HERITAGE PAPER

Auxologic categorization and chronobiologic

specification for the choice of appropriate
orthodontic treatment
There is in orthodontics, a rich tradition of collaboration with scholars in other fields. Members of
this Association know the names of Krogman, Garn, Meredith, Schour, as well as they do Angle,
Case, and Tweed. Many fields of science are interested in the human face and its development for
the formation and growth of the face is one of the most complicated stories in human biology. Our
next speaker, Prof. Alexander Petrovic of the National Institute for Health and Medical Research,
Strasbourg, France, though not an orthodontist, has gained our respect and attention by a series of
brilliant papers based on continuing research from a superb team of scientists at Louis Pasteur
School of Medicine. His career as an eminent scientist started with his medical training and his
work in cell biology, followed by research at Northwestern University in Chicago on otosclerosis and
further research work at the University of Montreal. He realized there were a number of intriguing
questions in the bone biology, both of the mandibular condyle and the alveolar support for teeth.
With meticulous care, he and his group have produced a series of brilliant papers, delineating the
fundamental growth and developmental factors in the craniofacial complex. And, with a strong
clinical bent, he has actually shown the reaction of the tissues to various types of orthodontic
appliances. But, I don't want to steal his own story, like a good meal, his work speaks for itself.
Without further ado, I introduce Professor Alexander Petrovic.

-Robert Moyers

D u r i n g the last 25 years, there has been was privileged to have in Chicago a great master,
an extraordinary evolvement of the science and art T.M. Graber, who, through his writings and in many
of orthodontics and dentofacial orthopedics. This "private" lectures, gave me a deep reaching insight
has resulted primarily from the awareness and into orthodontic thinking and problems. Intellectual
propensity of the researchers to ask a new set of interactions with Tom Graber, R. Shaye, Jim
questions concerning the relationship between McNamara, Bob Moyers, J. Delaire, and many other
craniofacial growth mechanisms and the modus orthodontists gave me a rewarding and enjoyable
operandi of mechano therapy. The real progress, ingress and "implantation" into the research field of
however, lies less in the technological advances experimental and clinical dentofacial orthopedics. I
than in the questions that the investigators have was in the medical school under Dr. Shambaugh
been asking. The orthodontist today is confronted studying the cartilage surrounding the cochlea and
with a challenging and interdisciplinary situation, the labyrinthine cartilage, t'2 In my research I noted
ranging from anatomy and physiology to molecular that it never grows in organ culture. Primary carti-
biology. In my opinion, orthodontists are more lage grows well in this medium, but condylar carti-
involved in different realms of knowledge than in lage grows very little. I saw a copy of book by
any other field of dentistry. We have produced Tom Graber, 3 who had also been teaching at North-
critical and exacting research, superseding the an- western, and read the various discussions of mandib-
ecdotal and armchair speculations of the past 50 ular growth. According to my research, the pictures
years of the specialty. of Sarnat 4 showing the condylar cartilaginous archi-
Using my own work and that of my co-workers, tecture as similar to primary cartilage were wrong.
which is my assignment for this Heritage lecture, I Condylar cartilage clearly was unlike the cartilage in
must pay a special tribute to Drs. Tom Grabcr and the epiphyseal plate. My researchers and I decided
Robert Moyers for the stimulus and inspiration they to explore this further and to determine the biologic
have provided for me in my research, which actually peculiarities of the mammalian condylar cartilage.
started at Northwestern University in Chicago, many During the period 1967 to 69, my coworkers and
years ago. As Dr. Moyers said, I was not trained myself 5-9 published the first rigorous demonstration
in orthodontics. Formally, he is right. Actually, I that condylar cartilage growth rate and amount
192
American Journal of Orthodontics and Dentofacial Orthopedics Heritage paper 193
Volume 105, No. 2

