CHAPTER 3

CHAPTER 3

A BERRANT F
ABERRANT ACIAL G
FACIAL GROWTH
ROWTH

Chapter one emphasized how long-term development and that its consequence is
Chapter
muscle one emphasized
‘Posture’ can change how bonylong-term
form by malocclusion but
malocclusion but we
we still
still need
need to
to have
have aa clear
clear
inches rather than millimetresbony
muscle ‘Posture’ can change even form by
if little idea of how this happens and what
idea of how this happens and what can be can be
inches rather
obvious force is than millimetres
involved (Fig I/5).even if little
Clinicians done to
done to diagnose
diagnose and
and hopefully
hopefully treat
treat it.
it.
obvious force
frequently talkisofinvolved
‘Function’ (Figand
I/5). Clinicians
‘Functional
frequently talk
Appliances’ of ‘Function’
despite being and ‘Functional
aware that This was
This wasa subject
a subjectthatthat
fascinated Arne Bjork.
fascinated Arne
Appliances’
‘activity’ despite
has little affect being
on the aware
teeth that and We discussed
Bjork. in the 1st
We discussed in chapter
the 1st how bonehow
chapter has
‘activity’
bone. has little
However, affect and
posture on the teeth and
function are a tendency
bone has atotendency
remodel, thus disguisingthus
to remodel, any
bone. However,
intimately related,posture
contrasting andonly function
in time.are If underlyingany
disguising movement
underlying andmovement
how this has andmisled
how
intimately
you bite your related,
teethcontrasting
together they onlywillin time.
hardlyIf clinicians
this in the past.
has misled Bjork bravely
clinicians decided
in the past. to
Bjork
you bite
move butyourkeepteeth
themtogether
in contact theyover will hardly
a period insert metal
bravely implants
decided to into
insertthemetal
facial implants
bones of
move
of justbuta few keep them
hours and in they
contactwillover a period
certainly do somethe
into of facial
his patients.
bones There
of some is no
of way that this
his patients.
of just
so, evena withfew hours,
forces they will
of just certainly
a few grams. doItso,
is would isbeno
There allowed
way that these
thisdays
wouldandbe this makes
allowed
evenimportant
very with forcesthat of just a few grams.
all clinicians It is very
understand it all the
these daysmore
andimportant
this makes to it
make use of
all the his
more
important
this and actthat on it.all clinicians understand this material. He
important to initially
make use started
of histhese studies
material. He
and act on it. to discover what happened to the mandible
As we discussed in chapter I, Proffit Figure III/1
As we that
suggested discussed
a lightinforce chapter
maintained I, Proffitfor
suggestedfour
between thatanda light
eightforce
hoursmaintained
a day would for How the Upper Jaw Affects
between afour
maintain givenand eight hours
occlusal height.a Indeed
day would the the Growth of the Lower Jaw
maintain aof
influence given
oralocclusal
postureheight.extends Indeedto the the
influence
Cranial Vault,of oral posture and
Basi-cranium extends to the
less directly
Cranial
to Vault,
the spinal Basi-cranium
vertebra where the andphenomenon
less directly
to ‘postural
of the spinal deformity’
vertebra where the phenomenon
has been recognized
of ‘postural
for many years. deformity’
There has has been
been muchrecognized
debate
for many
within years. There
Chiropractic and hasOsteopathic
been much debate circles
within
on Chiropractic
‘Ascending’ and Osteopathic
and ‘Descending’ circles
influences
onsome
as ‘Ascending’
considerand that‘Descending’
distortion of influences
the lower 51 average
as some
spine andconsider
legs is the that distortion
initial of theothers
factor while lower
Bjork 1964.
spine is that
believe the initial
manyfactorof these while others believe
distortions arise
that birth
manytrauma of these distortions arise from 54 average
from to the cranial bones.
birth trauma to the cranial bones. Ruf 2001
There is little convincing research in this Bjork (1984) showed that the maxilla may grow
There
field is littleit convincing
because is almost research
impossible in this
to horizontally or vertically
field because
measure long-term it posture
is almost but impossible
I am confidant to
measure
that it willlong-term
eventuallyposture be but I am confidant
established that during growth
initially started but
these he studies
soon realized that
to discover
that‘precipitating’
the it will eventually factors be forestablished
malocclusion, that the maxilla
what happenedwas the
to crucial bone. Hisduring
the mandible 1966
the ‘precipitating’
include factors forand
nasal restriction malocclusion,
tongue- study showed
growth that realized
but he soon the mean thatdirection of
the maxilla
are nasal restriction and tongue-between–
between-tooth-swallows, usually arising maxillary
was growth
the crucial for aHis
bone. selected
1966 studygroup of 37
showed
tooth-swallows,
from reduced muscle usually
tone, coupled
soft diet with and boysthe
that wasmean51 (Figure III/1)
direction ofbut he noted
maxillary that
growth
reduced muscle tone, soft diet and allergies.
allergies. theya “varied
for selected individually
group of from almost
37 boys waspurely
51
sagital to
(Figure purely
III/1) but vertical”.
he noted This thatisthey
a very wide
“varied
What Actually
What Actually Goes
Goes Wrong?
Wrong? range and itsfrom
individually impact on mandibular
almost growth
purely sagital to
can be imagined
purely vertical”. (Figure
This is I/7).
a very wide range
II hope
hope we
we cancan now
now accept
accept that
that incorrect
incorrect
and its impact on mandibular growth can be
oral posture
posture is
is the
the major
major factor
factor in
in facial
facial mal-
mal- Bjork (Figure
was in
oral
development and that its consequence is imagined I/7).fact confirming the
observations of Schwartz (1961) who

