Three-Dimensional Analysis of Maxillary and Mandibular

Growth Increments
CHRISTOPHER J. LUX, D.D.S., DR. MED. DENT.
CHRISTIAN CONRADT, PH.D.
DONALD BURDEN, B.D.S., M.SC., PH.D., F.D.S.R.C.S., M.ORTH.R.C.S.
GERDA KOMPOSCH, D.D.S., PH.D.

Objective: To analyze changes in the facial, maxillary, and mandibular skel-

eton in the vertical, sagittal, and transverse dimensions during an orthodon-
tically relevant period of dentofacial development (i.e., between 7 and 15 years
of age).
Subjects and Method: This longitudinal study comprised posteroanterior
(PA) and lateral cephalograms at 7, 9, 11, 13, and 15 years of 18 untreated
Class I subjects with good occlusion. Transverse growth (width) was analyzed
on the basis of PA cephalograms and sagittal (depth) and vertical (height)
growth by means of lateral cephalograms. For each linear measurement, mean
percentage increases were calculated relative to the size at 7 years of age.
Results and Conclusions: Between 7 and 15 years of age, in the whole facial
skeleton and the maxilla, percentage increases were most pronounced in the
vertical dimension when compared with the sagittal and transverse dimen-
sions. In the mandible, the largest percentage increases were found in both
sexes for vertical growth of the ramus, followed by sagittal growth (body
length) and then mandibular width. In the sagittal dimension, development was
more pronounced in the mandible (at pogonion more than at B point) than in
the maxilla (A point). With respect to vertical growth, percentage increases in
posterior face height exceeded the increases in anterior face height. When
facial shape changes were analyzed between 7 and 15 years of age in both
sexes, the ratio facial height/facial width increased and the ratio facial depth/
facial height decreased, which points toward an age-related increasing influ-
ence of vertical development.

KEY WORDS: facial skeleton, maxillary and mandibular development, three-di-

mensional growth analysis

In orthodontics and dentofacial orthopedics, patients with
dentofacial anomalies and malrelationships of the jaws often
require complex treatment with modification of facial growth
in all three planes of space. Therefore, an in-depth understand-
ing of the facial growth patterns during childhood and adoles-
cence is a necessary prerequisite for treatment timing and plan-
ning. First contributions in the field of the three-dimensional
(3-D) analysis of facial growth were carried out by Hellman
(1932). He investigated craniofacial growth using direct an-
thropometric measurements in children between 5 and 22 years
of age and found that the dimension of the human face is
Dr. Lux and Dr. Komposch are with the Department of Orthodontics, and
Dr. Conradt is with the Institute of Medical Biometry and Informatics, Uni-
versity of Heidelberg, Heidelberg, Germany. Dr. Burden is with the Department
of Orthodontics, Queens University, Royal Group of Hospitals, Belfast, North-
ern Ireland.
Submitted January 2003; accepted June 2003.
Address correspondence to: Dr. Christopher J. Lux, Poliklinik fur Kieferor-
thopadie Univ.-Mund-, Zahn-, und Kieferklinik, Im Neuenheimer Feld 400,
69120 Heidelberg, Germany. E-mail christopherplux@med.uni-heidelberg.de.
greatest in width, less in height, and least in depth. During
growth, the largest dimension increased least and the smallest
most. In addition, the face increased vertically more in the
posterior aspect than anteriorly. Similarly, Goldstein (1936)
made direct anthropometric measurements in a sample of male
subjects between 3 and 21 years of age. He found that the
most growth and the highest rate of growth occurred in facial
height, with growth in depth next in order, followed by growth
in facial width. Moreover, he found that growth is generally
completed first in the cranium, followed by facial width, and
finally facial height and depth.
Meredith (1960) investigated the facial growth of 60 Amer-
ican-born white girls between 5 and 11 years of age through
direct and radiographic measurements of the face. During this
period, face depth decreased relative to face height, and face
height increased relative to face width. The series of investi-
gations conducted by Savara and colleagues (Singh and Sa-
vara, 1966; Tracy and Savara, 1966; Savara and Tracy, 1967;
Savara and Singh, 1968) made a major contribution to our
understanding of maxillary and mandibular growth in all three

