GROWTH AND DEVELOPEMENT

CONTENTS

• DEFINITIONS
 GROWTH
 DEVELOPMENT
 DIFFERENTIATION
 TRANSLOCATION
• GENERAL PRINCIPLES OF GROWTH
• CEPHALOCAUDAL GRADIENT OF GROWTH
• SCAMMON’S CURVE OF GROWTH
• GROWTH SPURTS
• MECHANISM OF BONE FORMATION.
• PRINCIPLES OF SKELETAL GROWTH
• ENLOW’S COUNTERPART PRINCIPLE
• ENLOW’S EXPANDING ‘V’ PRINCIPLE
 growth
• Todd(1931): An increase in size

• Stewart(1982): Developmental increase in mass.

• Proffit(1986): Increase in size or number

• Moyer’s(1988): Normal changes in amount of living

substances.

• WHO(2001): Gradual increase in size, number or strength as

pertaining to an animal , human or vegetable body.
 Development
• Todd(1931): Development is progress towards maturity.

• Proffit(1986): Refers to increase in complexity.

• Moyer’s(1988): Refers to all unidirectional changes occurring

in the life of an individual from its existence as a single cell to
elaboration as a multifactorial unit terminating in death.
•
Differentiation
According to Moyers
• Differentiation :It is the change from generalized cell or
tissue to more specialized kind during development. It is
change in quality or kind.

•
 Translocation
• According to Moyers
• Translocation: It is change in position
 MATURATION
• According to Moyers,
• Qualitative changes which occur with ripening or aging.
 General Principles of growth
GROWTH
• Pattern
• Variability
• Timing
 Pattern

• PATTERN: (According to MOYERS) is defined as a set of

constraints operating to preserve the integration of parts under
varying condition or through time.

• PATTERN: (According to PROFITT) is defined as a change in

proportional relationship over time.
 Cephalocaudal gradient of growth

• In fetal life,
• At about third month of
intrauterine life head is almost 50%
of the total body length, at this
stage cranium is relatively larger to
the face.
• In contrast the limbs are still
rudimentary and the trunk is under
developed.
•At birth
• the head has decreased to about 30% of
the total body length and the limbs and
the trunk has increased in size.
• In Adult
• There is a progressive
• reduction of the relative
• size of the head to about
• 12% of the entire body.
• This means there is an axis of increased growth extending
from head towards feet.
• All these changes which are a part of the normal growth
pattern reflects the Cephalocaudal Gradient of Growth.
 Scammon’s curve of growth
• Richards Scammon(1930) reduces the growth curve of the
tissue of the body to four basic curves.

• The curve covers the post natal period of 20 years and

assumes that during that span of time, dimensions have been
100% of the value starting at the birth with zero.
•
• The four major tissue system of the body are :-
• Lymphoid Tissue
• Neural Tissue
• General Tissue
• Genital tissue
• Lymphoid curve-
• It includes the adenoids,
lymph nodes and interstitial
lymphatic masses.
• Lymphoid tissues proliferate
far beyond the adult amount
in late childhood and undergo
involution at the same time
that the growth of genital
tissue accelerates rapidly.
• Neural curve-
• It includes brain, spinal
cord.
• The curve rises strongly
during childhood at the age of
8 years; the brain is 95 % of
its adult size.
• General curve-
• General body tissue includes
muscle, bone and viscera.
• It shows an S shaped curve
and rises steadily from birth to
five years of age and then
reaches a plateau from 5 to 10
years, followed by another up
sweep during puberty and
finally slows down in adult.
• Genital curve-
• The curve has a small up
turn in the first year of life
and quiescent up to 10 years
and growth of the tissue
increases during the time of
puberty
 Variability

• Variability in physical growth can be expressed

quantitatively as the range of differences found in the
large population of the individuals of similar age,
sex, socio- economic background and race.
Variability

• Variation is expressed quantitatively in terms

of deviation from the usual pattern
• This can be evaluated by comparing a given
child with the peers on a standard growth
chart .
Variability

• These charts help the clinician to determine

whether the growth is normal or abnormal
by telling :
1. The location of the Individual relative to
the age group
2. Any unexpected change in the growth
pattern.
 Timing

• Variations in growth and development because

of timing are particularly evident in human
adolescence.
 TIMING
• Same event occurs for different individuals at different
times.
• Some children develop
and grow early and others slowly.

• Growth spurts are seen

more earlier in girls than boys.
 Growth spurts

• Acceleration in the incremental changes in a body part that occur at

certain age
• Following are the timings of growth curve:
 Just before birth.
 One year after birth.
 Mixed dentition growth spurts: boys 8-11 years
• girls 7-9 years
 Pre- pubertal growth spurts: boys 14-16 years
• girls 11-13 years
 IMPORTANCE OF GROWTH
SPURTS:
• Pubertal increments offers best time for large number of cases
for the orthodontic and orthopedic treatment.
• It also helps in determining the
predictability,
growth direction,
patient management and
total treatment time.
 Methods of Studying bone Growth

• Measuremental approaches

• Experimental approaches
 Measuremental approach
 Non destructive Technique for measuring growth in living animals
including man.
 The Species will be available for additional measurements at another
time.
Craniometry : Based on measurement of skulls
found among human skeletal remains.
• Advantage: Precise measurements can be made on dry
skulls.

