Published online: 2020-08-05

484 Original Article

3D Evaluation of the Relationship between

Different Vertical Growth Patterns and Cranial
Base Angulations
Mehmet Ugurlu1 Rıdvan Oksayan1 Ibrahim Sevki Bayrakdar2 Fatih Kahraman3
Ilhan Metin Dagsuyu1 Mehmet Aydın1 Kaan Orhan4

1 Department of Orthodontics, Faculty of Dentistry, Eskisehir Address for correspondence Ibrahim Sevki Bayrakdar, PhD, DDS,
Osmangazi University, Eskişehir, Turkey Department of Oral and Maxillofacial Radiology, Faculty of Dentistry,
2 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Eskisehir Osmangazi University, 26240 Eskişehir, Turkey
Eskisehir Osmangazi University, Eskişehir, Turkey (e-mail: ibrahimsevkibayrakdar@gmail.com).

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3 Department of Orthodontics, Private Clinic, Istanbul, Turkey
4 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry,
Ankara University, Ankara, Turkey

J Neurol Surg B Skull Base 2021;82:484–490.

Abstract Objective This study aimed to compare cranial base angulations in subjects with high-
angle, low-angle, and normal-angle vertical growth patterns using cone beam com-
puted tomography (CBCT).
Design This study is a retrospective clinical research.
Settings This study was carried out at the Dentistry Faculty of Eskisehir Osmangazi
University.
Participants According to skeletal vertical face growth patterns, 78 subjects (48
females and 30 males, average age: 13.19
1.73 years) were divided equally into three
groups: high angle, low angle, and normal angle groups.
Main Outcome Measures Cephalometric images were derived from CBCT, and
patients were classified according to the SN-GoGn angle (sella-nasion, gonion gnathion
angle). Sagittal, axial, and coronal cranial base angulations were measured in three-
dimensional (3D) CBCT images. Data were analyzed using the Kolmogorov–Smirnov
normality, Kruskal–Wallis, and Mann-Whitney U statistical tests.
Results There were statistically significant differences between the low-angle and
high-angle groups according to sagittal cranial base angulation parameters (p ¼ 0.01).
Conversely, there were no statistically significant differences between vertical facial
Keywords growth patterns according to coronal and axial cranial angle variables (p > 0.05).
► Cranial Base Conclusion According to the study results, there were no effects of cranial base
► three-dimensional angulations in two planes (coronal and axial) on different vertical skeletal growth
► cone beam computed patterns. In the sagittal cranial base angulation parameter, the high-angle group
tomography showed greater angulation values than the low-angle group. CBCT may be helpful for
► vertical face growth evaluating, diagnosing, and predicting 3D cranial base differences.

received © 2020. Thieme. All rights reserved. DOI https://doi.org/

November 25, 2019 Georg Thieme Verlag KG, 10.1055/s-0040-1713774.
accepted Rüdigerstraße 14, ISSN 2193-6331.
April 27, 2020 70469 Stuttgart, Germany
published online
August 5, 2020

