Development and growth of

Maxilla
By Monika.N
CONTENTS

1.Growth and Development

2.Prenatal growth
4. Postnatal growth of maxilla
3.Ossification of maxilla
4.Developmental defects of maxilla
5.Prosthodontic considerations of growth defects of maxilla
6. References
GROWTH AND DEVELOPMENT
• According to TODD- Growth is an increase in size and development is
progress towards maturity.

Growth and development of the maxilla

can be divided into two phases:
Pre – natal growth
Post – natal growth
Prenatal Growth of Maxilla
• During the 4th week of intrauterine life, a prominent bulge appears on
the ventral aspect of embryo corresponding to developing brain.
• Below this bulge a shallow depression which corresponds to the
primitive mouth appears called stomodeum.
Soon, mesoderm covering the developing forebrain proliferates , forms
a downward projection that overlaps the upper part of the stomodeum
This downward projection is called the Frontonasal Process
The branchial arches

• Around the same time, the 5 branchial arches are formed in

the region of the future head and neck.
• Each of these arches give rise to muscles, connective tissue,
vasculature, skeletal components and nueral components of
the future face.
• The first branchial arch is called the mandibular arch and plays
a major role in the development of the naso-maxillary region.
 The development of the face happens mainly through these 5
processes;
• The Frontonasal process
• 2. two maxillary procceses
• 3. two mandibular processes
• Mandibular process gives off a bud from its dorsal end. This
bud is called the maxillary process.
• It grows ventro-medially cranial to the main part of the arch
which is now called the mandibular process.
• Thus, at this stage the primitive mouth or stomodeum is
overlapped from above by frontonasal process and on either
side by maxillary process, and below by the mandibular
process.
The ectoderm overlying the frontonasal process shows
bilateral localized thickening above the stomodeum and these
are called Nasal Placodes.
These placodes soon sink and form the nasal pits. These pits
are continuous with the stomodeum below.
The edges of each pit is raised above the surface.
Medial raised edge- medial nasal process
Lateral edge- lateral nasal process.
• Each maxillary process now grows medially and fuses, first with the
lateral nasal process, and then with the medial nasal process.
• The medial and lateral nasal process also fuse with each other .
• In this way the nasal pits ( now called ecternal nares) are cut off from
the stomotodeum.
• The line of fusion of maxillary process and medial nasal process
corresponds to the naso-lacrimal duct.
• Nasomedial process grows quickly pushing the frontal prominence,
then fuse with the maxillary process to form the intermaxillary
segment and complete the arch of upper jaw.
• the maxillary process on each side also fuses with the intermaxillary
segment and takes part in the formation of upper lip, palate and the
maxilla.
Development of Upper lip
• The stomodeum is now bounded above by the upper lip which is
derived as follows
• 1. the mesodermal basis of the lateral part of the lip is fored from the
maxillary process. The overlying skin is derived from ectoderm
covering the process.
• 2. the mesodermal basis of the median part of the lip ( called
philtrum) is formed from the frontonasal process.
• The ectoderm of the maxillary process, however, overgrows this
mesoderm to meet that of the opposite maxillary process in the
midline.
Development of palate
• From each maxillary process, a plate like shelf grows
medially.
• This is called the Palatal Process.
• There are three components from which the palate will be
formed:
-the two palatal process
-the primitive palate formed by the frontonasal process.
The definitive palate is formed by the fusion of these three
parts.
Primitive palate
• It is a triangular wedge shaped structure, and is formed by
the intermaxillary segment( derived from frontonasal
process).
• It forms the premaxillary part of maxilla.
• In the adult hard palate it is represented by a small part
which lies anterior to the incisive fossa and is associated with
the central four incisors.
Secondary Palate
• Secondary palate begins to develop in the 6th week from the
maxillary process.
during the 6th week, the lateral palatine process start
developing from the palatal process.
• Initial growth of lateral palatine process is directed obliquely
downward along the sides of developing tongue .
• This prevents the two processes to meet and fuse with each
other.
• In later growth the palatine processes are directed horizontally
and lead to formation of secondary palate by fusion with each
other.
• At the same time, the nasal septum also grows down and fuses
with the medial edges of the palatine processes in the ventral
