Growth of mandibular prognathism after pubertal

growth peak
Hideo Mitani, DDS, MS, DDSc," Koshi Sato, DDS, DDSc, b and Junji Sugawara, DDS, DDSc =
Miyagi, Japan

This study deals with the growth changes of the Japanese face associated with mandibular
prognathism during 3 years after the pubertal growth peak. The investigation was based on the
serial lateral cephalometric roentgenograms of prognathic and normal males and females,
respectively. Maturational stages of the pubertal growth were determined individually by the
ossification events taken from hand-wrist radiographs. Results indicate that the morphologic
characteristics of the mandibular prognathism, which are established before the pubertal growth
peak, are strongly maintained during the period studied. However, mandibular prcgnathism seems to
show a manner of growth change fairly similar to that of the normal after the pubertal growth peak.
(AM J ORTHODDENTOFACORTHOP 1993;104:330-6.)

Normal occlusion is generally character-
ized with a balanced facial skeleton accompanied with
harmony in growth between mandible and maxilla in
size, form, and position within a certain limit. A true
skeletal Class III malocclusion is, however, character-
ized with a facial dysplasia produced by excessive
growth disharmony of the mandible in size, form, and
position with respect to the maxilla and/or the cranial
base. L2 This may imply that the Class III malocclusion
is associated with a different manner of craniofacial
growth when compared with normal occlusion. 3
Until now, several longitudinal studies have been
conducted to verify the manner of growth of the Class
III face.*VThose studies were, however, mostly con-
cerned tothe growth changes before and/or during the
pubertal growth period. In reviewing the literature, var-
ious results have been reported on the incremental
changes of the Class III maxillae, as well as mandibles,
but the studies generally agree that fundamental dis-
harmony of Class III structure is established in early
life. It is also indicated that the growth changes of the
Class III mandible are fairly similar to those of the
normal before the pubertal growth peak. 4.8 However,
those studies were done on relatively short-term serial
samples and of too short a duration to determine the
total growth behavior. Although it is essential for the
treatment and retention of Class III cases to verify the
total growth behavior of the prognathic face, few studies
From the Department of Orthodontics, School of Dentistry, Tohoku University.
'Professor and Chairperson.
qnstructor.
*Associate Professor.
Copyright 9 1993 by the American Association of Orthodontists.
0889-5406/93/$1.00 + 0.I0 811137006
330
have been done regarding the manner of growth during
the late stage of facial growth. 9 "
This study was undertaken to gain information from
the serial records of untreated samples as to how the
skeletal form of the prognathic mandible contributes to
the face and whether the remaining growth of the prog-
nathic face differs from that of the normal face after
the pubertal growth peak.
MATERIALS AND METHODS
The materials used in this study consisted of normal and
Class III groups of serial lateral cephalometric roentgeno-
grams of Japanese male and female subjects. Each group
consisted of a 3-year interval set of lateral head films, which
were taken at the ages of 15 and 18 years for the male subjects
and 14 and 17 years for the female subjects. The normal
group exhibited excellent or mild Class I malocclusion. None
underwent either orthodontic or any growth-related orthopedic
therapy. The normal group was used as a control in this study.
The Class III group exhibited severe crossbite relation of the
anterior teeth, but none underwent either orthodontic or any
growth-related orthopedic therapy before or during the period
studied. All subjects of the Class III group were obtained
from a list of patients waiting for orthognathic surgery.
No attempt was made to distinguish a particular form of
the mandible, but subjects suspected to have some pathosis
were excluded. However, prognathism is a relative condition
because the relationship of the mandible to the maxilla not
only varies with the total size attainment of the mandible but
also with anterior positioning of the mandible functionally to
the maxilla. The purpose of this study was to determine the
manner of growth of the face in a true skeletal Class III
disharmony. Therefore the Class Ill group was first screened
to exclude samples with anterior positioning of the mandible
functionally to the maxilla. To restrict Class III samples to
those with a distinct anteroposterior skeletal disharmony be-
tween the two jaws, the values of the angle formed by point
American Journal of Orthodontics and Dentofaclal Orthopedics Mitani, Sato, and Sugawara 331
Volume 104, No. 4