304
 Lux et al., 3D ANALYSIS OF GNATHOFACIAL GROWTH INCREMENTS
dimensions. Their material was based on mixed longitudinal
growth data of children between 3 and 16 years, and they
obtained anatomically correct values by correcting their radio-
graphic measurements for 3-D magnification and distortion.
Referring to these studies, Baughan et al. (1979) pointed out
that, unfortunately, growth and velocity curves were plotted
on absolute size scales instead of proportional scales, which
hampered a comparison of different anatomical regions inde-
pendent of absolute size.
Farkas et al. (1992) investigated facial development between
1 and 18 years of age through anthropometric measurements
of the facial soft tissues in North American Caucasians. He
showed that by 1 year of age, the widths of the face and the
mandible as well as the depths of the maxilla and mandible
are further developed in relation to their adult size than are
vertical heights. In addition, he showed that the mandible is
less developed at 1 year of age in the sagittal dimension than
the maxilla (relative mandibular retrognathism) with greater
subsequent growth increments of the mandible in the following
years.
As reviewed in detail by Basyouni and Nanda (2000), sev-
eral 3-D studies on facial growth are based on direct measure-
ments of the face or on measurements made on dried skulls.
Studies with direct measurements on the face have their lim-
itations because of the overlying soft tissues as well as the fact
that it is difficult to analyze anatomical parts of the skeleton
separately (Singh and Savara, 1966). The limitations of ana-
lyzing dried skull material were recognized early on by Todd
(1931), who highlighted the detrimental effects that disease
processes can have on facial development. With respect to
cephalometric radiographic studies, the majority of investiga-
tions have focused on sagittal or vertical growth based on the
lateral cephalogram. Radiographic analysis of growth in all
three dimensions including the transverse component has rare-
ly been addressed in the literature. Very little information is
available, in the same population, about the developmental
changes that occur in facial height, depth, and width. Hence,
the aim of the present study was to analyze the growth-related
changes in all three planes of space during an orthodontically
relevant period of dentofacial development (i.e., between 7 and
15 years of age). Growth changes were measured in the facial
skeleton as a whole. In addition, the contributions made by
maxillary and mandibular growth were evaluated.
METHODS
Subjects
The data for this longitudinal study comprised the lateral
cephalograms and posteroanterior (PA) cephalograms from or-
thodontically untreated subjects of the Belfast Growth Study
(Adams, 1972). The Belfast Growth Study was carried out in
the 1960s and 1970s and included 300 orthodontically untreat-
ed children who had PA and lateral cephalograms taken an-
nually. From among these 300 patients, 18 subjects (10 boys,
8 girls) were selected who met, on the basis of the plaster casts
305
at 15 years of age, the following inclusion criteria: (1) bilateral
Class I molar and canine relationship; (2) no congenitally
missing teeth (i.e., all teeth except third molars in occlusion);
(3) correct overjet and overbite ($ 1 and # 4 mm); (4) no
crossbites or transverse anomalies; and (5) crowding in upper
and lower arches # 3 mm. Growth was analyzed longitudi-
nally at ages 7, 9, 11, 13, and 15 years. The precise mean ages
were 7.52, 9.36, 11.44, 13.50, and 15.55 years for the boys
and 7.71, 9.67, 11.71, 13.71, and 15.78 years for the girls with
SDs ranging between 0.30 and 0.37 years (Lux et al., 2003).
With respect to the small sample size of the Class I good
occlusion group, all percentage increases (Table 1, percentage
increases in brackets) were additionally calculated for a larger
Class I sample (n 5 37, 19 males, 18 females) of the same
origin without exclusion of Class I malocclusions. The inclu-
sion criteria for this group were only a bilateral Class I molar
and canine relationship and no congenitally missing teeth
(without the criteria 3 through 5 listed above).
Measurements: PA View
Transverse growth (width) was analyzed on the basis of PA
cephalograms and sagittal (depth) and vertical (height) growth
by means of lateral cephalograms taken at the same times. In
the Belfast Growth Study, PA radiographs were taken in the
depressed PA view (Adams, 1963). In this view, the line con-
necting the transporionic axis and the soft tissue point on the
orbital rim is inclined downward at an angle of 35 degrees to
the horizontal plane. In the present study, PA and lateral ceph-
alograms were scanned using high resolution (600 dpi). Sub-
sequently, the landmarks shown in Figures 1 (PA) and 2 (lat-
eral view) were digitized, and their coordinates were used to
calculate linear measurements and ratios.
In the PA radiographs (Fig. 1), landmarks were determined
according to common anthropologic/orthodontic landmark def-
initions (Martin and Saller, 1957; Svanholt and Solow, 1977;
Athanasiou et al., 1992; Major et al., 1994; Raghavan et al.,
1994; Hsiao et al., 1997). Measurements made on the PA ra-
diographs were corrected for differential magnification using
the method of similar triangles based on the combined use of
lateral and frontal radiographs as described by Adams (1963)
and Hsiao et al. (1997). Briefly, in this technique, the land-
marks have to be identified both on the frontal and lateral
radiographs. The actual size of any craniofacial measurement
made on the PA cephalogram can be determined if the distance
between the vertical plane of the respective landmarks to the
vertical plane of the transporionic axis is known. This distance
is determined on the lateral cephalogram. If the respective
landmark could not or not precisely be identified on the lateral
cephalogram (zygion, maxillare), mean values to neighboring
structures were used to define the position on the lateral ceph-
alogram (Adams, 1963; Hsiao et al., 1997; Lux et al., 2003).
In this context, one should consider that a slight difference
exists when the same landmark (e.g., gonion) is located in the
depressed PA and lateral view. The methodology of magnifi-
cation correction in the PA view, as well as the transverse
306 Cleft PalateCraniofacial Journal, May 2004, Vol. 41 No. 3