42 42

Bjork was in fact confirming the
observations of Schwartz (1961) who
demonstrated that all the common
malocclusions can be reproduced by swinging
the maxilla from an imaginary point ‘T’ a
short distance above it. He suggested that
malocclusion was due to the maxilla being,
either set down, set back or too small but
sadly he was ignored. More recently this was
confirmed by Dibbets (1996) who found that
“The difference between the Angle classes is
the cranial base” and concluded that “... the
mid-face above anything else creates the
characteristic difference between the three
Angle classes, not the mandible.” Sadly he
also has been largely ignored.
Battagel (1996) showed that lateral skull
X-rays do not always demonstrate this
displacement and later we will discuss
other means of identifying the position of
the maxilla. Her work too has been largely
ignored. However displacement of the
mandible is more obvious than changes to
the maxilla which may be why most so called
‘Functional’ treatment has been directed at
the former with little regard to the position
of the latter.
A year later, still on the same theme
Dibbets and his colleagues (Trotman 1997)
made a very interesting observation that
if the mouth was left open the face would
grow downwards but “Because the sella-
nasion dimension shortened proportionately,
the SNA and SNB angles were not affected”.
Many orthodontists fail to take this in to
account, but an increase in vertical growth
is constantly associated with a reduction in
the length of the base of the skull and this
disguises some of the change of both the
SNA & SNB angles. I drew attention to what
I called ‘Anterior Facial Collapse’ in the 1960s
although my first published paper on the
subject was not until 1979.
Ruf and his colleagues (2001) superimposed
a series of lateral skull X-rays taken from
an untreated group in the Bolton series
using traditional landmarks and followed
changes in the position of the Pogonion
over time. They found that the mean growth
direction of the mandible was 54º which is
presumably a reflection of the 51º for the
maxilla suggested by Bjork (1966). We should
note that the Bolton cases were not ‘ideal’
just untreated and in aesthetic terms an
Aberrant Facial Growth 3
angle 54º would seem rather high. As we will
discuss later an angle of as high as this is likely
to be associated with some facial flattening
together with a shortage of room for the
wisdom teeth.
At the London School of Facial Orthotropics
we aim for a mandibular growth direction of
around 40º which is almost always associated
with a nice face, little malocclusion and
good long-term stability. However these
are subjective viewpoints and need to be
tested by others because attractive and
unattractive faces can certainly be present
either side of 45º. The increasing use of Thin
Plate Spline Analysis and digital photography
should soon enable these comparisons to be
made without the use of specific landmarks.
The clues to maxillary growth are in
the literature, much of it published many
years ago. For instance Sheldon Peck (1970)
studied a series of good looking film stars
and found that their maxillae and teeth were
more ‘prognathic’ than average. Clearly
forward growing faces look more attractive,
conversely Lundstrom (1987).found that
people with vertically growing faces are less
attractive
Interestingly Peck (1970) also found that
“The general public admires a fuller, more
protrusive dentofacial pattern than customary
cephalometric standards would like to
permit”. This finding was later supported
by others (Tedesco 1983) who found that
“Lay judges seem to be more sensitive than
judges with orthodontic training to dental-
facial esthetic impairment”. This is not just
a Western concept as Soh (2005) using
a sample of Chinese subjects concluded
that “Orthodontists considered a flatter
male profile to be most attractive, but oral
surgeons preferred a fuller normal Chinese
profile”. Later we will discuss my more recent
research into facial appearance (Mew 2010)
which showed that Orthodontists placed a
rather flat face 13th in a sequence of 32 while
the lay judges placed it 32nd.
Other basic work by Platou and
Zachrisson (1983) showed that patients with
‘prognathic’ forward growing faces tend to
have straighter teeth and it is now generally
accepted that horizontally growing faces
look nicer, have straighter teeth, are easier
to treat, and more stable after treatment.
43
3 Aberrant Facial Growth
Muscle tone also plays an important part
in determining the amount of this vertical
growth. Children, who hang their mouths
open, generally have poor body posture
and muscle tone. I am not certain of the
sequence but logic tells me that few children
are born with poor posture or muscle
tone. Malocclusion seems more likely to be
related to today’s soft diets and possibly
lack of exercise in general. Whatever the
reason normal industrialized four year olds
on average leave their mouths open for a
worrying 80% of the time (Glatz-Noll & Berg
1991).
While most people might assume that open
mouth postures encourage vertical growth
there are not many papers to confirm this,
although I know of no evidence to suggest
the reverse. To some extent this is due to
confusion between the terms ‘open mouth
posture’ and ‘mouth breathing’, for the
two are not the same. This will be discussed
in greater detail later, but Trotman (1997)
found that “A more open lip posture was
associated with a downward and backward
rotation of the maxilla and mandible a more
obtuse gonial angle, a retruded mandible,
with retroclined incisors, extruded maxillary
molars and maxillary and mandibular incisors,
and an elongated total face height caused
mainly by a larger anterior face height”. This
should be a powerful incentive for all growing
children to keep their mouths closed.
The surprising thing is that most of this
information has been known for twenty
years or more and yet there has been little
change in orthodontic attitudes. Despite the
findings, few practicing clinicians are making
much effort to change oral posture.
Assessment of Skeletal Relationships.
Angle divided malocclusion into three
classes, I, II and III. He then subdivided the
Class II into division 1 and division 2. This
horizontal classification has the merit of
simplicity although it has some obvious
shortfalls. Johnson (BJO 1996) extended
Angles analysis with his own ‘Pitchfork’
analysis (Fig III/2) which is widely used to
assess the anterior-posterior relationship of
the teeth and jaws as separate units. However
the ‘Pitchfork’ is a purely horizontal analysis
and fails to allow for vertical changes. Some
years ago I suggested the ‘Trident’ analysis
44
as more appropriate (Mew 1996) (figure III/3)
because it is able to allow for changes in the
facial angles and head posture.
Figure III/2
Johnson’s Pitchfork
Maxilla
Alveolus and
Upper teeth
Lower teeth
and alveolus
Mandible
Lylle Johnson’s Pitchfork analysis (BJO 1996)
which analyses the horizontal relationship of the
teeth and jaws as seperate units.,
As discussed in the first chapter the
direction of facial growth varies widely
between individuals in industrialized
societies although there is little variation in
truly primitive countries. Failure to recognize
the importance of variations in growth
direction has severely restricted the progress
of orthodontics.
Figure III/3
Mew’s Trident
Maxilla
Upper teeth
SNBa and alveolus
Lower teeth
MM and alveolus
Mandible
I suggested (BJO 1996) that a Trident analysis
was more appropriate because it could allow for
changes in the tacial planes.
My own interest in Vertical Growth was
raised by a series of cases some of which
I have already mentioned (I/6 and I/7).
However one case in particular was bizarre
as I was conducting some research into
the contrasts between the characters of
individuals with different shaped faces. This
involved comparing a group with mandibular
angles of less than 20º and another with
 Aberrant Facial Growth 3

Figure III/4 Environmental Factors

Age 10 Age 17 Age 17

Open Mouth Postures - A boy who delevoped nasal obstruction. Note the change in Growth Direc-
tion that followed.

He now has a habitual open mouth posture.

angles overwith
individuals 35º.different
I asked shaped
a psychologist to
faces. This What goes
fortunate wrongthe
to witness with FacialtoGrowth?
change these two
assist
involvedmecomparing
and the paper a groupwaswith
one mandibular
of first to individuals as they gave me the first clues to
establish
angles ofa less
relationship
than 20º between facial form
and another with In 1979facial
vertical Bjorkgrowth.
and his colleagues compared
and
anglespersonality
over 35 º. characteristics
I asked a psychologist(Squires,R,
to the craniofacial growth of an Australian
& Mew,
assist meJ.R.C. 1981).
and the Short
paper faced
was one people
of firstare
to aboriginal
What goes andwrong
a Dane.withThey found
Facial that not
Growth?
more conventional,
establish a relationship longbetween
faced lessfacial
so. form only was the growth direction very different
and personality characteristics (Squires,R, & In interestingly
but 1979 Bjork and thehisshape
colleagues
of the compared
individual
About five
Mew,J.R.C. years
1981). Shortlaterfacedthe psychologist
people are more the
facialcraniofacial
bones changed growthveryoflittle,
an Australian
instead it
contacted me long
conventional, to say thatless
faced he thought
so. his own aboriginal and a positions
was the relative Dane. They of found
the bonesthat that
not
son was changing from a horizontal to vertical only was the
changed. growth direction
Presumably very different
the Australian kept his
grower.
About I five
suggested
years that laterhethebrought him to
psychologist but
mouthinterestingly
closed more.the shape
Theseofare the important
individual
see me andme
contacted theytocamesay with
that his
he mother
thoughtwho his facial bones to
observations changed
which we verywill
little,
returninstead
later. it
showed
own sonmewas a photograph
changing from of their son at the
a horizontal to was the relative positions of the bones that
age of ten.
vertical The change
grower. I suggested was remarkable
that he brought (see What isPresumably
changed. it that initially causes so
the Australian many
kept his
figure
him to III/4).
see meHis andmother
they cametold with
me that at the
his mother childrenclosed
mouth to develop
more.openThese mouth postures?
are important
age of
who ten David
showed me a had started keeping
photograph of their sonsomeat Bakor and his
observations colleagues
to which we will(2011) studied
return later.
pet Gerbils
the age of ten.and hadThe subsequently developed
change was remarkable tracheotomized children and found as
an allergy
(see figuretoIII/4).
them.His Somother
much sotold thatme he that
had Whatmany
have is it others
that initially causes sohaving
that “Patients many
required
at the age surgery
of tento restore
David hadhis airway.keeping
started children to develop
predominantly oral open mouth
breathing hadpostures?
smaller
some pet Gerbils and had subsequently Bakor
maxillaryandwidths,
his colleagues
mandibular(2011) widths, studied
and
It is interesting
developed an allergy to see that although
to them. So much his so tracheotomized
facial widths compared childrenwithandnasalfound
breathersas
airway
that heishad
now patent surgery
required he has developed
to restore the his have
(5%)” many others amazingly
but rather that “Patientsalso having
“those
long-term
airway. habit of leaving his mouth open. predominantly
who had been oral breathing had
tracheotomized (6%)”.smaller
The
As a result he has suffered in the same way as maxillary
tracheotomisedwidths,children
mandibular also widths,
had higher and
the
It unfortunate
is interesting girlto
in figure
see thatI/7. although
I was indeed his facial
musclewidths
tone thancompared
either with
of thenasal
other breathers
groups.
fortunate
airway to witness
is now patentthe hechange to these two
has developed the (5%)”
Why, one but wonders,
rather amazingly also “those
should a tracheotomy
individuals habit
long-term as they ofgave me the
leaving first clues
his mouth to
open. who had been
encourage the tracheotomized
mouth to close?(6%)”. Does Thethis
vertical
As a resultfacial growth.
he has suffered in the same way as tracheotomised
suggest that it is children
natural toalsokeephad higher
the mouth
the unfortunate girl in figure I/7. I was indeed muscle
closed?tone than either of the other groups.

