Scientific Article

Assessing Growth and Development of the Facial Profile

Abstract
The study of growth and development of the facial profile is of interest to clinicians and
researchers in the fields of pediatric dentistry, orthodontics, and craniofacial surgery,
enabling diagnosis, planning, and evaluation of treatment. Until recently, craniofacial
studies addressed facial growth, facial asymmetry, and gender differences by examining
changes in size. However, size changes alone do not represent fully the complicated pro-
cess of craniofacial growth which also involves changes in shape. The shape of the facial
profile can now be quantified with Fourier analysis, contributing to a better understanding
of growth. A combination of recently developed methods, such as 3-dimensional facial
morphometry and Fourier analysis, should allow a more comprehensive knowledge of
growth and development of the craniofacial structures, including the facial profile. This
article examines various methods for assessing facial growth and development currently
available with particular reference to the facial profile, and addresses the value of Fou-
rier analysis in assessing shape changes. (Pediatr Dent. 2003;25:103-108)
KEYWORDS: FACIAL PROFILE, GROWTH AND DEVELOPMENT, FOURIER ANALYSIS
Received April 10, 2002 Revision Accepted September 25, 2002

G
rowth and development of the craniofacial struc- determining size and shape changes of facial components
tures have been studied extensively, as many clini- including timing, direction, and magnitude of change dur-
cal disciplines rely on the understanding of these ing growth and development. This paper examines various
processes for diagnosis, timing, and planning of treatment. methods for assessing facial growth and development cur-
This knowledge is important to clinicians and researchers rently available with particular reference to the facial profile,
in disciplines such as pediatric dentistry, orthodontics, and and addresses the value of Fourier analysis in assessing shape
craniofacial surgery—enabling detection of normal or ab- changes.
normal changes, assistance in diagnosis and treatment
planning, and prediction of posttreatment outcomes.1 Sev- Direct assessment of growth
eral methods have been used to investigate growth and using facial anthropometry
development in relation to changes in both size and shape. Direct measurement of facial landmarks (anthropometry)
Changes in size have been studied by direct measurements allows a 3-dimensional study of the soft tissue facial pro-
(anthropometry),2 metric analysis of hard and soft tissues file. Because measurements are made directly on the
(cephalometry and photography),3-7 and 3-dimensional subjects and the landmark coordinates cannot be digitized
studies of soft tissue landmarks.8-13 Recently, changes in to allow other measurements at a later stage, the approach
shape have been studied by Fourier analysis.14-20 is time consuming. Inaccuracies may occur in determin-
One of the important effects of growth and develop- ing landmarks and soft tissues may be deflected by pressure
ment is change in the facial profile, whereby different from the measuring device.10-12,21 Longitudinal studies per-
components achieve balance through the cellular and tis- mit changes to be evaluated during maturation and over
sue control processes of morphogenesis.1 Growth involves time. However, data acquisition is difficult as the study
change of the components, whereas development involves participants may fail to return for recall and few large study
the components reaching a state of structural and func- populations have been followed over long periods. Conse-
tional equilibrium.1 Craniofacial studies have aimed at quently, anthropometric studies of facial profiles have been

Pediatric Dentistry – 25:2, 2003 Craniofacial growth and development Darwis et al. 103
few and cross-sectional in design. Cross-sectional studies Gender differences in growth studies
are easier to perform and allow study populations to be A recent University of Michigan study of cephalometric
investigated with less cost.2,11 However, in cross-sectional radiographs from the Bolton study used linear and angu-
studies, different individuals are examined and the results lar measurements to evaluate gender differences in normal
may be biased. craniofacial growth.5 Study of the records of 16 males and
A cross-sectional study of facial growth was performed 16 females (Caucasian) at ages 6, 9, 12, 14, 16, and 18 years
at the Craniofacial Measurement Laboratory, University of indicated that sexual dimorphism started at 9 years of age
Toronto, Canada, on 1,594 Caucasian subjects aged 1 to and was most apparent at 14 years of age and onwards for
18 years.2 Vertical, horizontal, and sagittal measurements most skeletal measurements, which is the time when fe-
were performed with a sliding caliper. Descriptive in na- males reach their final size while males continue to grow.5
ture, the study concluded that, with age, major changes Soft tissue investigations from cephalometric radio-
occurred in facial proportions until maturity, resulting from graphs have investigated profile changes, comparing
different growth rates of the width, height, and depth of measurements of landmarks at different ages. A combined
