Symposium on Oral Health

Craniofacial Growth and the Dentition

Robert E. Williams, D.M.D., M.A.,*

and Richard F. Ceen, D.D.S. t

A knowledge of the mechanism and pattern of normal craniofacial growth

and development must be coupled with an understanding of how this
information can be applied to the individual patient commonly seen in a
pediatric practice. Physicians need to be aware that the ability of an orthodon-
tist to successfully treat a skeletal malocclusion is greater in patients who are
growing. 31 Since the pediatrician may be the only health-care provider to see a
child during the growing years, the early recognition and referral of patients
manifesting abnormal growth patterns (for example, retrognathic or prog-
nathic mandibles, open or deep bites, short or long faces) can be a major factor
in an orthodontist's ability to achieve a significant modification of the patient's
facial growth pattern. The ability to predict the extent and direction of
craniofacial growth with the accuracy necessary to achieve clinical signifi-
cance has been an area of major interest to those involved in treatment of the
craniofacial complex. It is the objective of this chapter to discuss the patterns
of growth of the craniofacial complex, the effect of this growth on the
dentition, and to describe the current research in craniofacial growth predic-
tion.

CRANIOFACIAL GROWTH

Studies of craniofacial growth in humans fall into three categories based

on the methods used: (1) cross-sectional material has been compared and
longitudinal conclusions derived (for example, using dried skulls), 50 • 51 (2)
combinations of longitudinal and cross-sectional data (for example, cephalo-
metric radiographic data), 29 ' 30 (3) true longitudinal cephalometric sh1dies
using metallic implants.t2-25, 58, 92, 97. 98

Cephalometric Technique
Cephalometric roentgenography is an outgrowth of craniometry and the
craniostat, a device employed by anthropologists since the nineteenth century

*Assistant Professor of Orthodontics, Baltimore College of Dental Surgery, University of Maryland

School of Dentistry, Baltimore, Maryland
f Associate Professor of Orthodontics, Baltimore College of Dental Surgery, University of Maryland
School of Dentistry, Baltimore, Maryland

Pediatric Clinics of North America- Vol. 29, No.3, June 1982 503
504 ROBERT E. WILLIAMS AND RICHARD F. CEEN

to measure dry skulls. 46 • 71 Since 1922, roentgenographic images have been

employed to study facial anthropometry. 107 In 1931, the standardization of
cephalometric radiographic procedures as they are employed today was ini-
tiated.28· 76
Cephalometric roentgenography differs from other radiographic tech-
niques in that the anode-subject film distances are standardized, and the
patient's head is fixed in a reproducible position (Fig. 1). Orientation of the
film, either parallel or perpendicular to the sagittal plane of the head, provides
a means for measuring the size and relationships of various craniofacial areas.
For orthodontic purposes, the disadvantage of measuring three-dimensional
facial structures on a two-dimensional image is outweighed by the ability to
obtain initial measurements and serially follow changes in an individual's
facial dimensions over time.
In an attempt to identify skeletal disharmonies and monitor the effects of
growth and treatment, orthodontists have developed a multitude of cephalo-
metric analyses that attempt to quantify selected angles, dimensions, or
relationships of craniofaciallandmarks. 38 • 44 • 53 • 113 • 127 • 145 • 153 These analyses, in
general, are based on mean values from limited populations usually selected
for their pleasing facial esthetics and occlusion. Measurements obtained from
an individual's cephalogram are usually compared with these means. The
validity of some of these analyses may be questioned, however, because of
biases in the selection of subjects. For example, few studies pertain to
non-white racial groups. 2 • 40 • 4 5, 15 4
All clinically acceptable cephalometric analyses are capable of assessing
the following relationships: (1) basal bones to cranium: the relationship of the
maxilla and mandible to the cranium, and to each other; (2) teeth to basal
bone: the relationship of the teeth to their supporting structures; (3) teeth to
teeth: the relationship of the upper and lower teeth to each other; and (4) the
contour of the soft tissue profile.
Problems of Analysis of Craniofacial Growth
Several problems arise with any attempt to examine or quantify craniofa-
cial growth. 61 First, although the studies of craniofacial growth are basically
anatomic research, longitudinal measurements must be derived from radio-
graphic projections that are subject to varying bias. Radiography reduces a
dynamic three-dimensional structure to a series of two-dimensional pictures.
Second, no absolute reference points exist from which growth can be
measured. Depending on the interest and awareness of the observer, any

60" -14cm

Figure L Anode-subject-film
relationships and standardized dis-
tances used in cephalometric radiog-
raphy.