MP3-cap. MP3- fu s .MP3- uni

S; clear appearance

RAD-cap 9 RAD-I 9 RAD-IJ 9 RAD-J

Fig. 1. Ossification events of hand-wrist roentgenograms used in this study to evaluate maturational
stage of each sample in pubertal growth. MP3; middle phalanx of third finger, cap; epiphysis caps its
diaphysis, fus; epiphysis starts fusion to its diaphysis, uni; complete epiphyseal union to its diaphysis.
RAD: radius, cap; epiphysis caps its diaphysis, I; early stage of epiphyseal fusion, IJ; late stage of
epiphyseal fusion, J; complete epiphyseal union.

A, nasion, and point B (ANB angle) and the distance between
points A and B on the occlusal plane (Wits appraisal t2) were
used to examine whether each of the Class III samples was
within two standard deviations of its normal mean at the initial
age. When a sample was within two standard deviations of
either of the measurement, it was excluded from the Class
III group.
Several ossification events of the hand-wrist roentgeno-
grams were studied to determine the developmental stage of
each subject. Those roentgenograms were taken at the same
time as lateral cephalograms. According to studies by Grave"
and others, '4-~8the peak stage of the pubertal growth spurt
was determined to occur shortly before the appearance of
epiphyseal capping on its diaphysis at the middle phalanx of
the third finger and radius, and shortly before the epiphysis
starts fusion to its diaphysis at the distal phalanges of the
fingers and radius. By this time, clear appearance of the ulnar
sesamoid at the metacarpophalangeal joint of the first finger
should be seen. All samples used in this study were carefully
examined for the above criteria. Samples evaluated to be
before or in the peak stage of the growth spurt at the initial
age were excluded from the normal and Class III groups. Fig.
1 shows the ossification events used in this study to evaluate
the stage of maturation.
After all screenings, the sample size of the normal group
became 16 for the male subjects and 20 for the female sub-
jects. For the Class III group, it became 14 for the male
subjects and 20 for the female subjects. Fig. 2 shows the
distribution of their maturational stages. Those of the Class
III groups show a protruded mandible disharmonized with the
maxilla anteroposteriorly with severe anterior crossbite, but
with no functional shift of the mandible, all passed the pu-
bertal growth peak and in the decelerating phase of facial
growth.
Lateral cephalometric films were traced. Fig. 3 illustrates
the points and planes and the diagrams for linear and angular
measurements used in this study. Measurements of the facial
depth and height were taken according to Coben's coordinate
system19 in which the Frankfort horizontal plane was em-
ployed as a plane of orientation. Measurements of facial depth
were taken parallel to the Frankfort plane; vertical height was
measured along lines perpendicular to the Frankfort. Other
measurements, however, were made directly between two
points. This was done to avoid the effects of angular change
in length during growth when projected to the Frankfort plane.
For the measurements of the mandible, the top of the
condyle (condylar) is the most appropriate point at which to
determine the actual size of the mandible when the image of
the condylar head is applicable for tracing. This image is
rather difficult to trace and often permits unavoidable errors
in measurement. To avoid such errors, tracing of the condylar
head was aided by the headfilm taken during a wide open
332 Mitani, Salo, and Sugawara American Journal of Orthodontics and Dentofacial Orthopedics
October 1993

9 class III
O
O Normal O
O
O
QO O
QO OO
0 IO OO
0 QO 9 O
Q 0 O0 9 O
O0 OO oO
9 O 9 o
9. oo 88 |o 9 O oO 9 ,
M P 3 - c a p / M P 3 - f u s / MP3-uni / / ~D-cap/ RAD- I / RAD-IJ / RAD-J
0 O0 eo 0 9 0 OO OO
o oo 9 o 9 0 OO OO
o oo 9 0 OO
8 ~ 9 0 OO
o QO 9 0 O
QO 9 0 O
O0
8O 0 ~ 00
00
9 0
:8 00
:O80

Fig. 2. Distribution of samples on each maturational stage. All samples showed a clear appearance
of ulnar sesamoid at metacarpophalangeal joint of first finger. There was no statistical difference on
the proceeding stage of maturation between the Class III and the normal groups for male subjects
and female subjects.