could be modified by using appropriate functional functional and orthodontic appliances. Claudine
and orthopedic appliances. This stimulated a host of Oudet and other workers in our research labora-
studies by many other researchers who produced tory demonstrated on both the rat and the human
affirmatory efforts. During this time, it was shown by being, significant variations in the effectiveness of
our work ~°'H that the lateral pterygoid muscle also functional and orthodontic appliances during the
plays a regulating role in the control of condy- day-night cycle, as well as a circannual rhythm. 2~2a
lar cartilage growth rate. This work was replica- Of further interest was the fact that the reduced
ted by McNamara ~ and corroborated. Incidentally, rate of growth in the rat lateral pterygoid muscle,
Jeanne Stutzmann of our research laboratory dis- as produced during treatment with functional ap-
covered that the retrodiskal pad plays a mediator pliances, was significantly higher in the resting
role in the efforts of the lateral pterygoid muscle to phase than in the active phase of the person. This
control condylar growth. 1~'14This called attention to diminished rate of muscle length increase (along
the importance of this tissue and subsequently it has with analogous variations in other masticatory mus-
been intensively researched, particularly with regard cles) plays an important role in the mechanism of
tQ temporomandibular joint disturbances. action of some functional appliances (for instance,
In an attempt to explain the ramifications for the R. Shaye's L.S.U. Activator, New Orleans, La.),
the orthodontist and possible interdisciplinary im- by maintaining during the day the mandible in a
plications, we employed the phraseology of cyber- more forward positionY '26
netics and control theory to account for the cra- It is hoped that these interesting chronobiologic
niofacial growth mechanisms and the modus oper- findings will stimulate future research and that they
andi of functional and orthopedic appliances. ~5"16A will have an impact on everyday practice. ~7"27It is
sophisticated viewpoint of orthodontics permits the imperative that there continue to be a constant
display of qualitative and quantitative relationships interplay and cross-fertilization between clinical
between phenomena that are observed and exper- and biologic research. In the place of a flood of
imentally determined. This brought us out of the assumptions are emerging small islets or even con-
anecdotal "What I see is what I report," "horse tinents of solid, well-grounded knowledge. Yet
with blinders," approach and provided a concep- much of the etiology and pathology of major dento-
tual tool for a broader understanding of clinical facial malrelations is still unknown. The answers
orthodontic problems, particularly since the rigor- are not likely to come solely from observations of a
ous language of cybernetics is the most appropriate patient, but from combined research. Our research
way to lead to the current use of the computer. 17 in the National Institute of Health and Medical
Again, by using our own research efforts, we Research in Strasbourg has been assisted by several
embarked on a second major effort pertaining to leading clinically oriented reseachers from around
the emergence of orthodontics as'a major field of the world. Too often in the past, words like science,
biomedical science. In the mid-1970s, using cell theory hypothesis, explanation, meaning, cause, effect,
culture, tissue culture, and organ culture methods and mechanism of action have been used in a way
of studying human alveolar bone taken from the that may be equivocal, irrelevant, and misleading
mesial and distal sides of premolars and molars, with the result being confusion and misunderstand-
both before and during treatment with orthodontic ing. It is high time that the orthodontist analyzes
and functional appliances, Jeanne Stutzmann and I the proper object of his specialty (both the knowl-
and other members of our Institute introduced edge and activity), the manner in which orthodon-
precise, quantitative, evaluations of different pa- tics develops, the characteristics and statements,
rameters of the bone turnover rate. '8:° No longer the generalizations, theories, and paradigms that
accepted were speculations of when, how, and how orthodontics involves in the nature of its method-
much various appliances produced change. Rigor- ologic and conceptual foundations or assumptions,
ous research investigations demonstrated the pre- as well as the relations to other scientific, techno-
cise response. In our highly specialized laboratory logic, and biomedical branches. This epistemologic
procedures, we were able to emulate clinical situ- approach is in accord with the philosophical vision
ations and produce precise measurable infor- of Karl Popper 2'~ who has noted that science is not
mation. a static acceptance of truth, but rather a permanent
As we continued our research, a third major search for truth. For the orthodontist, this means
event is represented by the chronobiologic aspect that not only should support for a working hypoth-
of cartilage in bone growth and the effectiveness of esis be looked for, but also we should be especially
194 Heritage paper American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

alert to biomedical concepts and clinical cases that trophe is an excellent topologic tool to represent
could refute concepts. discontinuites (i.e., the bifurcation type of situa-
Now, which types of biomedical and clinical tions during growth and development).
explanation are we encountering in scientifically Four, evolutionary type. A morphophysiologic
based orthodontics? It is superfluous to emphasize entity, like the temporomandibular joint, that char-
the inappropriateness of bare, unsupported, verbal acterizes mammalians, may be accounted for by
statements, even though they still survive in the describing how it has evolved from some earlier
literature. For a more formal viewpoint, let us turn phylogenetic types. In the evolutionary type of
to four basic types of explanation current in the explanation, the first step is to set out the sequence
literature dealing with craniofacial growth and of major events through which an earlier system
orthodontic therapy) 7"29 has been transformed into a later one. The second
One, deductive type. In this case the explican- step is to discover events that are causally pertinent
dum appears as a necessary consequence of certain to the transformation of the system. The third step
premises. Such an explanation may be used for is to give reason for the transformation by detecting
description and classification of observations, as the morphophysiologic appropriateness of the
well as for the forecast of future events, including newly evolved system. The fourth step is to eluci-
the degree of probability. The deductive explana- date the evolutionary successfulness of one versus
tion requires a logically organized framework of some other transformation. It should be remem-
knowledge (e.g., a cybernetic diagram containing bered that an evolutionary explanation is at best
precise, quantitative data). presumptive. Since the evolutionary transformation
Two, deductivo-probabilistic type. In this type is generally a nonreoccuring event, its hypothetical
of explanation, at least one of the premises consists explanation is hard to test. Yet the evolutionary
of probabilistic statements (theories or concepts explanation for the peculiarities to the condylar
relative to specific categories of individual occur- cartilage does prove tempting. In reptiles, the joint
rences). Deductivo-probabilistic type concerns not between the skull and the lower jaw is formed by
only the degree of validity of the premises, but the two bones originating from the primary type carti-
relationship between the premises and the expli- lages. The mammal's joint is formed by two der-
candum. This type of explanation is the most com- mal bones the squamosal and dentary (i.e., the
mon in medicine and this includes orthodontics. It mandible). The latter developing three posterior
is the basis of rules of differential diagnosis and secondary types of cartilages, coronoid, condylar,
prognosis. The current emphasis on computer angular, the last one differentiating only in small
based orthodontic decision making is an illustration animals.
of such types of reasoning. According to Symons in 1951,30 in the mamma-
Three, functional type. In this case, the expla- lian embryo, the condylar cartilage also develops
nation takes the form of specifying the function independently of the chondrocranium. This phylo-
that an element performs in maintaining, against genetic data throws light on ontogenetic data. The
random variations and intrinsic or extrinsic distur- prechondroblastic zone of the condylar cartilage
bances, some major characteristics of the system as and of any secondary cartilage appears to be, bio-
a whole to which it belongs. This type of explana- logically, closer to craniofacial sutures and to the
tion corresponds to the so-called goal-seeking de- periosteal zone than to epiphyseal cartilage. It
scription of the technologic system. Various com- would seem that the responsiveness of the condylar
ponents of the system controlling craniofacial cartilage growth to local factors may explain the
growth and development stand with each other in extraordinary success of the phylogenetically new,
precise causal interdependence and responsive- mammalian joint between the skull and the lower
ness, involving interactions and feedbacks. Here jaw. The condylar cartilage growth is integrated
again, the functional explanation presupposes a into an organized functional whole, having the form
cybernetically organized knowledge. of a servosystem and is able to modulate the
One point should be emphasized. Since mor- lengthening of the mandible in such a way that the
phophysiologic systems are almost always nonlin- lower jaw adapts to the upper jaw during growth.
ear, quantitative descriptions may only exception- Indeed, the "operation of confrontation" between
ally be restricted to usual differential equations; the position of the upper and lower jaw is the
"discontinuities" must be taken into account. Prac- "comparator," cybernetically, of this servosys-
tically, the so-called mathematical theory of catas- tem. 15"16"3~The comparator is at the origin of the
American Journal of Orthodontics and Dentofacial Orthopedics Heritage paper 19S
Volume 105, No. 2