3/4th area.
• This fusion of palatine process with each other and the down
growing nasal septum begins anteriorly and proceeds backward.
• It is completed by the 8th week of intrauterine life.
Definitive palate
• Definitive palate is thus formed by fusion of secondary palate with
primitive palate ventrally in a Y- shaped manner
• This junction is represented in adult by the incisive fossa.
• Definitive palate on further development consists of two parts:
• 1. the hard palate
• 2. the soft palate.
Ossification of maxilla
• Maxilla is pure intramembranous bone and there is no arch cartilage
existing in maxillary process.
• The maxilla proper develops from a single centre of ossification in
mesenchyme of maxillary process of 1st arch.
• This centre in the maxilla proper appears above the canine fossa during 6th
week.
• Around the 6th week of intrauterine life, the centre of ossification appears
at the termination of infraorbital nerve just above the canine tooth.
• The pre maxilla ossifies from two centres: 1.above the incive fossa
2. ventral margin of nasal septum.
• From these primary ossification centres , formation of bone spreads in
3 dimensios and 5 directions.
• At around the 8th week of intrauterine life, 3 secondary ossification
centres appear named – zygomatic, orbitonasal and nasopalatine.
• Out of these, zygomatic/ malar cartilage mainly contributes to the
zygomatic process development and also for a short time for the
development of maxilla.
Postnatal growth of Maxilla
• The growth of nasomaxillary process is produced by following
mechanisms:
• 1.Displacement
• 2.Growth at sutures
• 3. Surface remodelling
 Displacement
• Maxilla is attached to the cranial base by means of a number of
sutures. There is thus a strong influence of the latter on the former.
• Displacement can be further divided into two types:
-primary displacement
- secondary displacement
Primary
displacement
-A primary type of
displacement is seen when
maxilla grows on its own. This
growth is seen in the forward
direction.
-Enlargement of the bone due
to sinus formation also
displaces the maxilla forwards
-The active displacement of
maxilla is an important
mechanism of growth in later
years of life (6-18 yrs)
Secondary displacement
• Secondary or passive
displacement of maxilla occurs
due to growth of middle cranial
fossa.
• The nasomaxillary complex simply
translates anteriorly as middle
cranial fossa grows in that
direction
• Passive displacement is an
important mechanism during early
years of life(2-6 yrs)
Growth at sutures
• The maxilla is connected to the
cranium and cranial base by a
number of sutures. These include:
• FRONTO-NASAL SUTURE
• FRONTO-MAXILLARY SUTURE
• PTERYGO-PALATINE SUTURE
• ZYGOMATICO-TEMPORAL SUTURE
• Growth at these sutures allows the
downwards and forwards
repositioning of the maxilla.
Surface remodelling
• Massive remodelling by bone
deposition and resorption occurs
to bring about:
• 1 increses in size
• 2 change in shape of bone
• 3 change in functional relationship
• Selective resorption and
deposition takes place in the
maxilla to attain its typical shape.
Developmental defects of maxilla
A number of congenital developmental defects are seen in the maxilla.
These defects can affect the growth and functional capability of the
maxilla .
The conginetal defects are those present since birth. Congenital defects
can occur due to reasons such as the mother during pregnancy is
practising pernicious habits like smoking, alcoholism and drug abuse.
Or it can also be cause due to some obstruction during the
developmental phase of the fetus which hampers the normal
development of tissues.
Facial cleft
• A rare anomaly, which occurs due to failure of fusion of maxillary
process with the lateral nasal process.
• The nasolacrimal duct is exposed to the exterior.
• Also there is cleft lip on the associated side.
Macrostomia
• Large sized oral fissure may occur due to unilateral or bilateral failure
of fusion of maxillary process and the mandibular process.
• It can be associated with Ablephoral-macrostomia syndrome(AMS)
which is a rare genetic disorder characterised by absent or
underdeveloped eyelids( ablepheron), and a wide
mouth( macrostomis).
• AMS is caused by changes in the gene called
• TWIST2.
Microstomia
• A small sized oral fissure occurs due to excessive fusion between the
maxillary process and the mandibular arches.
• Microstomis can be seen sometimes
• In association with syndromes such as
• Freeman Sheldon syndrome
• Fine –lubinsky syndrome
Mandibulofacial dysostosis
• Also known as first arch syndrome.
• It occurs due to underdevelopment of first pharyngeal arch and is
characterised by maldevelopment of lower eyelid,maxilla, mandible,
cheeks and external ear.
• It is often seen associated with Treacher
Collins syndrome.
Cleft lip and palate

