Vev-tical growth of the human face

MEI,VIN I,. MOSS, D.D.S., P’r.1).

New York, N. I’.

GROWTH ANALYSIS
GROWTH has been defined as any change, in time, which is measurable: length.
volumes, concentrations, pressures, etc. 78,7g It may include decreases as well as
increases.40, 431*6 The present study deals exclusively with linear increase. Growth
data are gathered in two fundamentally different ways-cross-sectionally and
longitudinally. Cross-sectional data are obtained, for example, by measuring
total face height in ten comparable sets of children grouped a year apart. Each
set is measured once. The resulting mean trend of increase is an estimate of
how this average dimension might change during a period of 10 years in ot,her
sets of otherwise comparable children. Individual growth patterns are detclr-
mined by longitudinal study. To obtain such data, a child (or a set of children J
is measured serially for 10 years, as in the present example. Such data ark
more meaningful for the study of individual variation.27
We are concerned not only with dimensional increase in t.ime (the curvt’
of growth) but also with rates of growth, velocities of growth, and accelerations
and decelerations of growth rates, as well as those methods of expressing rela-
t,ive proportions between parts (allometric growth) .6. 21, 73 The present discux-
sion will not attempt a rigorous analysis of all these aspects. The inter&cd
reader is referred to previous articles for an introduct,ion to these methods.4”T ‘L ”

FTJXCTIOXAL CRASIAL ANALYSIS

All growth phenomena reflect fundament.al changes in the size and/or shnp
of the measured body parts. Such changes in form frequently indicate chang:cls

From the Department of Anatomy, College of Physicians and Surgeons, Columbia

Cniversity.
This study was aided, in part, by Grant NB-965 from the National Institutes of
Health.
Presented before the Great Lakes Society of Ort,hodontists, Toronto, Ontari(s.
October, 1963.
360 Xoss Am. J. Orthodontics
Ma!/ 1984

in function or changes in functional capacity. Modern growth study attcmpt.s

to correlate the mcnsurational data with these functional, biologic considerations.
In a series of articles we offered the concept that the head consists of a
number of relatively independent and yet coordinated functional cranial com-
ponents. These components are related t,o the major functions of the hcad-
sight, respiration, speech, swallowing, and so forth. Each cranial component
includes all of the skeletal and related soft tissues necessary to carry out these
separate functions effectively.“”
In the present context it is necessary to clarify several points. It is somc-
what meaningless to study the growth of t,he classic anatomic units called bones.
Each supposedly individual bone is, in reality, composed of a number of rela-
tively independent functional components. I have previously established these
components in both the maxilla and the nlandible.4”, 5”1j4 Each bony component
is, in turn, relat,ed to its functional n&&x-those soft tissues within which
the individual osseous components exist and grow, It is of the utmost importan,ce
that we +ealize that the growth of bone is dependent p,rinaa.rily upon the growth
of its functional matrix. In other words, while intrinsic (genetic) factors pro-
vide the potentiality of growth, its expression can occur only through the
operation of those extrinsic (functional) factors provided by the matrix.4”! 43,“-“~
w w 53s54 The present article attempts, in so far as the available data allow,
a functional analysis of the vertical growth of the face. The several biologic
processes underlying these dimensional changes will be indicated, and their
integration will provide a dynamic, biologically valid understanding of vertical
growth.

THE ORTHODONTIC PROBLEM

In current terminology we can safely say that orthodontists have a clearly

established “need to know” about the growth of the head. It is not necessary
to belabor the potential utility of such information for both diagnosis and
prognosis. It is fairly stated that while there exists a plethora of data on
vertical growth of the head, some of it is relatively worthless and most of it
suffers from a lack of subsequent biologic synthesis or meaningful analysis.
All too often the orthodontic clinician has been provided with only a few rela-
tively unreliable “standards” obtained from cross-sectional studies of minuscule
and dispa.rate populations which, at best, offer only the most generalized in-
dications of growth trends. These standards have been utilized in an overly
rigid fashion to provide both a diagnostic and a prognostic goal toward which
many patients have been therapeutically directed by rather Procrustean modes
of thought and treatment.
Let us now examine the present state of knowledge concerning vertical
growth of the face, underscore the biologic processes involved in these changes,
and provide a prolegomenon to a rational approach to the problem.

CURRENTLY AVAILABLE DATA

There are large amounts of data on vertical growth of the human cranium
in the anthropometric and orthodontic literature.“0-3*~ So>ST These data, which
 Vertical growth of human face 361

are of uneven quality and variable usefulness, are chiefly cross-sectional al-
though several excellent longitudinal studies are available.75 A selection of YO~C
interesting papers includes those by Lebret,“” Dreyer.2’ Sarnas,5’” Bjiirk and
Palling,8 and A1temus.l
The present situation is easily summarized. We may clearly define t,hc
general trends or tendencies of absolute and relative growth for the scvrral
subdimensions that compose total vertical face height,. We would be less than
candid if we did not point out that the usefulness of such cross-sectional data
for individual orthodontic diagnosis and prognosis is minimal.
That is vneasured? We are interested in the size of the face (or skull) CBS-
tending between the root of the nose to the lower border of the chin or. iu
more sophisticated terms, the nasion-gnathion dimension. ( Martin3j has pre-
sented precise definitions of these points, as well as all other anthropomctrit
points.) Within this over-all midsagittal dimension, several other dimensions
are ordinarily delineated-upper face height,, lower face height, nasal height,
lip height (upper and lower), dental height, alveolar height, and so Porth-----
depending upon the individual investigator and the needs of his pa,rticular
study. When comparing data of several workers, one should take care to set!
whether different investigators use identical points of reference; if not, valici
comparison is difficult. Any discussion of the statistical problems involved-
sample size and composition, controls, etc.-is beyond the scope of this article.
Basically, there are two points of clinical interest to the orthodontist : First,
will the growth of vertical distance between maxilla and mandible be sufficient
to allow full eruption and normal position of the dentition? Second, will this
increase in potential dental vertical space be harmonious (or proport.ional i
with vertical changes in other facial regions! From these questions arise:
secondary questions: To what extent does a lack of “normal” vertical growth
dispose toward malocclusion! To what extent, if any, can therapy influence
this “normal” growth in an “abnormal” condition?

