The frontal sinus and n andibutar growth prediction

P.E. Rossouw,* BSc, BChD, Hons BChD, MChD, C.J. Lombard,** BSc, MSc, PhD, and
A.M.P. Harris,* BChD, Hons BSc, DTE
Tygerberg, South Africa

The skeletal growth patterns of 103 subjects with Class I and III malocclusions were
cepha[ometrically analyzed as advocated by Ricketts el al? to assess abnormal mandibular growth.
The surface area (mm 2) of the frontal sinus was assessed by a Summagraphics decoder linked to a
microcomputer. The results indicate that there is a significant correlation between maxillary length,
mandibular length, symphysis width, condylar length, and frontal sinus size on a lateral cephalogram.
The frontal sinus can possibly be used as an additional indicator when one is predicting mandibular
growth. (AMJ ORTHOD DENTOFAO ORTHOP 1991 ;100:542-6.)

G r o w t h prediction has been a controversial
topic ever since it was advocated by Ricketts.' Predic-
tion would involve forecasting a change in direction or
different growth rates for two patients who were the
same age, sex, and race on the basis of some prior
knowledge, such as a cephalometric measurement. 2
A main problem associated with patients who have
Class III malocclusion has to do with the differential
diagnosis in these cases. Would treatment involve only
orthodontic therapy, or would the patients require sur-
gery in the corrective therapeutics? This decision usu-
ally has to be made during the patient's childhood;
therefore growth and development are important con-
siderations in the prediction of abnormal or excessive
growth. The typical characteristics of the growing per-
son with Class [II malocclusion have previously been
described. 3-4 An error in the diagnosis of these cases of
excessive mandibular prognathism may indicate an er-
ror in attainment of a favorable prognosis. 5 Even normal
growth during adolescence will favor relapse in the
patient with Class III malocclusion, and accurate pre-
diction would therefore be helpful. ~
There is a small but significant linear correlation
between the shape of the mandible and a change in
gonial angle. 7 Bjrrk, 8 with the use of implants, reported
his observations of anatomic characteristics of individ-
ual mandibles that grew abnormally both vertically and
horizontally. Rieketts 9 proposed a method based on the
This project was supported by the Medical Research Council, Ty-
gerberg,
*Department of Orthodontics, University of Stellenbosch. **Institute for Bin.
statistics, Medical Research Council, Tygerberg.
8/1/25571
542
theory that the mandible grows along an arc, which is
basically in agreement with Moss's theory that the man-
dible grows in a logarithmic spiral. 10Mitchell, Jordan,
and Ricketts ~ evaluated Rickett's method for predicting
the size and form of the mandible and found the arcial
method valid for the prediction of mandibular growth.
Hand-wrist radiographs, however, will improve the ac-
curacy of the amount of growth expected during short-
range predictions. It would seem therefore that it is
possible to predict the form of the mandible with the
use of an individualized m e t h o d )
A visual treatment objective t2-~4 should be devel-
oped with long-term results in mind. Certainly, the
maxillomandibular relationship seen 2 years after the
start of treatment in a growing child may not be the
same at maturity. Therefore treatment of a case
(whether Angle Class I, II, or III) to proper facial bal-
ance at the age of 12 years may prove unsuccessful at
the age of 25 years. This consideration is especially
true in cases in which an abnormally large amount of
mandibular growth is predicted for the teen years. 3
Schulhof, Nakamura, and Williamson 2 found that
a high cranial deflection (28 ° -_+ 3°), short porion lo-
cation ( - 3 7 mm +__ 2.5 mm), forward ramus position
(75.5 ° +_ 2.8°), and Class III molar relation ( - 3 . 0
m m _ 2.6 mm) were telltale signs that excessive man-
dibular growth was likely to occur. It has been dem-
onstrated that cases exhibiting a wide symphysis and a
long condyle axis also tend to indicate excessive man-
dibular growth. Ricketts 3 claims that with the use of
these six measurements accuracy in predicting abnor-
mal mandibular growth has increased to approximately
9O%.
Acromegaly is associated with prominent frontal
sinuses and overgrowth of the jawbone, and one usually
 Volm,e 1oo
Nit/tiber
Fig. 1. Six specific cephalometric measurements to predict ex-
cessive mandibular growth,za
finds a Class III-type prognathic mandible in these
cases.~5 The frontal sinus bud is present at birth in the
ethmoid region but is not evident radiographically until
the fifth year, when it projects above the orbital rim.J6
Rapid growth of the sinuses continues until the age of
12 years, when they reach nearly adult size. ~7 Joffe ~
found frontal sinus enlargement to be associated with
prognathic subjects, but no indication was given as to
the correlation with growth-prediction indicators. Tan-
ner 19 found that the annual height (stature) growth in-
