CRANIOFACIAL GROWTH AND

DEVELOPMENT :
POSTNATAL
Sites and Types of Growth in the Craniofacial Complex

1. CRANIAL VAULT
(the bones that cover the upper and outer surface
of the brain)
. made up of a number of flat bones
.. that are formed directly by intramembranous
bone formation, without cartilaginous precursors
 At birth, the flat bones of the skull are widely
separated by loose connective tissues. These
open spaces, the fontanelles, allow a
deformation of the skull at birth. This helps in
allowing the large head to pass through the
birth canal.

After birth, apposition of bone eliminates

these open spaces, but the bones remain
separated by a thin, periosteum-lined suture for
many years, eventually fusing in adult life.

Mechanism of growth in cranial vault:

a) apposition of new bone at sutures
b) remodelling at inner and outer surfaces.
2. CRANIAL BASE:
Bones of the cranial base are formed initially in cartilage
and are later transformed by endochondral ossification to
bone.
. This is particularly true of the midline structures. As one
moves laterally, growth at sutures and surface
remodeling become more important.
. As ossification proceeds, bands of cartilage called
synchondroses remain between the centers of
ossification
. These important growth sites are the synchondrosis
- between the sphenoid and occipital bones: spheno-
occipital
synchondrosis,
- intersphenoid synchondrosis, between two parts of
the
sphenoid bone,

Histologically, a synchondrosis looks like a two-
sided epiphyseal plate.
.
The synchondrosis has an area of cellular
hyperplasia in the center with bands of maturing
cartilage cells extending in both directions,
which will eventually be replaced by bone.

.
A significant difference from the bones of the
extremities is that immovable joints develop
between the bones of the cranial base
3. NASOMAXILLARY COMPLEX:

Nature of growth:
The maxilla develops postnatally entirely by
intramembranous ossification.

Sites of growth:
Since there is no cartilage replacement, growth
occurs in two ways : (PRIMARY TRANSLATION) -
(1) by apposition of bone at the sutures that connect the
maxilla to the cranium and cranial base, ( the space that
opens up at the sutures is filled in by proliferation of bone at
these locations
(2) by surface remodeling

In addition, the maxilla is moved forward by growth of the

cranial base behind it. (SECONDARY TRANSLATION)
 The growth pattern of the face requires
that it grow "out from under the cranium,
which means downward and forward

Accomplished in two ways:

(1) By a push from behind
created by cranial base
growth(secondary
translation)
(2) By growth at the sutures
and/or remodelling
(primary translation).
TIMING :
. Up until about age 6, displacement from
cranial base growth is an important part of
the maxilla's forward growth.

. At about age 7, cranial base growth stops,

and sutural growth is the only mechanism
for bringing the maxilla forward.

ADVANTAGES OF GROWTH PATTERN:

This displacement allows for growth at
the posterior aspect of the maxilla as well
as at the maxillary tuberosities to
accommodate for the eruption of the
. Also allows for the enlargement of the
nasal and oral pharynx to accommodate
for the increased respiratory functional
demands of the growing child.

. To allow for the increased functional

demands in the nasal cavities, the nasal
floor is lowered by being translated bodily
downward and simultaneously undergoing
surface resorption.

. This is accompanied by bone deposition on

the oral side of the palatal shelves of the

Note : Bone is removed from
most of the anterior surface,
although the anterior surface
is growing forward.

Changes in Maxillary Width

- Growth in width at the mid-palatal suture occurs
during the first 5 years of life.

- At later stages of development, increase in the

width of the anterior maxilla occurs as a result of
bone deposition on the outer surfaces of the maxilla
and by the buccal eruption of the permanent teeth.
4. MANDIBLE :
Nature of growth:
In contrast to the maxilla, both endochondral

and periosteal activity are important in

growth of the mandible.
. It needs to be remembered that the original
(embryonic) primary cartilage of the mandible
(Meckel's cartilage) disappears early during
intrauterine life with only few remnants,
namely the malleus and incus ossicles in the
middle ear and the sphenomandibular
ligament.
. Therefore the condylar cartilage is solely
derived from secondary cartilage.
Growth pattern of mandible:

The overall pattern of growth of the mandible can

be represented in two ways :

- If the cranium is the reference area, the chin

moves downward and forward.

- On the other hand, if data from vital staining

experiments are examined, it becomes apparent
that the principal sites of growth of the mandible are
the posterior surface of the ramus and the condylar
and coronoid processes. There is little change along
the anterior part of the mandible. From this frame of
reference this is correct.
 As a growth site, the
chin is almost inactive.
It is translated
downward and forward,
as the actual growth
occurs at the
mandibular condyle and
along the posterior
surface of the ramus.

