Craniofacial growth studies in orthodontic

research – lessons, considerations and

controversies
Morgan Wishney, M. Ali Darendeliler and Oyku Dalci
Discipline of Orthodontics, Faculty of Dentistry, University of Sydney, Sydney Dental Hospital, Sydney South West Area
Health Service, Sydney, Australia

The distinguishing features of Class I, Class II and Class III craniofacial growth have been subjects of orthodontic research since
the middle of the 20th century. However, the moral and practical issues related to studying craniofacial growth in modern times
have presented unresolved challenges to researchers. While previous longitudinal growth investigations are typically based
on historical data sets, the cephalometric growth studies of contemporary populations must now rely on cross-sectional data.
Furthermore, clinical orthodontic research has faced similar ethical challenges in which therapeutic outcomes are analysed using
historical control data. These limitations, amongst others, have obscured the conclusions that can be drawn from both types of
studies. This article begins with a review of the defining characteristics of Class I, Class II and Class III growth and then explores
the limitations of growth studies and the use of historical control groups in orthodontic research.
(Aust Orthod J 2018; 34: 61-69)

Received for publication: August 2017

Accepted: February 2018

Morgan Wishney: levelandalign@gmail.com; M Ali Darendeliler: ali.darendeliler@sydney.edu.au; Oyku Dalci: oyku.dalci@sydney.edu.au

Introduction individuals grow with reference to the distinguishing

The orthodontic profession has had a long-standing features identified in growth studies. A second part
of the review considers key methodological issues
interest in the growth pattern of different facial types.1
underlying growth research and the problems arising
This has been driven by a desire to understand the
from historical growth data when used as a control
aetiology of malocclusions and to improve therapy.
comparison.
Understanding growth differences between individu-
als is important, not only for diagnosis but also for
understanding treatment effects and relapse. Despite Class I
its many limitations,2 lateral cephalometry has been Early anatomists noted that pre- and postnatal
the traditional tool to study the growth of the face development occurred in a ‘wave adopting a head
and jaws. The moral and practical challenges of gath- to tail direction’,3 giving rise to the concept of a
ering observational growth data using cephalograms ‘cephalocaudal gradient’. In childhood, the relative
has been partly overcome by using historical data as maturity of the maxilla in relation to the mandible
well as cross-sectional studies. Historical growth data gives rise to a profile convexity that can make it
is also used to construct control groups for orthodon- difficult to differentiate a Class I from a Class II
tic research in which concurrent controls may not be growth pattern.4
feasible on ethical grounds. The growth of the maxilla is closely related to the
The present literature review firstly examines how maturation of the cranial base (and brain),5-9 and
untreated Class I, Class II/1, Class II/2 and Class III from approximately six years of age until adulthood

© Australian Society of Orthodontists Inc. 2018 Australasian Orthodontic Journal Volume 34 No. 1 May 2018 61
 WISHNEY, DARENDELILER AND DALCI

