Shilpa Shirlal

Contents
► Introduction
► definitions.
► Factors affecting physical growth
► Concepts of growth
► Theories of growth
► Growth and development of maxilla
1.prenatal
-pre embryonic
-embryonic
- post embryonic
2.Post natal
► Paranasal sinuses
► Anamolies of maxilla
► prosthodontic considerations
► Summary and conclusion
► References
DEFINITIONS OF GROWTH

► Krogman : Increase in the size, change in proportion

and progressive complexity.

► Todd : An increase in size.

► In general : Growth is increase in spatial dimensions in

weight; it may be multiplicative (increase in size of cells)
or accretionary (increase in the amount of non-living
structural matter) or auxetic / intersuceptive (increase in
the size of cells).
DEFINITIONS OF DEVELOPMENT

► Todd: Development is progress towards maturity.

► Moyers : Development refers to all the naturally

occurring unidirectional changes in the life of an
individual from its existence as a single cell to its
elaboration as a multifunctional unit terminating in
death. Thus, it encompasses the normal sequential
events between fertilization and death.
 FACTORS AFFECTING PHYSICAL GROWTH

► Heredity
► Nutrition
► Illness
► Race
► Socioeconomic factor
► Climatic and seasonal effects
► Psychological disturbances
► Exercise
 SOME CONCEPTS OF GROWTH

► Concept of normality
► Growth spurts
► Differential growth
Scammon’s growth curve
Cephalo-caudal gradient of growth
The following are the timings of growth spurts:
1. Just before birth
2. 1 year after birth
3. Mixed dentition growth spurt
Boys: 8-11 years
Girls: 7-9 years
4. Pre pubertal growth spurts
Boys: 14-16 years
Girls: 11-13 years
Differential growth

1.Scammon’s curve of growth

 2.Cephalo-caudal gradient of growth

It simply means that there is an axis of increased growth

extending from head towards feet.
A comparision of the body proportion between pre-natal and
post natal life reveals that growth of regions of the body
away from the hypophysis is more.
 Theories of Growth and Development:

1.Genetic Theory- By Raye Stewart- the theory states

that all growth is controlled by genetic influence and is
preplanned.
2.Sutural Dominance Theory – By Weinmann and
Sicher in 1955: the theory supports the fact that
genetic control is expressed directly at the level of bone.
Particularly the sutures between the membranous bones
especially of cranium and jaws were considered as
growth centers, along with the sites of Endochondral
ossification in the cranial base and mandibular condyle.
3.Cartilage Dominance Theory – By James scott, 1953–
according to the theory the genetic control is expressed
at cartilage. Scott said that the cartilaginous sites
through out the skull are primary growth centers.
-   The nasal septal cartilage is the pacemaker for growth
of the entire nasomaxillary complex.

4.Functional Matrix Theory – By Melvin Moss, 1960

-He theorizes that growth of the face occurs as a result of
functional needs and is mediated by the soft tissues in which
the jaws are embedded.
-He also states that the major determinant of growth of
maxilla and mandible is the enlargement of the nasal and oral
cavities, which grow in response to functional needs.
-Growth of cranium occurs almost entirely in response to
growth of the brain.
5. Van Limborgh’s Theory, 1970
Limborgh explains the process of growth and development in
the view that combines all the major theories.
- He supports the Moss’s functional Matrix theory
- Acknowledges certain concepts of Sicher’s theory
- Never did he rule out the genetic theory.

6.Enlow’s expanding “v” principle

-Many facial bones or parts of bone have a “v” shaped growth
-The growth movements and the enlargement ---towards the
wide end of the “V”
-Bone deposition occurs on the inner side of the “v” and bone
resorption on the outer surface.
► Growth and Development of Maxilla

Will be considered in 2 periods:

1. Prenatal period (intra uterine).

a.Preembryonic (0-2nd week).
b.Embryonic ( 3rd to 8t week).
c.Foetal ( 9th week til birth).