. The body of the mandible grows longer by

periosteal apposition of bone on its posterior
surface
. while the ramus grows higher by endochondral
replacement at the condyle accompanied by
surface remodeling
.
It is correct to view the mandible as being translated
downward and forward, while at the same time
increasing in size by growing upward and backward.

.
The body of the mandible grows longer as the ramus
moves away from the chin, and this occurs by
removal of bone from the anterior surface of the
ramus and deposition of bone on the posterior
surface.

.
The bony chin becomes more prominent with age
mostly as a result of bone resorption above the chin
(rather than bone deposition on the chin) accompanied
with forward mandibular growth
5. ALVEOLAR PROCESSES :
. The growth of the alveolar bone is
completely dependent on the presence
and eruption of teeth.

. The increase in the vertical height of the

face is the result of the growth of the
maxillary and mandibular alveolar
processes, which is associated with the
eruption of teeth.

. Following tooth extraction, the alveolar

processes start to resorb.
6. FACIAL SOFT TISSUES :
.Growth of the facial soft tissues does not
perfectly parallel the growth of the
underlying hard tissues.
Growth of the Lips:
- The lips trail behind the growth of the jaws prior
to adolescence.
- Because lip height is relatively short during the
mixed dentition years, lip separation at rest (often
termed lip incompetence) is maximal during
childhood and decreases during adolescence.
- Undergo a growth spurt to catch up the jaws
during adolescence.
Growth of the Nose :
- Growth of the nasal bone is complete at
about age 10.
- Growth thereafter is only of the nasal
cartilage and soft tissues in the adolescent
spurt.
Growth trends for maxilla nad
mandible
The growth pattern relationship between
maxilla and mandible were given by Tweed
by studying sequential cephalograms. The
main groups into which he categorised
them are:

a. TYPE A:
--Maxilla nad mandible grow together,
--ANB angle unchanged
--If it is associated with Class 1 molar
relationship and ANB not exceeding 4.5
Growth trends for maxilla nad
mandible
b. TYPE A subdivision:
-- Maxilla protrudes with ANB exceeding 4.5
--Restriction of growth of maxilla and
allowing mandible to grow is needed.
---may require extractions
-- prognosis is good

c. TYPE B:
-- maxilla and mandible grow together
downward and forward with growth of
maxilla exceeding that of mandible.
Growth trends for maxilla nad
mandible
-- Has poor prognosis as point B will
not catch up with point A
-- such people are vertical growers

d. TYPE B subdivision:
-- ANB is large and continues to
increase
-- unfavorable prognosis
Growth trends for maxilla nad
mandible
e. TYPE C:
-- Mandible grwos forward and downward more than
maxilla with ANB decreasing
-- favorable
-- no treatment needed

f. TYPE C Subdivision:
-- Mandible grows at avery rapid rate than maxilla
-- mand. Incisors touch lingual surface of maxillaty
incisors.
--this causes mand incisors to tip lingually or
maxillaty incisors to tip labially
CRANIOFACIAL
GROWTH THEORIES

. Since a major part of the need for orthodontic

treatment is created by disproportionate growth
of the jaws, in order to understand the etiologic
processes of malocclusion and dentofacial
deformity, it is necessary to learn how facial
growth is influenced and controlled.

. Exactly what determines the growth of the jaws,

however, remains unclear and continues to be the
subject of intensive research
CRANIOFACIAL
GROWTH THEORIES
Three major theories in recent years
have attempted to explain the
determinants of craniofacial growth.

. The major difference in the theories

is the location at which genetic
control is expressed
Growth Centers vs. Growth
Sites
A site of growth is merely a location at which
growth occurs, whereas a center is a location at
which independent (genetically controlled) growth
occurs.

. All centers of growth also are sites, but the

reverse is not true.
CRANIOFACIAL
GROWTH THEORIES
(1) FIRST THEORY
Bone is the primary determinant of its own
growth.
. In this theory the genetic control is expressed
directly at the level of the bone, so that it is
the growth centre.
. The sutures between the membranous bones
of the cranium and jaws were considered
growth centers, along with the sites of
endochondral ossification in the cranial base
and at the mandibular condyle were
considered growth centres.
 If this theory were correct, growth at the
sutures should occur largely independently
of the environment, and it would not be
possible to change the expression of
growth at the sutures very much.