• Disadvantage: Same individual can be measured at only one

point of time.
Anthropometric Study: On either a
dried skull or a living individual, but
results would be different because of the
soft tissue thickness overlying bony
landmarks.

Advantages: repeated measurements of

the same individual are possible.
Cephalometric radiology: BROADBENT in 1931, This
approach combines the advantages of craniometry and
anthropometry. It allows a direct measurement of bony
skeletal dimensions, but it also allows the same individual
to be followed over time.

Disadvantage –two dimensional representation of a three

dimensional structure.
 Experimental approach

 Detailed study may be destructive

 Largely restricted to non human beings

Experimental approaches:
1. Vital Staining:
John Hunter originated this method. In eighteenth
century, hunter observed that bones of Pigs that are
occasionally fed with textile waste were often stained
in an interesting way. He observed that active agent
was a dye called alizarin, still used for vital staining
studies.
These dyes react strongly at sites where bone
calcification is occurring. Since these are the sites
of active skeletal growth, the dye marks the
locations at which active growth is occurring.
Tetracycline was discovered too late in
1960’s as an excellent vital stain that
binds to calcium often resulting in
discoloration of tooth

Disadvantage- doesn’t provide

direct evidence of bone resorption.
Dyes used for vital staining
Alizarin Red 5
Alizarin dye
Tetracycline
Lead Acetate
Trypon Blue.

Lead acetate
Radio-Isotopes
Radioisotopes of certain elements or compounds often
are used as in vivo markers for studying bone
growth. Such labeled material is injected and after a
time , located within growing bone by means of
geiger counters or autoradiography techniques.
In Autoradiography a film emulsion is placed over this
section of tissue containing the isotope and then it is
exposed in dark by the radiation that indicates where
growth is occurring.

• Technitium 33
• Calcium 45
• Potassium 32
• 14C Proline
• 3H Thymidine
 Implant Radiography:
- This method of study was developed by professor Arne Bjork and
Coworkers at Royal Dental College in Copenhagen Denmark in
1969. This has provided important new information about growth
pattern of jaws.
• Bjork devised a method of implanting tiny bits of
tantalum or biologically inert alloys into growing bone
which served as radiographic reference markers for serial
cephalometric study.
Cephalometric reading taken periodically and
superimposition of radiographs provide precise changes in
position of bone and Jaw growths.
 Natural markers.
• The persistence of certain developmental
features has led to their use as natural
markers by means of serial radiography.
• Eg: trabeculae, nutrient canals and lines
of arrested growth can be used for
reference to study deposition, resorption
and remodeling.
• Certain natural markers are used as
cephalometric landmarks.
• Microradiography
-study of inorganic matrix and its density.

• Comparative anatomy
Growth of human beings compared with that of other species.

•Genetic studies
Using cephalometrics to study parent child relationships,
sibling’s similarities and twins.
• Split line technique
- By BENINGHOFF
- By partial decalcification of bones-> soft ->punctured by
needles->India ink-> study superficial trabecular bone pattern
- Holes assumed a linear pattern in direction of bony trabeculae-
> beninghoff’s lines-> indicate direction of functional stresses.

•Laminography
To evaluate position of condyle in relation to fossa.
• Photographic analysis
Measurement of distance between subnasion and soft tissue
prominence on chin on photographs.

•Study models
Model analysis can be done at regular intervals to
determine growth.

•Facial mask
Impressions of face at regular intervals taken and compared
• Silhouette method
- Patient is told to sit at a particular distance in a particular
position-> light projected-> shadow obtained on screen->
measurement at regular intervals.
•Hand wrist radiographs
- Specially indicated in children in whom
discrepancy between chronologic
and maturational age exists.

- Carpals and distal ends of radius and ulna are used in assessing
skeletal or bone age.
 MECHANISM OF BONE GROWTH

• Concept of remodeling, relocation & cortical

drift

• Concept of bone displacement

• Growth centres & growth sites

• Growth fields
 Remodeling
• Remodeling- Is defined
as the relative selective
bone apposition by
osteoblast and resorption
by osteoclast resulting
differential changes and
alteration in the size and
morphology of a given
bone.
FUNCTIONS OF REMODELLING

1. Progressively change the size of whole bone

2. Sequentially relocate each component of the
whole bone
3. Progressively change the shape of the bone to
accommodate its various functions
4. Progressive fine tune fitting of all the separate bones to
each other and to their contiguous ,growing,
functioning soft tissues

5. Carry out continuous structural adjustments to adapt to

the intrinsic and extrinsic changes in conditions .
 RELOCATION
Due to bone deposition on an existing surface all
other parts of the structure undergo shift in relative
position , a process termed relocation
Relocation and
remodeling of the
mandible
during growth
The remodeling process
of the ramus takes place
toward the posterior.
The body of the
mandible becomes
lengthened by
remodeling parts of the
ramus, which
simultaneously shifts in
backward direction
Basic types of growth movement:

• Cortical drift.

