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Growth of the Face and Dental Arches

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DOI: 10.1016/B978-0-323-05724-0.50029-1

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CHAPTER
25
Growth of the Face and Dental Arches
▲ Donald J. Ferguson

CHAPTER OUTLINE

THE NATURE OF GROWTH Facial Growth Emulates General Similar Stage Sequencing
Basic Concepts of Human Growth Somatic Growth Ideal Dental Arch Pattern
Craniofacial Growth Principles GROWTH AND PATTERN Tooth Size/Arch Size Ratio as Pattern
Basic Concepts of Craniofacial OF OCCLUSION Determinant
Growth Consistency in Pattern Develop- Computation of Tooth Size/Arch
CRANIOFACIAL PATTERN ment Size Balance
Ideal Paradigms for Dentofacial Primary Dentition Terminus Compensations in Dental Arch
Pattern Opposing First Molars at Initial Development
GROWTH AND FACIAL PATTERN Contact Maintenance of Overall Pattern
Consistency in Pattern Maturation Ideal Static Occlusion Pattern Effect of Environmental Factors on
Ideal Frontal Facial Pattern Maintenance of Overall Pattern Dental Arch Pattern
Ideal Facial Profile Pattern GROWTH AND DENTAL ARCH SUMMARY
Maintenance of Overall Pattern PATTERN

H
istorically, patient care in medicine and den- moderate detail at the cellular level but is only beginning
tistry has been oriented toward the elimination to be described at the level of protein and peptide produc-
of disease and the resolution of debilitating tion.2 For this reason, this chapter discusses dentofacial
conditions. Competent care in dentistry today growth and development at a macroscopic level, from the
includes issues related not only to disease and functional perspective of the practicing clinician.
disability but also to the patient’s well-being. The appear-
ance of the face and dentition is recognized with increas-
ing frequency as a major factor in human psychosocial
THE NATURE OF GROWTH
health.1 Growth refers to an increase in anatomic size. Three pa-
This chapter is about dental and facial malocclusion— rameters commonly used in growth literature to assess
the recognition and anticipation of malocclusion during craniofacial size increase are magnitude, velocity, and
the growing years. The dentofacial pattern can be easily direction. Magnitude refers to the linear dimension overall
and accurately assessed at chairside. In clinical terms, or the dimension of a part. Direction means the vector of
pertinent growth issues are discussed in relation to how size increase as might be described on a three-dimensional
growth changes the pattern of the face, occlusion, and coordinate system. Velocity is defined as the amount of
dental arches. Knowledge of pattern appraisal and growth change per unit of time.
can be integrated into efficacious clinical decisions about Size increase is typically illustrated in one of two
a young patient. This chapter enhances the reader’s diag- ways. When growth is measured periodically and mea-
nostic and treatment planning skills with reference to surements are plotted as percentages of total growth, the
malocclusion in the pediatric patient. result is a cumulative or distance curve (Fig. 25-1). A hu-
The clinician treating malocclusion is primarily inter- man postnatal cumulative curve is characterized by
ested in the growth and development of craniofacial tis- two plateaus and one period of accelerated growth. A
sues as they result in facial and dentoalveolar pattern. Our second method of graphically demonstrating growth
understanding of how genes express their influence on change is by use of an incremental or velocity growth
dentofacial pattern and how environment influences gene curve (Fig. 25-2). A velocity curve plots growth incre-
expression has advanced at a remarkable pace. How mo- ments (e.g., centimeters per year) as a function of time.
lecular mechanisms are implicated at a clinically relevant Characteristic of an incremental human growth curve is
level, however, has yet to be elucidated. Mao pointed out rapid accelerating prenatal growth, rapid decelerating
that what we understand about induced treatment effects postnatal growth for the first 2 or 3 years, and a period
at the macroscopic phenotype level has been described in of relatively slow incremental growth during childhood

510
 Chapter 25 ■
Growth of the Face and Dental Arches 511

100 reference to “ideal” facial, occlusion, and dental arch

paradigms.
Growth is a complex phenomenon. There is a large
90
volume of information available on craniofacial growth.
Percent growth completion

Moreover, there is little consensus in the literature as to

80 which data or combination of data is most useful to the
practitioner committed to making competent decisions
70
about direct patient care. In light of these prevailing cir-
cumstances, the following concepts and principles about
craniofacial growth are presented in a way that should be
60 clinically useful and difficult to refute. These postulates
are derived and adapted in part from widely held tenets
50 about general human growth and development presented
by Valadian and Porter.3 The discussion of general cranio-
facial principles is followed by application of the princi-
40 ples to three areas of craniofacial growth: the face, occlu-
3 4 5 6 7 8 9 10
Age (years) sion, and dental arches. The goal of this chapter is to
integrate growth principles in patient appraisal to en-
Figure 25-1 Cumulative (distance) growth curve.
hance diagnostic and treatment planning efficacy.
BASIC CONCEPTS OF HUMAN GROWTH
6 1. Growth disposition is similar for all healthy individu-
als. Healthy individuals go through growth stages that
5.5 are the same for everyone, according to Valadian and
Porter.3 The prenatal period, from conception to birth,
5 averages 40 weeks in length. Infancy includes the first
2 years of life after birth, and childhood ranges from
Millimeters per year

2 to 10 years for girls and 2 to 12 years for boys. The

4.5
length of adolescence is the same for both sexes but
comprises different years, 10 to 18 years for females
4 and 12 to 20 years for males (Fig. 25-3).
Each growth stage is unique. Rate of size increase is
3.5 most remarkable during the prenatal period and declines
substantially during infancy. Generally, growth velocity
3 plateaus during childhood and increases again during
adolescence. All healthy individuals experience these
2.5 growth cycles, although the various basic tissues and
3 4 5 6 7 8 9 10 body parts are affected differently.
Age (years)
2. Different body parts increase in length at different
Figure 25-2 Incremental (velocity) growth curve. rates. From birth to adulthood, the head increases
about twice in length, the trunk about three times, the
arms about four times, and the legs about five times.
followed by growth acceleration for 2 or 3 years during Different parts of the body grow at different times and
pubertal adolescence. at different rates. For example, the head increases in
Three observations are central to a clinically relevant size very early in life, and its rate of increase is very
understanding of growth. First, growth implies change, a rapid during the prenatal and early postnatal periods.
transition from one condition to another. This broader 3. The overall potential for growth is determined primar-
meaning of growth helps define growth as a concept. ily by intrinsic or genetic factors. Genetic endowment
Conceptual growth refers to a passage from one anatomic is the main determinant of growth potential. Intrinsic
form (i.e., size and shape) to another. Transitions in func- factors are also those conditions and events that occur
tional stage or activity refer to development. Develop- from conception to birth. Maternal nutrition or dis-
ment, in biologic literature, usually means increased ease can modify child development before birth. Some
specialization or a higher order of organization and also tissues tend to demonstrate high genetic predilection.
connotes an interaction of functioning parts. Develop- Neural and primary cartilage tissue growth seems ge-
ment means increased organization or specialization of netically predisposed in size and growth timing. Tooth
functioning (physiologic) parts. size appears to be under strict genetic control.4,5
Growth is more readily understood when a physical 4. The extent to which an individual attains his or her
pattern is used to describe the effects of growth change. potential for growth is determined predominately by
Growth, by nature, is a relational concept. Without refer- extrinsic or environmental factors. Extrinsic factors in-
ence to a structural model, growth has little clinical clude all postnatal environmental conditions, such as
utility or meaning. This chapter discusses growth with nutrition, illness, exercise, and climate. Environmental
512 Chapter 25 ■
Growth of the Face and Dental Arches

