Craniofacial Growth and Development

Overview

Growth: increase in size or number, and is an anatomic phenomenon

Development: increase in complexity or specialization, and is both physiologic and behavioral
o When the mandible grows, some areas get bigger than others at different rates and
magnitude, while some areas like the internal angle area and actually resorb instead of
grow
Overview of Head/Face growth
o Infants head is comprised mostly of the eyes and brain with proportionally small jaws
(can fit through birth canal better)
o Vertical facial growth tends to outpace transverse growth
o 2/3 of growth is completed by age 10-12 (prior to orthodontic treatment)
o Infants eyes are wide set relative to the face // Adults eyes are not much wider
o Infants ears appear low // The rest of the face grows down and anterior so the ears
dont appear as low
o Childrens forehead is upright and bulbous // Adult foreheads are sloping down because
the face grows anterior and down
o Child nasal region is vertically shallow // Adults have a lot of vertical and lateral
expansion
o Child mandibles are proportionally underdeveloped and retrusive, as well as V shaped //
Adults have the face grow down and mandible grow so it is further down. It is also more
U-shaped
o Infants anterior surface of the maxillary arch is convex // Adult maxillary anterior
surface is concave (alveolar bone growth with teeth)
Concepts of Growth and Development
o Growth Patterns
Proportions Over time the head and torso decrease in proportion while the
legs and lower body increase in proportions
Cephalocaudal gradient of growth: structures further from the brain tend to
grow more and later than areas that are closer to the brain
Rate of growth
Not all tissues grow at the same rate, some are faster or slower than the
average body growth
Maxilla grows faster than the mandible, but the mandible catches up in
size later
o Growth variability
There is an extremely large range of growth, and they have charts based on
averages of a population and the standard deviations
Patients outside of 2 standard deviations might need to be examined
o Growth Timing
Females hit their adolescent growth spurt about 2 years before boys, and they
stop growing about 2 years earlier than males (males tend to be larger because
they grow longer than females do)

It is very difficult to predict when the adolescent growth spurt will start
Chronological age = poor predictor
Dental age = poor predictor
Skeletal Age = not that good of a predictor
o Hand-Wrist - Examined different areas of the hand and compare
to a hand atlas to determine skeletal age, not used much
anymore
If sesamoid on the thumb isnt ossified, pre-peak
growth.
If middle phalanx of 3rd finger is convex between
epiphysis and diaphysis, then at peak of growth velocity
Fused bones show post-peak growth
o Cervical Vertebral maturation determining the age based on
the development of the vertebrae see in cephalometric
radiographs
Used more commonly for ortho than hand
Puberty onset = best predictor
Growth Change devices (functional appliances) should be started at the
beginning of the adolescent growth spurt
Methods for studying physical growth
o Measurements
Craniometry: studying dry (dead) skulls with cross-sectional data
Anthropometry: soft tissue variability studied with longitudinal data (more
accurate than craniometry
Cephalometric radiology
Serial cephalometrics: 2D images gathered and superimposed over each
other to show progress
Implants place implantable devices for radiographs and see how much
and where they move over time
3D imaging with CBCT, but radiation exposure concerns
o Experiments
Vital stain
Give stain to animals that will be incorporated into new tissues, then
sacrifice them and investigate the tissues
Stain will show up in remodeling tissues
Tetracycline staining in humans can be studies

