Good

Morning
BY-
DR. Ranjeet k. chaudhary

PG 2st YEAR
2
• Growth is an increase in size TODD
• The self multiplication of living substance JX Huxely.

• Increase in size, change in proportion &

progressive complexity Krogman
• Quantitative aspect of biologic development per unit of
time Moyers
• Change in any morphological parameter, which is
measurable Moss
 Multiplicative growth
Cellular hyperplasia(increase in number)
 Auxetic growth
Cellular hypertrophy(increase in size)
 Accretionary growth
Increase in extracellular matrix
 Interstitial growth
Increase in bulk within tissue
 Appositional growth
Surface deposition
 Progress towards maturity –TODD

 Sum of all naturally occuring irreversible

physiologic al changes taking place in the body
from its initiation as a single cell to a
multifunctional unit progressing towards a
complex organism finally terminating in death-
MOYERS
 According to proffit

“Growth is largely an anatomic phenomenon,

whereas development is physiologic and

behavioral .”
Growth does not takes place uniformly at all times. There
seems to be periods when a sudden acceleration of
growth occurs. This sudden increase in growth is termed
as “growth spurts”.
Growth spurts Male Female

INFANTILE 3 yrs 3yrs

(child hood)

MIXED DENTITION 7-9 yrs 6-7 yrs

(juvenile)

ADOLESCENT 14-15 11-12 yrs

(Pubertal) yrs
 Cephalocaudal gradient of growth simply means
that there is an axis of increased growth extending
from head towards the feet… axis of increased
growth extending from head towards the
feet..
 12%- adult

25% - at birth

35% -beginning of 5th

month

50% -beginning of
fetal period
 Rudimentary –
beginning of fetal
period

35% -at birth

50% - adult
 When facial growth is viewed against the perspective of
cephalocaudal gradient, it is found that mandible, being
further away from brain, tends to grow more and later
than the maxilla, which is closer to brain.
 Richard Scammon reduced the growth curve of the tissue to
four basic curves.

- Lymphoid
- Neural
- General / somatic
- Genital
 Lymphoid

Neural

General

Genital
Terminology Related To Growth:
Growth Fields :
Areas spread all along the bone in a mosaic-like pattern
capable of producing an alteration in the growth of the
particular bone.

Growth Sites :
Growth sites are growth fields that have a special
significance in the growth of a particular bone.
Eg. Mandibular condyle in the mandible,
Maxillary tuberosity in the maxilla.
Intrinsic growth potential ????
Growth Centers:
Intrinsic growth potential

Growth centers are special growth sites , which control the

overall growth of the bone.
Eg. Epiphyseal plates of long bone.
GENETIC THEORY

 This is one of the earliest theory put

forward.

 It simply states that all growth is

controlled by genetic influence and is
preplanned
SUTURAL THEORY [sicher &weinmann]

 Growth occurs at sutures.

 “SUTURAL DOMINANCE THEORY” with

proliferation of connective tissues & its
replacement by bone in the sutures.

 Acc. To him paired parallel sutures That attach

facial areas to the skull& the cranial base
region push the nasomaxillary complex forward
to pace its growth with that of the mandible
CARTILAGINOUS THEORY [J.SCOTT]

 Intrinsic growth controlling factors were

present only in the cartilage & in
periosteum and growth in sutures was
secondary
 Growth of maxilla is attributed to nasal
septum cartilage
POINTS IN FAVOUR

 In many bones cartilage growth occurs ,while

bone merely replaces it.

 If a part of epiphyseal plate is transplanted to

different location it will continue to grow in the
new location.this shows the innate growth
potential of cartilage

 Nasal septum cartilage also shows innate growth

potential on being transplanted to another site.
FUNCTIONAL MATRIX THEORY [MELVIN MOSS]

 1962 Melvin moss introduced the functional matrix

hypothesis to the orthodontic world

 This analysis was a conceptualised framework

designed to unify the existing concepts and to
emphasize the contention that the bones donot just
grow.