12

10
Females
Males
8
Increments per year

0
-2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Age (years)

Childhood–Female Adolescence-Female
Prenatal

Infancy

Childhood–Male Adolescence-Male

Figure 25-3 Incremental growth curve illustrating growth stages.

factors of particular interest to the dental clinician are 140

oral habits, pathology, caries, premature loss of teeth,
and metabolic disease. In the absence of detrimental 120
extrinsic factors, the dentofacial complex will tend to
Percent growth completion

attain its maximum potential in growth. 100

CRANIOFACIAL GROWTH PRINCIPLES
80
1. The basic tissue types and functioning spaces that com-
prise the head and face are subject to growth timing
60
differences. The human head is composed of a variety Tonsils and
of basic tissue types; the relative percentage of these adenoids
types, at any given age, depends on timing of their 40 Brain
growth. Neural tissue completes its growth at an early Head muscles
age. By contrast, general somatic tissues, such as mus- 20
cle, bone, and connective tissue, mature at a slower
rate. Neural tissue has attained about 60% to 70% of 0
adult size by birth and its growth is about 95% com- 0 2 4 6 8 10 12 14 16 18
Age (years)
pleted by middle childhood. This is in sharp contrast to
growth of other craniofacial soft tissues (Fig. 25-4). Figure 25-4 Cumulative growth curve for craniofacial neural,
Muscle tissue is only 40% to 45% of its adult size by muscle, and lymphoid tissues. (From Linder-Aronson S,
birth, and its growth is approximately 70% completed Leighton BC. A longitudinal study of the development of
by 7 years of age. The size of craniofacial lymphoid the posterior nasopharyngeal wall between 3 and 6 years of
age, Eur J Orthod 5:47-58, 1983.)
tissue (tonsils and adenoids) is about 125% of adult size
at 5 years of age and decreases gradually to adulthood.
Linder-Aronson and Leighton have shown that func- contrast, primary cartilage of the head and face has
tional pharyngeal space increases in relation to achieved approximately 75% of adult size by birth and
decreased tonsillar-adenoid mass.6 95% by 7 years of age (Fig. 25-5). The small amount of
Growth timing of skeletal tissues also demonstrates primary cartilage remaining in the head and face after
variation. Craniofacial bone growth is about 45% com- middle childhood, however, continues to grow through
pleted by birth and 70% completed by 7 years of age. In puberty.
 Chapter 25 ■
Growth of the Face and Dental Arches 513

and space is required for the brain and central and pe-
ripheral nervous system expansion. Respiration and de-
100
glutition are also essential to life and require develop-
Percent growth completion

ment of nasal, pharyngeal, and oral spaces. Sight,

olfaction, hearing, and speech are important but less
80 critical craniofacial functions that also require develop-
ment of functioning spaces for operation.
According to Moss and Salentijn, a likely craniofacial
60
growth scenario of functioning space development in
Bone head and facial patterns includes the following sequence
Primary of events.13 Rapid size increase of the brain during pre-
cartilage natal and early postnatal life thrusts the calvarial bony
40 plates outward and the midface forward. Birth invokes a
set of functional processes previously not essential for
life (i.e., breathing and swallowing). Repositioning of
20 the mandible and tongue takes place to ensure patency
0 2 4 6 8 10 12 14 16 18 20 22 of nasal-oral-pharyngeal spaces. The mandible is de-
Age (years) pressed and thrust forward for these functions to be
Figure 25-5 Cumulative growth curve for craniofacial bone supported and maintained.
and primary cartilage. 3. Mandibular condylar cartilage, craniofacial sutures,
and appositional-resorptive bone change facilitate
pattern growth of the head and face. Koski identifies
2. Growth of primary cartilage and functioning spaces the mandibular condyles, once considered growth
has a directing influence on craniofacial pattern centers with directive capacity, as an adaptive growth
change. Primary cartilage is a tissue of particular inter- mechanism.14 Cartilage found at the head of the con-
est to craniofacial growth theorists. According to En- dyle is a secondary, fibrous cartilage and differs sig-
low and Hans, it is singular in form; has the capacity nificantly from the primary, growth plate cartilage
to grow from within (interstitial growth); is pressure considered to be under high genetic control.15 During
tolerant, noncalcified, flexible, and nonvascular; and craniofacial growth, the mandible is repositioned
does not require a covering nutrient membrane for continuously to its best functional advantage. Repos-
survival.7 Primary cartilage found in the head and face turing alters the anatomic position of condyle to
is identical to the growth plate cartilage of long bones. glenoid fossa. Compensatory growth of secondary
Scott contends that primary cartilage is genetically condylar cartilage is one mechanism that facilitates
predisposed, acts during growth as an autonomous maintenance of mandibular position.
tissue, and is able to directly influence the craniofacial Koski also points out that craniofacial sutures are im-
pattern.8 portant growth sites that serve to facilitate calvarial and
Sperber documents that primary cartilage first appears midface growth.14 Calvarial sutures close by 5 years of
in the head during the fifth week prenatally.9 By the age, but some facial sutures remain patent through pu-
eighth prenatal week, a cartilaginous mass called the berty. Craniofacial bones are thrust apart by primary
chondrocranium is present and is the precursor to the adult cartilage and functioning space increases. Sutures enable
cranial base and nasal and otic structures. By middle osseous deposition at bone edges, which allows bones of
childhood, most primary cartilage is replaced by bone in the face and skull to adapt.
a process called endochondral bone formation. Enlow and Hans have shown that bone, unlike primary
The overall growth-directing influence of primary car- cartilage, is subject to environmental controls.16 Bone
tilage on craniofacial pattern change is most profound may assume many forms during growth; it is pressure
in early life. By birth, cartilage comprises a substantial sensitive, calcified, vascular, and relatively inflexible, and
portion of the nasal septum and cranial base. Interstitial requires a covering membrane for survival. The craniofa-
expansion of primary cartilage probably has a direct in- cial skeleton increases in size by way of surface addition
fluence on the position of the maxilla by way of the only and increases in shape through differential apposi-
septopremaxillary suspensory ligament, as suggested by tional-resorptive bone growth. This differential growth
Latham10 and later contended by Gange and Johnston.11 process accounts for a considerable amount of size in-
The maxilla is most likely thrust downward and forward crease after middle childhood.
during infancy and early childhood. The contributions to Growth theorists Moss and Salentijn12 believe that
midface growth of primary cartilage is greatly diminished the general somatic tissues (i.e., bone, muscle, and con-
after middle childhood. nective tissue) demonstrate growth change as a conse-
The development of functioning spaces has also re- quence of supporting the functioning operations of the
ceived considerable attention as a key concept among head. Indeed, the research evidence of Linder-Aronson17
craniofacial growth theories.12 The head carries out nu- and of Harvold and associates18 are convincing in that
merous functions. Some functions are more essential bone and muscle, as basic tissues, are adaptive and com-
than others, but all require the development and mainte- pensatory in nature. Understanding bone and muscle
nance of spaces. Neural integration is a critical function, growth may come through understanding the temporal
514 Chapter 25 ■
Growth of the Face and Dental Arches