Table I. Calculated external dimensions of nasion-menton and vertical head

height at the close of each month of the fetal period”

I Nasion-menton Vertical head height

Proportion of ,vertical

3 7.9 21.1 37.5

4 16.8 8.9 40.4 19.3 41.6
5 24.4 7.6 56.8 16.4 43.0
6 31.2 6.8 71.4 14.6 43.5
7 37.3 6.1 84.7 13.3 43.7
8 43.0 5.7 97.0 12.3 45.3
9 48.2 5.2 108.4 11.4 44.4
10 53.2 5.0 119.2 10.8 44.6
*After Scammon and Calkins: The Development and Growth of the External Dimensions
of the Human Body in the Fetal Period, Minneapolis, 1929, University of Minnesota Press.
362 Moss

GENERAL GROWTH TRENDS

Out of the vast literature, I have arbitrarily selected a few papers whose
data demonstrate the general patterns of vertical facial growth. Let us non
turn to an examination of the individual differences and variations.
PRENATAL GROWTH. Clinically observed growth in the child is, of course,
a continuation of prenatal processes.
Table I, based on data presented by Scammon and Calkins,6” gives a con-
ception of the relative constancy of proportions while absolute dimensions are
rapidly changing. As can be easily seen in Fig. 1 and in Table I, the percentage
of total vertical head height occupied by the distance between nasion and
menton is relatively constant. Some idea of the role of sexual factors in the

120 - Absolute growth .

,I’
110 - f
i

100 -
height ;
I
90 -
r’
i
80 -
:
:
70 - i
:
60-

ol 3 4 5 6 7 8 9 IO

Age in prenatal months

Fig. 1. Absolute growth and growth rate of two vertical dimensions in the human fetal head.
These cross-sectional data are taken from. Scammon and Calkins.62
l”o7unLe
~llntha?~ 3
.>(.I T’ertical growth of humctn fnce 363

statistical distribution about such mean values. as reported by Catrs and (iood-
win,‘:’ is given in Table II. Within the increasing total facial height WC not,(t
that the relative height of the nose remains fairly constant.“’

NO. I ,
I
Sex of cases AXwua (cm) ) rttl c s. I). j T’

M 343 4.75 0.011 0.30 6.30

F 327 4.70 0.013 0.35 7.4CB
*Aft,er Catw and Goodwin: TIM Twelve-Day-Old Baby, Human Eiol. 8: 433-450, 19:iti.

POSTSATAL GROWTH. An early study by Smyth and l-oung” of Knglisll

school children, male and female, provides good data. Ilnfortunately, however,
their cross-sectional study does not cover the years between 5 and 8 alt,hough
it does provide mean values for boys and girls between the ages of 2 and 11,
with appropriate statistical measures. Among other dimensions, this study re-
ports on total face height, nasal height, and upper and lower face heights
which include the respective incisor tooth lengths (Fig. 2). The analysis is aided
if we now consider the growth rate (or velocity), which is a mcasurc ol’ the
incremental change per unit of time. Fig. 3 shows that all of thcne dirncnsions
demonstrate mean maximal growth rate change at about the same age.
One of the most comprehensive studies of facial vertical growth is that;
by Krogman”3 which, unfortunately, is not yet available for general distribution.
This st,udy reports on total face height. of white and Negro children, male and
female. between 6 and 11 years of age. There are two distinct measurements
each of upper and lower face height (with and without including incisor
height), total dental height, nasal height, total lip height, and ramus height,.
The Negro data are cross-sectional, whereas the data on whi1.c children are
mixed longitudinal (that is, the data are pooled and trcatcd cross-scctionall)-).
Fig. 4 presents several of these parameters for male white children. In this
graph the curve represents cumulative inrrcmcnts of gl’owth. WC note that
nasal height and upper face height are virtually identkal, the added factor
of alveolar bone height eventually causin g the latter to surpass rraswl hcightf
increments. Increments of lower face height, are consistently less than those
of upper face height, while posteruptive dental height, as csprctcd, remains
essentially constant. The intermediate position of mandibular ramus height
indicates that this dimension “sqans,” as it were, both upper and lowrr face
heights.
It is interesting to not,e that upper face height remains a relatively con-
stant proportion of total face height (mean for all ages, 61.9 per cent,), a find-
ing that is not at all surprising since we arc now measuring a part against a
whole which includes the part. However. similar rclativr proportionality is
seen when we compare lower face height, to upper face height (mean for all
ages, 53.7 per cent). Ramus height remains relatively constant at 67.4 per ectnt
of upper face height.
 In summary, Krogman’s data”” give us a picture of differential facial growth
during the period of eruption of the majorit,y of the permanent teeth which
stresses regularity and relative constancy. While the precise figures are dif-
ferent for males and females and for Negro and whit,e children, one can
safely verbalize the changes in vertical dimensions in the following way:
Growth of total face height (and of all its subdimensions) follows the gen-
Facial growth in ? English school children