Introduction
Growth and development of craniofacial structures play a
very crucial role for diagnosis, treatment, finishing, and
retention periods in orthodontic practice. It is known that
approximately 86% of the growth of the anterior cranial
base is complete by the age of 4.5 years. In addition to this,
98% of cranial base growth is totally completed by the age of
15 years.1,2 Several studies have shown that the anteropos-
terior dimensions of the presphenoid part and cribriform
plate can be considered stable after the age of 7.3 The front
region of the cranial base has long been described as a
stable morphological cephalometric landmark for diagnos-
ing skeletal disharmony between the upper face and lower
jaw. The upper skeleton–facial complex is placed under the
anterior cranial base and the lower jaw is associated with
the middle cranial fossa in the neighborhood of the tempo-
romandibular joint. Therefore, different growth modifica-
tions and angulations of the cranial base may lead to
variable jaw relationships. The relationship of the upper
and lower jaw in the sagittal plane is evaluated according to
the angle (ANB angle) value formed between point N, point
A, and point B. ANB angles from 0 to 4 degrees were
classified as the Class I group, >4 degrees were classified
as skeletal Class II, < 0 were classified as Class III.4 Dibbets
remarked that the cranial base angle (nasion-sella-basion
[N-S-Ba]) was decreased and both the anterior and posteri-
or lines (S-N and S-Ba) were shortened from Class II, then
Class I, and Class III malocclusion, respectively. Another
study revealed that the glenoid fossa was placed anteriorly
more often in skeletal Class III than Class II subjects.5,6
In orthodontic literature, although the relationship
between the cranial base and sagittal malocclusion has
been substantively compared in several studies,7,8 there
has not been any three-dimensional (3D) comparison
study between cranial base angulations and different
vertical growth patterns performed. The classification of
vertical skeletal development pattern stems from the need
to evaluate diagnosis, treatment, and prognosis with dif-
ferent approaches in patients with different vertical
dimensions. Understanding of vertical pattern of facial
growth will be meaningful to prevent skeletal and dental
abnormality.
The vast majority of the literature on cranial base angu-
lations is associated with sagittal malocclusion by using two-
dimensional (2D) radiographs. Cephalometric 2D images
have distortion and inaccuracy in diagnosis and treatment
planning of orthodontic treatment.9 Cone beam computed
tomography (CBCT) is more beneficial than conventional 2D
cephalometric radiographs in that it provides 3D multiplanar
images, models, and knowledge of craniofacial struc-
tures.10,11 There is a lack of other 2D and CBCT-induced
cephalogram studies which only investigated the cranial
base angulation in a single plane. Because of this situation,
our study was designed to investigate the relationship be-
tween the vertical growth pattern of the dentofacial skeletal
structures and cranial base morphology using CBCT with the
real 3D multiplanar model.
Journal of Neurological Surgery—Part B
Cranial Base Angulations Ugurlu et al. 485
Materials and Methods
This retrospective study was sourced from the pretreatment
3D CBCT archive records of patients from the Orthodontic
Department of the Eskişehir Osmangazi University Dentistry
Faculty and approved by the Human Research Ethical Com-
mittee at the Eskişehir Osmangazi University (2019–2089).
The study sample consisted of 78 subjects (48 females, 30
males, average age: 13.19
1.73 years) diagnosed as high-
angle, low-angle, and normal-angle groups according to
skeletal vertical face growth patterns.12 CBCT-derived ceph-
alometric images were used, and the cephalometric angular
parameter SN-GoGn (angle drawing between the gonion-
gnathion line and the sella-nasion line) was traced for the
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classification of vertical skeletal growth pattern determina-
tion with the Dolphin 9.0 (Dolphin Imaging & Management
Solutions, Chatsworth, California, United States) cephalo-
metric tracing program. None of the subjects had any bad
oral habits, craniofacial malformations, and syndromes, pre-
vious fixed orthodontic treatments, or orthognathic surgery.
Patients were divided into groups according to the fol-
lowing criteria: (►Table 1, ►Fig. 1)
• Low-angle group: Sn-GoGn angle was less than 26 degrees
(n ¼ 26).
• Normal-angle group: Sn-GoGn angle was between 26 and
38 degrees (n ¼ 26).
• High-angle group: Sn-GoGn angle was more than
38 degrees.
CBCT images were procured in a standing position with a
CBCT machine (Planmeca Promax 3D mid, Helsinki, Finland)
and taken under the following exposure parameters: 94 kVp
tube voltage, 14 mA tube current, and 27 second time. Sim-
plant O&O (Materialise, Leuven, Belgium) tracing software
was used to define the sagittal, axial, and coronal cranial base
angulations in 3D images.10 Measurements were performed
by a single orthodontist who was skilled in 3D tracing (F.K.).
Cephalometric landmarks used in both cephalometric radio-
graphs and multiplanar 3D images are described in ►Table 2.
3D cephalometric angular variables are specified in ►Table 3.
All 3D cephalometric tracings are shown in ►Fig. 1 (►Tables
2 and 3; ►Figs. 2–5)
Statistical Analysis
Descriptive statistics of the study groups were performed
using Excel software (Microsoft Corp., Redmond, Washing-
ton, United States). The MedCalc Software for Windows
Table 1 Descriptive statistics of study groups
Groups Mean age
Male Female Total
standard (n) (n)
deviation
Low angle 13.59
1.66 12 14 26
Normal angle 12.83
1.65 10 16 26
High angle 13.16
1.86 8 18 26
Total 13.19
1.73 30 48 78
Vol. 82 No. B4/2021 © 2020. Thieme. All rights reserved.
486 Cranial Base Angulations Ugurlu et al.

Fig. 1 The classification of different growth patterns. (A) Low-angle group: Sn-GoGn angle was less than 26 degrees. (B) Normal-angle group: Sn-GoGn
angle was between 26 and 38 degrees. (C). High-angle group: Sn-GoGn angle was more than 38 degrees. Sn-GoGn, sella-nasion, gonion gnathion angle.

