ORIGINAL ARTICLE

Cranial base growth in patients with Down

syndrome: A longitudinal study
Juan J. Alio,a Jose Lorenzo,b and Carmen Iglesiasc
Madrid and Ourense, Spain

Introduction: The purpose of this study was to assess the growth of the cranial base in a sample of patients
diagnosed with Down syndrome (DS). Methods: The sample comprised 47 subjects (25 boys, 22 girls) with
DS. All patients had at least 2 x-rays that showed the cranial base. To make comparisons among age groups,
the sample was divided into 3 groups: prepubescent (8-11 years), pubescent (12-14 years), and postpubes-
cent (15-18 years). A control group included 38 normal subjects (22 boys, 16 girls, without DS) who were part
of a longitudinal growth sample. Computerized cephalometric analysis was performed on all subjects, and
cephalometric superimpositions were made. Two-way ANOVA was used to study the overall changes
between groups. In addition, 1-way ANOVA and the Duncan multiple range test were used to analyze
possible differences in the age groups. Results: Cranial base growth in patients with DS from age 8 to 18 was
similar to that of the control group. Structural differences in the cranial base are established before 8 years
of age and consist of shorter, flatter anterior and posterior bases. (Am J Orthod Dentofacial Orthop 2008;133:
729-37)

own syndrome (DS), described by Down1 in sinus.8 The ethmoid bone is retruded, thereby forming