Craniofacial Growth

Types of skeletal growth

o Hypertrophy: increase in size of individual cells
o Hyperplasia : increase in the number of cells
o Secretion of extracellular matrix (ECM)
 o Interstitial growth/Endochondral formation: growth from certain centers (like
epiphysis), only occurs with softer tissues like most cartilage that can later calcify into
bone
Cranial base
o Intramembranous bone formation: soft tissue/mesenchyme develop into bone through
a maturation process
Maxilla and skull
o Surface Apposition (modeling): adding layers of tissues down, like with bones and some
cartilage. Periosteum hyperplasia, hypertrophy, and secretion of ECM on the surface
o Resorption (Remodeling): removal of calcified tissues
Different mechanisms of bone movement
o Cortical drift: modeling on one side and remodeling on the other occur evenly so that
the bone ends in a different place but is the same size
Forehead/eyebrow area
o Primary Displacement: only one end has modeling against a fixed surface. This causes
the bone to elongate and the end opposite to modeling moves further out but the
modeling side is still in the same place
Maxilla and mandible growth
o Secondary Displacement: adjacent bone undergoes modeling, which pushes the
secondary bone into a new location over time
Base of the skull grows and pushes the maxilla and mandible anteriorly and
inferiorly
Growth in Craniofacial Complex
o Cranial Vault
Growth is entirely due to periosteal activity at the inner and outer surfaces of
the bones (cortical drift) and apposition along the cranial sutures/fontanelles
Sutures/fontanelles are flexible because brain grows faster than skull
can
The anterior cranial fossa grows forward due to cortical drift of the
frontal bone which leads to frontal sinus and frontal prominence
(supraorbital ridge/eyebrows) increase
Formation- entirely intramembranous bone
Controlling factors brain development completely drives this process
Brain reaches full size by 7-8 years old
o Cranial Base
Made up of the basioccipital, sphenoid, and ethmoid bones
3 areas where they meet are areas of growth.
o Spheno-occipital snchondrosis closes at 14 (most growth)
o Intersphenoid synchondrosis closes at birth (little effect)
o Spheno-ethmoidal synchondrosis closes by age 6
Formation- endochondral ossification to bone from synchondrosis
Anterior-posterior lengthening of the cranial base
Middle cranial fossa grows downward and forward leads to
displacement of Mx and Mn inferiorly and anteriorly
 Majority of the cranial base is completed by age 7 (when brain finishes)
Controlling factors- brain development, olfactory organ development
o Nasomaxillary complex
Formation- intramembranous bone formation
Forward displacement due to displacement of cranial base up to age 7/8
Apposition of bone at the sutures that connect the maxilla and cranial
base after age 7 (2 displacement)
Maxilla models bone posteriorly (pterygomaxiilary fissure), leading to
1 displacement forward
Hard palate and base of the nasal cavity move downward through
cortical drift, increasing the vertical dimension of sinuses
Alveolar bone grows down with teeth as they erupt
Zygoma has apposition laterally along with 1 displacement forward
Surface remodeling of the anterior surface makes it concave instead of
concave
Palate also undergoes remodeling and the mid-palatal suture is open
until the mid-teens (13-15 years)
Transverse growth (V principle): maxillary width increases due to mid-
palatal suture growth up to age 6, then the increase is primarily due to
surface remodeling and alveolar bone development (growth occurs in a
V-shaped pattern that widens over time)
o Applies to both maxillary and mandibular growth
Controlling factors- airway/sinus and naso-cartillage
Removal of the naso-cartilage leads to lack of maxillary growth
anteriorly
o Mandible
Principle site of growth is the posterior surface of the ramus (increase A-P
length) and the condylar & coronoid process (vertical height of the ramus)
Grows posteriorly rather than anteriorly
Slightly displaced anteriorly and inferiorly by the cranial base through 2
displacement (much less than maxilla)
Formation primarily intramembranous bone formation, but both
endochondral (condyle) and periosteal (surface) activity are important
Intramembranous formation alongside Meckels cartilage, but doesnt
develop from it (Meckels ends up in the inner ear)
Endochondral growth from the head of the condyle does cause 1
displacement anteriorly and inferiorly, but it doesnt play that big of a
role in growth. 80% of the time the mandible fully develops even if the
condyle is severed.
Resorption occurs on the anterior border of the ramus to make room
for the molars
Vertical height (occlusal plane) is maintained as teeth erupt by alveolar
bone developing and filling up the space being made
 Front of the chin has some resorption while the posterior of the chin
has deposition (uprights incisors)
Growth of the face
o Maxilla and Mandible (Growth occurs in all three planes of space)
Width width is completed first, by age 12 before the pubertal growth spurt. So
width of the dental arch is established by 12 years
Length continues to grow throughout puberty
Height/vertical growth- can continue through early adulthood/later teens
Significant variability with most individuals
o Soft tissue
Lips
Grow later and longer than bone. They stay behind bone until the
adolescent growth spurt when they catch up
Tends to increase in the vertical dimension in the adolescent years
Lip thickness reaches maximum during adolescence. It then decreases
over time as we age
Lower incisors become visible over time as lower lip sags
Nose
Growth of the nasal bone is complete around 10 years old
Growth after 10 is only the nasal cartilage and soft tissue
Grows downward and forward (vertical slightly more than anterior-
posterior)
Class I patients straighter, class II curves downward
Some cartilage can keep growing after bones stop (can increase
throughout life)
Maturation and aging changes
o Teeth
Active eruption during the teens causes migration of alveolar bone and
periodontal structures
Gingiva should always be at the CEJ
o Occlusion and dental alignment
Interproximal and occlusal wear continually happen, and are compensated for
by eruption forces
Mandibular incisors crowding
Crowding is on the rise
Pressure from 3rd molars, later mandible growth, and a lack of attrition
with softer diets are believe to be the cause
Theories of growth control
o Growth is influenced by genetics (largest influence), environment, nutritional status,
degree of physical activity, and health/illness
o Theories of what control craniofacial growth
Bone (periosteum) as the primary determinant
Cartilage as the primary determinant
Soft Tissue matrix as the primary determinant
o Growth Sites vs Centers of Growth
Growth sites: a location where growth occurs
Sutures
Center of growth: a location at which independent, genetically controlled
growth is initiated
Epiphyseal growth cartilage of long bones
All centers of growth are growth sites, but not the reverse. Growth sites
can be spontaneous areas like with intramembranous bone formation
Nasal septum and cranial base synchondroses are growth centers since
studies destroying them resulted in a lack of growth of the structures
Condyle cartilage is not a center of growth since 80% of children grow
mandibles to normal size after it breaks. Even some have the condyle
grow back properly.