 Moss introduced the doctrine of functional matrix

complimentary to the original concept of functional
cranial component by van der klauss
 FUNCTIONAL CRANIAL COMPONENT

RELATED SKELETAL UNIT

TISSUES AND SPACES THAT
SUPPORTS
PERFORM FUNCTION
FUNCTIONAL MATRIX

SKELETAL CRANIAL
FUNCTIONAL MATRIX
COMPONENT
 SKELETAL UNIT

MICROSKELETAL
MACROSKELETAL A bone consists of
Adjoining portion of a number a number of small units
of bone unite to function as Eg. Mandible,maxilla
a single cranial component
Eg. Endocranial surface
of the calcarium
 It not only includes soft tissue ie muscle,
glands, nerves, blood vessels, fat but also teeth.

non functional
PERIOSTEAL
units adjacent to
MATRIX
skeletal unit..

organs and
CAPSULAR spaces that
MATRIX occupy a broader
anatomical
SERVOSYSTEM THEORY

Petrovic and stutzmann 1980

Characterized by 2 principal factors

 1.hormonally regulated growth of midface and

anterior cranial base which provides a
constantly changing reference input via
occlusion.

 2.rate limiting effect of the midfacial growth

on the growth of mandible
 Input
 Comparator
 Output

It provides a road map for further

experimentation
 Maxillary
growth

Condylar
growth
Occlusal
deviation
Muscle
function

Proprioceptors-
CNS Periodontium &
Tmj
VAN LIMBORG’S THEORY
A multifactorial theory was put forward by van limborg in
1970
5 factors-
 Intrinsic growth factor- they are the genetic
controller of the skeletal units themselves.
 Local epigenetic factor- genetic control originating
from adjacent structures
 General epigenetic factors- genetic growth
determining from distant structures
 Local environmental factors- non genetic factors
from the local non genetic environment e .g habits,
muscle
 General environmental factors- non genetic
influences such as nutrition & oxygen.
 ENLOW’S EXPANDING ‘V ‘ PRINCIPLE

 Many facial bones have a V shaped growth

pattern.the growth movements
&enlargement of the bone occurs towards
the wide ends of V as a result of
differentiation and selective resorption of
bone.

 Bone deposition –inner side of V

 Bone resorption-outer surface

and at ends of 2 arms of V
 ENLOW’S COUNTERPART PRINCIPLE

 The counterpart principle of craniofacial

growth states that the growth of any
given facial or cranial part relates
specifically to other structural and
geometric counterpart in the face and
cranium
 There is regional relationship
throughout the whole face and cranium
if each regional part and it’s particular
counterpart enlarge to the same extent
balanced growth occurs.
 Bone
Cortical drift Displacement
remodelling
Bone deposition & resorption together are called “ BONE
REMODELING”.

Chang
e in
size
Change in
relationship of the
Change in
bone with
proportion
adjacent
structures.
Chang
e in
shape
- A combination of bone deposition &
resorption resulting in a growth
movement towards the deposition surface
is called “Cortical Drift”.

bone deposition & • the thickness of the

resorption equal on bone remains constant.
both side

more bone is deposited

on one side & less • The thickness of the
bone resorbed on the
opposite side
bone increases
It is the movement of the whole bone as a unit.
Primary Secondary
displacement: displacement:
If a bone gets If the bone gets
displaced as a displaced as a
result of its own result of growth &
growth enlargement of an
adjacent bone
2 types of bone growth is normally seen.

Intra-membranous ossification :
The transformation of mesenchymal connective tissue into
osseous tissues.

Bundle bone-develops directly in uncalcified connective tissue

Lamellar bone-develops in mineralised matrix
Enchondral ossification:
The conversion of hyaline cartilage prototype models
into bone.

Depending on location of mineralisation

Perichondral
Endochondral
 Pre implantation period (first 7 days)

 Embryonic period (next 7 weeks)

 Fetal period (next 7 months)

PREIMPLANTATION
PERIOD
 Ovulation
 Fertilization
 Cleavage
 Blastocyst formation
Embryonic
period
 Presomite(8-21 day)
Foetal membranes& primary germ layers are formed in
the inner cell mass
 Somite(21-31day)
Basic pattern of body & organs are established
 Post somite(32-56day)
Formation of body’s external features
 Accelerated growth of the cranio-facial structures
occurs resulting in an increase in their size.