D 1866, is an autosomic chromosome abnormal-

ity related to the trisomy of the 21st pair. It is
the most frequent chromosomal alteration with an
incidence of 1:800.2 This syndrome is marked by
external characteristics that make it exclusive and well
defined. These include small cranium with a round face
and flattened occiput, flat bridge of the nose, flat
cheekbones, strabismus, and oblique orbits, with the
external epicanthus higher than the internal epicanthus.
There is lingual protrusion due to macroglossia that can
cause open bite.3 There is a general hypotonicity of the
musculature of the orofacial, tongue, upper lip, and
ligamentary tissue of the temporomandibular joint,4
accompanied by less maxillary growth.
A general reduction in growth has been described in
this syndrome,5 with a reduction in overall head size,
which tends to be brachycephalic.6 Along these lines,
Muir7 described the sagittal area of the endocranium as
significantly smaller in these patients than in normal
subjects. The same can be said for the midfacial area,
the cranial base, the frontal bone, and the paranasal
a
Professor, Prophylaxis, Odonthopediatrics and Orthodontics Department,
Universidad Complutense de Madrid, Universidad Complutense de Madrid,
Madrid, Spain.
b
Partner, Prophylaxis, Odonthopediatrics and Orthodontics Department, Uni-
versidad Complutense de Madrid, Madrid, Spain.
c
Private practice, Ourense, Spain.
Reprint requests to: Carmen Iglesias, Bedoya 3 entlo 2-3, 32002 Ourense,
Spain; e-mail, miglesiasc@infomed.es.
Submitted, April 2005; revised and accepted, March 2006.
0889-5406/$34.00
Copyright 2008 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.03.036
a deep valley between the 2 orbits. All of this leads to
vertical hypoplasia of the central structures of the
cranium, with lowering in the position of sella turcica
and consequential flattening of the cranial base.3,8,9
These cranial characteristics led many authors to talk
about authentic cranial dysplasia,10,11 with a high
incidence of Class III malocclusion.12 Consequently,
most studies so far share the opinion that the reduction
in the general growth rate in DS patients also affects
cranial length.13,14
Fischer-Brandies15 found that the linear length of
the anterior cranial base (Se-N) was shorter than
normal. The reduction was an average of 3 to 5 mm in
the youngest patients (0-3 years), although that study
was a transversal analysis. In this same study, the
author found that, in the group of oldest patients (14
years old), the smaller size of the anterior cranial base
was even more evident, with an average reduction of 6
to 9 mm. These results agree with those of Kisling.16
However, the angle of the cranial base found by
Fischer-Brandies15 was greater in DS patients, and the
value dropped as age increased. The reduction in the
angle value might be due to an increase in the vertical
growth of sella turcica.17 Other authors think that the
flattening of the cranial base is due to increased cranial
pressure associated with growth.18,19 In any case, some
studies agree on the increase of the angle of the cranial
base, and that this anatomical characteristic is identified
as a typical feature in DS patients.15-17
Other authors18,20 believe that cranial lengths in
729
730 Alio, Lorenzo, and Iglesias
these patients are within normal values, especially in
the first months of life, but Lutz21 obtained the opposite
results. This discrepancy in results could be because the
samples in these studies were transversal. Regarding
the differences between sexes, it seems clear that linear
lengths of the cranial base are shorter in women.21,22
As mentioned above, most of these studies are
transversal and do not compare the results of normal
subjects. In this study, we hoped to carry out a
longitudinal analysis of anterior and posterior cranial
base growth, and to compare the results with a longi-
tudinal sample of facially normal subjects.
MATERIAL AND METHODS
The experimental group included 47 subjects (25
boys, 22 girls). The selection criteria for the sample
were that they were diagnosed with DS and still
growing at the time of the first x-ray. At least 2 x-rays
were taken of each patient. Only x-rays of the lateral
cranium were used for this study according to the
commonly accepted practice.23,24 All x-rays were made
with the same machine, with a magnification index of
1:1.10 (10%). The average age of the group in the
initial x-ray was 11 years, 8 months, with a range of 7
years, 7 months, to 16 years, 4 months. We chose some
patients past the age of 16 to try to identify late growth
spurts that have been found in these patients.15,16 The
average age in the last x-ray was 14 years, 1 month,
with a range of 8 years, 7 months, to 18 years, 6
months. To draw comparisons between the different
stages of growth, the sample was divided into 3 age
groups: prepubescent (ages 8-11), pubescent (ages
12-14), and postpubescent (ages 15-18). This classifi-
cation was made according to other authors who
believed that the pubescent period in DS occurs simi-
larly to the general population, although with a lower
rate of growth.25-28 The control group included 38
subjects from the longitudinal growth study carried out
by the Department of Orthodontics at Universidad
Complutense de Madrid. Subjects in the control group
satisfied the following criteria: still growing at the time
of the first x-ray, no apparent craniofacial deformities,
no history of craniofacial trauma or congenital anom-
alies, occlusal stability with clear intercuspation, no
extractions of permanent teeth, no dental anomalies,
and no maxillofacial surgery or surgical treatment.
They also had to be born in Spain or be a direct
descendent of Spaniards. This group included 16 girls
and 22 boys. The average ages at the first x-ray were 10
years, 4 months, for the girls and 10 years, 1 month, for
the boys. At the last x-ray, the ages were 13 years, 6
months, for the girls and 13 years, 8 months, for the
boys.
American Journal of Orthodontics and Dentofacial Orthopedics
May 2008
Fig 1. Method used to superimpose cranial base.
In all lateral cranium x-rays, a cephalometry was
traced with a computerized analysis (Nemotec Dental
System, Nemoceph Studio, Madrid, Spain) by marking
the following cephalometric landmarks: N (nasion), S
(sella), Ba (basion), CC (pterygomaxillare), and Po
(porion). The following cephalometric parameters were
then traced by using those: S-N length, S-Ba length,
N-Ba length, SNBa angle (basal angle), CC-N length,
NBa/Frankfort horizontal angle (cranial deflection),
and CC-Po length.
To determine the growth value, we used the super-
imposition of the initial and final lines drawn in the S-N
plane with S as the fixed point.29 Landmarks N and Ba
were projected over the Frankfort horizontal plane as a
horizontal reference and over the vertical pterygoid as
a vertical plane of reference. A positive value was
given to landmark N when the displacement of this
point was forward and upward. For Ba, a positive value
was given when the displacement was downward and
backward (Fig 1).
All cephalometric analyses were made by 2 re-
searchers from a project of the general growth study in
the orthodontics masters program at the Universidad
Complutense de Madrid. These researchers (J.L. and
C.I.) calibrate their instruments annually to prevent
errors in the cephalometric measurements. After they
measured the lines, they compared the findings and
obtained these possibilities: (1) concordance type I,
absolute coincidence of the 2 lines; (2) concordance
type II, some difference in the parameters of the 2 lines:
S-N length, 1 mm; S-Ba length, 1 mm; N-Ba
length, 1 mm; SNBa angle, 3; CC-N length, 1
mm; NBa/Frankfor horizontal angle (cranial deflec-
tion), 1; and CC-Po length, 1 mm; and (3) con-
American Journal of Orthodontics and Dentofacial Orthopedics Alio, Lorenzo, and Iglesias 731
Volume 133, Number 5