• Displacement
 Cortical drift

• A combination of bone deposition and

resorption resulting in a growth movement
towards the depositing surface is called cortical
drift .

• If resorption and deposition take place at the

same rate,the thickness of the bone remains
constant. Should more bone be deposited than
resorbed, the thickness of the structure
increases.
 Displacement

• In process of displacement, the whole bone is

carried by the mechanical force as it simultaneously
enlarges.
• It can be of two types:
Primary Displacement
Secondary displacement
• In Primary Displacement,
• the process of physical carrying takes place
in conjunction with the bone’s own enlargement.
The whole bone is displaced in the opposite
anterior and inferior direction and the amount of
primary displacement exactly equals the amount
of new bone deposition that takes place within
the articular contacts .
• In secondary displacement ,
• the movement of the bone and its soft tissue is not
directly related to its own enlargement e.g. the
anterior direction of growth by the middle cranial
fossa and the temporal lobes of the cerebrum
secondary displaces the entire naso maxillary
complex anteriorly and inferiorly.
 Donald Enlow’s counterpart principle

• Enlow states that the growth of any craniofacial

bone relates specifically to other structural and
geometric counterparts in the craniofacial region.
• As ‘force a’ carries the
mandible anteriorly and
inferiorly, the condyle
is triggered to respond
in response to mutual
developmental and
functional signals by an
equal amount of growth
at ‘b’
 Enlow’s expanding ‘v’ principle
• The most useful and basic concept in facial growth is the
V principle.
• Many facial and cranial bones, have a V-shaped
configuration (or a funnel-shaped in three dimensions ).
• The bone deposition occurs on the inner side of the of the
V, resorption takes place on the outside surface.
• The direction of movement is towards the wide end of
the V.
• Thus, a simultaneous growth movements and
enlargement proceeds by additions of bone on the inside
with removal from outside.
Examples,

• Neck of the condyle

• Palatal process of maxilla
• Ends of long bones.
 GROWTH
• FIELDS
All surfaces, inside and outside, of every bone are covered by an irregular
pattern of “growth fields” comprised of various soft tissues osteogenic
membrane or cartilages.

• Bone does not grow itself, it is grown by this environment of soft tissue
growth fields.

• The genetic program for bone growth is not contained within the hard bone
tissues. Rather, the determinants of bone growth reside in the bone’s
investing tissues-muscles, integuments, mucosa, blood vessels, nerves,
connective tissue, the brain.
Some growth fields have special role in growth of particular bones are
called GROWTH SITES.

These includes :
 mandibular condyle
 maxillary tuberosity
 synchondroses of the basicranium
 Sutures
 alveolar processes

These growth sites do not cause all of the growth in their bone, or
carry out even the most of the growth processes of a particular bone,
for all other inside and outside surfaces must actively participate as
well in the overall growth process.
• Some growth fields have been called “GROWTH
CENTRES”, a term which implies that a special area some
how controls the overall growth of the bone.

• The term “growth centre,” also implies that the “ force,” “

energy, “ or “motor” for a bone resides primarily within its
growth centre.

• The epiphyseal plate of long bones which continue their

growth against the large forces of gravity, muscle of
contraction, etc.
 CONCLUSIO
NS
A thorough knowledge of growth and
development of face and jaws is very
important for any dentist so as to have
a proper knowledge of the etiology of
various facial defects and to know how
to prevent
or intercept any malocclusion by
modifying the factors for growth at a
particular time so as to deliver
optimum oral health care and facial
harmony to the individual. As
childhood is the right time to modify
growth, all pediatric dentists should
have good knowledge of growth and
development of face and jaws.
REFERENCES:
• TenCate, A.R.: “Oral histology”. 3rd Ed.,
C.V. Mosby Co., St. Louis, 1989.
• Sperber, G.H.: “Craniofacial embryology”.
4th Ed., Wright, London, 1989: 147-159.
• Singh I.B. (2000): “Alimentary system – I
mouth, pharynx and related structures”. In
human embryology, Singh I.B., 6th Ed.:
156-159.
• Bhalajhi, S.I.: “Growth and development in
orthodontics. The art and science”. Bhalajhi
S.I. (ed), 2nd ed, 2000: 7-44.
THANK
YOU
Theories of Growth and Development
• It is a truism that growth is strongly influenced by genetic factors, but it can
also be significantly affected by the environment in the form of nutritional
status, degree of physical activity, health or illness, and a number of similar
factors.
• Great strides have been made in recent years in improving the knowledge
of growth control.
• Genetic theory
• Sutural dominance theory
• Cartilaginous theory
• Functional matrix theory
• Von Limborgh’s theory
• Petrovic cybernetic theory
 Genetic theory
• Genetic control theory was given by Brodie in 1941.
• It is one of the oldest theory.
• Genetic control theory stipulates that the genotype supplies all
information required for phenotypic expression.
• However, although the role of genes is widely acknowledged,
disagreement exists concerning whether general, regional, and
local factors modify the gene expression and the way in which
such modification occurs.
• According to Nakasima, Motosi, Takahama (1982 )
• There appears to be a strong familial tendency in the
development of class II and class III malocclussion.
• They showed that there was correlation between parents and
their offspring in the Class II and Class III groups
• The skeletal pattern was thus more directly related to genetic
factor.
Sutural theory
• It was given by sicher (1955).
• Also known as sicher’s sutural dominance theory / sicher’s
hypothesis
• He believed that cranio-facial growth occurs at the sutures.
• He said that “ the primary event in sutural growth is the
proliferation of the connective tissue between the two bone”.
• According to him paired parallel
sutures that attach facial areas to
the skull and the cranial base
region push the naso-maxillary
complex forwards to pace its
growth with that of the
mandible.
•If this theory was correct, growth at the sutures should occur
largely independent of the environment and it would not be possible
to change the expression of growth at the sutures.