TABLE 1 Descriptive Statistics for the Linear Measurements and Ratios at 7 and 15 Years (in mm)

Boys Girls
Variable Age Mean SD Min Max PI (%) Mean SD Min Max PI (%) p-Value

Vertical (height)
N-Me (v) 7 96.16 3.68 91.39 103.37 23.0 91.70 4.87 84.70 98.59 16.9 .083
15 118.25 3.63 112.31 122.24 (21.9) 107.13 5.30 100.20 113.85 (16.1) ,.001*
N-ANS (v) 7 43.32 1.87 39.42 45.82 21.7 42.17 2.02 39.89 45.73 18.8 .20
15 42.71 2.66 47.44 55.56 (20.7) 50.05 1.86 47.94 52.54 (16.2) .083
ANS-Me (v) 7 52.84 3.08 49.24 57.55 24.2 49.53 3.76 42.99 52.86 15.4 .23
15 65.55 3.49 61.21 71.59 (22.9) 57.08 3.75 51.82 62.35 (16.3) ,.001*
N-Pr (v) 7 55.20 2.71 51.41 60.67 24.6 52.14 3.90 45.01 57.90 21.8 .069
15 68.72 3.12 63.32 71.84 (24.3) 63.36 3.75 58.29 68.59 (20.2) .007*
S-PNS (v) 7 35.39 1.90 31.37 38.00 24.3 34.83 2.77 29.31 37.67 15.7 .89
15 43.97 1.98 39.54 46.33 (22.9) 40.32 3.39 33.79 43.90 (15.7) .011*
S-Go (v) 7 60.69 3.12 56.95 66.40 29.2 58.50 5.40 51.19 67.63 22.4 .31
15 78.38 4.14 72.26 86.84 (27.1) 71.55 6.08 62.43 80.60 (21.7) .011*
Ar-Go (v) 7 35.19 1.64 32.43 37.58 34.4 34.67 2.52 31.98 39.21 26.9 .45
15 47.25 3.12 42.02 51.09 (30.1) 43.99 3.74 38.52 48.98 (25.1) .10
Co-Go (v) 7 41.85 2.25 37.83 46.95 35.7 40.20 3.23 36.24 47.03 28.7 .069
15 56.72 3.31 53.43 63.66 (30.6) 51.71 4.17 45.27 58.91 (25.9) .019*
Sagittal (depth)
S-N (h) 7 61.83 2.54 58.46 67.32 11.3 58.98 1.65 56.71 61.20 8.2 .023*
15 68.82 2.85 65.74 73.18 (10.4) 63.85 2.33 59.04 66.95 (8.4) .002*
S-A (h) 7 60.34 2.89 55.29 64.46 11.9 57.95 2.28 55.34 61.97 9.0 .10
15 67.53 3.34 61.79 72.49 (10.9) 63.18 2.96 59.76 66.57 (10.3) .011*
Ba-A (h) 7 80.77 2.48 77.32 85.08 14.1 77.33 2.89 72.01 81.15 11.3 .037*
15 92.16 4.00 86.52 98.34 (12.7) 86.06 4.19 80.60 92.65 (10.9) .015*
PNS-A (h) 7 41.75 1.93 38.68 44.46 15.2 40.15 1.67 37.84 42.91 14.4 .143
15 48.10 2.76 43.25 53.36 (14.8) 45.92 2.51 43.08 50.81 (13.6) .10
PTM-A (h) 7 43.19 1.92 40.08 46.40 14.5 41.95 1.80 39.98 44.76 12.8 .31
15 49.47 2.81 44.63 54.73 (13.7) 47.36 2.80 43.68 52.58 (13.5) .12
S-Pr (h) 7 60.86 3.53 54.85 66.03 15.5 58.71 2.63 54.96 62.42 11.1 .14
15 70.24 3.80 64.11 74.91 (14.6) 65.23 3.00 61.18 68.93 (12.8) .015*
Ba-Pr (h) 7 81.29 2.85 76.88 86.65 16.7 78.09 3.40 72.50 82.20 12.8 .083
15 94.88 4.02 88.83 100.67 (15.4) 88.11 4.20 82.44 95.48 (12.7) .007*
S-B (h) 7 53.03 3.72 47.39 59.33 16.9 52.73 2.33 48.28 55.12 13.0 .82
15 61.96 4.62 55.63 69.33 (15.1) 59.52 1.82 56.79 61.80 (16.3) .27
