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being particularly difficult to treat.10-14 Close observation is often required throughout the course of therapy
to deal with effects of the rotational pattern.
The ability of an orthodontist to predict future
mandibular growth rotation would greatly aid in diagnosis and treatment planning. Better therapeutic decisions could be made regarding timing and length of
treatment, appliance selection, extraction pattern, and
possible need for surgery. Therapy could truly be tailored to the individual with the possibility of optimal
results in a shorter period of time.
A number of techniques have been proposed to predict growth based on cephalometric landmarks,6,15-20
and a few of these specifically address rotational
growth of the mandible. Skieller, Bjrk and LindeHansen16 proposed a method for predicting future
mandibular growth rotation from an initial prepubertal
lateral cephalogram. Of a group of 100 children who
had been enrolled in an implant growth study, 21 subjects were selected retrospectively on the basis of a pattern of extreme backward or forward growth rotation.
659
660
Leslie et al
None of the subjects had received orthodontic treatment before or during the period of study. Metallic
implants had been placed in their mandibles, and jaw
growth was followed from childhood into early adulthood. Growth rotation was calculated on the basis of
the change in inclination of the implant line on radiographs. A 6-year observation period was selected,
with the initial lateral cephalogram made 3 years
before puberty and the final cephalogram made 3 years
after pubertal onset. Forty-four morphologic variables
were measured from each initial lateral cephalometric
radiograph and multivariate statistical methods were
used to identify which variables, alone or in combination, showed the highest predictive value for
mandibular growth rotation. The authors reported that a
combination of four variables accounted for 86% of the
variability observed. These included: mandibular inclination, intermolar angle, shape of the lower border of
the mandible, and inclination of the symphysis.
Regression equations were given based on these variables that could be applied to an initial prepubertal lateral cephalogram and were believed to predict future
mandibular growth rotation.
Limitations of this study are apparent. For instance,
the sample size was small relative to the large number
of measurements investigated. In order to provide some
Table I.
Variable description
3
4
1a
661
Definition of variables
Variable number
1
Leslie et al
ing the onset of pubescence were not available, an initial age of 9 years was selected with the follow-up lateral cephalogram at age 15. All subjects in the Iowa
Facial Growth Study had lateral cephalograms made at
these ages. It was assumed that puberty would fall
within this time period. The initial profile headfilms
were traced and the following anatomic landmarks
identified (Fig 1):
Nasion (N): The most anterior point of the nasofrontal
suture.
Sella (S): The center of the cavity outlined by sella turcica.
Menton (Me): The most inferior point on the mandible at
the symphysis.
Articulare (Ar): The point of the intersection of the inferior surface of the cranial base and the averaged posterior
surfaces of the mandibular condyles.
Tangential gonion (tGo): Found by bisecting the angle
formed by a line tangent to the averaged inferior borders
of the mandible and a line through articulare tangent to
the averaged posterior borders of mandibular rami.
Each landmark was then verified by another investigator. The following lines were drawn using definitions established by the Skieller et al study (Fig 1 and
Table I):
Nasion-sella line (NSL).
Mandibular line 1 (ML1): The tangential line formed by
the lower border of the mandible.
Mandibular line 2 (ML2): The line formed tangent to the
lower gonial border and passing through menton.
Molar long axis (MOL) inferior (i) and superior (s).
Chin Tangent Line (CTL).
Method of measurement
s-tgo distance
100 (Fig 2)
n-me distance
Angle between SN line and
mandibular line 1 (Fig 3)
Angle between the maxillary first molar long
axis and the mandibular first molar long
axis (Fig 1)
Angle between the two mandibular lines (Fig 1)
Angle between chin tangent line and SN line
(Fig 1)
662
Leslie et al
75.6 -
R2 =
0.59
(variable 1)
0.32
(variable 2)
0.98
(variable 3)
0.15
(variable 4)
predicted rotation
0.8612
+
=
ative to the pool of possible predictor variables, the forward stepwise selection procedure is unreliable in the
sense that the R-squared statistic will be quite high,
even when the independent variables have no predictive power whatsoever.
To illustrate this point, we performed a Monte
Carlo study that mirrored the number of subjects and
number of possible predictor variables in the Skieller
et al study; however, all the variables were unrelated.
For each simulation, 945 random numbers were generated from a normal distribution and then randomly
grouped into 45 columns with 21 random numbers per
column. The first column of 21 numbers was taken to
be the response variable and the remaining 44 columns
to be the candidate predictor variables. For each simulation a forward stepwise selection procedure was performed and the following quantities were recorded: (1)
Fig 3. Independent variable no. 1a. Mandibular inclination determined by the angle NSL-ML1.
18.3 +
R2 =
0.44
(variable 1a)
0.29
(variable 2)
0.94
(variable 3)
0.14
(variable 4)
predicted rotation
0.8201
+
=
Leslie et al
Table IV.
Table V.
663
Skieller et al
Lee et al
Present study
21
25
40
12
9
11.3 1.00
Untreated
Extreme growth patterns
11
14
8.5 0.0
Mixed
Less extreme
20
20
9.0 0.0
Untreated
Less extreme
Skieller et al
Lee et al
Present study
63.6 6.4
63.4 2.8
63.5 4.1
35.9 8.2
35.3 4.3
36.2 5.3
173.6 5.6
177.7 3.5
173.3 4.2
2.4 1.8
1.1 0.9
1.4 0.9
87.4 12.2
98.7 7.4
83.6 8.4
Independent variables
1
Post face height
Ant face height
1a
(NSL - ML1)
2
(Intermolar angle)
3
(ML1 - ML2)
4
(CTL - NSL)
The means and standard deviations for the independent variables for each investigation are listed in Table
V. The means appear to be remarkably similar with the
exception of variable no. 4 (CTL-NSL). The standard
deviations are much greater in the Skieller et al sample
than either the Lee et al or the current sample. This is
consistent with the Skieller et al selection of a group of
subjects with extreme growth rotation. A comparison
of the ranges for the independent variables in the
Skieller et al study and the present study are shown in
Table VI. These data were not published for the Lee et
al study. Again, the disparity is indicative of the selection of a specific sample of extreme rotators by
Skieller.