26 -

24 -

22 -

20 -

I8 -

16 -

14 -,
i
0
.-c 12 -
r

&% IO -

8-

6-

4-

2-

I I I, I,, , I, 1, ( ,
2 3 4 5 6 7 8 9 IO II 12 13 14 15
Age in years
Fig. 2. The curve of growth (absolute growth) of five selected vertical dimensions in female
English school children. The dimensions are as follows: 2, nasion-submandibular point
(menton) ; d, nasion-incisal edge of upper central incisors; PI, nasion-subnasal point ; 4,
palatal height; and 5, incisal edge of lower central incisors to submandibular point (menton).
These cross-sectional data are derived from Smyth and Young.74
eralized sigmoid curve of growth. The upper fact increases more than the
lower face, although all subdimensions retain a relatively constant propor-
tionality. By far the greatest increments of growth in upper face height arc’
associated with concomitant increases in nasal height, while lower face he&hi
is closc~l~ correlated with increases in the region of the mandibular symphpsis.
The mandibular ramus, spanning as it does both the maxilla and the mandibular
body, shows an intermediate range of inrrcmcntal growth, again retaining
proportionality.

Facial growth in 0 English school children

t Smyth 4 Young )

II -

IO -
9-

8-

7-

$ “,.

* 4-

3-

2-

I -

O-

I I I I I I I I I,, I , I
2 4 6 8 IO 12 14

Age in yeors

Fig. 3. Growth rates of the five dimensions given in Fig. 2. Obse1772 tlw apparerlt conelntiw
between the rate maxima and minima for these five dimensions. Compare with Pigs. 4 and 6.

Facial growth continues, although at a diminished rate, into the thiytl

decade, assuredly, and most probably into the fifth dccadc.3 Here again, rela-
tive proportions of the several components of face height, as judged from mean
values derived from cross-sectional data, remain constant. Significant increases
in vertical facial dimensions in the eighth decade of lifci7 have been reported.
Accordingly, it is obvious that vertical facial growth is a continuous event
and that the curve of growth is asymptotic. Therefore, while we speak cot’-
rectly about growth spurts, accelerations and decelerations of growth rates,
and prenatal, childhood, preadolescent, adolescent, and adult growth periods,
there is really only a unitary growth process. It is necessary to note, howcve~~,
that different biologic events may be dominant at different ages.
None of this is either new or startling. The apparent relative constancy
has been variously expressed by many workers. Indeed, it furnishes the basis
for most of those diagrammatic illustrations, now well known to all orthodox-
t,ists, which depict, the growth of the human facial skeleton. What is perhaps
not quite so apparent is the validity and uscfnlncss 01’ this statement (or of
any others like it), based as it is on either cross-sectional data or cross-sec-
tional treatment of longitudinal data. It is not that these data are in thcm-

Facial dimensions in male white

Philadelphia children
( Krogman)

17 -

4-

2-

, , , , , ,

6-F 7-8 8-9 9-10 IO-II II-12 12-13 13-14 _,

Age in years
Fig. 4. Cumulative growth increments (not absolute growth) and the groxvth rates (at right)
of six selected dimensions. These data, taken from Krogman,ss are longitudinal but have
been pooled and treated cross-sectionally. 1, Total facial height; 3, nasal height; 3, upper
facial height; 4, ramus height; 5, dental height; 6, lower facial height.
selves, incorrect. It is only that the inferences that mc tend to draw from thclll
may not be true for the individual case under clinical consideration.
I?~DIVIDT?AL VARIATION. Longitudinal growth studies provide us with thti
h NASAL HEIGHT x ,OO
7g- SUBNASAL HGT

. MEAN TREND FOR

276 AND 28.?

4 5 7 6 8 9 10 I I 12
AGE IN YEARS
Fig. 5. Cross-sectional treatment of longitudinal data on t,hc ratio of nasal to subnasal
height. Xote the seeming regularity, comparable to that shown in Pigs. I, 2, and -1. (From
Meredith, Knott, and Hixon: ASI. J. ORTHOD~WTICS 44: 285'794, 195‘3.)

%
84

82

80 78.

7e 76.

76 74.

Ii
74 721 ./
.-. /
72 70 i Il.-.l-- _-- I_-_ --,.,-,
F-.. ,_----- ,_ -’ __. “_ ._-_

70 4

76-l .
‘N.
1.
74. - .-. /
68

4 6
AGE IN YEARS
8 IO I: m AGE IN YEARS
Fig. 6. Four individual longitudinal growth curws for the same ratio shown in Fig. 5.
The range of normal human variation in vertical growth is well exemplified here, / From
Meredith, Knott, and Hixon: AX J. ORTHODONTICS 44: 285094, 1958.)
best way of accumulating data that demonstrate the extent of normal variation
from the average (mean) trends discussed above.3Y
In one of a long and excellent series of papers derived from a University
of Iowa study, Meredith and associates”” reported on the relation of nasal
and subnasal components of facial height in children 4 to 12 years of age. While
reporting that, on the average, the nasal component usually increases absolutely
relative to the subnasal component and that their relative proportions remain
“practically constant,” they go to some pains to note the great range of in-
dividual variation. Specifically referring to the relative proportions of nasal
height to subnasal height, they report an individual distribution ranging from
65.0 per cent to 91.6 per cent (Figs. 5 and 6).
In a more expansive study, Nanda”“s 5i reported on longitudinal data de-
rived from a University of’ Colorado study for the age range of 4 to 20 years.
He plotted not only individual growth curves for a number of cranial dimcn-
sions but relative increment (per cent increment per unit time) curves as well.