development of functioning spaces and the effects of in- calvaria and forehead compared with the adult be-
terstitial cartilage expansion on surrounding tissues. cause growth of the neural tissue takes place earlier in
4. Growth of the head and face tends to demonstrate life than facial growth.
relative equivalency. Humans tend to grow with rela- Size increase of the face and calvaria in the three spa-
tive consistency. A percentile growth chart is a valu- tial planes is a differential growth process. Scott,19 Mere-
able instrument for assessing growth consistency over dith,20 and Ranly21 have contributed to an understanding
a time period (Fig. 25-6). Percentile charts are custom- of this process. By birth, the cranial height dimension has
arily divided into the following seven percentile levels: attained about 70% of its adult status; cranial width,
97th, 90th, 75th, 50th, 25th, 10th, and 3rd. Healthy 65%; and cranial length or depth, 60% (Fig. 25-7). In
children tend to maintain a similar percentile level contrast, only 40% of facial height and 45% of facial
through successive stages of development. Deviations length (depth) has been achieved by birth. Face width
during growth of more than two percentile levels may (i.e., bizygomatic and bigonial), on the other hand, has
indicate developmental problems, such as illness or attained about 60% of adult stature. Growth in face width
disease. actually falls between the classic neural and general
Attributes (craniofacial parts) that are structurally re- somatic growth curves.
lated also maintain a consistent relationship throughout After birth, a pattern in facial growth timing emerges.
successive stages of growth after infancy. Enlow and Hans16 The anterior cranial base completes most of its growth
identify the dental arches of the maxilla and mandible during infancy and early childhood, but frontal and nasal
as an example of a structural part-counterpart relation- bones continue outward expansion through appositional-
ship. An Angle class II skeletal pattern at 3 years of age is resorptive bone growth.22 Growth magnitude and dura-
maintained into adulthood without corrective therapy. tion are greater for the anterior maxilla than for the
Both dental arches in healthy individuals tend to increase forehead but less than for the anterior mandible. The
in size at about the same rate. Hence, balanced or equiva- posterior face demonstrates the greatest incremental
lent growth tends to maintain architecturally related growth during late puberty.
structures of any craniofacial pattern that is present after 2. Differences in growth size, direction, velocity, and tim-
2 years of age. ing are observed among individuals. Bergersen has
also noted large variations in growth patterns among
BASIC CONCEPTS OF CRANIOFACIAL individuals and has shown that any measured attri-
GROWTH bute will demonstrate a range of expression about a
1. Different parts of the craniofacial complex grow at dif- central tendency.23 Incremental growth curves for
ferent times. The head takes on appearance character- healthy males and females will demonstrate the same
istics unique to each particular growth stage. Different general disposition but may show marked differences
parts of the face experience differences in growth tim- in maturation timing (Fig. 25-8). Generally, females
ing as well. The infant has a disproportionately large mature 2 years earlier than males, but Valadian and

100
135 97th
90th
75th 90
Percent growth completion

125 50th
25th 80
10th
115 3rd
Millimeters

70

105 Cranial width

60 Cranial height
Cranial depth
95 Facial width
50 Facial height
Facial depth
85 40

75 30
2 4 6 8 10 12 14 16 18 20 0 2 4 6 8 10 12 14 16 18
Age (years) Age (years)
Figure 25-6 Cumulative growth chart for male face height Figure 25-7 Cumulative growth curve for calvaria and
(hard tissue nasion to menton), illustrating seven percentile face in width, height, and depth. (From Scott JH. The
levels. • Relatively normal growth; ■ deviation of several growth of the human face, Proc R Soc Med 47:5, 1954;
percentile levels during growth, suggestive of abnormalcy. Meredith HV. Changes in form of the head and face dur-
(From Broadbent BH, et al. Bolton standards of dentofacial ing childhood, Growth 24:215-264, 1960; Ranly DM. A
developmental growth. St Louis, 1975, Mosby.) synopsis of craniofacial growth. New York, 1980,
Appleton & Lange.)
 Chapter 25 ■
Growth of the Face and Dental Arches 515

12 A standard deviation (SD) of ⫾1 includes about 68% of

11 the entire population; ⫾2 SD and ⫾3 SD are equivalent to
approximately 95% and 99% of the distribution, respec-
10
tively. The mean values and SDs for a normative popula-
9 tion are invaluable aids in describing a patient’s condi-
Increments per year

8 tion. By comparing a patient’s value to a population

value for the same trait, the clinician can make state-
7
ments about relative largeness or smallness. Generally,
6 measurements beyond ⫾2 SD are considered clinically
5 important because those values fall outside 95% of the
population on which the normative value is based.
4
In the remainder of this chapter, references are made
3 Early female
to craniofacial growth principles and concepts in discuss-
Early male ing growth of the face, occlusion, and dental arches.
2
Late female
1 Late male
0 CRANIOFACIAL PATTERN
6 3 10 12 14 16 18 20 22
Age (years) In clinical assessment and treatment planning for the
young patient, information about growth is often not
Figure 25-8 Incremental growth curves for early- and late-
considered to the degree that it should be. Craniofacial
maturing males and females.
growth issues can be made more central to patient care
concerns when a physical model is used to help visualize
Porter have indicated that variations are so great that growth effects. For this reason, a particularly strong effort
an early-maturing boy may mature earlier than a late- is made here to define physical craniofacial pattern.
maturing girl.3 Males tend to grow larger in size than There are two methods commonly used in dentistry to
females. gather information about craniofacial pattern. One
3. The heads and faces of no two humans are exactly the method is to examine the patient physically at chairside.
same. Brodie pointed out that no two humans are ex- Information collected in this fashion is based on criteria
actly the same.24 This fact is no more clearly evident contrived and established in the practitioner’s mind. The
than when one compares, at any given age, a mea- second method is to analyze dental records. Historically,
sured attribute shared by healthy individuals. Most cephalometric analysis has been a particularly useful tool
attributes have a range of expression that can be for collecting objective information about craniofacial
graphically illustrated by a normal distribution curve patterns. Generally, the patient’s radiographic values
(Fig. 25-9). measured on the cephalogram are compared with norma-
If the same attribute was measured in a population of tive values derived from a population database. In this
individuals, the most frequently occurring value (mode), way, degrees of normalcy can be estimated by the clini-
middle value in the series (median), or arithmetic average cian. One database is unique in its composition in that
of all the measured values combined (mean) would repre- only individuals presenting with optimal or ideal cranio-
sent the central tendency of the population. Central facial pattern were included in the study.25 This unique
tendency is often referred to as normalcy. Another way to conceptual approach to defining craniofacial pattern en-
describe attribute distribution is by using percentile ables the practitioner to make assessments about patient
equivalents. The 50th percentile indicates the center of optimality. Patient-measured values are compared with
the distribution, the 25th percentile the lower one fourth, values from cephalograms that have relatively ideal pat-
and so on. terns. Cephalometric analysis is discussed in Chapter 26.
A third statistical parameter often used in growth lit- Darwis and colleagues suggest that using a combination
erature to indicate distribution is the standard deviation. of methods, such as three-dimensional facial morphom-
etry and Fourier analysis, can provide a more comprehen-
50
sive knowledge of growth and development of craniofa-
cial structures and thus may allow improved prediction
Number of cases