Table I. Cephalometric superimposition variables and cephalometric variables: comparison of the 2 groups (Student
t test)
Postpubescent (15-18
Cranial base parameters Total (8-18 y) Prepubescent (8-11 y) Pubescent (12-14 y) years)

Variable Unit Group Average SD Sig Average SD Sig Average SD Sig Ave. SD Stat. Sig.

Horiz N (mm/y) D 0.47 0.49 0.49 0.37 P 0.01 0.69 0.60 NS 0.25 0.33 P 0.01
C 0.75 0.41 0.77 0.42 0.73 0.42 0.76 0.29
Vert N (mm/y) D 0.13 0.15 0.18 0.18 NS 0.17 0.14 NS 0.05 0.11 P 0.05
C 0.14 0.07 0.14 0.06 0.14 0.08 0.15 0.06
Horiz Ba (mm/y) D 0.48 0.53 0.77 0.62 P 0.01 0.55 0.50 NS 0.21 0.33 P 0.05
C 0.40 0.45 0.32 0.40 0.48 0.52 0.49 0.24
Vert Ba (mm/y) D 0.36 0.45 NS 0.60 0.56 NS 0.41 0.46 NS 0.16 0.23 NS
C 0.40 0.47 0.47 0.46 0.32 0.50 0.25 0.22
Basal (/y) D 0.49 1.19 0.74 1.36 P 0.01 0.38 1.20 NS 0.42 1.05 NS
angle C 0.15 0.70 0.06 0.66 0.39 0.71 0.47 0.26
SN (mm) D 63.77 4.04 P 0.001 61.85 3.68 P 0.001 63.99 3.91 P 0.001 64.81 3.98 P 0.001
C 72.26 2.84 71.15 2.66 73.02 2.80 73.83 2.00
CCN (mm) D 52.42 3.19 P 0.001 50.59 2.96 P 0.001 52.62 3.11 P 0.001 53.42 2.91 P 0.001
C 60.23 3.00 58.97 3.06 61.04 2.59 62.23 2.06
SBa (mm) D 42.33 3.22 P 0.001 39.94 2.91 P 0.001 43.04 3.00 P 0.001 43.31 2.81 P 0.001
C 46.30 3.03 45.53 2.78 46.78 3.13 47.52 3.02
NBa (mm) D 100.90 5.55 P 0.001 96.98 4.26 P 0.001 101.50 5.49 P 0.001 102.90 5.10 P 0.001
C 109.60 4.36 107.90 4.40 110.60 3.81 112.90 3.00
SNBa () D 143.40 4.76 P 0.001 143.30 5.37 P 0.001 142.60 4.06 P 0.001 144.00 4.83 P 0.001
C 133.90 4.12 133.90 3.95 133.50 4.19 135.60 4.31
Deflection () D 27.12 2.26 P 0.001 27.48 2.92 P 0.001 26.92 2.08 P 0.001 27.05 1.87 P 0.05
C 29.01 1.84 29.25 1.76 28.93 1.94 28.35 1.70
CCPo (mm) D 43.37 3.84 NS 42.42 4.33 NS 43.61 3.57 NS 43.80 3.66 NS
C 43.27 2.47 42.72 2.63 43.75 2.29 43.69 2.06

D, Down syndrome group; C, control group; Sig, statistical significance; NS, not significant.