• CLASSIFICATION
• Acording to location and severity:
• UNILATERAL
• BILATERAL
• COMPLETE
• INCOMPLETE
NAGPUR CLASSIFICATION
• GROUP 1: CLEFT LIP ONLY
• GROUP 1 a: CLEFT LIP AND ALVEOLUS
• GROUP 2: CLEFT PALATE ONLY
• GROUP 3: CLEFT LIP+ ALVEOLUS+ PALATE
KERNAHAN AND STARK
CLASSIFICATION
• GIVEN BY KERNAHEN AND STARK IN 1958
• It describes all common types of cleft lip, palate with the incisive
foramen as the reference.
• The most severe and extensive form of the cleft lip and palate i.e
bilateral total cleft can be represented as a Y.
• Anterior to the foramen can be divided into 3 –the most ant.
representing the lip,the middle representing the alveolus,the
posterior representing the hard palate.
Elsahy modification of kernahan and stark
clssification
• Given in 1971.
• Triangles 1 and 5-represent the lip
• Square 2,6,3 ,7 ,4 and 8 represent
the alveolus.
• Square 9 and 10-indicate hard
palate
• Square 11- represents soft palate.
• The circle 12 represents
valopharyngeal closure.
• Circle 13- premaxilla.
Obturator
• Obturator is a prosthesis that is used to close a congenital or acquired tissue
opening primarily of the hard palate or contiguous alveolar/soft tissue
structures-GPT
• Obturators serve fuctions such as
• 1.closing the defect
• 2.help feeding
• 3. keeping wound/defect area clean
• 4.fuction as a stent to hold the dressing
• 5.reduce possibility of post operative heammorhage
• 6. help reshape and reconstruct the palatal contour and/or soft palate
• 7. improve speech or make speech possible.
• 8. improve esthetics
Feeding obturator
• A child born with cleft lip and palate may face difficulties while
feeding.
• Nasal regurgitation and choking are common in infants with cleft lip
and palate .
• There is also an inability to create negative pressure inside oral cavity.
• A feeding appliance is a necessity in such cases. A feeding appliance is
a device that creates a seal between the oral and nasal cavities and
helps the infant express milk.
Nasoalveolar Molding in Early Management of Cleft Lip and Palate

• While advances in reconstructive surgery have significantly

improved the quality of repair for clefts of the lip, alveolus, and
palate, surgery alone cannot correct all aspects of the cleft detect.
A new approach of presurgical nasoalveolar molding (PNAM)
therapy developed at the Institute of Reconstructive Plastic Surgery
at New York University Medical Center.
• PNAM includes not only the reduction of the size of the intraoral
alveolar cleft through the molding of the bony segments, but also
the active molding and positioning of the surrounding soft tissues
affected.
• Following evaluation and after a thorough explanation of the
procedure and treatment goals to the parents, an impression
of the intraoral cleft defect is taken.
• The impression is obtained with the infant fully awake and
without any anesthesia. The infant is held face down to
prevent the possible aspiration of regurgitated stomach
contents made using an elastomeric material
• The head is gently held in a slightly upright position during
the impression procedure. A properly sized and fitted infant
acrylic tray is used in delivering the impression material
• The infant should be able to cry during the impression-making
procedure. If no crying is heard, the airway is blocked.
• A finger motion should be used to clear any impression material
posterior to the tray and to prevent the infant from closing down on
the tray, which also will compromise the airway.

• A properly sized and fitted infant acrylic tray is used in delivering the
impression material.
• Care is taken to ensure that the material has registered the border
regions of the maxilla and premaxilla as well as the cleft region.
• An acceptable impression is then carefully poured in modified dental
stone
A second cast is poured and recovered. One cast will serve as the
working cast upon which the intraoral molding plate will be fabricated
while the second cast will become part of the patient’s permanent
record.
The cleft region of the palate and alveolus may be filled in with wax to
approximate the contour and topography of an intact arch prior to the
fabrication of the oral portion of the molding appliance.
• The remainder of the oral molding plate is fabricated from clear
methyl methacrylate orthodontic resin (LD Caulk/Dcntsply) using one
of many acceptable techniques.
• Ideally, the oral molding should be waxed from two layers of
baseplate wax and then packed and lab processed
At the delivery appointment, the oral molding appliance is carefully
fitted in the infant’s oral cavity. Initial attention is given to the retention
of the appliance.
The infant must be able to easily suckle without gagging or
struggling.
The tissue surface of the appliance is also modified at the
initial insertion appointment to begin the molding of the
greater and lesser alveolar segments on either side of the
cleft.
This is achieved through the selective removal of acrylic from
the region into which one desires the alveolar bone to move
At the same time, Permasoft is added to line the appliance to
a thickness of approximately 1 to 1.5 mm.
The usual movement is to direct the greater segment inward
toward the cleft by
1.adding Permasoft to the inner surface of the labial aspect of
the alveolus portion of the appliance while
2.reducing the acrylic from the palatal aspect of the appliance.
The alteration of the lesser segment of the alveolus is the
converse of that applied to the greater segment.
To achieve this, the acrylic is selectively removed from the inner
labial aspect of the lesser segment of the alveolus
(approximately 1 to 1.5 mm) while adding an equal amount of
resilient soft liner on the palatal aspect of the alveolus in the
lesser segment.
Prosthodontic Management in Conjunction with Speech
Therapy in Cleft Lip and Palate: A Review and Case Report
M R Dhakshaini1 , M Pushpavathi2 , Mirna Garhnayak3 , Angurbala Dhal4