the maxilla has a small but steady rate of growth.10 relationship between skeletal growth and profile
Longitudinal studies show that during puberty and change is rarely linear.28 A relatively large growth
adolescence the horizontal growth of the mandible of the nose during and after adolescence is well
exceeds that of the maxilla by about twofold in Class documented22,29 and longitudinal data suggest that lip
I individuals.5,6,11 This ‘differential horizontal growth’, thickness peaks around mid-adolescence,15,30 whilst
in combination with a tendency in most individuals lip length continues to increase7,15 into adulthood.
for forward (clockwise) mandibular rotation,12-14 A recently-published investigation using consecutive
results in a characteristic profile straightening as Class laser scans found that, whilst soft tissue growth was
I children mature.5,7,8,15 Cross-sectional data reflect generally constant before and during puberty, mid-
this change by a decline in the proportion of Class II facial height had a greater increase pre-puberty and
individuals in the population from childhood through chin projection increased more during puberty.31
adolescence.16
Facial growth in the transverse dimension is less well
Class II division 1
documented than growth in the anteroposterior
and vertical dimensions.17 Transverse growth of A key difference between a Class I and Class II/1
the mandible and maxilla is closely related to the growth pattern is that the ‘normal’ profile convexity
maturation of the cranial base due to their common seen in childhood persists or worsens in Class II/1
articulation.18 Consequently, about 80% of transverse during puberty, whereas in Class I individuals it
facial growth is completed by the age of six years.11,19 straightens.5,32 Although the malocclusion pattern in
Thereafter, there is a slow decline in the rate of the mixed dentition is generally stable with age,10,33
transverse growth of both jaws.20 Interestingly, it has been found that some individuals initially
however, mandibular width increases more than classified as Class II in childhood can experience ‘catch-
maxillary width during adolescence,20,21 which could up’ growth to become Class I during puberty.34,35
help preserve occlusal contacts as the mandible Similarly, some Class I children may become Class
undergoes differential horizontal growth. II.34 However, the transformation of Class II to Class
The pattern of vertical development is established early I via adolescent growth has been questioned33 and
and persists throughout life.5,7,22 During childhood it is possible that such observations reflect the early
and adolescence, the total vertical growth of the difficulty of differentiating milder cases of Class II
face exceeds both transverse and sagittal growth.9,11 from Class I growers.
Vertical facial growth largely reflects maxillary descent There has been historical debate regarding whether
from the cranial base,5 as well as vertical alveolar maxillary protrusion36-38 or mandibular retrusion4,9,39-41
development.23 Implant studies demonstrate that is the most common cause of the Class II/1 pattern.
rotations of both the maxilla and mandible take place, It has been proposed that mandibular deficiency is
but these are mostly masked by remodelling.13,24 more prevalent since the mandible matures later than
According to the servosystem theory of facial growth, the maxilla and, consequently, is more susceptible to
maxillary descent also promotes mandibular growth adverse environmental influences.4 The majority of
by creating occlusal interferences that cause postural the literature using longitudinal rather than cross-
adaptation and stimulate growth.25 sectional data points to a lack of mandibular growth
Maxillary vertical growth must be matched by as the predominant cause of Class II/1.4,33-35,41,42 It is
vertical growth of the mandible, otherwise backward also possible that a Class II/1 pattern might develop
(counterclockwise) rotation will redirect mandibular in an individual in whom mandibular length increase
length gain vertically, rather than horizontally, and is normal but the mandible is either retropositioned9,43
create a retrognathic profile.8 In this respect, it has been or hyperdivergent.8,44,45
estimated that 1 mm of vertical mandibular growth A vertical growth pattern may predispose to a Class
can counteract 1 mm of horizontal length increase.26 II/1 by redirecting mandibular growth more down-
Therefore, hyperdivergent individuals require more ward and backward.8 Indeed, some studies have noted
growth in mandibular length than hypodivergent an increased gonial angle46 or an overall increased ver-
faces for a Class I relationship to eventuate.7,27 tical growth tendency in Class II/1 individuals.41,45,47
Due to the variable thickness of the soft tissues, the Similarly, a more obtuse cranial base angle may