Characterised by first appearance of

ossification centres

At 3rd month the sex of the fetus can

be observed externally

At 4 months the face assumes a

human appearance

no. of skull bones is reduced from 45

separate bones at birth to 22 in adult
 Development of zygote from two cell stage to
the morula
embryoblast
 The second week of development is known as
“week of two”

The trophoblast differentiates into

--the cytotrophoblast
--the synctiotrophoblast
SYNCYTIOTROPHOBLAST CYTOTROPHOBLAST

The embryoblast forms two layers

--epiblast
-- hypoblast
EPIBLAST HYPOBLAST
 Primordial embryonic disc consists of two germ
layers
 Ectoderm(floor of amniotic cavity)
 Endoderm(roof of yolk sac)

14 th day
3rd week
Appearance of MESODERM
Ectodermal cell proliferation &differentiation in the caudal
region of embryonic disc

BILAMINAR DISK TRILAMINAR DISK

The resultant bulge in the disc is grooved craniocaudally it is

called “PRIMITIVE STREAK"
Demarcation of anterior pole ,an endodermal thickening appears
known as PRECHORDAL PLATE headorganising function

serves as
axial
Cranial end Midline axis It terminates skeleton of
of the becomes anteriorly at embryo &
primitive PRECHORDAL induces
defined by PLATE
streak formation of formation of
proliferates & (future site of the NEURAL
differentiates NOTOCHORD pituitary gland) PLATE in the
overlying
ectoderm
Pharyngeal arches
 During late somite period(4th week), mesodermal
lateral plate of the ventral foregut region
 Segments forms 5 bilateral swellings called as
PHARYNGEAL ARCHES
 Pharyngeal arches are separated by pharyngeal
grooves
 1st-mandibular arch
 2nd-hyoid arch
 3rd-
 4th
 5th-degenarate very early
 6th

Size decreases from cranial to

caudal
Each pharyngeal arch contain
 Central cartilage rod

 Muscular component

 Vascular component

 Neural element

Mandibular nerve
Facial nerve
Glossopharyngeal nerve
Superior laryngeal

Recurrent laryngeal
 MANDIBULAR ARCH

Precursor of both maxilla

& mandible

Maxilla is derived from

small maxillary
prominence which extends
from the much larger
mandibular prominence
Cartilage Meckel’s cartilage
Musculature muscles of
mastication,
anterior belly of
digastric TVP
Nerve Mandibular div. of
5th cranial nerve
ANOMALIES
 agnathia microstomia
 Treachers collins syndrome
 Pierre robin syndrome
 External ear deficiency
 PRIMARY CENTRE-
7TH WEEK
AT TERMINATION OF INFRAORBITAL
NERVE.

 SECONDARY CENTRE-
ZYGOMATIC.
ORBITONASAL
NASOPALATINE.
INTERMAXILLARY.
 Frontal process

Orbital surface

Zygomatic process

Alveolar process
 frontozygomatic

frontonasal
frontomaxillary
nasomaxillary
Midpalatal suture
zygomaticomaxillary
temporozygomatic
 ORAL DEVELOPMENT

Demarcated early in life by the

formation of PRECHORDAL PLATE
Endodermal thickening of
prechordal plate designate the
cranial pole
later form Oropharyngeal membrane
One of the only two sites where
ectoderm &endoderm are contigous
Other being the Cloacal membrane
Around the fourth week of
intra-uterine life, a prominent
bulge appears on the ventral
aspect of the embryo
corresponding to the
developing brain.
Below the bulge a shallow
depression which corresponds
to the primitive mouth appears
called “STOMODEUM”.
The floor of the stomodeum is
formed by the oropharyngeal
 mesoderm covering the developing forebrain
proliferates & forms a downward projection that
overlaps the upper part of stomodeum .This
downward projection is called “FRONTO-NASAL
PROCESS”.
FACE develops from five prominence

MAXILLARY- MANDIBULAR-
FRONTONASAL-
upper part of Ist lower part of Ist
mesenchymal
pharyngeal arch pharyngeal arch
Frontal prominence
stomodeum
Maxillary arch
Mandibular arch
 FRONTONASAL PROCESS develop two
thickening near its lateral edges called NASAL
PLACODES