correction signals intended to modulate the pos- isolates them from local factors able to restrain or
tural activity of the lateral pterygoid muscle, so as stimulate cartilaginous growth. Secondary carti-
to place the mandible in a position of either an lages exist in the condylar and coronoid processes
optimal or a suboptimal occlusal adjustment. The of the human and sometimes in the sutures; divid-
variations in the postural activity of the lateral ing cells, skeletoblasts, prechondroblasts, are not
pterygoid and in the iterative activity of the retro- isolated by the cartilaginous matrix (that is, they
diskal pad will either stimulate or restrain the are not isolated from local factor influence). This is
condylar cartilage growth rate and modify the rate an attempt to make intelligible the differences
and the direction of growth of the condyle. This betwen primary and secondary cartilage. It is our
would then produce some more anterior or poste- hope that this analysis regarding the singular bio-
rior growth rotation of the mandible. logic behavior of the condylar cartilage will help to
How can we conceive growth mechanisms of the explain the evolutionary supremacy of the new joint
mammalian mandible? The research in our labora- between the skull and the lower jaw--namely, that
tories has led us to the following theorizations. 32 it characterizes all mammals, as well as allows their
•A relatively stable pedosteal contribution exists phylogenetic success.
that is subordinated both to orders affecting the In the short time allowed in this discussion, it is
whole organism and to local control factors, repre- not possible to go into a detailed cybernetic anal-
sented primarily but not completely by muscle ysis of the complex process of cranial facial growth.
contractions. Thus by the very nature of bone For this purpose, I refer you to Chapter 1 of
growth and remodelling (i.e., by surface apposition Dentofacial Orthopedics with Functional Appliances
or resorption), the periosteal growth of the mandi- by Graber, Rakosi, and myself) ~ There we discuss
ble is commanded rather than regulated. The in detail and with diagrams how cybernetics has
mechanisms involved are necessarily slow and brought to biologic and biomedical sciences new
rough. and advantageous concepts-e.g., negative and
A cartilaginous contribution that is, condylar, positive feedback, self regulation, reference input,
coronoid and angular, exists that is more easily open and closed loop, regulation versus servosys-
modifiable and more subject to local control sys- tern, gain (amplification of attenuation), and sys-
tems through feedback loops. Integrated within the tems and circuit analyses.
local regulative loop, the cartilaginous contribution We also discuss the so-called catastrophe theo-
to mandibular growth is more rapidly brought into ry35 that is a topoIogic concept designed to describe
play and is intended for fine growth adjustment, discontinuities. In the framework of cybernetic
insuring an efficient occlusion. Viewed from this models, discontinuities correspond to sudden
standpoint, the growth of the condylar cartilage is changes from one reference of the control system
seen as a mechanism that at each moment depends to another. Such cybernetic models have, above all,
on messages of local and regional origin. Thus it is a heuristic value: They open new perspectives,
the expression of a regional structural homeostasis provide a new working hypothesis to be tested. It is
that enables the coordinated growth of the sto- inherent in the methodology of scientific investiga-
matognathic system. This is not to say that peri- tion that the construction of a general model pre-
osteal deposition of bone is only an accessory cedes any long experimental work designed to re-
mechanism; the consequences of condylectomy and fute or corroborate the working hypothesis result-
acromegaly bear witness to the contrary. However, ing from a model. Cybernetic models are
since in both these situations, the increase in size of continuously revised to conform to new findings.
the mandible is more subject to an overall com- They offer a general overview while also enabling
mand than to local regulation, mandibular over- close critical scrutiny to be performed. And, in so
growth from an intense and perpetuated subperi- doing, reduce the possibility for confusion. On the
osteal ossification or mandibular underdevelop- basis our research methods, animal experimenta-
ment resulting from insufficient bone apposition tion is designed to detect causal relationships. In
alone may well lead to occlusal disharmony. clinical research, conditions are not always set up
In our laboratory, Jeanne Stutzmann 33~' has so that a phenomenon is actually produced orth-
placed emphasis on the fact that primary cartilages odontically or orthopedically. For instance, select-
exist in the axial skeleton, the skull base, and the ing a given parameter of facial growth and compar-
limbs; the dividing cells, differentiated chondro- ing a person with a general population is not an
blasts, are surrounded by cartilaginous matrix, that ideal procedure for evidencing therapeutically pro-
196 Heritage paper American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