•Thus it is clear that sutures and the periosteal tissues are not
primary determinants of craniofacial growth.
Two lines of evidence lead to this
conclusion:
•First,
• When an area of suture between two facial bones is
transplanted to another location,(to a pouch of abdomen),
the tissue does not continue to grow. This indicates a lack
of innate growth potential of sutures.
Second,
•Growth at sutures will respond to outside influences under a
number of circumstances.
•If cranial or facial bones are pulled apart at the sutures, new
bone will fill in, and the bones will become larger than they
would have been otherwise.
•If a suture is compressed, growth at that site will be impeded.
•Thus sutures must be considered areas that react- not primary
determinants.
• In 1880, kingsley described an appliance that could influence
the position of the dentition in the jaw with the aid of extra oral
forces.
• Klohen drew renewed attention to the use of extraoral traction.
• These studies showed that by applying mechanical forces, not
only the position of the dentition could be changed, but more
over that the growth of the entire maxillary complex could be
modified by influencing sutural growth.
 CARTILAGENOUS THEORY (James Scott-1956)
According to this theory the genetic control is expressed at cartilage.
Sutural growth is passive and secondary to cartilaginous growth .
Also known as scott’s hypothesis / nasal septal theory
According to Scott:-
-Spheno-occipital synchondrosis cartilage -Responsible for the growth of
cranial base.
-Nasal septal cartilage – Responsible for the growth of nasomaxillary
complex.
-Condylar cartilage – Responsible for the growth of mandible.
Synchondrosis of the cranial base

1. Spheno ethmoidal

2. Inter-sphenoidal

3. Spheno-occipital

Synchondrosis: A synchondrosis is a cartilaginous joint where hyaline cartilage

divides and is subsequently converted into bone. (Bishara)
• If cartilagenous growth were the primary influence, the
cartilage at the condyle of the mandible could be considered as
a pacemaker for growth of that bone and remodelling of ramus
and other surface changes as secondary to the primary
cartilagenous growth.
• Mandible is like the
diaphysis of a long
bone, bent into a
horse shoe with the
epiphysis removed, so
that there is cartilage
representing “half an
epiphyseal plate” at
the ends, which
represent the
mandibular condyles.
• Growth of maxilla is
difficult but not impossible
to explain on the cartilage
theory basis.

• Although there is no
cartilage in the maxilla itself
but cartilage is present in the
nasal septum
Cartilaginous theory hypothesize that cartilaginous nasal
septum serves as pacemaker for maxillary growth.

Cartilage is located so that its growth could easily lead to a

downward and forward translation of the maxilla.

If the sutures of the maxilla served as a reactive areas, as

they seem to do, then they would respond to the translation
by forming a new bone when the sutures were pulled apart
by forces from the growing cartilage.
Experiments
• 2 types of experiments:
• Transplantation of cartilage
• Removing of cartilage.
Transplantion experiments
• not all skeletal cartilage act the same when transplanted.

o If a piece of Epiphyseal plate of a long bone is transplanted, it

will continue to grow in a new location or culture, indicating
that these cartilages do have innate growth potential.

o Cartilages from spheno-occipital synchondrosis of the cranial

base also grows but not as well.
o In early experiments, transplanting cartilage from the
nasal septum gave equivocal results

o In more precise recent experiments, nasal septal cartilage

was found to grow nearly as well in culture as epiphyseal
plate cartilage.

o Little or no growth was observed when mandibular

condyle was transplanted, and cartilage from mandibular
condyle showed significantly less growth in culture than
other cartilages.