Anode Subject Film

CRANIOFACIAL CROWTH AND THE DENTITION 505

Figure 2. Mean growth pattern of the cranium and cranial base from age 12 to 20 of 243 male
subjects. (From Bjiirk, A.: Cranial base development. Am. J. Orthod., 41(3):198, 1955).

number of landmarks can be used for orientation. However, the way one
chooses to superimpose serial cephalograms influences the position of the
face in space and may add to, or subtract from, real growth. Third, examination
of the pattern of development of the face as a whole obscures the actual
growth pattern of individual facial bones. For example, routine cephalometric
methods produce a picture suggesting that the pattern of facial growth is
downward and forward. The actual growth of the face is much more complex
than this oversimplified picture, and thus the growth of individual bones must
be examined separately if the pattern of total facial growth is to be meaning-
ful.47, 48

With the above considerations in mind, this discussion of growth of the

component parts of the cranial base and face is based on longitudinal
cephalometric studies using individuals who have had metallic implants
placed in their jaws. 12' 25 • 58 • 92 • 97 • 98 By inserting vitallium implants into the
facial bones of subjects, fixed landmarks may be obtained that permit the
examination and description of the location, direction, and magnitude of
growth changes in the facial area. The findings of these studies have also been
supplemented by results of histologic studies on dry skulls. 47 - 53

GROWTH OF THE CRANIAL BASE

The evaluation of growth of the face as a whole is usually based on serial

cephalograms superimposed on the anterior cranial base, especially the ·
cribriform plate of the ethmoid. 20 Using this procedure, the general growth
pattern of the cranium and cranial base is shown in Figure 2.
506 ROBERT E. WILLIAMS AND RICHARD F. CEEN

Anterior Cranial Base

The anterior cranial base comprises the bones of the anterior cranial
fossa, the frontal and ethmoid, and that portion of the sphenoid anterior to
sella turcica. The length of the anterior cranial fossa increases by sutural
growth until about age ten, when growth of the ethmoid ceases. 16 · 146 From
then on, increases in length are due to anterior displacement of the frontal
bone as a whole, accompanied by frontal apposition of the glabella and
sinus. 16, 52, 146
As a result of the relatively early cessation of growth in the ethmoid area,
this region is often used as a reference to evaluate other faster and later
growing areas of the face. Any increase in length of the anterior cranial base
will result in a corresponding anterior displacement of the articulating
maxilla and midface.
Posterior Cranial Base
The posterior cranial base extends posteriorly from sella turcica to the
anterior border of the foramen magnum and includes portions of the sphenoid
and occipital bones. Growth in this region occurs primarily in the spheno-
occipital synchondrosis and continues until late adolescence or early adult-
hood.16· 52 Dorsal and vertical increases in length of this region result in a
distal and inferior displacement of the mandible (averaging 3 to 4 mm). 16
Cranial Base Angle
In addition to the anterior, posterior, and vertical displacement of the
maxilla and mandible which occur with absolute increases in length of the
anterior and posterior cranial base, changes in maxillomandibular relation-
ships may also occur because of changes in the angle between the anterior
and posterior cranial base.
While the mean anterior-posterior cranial base angle remains stable,
individuals may demonstrate a 10-degree widening or flattening of the cranial
base angle in response to differential brain growth 16 · 49 · 52 (Fig. 3). The angle of
the cranial base will directly influence mandibular position, since change will
displace the glenoid fossa anteroposteriorly and directly affect the degree of
protrusion of the mandible.

Figure 3. Variation in cranial base angle due to growth from age 12 to 20 of two individuals:
(a) decreasing angle; (b) increasing angle. (From Bjiirk, A.: Cranial base development. Am. J.
Ortbod., 41(3):198, 1955)
CRANIOFACIAL CROWTH AND THE DENTITION 507
5cm

Figure 4. Mean growth pattern of

the maxilla and maxillary dentition from
age 6 to 14 of 45 male subjects. (From
Bjork, A.: Sutural growth of the upper
face studied by the implant method,
Acta Odont .. Scand., 24:109, 1966)

In addition, changes in the cranial base angle result in a change in head

position or balance of the head on the spinal column. A flattening of the
cranial base usually will have the effect of tilting the face upward, thereby
giving an impression of greater facial prognathism. 16
Rotation of the lateral parts of the cranial base may also be transmitted
through the zygomatic processes of the maxilla and have a direct influence
on the vertical lowering of the upper facial structures.