crements in children reached a plateau at 16 years in
boys and 14 years in girls, and it was thought that these,
too, are the ages at which frontal sinus enlargement
ceased. This was supported by Brown, Molleson, and
Chinn, 2° who found during a study on lateral cepha-
lograms that the main enlargement of the fi'ontal sinuses
ceased at 151/2 years in boys and 133/4 years in girls.
This suggests that the increase in the sinuses follows
the trend in growth in bone lengths very closely.
The aim of this study was to assess whether a large
frontal sinus size could be correlated with excessive
mandibular growth. This, together with the other known
indicators mentioned, would enable the orthodontist to
make an even more accurate prediction of expected
excessive mandibular growth.
MATERIALS AND METHODS
A random selection of 103 cephalograms, consisting
of 53 adult skeletal Class I growth patterns and 50 adult
Fro~ltal sitars and mandibular growth prediction 543
Fig. 2. Photograph of measurements of the frontal sinus on the
computer.
skeletal Class III growth patterns of both male and
female white subjects were analyzed. The six mea-
surements described by Ricketts 7 (Fig. 1) were used to
determine the presence of abnormal mandibular growth.
The size of the frontal sinus was expressed in square
millimeters as measured on a digitizer connected to a
microcomputer (Summagraphics decoder to Olivetti
M24, Ing C. Olivetti e C.S.p.A., Ivrea(To), Italy) (Fig.
2). The ANB angle al was used to ensure that the subjects
conformed to skeletal growth differences. Although the
ANB angle has its shortcomings, it is still widely ac-
cepted as an indicator of maxillomandibular harmony. "-2
The facial axis angle 23 and the FMA angle 24 were mea-
sured to give an indication of growth direction. Max-
illary length and mandibular length 25 were measured to
give an indication of the size of the bones (Table I).
All these measurements were checked for accuracy by
two investigators familiar with the analyses.
The results of this cross-sectional study were ana-
lyzed with the SAS. Spearman correlation coefficients
were used to assess associations between the frontal
544 Rossouw, Lombard, (md Ht~rris
rT~Sll4
8~808
i h
27 ~9
161~3
140 i1
985O
Fig. 3. Three-dimensional scatter plot of frontal sinus, mandibular length, and ANB angle.
sinus and the ether measurements made on the lateral
cephalometric radiograph.
RESULTS
The descriptive statistics of all the variables are
given in Table I, From TabIe I and the three-dimensional
plots of frontal sinus size versus mandible and ANB
angle (Fig. 3), we see that the patient with the largest
frontal sinus had the longest mandible with an ANB
angle in the lower tail of the distribution of this angle.
The Spearman correlation between the frontal sinus
and the other variables are given in Table I1. The pos-
itive correlation (r~ = 0.48) between the frontal sinus
and the mandible is also evident in Fig, 3. The negative
correlation between the frontal sinus and the ANB angle
is - 0 . 181 and is not significant for this sample but
confirms the mandible and the frontal sinus associa-
tion (i,e., a small angle goes with a large frontal
sinus).
DISCUSSION
During the last few years orthodontists have come
to realize that esthetics, function, and stability of results
go hand in hand, Many factors play a role in achievit~g
this balance. The orthodontist may eliminate many of
the negative factors that could influence the stability of
his treatment result if they form part of the diagnostic
Am. J. Orthod. Detltq/'tt,'.Orthtq~.
December 1991
,~b.lll
<2b,
elimination process. Prediction of an abnormal skeletal
growth pattern based on morphologic analysis can rep-
resent an important step in orthodontic diagnosis and
treatment planning.
The size of the frontal sinus on radiographs is one
factor that may help the clinician to determine whether
he would be able to attain stability by treating a Class
III malocclusion, for example, with only orthodontic
appliances, whether he could expect relapse of the post-
treatment results, or whether he should refrain from
doing extractions as part of a treatment regimen.
A negative ANB angle is indicative of a small
maxilla (retrognathism) and a large mandible (prog-
nathism) as expressed in the Class III syndrome.
This is confirmed when the negative correlation for
ANB ( - 0.181) and positive correlations for maxillary
(0,2.65) and mandibular (0,480) lengths are compared
with the large frontal sinus size (Table II).
A long condylar dimension and a wide symphysis
play a major part in the makeup of a large mandible.
These values show positive correlations with the large
frontal sinus of 0.233 and 0.257, respectively (Table
II),
The growth direction influences the eventuaJ posi-
tion of the chin. Obviously, a more horizontal growth
pattern (small FMA angle or large facial axis angle)
will tend to give a more anteriorly positioned chin, The
 ~;,I,m,. 1oo Frontal .,'inus aim mandibMor growth prediction 545
Nmnher 6