.
Removing cartilages

• In rodents, removing a segment of the cartilaginous nasal

septum causes a considerable deficit in growth of the mid face.
• It can be argued that the surgery itself and the accompanying
interference with the blood supply to the area, and not the loss
of cartilage causes the growth changes.
 A B
Effect of removal of the cartilaginous nasal septum
on forward growth of the snout in the rabbit.
-removal of nasal septal cartilage resulted in deficient
growth of nasomaxillary complex.
Profile view of man whose cartilaginous nasal septum was removed at age 8,
after an injury.
Conclusion
• Epiphyseal cartilages and cranial synchondrosis can act as
independent growth center.
• Nasal septum acts as a center to a limited extent.
• Condylar cartilage growth is secondary and not primary
 Functional matrix theory of growth

• It was given by MELVIN MOSS in 1960 and was reviewed

and updated by him in 1990’s
• His theory holds that neither the cartilage of the mandibular
condyle nor the nasal septal cartilage is a determinant of jaw
growth
• Growth of the face occurs as a response to functional needs
and neurotrophic influences and is mediated by the soft tissues
in which the jaws are embedded.
• The soft tissues grow, and both bone and cartilage react.
• Bone and cartilage lack growth determination and respond to
intrinsic growth of associated tissues.

• He termed these associated tissues as “functional matrices”.

• Each component performs a necessary service—respiration,

mastication, speech while the skeletal tissue support and
protect the associated functional matrices.
• 2 EXPERIMENTS OF NATURE—
•
• When the brain is very small, the
cranium is also very small, and the
condition of microcephaly results.The
size of the head is an accurate
representation of the size of the brain.
•
•The second natural experiment is the condition called
Hydrocephaly.
Resorption of CSF is impeded

Fluid accumulates

Intracranial pressure builds up

Development of brain is impeded.

Enormous growth of the cranial vault

 THE ORIGIN, GROWTH AND MAINTENANCE OF
ALL SKELETAL TISSUES AND ORGANS ARE
ALWAYS SECONDARY, COMPENSATORY AND
OBLIGATORY TO TEMPORARILLY AND
OPERATIONALLY PRIOR EVENTS OR PROCESSES
THAT OCCUR IN SPECIFICALLY RELATED NON-
SKELETAL TISSUES , ORGANS OR FUNCTIONAL
Each of these function is completely carried out by
SPACES.
FUNCTIONAL CRANIAL
COMPONENT
 Functional cranial
component

Functional
Skeletal unit
matrices

Macroskeletal
Microskeletal Periosteal Capsular
Eg-endocranial
Eg-coronoid, Eg-teeth and Eg-orofacial,
surface Of muscles
angular neurocranial
calvaria
 FUNCTIONAL MATRICES

• This consist of muscles, glands, nerves,

vessels, fat, teeth as well as the functional spaces.
DIVIDED INTO TWO TYPES-
• Periosteal matrices
• Capsular matrices
PERIOSTEAL MATRICES
• All non skeletal functional units adjacent to
skeletal unit form the periosteal matrices.
• They act directly and actively by bringing
secondary, compensatory transformation of the
related skeletal units.
• Best explanation – coronoid process and temporalis
muscle : the shape and size of coronoid process
accurately reflects the functional requirements of the
temporalis muscle.
• Examples of periosteal matrices are teeth, blood
vessels, nerves, glands.
• The influence of periosteal matrix is restricted to part
of a bone, i.e. it affects the “micro-skeletal unit.”
CAPSULAR MATRICES.
- Act indirectly and passively, producing
secondary compensatory translation in space.
- capsular matrix includes the capsule that
surrounds masses and spaces.
- Capsular matrix causes growth of whole bone.
- e.g.-
• NEURO CRANIAL
• ORO FACIAL
• OTIC
• ORBITAL
NEUROCRAINAL
CAPSULE
Sandwiched between-
skin and dura mater

Consists of
-5 layers of scalp
-bone
-two layers of dura
mater
 ORO FACIAL MATRIX
• Surround and protect oronaso-pharyngeal space.
• Surrounded by skin and mucous membrane on
either side.
• Primary function is maintaining airway.
 Growth of functional spaces

increase in the size of capsule

Followed by passive movement of functional cranial

component
Orofacial Capsule
 Skeletal unit

• Composed of –bone, cartilage and tendinous tissue

• It is of two types
• Macro-skeletal unit
• Micro-skeletal unit
 MACROSKELETAL UNIT

Adjoining portions of number of

neighbouring bones carrying
out a single function
eg- entire endocranial surface of
calvarium
 MICROSKELETAL UNIT
Bones consisting of a number of small skeletal units
• MAXILLA
- orbital
- pneumatic
- palatal
- basal
• MANDIBLE
- coronoid
- Condylar
- angular
- Gonial
- alveolar
- Mental
 • Skeletal unit
• Micro-skeletal unit Macro-skeletal unit

• Parts of bone core of bone

• Affected by periosteal matrix Affected by capsular matrix

• Cause transformation of the bone Cause translation of the bone

• transformation + translation
•

GROWTH
Clinical implication of functional matrix
theory

• Orthodontic correction of malocclussion is done

either by intraoral and extraoral appliances
• Force application by these appliances tend to alter
functional matrix
• Alteration of periosteal functional matrix produces
changes in micro-skeletal unit
• Alteration of capsular functional matrix produces
changes in macro-skeletal unit
• Orthodontic treatment

• Periosteal matrix Micro-skeletal

unit
• (Teeth) (Alveolar
bone)

