Craniofacial growth and the timing of treatment

P. Lionel Sadowsky, DMD, BDS, DipOrth, MDent

Birmingham, Ala.

The timing of orthodontic treatment to achieve an optimal outcome is an issue of paramount

importance to the clinical orthodontist. In this article I highlight those facts we know, list some we
do not know for certain, and discuss aspects of the decision-making process in orthodontics. With
increased insight into proven data and decisionmaking processes, the clinical orthodontist should
be better able to appropriately time orthodontic treatment. (Am J Orthod Dentofacial Orthop 1998;
113:19-23.)

I
f we accept the tenet that optimal ortho-
dontic treatment should achieve the best possible
continual osteogenic deposition and resorption, as
does the entire osseous component of the human
outcome in the shortest possible time with the least body. We know that growth and development in-
biologic, psychosocial, and financial cost, then the volve complex mechanisms. We know descriptively
timing of treatment is of the essence. To accomplish that the dentofacial structures are displaced down-
the aforementioned objectives, the clinical ortho- ward and forward, whereas the direction of growth
dontist must appreciate craniofacial growth so that
is essentially upward and backward. In general we
the treatment plan and the mechanics to be used can
be optimized both in method and in time. can appreciate that each individual pattern ex-
Although considerable data exist with regard to presses itself for that individual. Most of the data
craniofacial growth, in many areas we have limited regarding growth curves and trends have been taken
understanding and only have theories or hypotheses. from studies of large groups of individuals so that
This uncertainty has resulted in the many treatment statistical data could be generated. This practice
approaches that have been suggested and advo- permits assessment of an individual compared with
cated, some with limited or no scientific foundation. the general statistical data.
To optimize our treatment efforts and their out- Baumrind1 provides examples of what we can
comes, we must understand the probable effects of predict with a fairly high degree of confidence.
our biomechanical efforts in orthodontic treatment Included in his list is the phenomenon that the
and the likelihood of their success.
heads of preadolescent and adolescent children
WHAT WE KNOW AND DO NOT KNOW continue to change in size and shape until at least
age 20. The prominence of the dentition decreases
A large body of data exists with regard to the
during maturity; Class II malocclusions after erup-
biology of growth and development in general, and
tion of the first permanent molars rarely, if ever,
craniofacial growth in particular, as it relates to
resolve spontaneously; and anterior crowding and
orthodontic treatment and its outcomes. We know,
rotations, evident after the permanent incisors have
for example, that the craniofacial skeleton is formed
completely erupted, only rarely resolve spontane-
both endochondrally and intramembranously. The
ously. Furthermore, in the absence of ankylosis,
cranial base, the nasal septum, and the condyle of
permanent teeth tend to migrate into extraction
the mandible are endochondral in origin, whereas
sites, and unopposed teeth tend to extrude. The
the maxilla and cranial vault are intramembranous
mandibular plane angle relative to the cranium
in origin. The condyle of the mandible contributes
tends to close spontaneously from the mixed-denti-
significantly to mandibular and facial growth and
tion period to maturity in the absence of treatment.
development.
Björk2-4 and Björk and Skieller5 have carefully de-
All areas of the craniofacial skeleton undergo
tailed the contributions of matrix and intramatrix
rotations of the mandible, as well as the rotations of
Professor and chairman, Department of Orthodontics, School of Dentistry,
University of Alabama. the maxilla. Treatment associated with increases in
Reprint requests to: Dr. P. Lionel Sadowsky, Department of Orthodontics, the transcanine dimension are difficult to maintain
University of Alabama School of Dentistry, 1919 Seventh Ave. South, SDB in the postretention period, particularly in the man-
23, Birmingham, AL 35294-0007.
Copyright © 1998 by the American Association of Orthodontists. dibular arch.
0889-5406/98/$5.00 1 0 8/5/86140 Baumrind1 states that there is a body of infor-
19
20 Sadowsky American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