of clinical outcomes.26 Fourier analysis is a mathematical

curve-fitting procedure that can represent boundaries so
25 that the outlines of objects can be addressed.
IDEAL PARADIGMS FOR DENTOFACIAL
PATTERN
0
-4 -3 -2 -1 0 1 2 3 Standard Standards for chairside facial appraisal have been offered by
deviations Ackerman and Proffit,27 Angle,28 Bell and colleagues,29
0.1st 2nd 16th 50th 84th 98th 99.9th Percentile Cox and van der Linden,30 Lucker and coworkers,1 and
equivalents Patterson and Powell.31 Most of these physical appraisal
Figure 25-9 Normal distribution curve illustrating standard models refer to the adult face. Horowitz and Hixon32
deviations and percentile equivalents. describe idealized facial pattern as “the way things ought to
516 Chapter 25 ■
Growth of the Face and Dental Arches

be.” Models available for examining the face espouse

an assessment of proportion, balance, and harmony—
concepts that help define overall facial attractiveness. The
concept of an ideal face can be a useful clinical tool if it is
used properly and its limitations are acknowledged. The
first limitation is the fact that an ideal has little or no bio-
logic basis. Biologic data can neither refute nor support the
contention that the face should be ideal. Second, faces do
not need to be ideal to work properly; ideal pattern, for the
most part, has little connection with physiologic function.
Third, an ideal model is simply a mental construct, a fic-
tion. The words ideal paradigm mean “perfect example.”
A perfect example can, on the other hand, be a power-
ful diagnostic and treatment-planning tool. The patient’s
facial pattern can be compared with criteria for idealness,
the differences noted, and hence a problem list con-
structed. Criteria for an ideal face can help organize a vast
array of information that is readily available to the clini-
cian through physical observation. An ideal facial para-
digm can serve as a treatment planning tool as well.
Although the concept of an ideal face is fictitious and
biologically unsupported, it can serve as a guide by pro- Figure 25-10 Graphic illustration of facial profile flattening
viding an example toward which treatment may be from 6 years of age (solid line) to 18 years of age (broken line).
directed. Ideal paradigms for dental occlusion and dental
arch pattern are also represented in dental literature;
good examples may be found in the works of Angle,28
IDEAL FACIAL PROFILE PATTERN
Andrews,33 and Roth.34 The purposes served by these Use of a reference plane is very helpful for evaluation of
paradigms are the same as for ideal facial models; they are the facial profile at chairside. The Frankfort horizontal
powerful diagnostic and treatment-planning aids. plane is an anthropometric reference line frequently used
for analysis of the lateral face. It is defined by Farkas as
the superior limit of the external auditory meatus and
GROWTH AND FACIAL PATTERN the palpated border of the infraorbital bony rim.36 A sec-
ond reference line constructed perpendicular to the
CONSISTENCY IN PATTERN MATURATION Frankfort horizontal plane and through the glabella
Following birth, the face increases in size to a greater ex- (FHP) has been used in lateral profile assessment by Legan
tent than does the calvaria. Bell and associates propose and Burstone.37
that, by adulthood, the ideal face should be equally pro- The ideal profile pattern for a 7-year-old child might
portioned in forehead, midface, and lower face heights.29 include the following criteria (Fig. 25-12):
Enlow demonstrated that the facial profile flattens as the 1. Chin 5 mm behind FHP
face ages. Nose and chin become more prominent, and 2. Most anterior aspect of lower lip on FHP
lips become less pronounced35 (Fig. 25-10). Every healthy 3. Most anterior aspect of upper lip 5 mm ahead of FHP
individual, regardless of the overall craniofacial pattern, 4. Nasolabial angle of 100 degrees
experiences profile flattening and face height increases 5. No more than 2 mm lip separation when relaxed
relative to cranium.
MAINTENANCE OF OVERALL PATTERN
IDEAL FRONTAL FACIAL PATTERN The overall pattern presented by the individual at an
Criteria for facial idealness are age dependent. Because early age will be maintained into adulthood. Although
the face elongates and the profile becomes less convex every individual experiences profile flattening and fa-
with maturity, ideal criteria appropriate for the adult face cial elongation as the face matures, Enlow and col-
would not necessarily apply to the younger face. The leagues demonstrated that the magnitude of these
ideal frontal facial pattern for a 7-year-old child might changes is not great enough to offset disharmonies in
include the following criteria (Fig. 25-11): overall facial structure.38 Discrepancies between the po-
1. Right and left face halves are symmetrical. sition of the maxilla and mandible persist throughout
2. Glabella (midpoint between eyebrows) to subnasale life unless clinical therapy is employed to rectify the
(point where columella merges with upper lip) equals disharmonies.
subnasale to menton (inferior aspect of chin). At chairside, disharmony between the maxilla and the
3. Subnasale to lower border of upper lip represents one- mandible can be simply and readily identified. A list of
third the distance from subnasale to menton. differences can be formulated by comparing the patient’s
4. Upper central incisor edge is 2 mm inferior to lower facial measurements with the criteria of an ideal face. The
border of upper lip. differences serve as a patient problem list. Adding average
5. Alar base width equals inner canthal width. growth change (i.e., magnitude, direction, and velocity)
 Chapter 25 ■
Growth of the Face and Dental Arches 517

Figure 25-11 Ideal frontal facial pattern for a 7-year-old child. Figure 25-12 Ideal profile facial pattern for a 7-year-old child.