45
3 Aberrant Facial Growth

3 It was Luzi Facial

Aberrant (1982) who noticed that the
Growth Essentially the smaller the saddle angle, the
quadrahedron formed by the planes SN, NA, greater the forward growth of the Nasion
ABa and
Why, oneBaS distorted
wonders, in a apredictable
should tracheotomy way and mid-face.
This is highly relevantThese are to ourmovements
discussionthat
in all class Ithe
encourage patients.
mouthAstoSNA increased
close? Does thisNSba benefit
and I havefacial little appearance
doubt that and providethe
retracting more
reducedthat
suggest so that
it istheir combined
natural to keepvalues always
the mouth room for
maxillary the teeth.
incisors in a (Tanabe et al reduces
young child 2002), and
remained the same (Fig III/5): so precise was
closed? of course
SNA and increasesthe reverse also applies.
the saddle angle, taking
this that within a random sample of 160 Class the mandible down and back. This also is a
It was Luzi
I patients the (1982)
sum ofwho the noticed
two angles thatvaried
the veryThese
important rulesconcept
also fittoclass II and III cases
understand.
quadrahedron
less than 2 degrees formed by the planes
(203.5º SN, NA,as
to 205.4º) but not so precisely. As will be seen later
ABa
the and
maxillaBaS hinged
distorted in a an
back; predictable
almost unique way ‘Orthotropics’
Essentially aims to
the smaller theconvert
saddle all occlusions
angle, the
in all class I patients.
consistency As SNA
of biological increased NSba
form. greater
to classtheI,forward
and sogrowth of therule
that Luzi’s Nasion and to
is likely
reduced so that their combined values always mid-face.
apply to Thesemost areBiobloc
movements cases.that Anbenefit
enlarged
remained
Luzi’s workthe same shows(Fig that
III/5):there
so precise
is a wasclear facial appearance
saddle angle isand provide more
associated withroom for all
almost
this
and that
precisewithin a random sample between
inter-dependency of 160 Class the the teeth.
the things (Tanabe
that etorthodontists
al 2002), and of course
don’t want.
ISaddle
patients the and
angle sum ANB;
of theastwo oneangles
increasesvariedthe the reverse
For example also aapplies.
long face, receding chin, flat
less
other than 2 degrees
reduces. This (203.5º
explainstowhy 205.4º) as
forward cheeks, narrow and crowded arches together
the maxilla hinged back; an
growing faces have a low saddle angle and almost unique These rules also
with recurrent fit class
lower incisorII crowding.
and III cases
consistency ofisbiological form. but not so precisely. As will be seen later
vice-versa. It as though the SN plane was
‘Orthotropics’
This obvious aimsconclusion
to convertmust all occlusions
cast doubt
bolted to the base of the skull and the maxilla
Luzi’s work shows that there is a clear toon
class I, and so that
the wisdom of any treatment Luzi’s rule is likelythat
to is
and its associated bones are free to swing
and precise inter-dependency between the apply to most
retractive Biobloc Certainly
in nature. cases. Ananenlarged
increasing
backwards
Saddle angleand andforwards
ANB; as one beneath it, just
increases theas saddle angleofis schools
associatedhave with now almostbanned
all
Schwartz (1961)Thissaid explains
half a century number
other reduces. why before
forward(is the things that orthodontists don’t want.
anyone listening outathere?). retractive headgear as we will discuss later.
growing faces have low saddle angle and For example a long face, receding chin, flat
vice-versa. It is as though the SN plane was cheeks,
Thenarrowsaddleand crowded
angle arches
itself can together
vary quite
This to
bolted is the
highly
baserelevant
of the skull toandourthediscussion
maxilla with recurrent lower and incisor crowding.
and I have little doubt that retracting the widely and Timms Trenouth (1999) found
and its associated bones are free to swing
maxillary incisors in a young child reduces that NSBa
This obvious ranged from 118
conclusion to 138
must castin doubt
a random
backwards and forwards beneath it, just as
SNA and increases
Schwartz (1961) saidthe halfsaddle angle,
a century ago taking
(is onsample
the wisdom of 82 of British
any school
treatment children
that iswith
the mandible
anyone listening down and back. This also is a
out there?).
malocclusion.
retractive However
in nature. I have
Certainly anseen extremes
increasing
very important concept to understand. approaching
number of schools150º and have90ºnow and banned
contrasts

Figure III/5 Luzi, V. 1982.

46
46
 Aberrant Facial Growth
Growth
Aberrant Facial Growth 33
retractive
of this sizeheadgear
retractive
retractive headgear as
aswe
wewill
will be associated
headgear as we willdiscuss
will discuss later.
with entirely
discuss later.
later. Figure III/7
different
The facial
saddle forms
angle despite
itself can their
vary owners
The very
The
having saddle
saddle angle
angle
similar itself can
itself
genes. can vary vary quitequite
quite
widely
widelyand
widely and Timms
andTimms
Timmsand and Trenouth
andTrenouth
Trenouth(1999) (1999)
(1999)found found
found
that
that
that NSBa
NSBaranged
NSBa ranged
ranged from
from118
from 118
118 to
to138
to 138 in
138 in a
in aa random
random
random
Contrasting
sample of 82 Growth
British Patterns.
school children
sample of
sample of 82
82 British
British school children with
school children with
with
malocclusion.
malocclusion. However
However IIa
Figure III/6 illustrates
malocclusion. However I have
have
good
have seen
seen extremes
looking
seen extremes
extremes face
approaching
approaching
and its associated
approaching 150º
150º and
and 90º
150ºskeleton.
and 90º and
and contrasts
90ºOutlines
and contrasts
such as
contrasts
of
of this
this
thisthis
of size
size
aresize will
will
rarewill be
be associated
associated
in orthodontic
be associated with
with and
offices
with entirely
entirely
entirelythe
different
upright
different facial
facial forms
differentcervical
facial spine despite
forms
forms should their
despite
despite owners
theirspecially
be
their owners
owners
having
noted.
having very
havingveryThe similar
verysimilar
similar genes.
genes.
Saddlegenes.Angle (Ba S N) is 111º
giving her
Contrasting an attractive
Growth forward growing
Patterns.
Contrasting
Contrasting
face. Figure III/7 Growth
Growth Patterns.
shows Patterns.
a vertically growing
face with a Saddle
Figure Angle of 136º and curved
Figure III/6
Figure III/6 illustrates
III/6 illustrates a
illustrates aa good
good looking
good looking face
looking face
face
cervical
and its spine.
associated skeleton. Outlines
andits
and itsassociated
associated skeleton. Outlines such
skeleton. Outlines such as
such as
as
this
this
this are
are rare
rare in orthodontic
inseen
orthodontic offices
officesII/7 and
and the the
the
As are canrarebein orthodontic
from Figure offices and