mation on which orthodontists can base predictions. and is not a condition with any unequivocally de-
On the other hand, he contends many parameters monstrable health consequences, and that these
cannot be predicted with sufficient accuracy and factors must be taken into account when clinical
precision to be useful to the orthodontist in the study designs are adopted. They state that this is
planning of treatment and actual treatment. These especially pertinent if the rigor of the design—and
include the magnitude and timing of spontaneous therefore its value—lies in the application of rigor-
growth remodeling at specific sites in the heads, ous criteria that in medical models permit a systemic
jaws, and faces of particular individuals being ob- control of methodologic biases but that in orthodon-
served or treated; the impact of specific therapeutic tics do not actually exist.
interventions on the expression of each individual’s Brodie,12,13 as early as 1941, stated that the
inherent growth potential; the amount of correction morphogenetic pattern, once established, does not
(growth modification) that will be achieved at spe- change. His study covered individuals aged 3 months
cific anatomic loci as a consequence of specific to 18 years. Subsequently, “norms” for large groups
therapeutic interventions for particular individuals; were developed by Riolo,14 but, as Baumrind
and the amount of posttherapeutic accommodation stressed, although averages are useful and serve as a
or relapse that will occur at specific anatomical loci guide, prediction for the individual is more complex
after specific therapeutic interventions for particular and problematic.
individuals.1 Baumrind’s views are widely accepted Over the years, many theories or hypotheses of
in that orthodontists seem to be more successful in growth controls have been proposed, ranging from
predicting model development than they are in the sutural concept of Sicher15,16; to Scott,17-21 who
predicting individual events. An example of how described the importance of chondrocranial devel-
these factors are applied in clinical orthodontics is opment; to Moss22-24 and the theory of the func-
the use of the various types of visual treatment tional matrix. Koski25 discussed the issue of growth
objectives, either hand-drawn or computerized, that centers, which might control growth, as opposed to
apply average mean increments to the individual growth sites where growth occurred but were prob-
patient for the prediction of outcomes and then ably not initiators of craniofacial growth. Lim-
apply general treatment reaction, superimposed on borgh26,27 attempted to correlate the growth theo-
the predicted growth, to yield a treatment goal.6-10 ries into usable clinical applications. Enlow,28-32 in
As Baumrind correctly states, orthodontists are many excellent publications, detailed descriptively
“treating to the averages.”1 In a clinical study cited and spatially the growth and development of the
by Baumrind,1 it was concluded that none of the craniofacial complex and how changes in various
orthodontic judges could predict the direction of areas affect the relationship of anatomic parts in
mandibular rotation better than chance but that other areas. Björk3 carried out excellent research in
there was little doubt that each of the orthodontists an attempt to find stable superimposition markers
would have achieved very high levels of clinical by using metal implants in growing children, and he
excellence in treating the patients evaluated. outlined the contributions to the final craniofacial
form of maxillary and mandibular rotations. Many
GROWTH CONTROL authors have discussed the use and limitations of
If the clinician would find it advantageous to cephalometric superimposition in an attempt to
alter the progression of growth and development assess the contributions of growth versus mechanics
and thereby appropriately time treatment, an in- during the treatment of an orthodontic patient. The
depth understanding of the controls of the processes difficulty in finding stable anatomical areas for su-
of growth and development is invaluable. A large perimposition and the possible flaws in conclusion
body of information exists on descriptive growth arrived at are generally accepted.
activity, as well as detailed information of the effects
of the humoral and hormonal factors on growth and DECISION MAKING IN ORTHODONTICS
how these factors may influence disease and aber- The clinical orthodontist caring for patients is
rations of normal growth and development. continually faced with decisions, some fairly routine
The orthodontist is faced with the fact that and others having possible long-term effects on the
malocclusions are not diseases but variations from duration of treatment, the biologic and financial
the ideal or optimal. Vig and Vig11 emphasize that costs, and probable outcomes, both short- and long-
malocclusion is not a disease, is not definable by a term. As extrapolated from Weinstein et al33 in their
gold standard, is not a biologically abnormal state, discussions on clinical decision analysis in the med-
American Journal of Orthodontics and Dentofacial Orthopedics Sadowsky 21
Volume 113, No. 1

