Transverse Growth of Maxilla and Mandible

Ram Nanda, Stephen F. Snodell, and Prashanti Bollu

Growth in the transverse plane has not received due emphasis in the
diagnosis of craniofacial and dentoalveolar anomalies. Because the research
focus has largely been on sagittal and vertical planes of the face, inferences
on normal and abnormal growth patterns have been limited to these planes.
This article is based on a section of the extensive research done on growth
and development of dentofacial structures at the University of Oklahoma.
Nine transverse craniofacial and dentoalveolar measurements were made
on anteroposterior radiographs of 25 male and 25 female subjects between
the ages of 6 and 18 years. The average measurements at each age are
presented. Regression models suggest a strong prediction of adult size at
age 12. Large prospective longitudinal studies using regression models are
needed to validate this evidence. (Semin Orthod 2012;18:100-117.) © 2012
Elsevier Inc. All rights reserved.

rowth of the human face is a multidimen- The timing of orthodontic intervention is of-
G sional and dynamic continuum. To mea-
sure and interpret the incremental changes oc-
ten challenging to even the most experienced
practitioners. A good understanding is needed
curring during growth, the use of appropriate on the growth of jaws, including the total
diagnostic tools is paramount. A comprehen- amount of growth, timing of growth spurts, and
sive analysis of craniofacial growth includes cessation or near completion of growth. Many
monitoring growth changes in all 3 planes of longitudinal growth studies have been done to
space, that is, transverse, sagittal and vertical. measure these incremental changes and to de-
Each plane offers unique information on the velop normative values. Although it is important
extent and direction of growth status, ultimately to note that individual variations exist, these
aiding in the overall treatment planning. Trans- norms serve as a useful guide for the clinician in
verse growth changes shed light on dentofacial the overall decision process.
asymmetries, expanded/constricted jaws, and An invaluable aid in the proper diagnosis and
dental crossbites. The sagittal or anteroposterior orthodontic treatment planning of a growing
(AP) dimension offers a great deal of informa- child is the ability to predict future growth po-
tion on facial profile, arch length discrepancies, tential. Assessment of growth potential requires
and excessive/inadequate overjets. Vertical a thorough knowledge on the extent and se-
growth patterns allow visualizing facial propor- quence of growth completion. Although devel-
tions, deep bites, and open bites. opment and maturation continue throughout
life, growth reaches its maximum potential at a
certain age. In assessing the completion of
Professor Emeritus, Department of Orthodontics, College of Den- craniofacial growth, it is important to note that
tistry, University of Oklahoma, Oklahoma City, OK; Orthodontist, growth in all 3 dimensions does not stop at the
Private Practice, Cedar Park, TX; Orthodontic Resident, College of
Dental Medicine, Roseman University of Health Sciences, Hender-
same time. Several longitudinal studies have at-
son, NV. tempted to identify the age at near completion
Address correspondence to Ram Nanda, BDS, DDS, MS, PhD, of growth of the jaws. More congruence exists on
Department of Orthodontics, College of Dentistry, University of the sequence of growth patterns than the age at
Oklahoma, 7600 Dorset Drive, Oklahoma City, OK 73116. which maximum growth is achieved. Growth fol-
E-mail: ramnanda@sbcglobal.net
© 2012 Elsevier Inc. All rights reserved.
lows the sequential completion of cranium fol-
1073-8746/12/1802-0$30.00/0 lowed by facial width (transverse), then facial
doi:10.1053/j.sodo.2011.10.007 depth (sagittal), and lastly height (vertical).1 Al-

100 Seminars in Orthodontics, Vol 18, No 2 (June), 2012: pp 100-117

 Transverse Growth of Maxilla and Mandible 101

though AP and vertical growth continue well molar, and intermolar regions of the maxilla as
into adulthood, Class II, Class III relations and well as the mandible.
relapse of deep bites and open bites are often To measure transverse growth changes in the
seen.2 These continued structural changes are dentoalveolar structures of upper and lower
also responsible for deterioration of occlusal re- jaws, previous studies used dental casts, whereas
lationships and the relapse of malocclusion after more recent studies used posteroanterior (PA)
completion of orthodontic treatment.3 views. Arch width measurements are usually
Interestingly, facial width, the largest facial taken at the intercanine, interpremolar, and in-
dimension at infancy, shows the least relative termolar areas of the maxilla and mandible.
growth rate compared with the facial depth and Some studies recorded the intermolar distances
height.4 Transverse growth is found to achieve at first as well as second molars. Different meth-
near completion by late adolescence; however, ods have been used in measuring these widths.
sagittal and vertical growth continue well into For instance, intermolar width measurements
adulthood. Recent research, however, contests were done between bilateral gingival points of
this accepted phenomenon on sequential com- first molars,9 central fossae of maxillary first
pletion and shows evidence of overlap in 3 di- molars, and distobuccal cusp tips of mandibu-
mensions, indicating that although growth of lar first molars.12,13 Other studies used the
some transverse dimensions, such as cranial and most prominent lateral points on buccal sur-
interjugal width, end much before AP and ver- faces of the molars to measure the intermolar
tical growth, interzygomatic and intergonial distance.14
widths continue to increase well into adult- An overview of recent scientific literature
hood.5 Careful attention to these details is im- shows the limited emphasis and evidence avail-
portant in effective orthodontic treatment man- able on the transverse growth of jaws. A signifi-
agement, especially during the retention period cant number of people present with transverse
to control for the effects of late growth changes. jaw discrepancies, demanding special attention
Developing an effective orthodontic diagnos- to this plane of space. Intraarch asymmetries are
tic workup is a challenging process. Several found to be more severe in the transverse than
cephalometric radiographic analyses developed in the AP plane.15 Early diagnosis is critical for
over the years assist the clinician in diagnosing the correction and treatment of such discrepan-
transverse relationships between jaws. The cies. The multifactorial etiology behind the de-
Rocky Mountain analysis6 and the Ricketts anal- velopment of transverse discrepancies makes
ysis7 are among the most popular and widely identifying and eliminating the etiologic factor
used cephalometric analyses. These analyses, difficult. The goal of the present article is to
however, represent a certain demographic pro- provide an in-depth summary on transverse
file, and hence, caution must be applied in using growth changes of the craniofacial and dentoal-
them as true norms. veolar complex. In addition, the potential for
Annual growth increments assist in measur- predictive growth changes at 6 years and 12 years
ing the growth extent and rate. Various land- will be presented.
marks have been used to monitor growth incre-
ments. Transverse craniofacial measurements
Methods
include widths of cranial, facial, nasal, maxillary,
and mandibular structures. The use of interjugal The research16 done at the University of Okla-
distance (bijugale) in measuring maxillary width homa presents information on longitudinal re-
has been validated by previous studies.8-10 Man- cords of 25 males and 25 females between the
dibular width, however, has been measured us- ages of 6 and 18 years. All subjects had Class I
ing the distance between gonions10 and antego- occlusion with absence of crossbites and no his-
nial notches.8,11 Hesby et al9 measured both tory of orthodontic treatment. The current study
intergonial and interantegonial distances. Den- uses the same data to investigate the age at
tal arch dimensions change gradually as a result which predictive potential of future growth is
of growth and as a result of orthodontic treat- the strongest. The information recorded as av-
ment. These changes in the transverse plane are erage size and annual increments of 9 transverse
typically measured at the intercanine, interpre- dimensions (Fig. 1) identified relationships be-
102 Nanda, Snodell, and Bollu