GROWTH OF THE MAXILLA

The midface of the growing child undergoes a dramatic increase in

absolute size, particularly in relation to the cranium, which is more nearly
complete at birth. Increases in width, depth, and particularly height continue,
primarily in the maxilla, after the seventh year, when there is a cessation of
growth in the cranial and orbital cavities, and a reduction in sutural growth.
Average sagittal changes in the maxilla and maxillary dentition occurring after
age six are presented in Figure 4.
Change in Width
Comparison of a newborn's face with that of older children reveals that
interorbital width is completed by about three years of age in synchronization
with fusion of the midsagittal suture system. 88 Bizygomatic growth lags
behind cranial growth in the early years but continues to expand after cranial
growth stabilizes; as a result the cheek bones become more prominent with
age. 133, 134
Unlike the bones that are more closely related to the cranial base, the
maxilla maintains some capacity to expand beyond the time of ossification of
the sagittal suture system. Histologic and implant studies have demonstrated
that growth in the midpalatal suture continues until puberty, 86 • 99 • 141 with
508 ROBERT E. WILLIAMS AND RICHARD F. CEEN

sutural growth accounting for at least two thirds of the increase in maxillary
width. 25 Greater increases in width occur posteriorly, resulting in a lateral
rotation of the.maxilla, and a larger increase in width of the molar region when
compared with the canine region. 25 · 104 Increases in width between the
canines are smaller in females than in males, who demonstrate a larger and
later increase in width associated with the pubertal growth spurt of the
mandible. 103 However, both bimolar and bicanine widths show a gradual
decrease during adolescence, so that by age 20 the diameters are approximate-
ly the same as those at age 6. 24 · 25
Surgical extirpation of the mid palatal suture has been shown to dramati-
cally decrease lateral growth of the maxilla and increase the incidence of
dental crossbites. 55 Conversely, patency of the suture during childhood
permits orthopedic expansion of the maxilla and maxillary dental arch,
allowing orthodontists to correct many transverse deficiencies.
Occlusion of the maxillary and mandibular teeth also appears to influence
dental arch expansion, as the increase in width of the maxilla itself exceeds
that of the dentition. 25

Change in Depth
As the maxilla is displaced anteriorly by growth of the cranial base,
limited sutural growth in the body of the maxilla and periosteal apposition at
the tuberosity in a posterior direction provide space at the distal end of the
maxillary dental arch for eruption of the permanent molars. 16 · 19 · 25 While some
contend that the anterior surface of the maxilla and zygomatic process are
resorptive, 49· 50 implant studies show these areas to be relatively stable, with
resorption associated with more extreme forward rotations of the maxil-
la.15' 19· 23 · 25 For the zygomatic process there is general agreement that the
posterior surface is appositional, 25 · 50 while the infrazygomatic crest appears
stable beyond childhood. 25
In addition to changes in depth of the maxilla itself, the dentition as a
whole tends to drift forward on the maxilla, resulting in a decrease in incisor
space that may increase dental crowding. 25

Change in Height
In comparison with changes in width and depth, changes in midface
height show the greatest increase from 3 to 16 years of age. 129 Some of this
increase is due to apposition on the lower border of the alveolar process, but
approximately two thirds is due to growth at the frontal and zygomatic sutures.
This sutural change in height is associated with enlargement of the nasal
cavity. 16 · 19 · 20 · 25 Lowering of the nasal floor is usually greater anteriorly than
posteriorly and is due to resorption on the nasal surface and apposition on the
palatal surface. 19 · 20 · 25
Vertical displacement of the maxilla as a whole is often accompanied by a
forward or, occasionally, backward rotation in the sagittal plane. This may
result from growth of the pterygoid processes or changes in the angle of
flexure of the cranial base. 16 · 23 · 25 · 58 Forward rotation of the maxilla will result
in an increased alveolar and dental prominence, while a backward rotation is
associated with an increase in facial height (Fig. 5).
CRANIOFACIAL GROWTH AND THE DENTITION 509
v 132& v 177&
12 yr---- f2 yr -·--
20yr-- 20yr--

a b
Figure 5. Variation in dento-alveolar prominence due to growth from age 12 to 20 of two
individuals: (a) increased vertical height associated wit!:> a decreasing cranial base angle and dorsal
rotation of the maxilla; (b) increased prognathism associated with an increasing cranial base angle
and ventral rotation of the maxilla. (From Bjork, A.: Cranial base development. Am. J. Orthod.,
41(3):198, 1955)