Figure III/6

Her profile superimposed. Note how she has

tilted her head to keep her face vertical.
andIt suggested
It is
is interesting
interesting that “Consideration
that despite should
be It is
giveninteresting
toforthose that despite these
treatment these facts
facts
techniques
being
being
being known
known
known for many
many years,
years, many
many clinicians
clinicians
which
still increase
still believe
believe that dental
the arch length rather than
still
reduce believe
tooth that
mass”.the cause
cause of of most
most dental
dental
crowding
crowding is purely a disproportion
crowding is purely a disproportion between between
arch
arch size
arch size and
size and tooth
and size.
size. Howe
toothsupported et
et al
Howemore al noted
noted in
in
This view was recently
1983
1983 that
1983 that “Statistically
that “Statistically the
the crowded
crowded and
and non-
non-
by Bernabe and his colleagues (2005) who
crowded groups could
crowded
crowded not be distinguished
be
looked at groups could and
150 subjects notfound distinguished
that rather
on the
on the basis
basis of mesio-distal tooth diameters”
on
than the basis
tooth of mesio-distal
size “arch tooth
length is diameters”
the most
and suggested
and suggested that “Consideration should
and suggested
important factor” that
in “Consideration
dental crowding. should
be given
be given to those treatment techniques
be given to those treatment techniques
Note the SN plane is nearly horizontal and the which
which
Figure increase
increase
III/8 A dental
& B show arch length rather
a vertically than
growing
which increase dental arch length rather than
reducebeside
reduce tooth a horizontal one enabling
tooth
cervical spine upright. face
reduce tooth mass”.
mass”.
upright cervical spine
upright spine should be be specially the contrasts
This view to be seen more more clearly. An
recently
droppingcervical
upright cervical
of the spinemaxillashould
should be specially
is associated specially
with This
This viewview was
anthropologist was supported
supported more
for recently
noted. The Saddle
noted. Saddle Angle
Angle (Ba SS N) N) is is 111º
111º Bernabe andcould
by Bernabe be forgiven (2005) thinking
who
a majorThe
noted. The
changeSaddle Angle (Ba
in mandibular (Ba formS N) as is the
111º by
by
that Bernabe
they andfromhis colleagues
his colleagues (2005) who
giving
giving her
her an
an attractive
attractive forward
forward growing
growing looked
looked at come different species.
that rather
giving
vertical her
ramus
face. Figure
an remodels
Figure III/7
attractiveforward
III/7 shows
forward
shows aa vertically
to growing
protect
vertically growing
growing looked at at 150
150 subjects
subjects andand found
found that rather
face.
face.
the Figure
airway. III/7
Clearly shows
this a of
vertically
reduces theand growing
length of
face
face
face
the
with
with
with a
a
horizontal
a Saddle
Saddle
Saddle
ramus
Angle
Angle
Angle
and of
of
with
136º
136º
136º
it theand
and
space
curved
curved
curvedfor
Figure III/8
cervicalspine.
cervical spine.
cervical
the dental spine.
arch, creating another no-no for
anything that
be encourages from vertical growth;
AsAs
As an
again
dropping
dropping
can
can be
canimportant
be the
of
of the
seen from
seen
seen fromis to
concept
maxilla
maxilla is
Figure II/7
Figure
Figure
associated
associated
II/7 the
II/7 with
understand.
the
the
with A B
dropping
a major of the in
major change
change maxilla is associated
mandibular form as aswith
the
a It is interesting
avertical
major change in
in mandibular
that despite
mandibular form
these
form as the
facts
the
vertical ramus remodels
ramus remodels forward
forward to to protect
protect
being
vertical known
theairway. ramus
airway. for manythisyears,
remodels
Clearly forward
reduces many toclinicians
the protect
length of
the
still
the believe
airway. Clearly
that
Clearly this
the
this reduces
cause
reduces of the
most
the length
dental
length of
of
thehorizontal
the horizontalramus ramusand andwith
withititthe thespace
space for
for
crowding
the
thehorizontal
dental is arch,
purely
ramus a and
disproportion
creating with between
it the no-no
another space for
for
the
arch
the dental
size
dental andarch,
tooth
arch, creating
size.
creating another
Howe
another et alno-no
noted
no-no for
in
for
anything that
anything that encourages
encourages verticalvertical growth;
growth;
1983
anything
again that
an “Statistically
that encourages
important the crowded
concept vertical
to and
growth;
understand. non
again
crowded
again an
an important
groups could
important concept
not to
concept be understand.
to distinguished
understand.
on the basis of mesio-distal tooth diameters”
47
47
47
3 Aberrant Facial Growth

Clinicians
than tooth often
size find
“arch it difficult
length to is recognize
the most Figure III/9
this rotation
important on ainlateral
factor” dentalskull X-ray but an
crowding.
upward tilt of the SN plain is a valuable clue.
ForFigure
manyIII/8 A&
years B show
I have useda vertically
a point ‘F’growing
which
face
is placedbeside
on the a surface
horizontalof theone enabling
frontal bone
the contrasts
exactly 40mm to abovebe seen
point more
‘N’ toclearly.
avoid the An
anthropologist
frontal air sinuses. could be forgiven
This enables an foraccurate
thinking
that they come from
superimposition different
of ‘FN’ species.
(Fig III/9) to be made
at different points of time and it will be
Clinicians
found that theoften findSNF
angle it difficult
frequentlyto recognize
changes
this rotation on a lateral skull
during Orthotropic treatment indicating X-ray but an
upward
a movement tilt of the
of SN theplain is a valuable
cranial base within clue.
For many years I have used
the vault. This also explains why so manya point ‘F’ which
is placed on
individuals thebig
with surface
nosesof thehave
also frontal bone
receding
exactly 40mm above point ‘N’
chins and sloping foreheads. I hope that the to avoid the
frontal
reader isair sinuses. to
beginning This enables an
understand how accurate
logical
superimposition
all this is. of ‘FN’ (Fig III/9) to be made
at different points of time and it will be
found that the
Extremes angle
such as SNF
thesefrequently
emphasize changesthe
during Orthotropic
smaller changes that taketreatment
place in allindicating
patients
a
withmovement of the The
malocclusion. cranialcompensatory
base within
the vault.curve
forward This ofalsothe explains
cervical why so many
vertebra is
individuals
necessary with big noses
to allow the also have receding
extension of the
chins andonsloping foreheads. The skulls from figure II/8 superimposed on ‘FN’
cranium the Atlas, so thatI thehopeweight
that the of (the frontal bone).
reader
the head is beginning to understand
can be balanced how logical
(see figure III/10).
all
Thisthis is. can be seen in all vertically growing
curve with malocclusion.
The rotation The in compensatory
of the head figures III/8, 9
faces and inevitably leads to compensating forward curve
& 10 ‘B’ has of thethecervical
restored vertebra
facial plane to the is
Extremes
curves in thesuch as these
Thoracic and Lumberemphasize
vertebra the necessary
upright. Manyto allow
years the
agoextension
Marcotte of(1981)
the
smaller changes
with possible that take
long-term placeconsequences.
spinal in all patients noticed on
cranium thattheregardless
Atlas, so of
thatfacial form the
the weight of

Figure III/10

N S Ba 118 N S Ba 145

Skulls from figure II/8 & 9 compared on the SN’ plane. One could be forgiven for thinking they had
come from different species. This demonstrates the drop of the maxilla and its influence on the
mandible.