• Capsular matrix Macro-skeletal

unit
• (Dentofacial orthopaedics) (Jaws)
Orthodontic treatment that modifies
functional matrix
• Rapid palatal expansion : this causes
widening of palatal sutures .it is a
form of orofacial orthopaedics.
•Repositioning maxillary segments in clefts patients:
these procedures alter macro-skeletal unit.
•Condylectomy: in ankylosis, condylectomy restores
function and allow further development of mandible.
•Upper anterior inclined plane:they hold the
mandible to stimulate growth of condyle
• Activator : to stimulate the growth of
condyle.
• Functonal regulator:
stimulation of both periosteal
matrix through lip pads,
buccal shields and capsular
matrix by altering
oropharyngeal spaces.
• Adjuncts used with fixed appliances like class ii elastics,
interarch coil springs, herbst appliances and extraoral
appliances like headgear, facemask or chin cups have direct
effect on functional matrices, primarily because of alteration
of muscle and space
 Distraction osteogenesis

It is interesting and
potentially quite
significant clinically,
that under some
circumstances, bone can
be induced to grow at
surgically created sites
by the method called
DISTRACTION
OSTEOGENESIS.
• The Russian surgeon Alizarov
discovered in the 1950s that if cuts were
made through the cortex of a long bone of
the limbs, the arm or leg then the bone
could be lengthened by tension to
separate the bony segments.
• Best results – distraction started few days after
initial healing and callus formation

• Segments to be separated at a rate of 0.5 – 1.5

mm per day

• Distraction osteogenesis now is widely used to

correct limb deformities.
• The bone of the mandible is quite similar in its internal
structure to the bone of the limbs, even though
developmental course is rather different.
• Lengthening the mandible via distraction osteogenesis is
possible and major changes in mandibular length(a cm or
more ) are managed best in this way.
 AGAINST

• The theory does not make it clear how the functional needs
are transmitted to the tissues
• Craniostenosis – premature stenosis of sutures inhibits
growth – sutures have some capacity to regulate the activity
of functional matrix
VAN LIMBORGH’S THEORY
• A multifactorial theory was put forward by Van Limborgh in
1970.

• According to him the three theories of growth were not

satisfactory, yet each contains elements of significance.

• Explains the process of growth and development in a view that

combines all the three existing theories.
• Supports functional matrix theory of Moss,
• Acknowledges some aspects of Sicher’s theory
• And at the same time does not rule out genetic
involvement.
Factors controlling growth according to this
theory-
1. Intrinsic genetic- by themselves.
2. Local epigenetic- adjacent soft tissues.
3. General epigenetic- distant structures. E.g.
hormones.
4. Local environment- habits, muscle force.
5. General environment-nutrition, oxygen.
• Limborgh lists the essential elements of the three
hypothesis –

a) Growth of the synchondroses and the ensuing

endochondral ossification is almost exclusively
controlled by intrinsic genetic factors
b) The intrinsic factors controlling intramembranous
bone growth i.e. the growth of the sutures and the
periosteum, are small in number and of a general
nature.
c) The cartilaginous skull parts must be seen as growth
centers
d) Extent of sutural growth is controlled by both the
cartilaginous growth and the growth of the other
head structures
e) Extent of periosteal bone growth largely depends on
the growth of adjacent structure
f) The intramembranous processes of bone formation
can be additionally influenced by local
environmental factors also.
The functional matrix hypothesis revisited: The role of
mechanotransduction Moss.

Functional matrix hypothesis revisited: The role of an osseous

connected cellular network. Moss

The functional matrix hypothesis revisited: The genome thesis.Moss.

The functional matrix hypothesis revisited: The epigenetic antithesis and

the resolving synthesis. Moss
PRENATAL GROWTH OF MAXILLA

13
9
Growth & development of an individual can be divided in to

Post-natal
Pre-natal

Period of Ovum Period of embryo Period of Foetus

1-14th day 14th – 56th day 56th – till birth
 Around 4th week IUL Prominent bulge on ventral side
corresponding to developing
brain

Buccopharyngeal Below the bulge, a shallow

membrane separates depression called
it from foregut STOMODEUM

Mesoderm covering of
developing forebrain FRONTONASAL PROCESS
proliferates downwards

Budding of
Mand. arches of
maxillary
both sides form
process VM
lateral walls

cntd.
BUCCOPHARYNGEAL MEMBRANE
14
3
14
4
 6th week
Now stomodeum Is bounded by:-
 frontonasal prominence
above
 maxillary prominences
on sides
 mandibular prominences
below

Bilateral localised thickenings above

stomodeum c/a nasal placodes

Sink and form nasal pits

Divide FN into –
- Medial and Medial nasal processes fuse --
- lateral nasal process primordium of bridge and septum
of nose
The maxillary prominences
Laterally, merge with the mandibular
prominences cheek
Medially, compress the medial nasal
prominences upper lip.

The medial nasal swellings merge with

each other in the midline to form the
intermaxillary segment

Philtrum of lip
Premaxillary part of the maxilla,
Primary palate
 8th week– i/m ossification at
termination of infaorbital nerve
just above the canine tooth
lamina.
2 centres for each half of maxilla.

