Facial growth in males 16 to 20 years of age

R. J. Love,* J. M. Murray,** and A. H. Mamandras***

London, Ontario, Canada

Postpubertal craniofacial skeletal and dental changes were examined from lateral cephalograms
taken when subjects were 16, 18, and 20 years of age. The sample consisted of males with no
previous orthodontic treatment who had Class I skeletal and dental characteristics. Mandibular
growth was found to be statistically significant for the age periods of 16 to 18 years and 18 to 20
years. Growth from 16 to 18 years was greater than that from 18 to 20 years. Maxillary and
mandibular growth were highly correlated at each age period. However, overall mandibular growth
was approximately twice that of overall maxillary growth. Mandibular growth was found to involve an
upward and forward rotation, a result of posterior vertical growth exceeding anterior vertical growth.
Lower incisors were found to tip lingually with increasing age. Incremental changes in mandibular
cephalometric measurements were found to be equivalent when measured from either articulare or
condylion, indicating the interchangeability of the landmarks for growth estimates. (AM J ORTHOD
DENTOFACORTHOP1990;97:200-6.)

Many studies have been published con-
ceming growth in the prepubertal and pubertal
years."" However, longitudinal studies in postpuber-
tal adults have been rare. Postpubertal growth has
been shown to produce dramatic alteration in skeletal
and dental relationships. ~2 Bjork ~3 studied mandibular
• growth in 45 Danish males. Although exact results were
not given, Bjork indicated a growth rate of approxi-
mately 3 mm per year between the ages of 16 and 17
years, decreasing to no growth between the ages of 21
and 22 years. Behrents, ~4 however, found mandibular
growth to be significant past the age of 35 years.
Two samples that include data on untreated adults
with Class I skeletal and dental relationships are those
of the University of Iowa and the Burlington Growth
Centre. Studies of the Iowa sample have resulted in a
series of articles on facial growth by Bishara and as-
sociates, z5~7Studies of the Burlington Research Centre
sample have resulted in articles by Woodside ~8and Sin-
clair and Little.~9 The Iowa and Burlington data indi-
cated that the magnitude of postpubertal craniofacial
growth was significant.
The data from the Iowa sample included no inter-
vening records between the ages of 17 and 25.5 years. ,6
The sample studied by Sinclair and Little ~9 had no in-
tervening records between the ages of 13 and 20 years.
Woodside ~8 studied untreated control subjects only to
From the Division of Orthodontics, Faculty of Dentistry, The University of
Western Ontario.
*Senior Graduate Student.
**Clinical Lecturer.
***Associate Professor and Director, Undergraduate Orthodontic Program.
811110440
200
the age of 16 years. Data to the age of 20 years incor-
porated cross-sectional controls and subjects with pre-
vious orthodontic treatment. Studies of continuous rec-
ords of postpubertal Class I skeletal growth cannot be
found in the literature.
The purposes of this study were to determine post-
pubertal skeletal and dental changes in males with Class
I skeletal and dental patterns and to interpret these
changes in a clinical context.
METHODS AND MATERIALS
The sample used in this study consisted of 30 pa-
tients from the Family and Serial Control Groups of the
Burlington Growth Centre. Sample selection was based
on the following criteria: (1) white male with no history
of orthodontic treatment or extractions, (2) Class I, both
skeletally and dentally (i.e., ANB angle < 4 ° and Angle
Class I molars), and (3) lateral cephalograms in both
habitual occlusion and with mouth wide open, available
for the ages of 16 and 20 years.
Of the 30 patients selected, 20 had lateral cepha-
lograms taken at the ages of 16, 18, and 20 years, and
10 had lateral cephalograms taken at the ages of 16 and
20 years.
All lateral cephalometric landmarks (Fig. 1) used
for linear and angular measurements have been de-
scribed previously. 2°'~'
Mandibular measurements from condylion to gna-
thion, condylion to pogonion, and condylion to gonion
were duplicated from articulare and compared by cor-
relation analysis to determine whether the two land-
marks could be substituted when mandibular growth
increments were being determined.
Voh,me 97
]Vumbcr 3
t
t
I
0
t
t
Ba
Go
Fig. 1. Cephalometriclandmarks and planes.
For comparison of maxillary and mandibular
growth, two methods were employed. Both used com-
mon landmarks from which to measure incremental
changes in length. The first method used condylion as
a common point. Maxillary length was measured to A
point, while mandibular length was measured to gna-
thion. The second method used sella and the S-N line
for measurement of growth of the maxilla and mandible
along the functional occlusal plane. Change in maxil-
lary length was measured along the functional occlusal
plane from a point formed from the intersection of a
perpendicular line from the S-N line at sella and the
functional occlusal plane to another perpendicular line
from S-N, which contacted the functional occlusal plane
after passing through A point. Change in mandibular
length was measured from the same posterior reference
point (i.e., the intersection of a perpendicular line from
sella and the functional occlusal plane to the intersection
on the functional occlusal plane of a perpendicular line
from S-N to gnathion, Fig. 1). Means and standard
deviations were determined for each linear and angular
measurement at each age (Table I). In addition, paired
t tests were performed for the differences in the means
of the measurements for the age ranges 16 to 18, 18 to
Facial growth in males 201
J,
t
qccI
Plane
20, and 16 to 20 years (Table II). Relationships between
the changes in selected measurements were investigated
by calculation of correlation coefficients between pairs
of measurements. 23 Correlation coefficients were tested
for significance with Student t tests.
Possible intraexaminer error resulting from land-
mark selection, tracing, and measurement was deter-
mined by random selection of 15 lateral cephalograms,
which were retraced and remeasured. Paired t tests were
carried out for all linear and. angular measurements.
Results indicated that all linear and angular measure-
ments fell within acceptable limits; that is, there was
no statistical significance between original and retraced
measurements.
RESULTS
The values of all cephalometric measurements at
the ages of 16, 18, and 20 years are given in Table I.
Values for SNA, SNB, and facial axis angles indicated
that the sample had a Class I skeletal pattern at all ages
examined. All linear measures showed an increase from
age 16 to age 20. Lower incisor angulation appeared
to be higher than the cephalometric standards described
by Downs 24 and Tweed. z5
202 Love, Murray, and Mamandras Am. J. Orthod. Dentofae. Orthop.
March 1990