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 CRANIOFACIAL GROWTH STUDIES IN ORTHODONTICS

predispose the mandible to a more retrognathic po- normal maxilla9,65-67 and variable mandibular size.9,57
sition, and some studies have implicated this in the Alternative studies have shown a tendency for a
development of a Class II/1.34,42,48 Alternative studies, small53,65,67 and/or retropositioned mandible64,66,67
however, have not been able to show any differences whilst others report that mandibular size and position
in cranial base flexure33,41,49 or glenoid fossa position is comparable with Class I individuals.57,65 Notably,
of a Class II/1 compared with a Class I pattern.50 Lux et al. found in their comparison of Class II/I
In the transverse dimension, there is a propensity and Class II/2 malocclusions that differences in
for a Class II/1 to be characterised by maxillary mandibular size depended upon which geometric
constriction.45,50-52 This observation has led plane of reference was used for the cephalometric
researchers to implicate maxillary constriction as an measurements.32
aetiological factor in the development of a Class II/1 There is a tendency for a decreased lower anterior face
as the mandible assumes a more posterior position to height in Class II/2,9,57,64 although this is not a universal
optimise occlusal contact.50 finding.53,66,67 The few published longitudinal studies
have shown a vertical deficiency that is evident in
childhood and the production of smaller increments
Class II division 2 of vertical growth throughout adolescence.9,57 These
There has been considerable and ongoing debate studies9,57 have also demonstrated a more acute gonial
regarding the diagnostic criteria related to a Class angle, which also agrees with reported cross-sectional
II/2.53,54 Angle originally described a Class II/2 as data, 9,65,68 as well as studies showing a pronounced
molar distocclusion in combination with incisor forward mandibular rotation.14,49,54 Consequently,
retroclination.55 Whilst the latter part of this characteristic profile features of a Class II/2 include
definition seems agreed upon, the other characteristics a well-defined chin64,65 and pouting of the lips with a
of this malocclusion are varied and consensus about tendency towards lower lip eversion.56
the growth pattern and morphology of a Class II/2 In light of these findings, authors have proposed that
is lacking.56 Furthermore, nearly all of the Class II/2 the Class II/2 is a distinct entity characterised by a
growth research has been cross-sectional in design and skeletal pattern somewhere between a Class I and Class
few longitudinal investigations exist.9,57 II/1, and a tendency toward hypodivergence.54,64,65
The discrepancies between the findings of various Others have suggested that incisor inclination is the
studies on Class II/2 growth have been well only feature that distinguishes a Class II/2 from a
recognised.56 The only common finding of the cited Class I,66,67 or a Class II/1.53
Class II/2 investigations appears to be upper incisor
retroclination. This is not surprising since this
represents the common inclusion criterion of subjects Class III
participating in these studies. It has been proposed Longitudinal growth studies of Class III individuals
that hypo-occlusion of the posterior segments causes have traditionally been lacking due to the relatively low
excessive resting upper lip pressure against the upper incidence of this occlusion in Caucasian populations
incisors resulting in their retroclination.58 The resulting and the propensity to treat Class III patients early.
influence of the upper incisor on the position of the As for Class II/2, the majority of Class III growth
mandible has been the subject of ongoing debate,59 studies have been cross-sectional in design and require
with some suggesting that the mandible is forced into a inferences from population averages.
posterior position from upper incisor retroclination,60 Although there has been a historical trend to make a
while others dispute this hypothesis.59,61 Another Class III malocclusion synonymous with mandibular
perspective is that a deep overbite in a Class II/2 prognathism,69 a deficient, or retropositioned, maxilla
restrains the mandibular dentition from growing may also be the cause.70,71 Similar to a Class II/1,
forward with the basal bone.54,56 cranial base morphology has been implicated in the
Individuals who are Class II/2 do not show the Class III phenotype. Shorter anterior cranial base
characteristic upper arch constriction observed in lengths have been associated with midface deficiency
a Class II/1.52,62-64 The majority of growth studies and an acute cranial base angle.70,72 A more anteriorly
suggest that a Class II/2 is characterised by a placed glenoid fossa33,73,74 has been associated with