24 SELLA-GNATHION

‘i ,j,
‘4 5 6 7 8 9 IO II 12 13 14 15 I6 I7 I8 19 20
AGE IN YEARS
Fig. 7. The relative independence of the various dimensions composing vertical height during
their growth is well shown in this longitudinal growth study of the indicated dimensions in
a single child. Maximal and minimal deflections are not constant. Accordingly, facial pro-
portions are similarly not constant. (From Nanda: Ergebn. Anat. Entwcklngsgesch. 35:
358-419, 1956.)
First, he noted that the facial circumpuberal maximums (of relative growth
rate) occurred slightly later than those for general body growth. Second, ant1
more important, he noted that “the time of both the onset and the peak of thtl
rate of growth are different for the various dimensions of the same child” (Fig.
7). In other words, relative proportionality between vertical dimensions was
not constant in any individual and, in fact, growth was accompanied by “dif-
ferential changes in the form of the face.“l’
In another paper from the same University study, Bambha’ reported on
the age range of 4 months to 30 years. He generally extends the work c~f
Nanda5”, 57 and goes on to make several additional points: (1) in addition
to the circumpubertal growth spurt, a distinct childhood spurt occurred in
most instances; (2) significant sex differences were noted during adolescctnc~c~,
with girls having smaller absolute measurements, sIow(~r rates of growth, and
earlier maturation than boys.

P i- 1
5
8- ‘;8
W
2- 6- -6
CL _

tsr ,
l 4- t4
s .

2 T
I’
1, ii
ui
1 1L
B 9 IO II 12 13 I4 15 16 17 I8
AGE IN YEARS
Fig. 8. The range of variation in maximal and minimal increments of mandibular condylar
increments of vertical height. This is a cross-sectional treatment of longitudinal data. For
both maximums and minimums, the range of age at which these deflections occur is indieatcsd
by the horizontal lines, while the range of the extent of rate of increase at thrse points
is shown by the vertical line. (From Bjiirk: J. ID. ROR. 42: 400-411, 1963.)

TTsing an entirely different technique, Bjiirk”, lo has followed longitudinal IF

a series of children in whose facial bones metallic implants were placed. For
example, he reports on the annual growth rate of the mandibular condylo.”
His illustrations most graphically demonstrate the great individual variation
in the direction of growth, while Fig. 8 from his paper”’ gires an excellent
summary of the range of variation in growth rate maximums and minimun~s
as well as the ranges of the ages at which these were attained.
It is possible to multiply these instances many times, but littlt would he
gained by such repetition. I believe that the main points have been made suf-
ficiently clear. No existing data enable the clinician to satisfactorily diagnosc~
3 70 la!OSS ~111. J. Orthodontics
May 1964

OP prognose vertical facial growth or the growth of any other cranial dimen-
tion, for that matter. Individual variation-is the rule, not the exception. The
apparent simplicity and seeming “mathematical” reliability of any mean values
in any analysis is an illusion and a snare. To this extent, orthodontic therapy
is, and should be, an art rather than a science.