48
 Aberrant Facial Growth 3

patient
the headwouldcan be rotate
balancedtheir(seeheadfigure
so that the
III/10). back of the head
McNamara’s ‘Nasion so Vertical’
that the moderately
face just looks so.
Nasion
This curvewascan more
be seenor less vertically
in all vertically above
growing the longer
Most of with
these a sloping
analyses forehead.
are based The onfinger
angular of
pogonion.
faces and Vig (1989) later
inevitably leadsshowed that if the
to compensating blame must point
relationships so that to the misleading
variations in sizenature
can be of
nose was
curves artificially
in the Thoracic blocked,
and Lumber then vertebra
within a profile
allowedX-rays.
for butItbecause
is only when oneradiate
the lines placesfrom
two
few minutes
with possiblethe patient spinal
long-term wouldconsequences.
tilt their head such cases
the base ofwith theirthis
the skull SN planes
makes parallel is the
it difficult to
back and maintain this posture. This is because placecontrast
true the maxilla.of form In my opinion
revealed irregularity
(figure III/10)
The rotation
opening the mouth of the head in
causes thefigures
mandible III/8,to 9 of the maxillary incisors rarely occurs until
&
drop10 ‘B’ has restored
restricting the facial plane
the pharyngeal airway. toThisthe theFew cephalometric
maxilla itself is set analyses
back moreplace the
then ten
upright.
pharyngeal Many years can
restriction agobeMarcotte
relived by either(1981) maxilla correctly. Steiner’s ‘normal’ of 82º is
millimetres.
noticed
holding the thatjawregardless
forward of or facial
depressingform the to my mind is markedly retrusive; and even
patient
hyoid bone would
but rotate
both these theirpostures
head soare that the
tiring The Frankfort
McNamara’s ‘Nasion plane suffersmoderately
Vertical’ in the same so.
Nasion was more
to maintain. On the or less
other vertically
hand it aboveis easythe to way; because
Most of these as the maxilla
analyses are baseddropsondownangular so
pogonion.
extend theVig head (1989)
on the later
Atlasshowed
for long that if the
periods does the infra
relationships orbital
so that margin,incausing
variations size canthe be
nose
without wasany artificially blocked, the
strain. However thenremaining
within a ‘FH’ to for
allowed tiltbut with it. Visually
because the linesthe Frankfort
radiate from
few minutes
cervical the patient
vertebra then flex would tilt their
forward head
in order Plane
the appears
base of thetoskull remainthishorizontal but thisto
makes it difficult is
back and maintain
to restore the overallthis posture.
balance, This is because
creating an because
place thethe patient
maxilla. In with a collapsed
my opinion maxilla
irregularity
opening
increasedthe mouth
cervical causes
flexure, whichthe ismandible
constantly to willthe
of have to tilt their
maxillary head
incisors backoccurs
rarely to restore
until
drop restricting
associated the pharyngeal
with those who leave airway.
their mouth This theirmaxilla
the airway,itself thusisrestoring
set back the more ‘FH’ to ten
then the
pharyngeal restriction
open. This rotation whichcanMarcotte
be relivedobserved
by either horizontal. This tilting has an adverse effect
millimetres.
holding
repositions thethejawchin forward
under the or depressing
Nasion. the on all those analyses which are based on the
hyoid bone but both these postures are tiring The Frankfort
Frankfort Horizontal plane such
suffersas in the same
McNamara’s
toI maintain.
think I was Onone the ofotherthe hand
first (Mew
it is easy 1983)to way;
Nasionbecause
Verticalas(McNamara
the maxillaand drops
Brudon down1993)so
to describe
extend the headthison sequence,
the Atlas suggesting
for long periods that does the infra
and figure orbital
III/11 taken frommargin,
his book causing the
labels this
“Childrenany
without whostrain.
lack lower
However facialthe development
remaining ‘FH’ tobeing
girl as tilt with it. Visually
5 millimetres the Frankfort
prognathic when
tilt theirvertebra
cervical heads then backflex toforward
maintain their
in order Plane
in my appears
view hertomaxillaremainishorizontal
down andbut backthisandis
pharyngeal
to restore the airway”.
overallInbalance,
the same articleanI
creating because
should be the patient
taken forwardwith by
a collapsed
about themaxillasame
continued “Disproportionate
increased cervical flexure, which facial growth is
is constantly will haveofto
number tilt their head back to restore
millimetres.
to some extent
associated disguised
with those whoby thistheir
leave backwards
mouth their airway, thus restoring the ‘FH’ to the
tilting
open. This of rotation
the head, which which
Marcottemaintainsobserved the The fullness
horizontal. Thisoftilting
the face
has isanusually
adverse assessed
effect
facial plane the
repositions while chin permitting
under themajor Nasion. adaptive with
on allthe
those‘SNA’ or ‘SNB’
analyses angles
which are but
based these are
on the
changes to occur in other parts of the at risk if theHorizontal
Frankfort associatedsuch changes as in the Saddle
McNamara’s
I think I was one of the first (Mew 1983)
cranium”. Angle are
Nasion not allowed
Vertical (McNamara for.and
AlsoBrudon
if the1993)
face
to describe this sequence, suggesting that
I have no
“Children whodoubt
lack that
lowerthis facialis the sequence
development Figure III/11
that their
tilt leads heads
to excessive back to vertical growth
maintain as
their McNamara used his
seen in mostairway”.
pharyngeal if not allInmalocclusions
the same article and itI ‘Nasion Vertical’ to
is this in turn
continued that precipitates
“Disproportionate many
facial of the
growth is diagnose this girl as
changes
to some in the rest
extent of thebyspine
disguised and limbs.
this backwards being 5 millimetres
Sadly although
tilting of the head, this which
hypothesis maintainswas put the prognathic but according
forward
facial planeover a quarter
while permittingof a major
century ago it
adaptive to an Orthotropic
still has limited
changes to occur acceptance.
in other parts of the assessment the upper
cranium”.
I have been surprised that some incisors are about 4 mm
orthodontists
I have no doubt havethat hadthis such difficulty
is the sequence in down and back from the
understanding
that that the vertical
leads to excessive collapse of the
growth as cranial vault.
maxilla
seen in ismost
the key
if notto malocclusion.
all malocclusions I think and partit
of this
is the reason
in turn for that this is the associated
precipitates many of tilting
the I consider that any form of retraction in this
back of the
changes head
in the so of
rest that thethespine
face andjust limbs.
looks case would be inappropriate.
longer with
Sadly a sloping
although this forehead.
hypothesis The was fingerput of
blame must
forward overpoint to the misleading
a quarter of a century nature
ago of it By kind permission of the authors and
profile
still hasX-rays.
limitedItacceptance.
is only when one places two Michigan University Ann Arbour.
such cases with their SN planes parallel is the
I contrast
true have been of formsurprised
revealed (figurethat III/10) some grows
and vertically
figure the from
III/11 taken length hisofbook
‘SN’labels
shortens
this
orthodontists have had such difficulty in so that
girl “the sella-nasion
as being dimension
5 millimetres prognathicshortened
when
Few cephalometric
understanding that the analyses
collapse place of the proportionately,
in the SNA
my view her maxilla is and
down SNBandangles
backwere
and
maxilla is correctly.
the key to Steiner’s ‘normal’
malocclusion. of 82º
I think is
part not affected”
should be taken (Trotman
forward1997).
by aboutIf the
theSaddle
same
to the
of my reason
mind isfor markedly
this is the retrusive;
associated andtilting
even

49
3
3 Aberrant Facial Growth
Aberrant Facial Growth

Figure III/12 Vertical Growth

Vertical growth occurs

when the Gnathion Sella
grows at over 45
degrees to SN plane.

Two sequential Xrays ahould be

superimposed on Sella along SN.
Or if using photographs, on Tragus
along a line to the tip of the nose.

Angle opens, the resting head posture will Measuring the Direction of Facial
number of millimetres. Because of my scepticism about X-rays, I
change in order to restore the airway and this Growth.
stopped using them other than for research
causes the ‘SN’ofplane
The fullness tendsisto
the face cant upwards
usually assessed more than authors
Various twenty years
have ago, however
suggested I have
the use
as
withis seen on allorlateral
the ‘SNA’ ‘SNB’ X-rays
angles ofbutlong
thesefaces
are been strongly planes
of different criticized
tofor this by
assess those
the that
growth
(Fig III/8). Thus superimpositions on this
at risk if the associated changes in the Saddle plane
feel they but
direction are Iindispensable.
recommend the In my
use opinion
of two
would
Angle are place theallowed
not maxilla for.
further
Alsoforward
if the than
face digital photographs
sequential provide much
X-rays superimposed alongmore
the
it
grows vertically the length of ‘SN’are
really is and many orthodontists misled
shortens information,
‘SN’ plane atespecially
‘S’ or ifalong
compared by using
the Frankfort
by this,“the
so that diagnosing
sella-nasionthedimension
face as prognathic
shortened the Thin Plate
Horizontal Spline
at the Analysis
Porion. but the using
Alternatively best
(see ‘Brian’ below Figure III/13).
proportionately, the SNA and SNB angles were information of all comes from a
photographs superimposed on the Tragus study of the
not affected” (Trotman 1997). If the Saddle face itself.
The ideal direction of maxillary growth
Angle opens, the resting head posture will Figure III/13
is probably around 35º to 40º and it only
change in order to restore the airway and this
requires a slight increase in this angle to
causes the ‘SN’ plane tends to cant upwards
have a marked effect on the mandible, which
as is seen on all lateral X-rays of long faces
maybe why the latter changes its shape more
(Fig III/8). Thus superimpositions on this plane
than any other bone in the body. For those
would place the maxilla further forward than
who ‘Read the Face’ the position of the
it really is and many orthodontists are misled
maxilla can more easily be assessed by using
by this, diagnosing the face as prognathic
measurements such as the ‘Indicator Line’
(see ‘Brian’ below Figure III/13).
and the ’Cheek Line’ (to be described. Figure
IV/14
The&ideal
24). direction of maxillary growth
is probably around 35º to 40º and it only
Because of my scepticism about X-rays, I
requires a slight increase in this angle to
stopped using them other than for research
have a marked effect on the mandible, which
more than twenty years ago, however I have
maybe why the latter changes its shape more
been strongly criticized for this by those that
than any other bone in the body. For those
feel they are indispensable. In my opinion
who ‘Read the Face’ the position of the
digital photographs provide much more
maxilla can more easily be assessed by using
information, especially if compared by using Brian Age 11. Overjet of 11mm. Slight upper
measurements such as the ‘Indicator Line’
the Thin Plate Spline Analysis but the best spacing and no lower crowding. Note the
and the ’Cheek Line’ (to be described. Figure
information of all comes from a study of the
IV/14 & 24). curvature of the cervical soine and flattened
face itself.
cheeks, to me this suggests vertical growth.

