1

CHANGES IN THE MANDIBULAR ANGLE IN

THE DENTUOULS AND EDENTUOLUS SAUDI
POPULATION.
Dr. Wafa'a Al-Faleh
ABSTRACT
The size of the gonial and antegonial angle as well as the antegonial
depth were measured in 200 panoramic radiographs which belong to 100
edentulous and 100 dentate individuals who attend dental clinic. Of the
college of dentistry, king Saud University. The panoramic radiograph of
the edentulous patients were taken before construction of the complete
denture.
There was no significance difference between edentulous and dentate one
regarding the gonial and antegonial angle, but there was a difference in
the depth where the edentulous patients had deep antegonial notch than
dentate one. Irrespective to the dental status, no significant differences
were observed for the gonial and antegonial angle between males and
females. Also no correlation was detected between age , gender and
dental status with changes in the mean of the gonial and Antegonial
angles in the edentulous individuals. This indicate that the masticatory
muscles did not affect the morphology the gonial and antegonial angle in
edentulous patients when compared with dentate one. The size of the
gonial and antegonial angle in Saudi population are within the same
ranges of others populations.

INTRODUCTION
During an adults life, the morphological changes undergone by the
mandible are influenced by the dental status and age of the patient.
Muscle function should preserve the bony structure of the gonial angle
and symphyseal regions irrespective of the dental status and age (1)
The edentulous mandible is subjected to various kinds of atrophic
alteration, such as reduction in the size of the mandibular angles,
resorption of the medial surface of the condyles and diminishing size of
the coronoid process after loss of the teeth. (2-5) Alveolar atrophy is not
restricted to the tooth-bearing alveolar process, but may involve the basal
part of the mandibular bone as well (6)
The gonial angle of the mandible has been observed to vary with the type
of dentition and perhaps also with age.(7,8) It has been shown to be greater
in edentulous individuals than in dentate one (7) . In 1927 Izard collected
data of several previous authors and cited the following averages of the
variability in the gonial angle: 135 to 150 degree at birth; 135 to 140
degree when the first dentition is finished; 120 to 130 degree up to the
time of eruption of the second molars; 120 to 150 degree in old age. (9)
The morphological changes in the antegonial region in edentulous
individual compared to young individual has received little attention in
the literature. Enlow et al and Xie et al (10, 11) found that bone deposition
take place throughout the inferior border, except in the antegonial region,
therefore, a resorptive pattern take place which would decrease the
antegonial angle and increase the antegonial depth. The changed in the
antegonial region were not the same as in the gonial region. The
antegonial region underwent resorption in the edentulous individuals
perhaps due to the reduced muscle function in this region in comparison

with that of the gonial angle. Muscle function tends to preserve bone at
its point of insertion; therefore the structure of the gonial region will be
maintained by the insertion of the medial pterygoid and masseter muscles
(12)

Little is known concerning remodeling in the antegonial angle with

ageing in the dentuouls and edentulous patients. Therefore, the aims of
this study are:
-To study the relationship between complete loss of the teeth and changes
in the gonial, antegonial angle and antegonial depth among different age
and, gender.
-To know the normal ranges of these angles among dentate and
edentulous adult Saudi population and compare it with others population
MATERIAL AND METHODS.
The study sample consisted of the records of the patients at the dental
college, King Saud University. Riyadh. The radiographic records of the
200 Saudi patients (dentate, partially edentulous and completely
edentulous patients) over age of 40 years who had previously undergone
panoramic radiographic examination were selected for this study. The
panoramic radiographs of the edentulous patients were performed before
construction of complete denture. While those of the adult dentate
patients had originally been taken for regular dental treatment and not for
the purpose of this study. The panoramic radiograph was performed with
orthopantomograph 10 ( siemens Germany) with exposure parameters of
57-90 KVP,5-12 mA and equivalent filtration of 2.5 mm Al/80 IEC-522
using cranex intensifying screen HI plus regular speed and Kodak XOMAT RP pan Df 75.the panoramic radiographs processed using HP
processor. The author evaluated each image to determine it is value for