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 WISHNEY, DARENDELILER AND DALCI

mandibular prognathism. Whilst these distinctions Cross-sectional studies involve comparing different
are important from the point of view of appreciating individuals at different stages during growth by using
the possible aetiology of a Class III malocclusion, averages. Whilst this methodology makes it easier to
the distinction between length versus a positional evaluate a larger sample size, interpretation is confined
discrepancy seems to have little bearing on therapeutic to inferences between growth stages and only tends
considerations in true skeletal Class III cases. to detect significant changes.44 Alternatively, longit-
Longitudinal75 and cross-sectional data69,74,76-78 show udinal data allows a clearer examination of the
that a Class III skeletal pattern is established early in growth trajectory since data are gathered on the same
life, although the sagittal differences between Class I individuals. However, ethical issues surrounding
and Class III may not be distinct in facial patterns radiation exposure means that longitudinal studies are
with vertical excess.78 The growth pattern of a Class now largely confined to historical populations, who
I and Class III is not dissimilar, in the sense that the are mostly Caucasian and may not be representative of
maxillary position tends to maintain a stable position contemporary populations (discussed below).
over time,69,72,77,79 regardless of whether it is classified Recent research has also suggested that many growth
as ‘normal’72 or ‘retrusive’,75-77 and mandibular growth studies may have been underpowered. This was
accounts for a worsening of profile concavity.71,72,80-83 highlighted by Yoon and Chung, who calculated
When present, maxillary hypoplasia appears to be that a sample size of between 79 and 143 individuals
multidimensional, since transverse75 and vertical was required for their longitudinal growth study.
deficiencies have also been reported in Class III Unfortunately, this was a size beyond the number of
individuals.69,76,77 subjects available to the authors, and is significantly
While the mandibular growth peak in Class III sub- larger than sample sizes in previously-published
jects occurs around the same time as Class I indi- studies.85
viduals, it is typically longer in duration and more Growth research has also suffered from a general
intense.77,79 Rapid mandibular growth has been ob- trend of relying on dental inclusion criteria to
served well into Cervical Stage 6, with gains in length provide a sample for analysis. The assumption that
of over 6 mm per year for males and 4 mm for females a malocclusion is representative of an underlying
during this time.72,77 Although these observations are skeletal base dates back to Edward Angle.86 Although
limited by their cross-sectional nature, a longer and lateral cephalometry has subsequently shown that
more intense mandibular growth spurt in Class III this is not always true,87 a considerable amount of
cases is consonant with clinical experience. growth research has continued on this assumption.
A tendency toward a more vertical growth pattern in For example, a Class II/1 malocclusion may not
Class III individuals has also been reported,69,71,75-77,83 necessarily have a skeletal component,51 and the
although, in some cases, a vertical growth pattern may number of dental Class II patients who also have
effectively mask a prognathic mandible.83 Similarly, a skeletal Class II has been estimated to be around
incisor angulations may also mask the skeletal 75%.4 Similarly, the Class III malocclusion has at least
disharmony in Class III cases.84 three distinct skeletal subtypes69 that can all present
with a reverse overjet. A reverse overjet may also arise
from a functional shift (pseudo-Class III), in which
Methodological limitations of growth case the underlying skeletal base could be Class I,
research II or III (Figure 1). Therefore, using overjet as an
The above discussion has presented key findings inclusion criterion in either a Class II/1 or a Class III
reported in the literature, which distinguish the growth study makes it difficult to draw meaningful
growth patterns of different facial types. Studies have conclusions, since it is difficult to be certain of the
not always agreed on where these differences lay, and skeletal patterns under examination. A similar
the possible reasons for this are important to consider. criticism has been made of randomised controlled
trials (RCT) of Class II treatment.88 A summary of the
One major cause for discrepancies is the comparison limitations of growth research is presented in Table I.
of cross-sectional and longitudinal data. It has been
shown that longitudinal and cross-sectional analysis of
the same population leads to different conclusions.44

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 CRANIOFACIAL GROWTH STUDIES IN ORTHODONTICS

Figure 1. Each of the patients shown above have a reverse overjet of 3 mm but different growth patterns.