2. Post natal period (extra uterine).

Pre embryonic period
(1st week)

Male Female
gametes gametes

Zygote

Morula(3 days)

Blastula
6th day 7th day
 2nd week

9th day
10th day 12th day

14th day 14th day

 3rd week
Formation of primitive streak
Formation of notochord
neurulation

► Process of formation of neural

plate ,neural folds and closure
of folds to form neural tube.
► As the notochord develops the
ectoderm over it thickens to
form neural plate.
► The neural plate precisely
corresponds to the length of
notochord initially but eventually
it extends beyond notochord .
► The neural plate invaginates
along its central axis to form a
neural groove that has neural
folds on either side of it .
► At the end of 3rd week , the
neural folds begun to move
together and fuse converting
neural plate into neural tube.
THE NEURAL CREST CELLS
They give rise to
Sensory ganglia
Schwann cells
Pigment cells
Odontoblasts
Meninges
Cartilage cells of branchial arches
They have a possible important function in
the formation of face.
 4th week
Folding of the embryo
1. Median plane

Head fold
Neural folds in the cranial region
thickens to form the primordium of
the brain.

The developing fore brain grows

cranially beyond the oropharyngeal
Membrane &overhangs-------

During folding , part of yolk sac is

incorporated into the embryo as
the foregut.
Oropharyngeal membrane separates
the --------
Tail fold

► Results from growth of the

distal part of the neural tube.

► Tail region project over the

cloacal membrane.

► Part of yolk sac is incorporated

into the embryo as hind gut.
 2.Horizontal plane
► Folding of the sides of the
embryo produces right and left
lateral folds

► Forms a roughly cylindrical

embryo.

► As the abdominal walls form

part of the yolk sac is
incorporated into the embryo as
the midgut .
 DEVELOPMENT OF BRANCHIAL ARCHES

• During the 4th week of i.u. the

mesoderm of foregut region becomes
segmented to form a series of distinct
bilateral mesenchymal swellings the
branchial arches.
 Branchial arches

Cartilage component :
Adapt to form Bony, Cartilagenous or Ligamentous structures

Muscle component :
Give rise to special visceral muscles
composed of straited muscle fibers.

Vascular component :
Provides necessary blood supply

Nerve component
•Enter mesoderm of branchial arches
• Initiate muscle development in the
mesoderm
 Pharyngeal pouches and branchial grooves

► Primitive pharynx project a series of pouches internally

between the branchial arches called pharyngeal pouches.
► Intervening between the branchial arches externally are
branchial grooves
► First branchial groove deepens to form the external
acoustic meatus and the membrane in the depth of groove
forms the tympanic membrane.
► 3rd and 4th branchial groove may form cervical sinus.
► Failure to obliterate completely these grooves may result in
branchial fistula or sinus.
1st pharyngeal pouch
► Ventral portion obliterated by the developing tongue.
► Dorsal portion deepens as tubotympanic recess to form auditory tube.

2nd pharyngeal pouch

► Forms tonsillar fossa and palatine tonsil.

3rd pharyngeal pouch

► Forms thymus and inferior parathyroid gland.

4th pharyngeal pouch

► Forms superior parathyroid gland.
► Forms the ultimobrachial body

5th pharyngeal pouch

► When it develops ,this rudimentary structure
becomes part of the 4th pharyngeal pouch
 DEVELOPMENT OF MAXILLA

► After formation of the head fold,

the developing brain and the
pericardium form two prominent
bulgings on the ventral aspect of
the embryo.

► These bulgings are separated by

the stomodeum. The floor of the
stomodeum is formed by the
buccopharyngeal membrane which
separates it from the foregut.

► Soon mesoderm covering the

developing forebrain proliferates
and forms a downward projection
that overlaps the upper part of
stomodeum called Frontonasal
process.
► The pharyngeal arches are laid
down in the lateral and ventral
walls of the cranial most part of
the foregut.

► At this stage the

mandibular arch forms the
lateral wall of stomatodeum.
This gives off a bud from the
dorsal end – maxillary process.