the study. Panoramic radiographs that show major positioning error that
may affect the measurement were excluded from the study. All
radiographs were examined on a standard viewing condition in a slightly
dimmed room.
The study sample divided into two groups, individuals who were
completely edentulous and the other group were individuals who had all
natural teeth present or partially edentulous individuals.
Tracing of the panoramic radiograph were made on acetate paper using a
0.5 mechanical lead pencil, the angles were measured using a protractor
and ruler.
The measurements were determined individually for the right and left
side in each patient.
The goinal, antegonial angle and the antegonial depth were measured
according to the guide line of measurement by Dutra et al (12)
-The gonial angle will be measured by tracing a line tangent to the lower
border of the mandible and another line tangent to the distal border of the
ramus on each side, the intersection of the two lines will be measured.
-The 4antegonial angles will be measured by tracing two lines parallel to
the antegonial region that will intersect at the deepest point of the
antegonial notch.
-The antegonial depth measured as the distance along a perpendicular line
from the deepest point of the notch concavity to a tangent through the
inferior border of the mandible.
Data consisting age, sex and angular and diatance measurement were
collected and entered into a spreadsheet.
The research is recognized and approved by the College of Dentistry
Research Center (CDRC) King Saud University.
Reliability

Twenty panoramic radiographs of good quality which belong to different

age with different dental status were selected then traced. Measurement
of the gonial, antegonial angles as well as the antegonial depth were
performed twice one week apart . These 20 cases were not included in
the study sample.
Assessment of measurement reliability of replicate measurement of angle
and distance was carried out using person t- test. The intraobserver
reliability was estimated between the two reading performed one week
apart. Data analysis was performed using SPSS software program.
The mean of the age of both group as well as the mean age of male and
female in each group was calculated. Each measurement calculated and
the significant difference between the two group were analyzed as well as
the difference between males and females. The level of statistical
significance was set at 5%.
RESULTS
Measurement of all angles and distance were made for edentuouls and
dentate patients on both sides independently.
Person correlation between the first reading of right gonial angle and the
second reading was performed and it was 0.997 with P value 0.000
indicating very high correlation. Also, by using Paired t- test the repeated
measurement of the right gonial angle of the first and second reading the
difference in average was 0.15 with standard deviation 0.67 and paired t
test was 1 with P value 0.33 that means no significance difference
between the first and second reading for right goinal angle. So the author
showed very high intraobserver reliability. Table 1 showed the person
correlation and the p value of the first and second reading for the right
and left side of gonial and antegonial angle and antegonial depth.

The mean age of the edentulous group was 60.09 years( SD 9.2) it rang
from 40 to 78 years (mean age for male is 61 and 58 for female). While
the mean age of the dentate group was 50.5(SD 9.4) years it rang from 40
to 70 years (the mean age is 50 and 50.8 years for male and female
respectively).
Analysis of variance (ANOVA) one and two way was applied to compare
the mean value of the jaw angles in dentate and edentulous groups.
Separate analysis was carried out for females and males in both group for
the right and left side.
When comparing edentulous (male and female) with dentate (male and
female) group, the edentulous individuals are older than dentate group
with P value 0.000. Using independent T test there was no statistical
significant difference between right and left side of both groups, neither
was there difference found between edentulous and dentate individuals
for the gonial and antegonial .The mean of the measurement and P value
are presented in table 2.
There was significant difference between the two groups regarding the
antegonial depth where the edentulous individual have deep notch than
dentate one. This explained by the small antegonial angle in edentulous
patients than in dentate patients. The edentulous male patients have
larger antegonial angle than females for both right and left side.
Using Tukey test, no significant difference was found between
females in the edentulous and dentate group as well as no significant
difference between male in both group. Small differences were observed
between right and left side in both group. The mean of the measurement
of the gonial, antegonial angle and antegonial depth of both right and left
side together with p value are presented in (Table, 3 &4). In edentulous
female patients the gonial angle of the right side is larger than male by

two degree. While, in dentate individuals the gonial angle of the right side
of the male is smaller than female with P value 0.04
Regardless of the dental status, there was no significant
difference was found between male and female with p value for the
gonial angle is 0.128 and 0.789 for the right and left side respectively,
moreover, the P value for the antegonial angle is 0.128 for the right side
and 0.789 for the left side. Table 5 showed the mean of each
measurement of the right and left side for both male and female
individuals included in the study without considering the dental status.
On testing the correlation, in the edentulous individuals, No
correlation was found between the age and increase in the gonial angle
with P value 0.48 and 0.19 for the right and left side respectively. as well
as no correlation between age and antegonial angle with P value for the
right side 0.33 and 0.12 for the left side .when testing the relationship
between age and depth, no correlation was found with p value 0.46 and
0.89 for the right and left side respectively Also, no correlation was found
between the gender and antegonial notch with P value 0.117.