Posterior cranial length (Ba-S)

Posterior cranial base angle to Frankfort plane (Ba-S/FH)
N Maxillary measurements:
Maxillary size (Ptm-A)
Maxillary position to anterior cranial base (SNA angle)
Maxillary position in total facial depth (Ba-Ptm)
Middle facial depth (Ba-A)
Upper anterior facial height (N-Arts)
Mandibular measurements:
Total mandibular length (Cd-Gni
Mandibular body length (Go-Pog)
Ba' ! " ~ ' : : : ~ ~ ~ A n s Mandibular ramal length (Cd-Go)
Lower facial depth (Ba-pog)
Lower anterior facial height (Ans-M)
Mandibular form (gonial angle)
Mandibular posture (mandibular plane angle)
Chin position to anterior cranial base (S-N-Pog angle)
Chin position to anterior maxillary base (A-N-Pog angle)
The means and standard deviations for each measurement
at each age were obtained in the norm.q, as well as in the
Class III groups. The means and standard deviations of the
total change of each measurement over the 3 years were also
obtained in both groups. Sexual dimorphism in the total
M growth increment of each measurement was examined during
the period studied.
Fig. 3. Tracing of lateral cephalometric roentgenograms show- For the evaluation of the significance of the mean differ-
ing points, planes, and diagram for linear and angular mea- ence of each measurement between.the two groups, a Student
surements used in this study. t test was used when F distribution indicated equal variance
of the samples. If not, a Welch t test was used.

RESULTS
mouth position at the same time as the lateral cephalograms
were take'n, This exhibited a clear image of the condylar head, The means and standarddeviations for each mea-
out of the articular fossa. surement of the Class III and the normal groups at the
The following measurements were used: initial age are shown in Table I. Those of the last age
Cranial base measurements: are shown in Table II. The means and standard devia-
Anterior cranial length (S-N) tions of the total changes of each measurement over
American Journal of Orthodonticsand Dentofacial Orthopedics Mitani, Sato, and Sugawara 333
Volume 104, No. 4

Table I. Results of measurements for Class III and normal groups at the initial age
Male Female

Class !11 Normal Class !11 Normal

I
Measurements Mean SD Mean [ SD Mean SD Mean SD

S-N (ram) 69.2 3.7 69.1 3.2 63.7 3.2 65.0 2.8
Ba-S 49.8 4.0 50.3 2.4 45.6 2.2 45.4 1.9
B a - S / R I angle 120.0 3.3 120.7 3.0 120.7 4.0 ** 123.9 3.4
Ptm-A (mm) 47.9 3.0 49.0 3.0 44.8 3.1 46.7 3.1
SNA angle 81.0 3.3 81.7 4.0 81.5 4.3 81.9 4.0
B.a-Ptm (mm) 45.2 3.7 44.9 2.8 41.7 3.4 * 44.0 3.2
Ba-A 93.0 5.7 93.8 3.7 86.5 4.3 ** 90.7 5.4
N-Ans 58.8 2.9 57.8 3.3 54.9 3.3 53.8 2.4
Cd-Gn 132.9 5.8 ** 120.9 4.5 120.1 7.8 ** 113.4 4.9
Go-Pog 84.6 4.2 ** 78.3 3.6 76.3 6.0 73.4 3.5
Cd-Go 62.3 4.7 59.5 4.5 56.0 3.6 55.3 5.3
Ba-Pog 99.6 8.9 ** 87.8 4.7 90.5 10.2 * 83.4 6.3
Ans-M 75.0 5.8 * 70.4 4.6 69.3 5.7 67.5 3.8
Gonial angle 130.4 5.7 * 123.8 8.8 132.3 6.2 ** 125.0 6.5
Mandibular plane angle 29.2 6.0 28.3 6.2 31.2 5.7 30.0 4.9
S-N-P~ angle 84.5 3.8 ** 79.3 3.7 83.6 5.4 ** - 77.9 4.3
A-N-Pog angle -3.5 3.0 ** 2.4 2.0 -2.2 3.6 ** 4.1 2.4
ANB angle -2.9 2.7 ** 3.0 1.8 -2.6 3.1 ** 4.5 1.9
A-B/Occlusal plane (mm) - 12.3 3.7 ** - 1.6 2.6 - 11.4 4.3 ** -0.6 2.6

*Significant at p < 0.05.