Facial width increases between 6 and 11 years

in females and 6-13 years in males at a rate of
1.5-2 mm per year, with a peak growth spurt at
14 years for females and 15 years for males.
Growth is complete at 17.5 years in females, but
it continues at the rate of 1.75 mm per year in
males even at 18 years. By 6 years, males reached
83% and females reached 86% of adult facial
width. Facial width showed positive correlation
with all skeletal transverse measurements in fe-
males; however, this correlation was not ob-
served in males.
The least square means for nasal width at 18
years ranged from 25.6 to 33.7 mm for females
and from 29.2 to 36.5 mm for males (Table 1).
The total increment was 5.8 mm for females and
7.5 mm for males, although both had about the
Figure 1. Transverse measurements. 1: cranial width
same nasal widths at 6 years. At 6 years, about
(bieuryon width); 2: facial width (bizygomatic width);
3: nasal width (bialare width); 4: maxillary width; 5: 75% of nose width is complete in males and 80%
mandibular width (bigonial width); 6, 7: maxiallary in females. The maximum increase in nasal
intermolar width (6-6 and 7-7); 8, 9: mandibular in- width is between 10 and 11 years in females. In
termolar width (6-6 and 7-7). (Reprinted with permis- males, it was observed at 8-10 years and again at
sion from Snodell et al.10)
15 years. Nasal width showed a positive correla-
tion with facial width.
Bizygomatic width, a measure of maxillary
tween various facial measurements, indicated width, increases most from 2 to 6 years. Bizygo-
growth patterns, and formulated predictive matic width is larger in males when compared
equations. Transverse growth of all 9 measure- with females by 2.0 mm at 2 years, 3.4 mm at 10
ments at 6, 12, and 18 years was compared. years, and 6.2 mm at 18 years. Maxillary width on
Regression analysis was performed to assess the an average increased 10.1 mm in males and 7.4
predictive potential at 12 years, using 18 years as mm in females (Table 2). The curve for total
the adult size. percent completion of growth of the maxilla
shows accelerated growth from 8 to 12 years and
a steady increase until full width is achieved at 15
Findings
and 16 years in males and females, respectively.
In this section, craniofacial and dentoalveolar The incremental pattern suggests accelerated
transverse measurements between 6 and 18 years growth in width with development of maxillary
will be summarized. The percentage growth molars. At 12 years, maxillary width is complete
completions have been assessed with reference by 98% in females and 95% in males.
to an adult size. The terminal age in this report The least square means of mandibular width
is 18 years, hence all references to adult size from 6 to 18 years are shown in Table 3. The
mean 18 years. Small growth increments may mandibular width increased by 15.8 mm in fe-
still be taking place in some measurements even males and 20.9 mm in males from age 6 to 18
after age 18 years, and hence, it is important to years. The growth increments during 8-11 years
note that the projected adult sizes are the closest contributed 6.3 mm in females and 7.3 mm in
possible approximations. Least square means for males. At 18 years, mandibular width continued
all measurements at each age were calculated. to show a small increase in males and females.
Cranial width is about 95% complete at age 6 Maxillary intermolar width from 6 to 18 years
years. Adult size is attained by 14 years in females is shown in Table 4. The intermolar width at the
and 17 years in males. Cranial width was found maxillary first molars increased by 2.0 mm in
not to be statistically correlated with any skeletal females and 6.3 mm in males. The average width
transverse measurement except facial width. at 18 years was 55.7 mm for females and 59.5 for
 Transverse Growth of Maxilla and Mandible 103

Table 1. LSMean, SD, Min, and Max Values for Nasal Width in Millimeters for Males and Females Aged 6-18
Years
Age (Years) Gender Subjects LSMean SD Min Max

6 M 22 22.93 1.92 18.21 26.98

F 17 22.88 1.66 19.87 26.42
7 M 19 23.48 2.03 20.77 27.50
F 20 23.17 2.10 19.13 26.78
8 M 21 24.56 1.87 20.13 27.86
F 22 24.09 2.16 20.16 27.97
9 M 21 24.70 2.06 21.05 28.88
F 21 24.58 2.42 21.83 29.60
10 M 19 26.12 2.11 23.30 29.72
F 22 24.94 2.55 20.09 29.87
11 M 19 26.49 1.77 23.98 29.72
F 21 26.14 2.23 20.09 29.87
12 M 21 27.39 2.54 23.02 32.20
F 23 26.55 2.45 21.38 30.58
13 M 20 27.84 2.44 23.54 32.70
F 22 27.14 2.60 21.10 32.40
14 M 16 27.81 2.64 22.93 31.93
F 21 27.70 2.15 25.08 33.06
15 M 18 28.98 2.66 25.48 33.88
F 17 28.12 2.50 25.31 34.08
16 M 19 29.10 2.42 24.57 35.07
F 14 28.32 3.13 22.90 33.25
17 M 20 29.88 2.40 24.81 35.26
F 15 28.76 3.12 21.72 34.62
18 M 11 30.48 2.07 29.25 36.55
F 9 28.64 2.49 25.56 33.68

LSMean, least squares mean; SD, standard deviation; Min, minimum; Max, maximum; F, females; M, males.

males. Interestingly, by 6 years of age, the max- skeletal and dentoalveolar measurements con-
imum intermolar width achieved was 96% in tinued to increase beyond 18 years.
females and 88% in males. Maxillary intermolar
width at second molars showed an increase of
Predictions of Dental Arch Widths
1.4 mm in females, whereas the males showed an
increase of 3.7 mm (Table 5). Different approaches have been proposed to
The least square means of mandibular inter- predict the maxillary and mandibular arch
molar width are shown in Table 6. Transverse widths. Some well-recognized indices to predict
growth change in this area was found to be little, maxillary arch width include analyses by Pont,17
with a slight decrease until 11 years. The man- Howe et al,18 and Schwarz and Gratzinger.19
dibular intermolar width at the second molars Mandibular arch width measurements have
(Table 7) decreased by 2.1 mm in females and been done in several different ways. Bonwill20
1.2 mm in males from age 12 to 18 years. used the sum of 6 anterior teeth to predict man-
Table 8 presents the percentage completion dibular arch width. Many earlier studies devel-
of each transverse craniofacial dimension at 6 oped indices based on limited variables leading
years and at age at which 100% growth was to potential biases. Recent investigations by Nim-
found to be complete. All dental measurements karn et al21 criticized the inaccuracies inherent
were found to be highly correlated with each in several indices. The advantages of using re-
other. Although most skeletal and dental trans- gression analyses over indices in making growth
verse growth was almost complete before 18 predictions of dental arches were first used by
years in females, mandibular width continued to Snodell et al10 (Figs. 2–19) and more recently by
grow beyond 18 years. Mandibular intermolar Alvaran et al.22
width at first and second molars, however, was Our research at University of Oklahoma indi-
fully complete before 15 years in both males and cates that growth at 6, 12, and 18 years showed
females. In males, except for facial width, most reliable and discernible patterns. Our investiga-
104 Nanda, Snodell, and Bollu