to the pattern presented by the individual will give an Correction of facial imbalance in the child is achieved
estimate of how facial patterns will look at a later age. through clinical manipulation of the means by which
This growth scheme is known as a mean-change-expansion adaptive, compensatory facial growth occurs. Some su-
scheme.32 Balbach demonstrated it to be the most useful tures of the upper face remain patent into adolescence.
to predict the effects of growth on facial pattern.39 The Application of forces through orthopedic headgear, con-
mean-change-expansion scheme is useful for evaluation trolled in direction and amount, can result in an altera-
of almost all patients routinely seen in the dental office. tion of maxillary growth direction and ultimately of
Balanced or average growth affecting all aspects of the maxillary position. Also maxillary transverse size can be
head and face relatively equally, however, cannot be as- increased by judicious expansion of the palatal suture.
sumed for all patients. The heads and faces of individuals The secondary cartilage of the mandibular condyle re-
who have some craniofacial congenital anomalies, hypo- mains responsive to mechanical stimulation throughout
plastic defects, or acquired deformities that alter primary life, but appositional response of this fibrocartilage de-
or compensatory craniofacial growth mechanisms do not creases with age, as shown by McNamara and Carlson.40
grow in a typical manner. Facial bones respond to changes in microenvironmental
Because growth change in healthy children affects the stress and strain by changing form. Patterns of osseous
face in a relatively consistent and predictable way, deposition and resorption can be altered by using appli-
the key to facial diagnosis and treatment planning is the ances that carefully load bone with physiologically com-
clinician’s ability to identify and diagnostically describe patible biomechanical forces.
facial pattern. Identification of balanced, proportional Successful treatment of a child with facial imbalance
facial pattern, as well as recognition of facial imbalance, secondary to mandibular retrognathia, for example, in-
should be routine during patient assessment. The use of volves manipulation of several growth mechanisms.
criteria related to ideal facial pattern can be helpful. Mandibular anterior repositioning with a functional
The goal in treating facial imbalance in children is to appliance probably affects many sites. Graber and Swain41
establish architectural balance in the facial pattern. If cor- believe that modification of the dentofacial complex
rective measures include compensation for the effects occurs by the following means:
from treatment rebound or relapse, the facial pattern 1. Condylar growth (secondary cartilage growth)
established by therapy will be maintained. As the face 2. Glenoid fossa adaptation (apposition-resorption bone
continues to grow and increase in size, all structurally growth)
related parts of the treated face will undergo relative 3. Elimination of functional retrusion
growth equality. 4. More favorable mandibular growth direction
518 Chapter 25 ■
Growth of the Face and Dental Arches

5. Withholding of downward and forward maxillary arch 5 mm relative to the lower anterior gum pad.42 The upper
movement (apposition-resorption bone growth) anterior gum pad usually overlaps (overbite) the lower
6. Differential upward and forward eruption of lower anterior pad by about 0.5 mm. In the first 6 months of
buccal segment (apposition-resorption bone growth) postnatal life, there is marked palatal width increase, and
7. Orthopedic movement of maxilla and upper dentition the overjet decreases rapidly.
(maxillary suture system growth)
PRIMARY DENTITION TERMINUS
FACIAL GROWTH EMULATES GENERAL By 3 years of age, the occlusion of 20 primary teeth is
SOMATIC GROWTH usually established. The relationship of the distal termi-
The degree to which the facial pattern can be altered nal planes of opposing second primary molar teeth can
through biomechanical therapy depends on the amount be classified into one of three categories (Fig. 25-14).
of growth potential remaining. In general, the magni- A flush terminal plane (flush terminus) means that the
tude of facial pattern alteration possible is inversely anterior-posterior positions of the distal surfaces of
proportional to age; the older the individual, the less opposing primary second molars are in the same vertical
the facial pattern can be therapeutically modified. The plane. A mesial-step terminus is defined as a lower second
opportunity to alter compensatory, adaptive growth primary molar terminal plane that is mesial to the maxil-
mechanisms is also greater in a rapidly growing indi- lary primary terminus. Distal-step terminal plane is de-
vidual. The adolescent growth spurt is characterized by scriptive of the situation in which the mandibular second
increased growth velocity at about 10 to 12 years of age primary molar terminus is distal to the upper second pri-
for girls and 12 to 14 years of age for boys. The maxi- mary molar terminus.
mum velocity or peak height velocity of growth is at- Statistical studies of primary terminal plane status re-
tained approximately 2 years after pubertal onset. Cu- port that 49% of the time, the terminal plane of the lower
mulative facial growth closely parallels general somatic
growth (Fig. 25-13). Analysis of skeletal hand develop-
ment can be helpful in estimating general skeletal DISTAL- INITIAL FINAL
maturation and, hence, facial skeletal maturation. It is STEP CONTACT OCCLUSION
relevant to evaluate a child’s maturity in direct relation
to the child’s own pubertal growth spurt to assess
whether maximum pubertal growth is imminent, has always always
been reached, or has been passed.

GROWTH AND PATTERN OF OCCLUSION

CONSISTENCY IN PATTERN DEVELOPMENT
FLUSH
Usually, no teeth are clinically visible at birth. Leighton
has shown that the upper anterior gum pad (intercuspid
width) is typically wider than the lower anterior pad, and
the upper anterior gum pad protrudes (overjet) about

110

100 MESIAL-
STEP
Percent growth completion

90
always
80

70
Figure 25-14 Graphic illustration of permanent first molar
60
occlusion development. Outlined crown images represent
Neural
three terminal plane relationships of primary second molars
50 Facial at about 5 years of age. Darkened images represent various
Somatic permanent first molar relationships at initial occluding con-
40 tact (about 61⁄2 years of age) and at full occlusion contact
(about 12 years of age). (From Arya BS, et al. Prediction of
30 first molar occlusion, Am J Orthod 63:610-621, 1973;
0 2 4 6 8 10 12 14 16 18 20 22 Carlsen DB, Meredith HV. Biologic variation in selected
Age (years) relationships of opposing posterior teeth, Angle Orthod
Figure 25-13 Cumulative growth curves for neural, facial, 30:162-173, 1960; Moyers RA. Handbook of orthodontics,
and general somatic tissues. 3rd ed. Chicago, 1973, Mosby.)
 Chapter 25 ■
Growth of the Face and Dental Arches 519

primary second molar is mesial to the upper terminus The major difference between ideal adult and child
(mesial step); the lower terminus is flush with the upper occlusions is the teeth present. By 7 years of age, the pri-
terminus 37% of the time; and the distal-step primary mary central and lateral incisors have been or are in the
terminus is seen in approximately 14% of cases. These process of being replaced by their permanent successors,
data are derived from studies reported by Arya and associ- and the permanent first molars have already erupted. The
ates43 and by Carlsen and Meredith.44 primary dentition remaining usually includes the canine
and first and second molars of both arches. Criteria for
OPPOSING FIRST MOLARS AT INITIAL ideal dental occlusion for a 7-year-old child might in-
CONTACT clude the following:
The permanent first molars are clinically visible at about 1. Class I molar and canine interdigitation
6 years of age and are the first permanent teeth to emerge. 2. 2-mm anterior and posterior overjet
The relationship of permanent first molars when initial 3. 2-mm anterior overbite
occluding contact occurs during eruption may be repre- 4. Coincident dental midlines
sented by one of four categories (see Fig. 25-14). A class I
relationship means that the mesial-buccal (m-b) cusp of
MAINTENANCE OF OVERALL PATTERN
the upper permanent molar contacts at or very near the Gum pad relationships at birth cannot be used as reliable
buccal groove of the lower permanent first molar. This diagnostic criteria for predicting subsequent arch rela-
occurs approximately 55% of the time. An end-on rela- tionship. The primacy of life-supporting functions (i.e.,
tionship means that m-b cusps of both molars oppose respiration and swallowing) is so great at birth that major
one another. The incidence of this situation is about 25%. unpredictable adjustments in maxillary and mandibular
A class II relationship, occurring 19% of the time, is one positions take place in the first few years of life. By 3 years
in which an upper m-b cusp is anterior to the lower of age, however, the relationship of maxilla to mandible
m-b cusp. Class III represents the situation in which an is well established, and overall maxillomandibular pat-
upper m-b cusp is distal to the lower buccal groove. This tern does not change significantly thereafter.
occurs in only 1% of the population.44 Table 25-1 shows One key diagnostic feature regarding future occlu-
the incidence of medial-step, flush, and distal-step pri- sion status is the relationships of the primary terminal
mary terminus and end-on, class I, class II, and class III planes. The likelihood of developing a class I relation-
permanent first molar occlusions during three stages of ship in the permanent dentition is greatest when a mild
occlusion development.43-45 mesial-step terminus exists during the primary denti-
tion stage (see Fig. 25-14). If an exaggerated mesial step
IDEAL STATIC OCCLUSION PATTERN exists, a class III permanent molar relationship will de-
The concept of ideal occlusion development has been velop. The possibility that a class I relationship will
described by Friel46 and by Lewis and Lehman.47 Sanin develop from a distal-step primary terminus is virtually
and Savara have also shown that, to a considerable ex- nonexistent. Hence, the presence of a distal step is
tent, ideal occlusion at a young age predisposes to an highly predictive of a developing class II permanent
ideal adult occlusion.48 The most desirable occlusion in molar relationship.
the permanent dentition is a class I interdigitation, and Another important diagnostic feature that is predictive
certain features in the primary and mixed dentitions, if of later occlusion status is the relationships of the first
observed accurately, can provide clinical clues as to permanent molars during initial occluding contact. The
whether a class I relationship of the dentition will even- first permanent molars erupt between 5 and 7 years of age.
tually develop. The chance that a class I interdigitation of the dentition