Table I. Limitations of growth research. allocation of subjects to either the control or inter-
Study Aspect Description vention,90 ethical and practical constraints (e.g., radia-
Inclusion criteria Dental versus skeletal discrepancies tion exposure and the withholding of treatment) have
meant that this is not often possible in the modern
Phenotypic variation within the same
malocclusion category context. In the past few years HCG data have become
freely available online the via the Craniofacial Growth
Variations in vertical growth pattern
Legacy Collection of the American Association of
Chronological verses skeletal age
Orthodontists Foundation (AAOF).91
Ethnic variations
The use of HCG in medicine has been mooted for
Exclusion of severe cases
almost half a century.92 Although there has been a
Secular trends modest increase in orthodontic randomised controlled
Study design Cross-sectional versus longitudinal trials in recent times,93 the use of HCG in orthodontics
data is still relatively common.94 As the profession shifts
Varying observation periods towards an ‘evidence-based’ paradigm, there has been
Insufficient sample size a natural interest in evaluating treatment outcomes,95
Data analysis Cephalometric tracing error which may account for the continued popularity of
the HCG in orthodontic research.
Variation in cephalometric analyses
For a control group to be valid, it must be com-
parable with the intervention group with respect
The use of historical controls in to all prognostic factors.96 Therefore, the relevant
orthodontic research prognostic factors of facial growth include maturation
Historical facial growth studies have also found ap- stage, gender and ethnicity, as well as the vertical and
plication in the creation of historical control groups sagittal skeletal pattern. Nevertheless, studies using
(HCG) in orthodontic research. A control group in HCG have not always matched ethnicity,97 or they
medical research provides a standard against which have used the occlusion as an indicator of the skeletal
a therapy can be evaluated.89 Whilst this is ide- pattern,98,99 or chronological age as in indicator of
ally achieved through a prospective and randomised maturity.100 Furthermore, even if it was feasible to

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 WISHNEY, DARENDELILER AND DALCI

match control and intervention groups for all relevant was used, which itself tends to bias results in favour of
growth variables, the problem of secular changes therapy.117 Whilst the reason for the negative direction
would remain. Craniofacial morphology appears to of this effect remains unclear, these results suggest that
be more prone to secular trends than the other bones readers should be cautious in how they interpret the
in the body.101,102 Antoun et al. recently measured findings of research using HCG.
the cephalometric records of 138 adolescents from
multiple growth collections over three generations in
the AAOF Legacy Collection, and found a general Conclusion
increase in the size of the maxilla and cranial base The present review has provided a summary of the
with a concomitant reduction of the ANB angle.103 characteristic features of Class I, Class II/1, Class II/2
Although no significant trends in mandibular length and Class III growth as presented in the literature,
were detected, other research has pointed to a tendency and has considered some of the limitations associated
towards a longer and narrower mandible noted in the with growth research in orthodontics. Although it is
first half of the twentieth century,104 and an earlier possible to create a general picture of the differences
onset of peak mandibular growth.102 in the respective growth patterns, methodological and
An additional requirement for control group valid- practical limitations associated with growth research
ity is a random selection of all the potentially avail- have, at times, led to contradictory findings that make
able patients.96 Although it is speculative to consider it difficult to obtain a detailed understanding and
whether historical participants were a random selec- draw firm conclusions. Additionally, recent evidence
tion of their contemporaries, within the study design has cast doubt on the validity of HCGs in orthodontic
eligible subjects should ideally be chosen in a random research generally, and so the conclusions drawn from
fashion from a database. Unfortunately, however, such studies need to be viewed accordingly.
studies generally do not specify how the HCG was
constructed beyond the inclusion criteria and name
Corresponding author
of the database(s) used. No doubt this reflects the lim-
ited availability of suitably matched controls. How- Morgan Wishney
ever, it does open the process to a selection bias that is Orthodontics Department
difficult to quantify. Sydney Dental Hospital
2 Chalmers St, Surry Hills
A final consideration is that the magnitude of the
NSW Australia 2010
observed effects in orthodontic research is typically
small. In general, the lesser the treatment effect Email: levelandalign@gmail.com
observed, the greater the potential influence of
bias on the outcome of the study.105 Orthodontic
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