Table 2. LSMean, SD, Min, and Max Values for Maxillary Width in Millimeters for Males and Females Aged
6-18 Years
Age (Years) Gender Subjects LSMean SD Min Max

6 M 22 56.17 2.34 51.13 60.19

F 17 54.44 1.86 51.28 59.00
7 M 21 57.67 2.23 53.66 61.64
F 21 55.52 2.10 51.28 60.04
8 M 21 58.63 2.16 54.76 62.55
F 24 56.71 2.23 51.34 62.45
9 M 22 60.04 2.53 55.83 64.56
F 23 58.06 2.39 54.60 63.40
10 M 19 61.37 2.88 57.18 66.42
F 22 58.86 2.34 55.25 64.07
11 M 21 62.81 2.82 58.17 68.73
F 22 59.73 2.68 55.03 65.30
12 M 21 63.03 2.99 59.69 68.90
F 23 60.26 2.79 56.73 66.68
13 M 23 63.51 2.99 59.69 68.90
F 22 60.83 2.57 56.73 66.68
14 M 18 64.16 3.20 59.20 68.69
F 20 61.42 3.19 56.65 68.40
15 M 15 65.81 3.17 62.41 72.07
F 17 62.09 3.06 57.65 68.32
16 M 20 66.02 3.56 60.49 72.22
F 14 61.96 2.49 57.42 64.84
17 M 20 66.17 3.34 60.73 71.51
F 15 61.88 2.54 56.32 64.86
18 M 11 66.24 3.12 61.08 70.80
F 9 61.80 2.97 58.67 66.88

LSMean, least squares mean; SD, standard deviation; Min, minimum; Max, maximum; F, females; M, males.

tion highlights the correlation between strength Age

of predictability and percentage growth-related
Age is an important determinant of skeletal as
changes. Cranial width increased only by 4%-6%
well as dental maturation. In this context, it is
between 6 and 18 years, indicating that most of
important to emphasize that chronologic age
the transverse cranial width is completed by this
and dental age do not match quite often. Al-
age, and that growth at 6 years could serve as a
though most transverse craniofacial growth is
valuable reference point when predicting trans-
complete by age 18 years, our research shows
verse growth. However, predictability of growth
that dental transverse measurements (maxillary
completion based on growth at 12 years was
and mandibular intermolar widths) reach adult
more significant than that at 6 years (Table 9).
size by age 6 years. The timing of the adolescent
At 12 years, maxillary width is complete by 98%
growth spurt largely influences treatment deci-
in females and 95% in males.
sions, and hence, it is important to seek appro-
priate diagnostic measures, such as hand-wrist
Factors Influencing Transverse Growth x-rays or cervical vertebrae, to identify peak of
the adolescent growth spurt. Transverse growth
Genetics of the maxilla, for instance, shows a distinct
“It is estimated that about two-thirds of the adolescent peak at 14-15 years.23 The findings
25000 human genes are involved in the complex from our research substantiate further the role
process of craniofacial development.”2 External of age in understanding transverse growth.
or internal influences on this process could alter
the pattern of craniofacial growth and develop-
Gender
ment. Developmental disturbances, such as
clefts in the lip and palate, may adversely influ- Transverse dimensional differences between
ence growth in the transverse dimension. boys and girls were most notable at age 16 years
 Transverse Growth of Maxilla and Mandible 105

Table 3. LSMean, SD, Min, and Max Values for Mandibular Width in Millimeters for Males and Females
Aged 6-18 Years
Age (Years) Gender Subjects LSMean SD Min Max

6 M 23 78.43 4.42 72.48 90.15

F 17 76.33 2.77 72.37 81.14
7 M 22 80.99 4.92 75.43 93.40
F 23 78.56 3.40 71.57 83.17
8 M 21 83.17 5.07 72.94 95.08
F 24 80.72 3.22 73.36 85.57
9 M 22 85.15 4.85 77.82 95.98
F 23 82.67 3.68 74.42 88.97
10 M 19 86.65 5.61 78.83 97.76
F 21 84.16 3.21 78.07 90.47
11 M 22 88.43 5.11 79.97 99.94
F 23 85.51 3.84 77.02 90.00
12 M 21 89.66 5.27 80.73 100.40
F 24 87.03 3.89 77.72 92.82
13 M 23 91.20 5.25 82.60 103.30
F 22 88.29 4.20 79.10 93.99
14 M 18 92.81 5.25 83.74 104.53
F 23 90.21 4.06 80.75 96.62
15 M 18 95.71 6.36 85.95 108.55
F 17 90.94 3.87 81.55 96.62
16 M 20 97.24 6.20 86.31 110.53
F 14 91.80 5.06 83.63 98.58
17 M 20 98.47 6.46 88.45 112.46
F 14 91.86 4.90 83.30 97.57
18 M 11 99.36 5.17 89.70 108.92
F 9 92.17 3.96 84.89 96.39

LSMean, least squares mean; SD, standard deviation; Min, minimum; Max, maximum; F, females; M, males.

in the maxilla and at age 17-18 years in the cantly between races. Chinese adults present
mandible.10,11 Gender differences in arch widths with significantly larger facial widths when com-
were reported at later ages by some authors24 pared with the American white population.26
and at younger ages by others.13,22 Boys have Another parallel phenomenon is the issue of
larger arch widths than girls, which become secular changes. Cranial size and morphology
more prominent in adolescence. Girls show have experienced a notable change over the past
more arch dimensional changes than boys. Gen- century. Although mandibular body width and
der differences in intermolar widths were more bigonial breadth show significant decrease, the
pronounced than interpremolar or intercanine mandibular body length has increased. These
widths with boys having larger intermolar secular changes were more pronounced in
widths.22 The difference in facial widths between whites than blacks.27
males and females is more prominent at the end
of adolescence, with males having a facial width Growth Patterns
of ⫹3.4 mm at 10 years and ⫹6.2 mm at 18
Growth of the craniofacial region occurs around
years.25 The adolescent growth spurt was found
an axis of rotation. There appears to be a defi-
to be 1-3 years later in boys when compared with
nite correlation between maxillary and mandib-
girls.23 Transverse growth changes were found to
ular transverse dimensional changes.28 The ex-
reach near completion by about 15 years of age
tent of transverse growth has been found to have
in females and about 17 years of age in males.
a relation to the morphogenetic facial pattern.
Vertical growers with a high mandibular plane
Race and Ethnicity
angle have been hypothesized to have lesser
Race is one of the biggest challenges in develop- transverse growth, and thereby lesser gain in
ing or using normative data. The transverse skel- intermolar width. Wagner and Chung8 studied
etal and dentoalveolar measurements, mean this relation in a final sample of 81 patients
growth rates, and maximum extent vary signifi- extracted from the Bolton and Burlington stud-
106 Nanda, Snodell, and Bollu