ical field, some clinical situations and decisions seem with certainty and a preferred treatment is well
fairly straightforward, and any well-trained orthodon- established, the treatment will still fail in some
tist will probably reach the same conclusions and treat patients who may be indistinguishable a priori from
the orthodontic patient in the same way. However, as those in whom the treatment will be successful.” In
in medicine, many orthodontic decisions are compli- addition, what would happen in the absence of
cated by ambiguity, with the decision being less clear- intervention is in itself usually uncertain in any
cut. This problem is readily extrapolated into the area particular case. Although, fortunately, in clinical
of craniofacial growth and treatment timing. The orthodontics most decisions made by the practitio-
patient’s data may not fall into a well-defined diagnos- ner do not carry irreparable, life-threatening conse-
tic category, or clinicians may disagree about the quences, it is nevertheless ethically, morally, biolog-
correct diagnosis or the most appropriate therapy.33 ically and financially significant that great efforts are
Indeed, as Baumrind points out, “What one investiga- made to ensure that the patient receives the best
tor defines as a ‘high angle case’ may not be the same treatment with the optimal outcome in the briefest,
as what another investigator classifies as a ‘high angle most efficient manner.
case.’ ” One clinician’s “Frankel treatment” is not Weinstein et al.33 state that a characteristic of
necessarily the same as another clinician’s “Frankel clinical decisions, in addition to uncertainty, is the
treatment.” need to make value judgments about which risks are
Maull,34 in an evaluation of successfully treated worth taking. An example in clinical orthodontics
cases previously presented to the American Board might be the young patient with a developing Class
of Orthodontics, reported on results that might III malocclusion. What are the benefits as opposed
indicate that some descriptors and predictors of to the disadvantages of early treatment? Can growth
orthodontic outcomes may not be as reliable as be “controlled” or modified? If orthodontics and
generally accepted and that the quality of the out- dentofacial orthopedics fail, is orthognathic surgery
comes achieved was most likely related to morpho- a possibility? Does the patient or parent understand
genetic patterns that have been shown to respond the reasons for the orthodontist’s decisions, as well
well to orthodontic mechanotherapy. Weinstein et as the reasoning behind the decisions? Furthermore,
al33 state that, regardless of whether clinical circum- in discussing medical care, Weinstein et al.33 note
stances are obvious or exceedingly complex, some the importance of the personal values of the patient
decisions—and often many decisions—must be made. and the physician with regard to possible outcomes
Extrapolated into the orthodontic arena, the timing of in reaching clinical decisions.
treatment is a case in point. Even in choosing not to In the timing of orthodontic treatment for chil-
intervene, the physician or orthodontist still makes a dren and adolescents, other factors must be consid-
decision that carries its own consequences.33 ered. For example, would the younger patient be
Weinstein et al.33 list areas of uncertainty in more likely to cooperate with headgear than would
medical decision making; some of them are applica- a teenager? Does the child or the parent believe that
ble to orthodontic decision making as well. These correcting some aspects of the malocclusion at an
include errors in clinical data such as inaccurate earlier age will have significant psychosocial advan-
recordings by the observers, as well as faulty obser- tages for the patient? The orthodontist must be
vation or misrepresentation of the data recorded prudent in not implying that correction at an earlier
with an instrument. There may therefore be uncer- time would provide unproven benefits. However,
tainty surrounding every piece of data, no matter maxillary incisors that are procumbent and protrud-
how precisely stated it may be. Other factors of ing may be less vulnerable to trauma if retracted at
significance include ambiguity of clinical data, as an earlier age. Also, there may be some advantage in
well as variation of interpretation of the data. Ex- partially correcting a malocclusion if, for example,
amples in orthodontics might include recordings of gingival stripping or a deep-impinging occlusion
mounted casts, classifications of malocclusions, and may adversely affect the periodontal tissues. Alter-
cephalometric tracings, superimpositions, and inter- natively, however, it may not be prudent to sow
pretations of these. Furthermore, in the evaluation seeds of concern for parents or patients by suggest-
of the timing of treatment in orthodontics, the factor ing adverse outcomes if early treatment is not
of uncertainty about the effects of treatment is most commenced. The orthodontist must have specific
significant. As Weinstein et al.33 note, the effects of goals and expected outcomes for any treatment that
any treatment are uncertain in any given patient: is advocated, but practice-building and “capturing
“Even in cases in which a diagnosis can be made the patient” should not be one of them.
22 Sadowsky American Journal of Orthodontics and Dentofacial Orthopedics
January 1998