Table I. Means and standard deviations of cephalometric measurements for males at ages 16, 18,
and 20 years
Age

16 yr 18 yr 20 yr

Measurements Mean I SD Mean [ SD Mean SD

I
SNA 82.3 3.8 82.0 3.6 82.8 3.8
SNB 79.5 3.9 79.6 3.7 80.4 4.1
ANB 2.8 1.5 2.4 1.8 2.4 ! .7
Facial axis 90.2 4.3 90.3 3.8 90.6 4.0
Mandibular plane 31.0 6.0 30.2 5.8 29.5 5.9
1 to mandibular plane 98.5 6.8 97.7 6.4 96.8 7.0
Na-ANS 57.27 3.11 57.75 3.42 58.12 3.50
ANS -Me 71.71 6.35 72.41 5.42 73.78 6.53
Co-A 97.35 4.20 98.33 4.30 99.51 3.95
Co-Gn 127.17 4.60 129.3 ! 4.00 131.54 4.50
Co-Pog 124.83 4.45 127.12 4.09 129.22 4.53
Co-Go 61.83 4.01 64.20 3.39 66.02 3.57
Ar°Gn 119.45 4.44 121.79 4.13 123.46 4.46
Ar-Pog i 17.54 4.45 119.92 4.21 121.44 4.64
Ar-Go 50.84 3.85 52.79 3.89 54.33 3.59
Go-Gn 82.63 3.47 83.87 3.78 84.59 3.72
Go-Pog 82.92 3.62 84.21 3.99 84.83 3.85
Occlusal plane (maxilla) 71.11 4.71 71.69 3.87 72.42 4.49
Occusal plane (mandible) 56.61 8.70 57.60 7.67 59.26 8.66