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Table 2 Cephalometric landmarks used in the three-dimensional images

Sella (S) 3D center of the pituitary fossa

A point Deepest point of the upper alveolar process between anterior nasal spine and the supradentale.
B point Deepest point in the profile mandibula between pogonion and infradentale.
Nasion (N) Located on the bony surface at the junction of the frontal and nasal skeleton.
Gonion (Go) Constructed intersection point formation of the mandibular plane and posterior border line
of the ramus mandibula.
Gnathion (Gn) Constructed intersection point formation of the mandibular plane and facial plane.
Basion (Ba) Most posteroinferior point of the clivus in the midsagittal plane.
Orbitale (Or) The most inferior point on the orbital inferior margin.
SAC point Sella at midpoint of the anterior clinoid processes.
Right pterygoid notch Most superior furcation point of right medial and right lateral sphenoid plate.
Left pterygoid notch Most superior furcation point of medial and left lateral sphenoid plate.
Right spheno-orbital Most anterior and upper point between right greater wing of the sphenoid bone
and right zygomatic bone.
Left spheno-orbital Most anterior and upper point between left greater wing of the sphenoid bone
and left zygomatic bone.

Abbreviation: 3D, three dimensional.

Table 3 Three-dimensional cephalometric angular parameters

used in the study
Results
According to the nonparametric Kruskal–Wallis and
Sagittal cranial Angle between the
angle nasion—SAC—basion points. Mann-Whitney U tests, the mean values for the 3D sagittal
cranial base angulation for the low-angle, normal-angle,
Axial cranial Angle between right spheno-orbital
angle to SAC to left spheno-orbital points. and high-angle groups were 126.27
5.65 degree,
128.01
6.29 degree, and 130.76
7.70 degree, respec-
Coronal cranial Angle between right pterygoid notch
tively. After applying the Kruskal–Wallis statistical test,
angle to SAC to left pterygoid notch points.
a statistically significant difference was found between
Sn-GoGn Angle between sella-nasion the groups for the sagittal cranial base angulation
angle line and gonion-gnathion line.
(p ¼ 0.04). The high-angle group showed significantly
Abbreviation: SAC, sella at midpoint of the anterior clinoid processes; greater 3D sagittal cranial base angulation values than
Sn-GoGn, sella-nasion, gonion gnathion angle. the low-angle group (p ¼ 0.01). In the evaluation of the
(Version 17.5, Broekstraat, Mariakerke, Belgium) program coronal cranial angle, the average values found for the
was used for all statistical analyses. To define the normality, low-angle and high-angle groups were 56.17 degrees with
the Kolmogorov–Smirnov statistical test was used, which a standard deviation of 5.54 degrees and 56.01 degrees
showed that the data were non-normally distributed. The with a standard deviation of 5.40 degrees, respectively.
nonparametric Kruskal–Wallis and Mann-Whitney U tests Although there was no statistically significant difference
were used for statistical analyses. A significance level of between the three vertical facial growth groups (p ¼ 0.38),
p < 0.05 was used for all statistical analyses. the average value of the coronal cranial angle for the

Journal of Neurological Surgery—Part B Vol. 82 No. B4/2021 © 2020. Thieme. All rights reserved.
 Cranial Base Angulations Ugurlu et al. 487

Table 4 Three dimensional cranial base angular measurements of low-angle, normal-angle, and high-angle groups

Variables Low angle Normal angle High angle Kruskal-Wallis Low and Low and Normal and
p-value normal high high
Sagittal 126.27
5.65 128.01
6.29 130.76
7.70 0.04a NS Sa (p ¼ 0.01) NS
cranial angle
Coronal 56.17
5.54 54.76
5.55 56.01
5.40 0.38 NS NS NS
cranial angle
Axial cranial 107.74
3.55 107.94
5.43 108.80
6.64 0.78 NS NS NS
angle
a
Statistically significance set at p < 0.05.

normal-angle group was slightly lower than the other Discussion

groups, with a value of 54.76 degrees and a standard

deviation of 5.55 degrees.
Also, there were no significant differences between the
vertical growth groups according to axial cranial angle
measurement (p ¼ 0.78). The high-angle group had a larger
axial cranial angle than the low-angle and normal-angle
vertical growth groups (►Table 4).
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In this study, the sample consisted of the CBCT images of 78
subjects selected retrospectively on the basis of the vertical
growth patterns. According to the different vertical facial
pattern (high-angle, low-angle, and normal-angle) groups,
sagittal, axial, and coronal cranial angles were identified and
measured in 3D CBCT images.

Fig. 2 All three-dimensional cephalometric landmarks for tracings. (A) Nasion (N), SAC point, and Basion (Ba) on sagittal CBCT slice. (B) Right
and left spheno-orbital points on axial CBCT slice. (C) Right and left pterygoid notch points on coronal CBCT slice. (D) 3D appearance of
cephalometric landmarks on CBCT. 3D, three-dimensional; CBCT, cone beam computed tomography.