Table 4. LSMean, SD, Min, and Max Values for Maxillary Intermolar Width (6-6) in Millimeters for Males
and Females Aged 6-18 Years
Age (Years) Gender Subjects LSMean SD Min Max

6 M 9 53.18 2.66 50.98 58.45

F 10 53.67 2.58 49.13 56.79
7 M 12 55.40 2.43 51.14 59.28
F 15 53.87 2.25 49.07 57.00
8 M 18 55.25 2.80 51.22 60.72
F 24 54.55 2.22 48.60 57.47
9 M 22 56.95 2.66 52.60 61.39
F 23 54.55 2.42 48.70 58.20
10 M 19 57.46 2.86 53.85 61.67
F 22 54.88 1.90 50.85 58.43
11 M 21 58.00 2.75 54.04 62.17
F 23 55.41 2.17 49.63 58.62
12 M 21 58.22 2.69 57.23 64.95
F 22 55.63 2.19 49.77 59.95
13 M 21 58.25 2.91 53.98 62.83
F 22 55.72 2.03 49.53 58.27
14 M 17 58.38 3.02 53.85 63.36
F 22 55.55 2.07 48.93 58.29
15 M 17 58.65 3.27 52.38 63.40
F 16 55.86 2.58 48.95 60.25
16 M 21 58.98 3.25 53.98 64.11
F 14 55.98 2.77 48.01 59.53
17 M 18 59.41 3.54 53.35 65.05
F 15 56.17 2.70 53.54 64.47
18 M 10 59.46 2.71 54.26 63.39
F 9 55.67 1.51 54.60 59.29

LSMean, least squares mean; SD, standard deviation; Min, minimum; Max, maximum; F, females; M, males.

ies, including low, average, and high mandibular analyzed 3-dimensional relationships between
plane angles. Intermolar width increased gradu- maxilla and mandible in relation to the mandib-
ally from 6 to 14 years and plateaued by age 14 ular plane angle in a Japanese sample of 56
in high-angle patients. Growth continued, al- subjects between 8 and 14 years. They found that
though at a slower rate in patients with low and the ratio of maxillary and mandibular width ([J-
average mandibular plane angles. This study J/Ag-Ag] Jugale-Jugale and Antegonion–Ante-
confirms that the vertical growth pattern exhib- gonion) decreased and reported a higher
ited by high-angle patients has a correlation to change in the low-angle group. Greater width
lesser gain in intermolar widths. Chen et al29 increases were noticed in the mandible when

Table 5. LSMean, SD, Min, and Max Values for Maxillary Intermolar Width (7-7) in Millimeters for Males
and Females Aged 12-18 Years
Age (Years) Gender Subjects LSMean SD Min Max

12 M 9 61.27 3.54 57.89 67.03

F 11 59.32 3.09 54.78 64.34
13 M 12 61.94 3.24 57.94 67.13
F 14 60.26 2.88 54.20 64.18
14 M 14 62.51 2.77 57.16 66.22
F 18 60.53 3.04 54.40 65.97
15 M 16 63.20 3.47 57.96 68.90
F 17 60.86 2.79 54.16 65.84
16 M 21 64.05 3.53 58.43 69.78
F 14 60.73 2.87 52.93 64.52
17 M 20 64.32 3.43 59.83 69.16
F 15 60.87 2.77 53.54 64.47
18 M 11 65.01 3.10 60.53 70.12
F 9 60.72 2.07 58.58 64.00

LSMean, least squares mean; SD, standard deviation; Min, minimum; Max, maximum; F, females; M, males.
 Transverse Growth of Maxilla and Mandible 107

Table 6. LSMean, SD, Min, and Max Values for Mandibular Intermolar Width in Millimeters for Males and
Females Aged 6-18 Years
Age (Years) Gender Subjects LSMean SD Min Max

6 M 10 56.00 2.96 49.66 62.38

F 13 54.10 2.17 49.45 59.84
7 M 18 55.70 2.83 50.92 63.03
F 20 54.22 2.08 50.33 60.18
8 M 20 55.90 2.89 52.11 63.77
F 23 53.90 2.04 48.00 57.37
9 M 22 55.74 2.35 51.55 60.54
F 23 54.30 1.97 48.38 57.37
10 M 19 55.68 2.39 52.61 61.90
F 22 54.19 1.67 51.14 57.21
11 M 21 55.92 2.23 52.30 61.22
F 22 54.17 2.07 48.30 57.57
12 M 20 56.33 2.39 52.38 61.56
F 24 54.32 2.33 47.56 58.22
13 M 22 55.93 2.45 52.02 60.75
F 22 54.03 2.34 47.17 57.25
14 M 18 55.86 2.69 50.67 61.92
F 22 54.23 2.61 45.56 57.66
15 M 17 55.94 2.97 49.84 61.89
F 17 54.07 2.74 45.93 57.84
16 M 21 56.39 2.61 51.17 60.88
F 14 53.84 2.91 46.45 57.12
17 M 20 56.30 3.18 51.19 62.20
F 15 54.05 3.21 45.91 57.43
18 M 10 56.12 2.17 51.57 58.39
F 9 53.72 1.55 52.28 56.98

LSMean, least squares mean; SD, standard deviation; Min, minimum; Max, maximum; F, females; M, males.

compared with the maxilla, confirming the find- has been regarded as one of the main contrib-
ings of previous studies.11 utors,30 the true mechanism responsible for
arch constriction is beyond the scope of this
Habits article. Paul and Nanda31 in their experimen-
Habits, such as mouth breathing, have a pro- tal study comparing mouth breathers with na-
found effect on the extent of transverse sal breathers found that the maxillary arch
growth of the jaws. An absolute correlation width was highly constricted, but the arch
exists between respiratory pattern and cranio- length was much longer in the mouth breath-
facial growth. Although muscular imbalance ers. Mouth breathers tend to have a poor lip

Table 7. LSMean, SD, Min, and Max Values for Mandibular Intermolar Width (7-7) in Millimeters for Males
and Females Aged 12-18 Years
Age (Years) Gender Subjects LSMean SD Min Max

12 M 12 64.55 3.24 58.13 68.84

F 16 62.43 2.88 56.33 65.65
13 M 21 63.72 2.73 58.25 67.65
F 21 61.17 2.48 55.47 64.74
14 M 17 63.03 2.43 57.00 66.69
F 23 61.26 2.71 55.06 65.34
15 M 17 63.21 3.39 56.52 71.07
F 17 60.65 2.69 54.09 63.89
16 M 20 63.46 3.06 57.74 70.89
F 14 60.39 2.77 54.17 64.14
17 M 19 63.72 3.77 58.29 72.59
F 15 60.73 3.29 52.50 64.63
18 M 10 63.36 2.71 57.20 66.49
F 9 60.37 1.36 52.28 63.98

