies. The
radiographic contour of the infraorbital canal is
thus no guidance in evaluating the normal growth
rotation of the face. Analysis of clinical cases, how-
ever, indicates that the inclination of the floor of
the orbit and the infraorbital canal in relation to
the anterior cranial base may be altered by use of
orthodontic forces.
Growth in Lengh
The view that the development of the maxilla is
associated with a pronounced resorption at the
anterior surface of the zygomatic process, is contra-
dicted by the fact that metallic implants in the infra-
zygomatic crest retained a stable position in relation
63
A. Bjork and V. Skieller
to the anterior radiographic contour of the process
from childhood to adult age.
The essential feature in our discussion is that we
have been able to demonstrate a forward shift of
the entire dental arch on the maxillary corpus in
relation to the metallic implants in the infrazygo-
matic crest. By this forward drift of the entire
dental arch on the maxillary corpus, the space for
the incisors decreases, which may result in late
secondary crowding. Clarifying the forces under-
lying this drift is of fundamental importance for
the understanding of the development of the
occlusion and requires further study.
Acknowledgement
This growth study was supported by United States Public
Health Grant DE-02858.
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