The means, standard deviations, and ranges for the
dependent variable (mandibular rotation) in each of the
investigations, when available, are presented in Table
VII. It was found that both Skieller et al and Lee et al
had observed mandibular rotations greater than what
was recorded for this study; the Skieller et al measurements were the largest.
The means, standard deviations, and ranges for the
expected mandibular rotation are listed in Table VIII
(variables 1, 2, 3, and 4) and Table IX (variables 1a,
2, 3, and 4). The means, standard deviations, and
ranges of the differences between the predicted and
the actual observed mandibular rotations are also presented. As can be seen, the difference between the
664
Leslie et al
Table VI.
Skieller et al
Independent variables
1
Post face height
Ant face height
1a
NSL-ML1
2
Intermolar angle
3
ML1 - ML2
4
CTL - SNL
Table VII.
Present study
Minimum
Maximum
Minimum
Maximum
54.4
76.8
57.1
74.0
19.0
52.5
23.3
45.0
159.8
180.1
163.0
181.5
0.0
5.5
0.0
4.5
65.0
116.0
65.5
104.5
Dependent variable
Skieller et al
Lee et al
Present study
6.0 4.5
+5.3
16.4
4.9 3.0
NA
NA
1.9 2.1
+3.3
5.8
Skieller et al rejection level of P > .1, the empirical distribution of the overall R-squared statistic for the forward stepwise selection procedure had a mean of
0.84328, a median value of 0.94741, and a standard
deviation of 0.21533. In approximately 20% of the simulations, the R-squared value was exactly 1. This happened whenever the procedure chose 20 variables to be
in the model. (For mathematical reasons, the overall Rsquared statistic will be 1 for any subset of 20 variables
selected from the 44 independent variables.)
DISCUSSION
Leslie et al
Predicted mandibular rotation with regression equation for independent variables 1, 2, 3, and 4
Table VIII.
Predicted mandibular rotation with regression equation for independent variables 1a, 2, 3, and 4
Table IX.
Range
Mean standard deviation
Predicted rotation
Difference from
observed rotation
6.71 2.57
4.76 2.94
Minimum
0.79
0.00
Maximum
12.99
11.41
the Skieller et al study sample was purposefully composed of extreme patterns of growth rotation. The
authors themselves pointed out this most serious limitation of their study. The Lee et al study selected a
sample to mirror the means recorded for the Skieller
et al independent variables but with less extreme patterns of growth rotation. As would be true of a typical
orthodontic practice, no predetermined rotational pattern was used in the random selection of the present
sample.
The baseline age of the sample from the present
study and from the Lee et al study differ from the baseline age of the Skieller et al study as exact data were
not available on the onset of puberty. Therefore, a
starting age of 9 years was chosen in an attempt to
incorporate puberty in the 6-year time frame set up by
Dr Skeiller. Certainly, clinical orthodontists would
only be able to make a best guess, based on the available information, as to the onset of puberty in their
patients. With further inquiry, actual pubertal onset
could be determined, but by then the growth spurt may
be well underway.
It is remarkable to note how similar the means for
the independent variables are for the three samples
(Table V), considering that there was no preconceived
selection on the part of the current study. The standard
deviations are quite different, which is reflective of the
differences in extremes between the samples selected.
The observed mandibular rotations (Tables VIII and
IX) are significantly different. This not only represents
the selection for extreme rotational patterns on the part
of Skieller et al, but also the absence of implants as reference points in the current study. As noted by Bjrk,6
half of the actual mandibular rotation that occurs is
masked by remodeling of the lower border of the
mandible. The mean rotation recorded using the
mandibular plane angle is consistent with Bjrks11
statement that, ...the mandible on the average rotates
forward a little during adolescence, and its inclination
thus decreases. Even though the absence of implants
may be viewed as a technical limitation of the present
study, our purpose was to assess the Skieller et al
method as applied to clinical practice where implants
665
Range
Mean standard deviation
Predicted rotation
Difference from
observed rotation
5.64 2.21
3.70 2.57
Minimum
0.57
0.20
Maximum
9.89
10.22
666
Leslie et al
Table X.
Skieller et al
Independent variables
1
Post face height
ant face height
1a
(NSL - ML1)
2
(Intermolar angle)
3
(ML1 - ML2)
4
(CTL - ML1)
Present study
R2
Level of significance
R2
Level of significance
0.62
P < .001
0.0075
P < .59
0.61
P < .001
0.0192
P < .39
0.39
P < .005
0.0558
P < .14
0.27
P < .025
0.0012
P < .83
0.38
P < .005
0.0007
P < .87
Table XI.
Skieller et al
Lee et al
Present study
Independent variable
R2
Independent variable
R2
Independent variable
R2
1
2
3
4
0.62
0.76
0.81
0.86
1
2
3
4
0.05
0.08
0.08
0.08
2
4
1
3
0.06
0.06
0.07
0.07
Variables are listed in order of entry and R2 are cumulative for all variables included in the model.
Table XII.
Present study
Independent variable
R2
Independent Variable
R2
1a
2
3
4
0.61
NS
NS
0.82
2
1a
4
3
0.06
0.07
0.09
0.09
Variables are listed in order of entry and R2 are cumulative for all variables included in the model.
CONCLUSION
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Leslie et al
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