the face. Males had a later maturation age of 15 years in longitudinal and cross-sectional study at the Child Research
total facial height, width, and mandibular height compared Council in Denver, using cephalometric radiographs of 17
to females, who had a maturation age of 13 years in facial males and 23 females at the ages of 7 to 8 years and 17 to
height and width, and in maxillary and mandibular depth. 18 years, indicated sexual dimorphism in the nose, lips, and
Mandibular width matured earlier than maxillary dimen- chin.4 Males showed a larger increase in size of these struc-
sions in both sexes (males at 13 years, females at 12 years).2 tures and this extended over a longer time period than in
females.4 Adult female size was achieved in most measure-
Cephalometric analysis as a ments by 15 years of age, whereas males continued to show
widely used clinical assessment linear increase until the final measurements at 18 years. The
Cephalometry is used widely for growth analysis, diagno- proportions of adult size attained in different facial struc-
sis, treatment planning, monitoring of therapy, and tures at 5, 15, and 18 years of age in males and females have
evaluation of treatment outcomes.22 Both hard and soft been tabulated, and such data can assist in planning treat-
tissues can be examined. Linear and angular measurements ment, anticipating growth-related changes, and predicting
can be compared over time, and radiographs taken at dif- posttreatment outcomes.4
ferent times under standardized conditions can be Confirmation of gender differences in the soft tissue pro-
superimposed using relatively stable structures. However, file was found in a combined longitudinal and cross-sectional
cephalometric analysis remains a 2-dimensional represen- study of cephalometric radiographs in Nijmegen, Nether-
tation of 3-dimensional features, resulting in vertical and lands.6 A total of 82 subjects (45 females, 37 males) was
horizontal displacement of structures in relation to the ra- studied longitudinally from ages 9 to 22 years. Gender-dif-
diographic film. Facial asymmetry cannot be assessed, and ferent growth patterns commenced at 9 years, when the soft
the technique is subject to magnification and distortion of tissue structures of girls changed in size rapidly compared
size, positioning, and processing errors, and difficulty in with boys who were still growing slowly, to reach a similar
determination of anatomical landmarks.22,23 rate of growth at 12 years of age when the velocity curves
One of the largest longitudinal studies utilizing cepha- overlapped. After this age, the velocity curve decreased in girls
lometry was the Bolton study, conducted at Case Western and increased in boys until final measurement of the soft
Reserve University from the 1930s to 1973. Approximately tissue profiles.6
22,000 recordings of 5,000 individuals of European descent A cephalometric study of soft tissue profiles conducted
were studied between 1 and 18 years of age.3 Using deter- by the Iowa Facial Growth Study used longitudinal records
mination of landmarks, cephalometric tracings, and of 20 females and 15 males aged 5 to 25 years.7 Similar
measurement of changes, the study established the Bolton direction and magnitude of changes occurred in males and
standards of dentofacial growth.3 These annual standards are females, but the greatest changes in soft tissue profile oc-
available for males and females as transparencies consisting curred earlier in females (10 to 15 years) than in males (15
of facial landmarks, lines, and angles representing lateral view to 25 years).7 In both sexes, there was an increase in total
norms from ages 1 to 18 years and frontal view norms from facial convexity from 5 years to adulthood due to a greater
ages 3 to 19 years.3 Both soft tissue and skeletal profiles are increase of the nasal prominence relative to the remaining
available, and the clinician may choose a suitable landmark soft tissue profile. Late changes were found in both the
for superimposition of cephalometric radiographs.1,3 These upper and lower lips, as they became more retruded in
standards are still widely used for comparative studies of both position, even up to 45 years of age.7
hard and soft tissue profiles. Due to ethical considerations
and possible adverse effects from multiple radiation expo- Three-dimensional methods
sures, annual radiography of nonpatient subjects is now to assess craniofacial growth
restricted. The cephalometric records in the Bolton study are, As indicated above, anthropometric studies are limited in
therefore, invaluable and have been reexamined in recent accuracy, and cephalometric radiographs and photographs
craniofacial growth studies.5,12,14

104 Darwis et al. Craniofacial growth and development Pediatric Dentistry – 25:2, 2003
provide only 2-dimensional representations of growth. 14 to 15 years. In males, the growth spurt was evident by 11
Since growth is a 3-dimensional process, it is argued that to 12 years and continued at a similar rate to 16 to 17 years.12
all directions of growth should be assessed. Three-dimen- Facial volumes were always larger in males than females in all
sional approaches to study growth now include age groups, but were similar during the youngest period (6-7