Table (1) Person correlation and the P value of the first and second
reading of the angle measurement to test the intraobserver reliability .
Gonial

Right side
Antegonial Antegonial Gonial

Left side
Antegonial Antegonial

angle
0.997
0.00

angle
0.991
0.00

angle
0.980
0.00

depth
0.967
0.00

angle
0.998
0.00

depth
0.978
0.00

Table (2) The mean angle of the measurement and P value in both
edentulous and edentulous individual for gonial, antegonial and
antegonial depth.
Dental status

Age

RT

gonial
Edentulous(100) 60.09 127
Dentate( 100)
50.5 125
P value
0.000 0.197

RT

RT

LT

LT

LT

antegonial
166.5
171.4
0.128

depth
1.39
0.8
0.000

gonial
129.04
127.55
0.168

antegonial
166.9
170.19
0.789

depth
1.3
0.83
0.001

Table (3) The mean angle of the measurement in both edentulous(male

and female) and dentate (male and female individual) for gonial
,antegonial and antegonial depth of the right side.
Edentulous (100)

Dentate individual(100)

gender

Female(50) Male(50) PValue Female(50) Male(50) Pvalue

Gonial

0.177 127.22

124.28

0.04

angle
Antegonial

128.24
164.78

126.06
168

0.088

171.08

171.9

0.26

angle
Antegonial

1.62

1.16

0.36

0.86

0.74

0.49

depth

Table (4) Mean angle of the measurement in both edentulous( male and
female) and dentate individual (male and females) for gonial ,antegonial
and antegonial depth of the left side .
Edentulous individual

Dentate individual

gender

female

male

P value

female

Gonial angle

128.9

129.16

0.88

127.56 127.54

0.98

Antegonial

165.7

168.1

0.27

170.08 169.4

0.174

1.08

0.05

0.74

0.30

angle
Antegonial depth 1.52

male

0.92

P value

Table (5) The mean of the gonial and antegonial angle and antegonial
depth in the male and female individual's irrespective to the dental status.

Gonial
Antegonial

Male(100)
Rt side
Lt side
125.84
128.37
170.08
168.75

Female(100)
Rt side
Lt side
127.73
128.34
167.93
168.34

Antegonial depth

0.95

1.24

DISCUSSION

1.13

10

It has been documented that the mandible descends in a downward and

forward direction (13-17). The mandible has also been shown to rotate
during growth (18-21). Bjork showed that numerous anatomical structures
could be associated with mandibular rotation. Accordingly, mandibles
with predominantly vertical growth pattern exhibit surface apposition
below the symphyses, which result in an overall concavity of the inferior
border. Where as mandibles that rotates backward and downward during
growth, usually exhibit pronounced bone apposition beneath the gonial
angles with excessive resorption posterior to the bony symphyses. Thus
excessive vertical mandibular growth result in bilaterally cranially
directed curvatures, or antegonial notches, of the inferior border of the
mandible (16, 20-22).
With respect to measurements, Cephalometric radiograph is
considered to be more accurate than panoramic radiograph, although the
panoramic radiographs are much readily available than Cephalometric
radiograph in the dental offices. Also, the panoramic radiograph is more
commonly used to examine the edentulous patients prior to denture
construction. As well as , lack of superimposition on right and left side
that occurs in the lateral Cephalometric radiograph . Accuracy of
mandibular angle measurement on panoramic radiographs was
demonstrated by Mattila et al (23). This justifies the use of panoramic
radiograph in this study.
For any study, concerning measurement using panoramic
radiograph. The panoramic radiograph must be free from any positioning
error. Because if the head tipped down, this will produced image with
erroneous acute angle, in contrast; if the head placed with chin tipped up
above the occlusal plane the final image will give erroneous obtuse angle.
Positioning of the patients in panoramic machine require
placement of the anterior teeth in the notched anterior bite block. For