In the decision making with regard to whether or clude patient age, morphogenetic pattern, descrip-
when to commence early treatment, perhaps among tive data, patient selection, appliance design, and
the most important factors to consider are the likely duration of treatment, among many others. Treat-
advantages of starting treatment earlier and pre- ment objectives, criteria of selection, and even treat-
cisely what the expected outcomes are. Consider- ment goals differ. Another significant area of con-
ation must also be given to the consequences of not cern is assessment of outcome and analysis of where
starting treatment early. Furthermore, the conse- the observed changes have occurred. Interpretation
quences of prognostic error must be factored into a of the result achieved may differ among clinicians.
treatment-timing error.1 Dermaut and Aelbers,35 in reviewing the literature
on orthopedic effect in orthodontics, concluded that
TREATMENT TIMING AND MECHANOTHERAPY orthopedic changes induced by Class II therapy fade
Many biomechanical treatment modalities have away; however dentoalveolar changes were found to
evolved, many of them predicated on the clinician’s be more stable. In studies reporting Class III ortho-
interpretation and understanding of craniofacial pedic change, changes were found to be rather small
growth and development. Although the purpose of and of little clinical value. These investigators also
this section is not to enumerate or discuss all of the concluded that the net result of therapeutic expan-
advantages or disadvantages of each treatment ap- sion did not exceed expected normal growth.
proach, examples will be used in an attempt to Most clinicians would accept that dentoalveolar
clarify the dominant themes of current mechano- changes can be attained. It must be emphasized that
therapeutic objectives. The orthodontic literature is change in dentoalveolar bone can alter the spatial
replete with methods aimed at altering, modifying, relationships of parts. An example is the use of
redirecting, increasing, and decreasing growth and cervical headgear on maxillary molars in the prepu-
development. bertal patient, which results in maxillary molar
This discussion will combine the effects of mech- eruption and counterclockwise rotation of the man-
anotherapy on growth and development. Although the dible. If the clinician believes that this change would
term “basal bone” is used in many articles on growth be advantageous—for example, in a severe hypodi-
and development, no histologic difference exists be- vergent skeletal pattern with a deep-impinging inci-
tween so-called basal bone and other types of bone. sor relationship— early treatment may be advisable.
Perhaps a more appropriate term might be “dentoal- Many examples exist of so-called early treatment,
veolar” and “skeletal” bone, the distinction being that which although primarily only affecting dentoalveo-
“skeletal bone” is that part of the skeletal craniofacial lar structures may still change skeletal spatial rela-
complex—more specifically, maxillary or mandibular tionships resulting in acceptable treatment out-
bone—that is present or absent, regardless of the comes. The argument as to whether the latter is
presence of teeth. Dentoalveolar bone would imply truly orthopedic may be moot. The advantages of
that bone that directly supports the dentition and that early treatment involving rapid palatal expansion
is directly reactive to the position of the teeth. Implicit have been well documented.36,37
in this concept is an understanding that changes in Orthodontic treatment involving tooth move-
dentoalveolar bone may result in altered spatial rela- ment alone, such as management of the leeway
tionships of anatomic parts between the nasomaxillary space and the deciduous second molar space, or
complex and the mandible. Clinical orthodontists, “E-space,” should obviously be carried out at the
using their understanding of growth and development appropriate time. Serial extraction, a once-popular
and its controls, attempt to correct malocclusions by treatment, was used to treat dental problems only.
applying orthodontic and orthopedic forces to the For alignment of all of the permanent dentition it is
various components of the craniofacial skeleton. Innu- obvious that these teeth should have erupted, so that
merable articles have been published in the various timing decisions become obvious.
dental and orthodontic journals, in addition to books,
describing various mechanotherapeutic techniques CONCLUSIONS
that report or describe changes both in the skeletal and Perhaps the crux of the matter on treatment timing is
in the dentoalveolar bone of the craniofacial skeleton. whether “dentofacial orthopedics” is possible. It may well
The difficulty in understanding the reported ef- be that the profession’s concerns with dentofacial ortho-
fects of treatment and their timing, and the claims pedics lies in its definition. If we accept that dentoalveolar
made in appliance design, is the result of the large change is possible, and if we deem that dentoalveolar
number of variables involved. These variables in- change is indicated in a particular situation, then a
American Journal of Orthodontics and Dentofacial Orthopedics Sadowsky 23
Volume 113, No. 1