duced changes. Also, failing to detect the effect of • Physiologically, the treatment is clinically rel-
a functional appliance does not allow one to con- evant mostly in higher auxologic categories,*' i.e., in
clude that the given parameter is "genetically de- the biologic categories where the growth potential
termined." Last but not least, one must take into and responsiveness to amplifying factors is rela-
account the existence of the temporal organization tively elevated (Fig. 1).
of tissue growth. 2~'36 In connection with this last • Chronobiologically, the treatment is particu-
observation, indeed the condylar cartilage and al- larly significant when applied during the ascending
veolar bone of growing children exhibit a higher portion of the pubertal growth spurt (Fig. 2).
percentage of cells in the DNA-synthesis phase What happens, however, if the treatment is
during the night than during the day. In other instituted at another time portion of the pubertal
words, the first sleeping hours are the most favor- growth spurt?
able moment for triggering therapeutically an in- We address this question by presenting a de-
creased number of cell divisions in both condylar tailed investigation of fixed appliance edgewise-
cartilage and alveolar bone. Logically, the mitosis bearing intermaxillary elastics applied on boys with
rate itself will be the highest during the "breakfast a skeletal Class II malocclusion at two different
time." Also the growth and the length of the time intervals of the pubertal growth spurt. The
masticatory muscles, especially the lateral ptery- samples consisted of all boys. In the first study, as
goid, appears to be more important during the Table III shows, there were 152 controls and 150
night than during the day. For this reason, it may treated patients. In the second, there were 138 boys
be that it is more important that some appliances in each of the control and treatment samples
be worn more during the night than during the day (Table IV).
because they are more biologically efficient on The statural height was measured at 3-month
muscle growth. intervals, from the age of 7 to 16 years. In boys
If we apply these general methodologie consid- having a Class II skeletal malocclusion, but with a
erations to all appliances, not only to functional normal vertical dimension. The individual growth
appliances and the biologic mechanisms of facial curve was constructed (Fig. 2), and points M and P
growth, and if we use the macrobiologic and cyber- were determined. By identifying the point M, the
netic approaches, we are certain to enhance the orthodontist may detect, rather than trying to pre-
scientific validity of our therapeutic approaches. dict, the beginning of the ascending portion of the
Let me now present some of my recent research pubertal growth spurt. Cephalographs were made,
investigations, which directly concern clinical orth- either near the point M, i.e., the prepubertal min-
odontics. These investiations were made, partly, in imum (two cephalographs at 6-month intervals), or
collaboration with Jeanne Stutzmann, Nicole Gas- at points 4, 5, 6 (three cephalographs at 6-month
son, Jean Lavergne, Robert Shaye, Roberto Deli, intervals) or at points 6, 7, 8 (three cephalographs
and Wilma Simoes. Physicist, physician, and radi- at 6-month intervals). The first research series was
ologist, Andre Meyer, introduced me to recent designed only for boys serving as controls; the
medical imaging procedures, including MRI and second and the third one, for control boys and for
Positron emission tomography which has assisted edgewise-bearing elastics treated boys (Fig. 3).
us in our investigation. The timing of the three cephalographs and of
Over the past decades, there has been consid- the edgewise treatment is represented in Fig. 3:
erable interest in the biologic mechanisms by which The cephalometric points 6, 7, 8 (research investi-
an edgewise-type appliance corrects malocclusions gation N ° 2) are easy to determine, because point 6
and intermaxillary malrelations. The tooth-moving is situated just after the point P, the points 4, 5, 6
effect of edgewise and similar appliances is unchal- (research investigation N ° 1) are more difficult to
lenged. By contrast, a possible lengthening effect decide on, so operationally, we selected for this
on the mandible is at least a controversial subject study only boys in which the point P, i.e., the
of thought, open to doubt if not to flat denial. pubertal growth peak, was situated between ceph-
However, in recent reports of ours,37-43methodolog- alometric points 5 and 6 (Fig. 2).
ically rigorous investigations have demonstrated The rotational group was determined by using
that the distance condylion-pogonion may be sig- the Lavergne-Petrovic's flow diagram (Fig. 4), al-
nificantly increased when appropriate appliances lowing for an indirect recognition of the auxologic
(Frfinkel, LSU-Activator, bionator, Begg tech- (tissue level growth) category. When extraction of
nique) were used, but under two conditions. mandibular premolars was clinically indicated, the
American Journal of Orthodontics and Dentofacial Orthopedics Heritage paper 197
Volume 105, No. 2

mandibular growth equals P3M/ Md b

maxillary growth Mda

1 P,M//,
Mx
,,,~ RZD . I~ ~ AIN in
biological growth ----- l ~ l IA,O I
_ @ _u _ _n _ _ P ~ '
u I
category
..... _®. .... J
/ l
A I I
A i
growth rotation
!
R i
of the mandible
i
P i i
P i

Hd : mandible
M× : maxilla
Hd : without occlusion dependant re8ulation
Hd~ : with occlusion dependant reEulatlon
- - - distance Co-Po E for each rotational type
Vertical relation : normal.