Table II. Mean changes and paired t values of cephalometric measurements for males during three
age periods
Age period

16-18 yr 18-20 yr 16-20 yr

(n = 20) (n = 20) = 3~
Measurements Mean I ' Mean 1 ' Mean

SNA 0.0 0.12 0.7 3.33** 0.5 2.53*

SNB 0.3 1.11 0.7 5.05*** 0.9 4.93***
ANB - 0.3 2. i 6* 0.0 0.20 -0.4 2.36*
Facial axis O. I 0.31 0.2 0.68 0.4 1.58
Mandibular plane - 1.0 3.36** -0.5 3.60** - 1.6 8.08***
1 to mandibular plane -0.9 2.88** - 0.8 2.87** - 1.7 4.02***
Na-ANS 0.48 3.49** 0.65 3.40** 0.85 4.83***
ANS-Me 1.02 3.70** 0.78 3.85** 2.07 7.07***
Co-A 1.13 3.64** 1.18 3.92*** 2.16 7.31"**
Co-Gn 2.53 5.76"** 1.59 6.85*** 4.36 9.45***
Co-Pog 2.44 6.51 *** 1.73 6.00*** 4.39 10.03"**
Co-Go 2.37 5.57*** 1.67 5.97*** 4.19 9.42***
Ar-Gn 2.40 6.75*** 1.28 6.18"** 4.00 9.95***
Ar-Pog 2.26 6.91 *** 1.29 5.54*** 3.90 9.77***
Ar-Go 2.07 6.17"** 1.26 5.40*** 3.49 10.36"**
Go-Gn 1.37 4.06*** 0.61 3.66** 1.97 6.36***
Go-Pog 1.32 3.89** 0.57 3.33** 1.91 6.36***
Occlusal plane (maxilla) 0.48 2.06* 0.95 4.80*** 1.31 6.48***
Occlusal plane (mandible) 1.24 2.80* !.35 4.52*** 2.65 7.76***

*p < 0.05,
**p < 0.01,
***p < 0.001.
 Volume 97 Facial growth ill males 203
Number 3