► Maxillary process grows

ventromedially cranial to the
main part of the arch which is
now called mandibular process.
► By the end of 4th week the ectoderm overlying the frontonasal process
soon show bilateral localized thickenings, situated a little above the
stomatodeum called as Nasal Placodes  soon sink below the surface
 nasal pits.

Each maxillary process now grows

medially and fuses first with LNP and
then with MNP. The MNP and LNP also
fuse with each other.

The maxillary process undergoes

considerable growth; along with it the
frontonasal process becomes much
narrower from side to side, so that
two internal nares come close to each
other
face1.avi.lnk
 INTERMAXILLARY SEGMENT

► As a result of the medial growth of the maxillary swellings, the two

medial nasal swellings merge not only at the surface but also at the
deeper level. The structures formed by the two merged swellings are
together known as intermaxillary segment.

► It is comprised of:
 labial component : forms the philtrum of upper lip.
 Upper jaw component : Which carries 4 incisor teeth.
 Palatal component : Which form the triangular primary palate.
 SECONDARY PALATE

► While the primary palate is derived from intermaxillary segment, the

main part of definitive palate is formed by fusion of 2 shelf like
outgrowths from the maxillary swellings at 6th week i.u life.
► They attain horizontal position at 7 week and fuse around 3th month
of gestation.
► This part of the palate is a direct extension of the maxilla from which it
develops.
 PERIOD OF FOETUS
► The beginning from 8th week until birth.
► Identified by the 1st appearance of ossification centre and
earliest movement by foetus.
► There is little new tissue differentiation or organogenesis
but there is rapid growth and expansion of the basic
structures already developed.
 Post natal growth and development of maxilla

► The postnatal growth of nasomaxillary complex is

► produced by the following mechanisms:

1. Growth at sutures
2. Surface remodelling
3. Displacement
 GROWTH AT SUTURES

1. Fronto-nasal suture
2. Fronto-maxillary suture
3. Zygomatico-temporal suture
4. Zygomatico-maxillary suture
5. Pterygo-palatine suture
PRIMARY DISPLACEMENT OF MAXILLA
SECONDARY DISPLACEMENT OF MAXILLA
SURFACE REMODELLING:

NASAL AND ORBITAL GROWTH

GROWTH OF PALATE EXHIBITING V PATTERN
 VERTICAL DRIFT OF TEETH

Bone remodeling of the palate resulting in its

downward displacement
CHEEK BONE AND ZYGOMATIC BONE
 OSSIFICATION OF MAXILLA

►The maxillary ossification centre lies above the

developing deciduous canine tooth germ and
appears in the sixth week of development.

► The palatine centres are situated in the region

forming the future perpendicular plate and appear
in the 8th week of development.

► The hard palate ossifies intramembranously from 4

centres of ossification,one in each developing
maxilla and one in each developing palatine bone.
 PARANASAL SINUS

Paranasal sinuses are bilaterally located intraosseous chambers that

are identified by the names of the bones in which they are
located. Hence they are known as:

1. Maxillary (ANTRUM OF HIGHMORE)

2. Ethmoidal.
3. Frontal.
4. Sphenoidal.
The maxillary sinus is the 1st sinus to develop around 3rd month of
intrauterine life.They develop as the outpouchings of the
sphenoethmoidal recesses and the mucous membranes of the middle
and superior nasal meatus.
 Paranasal sinus

Primary Secondary
Pnematization Pnematization

The early paranasal The sinuses enlarge into

sinus expand into the the bone from their initial
cartilage walls and small outpocketings always
roof of the nasal fossa retaining communication
by growth of mucous with the nasal fossa through
membrane sacs into ostia.
the maxillary
sphenoidal, frontal
and ethmoid bone.
Maxillary sinus: Develops at 10weeks.
Sphenoidal sinus. At 4 months i.u.
Ethmoidal sinus. At 4 months i.u.
Frontal sinus. 3 to 4 months.
 Maxillary sinuses are cavities
within the maxilla.largest
paranasal sinus.pyramidal in
shape.
.contains air and occasionally
mucous during sinusitis.