**Significant at p < 0.01.

the 3 years are shown in Table III. Sexual dimorphism
in the Class III group and the normal group is shown
in Table IV.
DISCUSSION
Maturational stages /ff the ossification events em-
ployed in this study were compared between the Class
III and the normal groups for the male subjects and the
female subjects (Fig. 2). There was no significant dif-
ference between the two groups, although some vari-
ation in maturation exists within a group. It was thought
that there was no difference in the progress of matu-
rational stages between the Class III and the normal
groups. Thus the samples of each group should be ad-
equate to compare for the purpose of this study,
Facial characteristics of the Class III samples
(Table I)
Male: Comparison of the cranial base measurements
showed that there was no significant difference in any
measurement between the two groups at the initial age.
Results indicated that there was no distinctive dishar-
mony in size and form at the cranial base in the present
Class III samples.
Comparison of the maxillary measurements showed
that neither the size (Ptm-A) nor its position (SNA
angle, Ba-Ptm) showed any significant difference be-
tween the two groups at the initial age. Results indicated
that there was no distinctive disharmony of the maxilla
and the middle face in the present Class III samples.
Comparison of the mandibular measurements
showed that the total length (Cd-Gn) and the body
length (Go-POg) were significantly greater than the nor-
mal, whereas the ramal length (Cd-Go) exhibited no
significant difference between the two groups at the
initial age. Gonial angle was significantly greater than
the normal but the mandibular plane angle was not.
Consequently, those showed greater values of lower
facial depth (Ba-Pog) and lower anterior facial height
(Ans-Me), which caused excessive protrusion of the
chin for the Class III group. This was supported by the
greater values of the S-N-POg and A-N-Pog angles of
the Class III group.
Comparison of each measurement between the two
groups at the last age (18 years of age) indicated that
the facial characteristics seen at the initial age (15 years
of age) in the Class III group were strongly maintained
during those 3 years. Results indicated that no new
significant difference took place in the measurements
between the two groups during this period (Table II).
Female: The posterior cranial base angle to Frank-
fort plane (Ba-S/FH angle) was significantly different
between the two groups at the initial age. The posterior
cranial base was more upright in relation to the Frank-
fort plane in the Class III than the normal group. How-
ever, the anterior cranial length (S-N) and the posterior
334 Mitani, Sato, and .~twawara American Journal of Orthodontics and Dentofacial Orthopedics
October 1993

Table II. Results of measurements for Class III and normal groups at the last age
Male Female

Class 111 Normal Class !11 Normal

Measurements Mean SD Mean [ SD Mean SD Mean [ SD

S-N (mm) 69.8 3.4 69.9 3.2 64.4 3.0 65.3 2.9
Ba-S 50.0 3.9 51.3 2.7 46.0 2.3 45.9 1.9
Ba-S/FH angle 120.9 3.4 120.4 3.0 120.0 3.8 ** 123.8 3.6
Ptm-A (mm) 49.0 2.9 50.4 3.3 45.2 2.9 47.2 3.3
SNA angle 81.3 3.0 81.8 4.1 81.3 4.3 82.0 4.2
Ba-Ptm (ram) 45.0 3.4 44.9 2.7 41.7 3.5 * 44.1 3.2
Ba-A 94.0 5.3 95.3 3.8 86.9 4.2 ** 91.3 5.5
N-Ans 59.7 3.2 ** 59. I 4.0 55.5 3.6 54.6 2.6
Cd-Gn 137.0 5.2 ** 124.9 5.1 123.0 8.6 ** 116.2 5.0
Go-Pog 86.5 4.5 80.4 4.1 77.9 6.0 74.9 3.7
Cd-Go 65.4 4.5 63.4 6.3 57.9 4.0 57.4 5.1
Ba-Pog 102.3 9.7 ** 90.2 6.0 92.9 10.2 ** 84.9 6.7
Ans-M 77.3 6.2 ** 72.2 4.3 70.4 6.3 69.2 4.0
Gonial angle 131.2 6.2 ** 122.7 9.2 132.2 5.8 ** 124.7 6.4
Mandibular plane angle 29.0 6.3 26.6 7.7 30.7 6.1 29.8 4.8
S-N-Pog angle 85.6 4.1 ** 80.1 3.9 84.5 5.9 ** 78.7 4.1
A-N-Pog angle -4.3 3.7 ** 1.8 2.6 -3.2 3.8 ** 3.3 2.0
ANB angle -3.8 3.3 ** 2.5 2.1 -3.2 3.2 ** 4.0 1.5
A-B/Occlusal plane (mm) - 13.8 4.9 ** -2.8 3.6 - 12.7 4.9 ** - 1.3 2.1