S-Pg (h) 7 51.84 4.19 45.49 59.03 20.8 52.52 3.15 47.20 55.80 17.3 .63
15 62.56 5.48 54.81 70.09 (19.6) 61.53 2.95 58.61 67.41 (19.9) .56
Ba-Pg (h) 7 72.27 3.66 67.12 79.64 20.6 71.90 3.28 66.92 77.12 17.5 .630
15 87.19 6.22 79.44 96.87 (19.0) 84.41 2.37 80.91 86.78 (17.7) .40
Go-Pg (h) 7 56.61 3.69 49.93 62.27 24.1 55.54 2.51 53.05 60.94 19.3 .31
15 70.20 5.01 64.72 82.30 (22.9) 66.20 2.62 60.53 69.41 (19.9) .056
Ar-Pg (h) 7 64.28 4.51 56.62 72.00 23.5 63.99 3.72 59.44 71.26 19.8 .83
15 79.38 6.29 70.75 88.83 (21.9) 76.61 3.46 72.13 82.53 (20.8) .31
Transverse (width)
Zy-Zy 7 110.97 4.00 106.26 119.05 15.5 109.43 3.22 104.19 114.43 12.3 .69
15 128.11 4.47 124.49 136.80 (14.5) 122.88 3.59 116.04 126.56 (11.9) .011*
Zm-Zm 7 79.99 2.18 76.59 83.01 18.6 77.59 3.33 72.79 82.00 12.3 .14
15 94.88 3.81 88.47 100.14 (17.6) 87.16 4.43 81.64 94.55 (13.2) .003*
Ma-Ma 7 55.14 1.63 52.12 57.99 15.6 52.93 2.10 49.25 55.84 10.4 .023*
15 63.75 2.46 59.46 68.17 (15.0) 58.46 2.84 52.25 62.07 (10.0) .001*
Go-Go 7 80.50 3.01 75.47 84.81 17.6 80.48 3.81 76.27 85.88 13.8 .89
15 94.64 4.63 87.46 101.23 (16.5) 91.54 3.17 88.28 96.58 (14.0) .20
Ag-Ag 7 72.94 2.41 69.25 76.92 15.4 73.02 3.70 68.55 77.74 13.6 .97
15 84.16 3.51 78.97 90.87 (15.2) 82.92 3.57 77.14 88.06 (13.5) .56
Skeletal base lengths
S-N 7 62.29 2.56 58.90 67.82 11.3 59.43 1.66 57.13 61.66 8.2 .023*
15 69.34 2.88 66.23 73.73 (10.4) 64.33 2.34 59.48 67.46 (8.4) .002*
PNS-A 7 41.97 1.81 39.19 44.74 15.7 40.34 1.63 38.25 42.94 15.2 .069
15 48.55 2.66 44.32 53.82 (15.2) 46.48 2.53 43.15 51.39 (14.2) .12
Co-Go 7 42.20 2.25 38.23 46.99 36.0 40.62 3.27 36.35 47.35 29.1 .083
15 57.33 3.30 54.04 63.69 (30.7) 52.41 4.24 45.66 59.75 (26.4) .011*
Ar-Go 7 36.12 1.86 33.33 39.11 34.0 35.75 2.72 32.61 40.55 26.7 .63
15 48.35 3.49 43.18 53.84 (29.5) 45.30 3.71 39.38 50.71 (25.5) .12
Go-Pg 7 61.00 3.44 56.07 65.77 22.2 59.20 2.26 55.85 63.33 17.6 .20
15 74.47 4.56 68.94 84.62 (21.4) 69.60 2.39 64.08 71.89 (17.9) .007*
Linear measurements: (v) 5 projection onto vertical reference line; (h) 5 projection onto the horizontal reference line. In addition, the percentage increases (PI) between 7 and 15 years are
given for the male and female Class I good occlusion groups (in brackets are the respective values for Class I subjects including malocclusions (n 5 37)).
* p-values indicate sex differences between absolute sizes at 7 and 15 years of age (* p , .05)
 Lux et al., 3D ANALYSIS OF GNATHOFACIAL GROWTH INCREMENTS 307