stereophotogrammetry and 3-dimensional facial mor- years) and preadolescence (11-12 years).12 Linear facial mea-
phometry.8,9,13 These techniques are useful in assessing facial surements in males were wider, longer, and deeper than in
volume and facial asymmetry, are noninvasive and relatively females of the same age group; the differences were statisti-
inexpensive, and are applicable to longitudinal studies of cally significant in all age groups, and especially after 14 years
large numbers of subjects. However, the techniques are lim- of age.11 These findings confirmed those of earlier soft-tissue
ited to recording coordinates of cutaneous points and cephalometric studies.2,4,24,25 The areas of the face most influ-
information may be lost during reconstruction of the face enced by sexual maturity were the nose and lips; features of
in a coordinate system (the process of “facial extraction”).10 particular interest to clinicians. In the future, this 3-dimen-
Stereophotogrammetry uses a dual-purpose stereomet- sional approach could be combined with cephalometry for
ric camera to stereoscopically record a pair of facial diagnosis and treatment planning.13
photographs and a contour plotting device; the result is a
computerized facial map.8,9 Anatomical facial landmarks are Limitations of metric measurements
plotted in 2 mm intervals from the tip of the nose to each The preceding approaches assess growth using conventional
landmark, and presented in x, y, and z coordinates. The measurements of linear distances, angles, and ratios—tech-
method allows linear measurements, which can be com- niques that were developed originally for measuring regular
bined to measure volume.9 The technique has been used geometric objects. Despite ease of use, metric analysis may
in longitudinal studies at the University of Sheffield, En- not be appropriate for measurement of irregular and com-
gland, on 26 boys and 26 girls to determine the adolescent plex biological forms such as the face.19,20 Shortcomings
growth spurt of facial soft tissues, including the nose.8,9 include the limited number and wide spacing of landmarks
Measuring several facial parameters, Burke and colleagues used to assess complex forms, bias and subjectivity in choos-
(1988) found the adolescent growth spurt of the facial soft ing landmarks to represent form, and difficulties in
tissue coincided in timing with general somatic growth, al- standardizing for size.26-29 The complex structures of the face
though some variations were noted.8 Boys experienced this cannot be represented fully by combining separate measure-
spurt at 12 to 13 years of age; girls varied in the observed ments of the different facial parts.1 Further, study of the
parameters, although a spurt was seen at 12 to 14 years old. process of growth and development in young subjects is in-
Concerning the nose, an adolescent growth spurt was noted fluenced by size differences which mask the more subtle
with a greater manifestation in anterior nasal growth com- shape differences.1,18 In summary, metric measurements are
pared to nasal height and width, which were influenced more sufficient to evaluate dimensions of craniofacial components
by overall facial growth.9 This spurt occurred at 13 to 14 and size, but are inadequate to quantify shape and changes
years of age in boys, and at 9 to 10 years of age in girls.9 in shape that occur with growth and development.13,17,18
A 3-dimensional method for craniofacial growth stud-
ies, 3-dimensional facial morphometry (3DFM), utilizes an Fourier analysis for
ELITE television image analyzer (ELaboratore di Immagini assessing changes in shape
Televisive, BTS, Milan, Italy), which consists of 2 charge A mathematical approach to quantify shape in biological
coupled device cameras to record the image, hardware for forms has been developed in the form of a Fourier analysis
identification of soft tissue landmarks, and software for (FA). The analysis was first described by Jean Baptiste Jo-
reconstruction of x, y, and z coordinates of the landmarks.10 seph Fourier (1768-1830), and it is a development from pure
After marking the facial landmarks visually, the subject is mathematics now applied in fields as diverse as physics, as-
positioned in front of the cameras to record the image from tronomy, optics, and electrodynamics, and, more recently,
different angles. The landmarks are then translated by the in the fields of pattern recognition, biology, and medicine.19
ELITE system and the face is reconstructed with the x, y, Fourier analysis is a curve-fitting procedure represent-
and z coordinates.10 ing boundaries that address the outline of objects. It is based
A series of studies has been performed with 3DFM at the on the separation of complex waveforms with a mathemati-
Universit· degli Studi di Milano, Italy, involving 2,023 exami- cal function to form a series of sinusoidal waves, or
nations.11-13 The studies were both longitudinal and harmonics, of different frequencies.27 This enables a math-
cross-sectional in design, examining 22 facial landmarks on ematical description of the outline of an object, quantitative
1,347 subjects (northern Italians) aged 6 to 32 years.11-13 Fa- analysis of global shape characteristics, and comparison of