decision on timing of treatment becomes more obvious. 11. Vig PS, Vig KD. Decision analysis to optimize the outcomes for Class II Division
1 orthodontic treatment. Semin Orthod 1995;1:139-48.
Changes in dentoalveolar relationships, as well as changes 12. Brodie AG. On the growth pattern of the human head from the third month to the
in growth proportionality, have a direct effect on skeletal eighth year of life. Am J Anat 1941;68:209-61.
and dental spatial relationships. The degree of orthopedic 13. Brodie AG. Late growth changes in the human face. Angle Orthod 1953;23:
146-57.
change and its duration are as yet undetermined.35,38 14. Riolo ML, Moyers RE, McNamara JA, Hunter WS. An atlas of craniofacial
Clearly more studies are required to answer important growth. Craniofacial Growth Series, vol. 2. Ann Arbor, Mich.: Center for Human
questions; some of these studies involving randomized Growth and Development, University of Michigan, 1975.
15. Sicher H. Skeletal disharmonies and malocclusions. Am J Orthod 1957;43:679-84.
clinical trials are in progress, with preliminary reports 16. Sicher H. Oral anatomy. 4th ed. St. Louis: Mosby, 1965.
already published.38 When more substantive clearly de- 17. Scott JH. The cartilage of the nasal septum. Br Dent J 1953;95:37-43.
18. Scott JH. The growth of the human face. Proc R Soc Med 1954;47:91-100.
fined research data become available, clinical orthodon-
19. Scott JH. Craniofacial regions: a contribution to the study of facial growth. Dent
tists will be better able to carefully select treatment Pract 1955;5:208-14.
mechanics and optimally time treatment. It is likely, 20. Scott JH. The cranial base. Am J Phys Anthrop 1958;16:319-48.
21. Scott JH. The analysis of facial growth. Am J Orthod 1958;44:507-12.
however, that clinical orthodontics will never be an exact
22. Moss ML. The primacy of functional matrices in orofacial growth. Dent Pract
science; although this may have its drawbacks, it may also 1968;19:65-73.
provide opportunities. 23. Moss ML, Salentijn L. The primary role of functional matrices in facial growth.
Am J Orthod 1969;55:566-77.
Clinicians seeking to make the clinical decision on the 24. Moss ML, Salentijn L. The capsular matrix. Am J Orthod 1969;56:474-90.
appropriateness of one- or two-phase treatment, early 25. Koski KL. Cranial growth center: facts or fallacies? Am J Orthod 1968;54:566-83.
intervention, or both must take into account the likely 26. van Limborgh J. A new view on the control of the morphogenesis of the skull. Acta
Morphol Neer Scand 1970;8:143-60.
risks and benefits of early intervention. 27. van Limborgh J. The role of genetic and local environmental factors in the
control of postnatal craniofacial morphogenesis. Acta Morphol Neer Scand
1972;10:37-47.
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