Frontonasal prominence
Nasal placode
Maxillary prominence

Mandibular arch
2nd arch
3rd arch
Nasal placode develops depression
NASAL PIT

Medially- Medial nasal process

Laterally- Lateral nasal process

Medial nasal process

Lateral nasal process

Maxillary process
 Union of facial prominences occur by 2 developmental
events
 Merging of frontonasal ,maxillary &mandibular
prominences or fusion of the central maxillonasal
component
 Fusion requires the disintegration of the surface
epithelium –nasal fin
 Nasolacrimal groove seperates the maxillary &
LNP
 MNP merges in the midline to form the primordia for
 Middle part of nose
 Philtrum
 Primary palate

 LNP enlarges to form

Alae of nose

 Lateral merging of maxillary and

mandibular process forms cheek & commisures of
mouth
by the 6-7th week, maxillary prominence fuse with
median and lateral nasal prominences to give rise
to upper jaw, lateral portion of upper lip, lateral
portion of nose
Shift in the blood supply

ICA ECA
 MNP +MAXILLARY PROCESS
 3 STAGES
 1.CONTACT OF TWO EPITHELIAL SHEETS.
 2.FUSION OF EPITHELIUM INTO SINGLE
SHEET.
 3.DEGENERATION OF THIS SHEET,
FOLLOWED BY INVASION OF THE
CONNECTIVE TISSUE OF THE LIP
GROWING THROUGH IT.
Development of Nose

Frontal prominence Bridge

Medial nasal Median ridge&tip

prominence(merged
)
Lateral nasal Alae
prominence
Cartilage nasal Septum & nasal
capsule conchae
 Nasal pits separates from stomodeum by fusion of MNP,
MAXILLARY process , LNP to form nostrils(Anterior nares)

 ORO NASAL MEMBRANE

initially separates nasal pit from stomodeum eventually
disintegrates establish PRIMARY CONCHAE(posterior nares)

DEFINITIVE CONCHAE of adult are created by the fusion of

palatal shelves
 Early palate
Stomodeal chamber oral cavity
nasal cavity

When FNP & maxillary process develop horizontal extensions .

 Vertically oriented palatal shelves on either side
of the tongue

Palatal shelves
 Critical step.
 8th week.
 Change from vertical
position from besides
the tongue to horizontal
positions overlying the
tongue.
 Involves movement of
both the tongue and
palatal shelves.
 Palatal shelves meet first in anterior region
where they unite with primary palate and
nasal septum.

Primary
palate
Palatal
Nasal shelf
septum
Mechanisms for rapid elevation of palatal shelves

Biochemical transformations in the PHYSICAL

CONSISTENCY of the connective tissue
matrix of the shelves.

Variation in the vasculature and BLOOD

FLOW to the structures.

A sudden increase in the TISSUE TURGOR.

Rapid differential MITOTIC growth.

By accumulation and hydration of HYALURONIC

ACID.
 Two lateral maxillary
palatal shelves
Secondary PALATE

Primary palate of the

fronto nasal process
Hard Palate is ossified by trabeculae spreading
from the single primary ossification centers of
each of the palatine bones.
Ossification does not occur in the most posterior part
of the palate giving rise to the region of the Soft
Palate.
Midpalatal suture
is first evident at 10 ½ weeks
in infancy- y shaped and binds the vomer with
the palatal shelves
in childhood the junction between the 3 bones
rises into a t shape
 Apposition of bone at the
sutures that connect maxilla to Surface remodelling
the cranial base

Maxilla develops postnatally entirely

by intramembranous ossification

Growth pattern of the face requires the maxilla to grow

forward & downward irt cranial base
Secondary displacement due to growth of the cranial
base(upto 6 yrs )
Growth at the sutures(>7yrs)
 Maxilla undergoes primary displacement in
ANTEROINFERIOR direction as it lengthens posteriorly
 Bone apposition occurs on both sides of a suture,so the bones
to which maxilla is attached also becomes larger.
Also as the maxilla grows forward
&downward its anterior surface
is remodelled (bone is removed)

 Roof of the palate

 Bone is removed on the nasal
side& added on the oral side
 sutural theory

cartilaginous theory

Functional matrix theory

Expression of genetic control

 at the level of the bone
 Expressed in the cartilage (epigenetic)
 outside the skeletal system (epigenetic)
 The sutures are sites of growth
but are not growth centers.
 Sutures must be considered areas
that react-
not primary determinants
Cartilaginous nasal septum pacemaker

downward and forward translation of the maxilla.