Table I. Descriptive statistics of the variables

VARIABLE N MEAN STD DEV MEDIAN M I N I M U M MAXIIMUM

FRONTAL SINUS AREA (rnm") 103 330.81 199,17 278.19 27.40 1198.4 3
AN6 ANGLE (decj) 103 -1,62 4.40 O.OO - 18.00 5.50
FMA ANGLE (deg.) 103 20.64 6.O3 21.OO 7.50 36.50
FACIAL AXIS ANGLE (deg) 103 92.82 5.24 92.50 81.00 108.O0
MAXILLARY LENGTH (rrm9 103 89.52 6.60 90.00 75.00 102.50
MANDIBULAR LENGTH (rnm) 103 126.19 9.41 127,OO 98.50 161.00
PORION LOCATION (ram) 103 42.09 4.69 42,OO 26.00 5-4,00
RAMUS POSITION (deg) 103 44.40 4.68 44.00 33.00 55.00
CONDYLAR LENGTH (rnm) 103 33. 73 5.77 34,50 19,00 52.SO
SYMPHYSIS WIDTH (mm) 103 15.70 2.32 16.00 I 0.00 22.00
CRANIAL DEFLECTION (deg) 103 29.89 3.40 29.00 21.00 4.5.00

FMA angle and the facial angle did not con-elate with Table II. S p e a r m a n correlation coefficients
the large frontal sinus (Table II). This indicated that a between different variables and frontal
large frontal sinus may also be present in vertical sinus size
growers.
Cranial deflection does influence the position of the FRONTAL SINUS
VARIABLE
mandible in space, as has been described in the liter- CORRELATION (r s )
ature, but it did not show a correlation with frontal
sinus size (Table II). One may postulate that the frontal ANB -O,181
sinus goes hand in hand with the large mandible, ir-
FMA O,O19
respective of its correlation to the cranial base.
The amount and direction of future facial growth FACIAL AXIS A N G L E -0,082
are of importance, especially in the young child. The MAXILLARY LENGTH O,265
necessity for early diagnosis has been particularly
MANDIBULAR LENGTH 0,480
stressed 2~ when orthopedic treatment is anticipated on
either the maxilla 27 or the mandible. -'8Despite numerous PORION LOCAT|ON 0,094
attempts, individualized growth prediction remains un-
RAMU8 POSITION -O,181
certain. ~J'2')3~ Any possible short-term or long-term ef-
fects of treatment on growth are also the subjects of CONDYLAR LENGTH 0,233
continuing debate) 4'3s SYMPHYSI8 WIDTH 0,257
To adequately analyze frontal sinus size, an occip-
CRANIAL DEFECTION -0,008
itomental radiograph may also be used, 36 but that was
beyond the purpose of this study. The lateral cepha-
logram is part and parcel of everyday orthodontic anal- FOR THIS SAMPLE (n=103): SIZE /rs/<O,19 p>0,05
yses, and this study indicates that the frontal sinus as
0,19 </rsl<O,24 0,05>p>0,01
seen on a lateral cephalogram may be an indication of
excessive mandibular growth. 0,24 </rs/<l 0,0 l<p<O,OOO

CLINICAL SIGNIFICANCE
Subjects with mandibular prognathism who can be
properly treated by orthodontic tooth movement alone
must be distinguished from subjects with mandibular
prognathism that requires orthognathic surgery. 3~
Treatment by orthodontic tooth movement alone can
improve dental occlusion and affect lip posture, but this
procedure does little to alter the prognathic profile. Or-
thognathic surgery combined with orthodontic treat-
ment can both improve the occlusion and significantly
alter the facial profile. 3~
It is thus necessary to predict as accurately as pos-
sible, at the initial case analysis, those subjects in whom
abnormal mandibular growth may be present. When a
visual treatJnent objective is part of the initial evalua-
546 Rossouw, Lombard, a n d H a r r i s
tion, additional millimeters per year may be added to
the mandibular growth per year. This will help to vi-
sualize the treatment possibilities. All the possible ways
and means at one's disposal should be used, and it is
here that the frontal sinus size on a lateral cephalogram
could very well play a significant role.
CONCLUSION
Although the frontal sinus is exposed to muscle
attachments and to influences from the external envi-
ronment that play a part in its size, it has been statis-
tically demonstrated in this study that the frontal sinus
as seen on a lateral cephalogram is a valuable indicator
of excessive mandibular growth. Its role in diagnosis
will thereby help the clinician in his attempt to attain
excellent treatment results.
Research with a longitudinal emphasis regarding
development of the frontal sinus in different ethnic
groups and in both sexes is being planned.
We thank Dr. H.J. Burger for his assistance during the
project and Mr. A. Louw for the graphic work.
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Reprint requests to:
Prof, P.E. Rossouw
Head, Department of Orthodontics
Faculty of Dentistry
University of Stellenbosch
Private Bag XI
P,O, TYGERBERG 7505
Republic of South Africa