TABLE 1 Continued

Boys Girls
Variable Age Mean SD Min Max PI (%) Mean SD Min Max PI (%) p-Value

Ratios (%)
Depth-Height 7 84.1 3.68 78.9 90.2 84.6 6.06 78.0 95.3 1.0
15 78.0 4.25 71.4 87.6 80.5 5.83 73.8 91.2 .40
Height-Width 7 86.7 3.28 83.0 92.9 83.8 2.73 78.6 86.7 .10
15 92.4 3.07 88.6 96.8 87.2 3.79 80.6 91.9 .011*
Width-Depth 7 72.9 3.69 66.5 77.6 70.8 4.03 65.1 77.9 .31
15 72.0 3.99 67.5 78.7 70.1 4.80 64.9 78.7 .35

development of the dental arches and the facial skeleton, was
investigated in a previous study (Lux et al., 2003).
Measurements: Lateral View
In the lateral cephalograms (Fig. 2), landmarks were deter-
mined according to the definitions of Riolo et al. (1974). Mea-
surements made on the lateral cephalograms were corrected
using a constant correction factor of 0.9214 (Adams, 1963).
For a separate analysis of sagittal (depth) and vertical (height)
growth components, a coordinate system was used based on a
constructed horizontal defined by the sella-nasion-line minus
7 degrees and a perpendicular to that line through sella (Fig.
2). This coordinate system is often used in orthodontics for
the differentiation between horizontal and vertical treatment-
induced or growth-related components (Baumrind et al., 1976;
Kalra et al., 1989; Mogavero et al., 1997; Gallagher et al.,
1998; Mobarak et al., 2001; Kolodziej et al., 2002).
Measurement Error
Replicate (double) measurements on 20 PA cephalograms
and 20 lateral cephalograms were used for evaluating the mea-
surement error of the distances according to the formula of
Dahlberg (1940). The combined error of the method ranged
between 0.32 mm and 0.70 mm except for the following mea-