Fig. 1. Six tissue-level growth categories of mandible and corresponding distances Co-Pog. On the
left side, the growth potential of the mandible is below the growth potential of the maxilla; on the right
side, the situation is reverse. During the puberty-linked growth acceleration of the mandible, i.e.
between the points M and 5, the intermaxillary growth potential relationship moves moderately from
the left to the right.

INDIVIDUAL PUBERTALGROWTH SPURT IN A BOY (and in a girl)

statural height measured
at 3 month-intervals
13- M : prepubertal minimum 5P 6
P : pubertal growth peak 4/~1~ 1, 2,ep31~a4o5ra6m:mBade
12.
11. .. ,/' ~ at 6 month-intervals

¢) 10. ./._....""""~\
g-

~ 7.

g 5"
> 4"

"c5 2"
"r 1"
0
-~ -.~-4: -~-~' -i 6 +i +~. +~yeo,'~
Fig. 2. Construction of such an individual curve allows, for majority of boys, to detect moment of
statural growth rate. This information is essential in physiologic and clinical research, it is useful in
therapeutic choice and in evaluation of results. At point 2 (and a fortiori for points 3, 4, 5, and 6), it
is possible to detect the rotational type and the auxologic potential. If the treatment starts after the
point 2, the interval separating the points t and 2 allows for comparison of investigated parameters
between treated boys and control boys (Rp versus CpO). Only the basal bone biopsies made
between the points 4 and 6 were used for comparative studies of mitotic index. According to our
biologic and clinical investigations, the therapeutic effectiveness of a functional appliance is greatest
between points 2 and 7, and smallest around the point M. So, such a treatment should mandatory
take advantage of the growth period between points 2 and 7; of course, the treatment may start at
an earlier age.
198 Heritage paper American Journal of Orthodontics and Dcntofacial Orthopedics
February 1994

Statural Growth rate : Pubertal acceleration (I-1) or deceleratlon (1-2)

- 6 to 0 Months 0 to 6 Months
Cephalograph 1st 2nd 3rd

Investigation I (1-1) point 4 point 5 point 6

Investigation 2 (1-2) point 6 point 7 point 8

Controls Cp0 Cpl Edgewise**

Edgewise* Rp ITp STp

*Edgewise treatment refers here to the period of use of intermaxillafy (Class II) elastics.
**After the point 6 or 8, controls are usually, but not always, treated by Edgewise*
Rp : Reference period corresponding to Control pedod 0 (CpO).
ITp : Initial Treatment period corresponding to Control period 1 (Cpl).
STp : SubsequentTrestment period.

Fig. 3. Timing of the three cephalographs and of edgewise treatment.

~,~ T. < 1.5 A3 MOB

_ / - P ~ f - 1.5<T=~;5.5 - - A 1 NOB
F 3 < T z ~ 5.5<T~<_8.5 - - A 1 DOB
8.5 <TI A2 DOB
t ~ - - - - - ~ T=_<0 A3MN
/ "r ~ . < < /~,---0<T=~4--A1NN
---- T,>6~ 'l ~7--0-Tz-3--~IIv,.'~4<T=~;7--A1DN
~ 7<'I"= .A2DN
~c--~- T3<-1.5 - - A 3 MDB
~ /T"~- -1.5<Tj<3 - - A 1 NDB
T = < u - ~ f l / 4 - - 3<`[~6 - - A 1 D D B
" " , / 6~r, A2DDB
T=_<I- - R3MOB
I-" 3<T,'-~ la/~ 1<T=~5 - - n l IqOB

/
SNB - - ~ ..>-0<-T,_<6--<. ,, .~-0_<T,_<3--<~I,..P-- 0<T3_<4 - - R 1 NN

/ ~ - - - - - - - 5.5<T=----- P2 DOB
~ ~T ~ 1~;T=<5.5 - - P 1 NOB
r . . . . . . . -6<T=<I - - - P 1 MOB
/ v . . . . T=<-6 P3 MOB
~ 4<-T~ P2DN
/ -- ~ < /-,-~0<T=<4--PI NN
........... T,<O-"~ I= j ~ - O _ T , _ < 3 - " ~ 1 , , ~ _ . 7 < T , < O _ _ P 1 M N

/~---- 3_<T=- - - P 2 DDB

I = ~ ^ /~-I<T=<3--P1NDB
. . . . / = < u ' - ¢ ~ II/,.I._ -8<'[ <4 - - P 1 MOB
]~2-8 P2,MDB

Fig. 4. Identification of positional growth rotation group (according to Lavergne-Petrovic). ML:

Mandibular line, the line tangent to lower border of mandible through gnathion; NSL: nasion-sella line,
the line through N and S; NL: nasal line, the line through ANS and PNS fANS: anterior nasal spine,
PNS: posterior nasal spine); ML/NSL: angle between mandibular line and nasion-sella line; NL/NSL:
angle between nasal line and nasion-sella line; /'I = expected ML/NSL - Measured ML/NSL;
T2 = expected NL/NSL - Measured NL/NSL, "1"3= Measured ANB; Expected ML/NSL = 192 -
2(Measured SNB); Expected NL/NSL = (Measured ML/NSL)/2 - 7. This cephalometrically ased flow
diagram allows for the indirect identification of the rotational group, i.e., for an indirect recognition of

alveolar bone specimens from the distal and mesial Along these lines, when two boys matched by
sides were collected, put for 3 days in organ culture clinical features, by auxologic category (1 to 5),
(see Ref. 20, Fig. 3) and analyzed according to rotational group (P2DN, A2DN, R2DN, R1NN,
Stutzmann and Petrovic :°'45 for testing biologically, A1DN, or A1NN), by statural height velocity and
i.e., directly, the auxologic category. by the lengthening of the distance condylion-pogo-
American Journal of Orthodontics and Dentofacial Orthopedics Heritage paper 199
Volume 105, No. 2

¢, <> CpM point M

0--0 CpO, Rp points 4-5]
0 ...... 0 Cpl points 5-6~ PGA
• ..... • ITp points 5-6J
• .......... •
--- [] . . . . [] CpO, Rp points 6-7] /
E5 []...... [] Cpl points 7-8}PGD/
E
ITp points 7 - 8 J .,/•
7"
o O. t'"
13..
I /*• "'" ",, .,-'" " • ~;..~.~..-" 8
o .- -. f.
02
i" "")"
o
..I . ~'s
r
o-
r'- ai ;© : 0 :'~'~:." .m . . . . . . . •
©~ .u . . . . . . -n:, ..... [] .......
c- o,-o-°" ~t,4 ............
_J

I l I I I I
P2D 2A2D 3R2D 4-R1N 5A1D 5A1N
Growth category ond rotational type
Fig. 5. Edgewise-induced supplementary lengthening (in mm) of distance condylion-pogonion
during 6 months. CpM: Control period corresponding to the pubertal minimum (M) of statural growth
rate; Rp: reference period corresponding to control period 0 (CpO); ITP: initial treatment period
corresponding to control period 1 (Cpl). Edgewise-supporting intermaxillary (Class II) elastics; PGA:
pubertal growth acceleration; PGD: pubertal growth deceleration•

nion between the first and the second cephalograph and, especially, 5 than in the category 1. Obviously,
(between the points 4 and 5 in the research inves- the differences were clinically relevant mostly in
tigation N ° 1; between the points 6 and 7 in the the auxologic category 5, i.e., in rotational types
research investigation N ° 2), one boy was treated A1D and A1N; and concomitant studies relative,
with fixed edgewise appliances with Class II elas- first, to the mitotic index in the ramus subperiosteal
tics, whereas the other boy served as control, i.e., layer (bone collected during surgery for trauma)
was not treated at that time (later on, in most but and, second, relative to the alveolar bone turnover
not all cases, he was treated with edgewise). The rate (bone collected during mandibular premolar
treated boy wore the Class II elastics for at least 1 extraction), have shown that the degree of actual
year but the lengthening of the distance was mea- supplementary lengthening of the distance from
sured, in treated and untreated boys, only for the condylion to pogonion, as induced by the edgewise-
6-month period between the second and the third bearing Class II elastics, depends basically on the
cephalograph (Fig. 3). tissue-level growth (i.e., auxologic) category.
By definition, i.e., by research design, there was A few points at issue should be discussed.
no significant difference in lengthening of the dis- 1. As evident from our research, edgewise is an
tance condylion-pogonion during the period be- appliance able, by means of Class II elastics, to
tween the first and the second cephalograph (Fig. induce a supplementary lengthening of the distance
5). Then the reference period of edgewise-treated condylion-pogonion, easily discoverable in method-
boys (Rp) was compared with the control period ologically standardized clinical conditions. It
(Cp0) of control boys. When the initial Edgewise- should be also recalled that in our previous rat
treated period (ITp) was compared with the corre- experiments, we have described a growth-stimulat-
sponding control period (Cpl), a statistically signif- ing effect of Class II elastics on the condylar
icant difference was found in both the research cartilage. 47 The question is" in which way? In rota-
investigations N ° 1 and N ° 2, both for the total tional types R2D and R1N, the angle between
populations and for the five rotational t y p e s . 46 corpus and ramus is not quite modified; conse-
However, the treatment-induced differences were quently, the appliance-induced supplementary
systematically much greater in the research inves- lengthening of condylion-pogonion distance results
tigation N ° 1 than in N ° 2; the treatment-induced almost entirely from a supplementary growth of the
differences were greater in the auxologie category 2 condylar cartilage. In rotational types A2D, A1D,
2(10 Heritage paper AmericanJournalof Orthodonticsand DentofacialOrthopedics
February1994

Table I. Lengthening (in mm) of the distance condylion-pogonion during 6 months as measured in
boys at pubertal minimum (M)
cc I I N I I Stan r e or
1 P2D 27 0.35 0.0097
2 A2D 29 0.48 0.0112
3 R2D 43 0.51 0.0092
4 R1N 39 0.56 0.0075
5 AID 33 0.61 0.0114
5 A1N 29 0.67 0.0129

Gc: Growth (auxological) category.