Incremental changes in cephalometric values are Table III. Correlation coefficients for mandibular
shown in Table II. Most measures showed highly sig- length measurements at three age periods
nificant changes in measurement increase for each age
Age period
period studied. The magnitude of the increases were
generally greater from 16 to 18 years than from 18 to 16-18 yr 18-20 yr I 16-20 yr
20 years. In some instances the totals of the 16- to 18- Measurement (n = 20) (n = 20) I (n =30)
plus 18- to 20-year increments did not equal the overall Co-Gn/Co-Go 0.69*** 0.70*** 0.80***
(16- to 20-year) increase. This was due to the fact that Co-Gn/Go-Gn 0.58** 0.24 0.63***
each of the 16- to 18- and 18- to 20-year totals was Go-Gn/Co-Go 0.26 0.18 0.29
derived from samples of 20, while the 16- to 20-year
*p < 0.05,
totals were derived from a sample of 30 subjects.
**p < 0.01,
Measurements of mandibular lengths (Co-Gn, Co- ***p < 0.001.
Go, and Go-Gn) indicated that significant growth in-
crements occurred between the age periods from 16 to
18 years and 18 to 20 years (Table II). The maximum
Table IV. Co-Gn and Co-A growth for three
and minimum growths (Co-Gn) recorded over the 4-
age periods
year period were 10.2 mm and 1.4 mm, respectively.
Nine subjects exhibited mandibular growth in excess Age period
of 6 mm. Correlation coefficients calculated for all pos-
sible pairs of mandibular growth measurements (Table
16-18 yr
(n = 20)
18-20 yr
(n = 20)
I 16-20 yr
(n = 30)
III) showed the strongest correlations to be between
overall length increase (Co-Gn) and ramus length in- Co-Gn (mm) 2.53 1.59 4.36
Co-A (mm) 1.13 1.18 2.16
crease (Co-Go), where the correlations reached statis-
Difference (mm) 1.40 0.41 2.20
tical significance at each age period. The weakest
relationships were between ramus length increase (Co-
Gn) and corpus length increase (Go-Gn). These cor-
relations failed to reach statistical significance at any Table V. Maxillary and mandibular growth
age period. The relationship between overall length in- along the occlusal plane for three age periods
crease (Co-Gn) and body length increase (Go-Gn) was
intermediate, with correlations reaching statistical sig- Age period
nificance at 16 to 18 years and at 16 to 20 years. Vertical I
16-18 yr I 18-20yr { 16-20 yr
mandibular growth (Co-Go = 4.19 mm) greatly ex- (n = 20) 01 = 20) } (n = 30)
ceeded horizontal mandibular growth (Go-Gn = 1.97
Mandible (mm) 1.24 1.34 2.65
mm) from 16 to 20 years of age.
Maxilla (mm) 0.48 0.95 1.3 I
Growth of the mandible and maxilla (from condyl- Difference (mm) 0.76 0.39 1.34
ion) is shown in Table IV. Growth of the mandible was
greater from 16 to 18 years than from 18 to 20 years,
whereas maxillary growth remained relatively constant.
Between the ages of 16 and 20 years the mandible increased 2.07 mm from 16 to 20 years of age while
outgrew the maxilla by a ratio of approximately 2: 1. posterior face height (Co-Go) increased 4.36 mm, a
When measurements of mandibular and maxillary rate more than double that of the anterior face height.
growth were related to the functional occlusal plane Lower incisors tipped lingually with respect to the
(Table V), a slightly different picture was seen. Man- mandibular plane an average of 1.7 ° from 16 to 20
dibular growth remained constant whereas maxillary years of age (Table II). Calculation of correlation coef-
growth increased from the 16- to 18-year age period to ficients for the degree of incisor tipping to overall man-
the 18- to 20-year age period. Overall, the mandible dibular length (Co-Gn) and maxillary and mandibular
still outgrew the maxilla by a ratio of approximately growth measured along the occlusal plane showed that
2: 1, but the increases in both mandible and maxilla no significant relationship existed between the variables
were substantially less than those measured from con- (Table VI). The only significant correlation was shown
dylion. between incisor tipping and the maxillary-mandibular
The mandibular plane angle closed an average of growth differential from 16 to 18 years of age.
1.6° over the study period (Table II), as in previous Values of correlation coefficients and mean differ-
studies? ~,'9 Lower anterior face height (ANS-menton) ences in mandibular length increments measured from
204 Love, Murray, a n d M a m a n d r a s Am. J. Orthod. Dentofac. Orthop.
March 1990

Table VI. Correlation coefficients and mean differences for the comparison of some cephalometric
measurements for three age periods
Age period

16-18 yr (n = 20) 18-20 yr (n = 20) 16-20 yr (n = 30)

I Mean Mean Afean
Measurement to comparison r difference r difference r difference

Co-Gn/Ar-Gn 0.89*** 0.12 0.70*** 0.31 0.87*** 0.36

Co-Go/Ar-Go 0.80*** 0.30 0.68*** 0.41 0.79*** 0.70
Co-Pog/Ar-Pog 0.86*** 0.17 0.66*** 0.44 0.84*** 0.49
Co-Gn/Co-A 0.71"** 1.39 0.55* 0.41 0.52** 2.20***
Occlusal plane (maxilla/mandible) 0.86*** 0.76 0.67*** 0.40 0.64*** 1.34"**
I-MP/Co-Gn 0.37 -- 0.07 0.23
l-MP/occlusal plane (maxilla) 0.10 -- 0.16 0.13
l-MP/occlusal plane (mandible) 0.22 -- 0.19 0.30
l-MP/occlusal plane (mandible-maxilla) 0.87*** -- 0.1l 0.28