Maxillary process

Frontonasal process

Lat. Nasal process

 OSSIFICATION CENTERS OF MAXILLARY
PROCESSES
PART OF BONE OSSIFICATION TIMING NO. OF
TYPE OSSIFICATION
CENTERS
Sphenoid bone i/m 8th week 02

Palatine bones i/m 8th week 02

Maxilla i/m 8th week 02

Zygomatic i/m 8th week 02

process
Temporal bone i/m 8th week 02
 DEVELOPMENT OF PALATE
 Medial walls of maxillary processes produce a pair of thin medial
extensions: palatine shelves
 At first these shelves grow downwards parallel to lateral surface of
tongue
 At end of 9th week, rotate rapidly upwards into a horizontal position
 Fuse with each other and primary palate: secondary palate
 Fusion starts at the site of the future incisive foramina..
 Proceeds both anteriorly & post. from there.
Innervations of the palatal region
 The greater and lesser palatine nerves from
the maxillary division of trigeminal nerve
enters the palate through greater and lesser
palatine foramen .

 The nasopalatine nerve which passes through

incisive foramen supplies hard palate .

 The glossopharyngeal nerve supplies the soft

palate.
15
2
DEVELOPMENTAL DEFECTS
 Cleft lip- U/L or B/L & True hare lip

 Cleft palate

 Oblique facial cleft

 Cyst in the nasolacrimal duct

 Microstomia or macrostomia

 Globulomaxillary cyst
Development of maxillary sinus
 The maxillary sinus forms around 3rd month
of IUL it develops by expansion of nasal
mucous membrane into maxillary bone .

 Later the sinus enlarges by resorption of

internal walls of maxilla.
 Stages of growth of maxillary
sinus
TIME GROWTH SHAPE

Birth Tubular Tubular

9 yrs 60% of adult size ovoid

12 yrs Antral floor parallels

nasal floor

18 yrs Adult size pyramidal

POSTNATAL GROWTH OF
MAXILLA
 Nasomaxillary complex

Functions:-
 Important role in mastication (attachments of
teeth and muscles).
 Provides significant portion of airway.
 Houses olfactory nerve endings.
 Encloses eyes.
 Adds resonance to the voice through the

sinuses contained within the region.

 Nasomaxillary complex

Mechanisms and Sites

Sites :-
 Growth observed at:-
◦ Sutures
◦ Nasal septum
◦ Periosteal and endosteal surface
◦ Alveolar process
 Maxilla

Mechanism:-
The growth mechanism is produced by
 Displacement
 Growth at sutures
 Surface remodelling
 Primary displacement
◦ Active, downward and forward
◦ Maxillary tuberosity lengthening posteriorly
 Secondary displacement-
◦ Passive, downward and forward direction
◦ Cranial base – middle cranial fossa grows
anteriorly
◦ Important during primary dentition periods
 Growth at sutures:-

 Fronto-nasal
 Fronto- maxillary
 Zygomatico-temporal
 Zygomatico-maxillary
 Pterygo-palatine

 All are oblique; more or less parallel to each other

 Downward and forward growth
Surface Remodeling
 In addition to the growth

occurring at the sutures,

massive remodeling by bone
deposition and resorption
occurs to bring about:

a. Increase in size
b.Change in shape of bone
c.Change in functional
relationship
 The anterior nasal spine
prominence increases due
to bone resorption from
the periosteal surface of
labial cortex. As a
compensatory
mechanism, bone
deposition occurs on the
endosteal surface.

 . This results in increase

in size of the maxillary
antrum.
 AGE CHANGES IN MAXILLA
At birth :-
 Vertical diameter is lesser than both the transverse and anteroposterior
diameters.
 Body is mainly occupied by sockets for the teeth.
 Maxillary sinus is seen as a shallow groove on the nasal aspect.

Adult :-
 Vertical diameter is greater than the transverse and anteroposterior
diameters.
 Maxillary sinus has greatly developed within the body.

Old age:-
 Due to falling of teeth and resorption of alveolar margin, the vertical
diameter is again greatly reduced.
 Alveolar margin is reduced in thickness at the expense of the labial wall.
Enlow’s V principle:-
Bone deposition
on inner side of V

Resorption on
the outer surface.
 Developemental anomalies
associated with maxilla
 Hemifacial microsomia :Craniofacial abnormalities -
maxillary, temporal, and zygomatic bones
Aperts syndrome
 Crouzon’s Syndrome
 Treacher Collin’s syndrome
 Clefts
 Fetal Alcohol Syndrome
 Conclusion
 No given tissue grows and differentiates in
an isolated, independent manner by a wholly
intrinsic regulatory process.

 Primary genetic control determines only

certain features & does not have complete
influence on growth.