FIGURE 1 Landmarks used from tracing of posterioanterior radiograph

in depressed view. Zy 5 zygion-bizygomatic width. Zygion is the most
lateral aspect of the zygomatic arch (Martin and Saller, 1957; Major et
al., 1994); Zm 5 zygomaxillare-midfacial width. Zygomaxillare is topo-
graphically closely related to the most lateral and inferior aspect of the
maxillozygomatic suture (Martin and Saller, 1957); Ma 5 maxillare-max-
illary skeletal base width. Maxillare is the intersection of the lateral con-
tour of the maxillary alveolar process and the lower contour of the max-
illozygomatic process of the maxilla (Athanasiou et al., 1992; Raghavan et
al., 1994; Hsiao et al., 1997); Go 5 gonion-bigonial width. Gonion is the
most inferior, posterior and lateral point on the external angle of the man-
dible (Martin and Saller, 1957); Ag 5 antegonion-biantegonial width. An-
tegonion is the deepest point on the curvature at the antegonial notch
(Svanholt and Solow, 1977; Athanasiou et al., 1992; Major et al., 1994).
FIGURE 2 Tracing of lateral cephalogram showing the landmarks used,
with definitions according to Riolo et al. (1974). For a differentiation be-
tween sagittal and vertical growth components, a coordinate system was
used based on a constructed horizontal defined by the sella-nasion-line
minus 7 degrees and a perpendicular to that line through sella (vertical).
S 5 sella turcica; N 5 nasion; Ba 5 basion; Co 5 condylion; Ar 5 arti-
culare; Go 5 gonion; PTM 5 pterygomaxillary fissure, inferior; PNS 5
posterior nasal spine; ANS 5 anterior nasal spine; A 5 A point; B 5 B
point; Pr 5 prosthion (supradentale); Pg 5 pogonion; Me 5 menton.
308 Cleft PalateCraniofacial Journal, May 2004, Vol. 41 No. 3
surements in which the error was larger: mandibular height:
Co-Go(v): 1.08 mm and Co-Go: 1.17 mm; and midfacial width
(Zm-Zm): 1.04 mm.
Data Analysis
Descriptive statistics including mean, SD, and range were
calculated for all measurements (i.e., linear measurements and
ratios). Linear sagittal measurements marked by (h) were mea-
sured parallel to the horizontal reference line (S-N-line minus
7 degrees) and linear vertical measurements marked by (v)
were measured along the vertical reference line. A Wilcoxon
test was performed to test for sex differences between the ab-
solute sizes at 7 and 15 years in the male and female groups.
In addition, a Wilcoxon test was applied to identify significant
changes occurring during the total period of observation (i.e.,
7 to 15 years) separately for boys and girls. The significance
level was set at a 5 .05.
To be independent of absolute size, mean percentage in-
creases were calculated for each measurement relative to the
size at 7 years of age. The percentage increases during the
total period of observation and during the respective 2-year-
intervals were calculated. The four sections of each column in
the graphs depict the contribution of each 2-year interval to
the total percentage increase between 7 and 15 years (with all
the increases relative to the size at 7 years). The height of each
column represents the total percentage increase for each mea-
surement between 7 and 15 years of age.
To obtain insight into the growth of the maxillary-mandibular
bases, their absolute skeletal base lengths were also measured
without subdivision into horizontal and vertical growth com-
ponents. Finally, the ratios between certain facial dimensions
were depicted by means of growth curves displaying size versus
age to illustrate facial shape changes during development.
RESULTS
Table 1 shows the descriptive statistics of the various di-
mensions at 7 and 15 years of age and the mean percentage
increases between 7 and 15 years for the vertical, sagittal, and
transverse measurements. The p values indicate possible sex
differences with respect to absolute sizes at 7 and 15 years of
age. With respect to the statistical testing of the changes oc-
curring during the total period of observation (i.e., 7 to 15
years), all vertical, sagittal, and transverse measurements as
well as the skeletal base lengths showed in both sexes an sig-
nificant increase (p values not depicted).
Figure 3 illustrates the percentage increases separately both
for boys and girls and the whole facial skeleton, maxilla, and
mandible. Apart from that, the separate depiction of the in-
creases in each 2-year interval gives insight into their respec-
tive contribution to the total growth process between 7 and 15
years. In the facial skeleton taken as a whole, relative growth
increments were largest for vertical development (Fig. 3), es-
pecially for posterior face height (S-Go[v]) with an average
increase of 29.2% in boys and 22.4% in girls (Table 1). Per-
centage increases in facial depth and width (Fig. 3) ranged
between 14.1% and 20.6% (boys) and between 11.3% and
17.5% (girls). Among these measurements, the lower facial
depth (Ba-Pg[h]) showed the most pronounced development.
With respect to maxillary growth, relative increments were
most pronounced between 7 and 15 years in the vertical di-
rection along with considerably less growth in the width and
depth dimensions. The mandible showed marked differences
concerning the relative increments in all three planes of space.
Among the boys, ramus height (Ar-Go[v]) increased by 34.4%,
followed by a moderate increase in mandibular body length
(Go-Pg[h], 24.1% increase). The least growth was found in the
transverse dimension in which bigonial width increased by
only 17.6%. A similar growth pattern with smaller relative
increments was found among the girls (Fig. 3). In general, the
four sections of each column reveal that it is the percentage
increase in the last time interval of 13 to 15 years of age,
which is responsible for the sex differences as indicated by the
significant differences recorded at 15 years of age (Table 1).
Figure 4 illustrates the percentage increases for various mea-
surements as conducted separately for the three planes of space
and permits a comparison of the various anatomical regions
within the sagittal, vertical, and transverse directions. With re-
spect to sagittal growth, among the boys, the mandible shows
the most marked development, in particular S-Pg (h), followed
by the maxilla (S-Pr [h], S-A [h]) and the least sagittal devel-
opment in the anterior cranial base (S-N [h]). With regard to
vertical development (Fig. 4), it is apparent in both sexes that
the development of posterior facial height (S-Go [v]) surpasses
the increase in anterior face height (N-Me [v]). This marked
posterior development is the result of a pronounced increase
in mandibular ramus height, which showed the largest relative
increments of all variables. In the transverse measurements
(Fig. 4), relative increments in the various anatomical regions
were rather similar. In comparison with vertical increases,
transverse increments were relatively small, ranging between
15.4% and 18.6% among the boys and between 12.3% and
13.8% among the girls.
Figure 5 contrasts the various increments in skeletal base
lengths without differentiating between vertical and horizontal
growth components. Again it is obvious that the mandibular
body (Go-Pg) is characterized by a stronger percentage in-
crease than the maxillary skeletal base (PNS-A). The mandib-
ular ramus (Co-Go, Ar-Go) exhibits by far the largest per-
centage increase, the anterior cranial base (S-N) the smallest
relative growth.
Finally, in Figure 6, ratios among facial height, depth, and
width were depicted as indicators of change in facial shape. In
both sexes, the ratio facial height/facial width increases between
7 and 15 years by a statistically significant amount (p 5 .002
among boys, p 5 .008 among girls), confirming the relative
dominance of vertical development. Similarly, in the ratio facial
depth/facial height, the downward trend (decrease statistically
significant in both sexes with p 5 .002 [boys] and p 5 .008
[girls]) confirms a relative dominance of vertical growth when
compared with sagittal development. In both sexes, the ratio
 Lux et al., 3D ANALYSIS OF GNATHOFACIAL GROWTH INCREMENTS 309