Correlations with Somatic Growth

The pubertal growth spurt at the facial sutures, which increases the
height and width of the maxilla, may occur before, concurrently, or after the
spurt in body height or the onset of epiphyseal-diaphyseal fusion. 19 • 105 • 106 The
spurt in width of the maxilla coincides with that of stature, but terminates
earlier. 24 Vertical growth of the maxilla exhibits an earlier and larger increase
than does depth or width; width shows the smallest increment of
change. 129 • 138 The adolescent spurt in maxillary growth occurs one to three
years earlier in females than in males. 129 Significant disagreement exists
among investigators regarding the relationship between pubertal facial
growth and dental development. 22

GROWTH OF THE MANDIBLE

The esthetics of an individual's lower face depends on the relative

position of the mandible in relation to the superior facial structures. Since
individuals maintain virtually the same vertical distance between the upper
and lower teeth (mandibular rest position) throughout life, mandibular growth
must constantly compensate for the vertical eruption of the teeth, growth of
the alveolar process, descent of the midface, and changes in the angle of
flexure of the cranial base. It must also attain differentially greater growth in
depth than the midface to produce the characteristic mandibular prominence
and flattening of the profile that occurs in childhood and adolescence. The
resulting mean growth pattern of the mandible and mandibular dentition is
shown in Figure 6.
Condylar Growth
Growth in length of the mandible occurs chiefly at the condyles. 15 • 18 • 20
Total protrusion of the mandible depends on both the amount and direction of
510 ROBERT E. WILLIAMS AND RICHARD F. CEEN

Scm
Figure 6. Mean growth pattern of the mandible and mandibular dentition from age 6 to 11 of
45 male subjects. (From Bjork, A.: Variations in the growth pattern of the human mandible. J. Dent.
Res., Supplement to No. 1, 42:400, 1963)

growth of the condyles, 16 and bodily displacement due to growth of the cranial
baseY· 13
The direction of growth of the condyles influences the general shape of
the mandible. Growth at the condyles is not usually aligned with the posterior
border of the ramus, but is slightly forward, with individual variations up to
45°. 18 • 21 Growth in an upward direction will increase vertical height, while
growth in a backward direction will increase sagittallength 16 (Fig. 7).

'
.
'

I,) . (--,_
'

.. /

Scm
a b
Figure 7. Variation in mandibular growth and path of dental eruption of two subjects: (a)
extreme vertical growth from 11 years, 7 months to 17 years, 7 months; (b) extreme sagittal growth
from 10 years, 6 months to 15 years, 6 months. (From Bjork, A.: Variation in growth pattern of the
human mandible. J. Dent. Res. Supplement to No. 1, 42:400, 1963)
CRANIOFACIAL GROWTH AND THE DENTITION 511
Both the amount and direction of condylar growth influence the shape of
the gonial (corpus-ramus) angle. Vertical growth of the condyle decreases the
gonial angle, and usually results in increased resorption beneath the angle
and apposition under the symphysis. In contrast, sagittal growth of the
condyle is usually associated with less resorption, or even apposition beneath
the angle, and reduced apposition beneath the symphysis 18 (Fig. 7).
Condylar growth in males averages approximately 3 mm annually, with a
well-defined prepubertal minimum at 11 years 9 months. A pubertal max-
imum of 5 mm occurs at a mean age of 14lfz years, with cessation of growth
varying from 12% to over 20 years of age. 18
Growth of the condyles and cranial base is more closely related to growth
in body height than the growth spurt in other facial measurements. Clinically,
orthopedic correction of maxillomandibular malrelations may be treated more
successfully during an active growth spurt. That is, a retrognathic mandible
will tend to become less severe with average mandibular growth, while a
prognathic mandible will tend to worsen.
In regard to the direction of growth, the average resultant of growth of the
face is downward and forward in approximately equal amounts. In an
individual with marked horizontal (forward) growth, there is a tendency
toward a skeletal deep bite, while with marked vertical (downward) growth,
there is a tendency for a skeletal open bite to develop. Every individual may
have periods when marked horizontal or vertical growth predominates, but
the overall pattern for most individuals is still downward and forward.
Symphyseal Growth
There is no appreciable growth on the anterior aspect of the chin except
in rare cases of pathology, in which either resorption or apposition may
occur. 18 • 20 · 21 The area between the chin and alveolar process is primarily
resorptive in nature. 88 • 138 Thickening of the symphysis is a result of apposition
on its posterior and inferior surface, the latter contributing somewhat to an
increase in height of the symphysis and a lengthening of the mandi-
ble.20· 2 1. 97 • 98 While Bjork' 8 originally found the inner cortex of the symphysis,
the mandibular canal, and the floor of the unerupted tooth germs to be
relatively stable areas, Matthews and Ware 98 demonstrated that only the
symphysis does not change substantially.
Mandibular Rotation
Rotational growth of the mandible often occurs about a point that may be
located anywhere between the symphysis and the condyles. Forward rotation
around the center of the temporomandibular joint is most common, with a
resulting reduction in anterior facial height, and an increase in vertical
overlap of the upper and lower incisors. 2 1. 58 • 92 • 93 Forward rotation around a
point near the incisors, accompanied by normal vertical anterior growth,
results in an increase in posterior facial height and movement of the posterior
part of the mandible away from the maxilla. Backward rotation of the
mandible occurs less often and is usually associated with an increase in
anterior facial height, development of the skeletal open bite, lingually
inclined mandibular incisors, a reduction in alveolar prognathism, and lip in-
competence.21
 512 ROBERT E. WILLIAMS AND RICHARD F. CEEN