Table 25-1
Incidence of Terminal Molar Relationships at Three Stages of Occlusion Development

Initial Permanent First Molar Occlusion

Primary Terminal Plane at Age 5 Years at Age 61⁄2 Years Final Occlusion at About Age 12 Years

1% Class III 3% Class III

49% Class I (ms) 27% Class I 59% Class I
37% Flush 49% End-on
14% Class II (ds) 23% Class II 39% Class II

ms, Medial step; ds, distal step.

Arya BS, et al. Prediction of first molar occlusion, Am J Orthod 63:610-621, 1973; Carlsen DB, Meredith HV. Biologic variation in selected
relationships of opposing posterior teeth, Angle Orthod 30:162-173, 1960; HEW reports on occlusion: Summary and discussion, J Clin Orthod
12:849-862, 1978.
520 Chapter 25 ■
Growth of the Face and Dental Arches

will evolve is best when a class I relationship is repre- show evidence of calcification, which takes place during
sented at initial permanent first molar occluding contact. the second postnatal month. The third molar is the last
A class II first permanent molar occlusion at initial occlud- to begin calcification, which occurs at about 9 years.
ing contact will predictably remain a class II occlusion The typical eruption sequence for the mandibular arch
into the complete adult dentition. Also indicative of a is as follows: first molar (in Palmer notation, designated
developing malocclusion are some initially occluding by the number 6), central incisor (1), lateral incisor (2),
end-to-end relationships. Three quarters of initial contact- canine (3), first premolar (4), second premolar (5), and
ing end-on first molar occlusions will shift toward a class second molar (7), followed by the third molar (8). For the
I during the transition dentition phase. However, 25% of maxillary arch, the usual sequence of eruption for the
these end-on relationships will shift into a class II rela- permanent teeth is as follows: 6-1-2-4-5-3-7-8. Eruption
tionship. A class III occlusion at initial contact will pre- timing in girls generally precedes that in boys by an aver-
dictably lead to a future class III molar relationship. This age of 5 months.
discussion regarding diagnostic and predictive informa- Eruption times for permanent teeth can vary consider-
tion is based on the work of Arya and associates,43 Carlsen ably depending on the specific tooth. According to Garn,
and Meredith,44 and Moyers.49 eruption time for the lower incisor varies the least; 90%
The development of the transitional phase occlusion of lower permanent incisors erupt within a span of
and malocclusion is graphically illustrated in Fig. 25-14. 3 years. In contrast, eruption time varies the most for the
Note that distal-step terminus always leads to class II ini- lower second permanent premolar, which shows a 61⁄2-
tial contact and final permanent first molar occlusions. year span.4
The probability that a class III final first permanent molar Dimensional changes for dental arch length, circum-
relationship will develop from a class III initial contact ference, and intermolar and intercanine widths during
occlusion is also very high. Development of the occlusion childhood and adolescence have been compiled by Moor-
from flush terminus, end-on, and class I initial contact rees.53,54 Average dimensional dental arch changes from
molar relationships is highly variable. age 6 to 18 years for maxillary and mandibular arches are
The occlusion relationship of upper to lower denti- as follows:
tion remains nearly the same throughout the growing Lower Arch
period.50 Exceptions are cases in which environmental Arch width: Bicanine: 3-mm increase
factors, such as premature loss of primary teeth, are Bimolar: 2-mm increase
superimposed on the developing occlusion, as shown Arch length: 1-mm decrease because of
by Northway and associates.51 Carlsen and Meredith up-righting of incisors
demonstrated that, 70% of the time, the lower perma- Arch circumference: Decrease of 4 mm
nent first molars move mesially relative to the upper Upper Arch
permanent first molar during the transition occlusion Arch width: Bicanine: 5-mm increase
phase.44 The magnitude of this shift, however, typically Bimolar: 4-mm increase
does not compensate for a permanent first molar mal- Arch length: Slight decrease because of
occlusion. Overall occlusion pattern is maintained dur- up-righting of incisors
ing growth. Arch circumference: Increase of 1 mm
IDEAL DENTAL ARCH PATTERN
GROWTH AND DENTAL ARCH PATTERN Development of dental arch malocclusion is predictable.
Development of a clinically acceptable dental arch like-
SIMILAR STAGE SEQUENCING wise can be predicted. The status of the dental arch at
The stage sequence of dental arch development is the mid-adolescence is contingent on clinical features that
same for everyone. According to Nery and Oka, the can be easily recognized during the transition phase den-
crowns of primary teeth begin calcification between 3 tition. The simplest method of evaluating the dental arch
and 4 months prenatally.52 The calcification of mandibu- for factors predisposing to malocclusion is to compare
lar teeth usually precedes that of the maxillary dentition; the patient’s mixed dentition dental arch with an ideal
the central incisors typically show first evidence of calci- dental arch pattern.
fication and the second molars last. Boys typically begin For the dental arch, the ideal pattern for a 7-year-old
calcification before girls. child might meet the following criteria:
The first primary tooth to erupt is the central incisor at 1. Tight proximal contacts
about 71⁄2 months, and the last to erupt is the second 2. No rotations
primary molar at about 21⁄2 years. Closure of root apex 3. Specific buccal-lingual axial inclinations
occurs at 3 years for the second primary molar. The usual 4. Specific mesial-distal axial inclinations
sequence of primary dentition eruption is the central in- 5. Even marginal ridges vertically
cisor (in Palmer notation designated by the letter A), the 6. Flat occlusal plane
lateral incisor (B), the first primary molar (C), and the 7. Excess (positive) leeway space
canine (D), followed by the second primary molar (E). Ethnic background can make a difference in the denti-
Hence, the typical eruption sequence is A-B-D-C-E. tion and occlusal development. An interesting study by
Calcification of the permanent teeth does not begin Anderson55 showed that the primary dental arch dimen-
until after birth.52 The first permanent molar is the first to sions of African-American children were significantly
 Chapter 25 ■
Growth of the Face and Dental Arches 521