cial volume changes over time were computed and compared outlines of different objects. The analysis is conducted on
for males and females. Growth patterns were similar for both scanned frontal and profile photographs taken simulta-
genders until age 11 years, then differed significantly thereaf- neously using an orthogonal camera system. The facial
ter.12 A growth spurt in facial volume was evident in females features are then extracted digitally, and shapes are com-
by 11 to 12 years then growth declined rapidly and ceased by puted using FA and Fourier descriptor software. Changes

Pediatric Dentistry – 25:2, 2003 Craniofacial growth and development Darwis et al. 105
in the outline of an object over time can be compared with- Recent developments in
out the influence of size, spatial orientation, or relationship elliptical Fourier analysis
to reference planes.13,14,16,18 Based on these advantages, the To overcome the problems associated with conventional
analysis has been proposed to assess shape changes in FA, an elliptical Fourier analysis (EFA) was developed re-
growth studies.15,17,18,20 cently to investigate more complex morphological forms.
The value of FA in representing the facial profile has been Originally developed in 1982 by Kuhl and Giardina,32 the
described. A study of both hard and soft tissues of the facial outcome is a set of numbers (harmonics or coefficients),
profile (from the nasal bridge to the chin) was conducted on selected based upon the detail required. Ellipses are pro-
77 males aged 25 to 74 years in the VA Dental Longitudinal duced when the separate harmonics are plotted and, on
Study in Boston.30 Twenty harmonics were used to assess the summing these, combine into the observed form. The first
fit of the computed function with the observed profile outline, few harmonics or lower order represent the global features
resulting in an overall excellent fit with less error than manual of shape, while the higher order represent the facial pro-
tracing and fewer digitizing errors.30 The FA has also been used file in more detail. 28 The number of harmonics used
to assess age differences in the Bolton tracings.14 Seven cepha- depends on the amount of detail required; 30 or fewer
lometric landmarks were connected and used to calculate the harmonics can represent the facial profile accurately.33
centroid (a neutral center within a represented object that re- The advantages of EFA include the ability to define com-
mains constant with rotation, similar to a center of gravity). plex structures the relative independence from the
Using 20 harmonics, an excellent correlation was found between centroid and landmarks, and the consistent orientation
the mathematical reconstruction and the original plot; a lesser of structures that allow comparison of different ob-
value was found when 6 harmonics were used. However, this jects.19,34 However, interpretations may be difficult, since
study was still dependent on landmark identification, and the each harmonic is an elliptical shape.14,27
investigation was performed on the outline created from con- With reference to growth, EFA has been used to cal-
nected landmarks instead of the facial profile per se.14 culate a “morphological distance” (MD) to measure
Other investigations with FA have assessed facial differences in shape.13,16,34 The MD is the distance be-
growth. In a cross-sectional study at the Universitá degli tween each harmonic pair of 2 different objects with a
Studi di Milano, Italy, of 122 subjects (northern Italian) given mathematical function. For example, if the objects
aged 7 to 15 years, seven cephalometric landmarks were compared are identical, the MD would be 0. The method
connected and superimposed.17 Shape was found to be in- allows comparison of different objects or the same object
fluenced by gender in all age groups, except for 10 to 12 at different times. Differences in the Bolton standards of
year olds. Boys showed greater variations of shape in dif- dentofacial growth have been examined using EFA, and
ferent age groups than girls.17 Soft tissue facial profile it was found that, between ages 1 to 17 years, the great-
growth was also investigated at the same institution, using est difference in shape occurred during the first year, and,
the Bolton standards and FA.18 Soft tissue landmarks were thereafter, the differences progressively declined, with
traced, plotted as polar coordinates, and compared between minimal differences occurring after 15 years of age.16
the ages of 1 to 18 years. The study concluded that facial A longitudinal study at the University of Glasgow
soft tissue size and shape were significantly determined by Dental School, Scotland, used cephalometric radio-
age and that soft and hard tissue changes were not corre- graphs of the mandible from Leighton’s archival growth
lated linearly and, therefore, should be assessed study35 of 24 subjects 9, 11, 13, and 15 years of age, and
independently.18 The growth of facial soft tissues was evalu- described shape changes with EFA.20 Mandibular points
ated further in a cross-sectional study at the same were traced on the outline of the mandible, and the dis-
institution, studying 144 children in 2 age groups—6 to 7 tances of these points from the centroid were calculated.