Size of maxillary sinus:

Anteroposterio Superioinferiorl
  Mediolaterally
rly y
Perinatal
7-16mm 2-13mm 1-7mm
period
1 year 15mm 6mm 5.5mm

15 years 31.5mm 19mm 19.5mm

Adult 34mm 33mm 23mm

 Function of Paranasal Sinuses

1. Humidifying and warming inspired air

2. Regulation of intranasal pressure
3. Increasing surface area for olfaction
4. Lightening the skull
5. Resonance
6. Absorbing shock
7. Contribute to facial growth

Microscopic features :
Lined by respiratory mucous secreting pseudostratified
ciliated columnar epithelium. Also known as schneiderian
membrane.
 Anomalies of Maxilla
1.Agnathia:
commonly a portion of the jaw is missing. Maxillary process or even
premaxilla…….

2.Micrognathia:
Small jaw….. Frequently due to deficiency of premaxillary area.

3.Macrognathia:
Abnormaly large jaws… increase in the size of maxilla… Conditions like

a)paget’s disease of bone- maxilla exhibits progressive enlargement –

spacing between the teeth. Edentulous patients with dentures
commonly complains of inability to wear dentures because of increasing
tightness.
 b) Fibrous dysplasia of bone:
2 types mono and polyostotic. Monoostotic is of greater concern to
dentist because…….leontias ossea –cases in which the fibrous
dysplasia affect the maxilla and facial bones to give the patient a
leonine appearance.

4.Torus Palatinus –It is a slow growing,flat based bony protuberance or

excrescence which occurs in midline of hard palate.

5.Epstein Pearls- These are found along the median raphe of hard
palate and appeared to be derived from entrapped epithelial
remnants along the line of fusion.

6.Dental Lamina Cyst: Epithelial remnants of dental lamina that develop on

the crest of alveolar ridge.
7.Down syndrome- It is a disease associated With subnormal mentality.It is
characterized by a flat Face,a large anterior fontanel,open sutures,open
Mouth,frequent prognathism,macroglossia,High arch palate,enamel
hypoplasia,microdontia.

8.Treachers Collins Syndrome –It involves hypoplasia of malar bones and

mandible,macrostomia,high palate,malocclusion of teeth,bird like or fish
like facies,grossly underdeveloped paranasal sinus.

10.Cleidocranial Dysplasia- It is characterized by abnormalities of skull,teeth

and jaws .It is characterized by open fontanel,flat skull and sunken
sagital suture,prominent frontal, parietal and occipitalbones,underdeveloped
paranasal sinus,high narrow arched palate under developed maxilla
,supernumerary teeth& partial anodontia.
 11.Achondroplasia- It is a disturbance of endochordal bone formation which
results in a characterstic form of dwarfism.It is characterized by
brachycephalic skull and bowed legs,limited motion of joints,retruded
maxilla,relative mandibular prognathism.

12.Craniofacial Dysostosis- Its facial manifestations are maxillary hypoplasia

with mandibular prognathism,high arched palate,patients nose resembling
parrot’s beak.

13.Marfans Syndrome- Acrachnodactyly or spidery fingers, hyper

extensibility of joints, bifid uvula, high arched palate, cardiovascular
complications.
 Most common developmental anomaly is
cleft lip and cleft palate

Cleft lip Cleft palate

•Results from abnormal •Results from a failure

development of of fusion of two
the medial nasal process
palatine process.
and maxillary process.
 CLASSIFICATION OF CLEFT LIP & PALATE

1.KERNAHANS AND STARK:

1. Block 1&4 – lip

2. Block 2&5 – alveolus
3. Block 3&6 – Hard palate
anterior to the incisive
foramen
4. Block 7&8- Hard palate
posterior to incisive
foramen
5. Block 9- soft palate
2.Veau (1931)
Group I - Cleft of the soft palate only.
Group II – Cleft of hard and soft palate.
Group III – Complete unilateral cleft extending from uvula to incisive
foramen and then deviates to one side extending through the alveolus
Group IV – Complete bilateral alveolar cleft.
 Classification of Cleft lip
I. Central
 Failure of fusion of two median nasal process.