LSMean, least squares mean; SD, standard deviation; Min, minimum; Max, maximum; F, females; M, males.
108 Nanda, Snodell, and Bollu

Table 8. Percentage Completion of Width at 6

Years, with 100% Being Considered at 18 Years
Extent of Growth
Completed at 6 100% Complete
Years (%) at Age (Years)
Transverse
Measurement Female Male Female Male

Facial width 83 86 18 17
Nasal width 75 80 18 17
Maxilla width 85 88 16 15
Mandibular width 78 88 18 16
Maxillary intermolar 89 89 17 17
width (6-6)
Maxillary intermolar 94 94 14 18
width (7-7)
Mandibular 100 101 — —
intermolar width
(6-6)
Mandibular 102 103 — —
intermolar width
(7-7)

tonicity leading to increased growth in the

sagittal plane. Hence, these patients often
present with an increased overjet. The limited
arch width was more noticeable in the maxilla,
whereas in the mandible, perhaps the tongue Figure 3. Regression line and 95% confidence interval
for facial width in males. Values at ages 6 or 7 and 18 or
19 years were used to calculate the regression line.

prevents the collapse of the arch form, thereby

preserving the arch width.

Muscles
The role of muscles on facial dimensions and
proportions has been studied extensively. The
review article by Kiliardis32 explores this topic
and identifies elevator muscles of the mandible
to exert an influence on the transverse and ver-
tical facial dimensions. The biomechanics in-
volved in this phenomenon are complex; heavy
muscle forces because of masticatory muscle hy-
per function, perhaps increase the sutural
growth and bone apposition, ultimately result-
ing in an increased transverse growth of the
maxilla and broader bone bases for the dental
arches. A definite correlation seems to exist be-
tween cross-sectional areas of temporalis and
masseter muscles with facial width.33 In the
lower jaw, the tongue being a very strong muscle
influences the arch width. Lateral growth of the
Figure 2. Regression line and 95% confidence interval lower jaw was significantly reduced in glossecto-
for cranial width in females. Values at ages 6 or 7 and 18 mized animals, leading to highly constricted in-
or 19 years were used to calculate the regression line. tercanine and intermolar widths.34
 Transverse Growth of Maxilla and Mandible 109

however, may be due to a deficiency in the initial

size and not because of growth differences in
later stages. Bishara et al38 confirmed that no
differences were observed in the growth changes
between normal and Class II subjects. Class II
tendency is observed early on in the primary
dentition and tends to persist into the mixed
dentition.39,40 If this problem is not corrected in
the initial stages, the discrepancy will not self-
correct and the same discrepancy continues into
adulthood.

Orthodontic Intervention
Beside changes observed in growth, increases in
transverse arch dimensions are often observed
during orthodontic treatment.41 A definite pat-
tern seems to exist between molar uprighting
and increase in transverse maxillary basal bone
width.9 Prolonged use of orthodontic appliances
could actually hinder growth.22

Discussion
Figure 4. Regression line and 95% confidence inter- Early growth studies were based on direct an-
val for facial width in females. Values at ages 6 or 7 thropometric measurements of human faces or
and 18 or 19 years were used to calculate the regres-
sion line.

Skeletal Differential
The mandibular posterior extent acts as a limit-
ing factor to the width of the maxillary intermo-
lar width. The review article by Vanarsdall35 pro-
vides great insights into this concept of skeletal
differential and highlights the importance of
early diagnosis of transverse discrepancy. The
difference in intermolar widths of the maxilla
and mandible is referred to as posterior trans-
verse interarch discrepancy. The clinical impli-
cation is that mandibular posterior teeth affect
the maximum extent of maxillary expansion
that a clinician can expect to achieve.

Malocclusions
Transverse development of jaws has been found
to be influenced by malocclusions, such as open-
bite36 or Class II division 1.12 Maxillary skeletal
base widths are smallest in the Class II division 1
category, and the difference in maxillary and
mandibular intermolar widths remained the Figure 5. Regression line and 95% confidence interval
same from 7 to 15 years of age.37 The transverse for nasal width in males. Values at ages 6 or 7 and 18 or
deficiency seen in Class II malocclusion patients, 19 years were used to calculate the regression line.
110 Nanda, Snodell, and Bollu

access to better imaging modalities has limited

researchers to continue using PA views for
growth studies. However, several geometrical ap-
proaches have since been developed to correct
the magnification errors,44 thereby aiding in bet-
ter interpretation of the data from PA views.
Beside superimpositions and image magnifi-
cations inherent in 2-dimensional images, any
attempts to extrapolate a multidimensional con-
cept with 2-dimensional views are debatable.
With the increasing access to cone-beam com-
puted tomography technology, more studies
may be expected to use the benefits that this
advanced imaging can offer. More importantly,
the use of multiple views to evaluate growth
changes is warranted.
Chronologic age serves as a simple milestone
in evaluating growth patterns and making pre-
dictions of future growth. However, several stud-
ies have investigated the accuracy of using
chronologic age as an indicator in comparison
with biological age.45,46 In an attempt to provide
a general guideline to the clinician when evalu-
Figure 6. Regression line and 95% confidence inter-
ating growth patterns, we have used chronologic
val for nasal width in females. Values at ages 6 or 7 and age as a marker to identify key growth mile-
18 or 19 years were used to calculate the regression
line.

dried skulls (craniometry).42 Variations in soft-

tissue thickness limited the accuracy of this ap-
proach. Another major limitation of the anthro-
pometry and craniometry is the inability to
perform longitudinal studies.2 As radiography
evolved, numerous growth studies have been
done using lateral cephalograms as the primary
imaging resource. Implants’ studies alongside
cephalometry have since been used by several
other researchers to monitor growth changes.
Although lateral cephalometric radiographs
can provide a good view to assess vertical and
sagittal growth, the frontal view (A-P) offers a
better perspective in measuring transverse and
vertical growth changes of the face. One major
concern with PA views, however, has been the
potential for magnification errors due to varying
distances between the objects and film. The
weaknesses inherent in PA views were pointed
out by Woods43 several decades ago. For in-
stance, the intercanine width was argued to be
less magnified than the bigonial width because Figure 7. Regression line and 95% confidence interval
the gonial angles are farther away from the film for maxillary width in males. Values at ages 6 or 7 and 18 or
when compared with the upper canines. Lack of 19 years were used to calculate the regression line.
 Transverse Growth of Maxilla and Mandible 111

for the maxilla and the mandible. The mandib-

ular width showed greater increase than the
maxillary width.11,47,48 In contrast, the intermo-
lar width showed greater increases in the maxilla
than the mandible.10,14,24 This distinction is of
great clinical significance in determining the
timing and extent of expansion.
Overdependence on the linear dentoalveolar
dimensional changes carries the risk of overlook-
ing underlying skeletal discrepancies. To estab-
lish sound treatment objectives, it is important
to recognize the correlation between dentoalve-
olar and supporting skeletal structures. This cor-
relation in transverse growth between craniofa-
cial skeletal and dentoalveolar structures has
been highlighted several decades ago.49
A review of some recent literature on trans-
verse growth follows. Using Bjork-type implants,
Korn and Baumrind50 reported longitudinal
data on transverse dimensions of the maxilla
and mandible on a sample of 31 subjects be-
tween ages 8.5 and 15.5 years. Lateral and fron-
tal radiographs were taken annually. Transverse
Figure 8. Regression line and 95% confidence inter- widening was observed in the posterior-most
val for mandibular width in males. Values at ages 6 or
7 and 18 or 19 years were used to calculate the regres-
sion line.

stones, using observations from previous studies.