cordance type III, a greater difference than previously
described.
In concordance type II, the arithmetic mean be-
tween the 2 values is established for the parameter that
does not coincide. When the difference is greater
(concordance type III), the lines are drawn, and the
measurements are made again, bearing in mind the 3
types of concordance. Standard error was determined
with the Dahlberg formula (SE 76d2/2n),30,31 and
the systematic error was found by using the Student t
test at P 0.05.32-34 A descriptive statistical analysis
was carried out to evaluate the data obtained in which
we included the arithmetic mean, percentage, and range
(maximum and minimum values) of each variable for
each group (DS and control) according to sex and age.
Then an analytical or inferential statistical analysis was
done in which the differences between the 2 groups
were analyzed by using the Student t test for indepen-
dent samples to establish comparisons between age
groups. To study the evolution of each variable over
time and to establish comparisons in the behavior of 1
particular variable in each group, we used the 2-way
analysis of variance (ANOVA) with interaction. When
this test did not show significant differences, we ap-
plied the least square means correction to find differ-
ences in the data of the arithmetic means.
Because the samples were unequal, we could only
compare the overall averages when the ANOVA with
interaction did not find statistical significance. Other-
wise, it is methodologically more appropriate to estab-
lish the comparison according to age groups, thereby
avoiding doing so with overall averages. When we
were able to compare overall averages (nonsignificant
ANOVA), we did so using the least square means
correction because it is more precise than the Student t
test when assigning statistical significance.
In each group and to compare the different age
groups, we applied 1-way ANOVA followed by the
Duncan multiple range test as an a posteriori test with
a 0.05 confidence level. To determine the differences
between the sexes, we also used the Student t test.
RESULTS
Table I gives average values, standard deviations,
and statistical significance, after the Student t test, of
the values obtained from the cephalometric superimpo-
sition method. The values studied were the horizontal
growth of N (horiz N), vertical growth of N (vert N),
732 Alio, Lorenzo, and Iglesias American Journal of Orthodontics and Dentofacial Orthopedics
May 2008

Table II. Cephalometric variables of superimposition and cephalometric variables: differences between the sexes in
the 2 groups (Student t test)
Females Males

Variable Group Average SD Average SD Sig

Variable of superimposition
Horiz N (mm/y) D 0.48 0.56 0.46 0.43 NS
C 0.68 0.40 0.81 0.41 NS
Vert N (mm/y) D 0.13 0.15 0.12 0.15 NS
C 0.15 0.08 0.13 0.06 NS
Horiz Ba (mm/y) D 0.45 0.48 0.50 0.56 NS
C 0.27 0.33 0.50 0.50 P 0.01
Vert Ba (mm/y) D 0.46 0.48 0.29 0.42 NS
C 0.18 0.25 0.58 0.53 P 0.01
Basal angle (/y) D 0.55 1.37 0.22 1.05
C 0.06 0.61 0.22 0.76 NS
Cephalometric variables
SN (mm) D 61.15 2.32 65.84 3.92 P 0.001
C 71.29 2.73 73.03 2.71 P 0.001
CCN (mm) D 50.34 2.06 54.06 2.96 P 0.001
C 59.46 2.71 60.87 3.10 P 0.01
SBa (mm) D 40.37 2.68 43.88 2.75 P 0.001
C 45.36 2.45 47.04 3.26 P 0.001
NBa (mm) D 96.80 3.51 104.13 4.67 P 0.001
C 108.51 4.28 110.49 4.25 P 0.01
SNBa () D 144.14 4.75 142.76 4.71 NS
C 135.65 4.15 132.55 3.55 P 0.001
Deflection () D 27.55 2.07 26.77 2.35 P 0.05
C 29.15 2.00 28.89 1.71 NS
CCPo (mm) D 41.53 3.32 44.83 3.60 P 0.001
C 42.56 2.58 43.84 2.24 P 0.01

D, Down syndrome group; C, control group; Sig, statistical significance; NS, not significant.