larger than those of European-American children in arch their permanent successors. Correlation coefficients of
width, length, perimeter and interdental space. r ⫽ 0.8 or higher are required to make predictions for
the individual patient at chairside.32 The combined me-
TOOTH SIZE/ARCH SIZE RATIO AS PATTERN sial-distal sizes of all primary teeth and the combined
DETERMINANT sizes for the permanent teeth show a correlation of
Tooth size and alveolar size are the primary factors that r ⫽ 0.5. Hence, Moorrees concluded that the size of the
determine the status of the permanent dental arch. If primary teeth is of little predictive value in estimating
tooth size and arch size are not balanced, the effect on the size of their permanent successors.53
the permanent dental arch is crowding or spacing. Crowd- The strength of the size relationships among the perma-
ing is the most common feature of dental arch malocclu- nent teeth, however, is clinically important for some com-
sion. Only when the combined size of the permanent parisons. Potter and Nance demonstrated that the size of
teeth is balanced with the size of the alveolar apical area an individual tooth is highly correlated with the size of the
is an ideal dental arch possible. contralateral tooth in the same arch, as reflected in an r
Van der Linden referred to the alveolar bone surround- value of around 0.9.59 The combined mesial-distal dimen-
ing the dental apex regions as the apical area.56 Ten Cate sions of contralateral quadrants of teeth show a slightly
reported evidence that the alveolus probably forms as a higher correlation of r ⫽ 0.95. Intra-arch comparisons of
result of inductive action from cells of the dental tooth groupings, such as mesial-distal size of the lower
follicle.57 The size of alveolar bone is influenced by the incisors versus mesial-distal sizes of the lower canine
many environmental factors that affect intra membra- and premolars combined, show only moderate correlation
nous bone growth. It is possible to clinically increase or (r ⫽ 0.6) and therefore are not useful clinically.60
decrease the size of the alveolar apical area during growth.
Fränkel has demonstrated that alveolar arch size can be
COMPUTATION OF TOOTH SIZE/ARCH SIZE
increased dramatically during childhood and that the
BALANCE
increases are stable into adulthood.58 The primary reason for dental arch malocclusion is im-
Tooth size, for the purpose of discussing dental arch balance between tooth size and alveolar apical size. In the
development, refers to the mesial-distal dimensions transition (mixed) dentition, it is possible to accurately
of each tooth. According to Garn4 and Potter and determine if combined mesial-distal tooth size will be
colleagues,5 mesial-distal tooth size is determined primar- balanced with alveolar arch size in later life. This process
ily by genetic factors. Four chromosomal gene loci appear of determination is called mixed dentition space analysis.
responsible for mesial-distal maxillary tooth size, and the Many methods of mixed dentition space analysis are
mandibular dentition seems to be under the genetic con- available.61,62 Common to all of these methods is the at-
trol of six loci. Tooth size is polygenically determined and tempt to determine the combined mesial-distal size of the
continuously variable (i.e., a wide range of individuality unerupted permanent canine and first and second pre-
exists in terms of the width of any single tooth). Dental molars. According to Horowitz and Hixon, the lower
size is expressed through X-linked inheritance, and racial dental arch is the focus for space analysis and the basis of
differences are known. The upper lateral incisor shows orthodontic diagnosis and treatment planning.32 The
the most variability in tooth size. mandibular alveolar base can be modified less therapeuti-
Tooth size and alveolar apical area size are the most cally than can the upper alveolus and therefore restricts
pertinent factors in the determination of the intra-arch treatment possibilities. The mandibular arch also under-
component of malocclusion. Therefore, it is relevant to goes less growth change than does the upper arch.
consider these factors at length. The alveolar apical area Efficacy studies by Gardner,63 Kaplan and colleagues,64
will respond to biomechanical stimulation from orth- and Staley and colleagues65-67 revealed one method to be
odontic appliances, because intramembranous bone is the most accurate in predicting the combined size of the
adaptive and compensatory in nature. Crown size, on the unerupted canine and premolars during the mixed denti-
other hand, cannot be predictably influenced during tion. This method, originally devised by Hixon and Old-
growth by clinical therapy. father,60 has been refined by Bishara and Staley.68 In
The clinical crowns of all permanent teeth, except for summary, the analysis involves the following steps:
the third molar, are completely formed by middle child- 1. Measure the combined width of the lower lateral and
hood. Mesial-distal crown widths will not change after central incisors on one side.
crown formation unless affected by factors such as caries. 2. Measure directly from the radiograph the crown sizes
Hence, mesial-distal crown dimension is a stable factor in of the unerupted 4-5 on the same side.
the tooth size/arch size ratio. In an attempt to exploit the 3. Add together the incisor and the premolar sizes.
clinical usefulness of crown dimension stability, tooth 4. Refer to the prediction chart to determine the sizes of
size relationships are examined. the unerupted 3-4-5.
Comparison of primary to permanent mesial-distal Techniques of mixed dentition space analysis allow
tooth sizes is one such consideration. Studies by estimation of the sizes of the unerupted canine and pre-
Moorrees revealed that there is little about primary den- molars on the lower arch. This size estimate must then be
tition size that predicts permanent dentition size.53 compared with a measurement of the arch space available
Correlation coefficient (r) values ranging from r ⫽ 0.2 to between the mesial aspect of the lower molar and the
r ⫽ 0.6 are indicative of the poor predictive relationship distal aspect of the lateral incisor in the same quadrant.
between primary mesial-distal tooth size and the size of The difference between the combined width of the three
522 Chapter 25 ■
Growth of the Face and Dental Arches