Rotational movements may also act as compensators for discrepancies in

growth of the maxilla and mandible themselves. 82 • 93 When mandibular growth
greatly exceeds that of the maxilla, the excess is dissipated through a high
degree of anterior rotation. Conversely, when growth of the mandible is
insufficient, there appears to be significantly less forward rotation. 92 A study of
the effect of orthodontic treatment indicates that orthodontics may be capable
of changing mandibular rotations into vertical translations, thereby influenc-
ing chin prominence. 82

Influence of Mandibular Growth on the Dentition

In general, the path of eruption of the lower dentition is primarily vertical
(Fig. 6). In cases of pronounced vertical growth of the mandibular condyle,
eruption appears to be directed more anteriorly, while posterior drift and a
reduction in arch length appear to be associated with sagittal condylar
growth 18 (Fig. 7). The path of eruption also seems to be strongly influenced by
the direction of mandibular rotation. Forward rotation of the mandible tends
to increase alveolar prognathism, dental crowding, and overbite; while a
backward rotation tends to decrease alveolar prognathism, increase the
incidence of dental open bites, and results in a lingual inclination of the
incisors. Arch length is increased not by the addition of bone to the
mandibular corpus, but through resorption of the anterior border of the ramus,
with a corresponding apposition on the posterior surface. Insufficient resorp-
tion of the anterior border may result in impaction of the mandibular third mo-
lars.

ASSOCIATED CHANGES IN THE DENTAL ARCH

Having reviewed the effects of craniofacial growth on the size and

position of the alveolar processes, let us now examine the changes that occur
in various dental arch dimensions.
In association with the greater increase in width and lateral rotation of the
maxilla from age 3 to 18, intercuspid width shows a mean increase of 5 mm in
the upper arch and 3 mm in the lower. lntermolar mean width increases 4 mm
for the upper arch, and 2 mm for the lower, with an individual variation ± 3
mm. 102 • 104 • 136 Bimolar diameter shows a more or less steady increase, while
bicanine diameter increases rapidly until the primary canines are shed, and
then decreases about 1 mm. 33 • 85
While the absolute length of the dental arches increases due to apposition
on the maxillary tuberosity and resorption of the anterior border of the ramus,
anterior arch length, as measured from the labial surface of the incisors to the
midpoint of a line connecting either the distal surface of the second primary
molars or the mesial of the first permanent molars, remains relatively constant
from 3 to 9 years of age, then decreases slightly in both the upper and lower
arches from age 9 to 16. 60 • 85 • 102 • 104 Similarly, arch circumference, measured
from either the distal surface of the second primary molar or the mesial
surface of the first permanent molar on one side, around the arch to the similar
surface on the opposite side, increases about 1 mm in the upper arch and
decreases about 4 mm in the lower from age 5 to 18. 104 These decreases in
CRANIOFACIAL GROWTH AND THE DENTITION 513
anterior arch length and circumference are due to a forward drift of the
posterior teeth during the transition from large primary molars to the smaller
permanent bicuspids that replace them.
The continuation of mandibular growth after the cessation of growth in
the maxilla results in a relative reduction in the protrusion of the upper
incisors in relation to the lower from age 12 to 20. 7 Vertical overlap of the
incisors averages about 40 per cent at age 6 and changes very little until age
16, when it decreases slightly. 14 · 104