50
50
 Aberrant Facial Growth 3
Aberrant Facial Growth 3
along the line from there to the furthest maxillary position correctly and the effect of
point on the nose. It does not matter much would
different betreatments
vertical. 35° on to
the40°
growthwould appear
direction.
which of these plains are used provided the to be close to the functional and aesthetic
‘before’ and ‘after’ superimpositions are ideal
CASE butEXAMPLE
there are1 many nice looking faces
Measuring
along the same the Direction
lines. of Facial
The direction of growth and straight teeth associated with angles as
is Growth.
then measured by marking Gnathion or Brian
high was Research
as 50°. an eleven year oldon
is difficult boy
thiswith
pointa
Pogonion on both tracings and drawing a line class
as few II division 1 malocclusion
serial records and an eleven
of outstandingly good
Variousthem
through authors have to
extending suggested the use
the plain used for millimetre
looking overjet.
people areHeavailable.
had a convex face with
However for
of different planes to
the superimposition (fig III/12).assess the growth no crowding
most in the lower and
severe malocclusions theslight
anglespacing
will be
direction but I recommend the use of two in the
over 80°.upper
Some(figure III/13). faces
character-full Facedare with
foundan
sequential
In geometricX-raysterms
superimposed
anything along the
less than overjet
with high ofangles
11 millimetres
but as the and a convex
growth face,
direction
‘SN’ plane be
45° would at horizontal
‘S’ or along the Frankfort
and anything over most orthodontists
increases there is less would
and lessbe room thinking
availableof
Horizontal at the Porion.
would be vertical. 35° toAlternatively
40° would appearusing somethe
for form of retraction
teeth. but examination
The following two clinical of
photographs
to be close tosuperimposed
the functionalonand the Tragus
aesthetic his face
cases showsthe
confirm that his cheeks
importance of look rather
diagnosing
along
ideal butthethere
line from there
are many to looking
nice the furthest
faces flat and itposition
maxillary will be noticed
correctly that
andhe thehas quiteof
effect a
point on the teeth
and straight nose. associated
It does notwith matter much
angles as curvaturetreatments
different in his neck suggesting
on the growth that his head
direction.
which
high asof these
50°. plainsisare
Research used provided
difficult the
on this point is extended when in his normal position.
‘before’ and records
as few serial ‘after’ of superimpositions
outstandingly good are CASE EXAMPLE 1
along the same lines. The direction
looking people are available. However for of growth The lateral skull X-ray (fig III/14, left) shows
is
mostthen measured
severe by marking
malocclusions Gnathion
the angle or
will be Brian
that thewasSNA an iseleven year old90°
approaching boywhich
with isa
Pogonion on both tracings and drawing
over 80°. Some character-full faces are found a line class II division
considerably 1 malocclusion
higher and an eleven
than most ‘norms’ which
through
with highthem
anglesextending
but as theto the plaindirection
growth used for millimetre
are aroundoverjet. He had athe
82°. Of interest convex face
records ofwith
this
the superimposition
increases there is less(fig
andIII/12).
less room available no crowding
particular caseinwere
the lower
sent toandeveryslight spacing
member of
for the teeth. The following two clinical in
thethe upper
British (figure III/13).
Orthodontic Faced
Society and with
they anall
In geometric
cases confirm theterms anything
importance less than
of diagnosing overjet
were asked of 11tomillimetres
provide their and
own a convex face,
prescription.
45° would be horizontal and anything over most
91% oforthodontists
those who replied would suggested
be thinkingthat of
Figure III/14

The SNA is 90 suggesting that his maxilla is However if compared with a good looking face,
placed forward. 91% of the British orthodontists the maxilla and upper incisors are too far back.
recommended extractions and 63% The SNA is not a safe guide.
recommended retractive head gear

51
51
3
3 Aberrant
Aberrant Facial
Facial Growth
Growth

extractions
some form of of retraction
teeth were butrequired, despite
examination of mandibular
result is showngrowth. This was
in figure probably
III/15. A paneldue of
the fact that
his face shows there
thatwashisspacing
cheeks inlookthe rather
upper to lay
six an overjudgesreliance
thoughtonhislateral
facial skull X-rays
appearance
archand
flat anditno willcrowding
be noticed in the
thatmandible.
he has quite63%a coupled
on a scale withfromtheoneuse (very
of measurements
unattractive)that to
recommended
curvature in his neck retractive head that
suggesting gearhisand
head a do not
ten (very clearly identifyhad
attractive) maxillary
changedposition.
from 5.5
further
is extended 15%when thought
in his head
normal gear might be
position. before treatment to 4.2 after. Of interest the
required. However the ‘Indicator Line’ (to CASE EXAMPLE
mandibular growth 2. direction which should
beThedescribed
lateral skull later)
X-raysuggested
(fig III/14,that
left)Brian’s
shows be around 55° for an averagely good looking
maxilla
that thewas SNA several millimetres
is approaching 90° retruded
which is Forincreased
face the sake to of 112°.
comparison let us consider
and if the outline
considerably higher (inthan
blue) of a‘norms’
most good looking
which the treatment of a younger girl also with a
forward
are around growing face is the
82°. Of interest superimposed
records of thison convex
This case face.wasEmily is eight
clearly years old and
misdiagnosed and
Brian’s cranial
particular case werevaultsent(figtoIII/14
everyright),
member this
of has a class II/1
mistreated. It malocclusion
reflects a worryingwith an lackoverjet
of
would
the British alsoOrthodontic
suggest that the maxilla
Society and theyand all of 14 millimetres
understanding and amongst
in 1995 a complete the overbite
majority
upperasked
were incisors are too far
to provide back
their own prescription. (fig the
of III/16).
UKHer mother asked
orthodontic for the about
specialists upper
91% of those who replied suggested that anterior teeth
maxillary positionto and
be retracted.
its effect However
on the
Brian wasoftreated
extractions teeth werewith required,
extractions and
despite the Indicator
mandibular Line (to
growth. be was
This described shortly)
probably due
head
the fact gear thattothereretract
was his maxilla
spacing andupper
in the the to an over reliance on lateral skulltoo
suggested that they were already far
X-rays
resultand
arch is shown
no crowding in figure III/15.
in the A panel63%
mandible. of back andwith
coupled needed
the usemoving forward so that
of measurements that
six lay judges thought
recommended retractive his head
facial gear
appearance
and a thenot
do lower jawidentify
clearly could maxillary
be allowed to come
position.
on a scale
further 15%from one (very
thought head unattractive)
gear might be to forward as well. Most conventionally trained
ten (very However
required. attractive)the had‘Indicator
changed Line’
from (to5.5 orthodontists
CASE EXAMPLE would2. find this a confusing
before
be treatment
described to 4.2
later) after. Of that
suggested interest the
Brian’s diagnosis but it serves to illustrate the
mandibular
maxilla wasgrowth severaldirection
millimetreswhichretruded
should For the sake
difference of comparison
between let us consider
‘Orthotropics’ and
be
andaround 55° for (in
if the outline an blue)
averagely
of a good
good looking
looking the
almosttreatment
all otherofapproaches.
a younger girl. Emily is eight
face increased to 112°.
forward growing face is superimposed on years old and has a class II/1 malocclusion with
Brian’s cranial vault (fig III/14 right), this anTheoverjetprecise
of 14method
millimetres of andtreatment
a completewill
This also
would casesuggest
was clearly
that themisdiagnosed
maxilla and upper and be described
overbite later Her
(fig III/16). but mother
was commenced
asked for
mistreated.
incisors are too It reflects
far back a worrying lack of by moving
the the maxilla
upper anterior teethand to upper incisors
be retracted.
understanding in 1995 amongst the majority forward so
However that
the after four
Indicator Linemonths
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the was UK orthodontic
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maxillary
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the III/17).
too farThisbackfreed the mandible
and needed movingtoforward
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Figure III/15

Note the “growth direction” was 112 degrees to Frankfort

The Indicator Line increased from +4 to +8

52
52
 Aberrant Facial
AberrantFacial
Aberrant
Aberrant
Growth
Growth
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3
33
time wear. information is available from
Figure III/16 time
time wear.
wear.
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the photographs
Sadly many and X-rays. (Figs
many orthodontic
orthodontic III/18,are
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malocclusion with an
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almost
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was
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posture. from
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III/17).
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had
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these methods.
to
to 3½mmand
3½mm andshe
and shestopped
she stoppedday-
stopped day-
day- Note the antigonial notch has disappeated.