FUNCTIONAL CRASIAL ANALYSIS OF VERTICAL GROWTH

Despite the apparent pessimism of the previous paragraphs, there is con-

siderable hope that a meaningful, and perhaps useful, method of growth analy-
sis may soon arise. One step in this direction is the technique of functional
cranial analysis. I have referred to our previous publications on this subject,
and I now propose to expand this analytic procedure to the study of vertical
growth.
Several other workers have made major contributions to functional cranial
analysis. My own work stems primarily from the fundamental concepts of van
der Klaauw.84 The works of ScotP7* and of Tucker81-S” demand particular
attention from the interested student of the problem, and the earlier papers
of Diamond18, I9 are also instructive.
Increases in linear distances (or changes in angular values), by themselves,
are without biologic meaning. These observed growth changes reflect, or are
the result of, growth processes which, in turn, are the result of growth in
functional cephalic components. Vertical facial growth reflects changes in the
following functional areas; vision, respiration, olfaction, digestion, and speech.
All of the bones protecting or supporting the soft tissues and spaces concerned
with these functions are involved either partially, as in the case of the frontal
bone, or completely, as in the ease of the maxilla and mandible. It is stressed
that, functionally, each bone is a conglomerate of a number of relatively in-
dependent cranial components. The mandible, for example, is really a morpho-
logic composite of alveolar bone responsive to the presence of teeth, an angular
and a coronoid process responsive to the presence of muscles, and a condyle
which arises independently from a basal mandibular corpus.4g, w w The maxilla
can be similarly analyzed into relatively independent functional components
primarily related to teeth, the orbital contents, respiration, muscle attach-
ment, and so forth.5J To illustrate how sensitively u-e delineate these areas,
let us consider the palatine processes of the maxilla. These, together with the
similar processes of the palatine bone, form the single entity known as the
hard palate. Functionally, however, WC isolate the upper (nasal) surface of
this thin plate from the lower (oral) surface. The smooth upper surface, grooved
to receive the vomer and the septal cartilages, is responsive to functionally re-
lated respiratory tissues and spaces, while the rough lower surface reflects di-
gestive and vocal functions. We term the tissues and spaces relat,ed to a given
function the functional matrix.54
The form (that is, the size and shape) of a bone, it,s spabial position, and its
growth are direct and mechanically obligatory responses to the growth of its
functional matrix. Therefore, the biologic processes that WC wish to study are
not those of bone growth per se, which are secondary, but rather those of the
functional matrix, which are primary. In other words, the form of the nasal
cayit,\- or of the oral cavity is not the space adventitiously left over by some
separat.irc bone growth processes. Quite the contrary. The empty spaces of thttse*
cavities are biologic realities; indeed, their 1~0110~~patency is prerequisite to
their normal functioning.
Hsperimental data support the hypothesis that the maxilla is a composittt
of several relatively independent functional cranial components. Orbital cnuclt~~-
tion, or removal of the entire orbital contents, in young rats” or in human in-
fants’!’ causes morphologic changes in only those portions of the maxilla that
are rclatcd to the orbital functional matrix. The primary mechanical role ot
the C~JY~ in orbital growth has been well established.“. I3 Xaxillary sinus pncuma-
tization is i?zdependent of orbital or oral events, but apparently it is related IO
nasal sclptum growth’” as well as to the normal development of nasal passage-
wa~ys.- “’ ‘U In other words, it is possible to have normal vertical growth of tht*
maxilla without concomitant pneumatization of the maxillary sinus. h-or is I 11th
sinus provided for by the eruption of t,he pcrmanrnt teeth, since congenitalI?
edentnlous persons may have normal sinus development, and, of conrsr, sinu<
enlarpcmrnt does not cause the eruption of teeth. An increase in or, iudec~tl.
the total presence of alveolar bone is entirely dependent. upon the prcxrlnce oi’
maxillary teeth-no teeth, no bone. Furthermore, intact maxillae are not IUW+
sary for normal vertical growth, a fact made clear by many studies of ~mop~‘ratc~~t
(and operated) cleft palate populations.“;, “:L “:a “’ This point has been t~xpt~ri-
mentally confirmed in monke;c-s by Sarnat.“l
Sasal-septum growth has been postulated by man.+;. Y”-i2 as the prim;rr\
factor in vertical height increase in the maxilla. Although t,his is seemingly tour.
let us consider the problem a little more closely. The initial positioning and tile
suhscquont, growth of the fetal maxilla are entirely dcprndcnt upon the growth
of tlic cartilaginous nasal capsule .p At birth, the upper (olfactory) portion of
t,hc nasal septum is virtually fully formed. Subsequent growth occurs chicfp in
th(b 1owc~1~(respiratory) septal area, accompanied by maturation of t hrl nasal
conchac. (I)ixon’(’ has presented some recent, techniques of stud>-. j
Our problem, however, is one of emphasis rather than process. In WI’ ;I?G-
lytic concepts, it, is more meaningful to sprak of growth of the respirator!- 1);~
sagrways than to refer to growth of t,he nasal septum. This point of v&v leas
been csprcssed implicitly by Subtelny’” and esplicitl- 1)~ Bosma,” who sti\t*ts :
“A rcccnt concept is that of the dcvclopmcnt of head and neck posture about
this pharyngcal airway,” which he properly terms thr “airxav-maintc~n;i~~~~(~
mechanism.“ An interesting article along these lines is that by Bench.7 Frc~n
our point of view, this physically empty hut physiologically necessary sp;tc~~is
the primary biologic object that grows. Tht 1 growth of the nasal septal eartil;ig(x
is, thc>n, a scxcondary, mechanically obligatory growth which is totall!. cl)m-
pcnsatory in nature.
WC have repeatedly demonstrated that the growth of the neural skull is
primarily a growth of the neural functional matrix, as in the case of the orbit
and the cyc. The calvarial bone growth is secondary to matrix (brain)
gro\\-th.“. hi JV\‘chave further postulated that facial bone growth is similar. with
372 Ness :I,,L d. Dvthodontics
Mny 1964

facial matrix expansion being primary. This is made biologically meaningful

by our repeated demonstration that sutures are not primary growth sites which
push bones apart but! rather, centers of secondary, compensatory adjusting
growth. Just as the brain does expand secondarily following primary calvarial
bone growth, so the oral and respiratory cavities do not expand because of
primar:- facial bone growth. Growth in maxillary vertical height is not the
result of expansive forces within the facial sutures. That statement has bern
documented many times.““. =s 5+ Kor is mandibular vertical growth a result of
primary growth at the mandibular condyle. A continuing longitudinal grow, th
study of vertical mandibular growth in a series of children following bilateral
mandibular condylectomy entirely supports this.“O, &cl
We view all of the facial bones as forming, growing, and being maintained
wdthin their respective functional matrices. It is these soft tissues and spaces
which grow. The bones are then passively carried within their expanding
matrices to new spatial positions. The growth observed both at facial sutures
and at cartilaginous areas (nasal cartilages, mandibular condyles, spheno-oc-
cipital synchondrosis) are nil secondary, compensatory events whose net effect is
to retain structural and functional continuity between skeletal parts. It now
becomes apparent that observations of distorted cranial growt,h following
operative interference with the spheno-occipital synchondrosis’* or with the
nasal septum”, 26 reflect the inability of these damaged tissues to permit neces-
sary compensatory changes in response to functional mat,rix growth rather than,
as is so frequently assumed, the inhibition of matrix expansion by lack of nor-
mal cartilaginous growth.
A complete exposition of the functional cranial analysis of the mandible
is not necessary at this time.“* It is necessary to emphasize only one point re-
lated to the preceding paragraph. The mandibular body does grow and relocate
in space normally without intact condylar cartilages. Similarly, ankylosis of
the temporomandibular joints, unilateral or bilateral, produces distortions of
facial growth because the mandible is prevented from moving normally within
its growing functional matrix. While the mandible cannot lower in space, the
matrix growth force vector remains unaffected in magnitude but its direction
is altered. Here again, the observed facial distortions are due to an inability
of the bone to undergo the usual compensatory growth changes.
In essence, these are the types of biologic data that we need in order to
understand more fully the problems of vertical growt,h. We need an integration
of embryologic, anatomic, and experimental data, with the totality newly syn-
thesized within the more current concepts of cranial function. We have not yet
arrived at our goal, but our direction is now clear.