. Though it was the dominant view until the

1960s, it has largely been discarded.
. It is clear now that sutures, and the periosteal
tissues more generally, are not primary
determinants of craniofacial growth. Two lines
of evidence lead to this conclusion.
. The first is that when an area of the suture
between two facial bones is transplanted to
another location (to a pouch in the abdomen,
for instance), the tissue does not continue to
grow. This indicates a lack of innate growth
potential in the sutures.
. Second, it can be seen that growth at sutures
will respond to outside influences under a
number of circumstances.
. SO THEY ARE NOT GROWTH CENTRES.
(1) SECOND THEORY
. Cartilage is the primary determinant
of skeletal growth, while bone
responds secondarily and passively.
. This theory suggests that genetic

control is expressed in the cartilage,

while bone responds passively to
being displaced.
.
This indirect genetic control is called
epigenetic.
 If cartilaginous 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 the remodeling of the ramus and other surface
changes could be viewed as secondary to the primary
cartilaginous growth.

. One way to visualize the mandible is by imagining that

it is like the diaphysis of a long bone, bent into a
horseshoe with the epiphyses removed, so that there
is cartilage representing "half an epiphyseal plate" at
the ends.
. Growth of the maxilla is more difficult but
not impossible to explain on a cartilage
theory basis.
. Although there is no cartilage in the
maxilla itself, there is cartilage in the nasal
septum.
. Proponents of the cartilage theory
hypothesize that the cartilaginous nasal
septum serves as a pacemaker for other
aspects of maxillary growth
. The cartilage is located so that its growth
could easily lead to a downward and
forward translation of the maxilla
. Transplantation experiments demonstrate
that not all skeletal cartilage acts the
same when transplanted.
. Epiphyseal plate of a long bone continue
to grow in a new location or in culture,
indicating innate growth potential
. Cartilage from the spheno-occipital
synchondrosis of the cranial base also
grows when transplanted, but not as well.
. Nasal septal cartilage was found to grow
nearly as well in culture as epiphyseal
plate cartilage.
. Mandibular condyle showed significantly
less growth in culture than the other
. Experiments to test the effect of removing
cartilages are also informative.
. In rodents, removing a segment of the
cartilaginous nasal septum causes a
considerable deficit in growth of the
midface.
. It can be argued that the surgery itself and
the accompanying interference with blood
supply to the area, not the loss of the
cartilage, cause the growth changes.
. There are few similar reported cases of
early loss of the cartilaginous nasal
septum in humans.
3. THIRD THEORY (Functional Matrix
Theory of Growth)
. The soft tissue matrix in which the skeletal
elements are embedded is the primary
determinant of growth, and both bone and
cartilage are secondary followers.
. The third theory assumes that genetic
control is mediated to a large extent outside
the skeletal system, and that growth of both
bone and cartilage is controlled
epigenetically, occurring only in response to a
signal from other tissues.
. This point of view was put formally in the
1960s by Moss, in his "functional matrix
theory" of growth, and was reviewed and
. In this conceptual view, the soft tissues grow, and
both bone and cartilage react.
. Eg : a) Pressure exerted by the growing brain
separates the cranial bones at the sutures, and
new bone passively fills in at these sites so that
the brain case fits the brain.
b) An enlarged eye or a small eye will cause a
corresponding change in the size of the orbital
cavity. In this instance, the eye is the functional
matrix.
. Moss theorizes that the major determinant of
growth of the maxilla and mandible is the
enlargement of the nasal and oral cavities, which
grow in response to functional needs (The theory
does not make it clear how functional needs are
transmitted to the tissues around the mouth and
. From the view of this theory, however,
absence of normal function would have
wide-ranging effects.
. Eg : We have already noted that in 75% to
80% of human children who suffer a
condylar fracture, the resulting loss of the
condyle does not impede mandibular
growth.
. What about the 20% to 25% of children in
whom a growth deficit occurs after
condylar fracture?
. the answer is ankylosis
. It appears that the mechanical restriction caused
by scar tissue in the vicinity of the
temporomandibular joint impedes translation of
the mandible as the adjacent soft tissues grow,
and that this is the reason for growth deficiency
in some children after condylar fractures

. under some circumstances, bone can be induced

to grow at surgically created sites by the method
called distraction osteogenesis
TYPES OF GROWTH
CHANGES
INDICES OF MATURITY
Several methods are used to assess the level of
maturity attained by a child during postnatal growth
1. MORPHOLOGIC AGE : based on height comparison
in the same age group.
2. DENTAL AGE : baesed on either tooth eruption or
developmental stage of the tooth as in
radiographs.
3. SKELETAL AGE : based on development of hand-
wrists as in radiographs.
4. SEXUAL AGE : based on secondary sexual
characteristics. Useful only in adolescents.