II. Lateral
- Failure of fusion of maxillary process with medial nasal
process.
III. Complete / incomplete
Complete – Cleft lip extends to the floor of the nose.
Incomplete – Cleft does not extend upto the nostril.
IV. Simple or compound:
Simple : Cleft lip not involving alveolus.
Compound : Involving alveolus.
 Problems associated with cleft palate

1. Interferes with swallowing.

2. Unable to make consonant sounds.
3. Upper lateral incisors, missing or absent.
4. Oral organism contaminate the upper respiratory tract
mucous membrane.
5. Hearing impairment.

Incidence:
Cleft lip - 1:1000
Cleft palate – 1: 2500
 Cleft lip and cleft palate repair
Cleft lip:
► Timing: Rule of TEN
Hb: >10gm%
Age : 10 weeks
Weight : >10lbs
TC: <10,000/mm3

►Expert, careful reconstructive surgery can have far-

reaching benefits for a cleft child’s appearance, speech
development, improvement of hearing, facial growth,
and psycho-sociological adjustment.
Cleft lip alone:
Unilateral - 5-6 months
Bilateral - 5-6 months

Cleft palate alone:

Soft palate alone – 5-6 months
Soft and hard palate – Two operations
Soft palate – 6 months
Hard palate – 12-15 months

Cleft lip + Cleft palate:

Unilateral and Bilateral
2 stages of operation
1st stage : Cleft lip + soft palate – 5-6 months
2nd stage : Hard palate + gum pad + lip recision – 12-15 months
 PROSTHODONTIC CONSIDERATIONS

CLEFT PALATE:
-Feeding plate
i -obturator

•Improvement in esthetics,
speech,
mastication.

Goals of cleft palate rehabilitation as fallows

“ A physical defect such as cleft palate does
Not necessarily constitute a social handicap.
Although the defect will be present always ,
the pt must learn to accept the things which
cannot be changed, must be encouraged to
Change the things that can be changed and
Must be taught to know the difference”
Dr Herbert Cooper
► Soft palate defect: Patient has a defect in the upper palate due to surgery to remove a
mucoepidermoid cancer.

Artificial velum

Large soft palate defect: The patient had a large portion of the soft palate
removed.
► hard palate defect: Tissue side of the obturator prosthesis. The
large bulb will fit into the hard palate defect of the maxilla restoring
the patient’s ability to speak and eat.

Torus palatinus:
large----surgery
Small----relief in denture
To improve the maxillofacial surgery outcome modern
manufacturing methods such as rapid prototyping (RP) technology
and methods based on reverse engineering (RE) and medical
imaging data are applicable to the manufacture of custom-made
maxillary prostheses. After acquisition of data, an individual
computer-based 3D model of the bony defect is generated. These
data are transferred into RE software to create the prosthesis using
a computer-aided design (CAD) model, which is directed into the RP
machine for the production of the physical model. The precise fit of
the prosthesis is evaluated using the prosthesis and skull models.
The prosthesis is then directly used in investment casting such as
“Quick Cast”pattern to produce the titanium model.
 conclusion
► The maxillary skeleton serves as the functional and esthetic keystones
of the midface.

Defects in the palatomaxillary complex can lead to devastating

functional and cosmetic consequences
 References
1.orthodontics—principles and practice
- T M Graber (3rd edition)

2. The developing human

-K L Moore, T V N Persaud (5th edition)

3.Contemporary orthodontics
- William R Profit ( 4th edition)

4.Orthodontics
- S I Balaji (3rd edition)

5. Individually prefabricated prosthesis for maxilla

reconstruction
- Journal of Prosthodontics (2007) 1–6
6.Essentials of facial growth-
- D H Enlow, M G Hans(1996).

7.Oral and maxillofacial pathology

- Neville, Damm, Allen, Bouquot(2nd edition)

8. Craniofacial development
- G H Sperber(2001)

9.Oral histology
-A R Tencate(5th edition)

10.Maxillofacial prosthesis
- A R Rahn, L J Boucher

11.Net references