Some of the pertinent literature dealing with the vertical growth of the
human face has been surveyed. Cross-sectional data have been utilized to point
out several general trends and patterns of growth; however, longitudinal data
illustrate the great range of individual variation and the dangers inherent in
any attempt to diagnose or prognose with the aid of available “standards.”
 l’erticnl growth of human face 373

An approach to a functional cranial analysis of vertical gron th has been

given with the aim of establishing the biologic basis for a more meaningful 11n-
derstanding of the problem.

REFERESCES
1. Altemus, L. A.: Horizontal and Vertical Dentofacial Relationships in Sormal and Class
II, Division 1 Malocclusion in Girls 11-15 Tears, Angle Orthodontist 25: 120-137, 1955.
2. Avery, J. K.: The Nasal Capsule in Cleft Palate, Anat. Anz. Erganz. 109: 722-i26, 1961,
3. Baer, M. J.: Dimensional Changes in the Human Head and FaCe in the Third Det:a~le
of Life, Am. J. Phys. Anthropol. 14: 5575i5, 1956.
4. Bamhha, 5. K. : Longitudinal Cephalometric Roentgenograplric Study of Face and (‘raniun~
in Relation to Body Height, J. Am. Dent. S. 63: 778-799, 1961.
5. Baume, I,. J.: The Postnatal Growth Activity of the Nasal Cartilage Septum, llelvet.
odont. act,a 5: 9-13, 1961.
6. Bayer, 1,. M., and Bayley, r\‘. : Growth Diagnosis, Chicago, 1939, University of (‘hicago
Press.
7. Bench, R. W.: Growth of the Cervical Vertebrae as Related to Tongue, Face, and I)enture
Behavior, AM. a. ORTHODONTICS 49: 183-214, 1963.
8. Bjiirk, A., and Palling, M.: Adolescent Age Changes in Sagittal Jaw Relation, Alveolar
Prognathy, and Incisal Inclination, Acta odont. scandinav. 12: 201.232, 1954.
9. Bjb;rk, A.: Facial Growth in Man, Studied With the Aid of Metallic Implants. A(,&.
odont. srandinav. 13: 9-34, 1955.
10. Bj&k, A.: Variations in the Growth Pattern of the Human Mandible: Longitudinal
Radiographic Study by the Implant Method, J. 1). R,es. 42: 400-411, 1963.
11. Bosma, J.: Oral and Pharyngeal Development and Function, J. D. Rrs. 42: 375380, 1963.
12. Brodie, A. G.: Late Changes in the Human Face, angle Orthodontist 23: 3, 1953.
13. Cates, II. A., and Goodwin, J. C.: The Twelve-day-old Baby, Human Biol. 8: 433450, 1936.
14. Coulombre, A. J.: The Role of Intraocular Pressure in the Development of the Chick
Eye. I. Control of Eye Size, J. Expel. Zool. 133: 211-226, 1956.
13. Coulombre, A. J., and Crelin, E. S.: The Role of the Developing Eye in the Morphogrnesis
of the Avian Skull, Am. J. Phys. Anthropol. 16: 25-37, 1958.
16. Coupe, T. B., and Subtelny, D.: Cleft Palate-Detlicirncy or Displacement of Tissue.
Plast. & Reconstruct. Surg. 26: 600-612, 1960.
17. Davenport, C. Il.: Postnatal Development of the Bead, I’ro~. Am. Philosophic*al See. 83:
l-216, 1940.
18. Diamond, M.: The Patterns of Growth and Development of the Human Teeth and Jaws.
J. D. Res. 23: 273-303, 1944.
19. Diamond, M.: The Development of the Dental Height, AM. J. ORTHODONTICS 8: ORX
SURG. 30: 589-605, 1944.
20. Dixon, A. D.: Studies of the Growth of the Upper Facial Skelet,on Using Radioactive
Calcium, J. D. Res. 40: 204-216, 1961.
21. Dreyer, C. .T.: Some Aspects of the Growth and Development of the Human Head. Johao
nesburg, 1960, Witwatersrand University Press.
22. DuBrul, L. E., and Laskin, D. M.: Preadaptive Potentialities of the Mammalian Skull:
An Experiment in Growth and Form, Am. J. Anat. 199: 117-132, 1961.
23. Graber, T. M.: The Congenital Cleft Palate Deformity, J. Am. Dent. A. 48: 375-395, 1954.
24. Gray, I-I., and Ayres, J. G.: Growth in Private School Children, Chicago, 1931, University
of Chicago Press.
25. Hagerty, R. F., and Hill, M. J.: Facial Growth and Dentition in the Unoperated Cleft.
Palate, J. D. Res. 42: 412-421, 1963.
26. Harvold, E.: A Roentgen Study of the Postnatal Morphogenesis of the Facial Skeleton