11

edentulous patients it is very difficult to achieve this requirement due to

loss of the anterior teeth that guide the dental radiographer to position the
edentulous patients properly. Therefore, proper positioning of the patients
in the panoramic machine is an essential part for accurate measurement.
Dutra et al (12) found that no significant differences were
observed between dentate and partially edentulous individuals. Therefore,
the second group in this study comprised patients either who is with full
set of teeth or partially edentulous. Also it is very difficult to find patients
at age of forty or above with complete set of teeth in the upper and lower
jaws. This indicates that peoples in Saudi society lose their teeth early in
their life either due to periodontal disease or dental caries.
The result of this study showed that there was no significant difference
between dentate and edentulous individual concerning the gonial and
antegonial angle. As well as no difference between male and female
individuals in each group. This is the same finding reported by Ceylan et
al (24) .
In a Cephalometric study of the gonial angle measurement Ohm and
Silness (25) found that the mean gonial angle measurement for edentulous
patients to be 131 degree versus 127 degree for partially dentate. without
consideration of sexes Casey and Emrich (26) used panoramic radiograph
and they found that the mean size of the gonial angle was 126.3 for the
edentulous and 123.9 for dentate patients Dutra et al(12) used panoramic
radiograph and he found that the mean of this angle is 123.9 for right and
123.8 for the left side .Raustia and Salonen (27) found that the mean
gonial angle is 123.9 and 127 for the right and left side respectively
therefore the mean gonial angle for the male and female Saudi population
(dentate or edentulous ) fall within the same range of the previous
population.

12

Raustia and Salonen (27) found no statistically significant difference was

seen between sexes and gonial angle, the result of this study found the
same findings.
Weinmann and Sicher (28) stated that the consecutive atrophy of the
masticatory muscles in old edentulous people, after many years of
increased function, lead to changes in the region of the mandibular angle.
Resorption of the bone at the posterior or inferior border of this region,
the area of the masseter muscle insertion, leads to increasing obtuseness
of the mandibular angle. Sicher and DuBrul (29) reported that after loss of
all teeth, especially if no denture is worn, the gonial angle widens again.
the result of this study did not confirm this finding
the result of this study showed that as the age increase in the
edentulous individuals the gonial angle and the antegonial notch did not
increases, this come in agreement with Dutra et al (12) and Ceylan et
al(24). Therefore, with determination of the correlation between the
gonial angle and the age, lake of correlation between them indicate that,
the angle does not change with increase the age of the individuals.
The general trend was that the goinal angles in male are
greater than those measured in female. This is consistent with knowledge
that males generally have larger mandible than females. However, the
result of this study exhibited slight difference between them where the
female have grater angle than male
.

The antegonial notch lies at the junction of the body and

the ramus of the mandible, and in this strategic position the shape is
probably a good indicator of how the mandible grows. It has been
documented that when the lower border of the mandible is relatively flat,
it grows forward and, that when the lower border of the mandible
represented by the antegonial notch is concave the mandible grows

13

downward (16,21) other study showed that when the condylar growth fails to
contribute to the lowering of the mandible, the masseter and the medial
petrygoid, by continued growth, cause the bone in the region of the angle
to grow downward producing antegonial notching. (22)
Dutra et al (12) found that the antegonial angle in male is significantly
smaller than females which contradict the finding of this study. In the
same study, when dental status was considered, the edentulous patients
had smaller antegonial angle than dentate which is the same finding
reported in this study.
Dutra et al(30) studied healthy edentulous females and compeer them with
osteoporotic patients and he found that the antegonial angle was 165.95
degree which is the same finding reported by this study.
Measurement of the gonial angle is not difficult because it's easy to trace
the line tangent to the posterior border of the ramus and intersecting line
tangent to the inferior border of the mandible, where as the antegonial
angle is not so easy to measure it, because the morphology of the
antegonial notch is highly variable between individuals. In some of the
individuals there are difficulties to locate the deepest point of the notch
concavity at which the two tangent line intersecting at this point. This
raised the question can we consider this angle as reliable predictor for
assessment of the growth and development of the mandible.
No correlation were observed between age, gender and
dental status and with increase in gonial and antegonial angle, this is in
agreement with Dutra et al(12) and Ceylan et al(24)

CONCLUSION
There are disagreement between the authors regarding the changes in the
gonial and antegonial angle measurement with increase the age as well as

14

the differences between dentate and edentulous individuals, however the

result of this study showed that there was no significant difference
between dentate and edentulous individuals as well as between males and
females for the gonial and antegonial angle measurement . also there were
no correlation between the age, sexes and dental status with increase in
the gonial and antegonial angle measurements.

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