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Postnatal Growth and Development
Postnatal Growth and Development
GROWTH AND
DEVELOPMENT
Postnatal growth of the
craniofacial complex
Postnatal Growth of the Craniofacial
Complex
Growth of the craniofacial complex can be divided into four
areas that grow rather differently:
a. The cranial vault the bone that covers the upper and
outer surface of the brain.
b. The cranial base the bony floor under the brain, which
is also a dividing line between the cranium and the face.
c. The nasomaxillary complex made up of the nose,
maxilla, and the associated structures.
d. The mandible
Cranial Vault
The growth in the cranial vault is because of the enlarging brain.
The rate of bone growth is more during infancy and by the fifth
year of life more than 90 percent of the growth of cranial vault is
achieved.
Cranial Vault
It is made up of a number of flat bones that are formed directly by
intramembranous ossification, without cartilaginous precursors.
From the time that ossification begins at a number of centers that
foreshadow the eventual anatomic bony units, the growth process is
entirely the result of periosteal activity at the surfaces of the bones.
Some selective resorption occurs early in postnatal life on the inner
surfaces of the cranial bones to help flatten them out as they
expand.
Cranial Vault
Remodeling and growth occur primarily at the periosteum lined
contact areas between adjacent skull bone, called the skeletal
sutures.
At birth, the flat bones of the skull are rather widely separated by relatively
loose connective tissues. These open spaces, the fontanelles allow a
considerable amount of deformation of the skull at birth—a fact which is
important in allowing the relatively large head to pass through the birth canal.
After birth, apposition of bone along the edges of the fontanelles eliminates
these open spaces fairly quickly, but the bones remain separated by a thin
periosteum lined suture for many years, eventually fusing in adult life.
Cranial Vault
With the general growth and thickening of the cranial vault there is an increase in
the distance between the internal and external plates in the supraorbital region.
This may be seen on the external surface as a ridge.
The spongy bone between the external plates is gradually replaced by the
developing frontal sinus.
The cranial vault increases in width primarily through ‘fill in’ ossification of the
proliferating connective tissue in the coronal, lambdoidal, interparietal,
parietosphenoidal and parietotemporal sutures. Despite early accomplishment of
the pattern, the parietal bones do not close until the middle of third decade of
life.
Increase in length of the brain case may be primarily due to the growth of the
cranial base with active response at the coronal suture.
Height of the brain case is due to the activity of the parietal sutures along with
the occipital, temporal, and sphenoidal contiguous osseous structures.
Cranial Base
Cranial base, unlike cranial vault , is not completely dependent on
brain growth and may have some intrinsic genetic guidance and a
pattern that is, similar in some dimensions, to that of the facial
skeleton.
In contrast to the cranial vault, the bones of the cranial base are
formed initially in the cartilage and are later transformed by
endochondral ossification into bone. This is particularly true of the
midline structures.
As one moves laterally, growth at sutures becomes more important,
but the cranial base is essentially a midline structure.
Centers of ossification appear
early in embryonic life in the
chondrocranium, indicating the
eventual location of the basis
occipital, sphenoid and ethmoid
bones that form the cranial base.
Activity at the intersphenoidal
synchondrosis disappears at birth.
The intraoccipital synchondrosis
closes in the 3rd to 5th years of
life. The sphenooccipital
synchondrosis is a major contributor
as the ossification here extends till
the 20th year of life.
Nasomaxillary Complex
The upper face, under the influence of cranial base inclination, moves
upwards and forwards; the lower face moves downwards and forwards on an
‘expanding V”.
The growth of the
cranium and facial
skeleton progress at
different rates
(Scammon). By
differential growth, the
face literally emerges
from beneath the
cranium.
Since the maxillary complex is attached to the cranial base, there is
a strong influence of the latter on the former. Although, there is no
sharp line of demarcation between cranium and maxillary growth
gradients, yet the position of the maxilla is dependent upon the
growth at spheno-occipital and sphenoethmoidal synchondroses.