*p < 0.05,
**p < 0.01,
***p < 0.001.

condylion and articulare are given in Table VI. Most
of the mean differences were not statistically signifi-
cant, and all correlation coefficients were highly sig-
nificant (p < 0.001) for all age periods. These re-
sults indicated that condylion and articulare may be
used interchangeably to record incremental mandibular
length changes, at least from 16 to 20 years of age.
DISCUSSION
The findings of this study on mandibular growth
and maxillomandibular relationships provide further in-
formation about craniofacial changes in postpubertal
adolescents and adults to supplement data already pub-
lished from previous investigations.~4"~s'2s2s
Values found for mandibular length (Co-Gn)
were less than those reported at equivalent ages by
Woodsidefl 8 possibly because of a difference in radio-
graphic technique (i.e., lateral cephalogram versus 45 °
lateral oblique). In contrast, data from this study show
that the Burlington sample exhibits greater mandibular
lengths than the samples of either Behrents '4 or Bishara
and Jakobsen.~7 These differences may be due to sample
selection or inherent sample variability, although it is
quite possible that they are a result of variable radio-
graphic enlargement factors. Cephalometric standards,
such as those published by Riolo et al.,2° Bishara,,5 and
Behrents, ~4may have more than one enlargement factor
because of changes in equipment or technique over the
course of the study, making data comparisons within
and between studies inaccurate.
It is apparent from the data (Table II) that significant
changes occur in the craniofacial skeleton after the age
of 16. Statistical significance was achieved for all linear
dimensions measured at each age period.
Overall mandibular length (Co-Gn) increased an av-
erage of 4.36 mm over the 4-year study period (Table
II). The increase was much larger than that determined
by Behrents ~ in his study of 84 boys at the age of 17
years and 39 men at the age of 83 years. Behrents found
statistically significant mandibular length increases up
to the age of 35 years and nonsignificant changes after
the age of 40 years. The average increase in mandibular
length from age 17 to age 83 was 2.7 mm. Mandibular
length in our study exceeded that in Behrents' study
(3.4 mm at age 18 and 3.8 mm at age 20). In Behrents'
sample, however, 23% of the subjects had Class II
malocclusion. Results reported by Buschang et al. 29
indicated that the inclusion of Class II malocclusions
would certainly reduce the mandibular length found at
each age but would not affect incremental values be-
tween ages.
Mandibular growth was twice the amount of max-
illary growth, whether measured fro m condylion or
along the occlusal plane. More mandibular growth oc-
curred between the ages of 16 and 18 years than between
18 and 20, whereas maxillary growth was constant in
both age periods. A steady rate of maxillary growth has
been previously noted by Linder-Aronson et al. 3°
MitanP ~ found synchronicity in the timing and rate of
maxillary and mandibular growth in 60% of his sample
of 30 children. Similarly, Jamison et alfl 2 found that
the maxillary-mandibular relationship remained con-
stant between the ages of 8 and 17 years. The high
correlation coefficients for maxillary and mandibular
Voh~me97
Number 3
incremental changes in this study also indicated a re-
lationship between maxillary and mandibular growth
rates. Such a relationship would be expected when a
balanced facial pattern is maintained.
The mandibular plane angle closed 1.6 ° between
the ages of 16 and 20 years. This is in agreement with
the findings of Bjork and Skieller, 33 Bishara, 15 Beh-
rents, '4 and Sinclair and Little ~9 but disagrees with the
findings of Forsberg. 28 Forsberg found that the man-
dibular plane angle increased 0.26" in men from the
age of 24.9 years to the age of 35.2 years. Upward and
forward rotation was a constant finding in this inves-
tigation; 26 of 30 persons showed a reduction in the
mandibular plane angle, whereas in 4 persons the man-
dibular plane angle remained constant. The reduction
in mandibular plane angle occurred despite a concom-
itant increase in anterior face height. It appears most
likely that this reduction was the result of the differential
increase between posterior and anterior face height
(4.19 and 2.92 mm, respectively) over the study period.