*Significant at p < 0.05.

**Significant at p < 0.01.

Table III. Total changes for Class III and normal groups during 3 years
Male Female

Class III Normal Class II1 Normal

Measurements Mean SD Mean [ SD Mean SD Mean [ SD

S-N (mm) 0.7 0.5 0.7 0.7 0.7 0.5 0.3 0.4
Ba-S 0.2 0.4 ** 1.0 0.9 0.4 0.5 0.5 0.5
Ba-S/FH angle 0.2 1.2 -0.3 1.3 -0.3 1.5 -0.1 1.0
Ptm-A (mm) 1.1 1.2 1.5 1.7 0.4 0.8 0.5 1.2
SNA angle 0.3 1.0 0.2 1.0 - O. 1 0.9 O. 1 1.0
Ba-Ptm (mm) -0.1 0.9 0 0.8 0.l 0.8 0.1 0.7
Ba-A 1.0 1.0 1.5 1.7 0.4 0.8 0.6 1.3
N-Arts 0.9 1.0 1.2 1.2 0.6 1.0 0.9 1.2
Cd-Gn 4.1 2.5 4.0 2.6 2.9 1.9 2.8 1.8
Go-Pog 1.8 2.1 2.0 2.2 1.6 0.9 1.5 1.4
Cd-Go 3.1 1.6 4.0 2.4 1.9 1.8 2.1 1.0
Ba-Pog 2.8 3.3 2.4 2.6 2.3 2.2 1.6 1.9
Ans-M 2.3 1.5 1.8 1.5 1.2 1.4 1.7 1.3
Gonial angle 0.8 1.7 ** - 1.1 2,0 0 1.6 -0.3 0.8
Mandibular plane angle -0.2 1.3 * - 1.8 1,9 -0.5 1.8 -0.3 1.5
S-N-Pog angle 1.1 1.3 0.8 1,2 0.9 1.4 0.8 0.8
A-N-Pog angle -0.9 1.3 -0.7 1.2 - 1.0 1.2 -0.8 1.1
ANB angle - 1.0 1.2 -0.5 0,9 -0.7 1.2 -0.5 0.9
A-B/Occlusal plane (mm) - 1.6 1.9 - 1.3 1.7 - 1.3 2.0 -0.7 1.3

*Significant at p < 0.05.

**Significant at p < 0.01.

cranial length (Ba-S) did not show any significant dif- anterior cranial base (SNA angle) showed any signifi-
ference between the two groups. cant difference between the two groups at the initial
Comparison of the maxillary measurements showed age. However, the maxillary position in the cranial base
that neither the size (Ptm-A) nor its position to the (Ba-Ptm) and the middle facial depth (Ba-A) were sig-
 American Journal of Orthodontics and Dentofacial Orthopedics Mitani, Sato, a n d S u g a w a r e 335
Volume 104, No. 4

Table IV. Sexual dimorphism in the Class III and the normal face
Class HI Normal Total change

Init~l Last Initial Last

Measurements age age age age Class HI Normal

S-N (mm)
** ** ** **
Ba-S
Ba-S/FN angle
** * ** ** $ *
Ptm-A (mm)
SNA angle
Ba-Ptrn (mm)
** ** *
Ba-A
** *$ ** **
N-Ans
** *# ** **
Cd-Gn
** ** ** **
Go-Pog
** * ** **
Cd-Go
Ba-Pog
** * ** *
Ans-M
Gonial angle
Mandibular plane angle
S-N-Pog angle
A-N-Pog angle
ANB angle
A-B/Occlusal plane (nun)

*Significant at p < 0.05.