FIGURE 3 Percentage increases in height, depth, and width dimensions within each anatomical region during the total period of observation and during
each 2-year-interval.

facial width/facial depth remains nearly constant during devel- DISCUSSION

opment, and the p values (p 5 .23 among boys, p 5 .38 among
girls) indicate no significant shape changes occurring during the In the present study, both articulare and condylion were used
total period of observation (i.e., 7 to 15 years). when measuring mandibular ramus length. As pointed out by
310 Cleft PalateCraniofacial Journal, May 2004, Vol. 41 No. 3

FIGURE 4 Percentage growth increases within each plane of space during the total period of observation and during each 2-year-interval.

Stickel and Pancherz (1988), in the absence of mouth-open
radiographs the condyle may be difficult to locate in lateral
cephalograms made in centric occlusion. This is supported by
the present study in which the distances Co-Go(v) and Co-Go
showed the largest measurement errors. Hence, it was reason-
able to endorse the findings by the additional use of articulare.
Stickel and Pancherz (1988) reported that, although articulare
may not be appropriate for analyzing growth at the individual
level, it is a suitable substitute for condylar landmarks when
analyzing groups of subjects as in the present study.
 Lux et al., 3D ANALYSIS OF GNATHOFACIAL GROWTH INCREMENTS 311

FIGURE 5 Percentage increases in absolute skeletal base lengths during the total period of observation and during each 2-year-interval.

3-D Growth Analysis of the Maxillary-Mandibular
Skeletal Regions
With respect to the paucity of studies and the differences
concerning landmark identification and methods used, e.g.
with or without magnification correction or radiographic ver-
sus direct anthropometric measurements, it is difficult to com-
pare the results of this study with previous investigations.
Singh and Savara (1966) and Savara and Singh (1968) inves-
tigated the 3-D maxillary development and found that absolute