Journal of Neurological Surgery—Part B Vol. 82 No. B4/2021 © 2020. Thieme. All rights reserved.
488 Cranial Base Angulations
Fig. 3 Frontal view of all three-dimensional cephalometric tracings.
Fig. 4 Right view of all three-dimensional cephalometric tracings.
Fig. 5 Left view of all three-dimensional cephalometric tracings.
Journal of Neurological Surgery—Part B
Ugurlu et al.
The important role of cranial base angulations in sagittal
jaw relationships has been clearly determined.13 The
straightening of the cranial base angle leads to clockwise
rotation of the lower jaw.14 It is known that the mandibular
plane (Go-Gn or Go-Me) and gonial angle used in vertical face
growth prediction and dimension measurements can be
affected by clockwise rotation of the mandible. In addition
to this, maxillary growth is also subject to the impact of
cranial base development.7 For these reasons, the vertical
growth pattern of the subjects may be influenced by the
cranial base growth direction and angulation. No previous
3D research has studied the relationship between skeletal
vertical face growth and cranial base angulations for predic-
tion of the patient’s growth direction.
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According to the results, 3D coronal and axial cranial base
angulations did not show any statistically significant differ-
ences between the low-angle, normal-angle, and high-angle
subjects. Also, there were no statistically significant differ-
ences between the vertical growth groups according to axial
cranial angle measurement. The high-angle group had a
larger axial cranial angle than the low and normal vertical
growth groups.
It may be considered that the 3D cranial base angulations
are not the only factors evaluating vertical growth patterns.
Some bad oral habits and differences between vertical ramal
growth and dentoalveolar growth are other factors that
influence the vertical face growth pattern.
Gong et al remarked that sagittal cranial base angulations
were significantly smaller in skeletal Class III malocclusion and
larger in Class II malocclusion.15 In the present study, for the 3D
sagittal cranial base angulation for the low-angle, normal-
angle, and high-angle groups, there were statistically signifi-
cant differences between the groups. The high-angle group
showed significantly greater 3D sagittal cranial base angula-
tion values than the low-angle group. When the results of this
study are supported by other studies investigating the effect of
anteroposterior malocclusions on cranial base angulation, it
can be said that there is a sagittal cranial angle increase in
skeletal Class II and high-angle individuals. Bhattacharya
et al16 studied the relationship between cranial base angle
and maxillofacial morphology.16 Similar to the results of the
present study, they revealed that the cranial base angle nasion-
sella-articulare (NSAr) was correlated with vertical pattern
angles, such as Y-axis (angle formed between the sella-gna-
thion line and Frankfort horizontal plane) and SN-GoGn.
According to the cranial base angle, the larger cranial base
angulation (NSAr >125 degrees) group showed a statistically
significantly greater SN-GoGn value than the smaller cranial
base angulation (120 degrees <NSAr) group. In addition to
this, they did not find any statistically significant difference in
the Y-axis parameter between the cranial base angulation
groups. In light of this information in the literature, it can be
thought that the increase in cranial base angle can cause a
clockwise rotation of the mandible. As opposed to the findings
of the present study, Klocke et al14 described that there was no
statistically significant difference between the large cranial
base angle group and the small cranial base angle group
according to the sella-nasion mandibular plane angle angle
Vol. 82 No. B4/2021 © 2020. Thieme. All rights reserved.

parameter at both 5 years and 12 years of age. In addition to
this, they revealed that there were no statistically significant
differences between the large and small cranial base angle
groups according to the upper vertical facial measurement, i.e.
palatal plane to mandibular plane.14 This contradictory situa-
tion may be due to certain reasons, such as the fact that the
other studies are 2D cephalometric studies and also that the
present study used SAC (sella at midpoint of the anterior
clinoid processes) point as an alternative to sella point (pitui-
tary cavity), which is a point in the gap that is not clearly a
certain landmark.
Within the limitations of this study, the following con-
clusions can be drawn:
• Axial and coronal cranial base angle measurements did
not show statistically significant differences between the
high-angle, low-angle, and normal-angle groups.
• The high-angle group showed significantly greater 3D
sagittal cranial base angulation values than the low-angle
group. The results of this study may be useful to predict
the vertical growth patterns of individuals before the time
for active orthodontic treatment.
• The use of 3D CBCT images and analysis might play a
crucial role in detection and evaluation of 3D cranial base
morphology and multiplanar angulations.
Conclusion
Only a small number of diagnostic tools are available for
early identification of a vertical pattern of facial growth that
will be useful to prevent abnormal and improper skeletal
and dental relationships. In orthodontic treatments, early
prediction is crucial for the intervention and prevention of
more serious vertical and sagittal malocclusions. Due to the
early growth completion of the cranial base structures, such
as cribriform palate and presphenoid region, cranial base
angulations in three planes may be useful for the early
prediction of orthodontic disorders. Further studies with
larger sample sizes are needed to determine the exact
effects of cranial base angulations on vertical growth pat-
terns on CBCT images.
Funding
None.
Conflict of Interest
None declared.
Journal of Neurological Surgery—Part B
Cranial Base Angulations Ugurlu et al. 489
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