53
53
53
3 Aberrant Facial Growth
Maxilla moved forward about 11mm, while
Gnathion advanced 27mm. It may be that
such changes have been achieved by other
methods but I have never been privileged
to see them and personally do not think
that any treatment other than Orthotropics
could achieve this amount of forward
growth. The final growth pattern is much
the same as might be expected for any good
looking child; the unusual feature is that she
started with a vertical growth pattern which
changed to horizontal during treatment. It is
important to note that no fixed appliances
were used at any point.
So what actually happened? I do not
believe that a mandible can be made to grow
more than a few millimetres although we can
certainly change its shape. The upper and
lower jaws are linked by a series of bones
and we discussed in chapter I the ability of
each of these bones to remodel and adjust
its relationship with its neighbours. Both
Bjork’s (1979) work comparing the growth of
Europeans with indigenous Australians and
Lobb’s (1987) work with twins demonstrated
that large contrasts in the shape and growth
of the cranial bones can be achieved by
many small changes in relationship rather
than form. If each of Emily’s facial bones
had moved a millimetre or so relative to its
neighbours then the combined movement
would have been substantial. Remember that
these bones can all rotate, cant and remodel.
What really concerns me is that
malocclusions like Brian’s are still being
treated in the same retractive manner with
long-term damage to the teeth and face.
Also the orthotropic treatment given to
Emily is still ridiculed and suppressed by
many Universities in the United Kingdom.
Worse still, the research we need to compare
such methods is blocked by even the most
respected authorities, so that the public
continue to suffer in the hands of those they
should be able to trust.
RESEARCH METHODS.
Having had my first successes with
‘Functional’ appliances in my early twenties
I ‘knew’ they worked, and it always surprised
me that so many orthodontists then, as now,
‘know’ that they do not. There are many
reasons for this, but I think the basic one is
that we all have to deliver reliable results
54
for our patients. It is demoralising to tell a
patient that you will avoid extractions by
making their jaw grow forward and then wait
for months with no visible change.
You are not sure if it is because they are
not wearing it enough, or whether there are
some situations when ‘Functionals’ really do
not work. Contemporary research suggests
that skeletal changes are limited to two
or at the outside three millimetres, which
many clinicians feel is hardly of clinical value.
Current conventional belief suggests that
any change beyond this 2 or 3 millimetres
is in the alveola bone not the skeletal bone.
Subsequently you may have to change to
headgear or intermaxillary elastics coupled
perhaps with the very extractions that you
had hoped to avoid in the first place.
Most of us have had this experience
and many currently say “well we will try a
Functional and if it works, fine, but if not,
we will use conventional means”, while
others avoid Funtional appliances altogether.
Certainly attempts to correct any type of
vertically growing face are fraught with risk
whatever method is used (Parks 2007) and
will often make faces look noticeably worse
(Faure 1998). Sadly a proportion of these
patients continue on to orthognathic surgery.
The evidence suggests that Orthotropics
can provide a successful result in such cases
provided, 1/ there is no genetic deformity
(less than 4% of cases), 2/ treatment is
started young enough (preferably under the
age of 9, depending on severity) and 3/ the
clinician and patient do what is required.
Physiology is predictable, children and
clinicians are not.
The Evidence.
My confidence comes from my personal
understanding of the basic evidence but this
does not seem to be reflected in the wider
world. There is a marked lack of consensus
within the Orthodontic Specialty when
considering the cause of malocclusion or
its appropriate cure. A major problem is the
contrast between ‘Clinical’ Evidence and
‘Scientific’ Evidence. To many people they
have equal significance but in my opinion
most clinical papers are overvalued, firstly
because many clinicians find it difficult to
separate their research results from their
personal prejudices and secondly because

of the large and confusing variables found
when comparing a disparate group of
unrelated patients, treated under different
circumstances.
It is also difficult to balance the relative
merits of different clinical techniques. For
instance, if one treatment is twice as good
but takes three times as long, is that good or
bad? If, more crucially, it is twice as good but
costs three times as much, do we say yes or
no? We talk of clinical effectiveness but how
broad is our assessment? Our paymasters
enforce ‘clinical governance’ but just how
different is this from clinical expedience, and
is it what the patients themselves want? If
a brain surgeon developed a technique that
was twice as beneficial but four times as
costly, would the world beat a path to his or
her door?
The main problem is that it takes two or
more years to correct a malocclusion and
another ten to twenty to assess the long-
term success. Not only do clinicians retire
but patients disappear.
Quality of Clinical Evidence.
Traditionally, the hierarchy of clinical
evidence (in reverse order) looks like this.
1/ Anecdotal Reports and Opinions.
2/ Retrospective Studies.
3/ Prospective Consecutive Trials (PCTs).
4/ Random Controlled Trials (RCTs).
To which I would add,
5/ Series of Identical Twins.
Anecdotal Reports
These are condemned by most researchers
but they are in fact the foundation of almost
all orthodontic treatment. They are also the
source of many misconceptions. Regrettably
they have in the past been open to abuse
by powerful characters that draw their own
conclusions from limited facts.
Retrospective Studies.
These are fraught with the risk of bias;
sometimes subconscious and sometimes
Aberrant Facial Growth 3
reckless. Even if the study is impartial there
is a strong risk that successful patients will
be more conscientious about returning for
follow ups, than unsuccessful. When patients
are selected retrospectively there is also the
risk of using selection methods that unfairly
skew the result. This can happen with even
the most respected researchers, for example
Bishara and Jakobsen (1997) compared
patients treated with and without extractions
and came to the conclusion “When based on
proper diagnostic criteria the post treatment
changes in the facial profile were perceived
as favourable in both the extraction and non-
extraction Class II division 1 groups when
compared to the pre-treatment profile”.
However when studying the ‘method’ we
see that “Subjects were selected from ‘well
treated’ patients and that ‘poor’ treatment
results were excluded” (one wonders how
these parameters were defined). Of even
more concern “Photographs in which there
was evidence of mentalis muscle activity
(puckered or flattened chin) were excluded”.
This obviously excluded those with open
mouth postures from the final results
although this exclusion does not seem to
have been applied at the start of the study.
In my view the only conclusion that should
be drawn from this paper is that “regardless
of extractions patients who keep their lips
together without effort do not suffer facial
damage”. In general, retrospective studies
tend to find that the method preferred by
the author is superior to others and many
must be considered suspect.
Prospective Consecutive Trials (PCTs)
These follow groups of patients during
the course of their treatment and if required
beyond. Because the patients are selected in
advance, selection biases can be controlled
but this requires the establishment of a
rigid acceptance protocol and satisfactory
pre-treatment records. They are ideal for
comparing different types of treatment
although it is wise for treatment to be carried
out at different centres to ensure that the
clinicians are suitably qualified for and
enthusiastic about each type of treatment.
With suitable reward most patients can be
encouraged to return out of retention but
those that fail to do so should still be included
in the results on the basis of their last visit.
55
3 Aberrant Facial Growth
One of the principal advantages of PCTs
is that the costs are minimal, requiring little
more than duplication of the records so that
they can be lodged at the monitoring centre.
Unfortunately they are unpopular with
those who believe that growth prediction is
unreliable as they worry that unfavourable
growth could damage their results and
therefore their personal reputation. There
is also the element of competition which is
considered as undesirable although in the
university setting where most of this type of
research takes place this should ensure that
skilled operators are used.
I described in the first chapter how
with the support of British Association
of Orthodontists, I set up such a study in
1972 but the university departments were
reluctant to expose their results to outside
examination. As was found in Shaw’s cleft
palate research (1992), this type of study
shows up clinical weaknesses which may be
why such studies are not popular. Shaw’s
study resulted in some painful realizations
and at some centres, heads rolled. Provided
record taking is good, PCTs enable the
categorization of the different groups to
be adjusted retrospectively as well as prior
to the study and in my view are by far the
best way of establishing the merits of rival
treatments.
Random Controlled Trials (RCTs)
These have become standard within
medical research and are especially suited
to pharmacological trials, but are they
appropriate for orthodontics: possibly not
for several reasons?
1. ‘Blinding’ is rarely possible.
2. Appropriate Controls are a basic
requirement for almost all medical research.
Unfortunately individuals with 32 perfectly
straight teeth are rare in civilized societies
and there is thus a risk that as we discussed
previously, less than perfect occlusions
will be used as ‘normal controls’. The most
commonly used ‘normals’ are the Bolton,
Burlington and Kings College studies,
the occlusions of which were ‘good’ or
‘untreated’ rather than ‘excellent’, and
available to us only as records. Here we are at
risk of comparing one group of ‘abnormals’
with another, both with retruded maxillae
56
and large variations. If a sample is skewed
it can be difficult to obtain meaningful
comparisons especially if both the patients
and controls are on the same side of the
possible range of variables. It is interesting
to note that the better the occlusion, the
smaller the variation when compared with
average population standards, a statistic that
researchers should ponder about.
3. Because of the substantial variations
between most malocclusions, large numbers
of patients are necessary to gain ‘significant’
results. This requires many operators who
inevitably have varying clinical experience.
The specific skills of any clinician may vary
by a factor of three or even four times, but
this is rarely allowed for. Djemal and his
colleagues (1999) found that the experience
of the operator carrying out treatment “had
a pronounced effect which was not readily
explained in terms of the distribution of
other significant factors”.
4. If patients in a trial are distributed
randomly, some clinicians may be required
to use techniques with which they are not
fully trained. This not only raises ethical
problems but is of particular relevance to the
success of the treatment which can be highly
dependent on the clinician’s experience and
enthusiasm (Djemal et al 1999).
5. Unfortunately the current UK emphasis
on teaching fixed appliances means that
there are now fewer clinicians with wide
experience in Functional or Growth Guidance
appliances, especially in the schools where
most RCTs are conducted. In a recent very
extensive UK study (Robinson 2001) some of
the clinicians were not only unfamiliar with
the Functional appliances being tested, but
in at least one instance had never used them
before.
6. RCTs are not very suitable for assessing
several variables simultaneously, and yet by
reducing the number of variables the results
can sometimes be prejudiced. For instance, a
recent RCT in the USA reduced the variables
by not expanding the maxilla before fitting
a Bionator (Tulloch et al 1998). Thus the
occlusion was not ‘unlocked’ and those
familiar with Functional appliances would not
be surprised to hear that this study failed to
show much difference between Headgear,
Bionators and controls.