It is imperative that the readers take into ac-
count individual variations when making infer-
ences on growth patterns and predictions.
A caveat to readers is the potential issue of
secular changes. The longitudinal records used
in the current research article were taken from
archives of the Child Research Council, Denver,
CO. The records were collected from the early
1930s to the mid-1960s of the 20th century. It is
possible that the growth behavior and size of the
current population may be earlier maturing and
larger.
A major limitation observed in the majority of
growth studies attempting to predict growth ex-
tent is the use of a certain age as near comple-
tion. Although transverse growth may be com-
plete by late adolescence, growth is found to
continue in other dimensions. Relative growth
in other dimensions could erroneously hamper
true calculations when one attempts to identify
Figure 9. Regression line and 95% confidence inter-
the complete extent of growth in 1 dimension. val for mandibular width in females. Values at ages 6
Several studies showed that the skeletal and or 7 and 18 or 19 years were used to calculate the
dentoalveolar growth increments are different regression line.
112 Nanda, Snodell, and Bollu

and girls. The authors found that the growth

patterns are similar in both genders until 11
years, and some differences are observed beyond
12 years.
The implant study by Gandini and Buschang28
was performed on a sample of 25 subjects between
12 and 18 years of age. Using Bjork’s technique,51
implants were placed on the maxillary and man-
dibular corpora. In the maxilla, implants were
placed on either side of the anterior nasal spine
for anterior measurement and on the zygomatic
process bilaterally for the posterior measurements.
In the mandible, implants were placed inferior to
the first molar bilaterally for posterior measure-
ment and in the midsymphyseal region anteriorly.
Lateral and frontal radiographs were taken peri-
odically during the study to capture the movement
of the implants along with skeletal growth-related
dimensional changes. The anterior maxillary im-
plants showed a decrease of 0.2 mm, whereas pos-
teriorly, the distance increased by 0.6 mm in the
mandible and 0.8 mm in the maxilla. The maxil-
lary growth was found to be 0.4 mm per year,
Figure 10. Regression line and 95% confidence in- whereas the mandibular growth rate was at 0.1 mm
terval for facial width in males. Values at ages 11 or 12 per year.
and 18 or 19 years were used to calculate the regres-
sion line.

area of the palate at a mean annual rate of 0.43

mm.
With the goal of establishing normative data,
Athanasiou et al14 performed a cross-sectional
investigation on a sample of 588 Australian chil-
dren between 6 and 15 years of age. Findings
from this study showed a gradual increase in the
transverse skeletal dimensions during the study
period. The maxillary and mandibular intermo-
lar widths, however, remained relatively constant
between 9 and 12 years. The ratio between the
maxillary intermolar width and interorbital
width decreased between 8 and 13 years but
increased during 14 and 15 years.
Cortella et al11 in an attempt to generate new
norms for PA cephalometric analyses used the
Bolton-Brush study sample to examine the trans-
verse relationship between the maxilla and man-
dible during growth. This study adjusted the
norms from Bolton-Brush study in accordance
with radiographic enlargement. Statistically sig-
nificant increases in annual rates of growth were Figure 11. Regression line and 95% confidence interval
observed at 7 and 10 years. This study focused on for facial width in females. Values at ages 11 or 12 and 18
the differences in growth patterns between boys or 19 years were used to calculate the regression line.
 Transverse Growth of Maxilla and Mandible 113

was achieved at about 4-5 years later in the sec-

ond molar region. Accelerated increases in the
canine arch width were noted between 5 and 8
years. Maxillary arch width increase was found to
be larger than that of the mandibular arch.
Yavuz et al47 investigated longitudinal trans-
verse and vertical growth changes between 10
and 14 years in a Turkish sample of 45 subjects.
The largest incremental width changes were ob-
served in mandibular intermolar width for the
study period. Gender differences were more no-
table in the transverse skeletal measurements
when compared with the vertical changes. Man-
dibular widths measured at 10 years were 93.2
mm in males and 92.3 mm in females.
Hesby et al9 investigated the growth-related
molar movements and torque changes. They re-
ported that maxillary and mandibular intermo-
lar crown torque changes are accompanied by
concurrent increases in the corresponding inter-
molar widths. Maxillary skeletal and dentoalveo-
lar transverse measurements were found to
reach adult extents by 16.5 years. Greatest width
Figure 12. Regression line and 95% confidence in-
terval for nasal width in males. Values at ages 11 or 12
and 18 or 19 years were used to calculate the regres-
sion line.

The longitudinal PA cephalometric study by

Lux et al13 used radiographs and dental models
of 18 normal occlusion subjects with the aim of
identifying craniofacial and dental transverse
growth patterns. These changes were observed
at 2-year intervals from ages 7 to 15 years. In
both males and females, statistically significant
growth changes were observed in the intermolar
widths between 7 and 11 years. The authors
found that except mandibular intermolar width,
all skeletal and dental transverse dimensions in-
creased from 7 to 15 years. Gender differences
were found to be most pronounced at 15 years.
Stephens et al52 evaluated arch dimensional
changes using radiographs of 21 Caucasian chil-
dren between 2 and 20 years of age. An interest-
ing finding from this study was that the maxi-
mum arch width was achieved not soon after
tooth eruption but 2-3 years later, in general.
The arch width gain was delayed further in the
Figure 13. Regression line and 95% confidence in-
molar region. The maximum arch width was terval for nasal width in females. Values at ages 11 or
noted about 6-8 years, following eruption in the 12 and 18 or 19 years were used to calculate the
permanent first molar region, whereas the same regression line.
114 Nanda, Snodell, and Bollu

Alvaran et al22 developed multiple regression

models for predicting arch widths, using anthro-
pometric measurements, including body size, fa-
cial breath, and height along with tooth sizes. In
this study, a sample size of 473 Colombian mes-
tizo children was grouped into primary, early
mixed, late mixed, and permanent dentitions.
The analysis of variance test showed nonsignifi-
cant interactions with age, gender and occlu-
sion. Using calipers, interpremolar and intermo-
lar widths were measured in each group.
Multiple regression analyses were used to delin-
eate the influences of each independent vari-
able. Beta coefficients were used to predict arch
widths. Bigonial width was found to be the most
influential predictor of interpremolar and inter-
molar arch widths. The sum of the incisor mesi-
odistal widths proved to be the best predictor of
maxillary and mandibular intercanine widths. In
essence, a direct correlation was observed be-
tween arch widths, incisors, and bigonial dis-
tance. For instance, individuals with large inci-
sors and wide bigonial widths can be predicted
Figure 14. Regression line and 95% confidence in- to have wide dental arches. Comparing their
terval for mandibular width in males. Values at ages 11
or 12 and 18 or 19 were used to calculate the regres-
sion line.