Rt: Rotational type.

Table II. Comparison between findings published by Falck and Zimmermann49 and those published by
Petrovic, Stutzmann and L a v e r g n e 39
Frankel's fimction regulator Control group
Aztrologic Rotational Standard Standard Mean differences
category group N Mean deviation N Mean I deviation Onm)

A2DN 5 boys 5.55 a 1.41" 16 (?) 3.82 ~ 1.77' 1.75"

10 girls
20 boys 3.95 b 0.45 b 19 boys 1.81 b 0.15 b 2.14 b
A1DN 11 boys 5.81" 1.58" 21 (?) 3.99 ~ 1.16 a 1.82"
10 girls
23 boys 8.88 b 0.98 b 21 boys 3.07 b 0.28 b 5.81 b

'Results according to Falck and Z i m m e r m a n n extrapolated at 2 years.

bResults according to Petrovic et al. m e a s u r e d during 1 year (we consider as biologically inappropriate to extrapolate our findings at
2 years).

and A1N, there is bt addition, an opening of the greatly on puberty-linked variations of the mandib-
corpus-ramus angle. ular growth rate.
How does the appliance-induced supplemen- Our previous research investigations relative to
tary growth of the condylar cartilage occur? In the the LSU activator, 37"3s to the Fr~inkel appliance, 39 to
edgewise technique with Class II elastics, elec- the Bionator, "° and Begg technique42 have shown
tromyography has shown a very small intensifica- that the therapeutic effectiveness of these appli-
tion in the contractile activity of the lateral ptery- ances is actually favorable in boys when put in
goid muscle. But the positron emission tomograph practice during the ascending portion of the indi-
technique (PET scans) revealed that the blood flow vidual pubertal growth spurt (after the point 2, Fig.
in the retrodiscal pad was strongly increased. If the 2), and in the auxologic category 5. What happens
genetically determined part of the morphogenetic when the functional treatment starts earlier? When
program is responsible for the species-characteris- the distance condylion-pogonion was measured in
tic form and size of the lower jaw, our findings control boys, near the pubertal minimum (point M,
further corroborate that details of the mandibular Fig. 2), it is obvious that the 6-month lengthening
size depend on influences originating within the was of a low magnitude (Table I). This means that
physiologic servosystem controlling the growth of the tissue-level responsiveness to a functional ap-
the facial skeleton. ~5a6 pliance is most likely negligible. So far, we have no
2. These research observations corroborate our treatment observations at point M or before. But it
previous statement: the higher the auxologic does not go beyond the bounds of reason that
growth category, the greater the therapeutic effec- recent observations published by Falck and Zim-
tiveness of an appliance stimulating the lengthen- merman,49 with the Frfinkel appliance, pertain to
ing of the mandible. 374°'44"48 Furthermore, they this growth period. In fact, these authors start
demonstrate that such an effectiveness depends treating children, boys and girls, at the mean age of
American Journal of Orthodontics and Dentofacial Orthopedics Heritage paper 201
Volume 105, No. 2

Table III. Edgewise* induced supplementary lengthening (in mm) of the distance condylion-pogonion
during 6 months
UNTREATED PATIENTS TREATED PATIENTS COMPARISON
TREATED vs UNTREATED
Mean Standard- Mean Standard- Test t
error error
Total Cp0 1.49 0.0435 Rp 1.49 0.6428 0.056 NS
Nu = 152 Cpl 1.52 0.0395 ITp 3.09 0.1393 10.83 ***
Nt =150

UNTREATED PATIENTS TREATED PATIENTS COMPARISON

TREATED vs UNTREATED
Gc Rt Mean Standard- Mean Standard- Test t
error error
1 P2D Cp0 0.83 0.0260 Rp 0.83 0.0267 0.009 NS
Nu = 27 Cpl 0.87 0.0279 ITIb 1.19 0.0551 5.25 ***
Nt =27

2 A2D Cp0 1.25 0.0524 Rp 1.29 0.0367 0.162 NS

Nu = 29 Cpl 1.33 0.0383 rip 2.46 0.0930 15.29 ***
Nt =31

3 R2D Cp0 1.23 0.0333 Rp 1.23 0.0396 0.010 NS

Nu = 23 Cpl 1.28 0.0281 rip 1.89 0.0641 8.38 ***
Nt=19

4 RIN Cp0 1.38 0.0364 Rp 1.38 0.0352 0.087 NS

Nu = 21 Cpl 1.46 0.0326 rip 2.26 0.0483 13.75 ***
Nt =23

5 AID Cp0 2.02 0.0493 Rp 2.02 0.0477 0.037 NS

Nu -- 27 Cpl 2.08 0.0424 rip 5.35 0.1238 24.98 ***
Nt =25

5 AIN Cp0 2.23 0.0472 Rp 2.23 0.6469 0.012 NS

Nu = 25 Cpl 2.12 0.0197 rip 5.33 0.0890 35.23 ***
Nt = 25

*Edgewise treatment refers here to the period of use of intermaxillary (Class II) elastics.
Gc : Growth (auxological) category.
Rt : Rotational type.
Nu : Number of untreated patients.
Nt : Number of treated patients.
t : Test for 2 independent samples.
Cp0 : Control period corresponding to the Reference period (Rp).
Cpl : Control period corresponding to the Initial Treatment per!od (ITp).
Cephalographs were made at6 month-intervals at points 4, 5 and 6 (Investigation 1)