horizontal growth of Ba (horiz Ba), vertical growth of
Ba (vert Ba), and changes in the angle of the base (basal
angle). In the first column are the total average values
for both groups. In the next 3 columns, the same values
appear but are separated into the prepubescent, pubes-
cent, and postpubescent stages. In the lower half of
Table I, we show these same data but here applied to
the cephalometric variables themselves. All variables
show significant differences between the groups for the
total sample as well as the 3 age groups.
Table II presents the differences between the sexes
in the DS patients and the control group. In the
cephalometric superimposition variables, the only sta-
tistically significant differences appeared in the control
group and in the growth of Ba, both vertically and
horizontally. The differences between the sexes in the
cephalometric variables were significant except for the
cranial base and cranial deflection angles.
Table III, in the first column, gives the results of the
2-way ANOVA, which allowed us to analyze the evolu-
tion of the different parameters over time between both
groups. In the next column, each group is analyzed
individually, comparing the 3 age subgroups (prepubes-
cent, pubescent, and postpubescent) with the 1-way
ANOVA and the a posteriori Duncan test. For the DS
group, regarding horizontal and vertical growth of N, the
group that distinguished itself from the others was the
postpubescent group. The same occurred for growth of
Ba, even though in this case and regarding horizontal
growth, its behavior was different in each of the 3 age
groups. To make these data easier to understand, we
present the same finding in Figure 2 regarding the hori-
zontal growth of N. In the DS group, there was forward
growth of N of 0.47 mm per year, whereas in the control
group, it was 0.75 mm per year. Therefore, the growth rate
was slower in the DS group, especially in the prepubes-
cent and postpubescent stages (P 0.01). In the vertical
plane (Fig 3), the prepubescent DS groups vertical
growth was limited (0.13 mm per year) but was similar to
the control groups 0.18 mm per year. From the age of 15
onward, growth of N in the DS group slowed to a halt,
vertically and horizontally, with virtually no annual
growth. However, this growth limitation was not seen in
the control group, where this landmark shows regular,
constant growth.
If we look at Figures 4 and 5 and Tables I and III,
American Journal of Orthodontics and Dentofacial Orthopedics Alio, Lorenzo, and Iglesias 733
Volume 133, Number 5

Table III. Cephalometric variables of superimposition and cephalometric variables

2way ANOVA 1way ANOVADuncan test

Prepubescent Pubescent Postpubescent

Variable Group Change (811 y) (1214 y) (1518 y)

Variables of superimposition
Horiz N D P0.05 NS NS P0.05
C NS NS NS
Vert N D P0.05 NS NS P0.05
C NS NS NS
Horiz Ba D P0.001 P0.05 P0.05 P0.05
C NS NS NS
Vert Ba D NS NS NS P0.05
C NS NS NS
Basal angle D P0.05 NS NS NS
C P0.05 NS NS
Cephalometric variables
SN D NS P0.05 NS NS
C P0.05 NS NS
CCN D NS P0.05 NS NS
C P0.05 NS NS
SBa D NS P0.05 NS NS
C P0.05 NS P0.05
NBa D NS P0.05 NS NS
C P0.05 P0.05 P0.05
SNBa D NS NS NS NS
C NS NS NS
Deflection D NS NS NS NS
C NS NS NS
CCPo D NS NS NS NS
C NS NS NS

D, Down syndrome group; C, control group; NS, not significant.

Fig 2. Superimposition variable: horizontal growth of

Fig 3. Superimposition variable: vertical growth of na-
nasion (mm/year).
sion (mm/year).