years old and 9 to 10 years old—as part of a 3DFM study Mandible outlines were also superimposed to visually
that provided frontal and lateral soft tissue facial land- inspect shape changes. No gender differences were
marks. 15 Using FA, the landmarks were plotted as found; however, significant shape changes were noted
coordinates. Shape modification during growth was again from 11 years onwards involving the mandibular inci-
found to be gender-specific, with boys and girls showing sor area, mental region, body of the mandible, and the
different timing and magnitude of change. Shape differ- gonial angle.20 Small sample size can limit such studies,
ences were most evident in both genders in the lower and the possibility of tracing and point identification
one-third of the facial profile, expressed more in a vertical errors (especially in overlapped areas), and errors in-
direction than a transverse direction. Facial asymmetry was curred in fitting the reconstructed outlines in areas of
found to increase between the ages of 6 to 7 years and 9 to dramatic contour change (eg, tip of the incisor and tip
10 years, particularly in girls.15 Conventional FA is rela- of the coronoid process), are possible.
tively straightforward, and the coefficients or harmonics can
be related to biological meaning.31 However, the use of FA Twin studies using
is limited to relatively simple morphological forms, and it elliptical Fourier analysis
is difficult to fit into complex or irregular forms.19,28 Knowledge of genetic and environmental influences on the
craniofacial structures during growth requires more attention.

106 Darwis et al. Craniofacial growth and development Pediatric Dentistry – 25:2, 2003
Better understanding of hereditary factors would assist cli- growing but males continue to grow. This age of maturity var-
nicians in treatment planning, enabling prediction of ies—in females it is reported to be 13 to 15 years old and in
craniofacial areas more susceptible to treatment or prone to males 17 to 25 years old. Late changes are observed to continue
relapse following treatment. Recent craniofacial growth stud- occurring in both the upper and lower lips, even into adult years,
ies have used twins as a tool to determine genetic and resulting in continued change in the facial profile.
environmental factors.36,37 In twin studies, identical twins While metric measurements are sufficient to assess di-
(monozygotic twins) are seen as genetically identical, and, mensions of craniofacial components and size, they are
thus, differences among them are due to environmental in- inadequate to quantify shape and changes in shape that
fluences, whereas nonidentical twins (dizygotic twins) share occur with growth and development. Better understand-
similar environmental experiences as identical twins, but ing of genetic and environmental influences during the
share the same genes as siblings.38 Previous growth studies process of growth and development of craniofacial struc-
in twins have utilized cephalometric radiographs only.36,37 tures is also required. Advances in the knowledge of
Craniofacial twin studies have been performed with EFA, craniofacial growth should include both size and shape
resulting in quantification of the facial profile of twins and changes in all dimensions. A combination of recently de-
relatively good classification of twins.39,40 A study of genetic veloped methods applicable to longitudinal studies, such
and environmental influences on the facial profile using EFA as 3-dimensional facial morphometry and Fourier analy-
was conducted at the University of Melbourne, Australia, sis, should allow a more comprehensive knowledge on
on 79 twin pairs (37 identical, 42 nonidentical) aged 4 to 6 growth and development of the craniofacial structures, al-
years old.40 This study found that EFA could classify twin lowing improved prediction of clinical outcomes.
type, quantify the facial profile of the twins, and differenti-
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108 Darwis et al. Craniofacial growth and development Pediatric Dentistry – 25:2, 2003