**Significant at p < 0.01.

nificantly shorter than those of the normal. This was
not due to retrusion of the maxilla but to the upright
posture of the Posterior cranial base. The upper anterior
facial height (N-Ans) showed no significant difference
between the two groups. Results indicated that there
was no distinctive disha.rmony of the maxilla in size
and position to the anterior cranial base.
Comparison of the mandibular measurements
showed that the total length (Cd-Gn) was significantly
9greater than the normal, whereas the body (Go-Pog)
and ramal (Cd-Go) length were not significantly greater
at the initial age. The gonial angle was significantly
greater than the normal, but the mandibular plane angle
was not. Those produced a greater value of the lower
facial depth (Ba-Pog), which caused excessive protru-
sion of chin indicated by the greater values of S-N-Pog
and A-N-Pog angles.
Comparison of each measurement between the two
groups at the last age (17 years of age) indicated that
the facial characteristics seen at the initial age (14 years
of age) in the Class III group were strongly maintained
during those 3 years. Results indicated that no new
significant difference took place in the measurements
between the two groups (Table II).
Total changes of each measurement during 3
years (Table III)
Comparison of the total changes of each measure-
ment during the three years from 15 to 18 years of age
for the male subjects and from 14 to 17 years of age
for the female subjects indicated that there was basically
no difference between the Class III and the normal face.
A few measurements, i.e., posterior cranial length
(Ba-S), gonial angle, and mandibular plane angle for
the male subjects and anterior cranial length (S-N) for
the female subjects showed a significant difference be-
tween the two groups, but the differences were minimal
and negligible in growth variation.
Sexual dimorphism in the Class Ill and the normal
face (Table IV)
Absolute values of the linear measurements in the
male subjects were all significantly greater than the
corresponding measurements in the female subjects for
both the Class III and the normal groups. However,
those of the angular measurements showed no signifi-
cant difference between male and female subjects for
both the Class III and the normal groups. This means
that the spatial proportions of the various craniofacial
structures are fundamentally similar in both sexes. Al-
though the linear measurements were significantly
greater in the male subjects, their total growth incre-
ments during the 3 years showed a much lower degree
of significant sexual dimorphism. Sexual dimorphism
was seen in the mandibular ramal length (Cd-Go) and
the maxillary length (Ptm-A) for both the Class III and
the normal face. Those two measurements showed
greater growth in the male subjects than in the female
subjects over 3 years. In other measurements, the lower
facial height (Ans-M) of the male subjects showed
336 Mitani, Sato, and Sugawara
greater change in the Class III face and so did the
mandibular plane angle in the normal face.
Even with a small sample size and relatively short-
term observation, the results obtained from this study
imply that the morphologic pattern o f the Class III face
associated with an oversized mandible but with no max-
illary deficiency does not change and is strongly main-
tained during growth after the pubertal growth peak.
The results showed neither excessive nor retarded
growth in the face at any skeletal component measured
after the pubertal peak, rather its incremental change
was within the limits o f normal variation. Although the
/ 7. Takeuchi U, Genba Y, Suzuki S, Nakamura S. Longitudinal
Class III subjects in this study exhibited an oversized
mandible and severe anteroposterior j a w disharmony at
the initial age, their total growth increments were about
the same as those of the normal mandible during the
period studied. Furthermore, neither the growth o f the
maxillary length nor its positional advancement takes
place to catch up with or adjust to the oversized man-
dible in the face during this period, although it should
be noted that some sexual dimorphism is present in the