we can analyze the horizontal (posterior) and vertical
growth of Ba. No significant differences were shown
with the Student t test. In the DS group, horizontal
growth was 0.48 mm per year, and, in the control
group, it was 0.40 mm per year. Vertical growth in the
DS group was 0.36 mm per year, and, in the control
group, it was 0.40 mm per year (Table I). When the
2-way ANOVA (Table III) was applied, horizontal
growth differences appeared between the 2 groups, but
there were no vertical differences. In short, the evolu-
tion of Ba growth over time is similar to that of N,
slowing to a virtual halt after age 15 years in the DS
group and remaining constant in the control group.
The behavior of the basal angle as seen through
734 Alio, Lorenzo, and Iglesias
Fig 4. Superimposition variable: horizontal growth of
basion (mm/year).
Fig 5. Superimposition variable: vertical growth of ba-
sion (mm/year).
cephalometric superimposition (Table III) indicated
that growth was different in each group (2-way
ANOVA). The differences appeared in the prepubes-
cent stage when the angle opened (increased) an aver-
age of 0.74 per year (Table I), but, in the control
group, the increase was practically nil (0.06 per
year). Starting from this prepubescent stage, both
graphs converge, reaching similar values in both
groups, about 0.4 per year. We found no differences
between the sexes (Table II).
The distance from Po to vertical pterygoid (CC-Po)
was almost the same in the 2 groups in the 3 age
subgroups. The average distances were 43.37 mm for
the DS group and 43.27 mm for the control group
(Table I).
DISCUSSION
Anterior cranial base
The 2 cephalometric variables used to evaluate
anterior cranial base (S-N and CC-N) showed shorter
American Journal of Orthodontics and Dentofacial Orthopedics
May 2008
Fig 6. Anterior cranial base (S-N) (mm).
lengths (P 0.001) in the DS subjects (Fig 6). This
finding was published by various authors.35-40 This
shorter length than that of normal subjects remained the
same throughout the study, while the growth rate
remained constant. In other words, the anterior cranial
base grew in the same proportion in both groups
between the ages of 8 and 18, suggesting a difference in
the size of the cranial base in the years before those that
we studied. This finding agrees with the studies of
Roche et al,10,18 in which they affirmed that, at birth,
the length and the cranial perimeter values in DS
patients are similar to those of normal subjects. How-
ever, in the first 4 years of life, the growth rate slows in
DS patients, and then the differences arise. Some
authors15 found a deficit in the anterior cranial base of
up to 4 mm at birth, suggesting that these differences
are prenatal. Other authors, such as Spitzer41,42 and
Roche,20 related this shortening of the anterior cranial
base to the lack of pneumatization of the frontal sinus
that frequently accompanies DS. However, Roche20
was quick to add that the absence or atrophy of the
sinus in itself is insufficient to explain the shortening of
the cranial base, since this is also seen in other patients
with well-developed sinuses. Frostad et al43 pointed out
that the nasal bone in DS patients is not fully devel-
oped. For this same reason, it would seem that this is
not a sufficient reason to justify the shortening of the
cranial base. In any case, when we analyzed the
variables of the cephalometric superimposition, we
found that the horizontal growth rate of N was consid-
erably less in the DS group than in the control group,
and, after age 15, it significantly dropped (P 0.05)
virtually to zero; this allowed us to mark the end of
growth at this landmark in the vertical and the horizon-
tal planes. This fact agrees with and is totally coherent
with the stabilization of the S-N and CC-N measure-
ments between the pubescent and postpubescent stages.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 133, Number 5
Fig 7. Posterior cranial base (S-Ba) (mm).
Growth of N in the horizontal plane was much greater
than in the vertical plane, but, in the DS group, it
stopped at age 15, whereas in the control group it had
a certain potential for growth. Frostad et al43 agreed
with our results when they put the end of growth of the
nasal bone in DS patients at about 16 years of age. We
found some sexual dimorphism in that the anterior
cranial base was larger in the male patients (P 0.001);
this coincides with findings of other authors.38 How-
ever, when we analyzed the cephalometric superimpo-
sition variables, these differences did not appear. This
might be because of the low magnitude of the super-
imposition measurements; this would make it difficult
to determine significant differences. Another possible
explanation is that this sexual dimorphism is already
present at an early age, and later both sexes keep the
same annual growth rates. This latter explanation was
also considered by Alonso-Tosso et al38 and Frostad et
al.43 In this respect, Baughan and Demirjian44 thought
that sexual dimorphism in cranial growth in the general
population must appear at an early agespecifically,
during the first 5 years of life.
Posterior cranial base
The posterior cranial base, represented by the S-Ba
measurement, was also significantly shorter in the DS
patients (P 0.001), as can be seen in the comparisons,
with respect to the overall averages and in all 3 stages
of growth in this study (Fig 7). Roche20 also found this
result. The way in which the posterior cranial base
grows was different in the DS group than in the control
group. Using the cephalometric superimposition anal-