Hence, while discussing the growth of nasomaxillary complex, we
have to look into two aspects.
1. The shift in the position of the maxillary complex, and;
2. The enlargement of the complex itself.
Enlow and Bang apply the principle of “area relocation” to the
complex and multidirectional growth movements. As the dynamic
process continues, “ specific local areas come to occupy new actual
positions in succession, as the entire bone enlarges. These growth
shifts and changes involve corresponding and sequential remodeling
adjustments in order to maintain the same shape, relative positions
and constant proportions of each individual area in the maxilla as a
whole”.
The maxilla develops entirely by intramembranous ossification.
Sutural connective tissue proliferations, ossification, surface
apposition, resorption and translation are the mechanisms for
maxillary growth.
Moss and Greenberg point out that the basic maxillary skeletal unit is
the infraorbital neurovascular triad, where the maxillary basal bone
largely serves as a protection mechanism for the trigeminal nerve. It
is this neurotrophic influence, which maintains the spatial constancy
for the infraorbital canal with respect to the anterior cranial base.
Thus, indirectly it produces a similar constancy of the basal maxillary
skeletal unit relative to the same base.
Moss cites three types of bone growth changes to be observed in the
maxilla.
1. Those changes that are associated with compensations for the
passive motions of the bone brought about by the primary
expansion of the orofacial capsule.
2. There are changes in bone morphology associated with
alterations in the absolute volume, size shape or spatial position
of any or all of the several relatively independent maxillary
functional matrices, such as orbital mass.
3. There are bone changes associated with the maintenance of the
form of the bone itself.
Just as the neurocranial bones are enclosed within a neurocranial
capsule, the facial bones are enclosed within the orofacial capsule.
Resultantly the facial bones are passively carried outward
(downward, forward, and laterally) by the primary expansion of
the enclosed orofacial matrices (orbital, nasal, oral matrices). In
addition there is an essential growth of the sinuses and spaces
themselves, which perform important functions. The resultant
maxillary changes would thus be secondary, compensatory and
mechanically obligatory.
In anteroposterior 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.
Specifically mentioning, the vertical
growth of the maxillary complex is due to
the continued apposition of alveolar bone
on the free borders of the alveolar process
as the teeth erupt.
Mandible
1. The basal portion is a tube like central foundation running from the
condyle to the symphysis.
2. The muscular portion (gonial angle and the coronoid process) is under the
influence of the masseter, internal pterygoid and temporalis muscle.
3. Alveolar bone exists to hold the teeth and it is gradually resorbed in the
event of tooth loss.
• Enlow and Harris feel that chin is associated with a generalized cortical
recession in the flattened regions positioned between the canine teeth.
• The process involves a mechanism of endosteal cortical growth. On the
lingual surface behind the chin, heavy periosteal growth occurs, with the
dense lamellar bone merging and overlapping on the labial side of the chin.
• Particularly in the male, the apposition of the bone at the symphysis seems
to be about the last change in shape during the growing period. This means
that some time between 16 and 25 years of age, appositional changes give a
new shape to the symphysis in males. This change is much less apparent in
females.
Development of dentition
and occlusion
MOUTH OF NEONATE- 0 to 6 Months
The alveolar arches of an infant at the time of birth are called Gum
Pads.
These are greatly thickened oral mucous membrane of the gums,
which soon become segmented, and each segment is a developing
tooth site. They are pink in color and firm in consistency.
The pads get divided into a labio/buccal and a lingual portion which
differentiates later. Transverse grooves separate the gum pads into
10 segments. The groove between the canine and the first molar
region is called the lateral sulcus, which helps to judge the inter-
arch relationship.
Relationship of gum pads
• Anterior open bite is seen at rest with contact
only in the molar region. Tongue protrudes
anteriorly through this space. The intermaxillary
space closure, occurs with eruption of primary
teeth, thus it is a self-correcting anomaly of the
developing dentition.