 It is important to know how growth occurs

and the influence acting on skeletal growth
to understand the etiology of malocclusion
and dentofacial deformity.
The Mandible :
• is the largest and strongest bone of the face.
• Develops from the First Pharyngeal arch
• Has horseshoe shaped body which lodges teeth
and has a pair of rami
 Foramina and Relations to Nerves and Vessels :

• Mental foramen transmitts mental nerve and vessels

• Inferior alveolar nerve and vessels enter mandibular canal

through mandibular foramen

• Masseteric nerve and vessels pass through the mandibular

notch
• Auriculotemporal nerve is related to medial side of the
neck of mandible

• Mylohyoid nerve and vessels lie in the mylohyoid groove

• Lingual nerve is related to medial surface of ramus in front

of myohyoid groove
Development Of
Mandible
 Prenatal
Development

Development
Of Mandible

Post Natal
Development
PRENATAL GROWTH
OF MANDIBLE
POSTNATAL GROWTH
OF MANDIBLE
What is post natal growth??

Post natal growth is the first 20 years of growth after birth.

How does it differ from prenatal growth??

Prenatal growth is characterized by a rapid increase in cell

numbers and fast growth rates

Postnatal growth is characterized by declining growth

rates and increasing maturation of tissues.
• Mandible undergoes the largest amount of growth post-
natally and also exhibits the largest variability

• The Functional Parts Include-

▫ Ramus
▫ Corpus
▫ Angle of mandible
▫ Lingual tuberosity
▫ The alveolar process
▫ The chin
 Ramus

Function-
Provides an attachment base for masticatory
muscles.

Plays key role in placing the corpus and dental

arch into ever-changing fit with the growing
maxilla and the limitless structural variations of
face.
 Mechanisms and sites

• Moves posteriorly ; combination of resorption and

deposition

• Resorption –anterior ramus while deposition posteriorly---

drift posteriorly

• Functions of remodeling—
– Accommodate the increasing mass of masticatory
– Enlarged breadth of pharyngeal space
– Lengthening of corpus
 Ramus to corpus
remodeling conversion

• Ramus relocated in a posterior direction; Bony arch length

increased.

• Resorption of anterior border of ramus---- making room

for the last molar.

• Follows the Enlow’s V principle.

Bicondylar dimension established much earlier in
childhood; bilateral growth separation between condyles
is minimal beyond early childhood years
 Corpus

• As anterior border of ramus resorbs – posterior drift

• Conversion of earlier ramus into posterior part of the body
of the mandible– REMODELING CONVERSION.
• Thus body of the mandible lengthens
 Coronoid process:-
• Propeller like twist.
• Lingual surface faces- 3 directions—posterior,
superior and medial.
• Addition made on lingual side—
-lengthens vertically- V oriented vertically
• Also posterior movement seen – V oriented
horizontally

Also carry the base of the coronoid & ant. part of

ramus in a medial direction– lengthening the corpus

• Buccal side of coronoid– resorptive.

Angle of the mandible:-
Lingual side- deposition antero-superiorly while
resorption postero-inferiorly

Buccal side vice versa

This results in flaring of mandible.
 ANTEGONIAL NOTCH

• A single field of surface resorption is present on the

inferior edge of mandible at the ramus corpus
junction. This forms the antegonial notch

• vertical growth - deep

• horizontal growth - shallow
 The lingual tuberosity
• Direct equivalent of maxillary tuberosity.
• Forms Boundary between ramus and body.
• Moves posteriorly by deposition on its posteriorly facing
surface.
• Ideally max. tuberosity closely overlies lingual tuberosity.
• Protrudes noticeably in a lingual direction.
• A large resorption field below it– lingual fossa.
• Tuberosity relocates posteriorly with only
relatively slight lateral shift.
• At the same time that part of the ramus just
behind the tuberosity remodels medially-----
becomes part of corpus, thereby lenghtening it.
 Alveolar process

• Develops in response to tooth buds

• As teeth erupt the alveolar process erupt

• Adds height and thickness to body of mandible

 Chin
• A specific human characteristic; fully developed in recent
man only

• It is the anterior inferiormost part of the mandible

influencing profile of the patient

• As age advances the growth of chin becomes significant

 Condyle
• Anatomic part of special significance.
• Evolutionary changes.
• Earlier thought to be the master center; now a regional
field of growth– regional adaptive growth.
 Mechanism

• Cartilage is special non-vascular tissue

• Secondary type of cartilage
• Endochondral mechanism of bone formation—due to
variable levels of compression
• Proliferative process – upward and backward growth of
condyle
• The neck is progressively relocated into areas previously
held by the much wider condyle.

• What used to be condyle in turn becomes the neck as one

is remodeled from the other .

• This is done by periosteal resorption combined with

endosteal deposition.
 The condylar question
What is the physical force that produces the forward
and downward primary
displacement of mandible ?

• Proliferation of cartilage towards its contact

thereby pushes the whole mandible away from it.

202
These observations suggested conclusions.

• First the condyles may not play the kingpin role

of a “master center”.

• Second the whole mandible can become

displaced anteriorly and inferiorly into its
functional position without a "push" against the
basicranium
Age Changes In Mandible
 Child
At Birth
hood

Adult
Old age
hood
At Birth
IN PEDIATRIC PATIENTS