FACIAL-SOMATIC GROWTH CORRELATIONS

One of the long-sought goals in the treatment of children with growth or

skeletal discrepancies is to identify those periods of growth when treatment
intervention will produce maximal results with minimal time and effort. Since
variations in both the magnitude and velocity of growth of various craniofacial
components have been identified, all that remains is to determine when and
to what extent these variations will occur in any given patient.
Unfortunately, children demonstrate considerable variation in the time
required to reach similar stages of development. For this reason, chronologie
age has not proved to be a reliable guide in the assessment of physical
maturity.6, 10, 62, 8o, 91, 125, 126, 130, 142, 149, 15o, 151 As a result, various measures of
developmental status, particularly skeletal maturation as indicated by stand-
ing height or hand-wrist radiographs, have been used to aid in growth
evaluation. Unfortunately, studies are divided between those that have shown
a high correlation between facial growth and standing height6 • 35 · 80 · 95 · 105 · 139
and others that have shown a low correlation. 74 · 79 · 101 · 124 · 125 · 128 Other studies
have shown high correlations between facial growth and skeletal age (as
measured by hand-wrist films or height) for males but not fe-
males."· 80 · 108 · 139· 140 · 142 · 150 In spite of these diverse findings, the following
trends may be of some assistance in gauging an individual's maturation.
Maturation of the ulnar-sesamoid as shown on hand-wrist films occurs
approximately 12 months prior to the pubertal spurt in standing heighe 2· 135 · 137
(about 11 to 12 years of age in females, and 13 to 14 years of age in
males.)."· 22 · 135 · 150 The spurt in height, in turn, occurs approximately 12
months prior to menarche in females (Fig. 8). 22 · 54 · 66 Girls with an early spurt
in height tend to mature earlier, to have an earlier menarche, and to exhibit
less growth than girls who mature later and have a later menarche. 43 · 150 The
spurt in maxillary growth also follows the spurt in standing height, and
approximates the spurt in mandibular growth (Fig. 9). 4· 105 · 135 Longitudinal
data presented in the growth atlases prepared by Riolo et al. 123 and Broadbent
et al.3° present gradual increases in mandibular length and position without
the dramatic circumpubertal spurt found in most studies.
Beginning as early as 1922158 numerous investigators'· 5· 8· 17 · 22 · 27 · 36 · 42 · 57 ·
59, 62, 64, 66, 78, 89, 91, 94, loo, 144, 147, 15B have examined the relationship between tooth
formation (or eruption) and skeletal maturation (or growth in stature). Most
of these studies report widely varying correlations between dental develop-
ment and skeletal maturation, ranging from near zero to a high of r = 0.97. 66
In virtually all cases, however, dental age is more closely correlated with
skeletal age than chronologie age. 22 · 37 · 62 · 66
514 ROBERT E. WILLIAMS AND RICHARD F. CEEN

MATURATION STAGES AT PUBERTY

.....
I
(.!) CM/YEAR H
jjj
I
>
0
0
CD
z
w
.....
<(
0::
I
.....
3:
0
0::
(.!)

,---.L----'---.L - - __J______ __ _j__--.-.JL______l___L___ __j__ ___[__ __..

10 11 12 13 14 15 16 17 18

AGE IN YEARS
Figure 8. Mean stages of maturation. and growth curves at puberty for both sexes. H, maximum
pubertal growth in body height; S, ossification of the sesamoid; M, menarche. (From Bjork, A., and
Helm, S.: Prediction of the age of maximum pubertal growth in body height. Angle Orthod., 37:134,
1967)

CM I MM PER YEAR GROWTH

TIMING

10 BOYS

T
I
I
I
I
5
I----A-_,
o-----"""'_...tL-_-+/ II ' ,'
CONDYLES / J. ',
', T
1
/ T '
SUTURE&-.. _,/, ..........•.•,,L., ..... ·-·• ',
"l··r.;- - "!!!-.+'-- r·· · J.. •••• •• '
0 ---~=2·=·~~::·~~·- ........ ::.-.:~.>~~-.::~~
8 10 12 14
l ..

16 18
. . . . .::::--
20 22
---=--=---::::L..-

24
AGE IN YEARS
Figure 9. Relationship between peak growth in standing height, growth of the condyles and
facial sutures. (From Bjork, A.: Sutural growth of the upper face. Acta Odont. Scand., 24:109, 1966)
CRANIOFACIAL GROWTH AND THE DENTITION 515
Simply knowing that craniofacial growth will occur is not sufficient.
Attempts to predict growth with the accuracy necessary to achieve clinical
significance have produced points of major controversy to those interested in
the treatment of the craniofacial complex. The final section of this article will
attempt to describe the current research and the state of the art in craniofacial
growth prediction.