growth increment of the mandibular ramus and max-
illary size.
The study did not refer to the denture changes o f
the Class III occlusion, such as, axial inclination o f
incisors, occlusal plane angle, arch length and arch
form, but findings obtained from this study should be
considered in the treatment and retention o f Class III
cases as an indication o f occlfisal change with time after
the pubertal growth peak. They may also be taken into
consideration for treatment planning for orthognathic
surgery applied to growing Class III patients.
CONCLUSIONS
1. Morphologic characteristics o f mandibular prog-
nathism that are established before pubertal
growth peak do not change fundamentally and
are maintained thereafter.
2. The total growth increment o f each component
o f the prognathic face is about the same as that
o f the normal face. Neither excessive nor re-
tarded growth occurs in any part o f the face after
the pubertal growth peak.
3. The Class III face, in which the mandible is
oversized and prognathic but the maxilla is
within the normal range o f size and position,
shows a manner o f growth change fairly similar
to that o f the normal face after the pubertal
growth peak.
REFERENCES
1. Sanborn RT. Differences between the facial skeletal patterns of
Class III malocclusion and normal occlusion. Angle Orthod
1955;25:208-22.
American Journal of Orthodontics and Dentofacial Orthopedics
October 1993
2. Jacobson A, Evans WG, Preston CB, Sadowsky PL. Mandibular
prognathism. AM J ORTHOD1974;66:141-71.
3. Susami R. A cephalometfic study of dentofacial growth in man-
dibular prognathism. J Jap Orthod Soc 1967;26:1-34.
4. Kuwahara M. A longitudinal roentgenocephalometric study of
dento-facial growth in Japanese child. Jpn J Orthod Soc
1961;20:170-91.
5. SawaS. Roentgeno-cephalometricstudyonthe dentocraniofacial
growth of the individuals with reversed occlusion. Jpn J Orthod
1978;37:237-68.
6. YamazakiO, Sawa S, Hayashi M, Hanai N, Hanada K, Ryokawa
H. Studies on the longitudinal and individual growth of the
children with anterior reversed occlusion. Jpn J Orthod Soc
1979;38:8-13.
growth study on untreated cases with reversed occlusion. Jpn J
Orthod Soc 1979;38:14-29.
8. Mitani H. Prepubertal growth of mandibular prognathism. AM J
ORIHOD 1981;80:546-53.
9. Sugawara J, Tsuchikawa T, Soya T, Mitani H. Late adolescent
growth of skeletal Class III craniofaces in Japanese girls--av-
erage growth from 14 to 17 years of age based on longitudinal
data. Jpn J Orthod Soc 1983;42:399-408.
10. Sugawara J, Tsuchikawa T, Soya T, Mitani H. Individual late
adolescent growth of untreated skeletal Class III cranioface in
Japanese girls. Jpn J Orthod Soc 1984;43:60-70.
11. Sato K, Sugawara J, Mitani H. Longitudinal study on average
craniofacial growth of skeletal Class IIl girls in late adolescent
period--possibilityof early orthognathic surgery. Jpn J Orthod
Soc 1989;48:21-8.
12. Jacobson A. The "Wits" appraisal of jaw disharmony. AM J
ORTitOD 1975;67:125-38.
13. Grave KC. Timing of facial growth: a study of relations with
stature and ossification in the hand around puberty. Aust J Orthod
1973;3:117-22.
14. Hagg U, Taranger J. Skeletal stages of the hand and wrist as
indicators of the pubertal growth spurt. Acta Odontol Scand
1980;38:187-200.
15. Houston WJB, Miller JC, Tanner JM. Prediction of the timing
of the adolescent growth spurt from ossification events in hand-
wrist films. Br J Orthod 1979;6:142-52.
16. Houston WJB. Relationship between skeletal maturity estimated
from hand-wrist radiographs and the timing of the adolescent
growth spurt. Eur J Orthod 1980;2:81-93.
17. Sato K. A study on growth timing of mandibular length, body
height, hand bones and cervical vertebrae during puberty. Jpn J
Orthod Soc 1987;46:517-33.
18. Kondo T. Craniofacial growth before and after the end of fusion
in the distal phalanx of the first digit--a longitudinal study. Jpn
J Orthod Soc 1991;50:293-302.
19. Coben SE. The integration of facial variants. AM J OR'HtOD
1955;41:407-34.
Reprint requests to:
Dr. Hideo Mitani
Department of Orthodontics
School of Dentistry
Tohoku University
Seiryo-cho 4-1, Aoba-ku
Sendal, Miyagi
Japan 980