changes were observed at the jugale points and

the smallest in the midalveolar point of the man-
dible. The authors indicated that because the
posterior teeth become upright and expand si-
multaneously by 3 mm in the maxilla and 2 mm
in the mandible, spontaneous mandibular molar
uprighting can be expected after maxillary ex-
pansion.
Chvatal et al53 developed the multilevel statis-
tical models for longitudinal craniofacial growth
prediction. Longitudinal cephalograms taken
on subjects from 6 to 10 years were used to
predict craniofacial growth changes from 10 to
15 years. The authors concluded that longitudi-
nal growth curves based on multilevel proce-
dures can accurately reflect on the population
growth curves. They confirmed that 5-year pre-
dictions using these models are highly accurate
and that more longitudinal data do not increase
prediction accuracy. Correlations between pre-
dicted and actual measurements ranged be-
Figure 15. Regression line and 95% confidence in-
tween 0.81 and 0.96. The study also verified terval for mandibular width in females. Values at ages
external validity of the sample using predictions 11 or 12 and 18 or 19 years were used to calculate the
with multilevel models. regression line.
 Transverse Growth of Maxilla and Mandible 115

width was an exception that was only 75%

complete by 6 years of age.
2. Statistically significant differences were found
between male and female measurements: at
age 6 years, between mean width of cranium,
face, and maxilla; at age 12 years, the differ-
ences were between cranial width, maxillary
width, and maxillary-mandibular intermo-
lar(6-6) widths; at age 18 years, all variables
were different, except the nasal width and
mandibular intermolar (6-6) width.
3. In females, the cranial and facial width spurts
were at 8 years and nasal width was at 11
years. In males, the cranial width growth
spurt was at 12 and 14 years, facial width was
at 7 and 15 years, and nasal width spurt was at
10 and 17 years. No growth spurts in the
maxillary and mandibular widths for females
were recorded.
4. Transverse growth of the face is near com-
plete by age 18 years, although, nasal width
still shows growth increments. As growth in
the width of the maxilla and the nose largely
Figure 16. Regression line and 95% confidence in- occurs between 7 and 11 years of age, patients
terval for maxillary width in males. Values at ages 11
or 12 and 18 or 19 years were used to calculate the
regression line.

results with Pont’s index, Schwarz analysis, and

the McNamara rule of thumb, the authors of this
study concluded that multiple regressions serve
as better tools in predicting arch widths.

Summary
Longitudinal records of 50 (25 male, 25 female)
AP cephalometric radiographs were selected
from the archives of Child Research Council,
Denver, CO. From serial cephalometric mea-
surements, growth was evaluated from the group
means. Annual increments for each variable and
periods of growth acceleration were identified.
Growth spurts were defined as the rate of mean
annual growth increment exceeding that in the
preceding annual interval by at least 0.75 mm.
The following observations may be considered:
1. The transverse growth was completed for the
majority of measurements for both males and
Figure 17. Regression line and 95% confidence in-
females by age 18 years. Each of the measure- terval for maxillary width in females. Values at ages 11
ments was complete by over 80% by age 6 or 12 and 18 or 19 years were used to calculate the
years relative to the size at 18 years. Nasal regression line.
116 Nanda, Snodell, and Bollu

Table 9. Predictability for Each Variable at Ages 6

Years and 12 Years
Male Female
Transverse
Measurement 6 Years 12 Years 6 Years 12 Years

Cranial width XXX XXX XXX XXX

Facial width XXX XXX XXX XXX
Nasal width XX XXX X XX
Maxillary width XX XXX XXX XXX
Mandibular width XXX XXX XXX XXX
Maxillary intermolar — XXX — XXX
width (6-6)
Mandibular — XXX — X
intermolar width
(6-6)
Figure 18. Percentage change for each variable in XXX, strong; XX, moderate; X, weak.
males and females from age 6 to 12 years expressed as
a proportion of the value at age 6 years. (Color ver-
sion of figure is available online.)
ment planning, further research is warranted in this
area.
requiring orthopedic expansion of the max-
illa may be treated with advantage during this References
period.
1. Goldstein MS: Changes in dimensions and form of the face
5. Linear regression analysis at 6 years revealed and head with age. Am J Phys Anthropol 22:37-89, 1936
strong predictability (R2 ⱖ 0.60) in both gen- 2. Profitt WR, Fields HW, Sarver DM: Contemporary Or-
ders for cranial width, facial width, and man- thodontics, 4th ed. St. Louis, MO: Mosby, 2007
dibular width. The predictability was only 3. Behrents RG: A Treatise on the Continuum of Growth in
moderate (R2 ⬎ 0.40 ⬍ 0.60) for nasal width the Aging Craniofacial Skeleton. Ann Arbor, MI, University
of Michigan Center for Human Growth and Development,
and maxillary width. However, at age 12 1984
years, the predictability for all craniofacial 4. Meredith HV: Changes in form of the head and face
and dentoalveolar transverse measurements during childhood. Growth 24:215-264, 1960
was strong. 5. Edwards CB, Marshall SD, Qian F, et al: Longitudinal study
of facial skeletal growth completion in 3 dimensions. Am J
Our data show a strong predictive potential at Orthod Dentofacial Orthop 132:762-768, 2007
12 years of age when measuring transverse 6. Ricketts RM, Roth RH, Chaconas SJ, et al: Orthodontic
growth in the craniofacial and dentoalveolar Diagnosis and Treatment Planning, Denver, CO: Rocky
Mountain Data Systems, 1982
structures. Considering the clinical implications 7. Ricketts RM: Perspectives in the clinical application of
of growth predictions in effective orthodontic treat- cephalometrics: The first fifty years. Angle Orthod 51:
115-150, 1981
8. Wagner DM, Chung CH: Transverse growth of maxilla
and mandible in untreated girls with low, average and
MP-SN angles: A longitudinal study. Am J Orthod Dento-
facial Orthop 128:716-723, 2005
9. Hesby RM, Marshall SD, Dawson DV, et al: Transverse
skeletal and dentoalveolar changes during growth. Am J
Orthod Dentofacial Orthop 130:721-731, 2006
10. Snodell SF, Nanda RS, Currier GF: A longitudinal cepha-
lometric study of transverse and vertical craniofacial
growth. Am J Orthod Dentofacial Orthop 104:471-483,
1993
11. Cortella S, Shofer FS, Ghafari J: Transverse development
of the jaws: Norms for the posteroanterior cephalomet-
ric analysis. Am J Orthod Dentofacial Orthop 112:519-
522, 1997
Figure 19. Percentage change for each variable in 12. Tollaro I, Baccetti T, Franchi L, et al: Role of posterior
males and females from age 6 to 18 years expressed as interarch discrepancy in Class II, Division1 malocclusion
a proportion of the value at age 6 years. (Color ver- during the mixed dentition phase. Am J Orthod Dento-
sion of figure is available online.) facial Orthop 110:417-422, 1996
 Transverse Growth of Maxilla and Mandible 117