in Cleft Palate; a Contribution to the Orthodontic Treatment of Cleft Palate, Oslo,
1954, A. W. Br@ggers, Boktnykkeri A/S.
27. Israelsohn, W. J.: Description and Modes of Analysis of Human Growth. In Tanner,
J. M. (editor) : Oxford, 1960, Pergamon Press, pp. 21-42.
28. Jolleys, A.: A Review of the R,esults of Operations on (~-left Palates With Referemt: to
Maxillary Growth and Speech Function, Brit,. J. Plast. Surg. 7: 229.241, 1954.
29. Ju, D., Moss, M. L., and Crikelair, G.: Efl’ect of Radiation on the Development of the
Face, Am. J. Rurg. 106: 867.815, 1963.
30. Krogman, W. M.: Growth of Man, Tab. Biol. 20: l-963, 1941.
31. Krogman, IV. M., and Sassouni, V.: A Syllabus in Roentgenographic Cephalometry,
Philadelphia, 1957, Philadelphia Center for Research in Child Growth.
32. Krogman, W. M.: A Guide Outline for t,he Study of Physical Growth in Children, Phila-
delphia, 1958, Philadelphia Center for Research in Child Growth.
33. Krogman, W. M.: The Growth of the Head and Face in American White and American
Negro Boys (and Girls) of Philadelphia, Age 6-14 Years, Philadelphia, 1958, Philadelphia
Center for Research in Child Growth.
34. Lebret, L.: Growth Changes of the Palate, J. D. Res. 41: 1391-1404, 1962.
35. Martin, R.: Lehrbuch der Anthropologie, rd. 3, edited by K. Kaller, Stuttgart, 1957,
Gustav Fischer Verlag.
36. Meredith, H. V., Knott, V. B., and Hixon, E. H.: Relation of the Nasal and Subnasal
Components of Facial Height in Childhood, AM. J. ORTHODONTICS 44: 285-294, 1958.
37. Meredith, H. V.: Recent Studies on Growth of the Body and Face, AX J. ORTHODONTICS
45: 110-124, 1959.
38. hgeredith, H. V.: Changes in Form of the Head and Face During Childhood, Growth
24: 215264, 1960.
39. Meredith, H. V., and Chadha, J. M.: A Roentgenographic Study of Change in Head
Height During Childhood and Adolescence, Human Biol. 34: 299-319, 1962.
40. Moss, M. L., and Young, R. W.: A Functional Approach to Craniology, Am. J. Phys.
Anthropol. 18: 281-292, 1960.
41. Moss, M. L.: Differential Growth Analysis of Bone Morphology, Am. J. Phys. Anthropol.
12: 71.75, 1954.
42. Moss, M. L.: Growth of the Calvaria in the Rat; the Determination of Osseous Morphology,
Bm. J. Anat. 93: 333-362, 1954.
43. Moss, M. L., and Greenberg, S. N.: Postnatal Growth of the Human Skull Base, Angle
Orthodontist 25: 77-84, 1955.
44. Moss, M. L., Noback, C. R., and Robertson, G. G.: Critical Development Horizons in
Human Fetal Long Bones, Am. J. Anat. 97: 155-175, 1955.
45. Moss, M. L., Noback, C. R., and Robertson, G. G.: Growth of Certain Fetal Cranial
Bones, Am. J. Anat. 98: 191-204, 1956.
46. Moss, M. L.: Experimental Alteration of Sutural Area Morphology, Anat. Rec. 127:
569-589, 1957.
47. Moss, M. L.: Premature Synostosis of the Frontal Suture in the Cleft Palate Skull,
Plast. & Reconstruct. Surg. 20: 199-205, 1957.
48. Moss, M. L.: Rotations of the Cranial Components in the Growing Rat and Their Ex-
perimental Alteration, Acta. anat. 32: 65-86, 1958.
49. Moss, M. L.: Fusion of the Frontal Suture in the Rat, Am. J. Anat. 102: 141-165, 1958.
50. Moss, M. L.: Embryology, Growth and Malformation of the Temporomandibular Joint.
In Schwartz, L. (editor): Disorders of the Temporomandibular .Toint, Philadelphia,
1959, W. B. Saunders Company.
51. Moss, M. L.: The Pathogenesis of Premature Cranial Synostosis in Man, Acta. anat.
37: 351-370, 1959.
52. Moss, M. L.: The Pathogenesis of Artifical Cranial Deformation, Am. J. Phys. Anthropol.
16: 269-286, 1959.
53. Moss, M. L.: Functional Analysis of Human Mandibular Growth, J. Pros. Dent. 10:
1149-1159, 1960.
54. Moss, M. L.: Inhibition and Stimulation of Sutural Fusion in the Rat Calvaria, Anat.
Rec. 136: 457-468, 1960.
55. Moss, M. L.: The Functional Matrix. In Kraus, B. S., and Riedel, R. A. (editors) : Vistas
in Orthodontics, Philadelphia, 1962, Lea & Febiger.
l’olwme 50 Terticnl growth of hums fwe 3 7.1
Smzher 5