Sutures reactive
areas
form new bone when the sutures are pulled apart
 major determinant

Functional
needs
enlargement of the orbital Soft tissue
GROW
nasal and oral cavities

bone and cartilage

react.
“skeletal units”
 Basal infraorbital
nerve
 Orbital unit eyeball
 Nasal unit septal
cartilage
 Alveolar unit teeth Basal
 Pneumatic unit maxillary
sinus
orbital
nasal

pneumatic

alveolar
 growth of the eyes
frontomaxillary and
frontozygomatic
frontozygomatic
 The nasal cavity frontonasal
frontomaxillary, frontomaxillary
frontonasal,
frontozygomatic zygomaticomaxillary
zygomaticomaxillary
sutures
 frontozygomatic

frontonasal
frontomaxillary
nasomaxillary
Midpalatal suture
zygomaticomaxillary
temporozygomatic
 Growth of the maxilla and its associated
structures occurs from combination

The maxilla is
as the face grows, new
translated downward
bone fills in at the sutures.
and forward

By the growth of surrounding

soft tissues and the cartilage
probably contribute
 Maxillary arch growth occurs in three direction
 Posteriorly- maxillary tuberosity
 Downward- deposition along alveolar ridges
 Laterally- deposits on buccal surface which
widen posterior part of palate
 Horizontal lengthening
by remodelling Depository field
 Arch widens
Lateral surface is depository
 Endosteal side of cortex within
Maxillary sinus is resorptive
 Maxillary sinus increases in size
 Maxillary tuberosity is a major “site” of growth for maxilla
but relates only to growth of the posterior part .
 CONCEPT OF MULTIPLE ASSURANCE

 Latham & Scott 1970

 processes & mechanisms to carry out growth are
multifactorial
 If any determinant becomes inoperative by pathology the
other morphological components compensates
 Provides alternative means to achieve same end result with
some degree of anatomical distortion
 NASOMAXILLARY REMODELLING

Growth centre concept is contrary to the actual

biology
Contributory components
 Key growth mediator
 Dimunitive flake of bony island
 Provides slippage of multiple
bones
 Without adjustive perilacrimal
system
 Development grid lock
 Major changes in surface contour occur
along the vertical crest below malar
protuberance.
 Known as KEY RIDGE
 differ from
eruption?

 Whole tooth & socket move as a unit

 Periodontal connective tissue provides
intramembranous bone remodeling
Location of
socket Tooth moves
changes itself
 Distance moved by socket tooth & pdl can be
substantial utilised by orthodontist working with
growth
 Lining surfaces- resorptive
 Floor – resorptive
 Lateral & anterior expansion of nasal chamber
 Oral side of palate depository
 Bony portion of internasal septum(vomer+perpendicular
plate of ethmoid) lengthens vertically
 breadth of nasal bridge below Frontonasal sutures
doesnot increase markedly from child hood to adulthood
 Laterally(medial wall of orbit) it expands
considerably in lateral direction in
conjunction with lateral enlargement of nasal
chambers
 Palatal remodelling
 External surface (labial) side of whole anterior
part of maxillary arch is resorptive,with bone
being added inside
 Laterally Arch expands
 fenestration
 Posterior side of malar protruberance within
temporal fossa- depository
 Anterior surface- resorption
 Moves laterally
 Laterally –deposition
 Medial –resorption
ORBITAL GROWTH
 RESORPTION on endocranial surface

 Deposition on orbital side

 V principle

 2nd factor

 Forward &downward movement of NMC deposition

on intraorbital (superior) side of orbital floor
resorption on maxillary sinus side(inferior)
 Sustains position of orbital floor i.r.t eye

 lateral

 Laterally deposition& medial resorption

In anteroposterio direction vector, the forward, passive
motion of the maxilla is constantly being compensated for
By the accretions at the maxillary tuberosity and at the
palatal processes of both the maxillary and the palatine
Bones.