13. Lux CJ, Conradt C, Burden D, et al: Transverse develop- 35. Vanarsdall RL: Transverse dimension and long-term sta-
ment of the craniofacial skeleton and dentition between 7 bility. Semin Orthod 5:171-180, 1999
and 15 years of age—A longitudinal postero-anterior ceph- 36. Hsu BS: The nature of arch width difference and palatal
alometric study. Eur J Orthod 26:31-42, 2004 depth of the anterior open bite. Am J Orthod Dentofa-
14. Athanasiou AE, Drosch H, Bosch C: Data and patterns of cial Orthop 113:344-350, 1998
transverse dentofacial structure of 6- to 15-year-old chil- 37. Lux CJ, Conradt C, Burden D, et al: Dental arch widths
dren: A posteroanterior cephalometric study. Am J Or- and mandibular-maxillary base widths in Class II maloc-
thod Dentofacial Orthop 101:465-471,1992 clusions between early mixed and permanent dentitions.
15. Maurice TJ, Kula K: Dental arch asymmetry in the mixed Angle Orthod 73:674-685, 2003
dentition. Angle Orthod 68:37-44, 1998 38. Bishara SE, Bayati P, Jakobsen JR: Longitudinal compari-
16. Snodell SF: A longitudinal study of transverse and vertical sons of dental arch changes in normal and untreated Class
craniofacial growth [master’s thesis]. Oklahoma City, OK, II, Division 1 subjects and their clinical implications. Am J
University of Oklahoma Health Sciences Center; 1991 Orthod Dentofacial Orthop 110:483-489, 1996
17. Pont A: Der Zahn-index in der orthodontie. Z Zahnarztl 39. Baccetti T, Franchi L, McNamara JA, et al: Early dento-
Orthop 3:306-321,1909 facial features of Class II malocclusion: A longitudinal
18. Howe RP, McNamara JA, O’Connor KA: An examination study from the deciduous through the mixed dentition.
of dental crowding and its relationship to tooth size and Am J Orthod Dentofacial Orthop 111:502-509, 1997
arch dimension. Am J Orthod 83:363-373, 1983 40. Nanda RS: The contributions of craniofacial growth to
19. Schwarz AM, Gratzinger M: Removable Orthodontic Ap- clinical orthodontics. Am J Orthod Dentofacial Orthop
pliances. Philadelphia, PA: W. B. Saunders, 1966 117:553-555, 2000
20. Bonwill WG: Geometric and mechanical laws of articu- 41. Fleming PS, Dibiase AT, Lee RT: Arch form and dimen-
lation. Trans Odont Soc 119-133, 1885 sional changes in orthodontics. Prog Orthod 9:58-64, 2008
21. Nimkarn Y, Miles PG, O’Reilly MT, et al: The validity of 42. Hellman M: An introduction to growth of the human
maxillary expansion indices. Angle Orthod 65:321-326, face from infancy to adulthood. Int J Orthodontia Oral
Surg Radiogr 18:777-798, 1932
1995
43. Woods GA: Changes in width dimensions between cer-
22. Alvaran N, Roldan SI, Buschang PH: Maxillary and man-
tain teeth and facial points during human growth. Am J
dibular arch widths of Colombians. Am J Orthod Dento-
Orthod Dentofacial Orthop 36:676-700, 1950
facial Orthop 135:649-656, 2009
44. Hsiao TH, Chang HP, Liu KM: A method of magnifica-
23. Savara BS, Singh IJ: Norms of size and annual incre-
tion correction for postero-anterior radiographic ceph-
ments of seven anatomical measures of maxilla in boys
alometry. Angle Orthod 67:137-142, 1997
from 3 to 16 years of age. Angle Orthod 38:104-120, 1968
45. Moorrees CFA, Chadha JM: Available space for the inci-
24. Sillman JH: Dimensional changes of the dental arches:
sors during dental development—a growth study based
Longitudinal study from birth to 25 years. Am J Orthod
on physiologic age. Angle Orthod 35:12-22, 1965
Dentofacial Orthop 50:824-842, 1964
46. Moorrees CF, Reed RB: Changes in dental arch dimen-
25. Meredith HV: Growth in bizygomatic face breadth dur-
sions expressed on the basis of tooth eruption as a
ing childhood. Growth 18:111-134, 1954 measure of biologic age. J Dent Res 44:129-141, 1965
26. Wei SH: Craniofacial width dimensions. Angle Orthod 47. Yavuz I, Ikbal A, Baydaş B, et al: Longitudinal posteroan-
40:141-147, 1970 terior changes in transverse and vertical craniofacial
27. Martin DC, Danforth ME: An analysis of secular change structures between 10 and 14 years of age. Angle Orthod
in the human mandible over the last century. Am J Hum 74:624-629, 2004
Biol 21:704-706, 2009 48. Huertas D, Ghafari J: New posteroanterior cephalomet-
28. Gandini LG, Buschang PH: Maxillary and mandibular ric norms: A comparison with craniofacial measures of
width changes studied using metallic implants. Am J children treated with palatal expansion. Angle Orthod
Orthod Dentofacial Orthop 117:75-80, 2000 71:285-292, 2001
29. Chen F, Wu L, Terada K, et al: Longitudinal intermax- 49. Meredith HV, Higley LB: Relationship between dental
illary relationships in Class III malocclusions with low arch widths and widths of face and head. Am J Orthod
and high mandibular plane angles. Angle Orthod 77: Dentofacial Orthop 37:193-204, 1951
397-403, 2007 50. Korn EL, Baumrind S: Transverse development of the
30. Hawkins AC: Mouth breathing as the cause of malocclusion human jaws between the ages of 8.5 and 15.5 years,
and other facial abnormalities. Tex Dent J 83:10-15, 1965 studied longitudinally with use of implants. J Dent Res
31. Paul JL, Nanda RS: Effect of mouth breathing on dental 69:1298-1306, 1990
occlusion. Angle Orthod 43:201-206, 1973 51. Bjork A: Facial growth in man, studied with the aid of
32. Kiliaridis S: Masticatory muscle influence on craniofacial metallic implants. Acta Odontol Scand 13:9-34, 1955
growth. Acta Odontol Scand 53:196-202, 1995 52. Stephens S, Currier F, Nanda RS: Growth of the dental
33. Weijs WA, Hillen B: Correlations between the cross- arches: A longitudinal study from 2-22years. J Paediatr
sectional area of the jaw muscles and craniofacial size Dent Care 10:19-22, 2004
and shape. Am J Phys Anthropol 70:423-431, 2005 53. Chvatal BA, Behrents RG, Ceen RF, et al: Development
34. Becker R, Hübner A, Pommerenke F, et al: The tongue and testing of multilevel models for longitudinal cranio-
as a factor in craniofacial growth. The influence of the facial growth. Am J Orthod Dentofacial Orthop 128:45-
width of the lower jaw. Anat Anz 167:81-86, 1988 56, 2005