Greater posterior vertical growth would result in a low-
ering of the gonion region and subsequent upward and
forward mandibular rotation.
The greater rate of growth in posterior face height
compared to anterior face height in postpubertal sam-
ples can be seen in the data of other longitudinal
studies. 14.16.19.34The greater rate of posterior versus an-
terior growth appears to be a reversal of the trend seen
before and during puberty in which anterior face height
increases more rapidly than posterior face height) 6'~9
Lavergne and Gasson J5 and Isaacson et al. 36 concluded
mandibular rotation was a result of disproportionate
growth. Lavergne and Gasson 35 found a high degree of
upward and forward rotation when mandibular growth
exceeded maxillary growth, a situation that was found
in all but two of the subjects in this study.
The decrease in lower incisor angulation to the man-
dibular plane does not appear to be a universal occur-
rence and is probably sample specific. Bjork and
Skieller 33 and Perera 37 found lower incisor angulation
to be functionally stable, the angulation remaining con-
stant. Forsberg 28 and Behrents '4 found lower incisors
proclined with increasing age. Retroclination of lower
incisors would result in loss of arch length and sub-
sequent crowding. This possibility coincides with what
is seen clinically in many posttreatment orthodontic
cases. In this study, change in incisor angulation was
not correlated with growth of the mandible or of the
maxilla (Table VI) but showed a high correlation with
the maxillomandibular growth differential from age 16
to age 18. The low correlations overall and between
the ages of 18 and 20 leave some doubt whether dif-
ferential jaw growth causes lingual tipping of incisors.
Facial growth in males 205
The cause is probably multifactorial in nature, with
differential growth one of the factors. Incisor inclination
at the age of 16 (Table I) was greater than that given
as a cephalometric norm by Downs 2~ and Tweed. 25
However, the lower incisor angulation found in this
study was in agreement with the findings of other in-
vestigations. ~5.~9.2o
Measurements of mandibular linear incremental
changes from condylion and articulare were found to
be equivalent. It may be impossible to locate condylion
on lateral cephalograms taken with teeth in occlusion,
and very few lateral cephalograms are taken with the
mouth wide open. Although this study did not measure
positional changes in articulare the data support the
conclusions of Agronin and Kokich 38 that remodeling
or displacement of arficulare is reflected in changes in
the glenoid fossa.
SUMMARY AND CONCLUSIONS
1. Cephalometric measurements at each age indi-
cated that the Class I skeletal pattern was maintained
throughout the study period. Comparison of mandibular
length measurements to norms from other studies re-
vealed significant differences, which may be attribut-
able to sample dissimilarity, radiographic enlargement,
or both.
2. The rate of change of mandibular measurements
was significant at each age interval. However, a much
greater rate of change was seen from 16 to 18 years
than from 18 to 20 years. Growth rates for this study
did not agree with some previous studies.
3. Mandibular growth was greater than maxillary
growth at each age interval when measured by either
of two methods. A larger differential was seen from 16
to 18 years than from 18 to 20 years. Despite the fact
that the magnitude of maxillary and mandibular growth
after the age of 16 years did not approach previously
reported pubertal levels, growth of both jaws was sig-
nificant and may need to be assessed in orthodontic
treatment planning.
4. The mandibular plane angle was significantly
reduced, indicating a upward and forward rotational
growth pattern. Forward rotation was thought to be
brought about by disproportionate anteroposterior ver-
tical growth.
5. Lower incisors were found to retrocline with
increasing age. The degree of tipping was not found to
be consistently related to maxillary or mandibular
growth or to the difference between them. However,
these results indicate that orthodontically treated pa-
tients retention may be advisable for extended periods
of time, perhaps to the age of 20 years and beyond in
male patients.
206 Love, .._:Murray, atzd Mamandras Am. J. Orthod. Dentofac. Orthop.
March 1990

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