In the vertical direction the growth of the Maxillary

complex is due to : continued Apposition of alveolar
bone on the free Borders of the alveolar process as the
Teeth erupt.
As the maxilla descends, continued Bony apposition occurs on the
orbital Floor, and at the same time resorption On the nasal floor and
apposition of the Bone on the inferior palatal surface

By the alternate process of bone deposition and resorption, the

orbital and nasal floors and the palatine vault move Downward and in
a parallel fashion
GROWTH OF LIPS
Lips trail in growth to jaws prior to adolescence.
LIP INCOMPETENCE- maximal in childhood
Decreases in adolescents
d/t downward growth of lips gingival display decreases
Lip thickness decreases max. in adol.
 GROWTH OF NOSE
nasal bone growth completes by 10 yrs
 Growth only by cartilage & soft tissues
 More prominent in adolescence
 Cleft palate.
 Micrognathia.
 Macrognathia.
 Treacher collins syndrome.
 Cleidocranial dysostosis.
 Crouzons syndrome.
 Apert syndrome.
 Achondroplasia.
 DEVELOPS DUE TO NON FUSION

-
CLEFT LIP FNP +MAXILLARY
- PROCESS

MIDLINE CLEFT OF MNP

UPPER LIP

OBLIQUE FACIAL CLEFT MAX. PROCESS + LNP

LATERAL FACIAL CLEFT UNILATERAL NON
FUSION OF MAX+MAND
PROCESS
 MACROSTOMIA –MAXILLARY .
+MANDIBULAR PROCESS

 MICROSTOMIA – TOO MUCH FUSION OF

MAXILLARY + MANDIBULAR PROCESS
 ALSO CALLED AS MANDIBULOFACIAL
DYSOSTOSIS.
 DUE TO UNDERDEVELOPMENT OF 1ST
ARCH, MAX. MESODERM AT AND AFTER
2 MTS OF I.U LIFE NOT DEVELOPED.
 HYPOPLASTIC MALAR AND MANDIBLE
BONE.
 MACROSTOMIA, HIGH ARCHED PALATE.
 RETARDED MAXILLARY GROWTH.
 ENLARGED CALVARIA.
 FRONTAL BOSSING.
 DISTURBED ENDOCHONDRAL BONE
FORMATION.
 SHORT UPPER FACIAL HEIGHT.
 OPEN FONTANELLES
 SUNKEN SAGITTAL SUTURE
 UNDERDEVLOPED MAXILLA
 NARROW PALATE
 APERT SYNDROME:
 IS A SINGLE GENE DISORDER, CHARACTERIZED
BY PREMATURE FUSION OF CRANIAL SUTURES,
 BIZARRE CRANIOFACIAL APPEARANCE,
 HIGHLY ARCHED PALATE,
 SYNDACTYLY (FUSION OF DIGITS)
 CONGENITAL HEART DEFECTS
 SAME AS APERT SYNDROME BUT WITHOUT
SYNDACTYLY
 TRIANGULAR FRONTAL DEFECT.
a.Maxillary Deficiency:

i.) Antero-posterior and vertical maxillary deficiency:

Both antero-posterior and vertical maxillary deficiency can

contribute to classIII malocclusions.
If the maxilla is small or positioned posteriorly, the effect is
direct.
If it does not grow, the maxilla rotates upwards and forwards
producing an appearance of mandibular prognathism,

Treatment: In children below 8yrs, this can be treated with

Delaire type of face mask that obtains anchorage from the
forehead and chin.
ii.) Transverse maxillary constriction:
Skeletal maxillary constriction is distinguished by a narrow
palatal vault.
It can be corrected by opening the mid-palatal suture
which widens the roof of the mouth and floor of nose.
The growth of this suture helps in arch-widening and
continues till late teens and then ceases .

Treatment modalities:

a.) Rapid maxillary expansion

b.) Maxillary excess:
Excess growth of maxilla in children leads to a skeletal
class II malocclusion which has a vertical as well as an
antero-posterior component i.e. too much downward and
forward growth.

The treatment goal is to restrict the growth of maxillae

while allowing the mandible to grow to a more prominent
and normal relationship with it.

Treatment:
Application of extra-oral force via head gear.
 Effect of Abnormal Habits on
Nasomaxillary Growth

a.) Digital Sucking:

Maxillary arch fails to develop in width in case of
prolonged thumb sucking habit due to alteration in the
balance between cheek and tongue pressures.
b.)Respiratory pattern:
An altered respiratory pattern such as breathing through
the mouth rather than nose can change the posture of the
head, jaw and tongue. This , in turn, can alter the
equilibrium of pressures on the jaws and teeth; and affect
both jaw growth and tooth position.

This leads to a condition called ADENOID FACIES.