56. Xanda, R,. 8.: The Rates of Growth of Several Facial Components Measured From St~i:il
(‘ephalometric Roentgenograms, AM. J. ORTHODOXTICS 41: 658-673, 1955.
57. Nanda, K. 8.: Cephalometric Study of the Human Face From Serial Koentgenograms.
Ergebn. Anat. Entwcklngsgesch. 35: 358-419, 1956.
38. Ojala, L.: Pneumatization of the Bone and Environmental Factors; Experimental Studies
on Chick Humerus, Acta. oto-laryng. (Supp.) 133: l-28, 1957.
59. Harnas, K. V.: Growth Changes in Skulls of Ancient Man in North America; an N-ray
(‘ephalometrie Investigation of Some Cranial ant1 Facial Changes During Growth in the
Indian Knoll Skeletons, Aeta. odont. scandinav. 15: 213-271, 1957.
60. Rarnat, B. G., and Engle, M. B.: A Serial Study of the Mandibular Growth After He
moval of the Condyle in the 34acacu rhesus Monkey, Plast. & Reconstruct. Rurg. 7: 364.
380, 195L.
61. Sarnat, B. G.: Palatal and Facial Growth in IClacaoa Ikrsus Nonkeys With Surgically
Produced Palatal Clefts, Plast. & Reconstruct. Rurg. 22: 29-41, 1958.
62. Kcammon, R. E., and Calkins, I,. A.: The Development and Growth of the External
Dimensions of the Human Body in the Fetal Period. Minneapolis, 1929, University o1
Minnesota Press.
63. S&mid, V. F., and Voelckel, E. W.: Biologische Daten zur Sel,enholllent~nt~vi~klung in
Kindesalter, Monatsschr. Kinderh. 105: 367-369, 1957.
64. Schult,x, A. H.: Fetal Growth of Xan and Other Primates. Quart. Rev. Biol. 1: 465-521,
1926.
65. Scott, J. II.: Studies on the Growth of the Upper Jaw, D. Record 67: 277-291, 1948.
66. Scott, J. H.: Basal and Alveolar Bone; a Study in Drnto-Facial Morphology, I). l’raI’-
titioner 5: 11, 1955.
67. Scott, J. H.: Craniofacial Regions; a Contribution to the Study of Facial Growth. I).
Practitioner 5: 208-214, 1955.
68. Scott, J. H.: The Variability of the Cranio-Facial Skeleton, Tr. European Orthodontic
SOP. 31: 83-102, 1955.
69. Scott, J. H.: The Analysis of Facial Growth. I. The Anteroposterior and Vert,ieal Dimen
sions, AM. J. ORTHODONTICS 44: 507.512, 1958.
70. Scott, J. H.: The Growth of the Human Skull, J. D. A. South Africa 13: 133-142, 1958.
71. Scott, J. H.: The Analysis of Facial Growth. II. The Horizontal and Vertical Dimensions,
AM. J. ORTHODONTICS 44: 585-589, 1958.
72. Scott, J. H.: Further Studies on the Growth of the Human Face, Proc. Roy. SW. Med.
52: 263-268, 1959.
73. Shuttleworth, F. K.: The Adolescent Period: A Graphic Atlas, Monograph. Sot. 311~.
Child. Devel. 14, Serial No. 49:1, 1951.
74. Hmyth, C., and Young, M.: Facial Growth in Children With Special Reference Tao
Dentition, Medical Research Council, Special Report, Series, No. 171, London, 1932,
His Majesty’s Stationery Office.
75. Stuart, H. C., and others: Longitudinal Studies of Child Health and DeveIopmrnt-
Series IT, Pediatrics 24: 875-974, 1959.
76. Subtelny, J.: A Cephalometric Study of the Growth of the Soft Palate, Plast. 6: Re-
construct. Surg. 19: 49-62, 1957.
77. Tallgren, A.: Changes in Adult Face Height Due t,o Ageing, Wear and Loss of Teeth
and Prosthetic Treatment, Acta odont. scandinav. Supp. 24 15: l-122, 1957.
78. Tanner, J. M. (editor) : Human Growth, London, 1960, Pergamon Press, vol. 3, pp. l-120.
79. Tanner, J. M.: Growth at Adolescence, ed. 2, Oxford, 1962, Blackwell Scientific Publica-
tions.
80. Tinoco, A. A.: Study of the Effects Produced in Facial Growth by the Removal of the
Condylar Growth Center in Rhesus Monkeys, M. S. Thesis, Northwestern University, 1962.
81. Tucker, R.: Studies in Functional and Analytical Craniology, I. The Elements of Analysis.
II. The Functional Classification of Mammalian Skulls. III. The Breviarcuate Skull
and Its Analysis. IV. More extreme Forms of the Breviarcuate Skull. V. The E’unc-
tional Metamorphoses of the Carnivorous Skull. VI. Strains and the Direction of Certain
Vectors in the Breviarcuate Skull, Australian J. Zool. 2: 381-430, 1954.
82. Tucker, R.: Studies in Functional and Analytical Craniology. VII. The Longoarcuate
Skull. VIII. The Planoarcuate Skull. IX. The Comparative and Evolutional Outlook.
X. The Density of the Bony Tissue in Nodes and Tracts, Australian J. 2001. 3: 513-522,
523-529, 530-540, 541-544, 1955.
83. Tucker, R.: Studies in Functional and Analytical Craniology. XI. Experiments With
the Decalcified Skull of the Dog. XII. Experiments With the Decalcified Skull of the
Rabbit. XIII. Experiments With the Decalcified Skull of the Calf. XIV. Experiments
With the Decalcified Skull of the Leaf Monkey, Australian J. Zool. 4: 40-49, 50-54,
55-59, 60-64, 1956.
84. Van der Klaauw, J. C.: Size and P osi ‘t’ ion of the Functional Components of the Skull,
Arch. neerl. zool. 9: l-559, 1948-1952.
85. Young, R. W.: Influences of Cranial Contents on Postnatal Growth of the Skull in the
Rat, Am. J. Anat. 105: 383-415, 1959.