CRANIOFACIAL GROWTH PREDICTION

The Need for Growth Prediction

When orthodontic treatment is indicated for a child, the clinician is
interested in developing a treatment plan that will allow for maximizing the
interaction of the patients' growth potential with their treatment needs.
Numerous cephalometric studies have confirmed that significant positional
changes of the teeth, and alterations in the spacial relationships of the maxilla
and mandible, occur during orthodontic treatment. The effects of these
movements are manifested by changes in the patient's facial profile in
addition to the changes that occur in the patient's dentition. It is important to
understand the extent that orthodontic therapy and normal growth contribute
to these changes. 34
Growth, whether or not it is altered by treatment, is always a major factor
in the end product of facial development. Once orthodontists realized the
impact of growth and treatment on the craniofacial skeleton, changes occurred
in the philosophy of orthodontic treatment that required a consideration of
growth prediction. These changes included the initiation of treatment prior to
adolescence, thereby allowing therapy to proceed during major growth
periods; the improvement of orthodontic treatment techniques, which allow
for modification of the skeletal pattern through the use of orthopedic forces;
and the recognition of the combined effect of orthodontic therapy and growth
on the facial soft tissue profile. 65
In the growing individual, an orthodontic treatment plan is designed to
develop ideal dental relationships that will harmonize with the child's
anticipated adult facial characteristics. The ability to predict changes in the
expected growth pattern of the patient enhances the orthodontist's ability to
develop treatment plans that attempt to achieve the desired esthetic and
functional results. Surgical treatment alternatives may be considered when
the skeletal dysharmony is too severe to be corrected with orthodontic or
orthopedic treatment alone. Additionally, prediction of an individual's growth
provides the clinician with a "visual goal against which treatment progress
can be measured and monitored." 65 Examination of serial cephalometric head
films taken during treatment allows the clinician to monitor the effects of
growth and treatment and to adjust for deviations from the predicted re-
sponse.
Considerations in Growth Prediction
Several variables of craniofacial growth have been considered in the
attempt to develop useful predictive techniques. For example, the future size
516 ROBERT E. WILLIAMS AND RICHARD F. CEEN