unerupted permanent teeth and this arch space has been Overall space appraisal is typically expressed as milli-
called leeway space. meters of arch length space excess or deficiency. Dental
The most favorable dental arch pattern is one in which arch space excess (1 to 2 mm) is a relatively ideal situa-
leeway space is excessive (i.e., combined size of unerupted tion. Clinically, little intervention is usually required be-
canine and premolars is smaller than arch space available). cause mesial drifting of the permanent teeth often results
If leeway space is deficient, dental arch crowding predict- in little or no crowding or residual spacing. Space excess
ably results. Average growth changes in the dental arch are exceeding 3 to 4 mm, however, can lead to dental arch
not great enough to compensate for leeway deficiencies. problems. For example, congenital absence of one or
more teeth can leave so much arch space that mesial
COMPENSATIONS IN DENTAL ARCH drifting cannot compensate. Decisions favoring retention
DEVELOPMENT of primary teeth as long as possible, extraction of primary
Tooth size/arch size imbalances result in dental arch con- teeth and retention of space for later restorative prosthe-
ditions that are less than ideal. When combined mesial- sis, or extraction followed by space closure must be made
distal tooth size exceeds alveolar arch size, compensatory as long-term planning decisions.
adjustments occur, which results in dental arch crowd- Space deficiencies less than ⫺2 mm can usually be man-
ing, excessive curve of Spee, or deviant axial tooth incli- aged with a lower lingual holding arch. Arch space deficien-
nations. Dental spacing results when alveolar arch size cies of ⫺3 to ⫺6 mm should be scrutinized carefully. Typi-
exceeds the combined mesial-distal size of the teeth. cally, a space-regaining lower lingual arch or arch length
Competent treatment planning during the mixed den- expansion treatment measure is indicated. Arches with de-
tition must account not only for differences between the ficiencies in excess of ⫺6 mm are candidates for aggressive
size of unerupted canine and premolars and the space space-regaining techniques, dental arch expansion treat-
available for them, but also for compensating dental fac- ment, or one of a number of serial extraction sequences.
tors. Ideal dental arch status provides a model for such Clinical approach to various conditions of space excess and
planning. Each compensating factor (i.e., crowding, spac- deficiency is based on overall space appraisal (space analy-
ing, excess occlusal curve, or deviant axial tooth position) sis plus compensating factors) as shown in Table 25-2.
can be appraised relative to an ideal dental arch. Altera-
tion of a crowded arch to an ideally aligned arch is not
EFFECT OF ENVIRONMENTAL FACTORS ON
possible without creating extra space to resolve the
DENTAL ARCH PATTERN
crowding. Consequently, a competent dental arch treat- The primary determinant of dental arch malocclusion is
ment plan must specify the manner in which space will mesial-distal tooth size/arch size imbalance. Nevertheless,
be clinically created. Several means are available for creat- secondary factors can dramatically influence the disposi-
ing dental arch space. They include the following: tion of the dental arch during childhood. Dental arch
1. Move molars distally. status is subject to the ravaging effects of environmental
2. Decrease the mesial-distal dimension of the teeth pres- factors that include early loss of primary teeth, inter-
ent in the arch. proximal caries, pathology, ankylosis of primary teeth,
3. Increase the buccal-lingual axial inclination of the oral habits, trauma, and early eruption of permanent
incisors. second molars.
4. Reduce the number of teeth in the arch by extraction. The environmental factors most commonly affecting
Resolution of excessive occlusal curve also requires dental arch status are probably caries and premature loss
more space. Merrifield indicated that generally, for each of primary teeth. Early primary tooth loss and caries can
millimeter of excessive occlusal curve, 1 mm of arch have a profound effect on dental arch status. Caries and
length space is required.69 To upright labially inclined early loss of the primary first molars (D), second molars
incisors, arch length space is also required. In contrast, (E), or both (D ⫹ E) result in a decrease in dental arch
more arch length is created when retroclined incisors are length. A study by Northway and colleagues51 showed the
proclined through therapy; the length of the arch is in- following specific details:
creased by repositioning the incisal edges from a lingual 1. E loss had the most deleterious effect on dental arch
to a more labial position. length.
2. Early posterior primary loss resulted in 2- to 4-mm
MAINTENANCE OF OVERALL PATTERN space closure per quadrant in both arches.
Space analysis combined with evaluation of the impact of 3. Space loss was age related in the upper but not in the
compensating factors on dental arch status is the means lower arch.
by which overall space requirements for the lower arch 4. Upper D loss typically resulted in blocked-out canines;
can be determined during the mixed dentition phase. upper E loss usually led to an impacted second perma-
Overall space appraisal during the mixed dentition is nent premolar.
highly indicative of future arch status. The condition 5. The greatest space loss was caused by mesial molar
presented during the mixed dentition will, to a high de- movement.
gree, be maintained in the permanent dental arch. For 6. More space was lost in the first year after premature
this reason, a nonideal adult arch status can be antici- tooth loss than in successive years.
pated early, and many undesirable conditions can be re- 7. No recovery of space was demonstrated during
solved during the transition from the primary to the growth in the upper arch, and little was found in the
permanent dental arch. lower arch.
 Chapter 25 ■
Growth of the Face and Dental Arches 523

Table 25-2
Clinical Disposition Guidelines for Various Dental Arch Space Conditions Resulting from
Overall Mixed Dentition Space Appraisal
Overall Appraisal mm Clinical Disposition

Large space excess Greater than ⫹3 Long-term planning

Space excess Less than ⫹3 to 0 No action; observation

Equivalency 0 Careful observation

Deficiency Less than ⫺3 to 0 Lower lingual holding arch

Moderate deficiency ⫺3 to ⫺6 Space regaining or arch expansion

Large deficiency Greater than ⫺6 Space regaining, arch expansion, or

extraction

SUMMARY 6. Linder-Aronson S, Leighton BC. A longitudinal study of the

development of the posterior nasopharyngeal wall between
This chapter integrates basic growth principles with 3 and 6 years of age, Eur J Orthod 5:47-58, 1983.
patient appraisal to enhance diagnostic and treatment- 7. Enlow DH, Hans MG. Essentials of facial growth.
planning efficacy. Merging growth principles with dento- Philadelphia, 1996, WB Saunders.
facial pattern brings to light specific growth features per- 8. Scott JH. The nasal septum, Br Dent J 95:37, 1953.
tinent to clinical patient-care decision making. This 9. Sperber GH. Craniofacial embryology, 3rd ed. Boston, 1981,
chapter focused on growth events germane to a better John Wright-PSG.
understanding of malocclusion as it affects the face, oc- 10. Latham RA. Maxillary development and growth: the septo-
premaxillary ligament, J Anat 107:471, 1974.
clusion, and dental arches. Two themes were consistent
11. Gange RJ, Johnston LE. The septopremaxillary attachment
throughout the chapter. First, overall pattern is main-
and midfacial growth, Am J Orthod 66:71-81, 1979.
tained from early childhood until growth completion. 12. Moss ML, Salentijn L. The primary role of functional matri-
Growth change affects architecturally equivalent struc- ces in facial growth, Am J Orthod 55:566-577, 1969.
tures in a balanced way. For this reason, craniofacial 13. Moss ML, Salentijn L. The capsular matrix, Am J Orthod
pattern can be predicted to a great extent. The best esti- 56:474-490, 1969.
mation of future status is obtained by taking the pattern 14. Koski KL. Cranial growth centers: facts or fallacies? Am J
present at an early age and adding the average growth Orthod 54:566-583, 1968.
change. Second, dentofacial pattern changes regionally as 15. Dixon AD, et al. Fundamentals of craniofacial growth. Boca
an individual matures, and these maturation changes are Raton, FL, 1997, CRC Press. p. 121-124.
16. Enlow DH, Hans MG. Handbook of facial growth.
common in all healthy individuals. Regional variation
Philadelphia, 1996, WB Saunders.
introduced by the maturing process, however, is not great
17. Linder-Aronson S. Effects of adenectomy on dentition and
enough to alter overall dentofacial pattern. nasopharynx, Am J Orthod 65:1-15, 1974.
18. Harvold EP, et al. Primate experiments on oral respiration,
Am J Orthod 79:359-372, 1981.
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