• Cleft lip and palate (CLP), a congenital disturbance needs a lot of attention
with respect to its rehabilitation as a person suffering from this defect can
lead a normal life given with the right type of treatment at the right time.
• However, if a patient cannot get surgical treatment at the appropriate
time either due to availability or economic constraints, it is still possible to
improve their social and psychological well-being with prosthodontic
rehabilitation.
• The available prosthodontic treatment options for improvement of
speech is discussed and highlighted the importance of prosthetic
management of such patients along with a speech therapist.
Indications for prosthesis
• Candidates can be selected based on failure/contradictions of surgery
to the cleft palate, general health of the individual and psychological
status including motivation of the individual
• In case of un-operated palates, a wide cleft with insufficient local
tissue available to accomplish a functional repair, which cannot be
closed by a vomer flap or other local tissue can be considered for
prosthesis
• Individuals with neuromuscular deficit of the soft palate and
pharynx, medical contra-indication to surgery or when a surgery is
delayed then the prosthesis can be used
Types of prosthesis
• Palatal obturator
• Palatal lift prosthesis
• Speech bulb obturator
Discussion
• Discussion Speech appliances are used to facilitate speech by
separating the nasopharynx from the oropharynx. However,
the device may be applied in several ways to achieve that
goal.
• It may be used as a permanent treatment for the individuals
with gross defects of closure, as a stimulus intended to
increase the movements of the pharyngeal walls and palate,
or as a temporary device to help in the evaluation of VP
closure adequacy.
 Dental and Prosthodontic Care for Patients With Cleft or
Craniofacial Conditions DAVID J. REISBERG, D.D.S.

• The American Cleft Palate–Craniofacial Association was founded in 1943.

The original name of the organization was The American Academy of Cleft
Prosthesis.
• It has been postulated that the first obturation of a cleft palate was by
Demosthenes (384–323 B.C.). Bien suggested that the great Greek orator
visited the seashore to search for appropriately sized pebbles adequate to
fill his palatal defect and thereby improve his speech.
• The prosthodontist remains an integral member of the cleft/ craniofacial
habilitation team. Prosthetic treatment requires cooperation with the
surgeon, orthodontist, pediatric/general dentist, speech and language
pathologist, and medical artist and dental laboratory technician.
Nasal conformer
• Surgical repair of a cleft lip can result in a
flattened contour of the nasal alar
cartilage.
• Aside from the cosmetic deformity this
presents, it can also contribute to nasal
airway obstruction.
• Often the patient must have a corrective
surgical procedure at a later age.
• Grayson et al. (1999) has described the
use of a nasal orthopedic molding
appliance to minimize or avoid this
problem.
• A resin palatal plate is made for the infant at 2 to 3 weeks of
age.
• A small projection of resin extends from the plate at the cleft
lip site up toward the alar cartilage.
• This projection is covered with a resilient denture-lining
material and makes contact with the cartilage to slightly
elevate it and mold it to proper contour.
• This conformer is retained with denture adhesive and is worn
continuously
Articulation development prosthesis
• Repair of a cleft palate is performed by 1 year of age in order to
minimize speech articulation abnormalities (Dorf and Curtin, 1982).
• However, in some cases surgical repair must be deferred.
• This may be due to an excessively wide cleft or a compromising
medical condition that precludes surgery at that time.
• Articulation development prosthesis is used to create a normal palate
for speech and development until surgical repair.
REFERENCES
• Human embryology, textbook by Inderbir Singh. 11th edition.
• Human embryology, textbook by B D Chaurasia . Second edition.
• Grays anatomy for students textbook by Drake, Vogl and Mitchell, second South Asian edition.
• Contemporary orthodontics by William R Proffit, 4th edition.
• Clinical maxillofacial prosthesis, textbook by Thomas D Taylor.
• Dental and Prosthodontic Care for Patients With Cleft or Craniofacial Conditions DAVID J.
REISBERG, D.D.S.
• Prosthodontic Management in Conjunction with Speech Therapy in Cleft Lip and Palate: A
Review and Case Report M R Dhakshaini1 , M Pushpavathi2 , Mirna Garhnayak3 , Angurbala
Dhal.
• Textbook of oral pathology by Shafer. South asia 8th edition.
• Maxillofacial defects and their classification; a review, by dr. akarshan dayal gupta.