ysis of variance, we see that the growth rate gradually
decreases with age, especially after age 15, whereas in
the control group the growth rate continues after this
age, especially in the horizontal plane (P 0.001).
Latham,45 in his histologic study of human specimens,
Alio, Lorenzo, and Iglesias 735
recognized gradual growth in the spheno-occipital syn-
chondrosis until age 18. Our results suggest that in DS
this synchondrosis finishes its growth earlier than in the
general population. Sexual dimorphism was again
present in this variable, with S-Ba length significantly
longer in the boys of both groups (P 0.001). None-
theless, the growth rate was not different in the sexes,
as shown in the results of Ba landmark cephalometric
superimposition variables.
The CC-Po distance remained almost constant over
time in both groups. Therefore, we concluded that the
middle cranial fossa size and the glenoid cavity position
are the same in DS patients and the general population.
On this point, we agreed with Surez-Quintanilla et
al,40 who also obtained a normal CC-Po distance in DS
patients.
Total cranial base
Obviously, if both the anterior and posterior cranial
bases are clearly shorter in DS patients, so will the
cranial base be shorter considered as a whole. This fact
can be seen in the N-Ba measurement, which is shorter
than that of the control group (P 0.001). This result
coincides with studies of Grosman and Vimeland46 and
Fischer-Brandies.15 In studies by Spitzer,42 Austin et
al,13 and Benda,47 there are references to generalized
microcephaly in DS. The way in which this measure-
ment evolves over time will also be in relation to what
happens in the anterior and posterior base. Therefore,
we observed slowing growth starting at 15 years of age.
This, in turn, coincides with the previously mentioned
results related to the end of growth in Ba and N and
reflected in the S-N, CC-N, and S-Ba lengths as well.
However, these differ from what happens in the general
population: cranial base growth continues until the
person is 18 to 20 years old.29,48 Likewise, if males
have a bigger anterior and posterior cranial base, one
would expect to find this sexual dimorphism when
considering the whole cranial base, as was noted by
Jensen and Clearll49 and Alonso-Tosso et al,38 who
noticed larger cranial bases in males with DS. Roche
and Lewis50 also wrote about the differences between
sexes in the elongation of the cranial base during
puberty, with males having greater N-Ba and S-N
increases.
Angulation of the cranial base
The angulation of the cranial base was analyzed
with a superimposition variable and 2 cephalometric
(BaSN angle, cranial deflection) variables (Fig 8).
These measurements show a flatter cranial base in the
DS group (P 0.001)ie, an increase in the BaSN
angle and a decrease in the cranial deflection angle in
736 Alio, Lorenzo, and Iglesias
Fig 8. BaSN angle ().
the DS group with respect to the control group. This
result was also reached by Burwood et al,14 Michejda
and Menolascino,51 Fischer-Brandies et al,22 and
Menndez et al.39 Menndez et al39 interpreted the
flattening of the cranial base as vertical hypoplasia of
the central part of the cranium accompanied by lower-
ing of sella turcica, rejecting as improbable that it is due
to a lesser degree of cerebral development. This agrees
with observations by Spitzer42 and James et al,52 who
described hypoplasic sphenoid bone and poor general
pneumatization of the cranial base, including the sphe-
noidal sinus, in DS. On the other hand, Michejda53
observed in macaque crania that the mediosphenoidal
or intersphenoidal synchondrosis did not fuse until the
animals reached 6 years of age. They, like all nonhu-
man hominids, have a flat cranial base. This author
noted that in DS this synchondrosis does not close until
the seventh year,51 but, in the general population, it
usually ossifies by the time of birth or in the first
months of life.54 Therefore, there would seem to be a
relationship between the degree of flattening of the base
and the closing of the synchondrosis, leading some
authors to attribute the cause of a flat cranial base in DS
to late ossification of the intersphenoidal synchondro-
sis.51 Our results provide evidence that the angle of the
base remains constant between the ages of 8 and 18, in
both the DS and the control groups. These results agree
with those of Burwood et al14 in the former group and
those of Lewis and Roche54 for the general population.
The differences in the angulation of the cranial base
with regard to sex were minimal in our study. Some
authors, however, found differences. Alonso-Tosso et
al38 found greater flattening in males, whereas Fischer-
Brandies et al22 found the same only for females.
American Journal of Orthodontics and Dentofacial Orthopedics
May 2008
CONCLUSIONS
1. Generally, growth of the cranial base in DS patients
does not substantially differ from that in the general
population between the ages of 8 and 18 years. The
structural differences are established before this
age, and then the proportional growth rate is simi-
lar.
2. Growth in the cranial base of DS patients is less
than in the general population.
3. There is some sexual dimorphism in DS patients
because the measurements in males are longer than
in females.
4. The cranial base in DS patients is flatter and shorter
than in the control group. This finding must be
considered for cephalometric diagnosis of a DS
patient with respect to the planes of references we
normally use.
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