• Complete overjet
• Class II pattern with the maxillary gum pad
being more prominent.
• Mandibular lateral sulci posterior to maxillary
lateral sulci.
• Mandibular functional movements are mainly
vertical and to a little extent anteroposterior.
Lateral movements are absent.
Neonatal Jaw Relationships
A precise “bite” or jaw relationship is not yet seen. Therefore, neonatal jaw
relationship cannot be used as a diagnostic criterion for reliable prediction of
subsequent occlusion in the primary dentition.
Occasionally a child is born with teeth already present in the mouth. Natal teeth are
present at birth whereas neonatal teeth erupt during the first month. Pre-erupted
teeth erupt during the second or third month. The incidence of natal and neonatal
teeth is estimated to be 1:1000 and 1:30000 respectively. These teeth are almost
always mandibular incisors, which frequently display enamel hypoplasia. There are
familial tendencies for such teeth. They should not be removed if normal but
removed if supernumerary or mobile.
• Extensive early transverse and ventral development of both jaws occurs
leading to an anteroposterior relation between the jaws.
• Overjet diminishes markedly during the first 6 months.
• Increase in jaw size provides enough space for harmonious arrangement of
deciduous teeth. Thus crowding seen in the pads disappears when the teeth
erupt.
• Eruption of deciduous teeth commences at about 6 months of age.
• Occlusion starts developing posteriorly when deciduous first molars attain
contact. By the time the first molars have settled, occlusion in the
posterior region is established.
DECIDUOUS DENTITION STAGE
The permanent dentition forms within the jaws soon after birth.
Calcification begins at birth with the calcification of the cusps of the first
permanent molar and extends as late as the 25th year of life.
Complete calcification of incisor crowns takes place by 4 to 5 years and of
the other permanent teeth by 6 to 8 years except for the third molars.
Therefore the total calcification period is about 10 years.
The permanent incisors develop lingual to the deciduous incisors and move
labially as they erupt. The premolars develop below the diverging roots of
the deciduous molars. At approximately 13 years of age all permanent
teeth except third molars are fully erupted. Before the deciduous incisors
are shed, there are 48 teeth / parts of teeth present in the jaws.
Features of the permanent dentition:
• Coinciding midline.
• Class I molar relationship of the
permanent first molar.
• Vertical overbite of about one-
third the clinical crown height of
the mandibular central incisors.
Overjet: Overjet and over bite
decreases throughout the second
decade of life due to greater
forward growth of the mandible.
Curve of Spee: Develops
during transition and stabilizes in
adulthood.
ERUPTION
Eruption
The developmental process that moves a tooth from its crypt position through the
alveolar process into the oral cavity and to occlusion with its antagonist.
Dental age 7
Eruption of maxillary central and mandibular lateral incisor.
Root formation of maxillary lateral incisor well advanced.
Crown completion of canines and premolars.
Dental age 8
Eruption of maxillary lateral incisor.
Delay of 2-3 years before any further teeth erupt.
Dental age 9
One-third root formation of mandibular canine and first premolar is complete.
Root development of mandibular second premolar begins.
Dental age 10
One-half root formation of mandibular canine and first premolar is complete.
Significant root development of maxillary and mandibular second premolar as well as maxillary
canine.
Root completion of mandibular incisors and near completion of maxillary laterals.
According to Moyers, mandibular canine erupts between 9 and 10 years.
Dental age 11
Eruption of mandibular canine (according to Proffit), mandibular first premolar and maxillary
first premolar.
Maxillary first premolar erupts ahead of canine and second premolar.
Dental age 12
Remaining succedaneous teeth erupt.
Second permanent molars nearing eruption
Early beginnings of third molar
Dental age 13, 14, 15
Completion of roots of permanent teeth
Third molars apparent on the radiograph