7. However the most important flaw with
all research involving functional appliances
is that success is almost entirely dependent
on the co-operation of the patient and this is
almost impossible to ascertain.
Sadly most RCTs in orthodontics have been
very expensive and because of problems such
as those mentioned above, have tended to
produce rather negative results, therefore
it may become more difficult for them to
obtain funding in the future.
Faced with these difficulties where do
we go for the answers that orthodontists
need so badly? I think that for orthodontics
PCTs are more appropriate than RCTs but
unfortunately they are victims of their
own success because rival universities are
frightened of the PCTs ability to expose
failure.
Systematic Searches and Reviews.
As more people come to recognize the
failings of RCTs, Systematic Searches
have become more popular. However they
face many of the same criticisms as RCTs,
sometimes representing no more than the
average of a number of flawed studies. As
Papadopoulos and Gkiaouris conclude after
one such review (2007), there is a “lack of high
quality research articles in the orthodontic
literature”. In my opinion it is unreasonable
to expect orthodontic research workers to
plan good research until they have a sound
hypothesis for the aetiology of malocclusion
to work around. As we discussed in the last
chapter the Tropic Premise seems to fit the
available evidence well, but few researchers
are familiar with it.
NEGATIVE EVIDENCE.
Unfortunately clinical trials of different
orthodontic methods have failed so far
to provide sound long-term evidence. In
my opinion the best orthodontic research
method would be to use identical twins,
treated with different techniques by skilled
clinicians who were convinced their personal
methods were correct, and followed up more
that ten years after treatment. However
it is very difficult to assemble this type of
material and it would undoubtedly present
ethical problems. I know of only one such
study and we will discuss that later.
Aberrant Facial Growth 3
It can be disappointing to undertake
a major study only to come up with
‘negative’ findings; but it is important
for us to know which relationships do not
exist. Unfortunately some clinicians will
use negative evidence to make positive
statements (a major crime in science). For
example saying “there is no evidence to
show that early treatment is of benefit”. This
sounds critical but in reality means just the
same as saying “there is no evidence to show
that early treatment is not of benefit”. For
example, in the correspondence columns of
a respected Journal a clinician faced criticism
because he had said “Temporomandibular
joint problems are not caused or cured by
orthodontic treatment”, this may be true
but the only evidence we have is negative, it
has never been shown that they do or don’t
cause or cure problems. He also suggested
that there is insufficient evidence to show
that Functional appliances work but again,
there is little sound evidence either way.
Negative evidence is dangerous; and if
an inexperienced student designed an
experiment that failed to show that gravity
existed, would anyone believe him?
The Quality of Orthodontic Research.
Orthodontics has been singled out for
some fierce criticism by some of the leading
researchers in the world.
David Sackett, Professor of Evidenced
Based Research at Oxford said in 1985
“Orthodontics is behind such treatment
modalities as acupuncture, hypnosis,
homeopathy, and on a par with scientology”.
Johnston L.E. Professor at Ann Arbour
Michigan. 1990 “Clinical practice … is at
bottom largely an empirical process that is
little influenced by theory inferred from any
of the life sciences”.
Derek Richards Director of Evidenced Based
Dentistry Oxford 2000 ‘. “The current focus
of dental schools leans toward the teaching
of technical skills rather than scientific
thinking”.
Bill Shaw Dean, Dean Manchester Dental
School. 2000 “Sadly it is hard to see this
situation change unless the inadequacy
of current (orthodontic) knowledge is
acknowledged by its practitioners”.
57
3 Aberrant Facial Growth
Frankel Rolf. 2001 “A mechanical approach
treats a symptom, not the cause”.
Papadopoulos M A and Gkiaouris I. 2007.
There is a “lack of high quality research
articles in the orthodontic literature”.
Bondemark and his colleagues (2007)
carried out a Systematic Review of long-term
treatment results and patient satisfaction.
They trawled the world literature and found
1004 abstracts or full-text articles, of which
38 met the inclusion criteria. They found it
“astonishing that only a few studies were
found on patient satisfaction in the long-
term” most of which were of poor quality.
They drew attention to the fact that the
benefits of treatment are usually assessed
by categorical scales from dental casts,
radiographs, etc which tend to reflect
professional standards rather than patients
preferences.
Bondemark continued, “Treatment of
crowding resulted in successful dental
alignment but the mandibular arch length
and width gradually decreased, and crowding
of the lower anterior teeth reoccurred post-
retention. This condition was unpredictable
at the individual level (limited evidence).
Treatment of Angle Class II division 1
malocclusion with Herbst appliances
normalized the occlusion, however this
was followed by relapse which could not
be predicted at the individual level (limited
evidence). The scientific evidence was
insufficient for conclusions on treatment
of cross-bite, Angle Class III, open bite,
and various other malocclusions as well
as on patient satisfaction in a long-term
perspective”.
They concluded “This review has exposed
the difficulties in drawing meaningful
evidence-based conclusions often because of
the inherent problems of retrospective and
uncontrolled study design”. As a result it is
very difficult to provide the public with easy
to understand evidence-based information
about the ability of orthodontic treatment
to meet their long-term expectations.
Orthodontic research appears to have one
of the worst records in medical science, how
could this have happened? Inevitably, despite
the common basis of our knowledge, beliefs
differ and the pattern of clinical practice has
58
been one of great variety, both in relation to
time and geographical location. The changes
have often been cyclical with succeeding
generations opposing each other. As the same
evidence is there for all to see, one might
make the rather surprising observation, that
the clinical practice of orthodontics is more
dependent on individual belief than overall
knowledge.
It is easy to be impressed by a new item
of research but one must not allow this to
overlay the importance of earlier work on
the same or similar subjects. The problem is
that research gives us facts but not reasons,
it informs, negates or confirms but it never
explains. It requires logic to apply each
snippet of new information to our pattern
of reality and as we know, there is as yet,
little agreement about the cause or cure of
malocclusion.
I have been dismayed at the conviction
displayed by some orthodontists when
expounding their current set of ‘empirical
rules’ and their reluctance to consider
alternate views.
What is a profession?
To understand this problem one needs to
consider the concept of professionalism. A
profession can be defined as “an occupation
that has assumed a dominant position in the
division of labour so that it gains control over
the determination and substance of its own
work” (Freidson 1970). Studying professions
means studying their exclusionary strategies,
their legitimizing tactics and how they seek
to maintain their control. Professions usually
claim to be the only legitimate authority in
their field.
Abbott (1988) provided some interesting
insights into the narrow line upon which the
professions tread. If on the one hand, the link
between diagnosis and treatment is clear,
and the professional work is highly routine
there is a risk that it can be taken over by
semi trained auxiliaries. If on the other hand
the professional work is too dependent
on inference, the profession is also in a
vulnerable position because it has trouble
demonstrating its clinical legitimacy on the
basis of efficacy. In the later respect the more
inference that is required the greater the
need for an ‘expert’. A clear understanding

of the cause and cure of malocclusion would
certainly weaken the establishment’s control
and trained auxiliaries might be able to move
in and provide treatment.
Each sub-specialty of medicine and
dentistry tends to lay down lay down its
own guide lines, some of which are quite
specific and these tend to be maintained
by the examination system set up by that
specialty. I am sure there are many merits
in this arrangement but it does restrict
freedom of thought and at times inhibits
new developments. If all students believe and
practice what they are taught then progress
halts. In many professions new concepts are
expected to be proven beyond reasonable
doubt while existing beliefs are allowed to
linger on in full control until convincingly
disproved. It is this distortion of the burden
of proof that we need to redress because
it should be the logical application of the
evidence that should guide us not established
belief.
These issues are addressed in greater
detail in chapter 12.
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