8 years and 1 month and extrapolate the results at ness to a functional appliance is not elevated (Ta-
2 years, using our auxologic categorization. When ble I).
one examines comparatively their results with ours This interpretation accounts also for the fact
(Table II), it appears that the clinical effectiveness that Falck and Zimmerman 49 have not detected any
of the Fr/inkel appliance, in Falck and Zimmer- significant difference between the auxologic cate-
man's patients, is certainly minimal. Appearances gories 2 and 5. It is also true that they have,
are in favor of the following explanation: at least in inappropriately, mixed results from boys and girls;
boys, the treatment was completed BEFORE the and, definitely, the pubertal growth peak does not
point 2 (Fig. 2), i.e., in the vicinity of or even before occur at the same age in boys and girls (Fig. 2).
point M. At that time, the tissue-level responsive- One other problem should be clarified. When
202 Heritage paper American Journal of Orthodontics and Dentofacial Orthopedics
February 1994

Table IV. Edgewise* induced supplementary lengthening (in mm) of the distance
condylion-pogonion during 6 months
UNTREATEDPATIENTS TREATED PATIENTS COMPARISON
TREATED vs UNTREATED
Mean Standard- Mean Standard- Test t
error error
Total Cp0 0.73 0.0133 Rp 0.73 0.0137 0.144 NS
Nu = 138 Cpl 0.49 0.0106 ITp 0.90 0.0283 13.66 ***
Nt =138

UNTREATED PATIENTS TREATED PATIENTS COMPARISON

TREATED vs UNTREATED
Ge Rt Mean Standard- Mean Standard- Testt
error error
1 P2D Cp0 0.51 0.0169 Rp 0.50 0.0193 0.144 NS
Nu = 23 Cpl 0.31 0.0155 ITp 0.49 0.0245 6.11 ***
Nt =21

2 A2D Cp0 0.68 0.0167 Rp 0.67 0.0206 0.660 NS

Nu = 25 Cpl 0.45 0.0117 ITI~ 0.85 0.0298 12.42 ***
Nt = 25

~qu R2D Cp0 0.72 0.0189 Rp 0.71 0.0189 0.196 NS

= 21 Cpl 0.46 0,0169 ITlb 0.70 0.0184 9.39 ***
hit =21

RIN Cp0 0.77 0.0174 ~pp 0.77 0.0204 0.110 NS

~u =23 Cpl 0.51 0.0145 0.82 0.0257 10.65 ***
Nt =21

5 AID Cp0 0.82 0.0194 Rp 0.81 0.0196 0.202 NS

Nu = 25 Cpl 0.57 0.0190 ITp 1.24 0.0658 9.76 ***
Nt =27

5 AIN Cp0 0.91 0.0291 Rp 0.92 0.0244 0.219 NS

Nu = 21 Cpl 0.63 0.0178 ITp 1.20 0.0502 10.58 ***
Nt =23

*Edgewise treatment refers here to the period of use of intermaxillary (Class II) elastics.
Gc : Growth (auxological) category.
Rt : Rotational type.
Nu : Number of untreated patients.
Nt : Number of treated patients.
t : Test for 2 independent samples.
Cp0 : Control period corresponding to the Reference period (Rp).
Cpl. :. Control period corresponding to the Initia! Treatment per!od,llTp),
epnmograpns were maoe ato month-interva=s at points t~, t ano u tmvestigation 2)

making an attempt to identify cephalometrically a growth) potential 1, 2, or 3; the cephalometric

rotational group, the recognition of phenomena growth potential "1" corresponds to the auxologic
named by "letters" is easy. 5° The difficulty concerns potential 4; the cephalometric growth potential "3"
the assessment of the so-called "cephalometric corresponds approximately of the auxologic poten-
growth potential" designated by number "2", "1", tial 5 and 6. However, this correspondence is valid,
or "3" and corresponding, respectively, to a man- in the usual course, only when the cephalometric
dibular growth potential which is inferior ("2"), categorization is made BEFORE the onset of the
equal ("1"), or superior ("3") to the maxillary functional treatment, in view of the fact that, ac-
growth potential. The cephalometric growth poten- cording to our research investigations at the tissue
tial "2" corresponds to the auxologic (i.e., biologic and cell level, no mechanical functional appliance
American Journal of Orthodontics and Dentofacial Orthopedics Heritage paper 203
Volume 105, No. 2

can increase the mandibular BASIC auxologic po- •Also, the higher the auxologic (i.e., biologic
tential (Petrovic, Stutzmann, and Lavergne, 1990). growth) category, the more effective the growth-
What happens then if, during a functional treat- stimulating effect of the functional treatment will
ment, the rotational group A 2 D N changes cepha- be at the tissue level. 5°
lometrically, for instance, into A1DN?
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