FIGURE 6 Ratios between facial dimensions: growth curves showing size (in percent) versus age.
312 Cleft PalateCraniofacial Journal, May 2004, Vol. 41 No. 3
increases in the maxillary complex were most marked in
height, less so in length, and least in width. Also after adjusting
their data to show percentage increases as in the present study,
relative growth was most pronounced in maxillary height (N-
ANS). This agrees with the present study in which maxillary
growth is dominated by vertical increases ranging between
21.7% and 24.6% among the boys and between 15.7% to
21.8% among the girls, followed by depth and width mea-
surements with smaller percentage increases in both sexes.
Tracy and Savara (1966) and Savara and Tracy (1967) in-
vestigated mandibular growth and found that, among the boys
(Savara and Tracy, 1967), between 7 and 15 years, absolute
growth increments were largest for width (bigonial width, Go-
Go), followed by depth (body length, Go-Pg) and height (ra-
mus height, Co-Go). However, when their data are analyzed
using a proportional scale as was done in the present study,
percentage increases were most pronounced for ramal height,
which again agrees with the present findings. Among the girls,
between 7 and 15 years of age, Tracy and Savara (1966) found
the absolute increments in all three mandibular variables to be
within the range of 10.7 mm and 11.3 mm.
On the basis of percentage increase, however, by far the
strongest increase occurred in ramal height (23.6% increase
between 7 and 15 years, when compared with 15.8% for depth
and 13.9% for width). This dominance of ramal height growth
was also identified by Baughan et al. (1979), who recorded
the most pronounced pubertal peak in this mandibular mea-
surement. On the basis of PA cephalograms, Snodell et al.
(1993) compared growth increments in vertical and transverse
dimensions between 6 and 18 years of age. In particular among
boys, they found greater percentage increases for vertical rath-
er than transverse measurements. Similar to the present study,
between 6 and 18 years of age, the largest increases were
found for ramus height (more than 40% increase in boys),
followed by the upper and lower anterior face heights with
increases between 30% and 40% (boys).
Sagittal Development in the Various Facial Regions
A comparison of the various anatomical regions with respect
to their sagittal development revealed, during 7 and 15 years,
a stronger sagittal growth in the mandible than in the maxilla.
In the present study, among the boys, S-Pg(h) which includes
the bony chin increased most (20.8%), followed by S-B(h)
(16.9%); S-A(h) (11.9%) representing maxillary depth showed
the smallest increase. Nanda and Ghosh (1995) also found,
between the pterygoid vertical and pogonion, more percentage
increase than between the same reference line and B point.
According to Enlow (1982) and Bishara et al. (1984), this can
be attributed to the fact that during postnatal growth, in ad-
dition to the translation of the mandible, bone resorption is
dominant in the area of B point, whereas bone deposition oc-
curs in the chin area. Hence, the sagittal mandibular devel-
opment should be analyzed on the basis of both B point and
pogonion. Pogonion is also an important factor for the deter-
mination of facial profile (Nanda and Merrill, 1994).
Indices of Facial Shape
Meredith (1960) investigated indices of faciocephalic form
among girls and found that the index face depth/face width
remained nearly constant between 5 and 11 years (only a 0.3%
decrease). Although not fully comparable with respect to age
period and landmarks used, the present study revealed similar
growth tendencies with a nearly constant ratio face depth/face
width between 7 and 15 years of age. In the case of the ratio
face depth/face height, Meredith (1960) found between 5 and
11 years of age an average decrease from 88.9% to 85.0% in
girls. Also, in the present study, this ratio decreased from
84.6% (7 years) to 80.5% (15 years) among the girls pointing
to an increasing influence of vertical development. This facial
shape change toward greater vertical growth also became ob-
vious when the ratio face height/face width was considered,
which, according to Meredith (1960), increased by 3.6% be-
tween 5 and 11 years, similar to the present study, which found
a 3.4% increase between 7 and 15 years (girls).
In the present study, for many of the dimensions investi-
gated, in the time interval between 13 and 15 years, there was
greater growth in boys and less growth in girls. This is similar
to the results of Ursi et al. (1993), who found, using the Bolton
standards, that the maxillary and mandibular lengths were sim-
ilar in both sexes up to 14 years; thereafter they remained
relatively constant in girls and they increased in boys.
Limitations
Although the Belfast Growth Study includes the longitudinal
records of 300 subjects, only 18 subjects fulfilled the inclusion
criteria of a Class I relationship with good occlusion and align-
ment. Nevertheless, only subjects with good occlusion were
selected in the present study because previous investigations
have shown that the presence of malocclusion such as open
bites or Class II malocclusions can affect the transverse di-
mensions (Staley et al., 1985; Buschang et al., 1994; Tollaro
et al., 1996; Lux et al., 2003). Malocclusion can also affect
the vertical development (Hunter, 1967; Adams and Kerr,
1981; Toutountzakis and Haralabakis, 1991; Hsu, 1998) and
the sagittal dimensions (Berg, 1986; Bishara et al., 1997). To
ensure that the present findings were not the result of random
variation resulting from a small sample size, all percentage
increases were additionally calculated for a larger Class I sam-
ple of the same origin without exclusion of Class I malocclu-
sions (Table 1, percentage increases in brackets). Although in
this larger sample, the percentage increases were slightly
smaller in many dimensions than the increases for the Class I
good occlusion cases (e.g., in ramal height), the larger Class I
sample supported all the general conclusions made about facial
growth. Finally, consideration should be given to the large
variation in facial growth, i.e., that, as pointed out by Nanda
and Ghosh (1995), mean growth changes provide only a group
pattern, but individual growth patterns may not necessarily fol-
low the group pattern.
 Lux et al., 3D ANALYSIS OF GNATHOFACIAL GROWTH INCREMENTS
CONCLUSIONS
Between 7 and 15 years of age, in both the facial skeleton
and the maxilla, the percentage increases in growth were most
pronounced in the vertical dimension when compared with
sagittal and transverse changes. In the mandible, in both sexes,
by far the largest percentage increases were found for the ver-
tical growth of the ramus, followed by the percentage increases
in body length. The smallest increases were found for man-
dibular width.
In the sagittal dimension, development was more pro-
nounced in the mandible (pogonion more than B point) than
in the maxilla (A point). With respect to vertical growth, the
percentage increases in the posterior face height exceeded the
relative increments in anterior face height.
When facial shape changes were examined between 7 and
15 years of age, the ratio facial height/facial width increased
and the ratio facial depth/facial height decreased in both boys
and girls, which points to an age-related increase in vertical
development.
Acknowledgments. We wish to express our thanks to the German Orthodontic
Society (Deutsche Gesellschaft fur Kieferorthopadie) for providing financial
support for this project.
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