and relationship of the bones of the craniofacial skeleton, the vectors and
velocity of growth, the timing of growth events, and the effect of orthodontic
treatment on these parameters, have all been considered important as possi-
ble predictors of craniofacial growth. 73 The current status of research in this
area may be summarized as follows:
The ability to predict the future size and relationship of facial bones with
accuracy on an individual basis would represent an important advance in the
diagnosis and treatment of patients with a skeletal imbalance. Unfortunately,
studies attempting to predict these parameters have not achieved the accuracy
necessary for individual patients. 3· 34 · 70 · 73 • 83 · 109
The assumption that a bone will grow along a single established vector
has been one of the more popular methods of assessing facial growth. 109 Since
it has been established that these vectors vary in many individuals,3· 83 this
method of prediction may be useful when considering population norms, but
it is not useful on an individual basis. The focus of research in this area is now
centered on predicting the change in these growth vectors, but the consisten-
cy of accurate prediction is stilllimited. 131
The timing of growth and the velocity of growth are separate but related
elements in growth prediction. As with other segments of the body, there is a
significant variation in both of these parameters. 81 While the time of onset,
duration, and rate of growth during a spurt are all important,73 the results of
research on these variables are too general to be clinically useful.2 2· 56
Prediction of the onset of peak growth velocity has significant treatment
implications for two reasons. First, when growth increments are at their
maximum, the amount of actual tooth movement required is decreased if the
patient is growing favorably. Second, there is a possibility that hormonal
changes associated with the circumpubertal growth spurt may enhance tooth
movement. 34 The accurate prediction of variations in velocity may be signifi-
cantly more complicated than other methods discussed thus far. 73
Clinical evidence suggests that orthodontic therapy itself has a consider-
able influence on many of the preceding variables. 53 · 114 · m Since orthodontic
treatment may result in a permanent alteration in facial growth, treatment
itself may be an important predictive factor. 3 Thus, of all the variables
considered, orthodontic treatment designed to achieve certain predicted goals
may enhance the success rate of the original growth prediction.
Prediction Methods and Controversy
Developmental studies of postnatal facial shape and proportion have
demonstrated significant individual variability. 12 · 15 · 18 · 38 · 105 Over the past
30 years, considerable research has attempted to accurately predict
individual skeletal and soft tissue changes using data generated from
cephalometric studies of orthodontically normal and abnormal popula-
tions.3· 9, 34, 41, 65, 10, 73, 77, 83. go, 96, 110-120, 122, 156, 157 However, considerable dis-
agreement exists regarding the accuracy of the methods currently available for
predicting individual growth. 63 · 75 · 84 · 131 Commentary on the subject of growth
prediction ranges from strong advocacy of the accuracy of computerized
cephalometric prediction techniques 121 to the critical assertion that cephalo-
metric studies fail to show any improvement in the prediction of individual
growth over mean population changes. 75
Interest in the prediction of craniofacial growth is also found in the fields
CRANIOFACIAL GROWTH AND THE DENTITION 517
of human genetics and mathematics. Investigators have sought information
regarding the effect of heritability on craniofacial growth and its contribution
to occlusal variation. 39 • 67 • 69 Noting that population norms used in cephalomet-
ric prediction are not an effective means of predicting individual growth in a
heterogeneous society, Harris 69 has proposed the use of familial information
to develop a system of prediction based on the presumption that heredity
plays a direct role in most malocclusions. 68 Others argue that environmental
effects are more important than heredity. 39 • 67 The phenomenon of family
resemblance may make the question of genetics vs. environment a moot
point. 143 Family resemblance may be cautiously used as an additional clinical
tool for prediction, regardless of why it occurs.
Various mathematical models have been proposed for growth predic-
tion.73 Models based on the transformed coordinate method 148 and the use of
equations to produce curves descriptive of growth processes have been found
to be too general to describe any single growth pattern. They are inadequate,
therefore, for routine use by orthodontists trying to predict growth in individ-
ual patients. Other mathematical methods used in industry and science have
also been evaluated for use. Four of these methods that initially appeared to
have promise may be categorized as (1) theoretical, (2) regressional, (3)
experiential, and (4) time series.
Theoretical and regressional methods were found to be either imprecise
or inadequate for use in the prediction of individual growth. 73 The experien-
tial method is currently the most popular 110' 116 and enjoys considerable use in
the orthodontic profession today. It is based on the experience of the clinician
using a data base of cephalometric means of a large sample of treated patients.
The information is stored in a computer and is continually augmented to
increase the data base. Criticism of this method arises from the assumption
that an individual will grow identically to the mean of the sample population,
irrespective of his similarities to that population group. This method also
assumes that the skeletal morphology of the mandible or other facial bones
can be used to determine future facial growth. Independent studies have not
confirmed the morphology hypothesis, and they find that the efficiency of this
prediction method is clinically negligible. 3 • 77
The time series method has recently demonstrated the greatest promise
for use in prediction of craniofacial growth. This method has been tested in
other scientific fields and found to be versatile, capable of modification, and
effective when applied to individual patientsY Adaptation of this method to
the needs of the orthodontist is now being studied. 72 • 73
The application of mathematics to craniofacial growth prediction has
been increasing steadily, and a new model for predicting craniofacial growth
using a transformational approach was recently published. 152 Although dis-
agreement exists among mathematicians regarding the appropriate methodol-
ogy,26 there is a considerable amount of ongoing research at this time.
What, then, is the current status of craniofacial growth prediction? Many
orthodontists currently use computerized cephalometric growth predictions
or other techniques to assist them in the development of treatment plans.
Unfortunately, it is not yet known when these methods are misleading, and no
technique for orthodontic growth prediction has achieved universal accept-
ance as a valid clinical tool.
From the previous discussion it is obvious that much research needs yet
518 ROBERT E. WILLIAMS AND RICHARD F. CEEN

to be done. The infinite complexity and diversity of human craniofacial

growth does not lend itself to one unique method of growth prediction. It
would seem that an answer may lie in the "synthesis of biology and
mathematical analysis." 155 The future holds significant promise in this re-
gard.
The ability to completely understand and accurately predict human
craniofacial growth may still elude the clinician. However, the importance of
this understanding to successful orthodontic treatment has been well substan-
tiated. Patients treated for skeletal malocclusions during an active growth
period have a significantly better prognosis, and the early recognition and
referral qf these children by the pediatrician can be a major factor in the
success of their orthodontic treatment.

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