GROWTH & DEVELOPMENT

Theories , Concept & principles

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CONTENTS
1. 2. 3. 4. 5.

Introduction Goals Objectives Definitions Theories

6.
7. 8. 9. 10. 11. 12.

Types of growth
Themes of development Methods of studying growth Types of growth Methods of gathering growth data Mechanism of bone growth Factors affecting growth

Aim
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To understand the

1. basic growth concepts.

2. growth and development of the main craniofacial components.

3. tissues involved in facial growth.

4. differences in facial form and patterns.

5. major deformities of growth.

6. why and how knowledge of facial and somatic growth and development is critical

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Definition of Growth
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Growth usually refers to an increase in size and number Proffit .1986

Self multiplication of living substance-

J.S.Huxley

Growth may be defined as the normal change in the amount of living substance- moyers 1988 Growth refers to increase in size - Todd 1931

Change in any morphological parameter which is measurable- Moss.

Definition of Development
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10

Development is a progress towards maturity Todd1931

Development connotes a maturational process involving

progressive differentiation at the cellular and tissue levels - Enlow

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Development

refers

to

all

naturally

occurring

progressive, unidirectional, sequential changes in the life of an individual from its existence as a single cell to its elaboration as a multifunctional unit terminating in death Moyers

Development is increase in complexity- Profitt 1986

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Key Definitions
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Morphogenesis A biologic process having an underlying control at the cellular and tissue levels Differentiation It is a change from generalized cells or tissues to a more specialized kinds during development

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Maturation
It is the emergence of personal characteristics and behavioral phenomenon through growth processes

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Theories
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The major theories explaining growth are

1.Genetic Theory 2.Sutural Theory 3.Cartilageneous Theory 4.Functional matrix Theory 5.Van Limborghs Theory

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Other theories related to craniofacial growth are

Enlows expanding V principle

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GENETIC theory Growth is controlled by genetic influence and is preplanned.

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Sutural dominance theory

SICHER 1940 stated that cranio facial growth occurs at sutures.

sutural growth is the proliferation of the connective tissue between the two bones.

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Growth of the cranial vault expansive proliferative growth by sutural conn ective tissue that forces the bones of the vault away from each other.

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Points against sutural theory

1.

Lack of innate growth

2.

Growth takes place even in absence of sutures

.

CONCLUSION:

Sutures are growth sites not centers.

Cartilaginous theory
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The Irish anatomist, James H. Scott, proposed an explanati on, the nasal septum theory or Scott's hypothesis sutures play little or no direct role in the growth of the craniofacial skeleton. Rather, sutures are secondary, and compensatory sites of bone formation and growth. Scott concluded :that the nasal septum is most active and important for crani ofacial skeletal growth late prenatally and early post natally , through approximately three to four years of age in humans.

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SCOTTS HYPOTHESIS: Intrinsic growth-controlling factors are in cartilage & periosteum. Sutures are secondary & dependent on extrasutural influences. Cartilaginous part of skull must be recognized as primary centers of growth, with nasal septum being a major contributor in maxillary growth.

Nasal septal cartilage

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Primary mechanism for growth of nasomaxillary complex. Experimental excision of the nasal septum affects the growth of the upper face considerably . Nasal septum acts as central support for the upper facial area, and its loss results in a predictable collapse in the area.

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Condylar cartilage

25

Growth of the condylar cartilage is responsible for the anteroposterior growth of the mandible- primary growth centre. Growth of the mandible- a bent long bone, with the mandibular condyar cartilage being equivalent to the epiphyseal plates of long bones whose growth forces the mandible downward and forward, away from the cranial base

Scott stated that :-

26

If the condylar cartilage is transplanted to a relatively nonfunctional site, such as the subcutaneous or brain tissue, it does not maintain its structure and does not behave like the condylar cartilage in situ. Bilateral condylectomy, congenital absence of the cartilage appreciable effect on the growth of the rest of the mandible in humans.

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FUNCTIONAL MATRIX HYPOTHESIS

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INTRODUCTION

Given by MELVIN MOSS IN 1969 and reviewed by him in 1990s Worked on the concept put by VAN DER KLAAUW of FUNCTIONAL CRANIAL COMPONENT The origin, growth and maintenance of all skeletal tissues and organs are always secondary, compensatory and obligatory response to all the temporally and operational prior events and processes that occur in specifically related nonskeletal tissues, organs or functional spaces

INTRODUCTION

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MOSS said that head and neck region consist of number of functions

Digestion

Respiration
Speech Olfaction Balance Vision

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INTRODUCTION

Each of these function is completely carried out by FUNCTIONAL CRANIAL COMPONENT Each functional cranial component consists of all the tissues ,organs, spaces and skeletal parts necessary to carry out a given function.

The functional cranial component is divided into 1.functional matrix 2.skeletal unit.

Skeletal unit

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Composed of bone, cartilage and tendinous tissue

MICROSKELETAL UNIT bones consisting of number of small skeletal units MAXILLA 1. orbital 2. pneumatic 3. palatal 4. basal MANDIBLE1. coronoid 2. angular 3. alveolar 4. basal

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MACROSKELETAL UNITwhen adjoining portions of number of neighboring bones carrying out a single function

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FUNCTIONAL MATRICES

This consist of soft tissuemuscle,gland,nerve,vessels,fat and teeth as well as non skeletal cartilages

DIVIDE INTO TWO TYPES Periosteal matrices

Capsular matrices

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PERIOSTEAL MATRICES

All non skeletal functional units adjacent to skeletal unit . act by bringing transformation of the related skeletal units .

Functional hypertrophy/hyperactivityincrease in size and change in shape

CAPSULAR MATRICES
consists of

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NEURO CRANIAL

ORO FACIAL

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Each of these capsules is an envelop containing functional cranial component

Sandwiched between two covering layers Capsules expands due to volumetric increase of capsular matrix

This results in the translative movement of the embedded bones

NEUROCRAINAL CAPSULE

37

1. 2. 3. 4. 5. 6. 7.

Sandwiched between-skin and dura mater Consists ofskin Connective tissue Apo neurotic layer Loose connective tissue Periosteum bone(base of skull) two layer dura mater

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The volumetric increase cause compensatory

expansion of surrounding capsule.

Later the calvarial functional cranial component as a whole are passively and secondarily translated.

ORO FACIAL MATRIX

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Surround and protect oronasopharyngeal space.

Surrounded by skin and mucous membrane on either side.

Volumetric growth of these spaces is the primary morphogenetic event in facial skull growth

Van Limborghs theory

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By Van Limborgh in 1970 He combines all the existing theories He supports the functional matrix theory , acknowledges some aspects of Sutural theory, and doesnt rule out the genetic involvement . Suggested the following five factors that he believed controls growth. Intrinsic genetic factor. Local epigenetic factor.

1.

2.

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3.

General epigenetic factor. Local environmental factor. General environmental factor.

4.

5.

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Timing and sequential change

a. Prenatal growth
b. Postnatal growth

c. Maturity
d .Old age

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Timing and sequential change Prenatal growth- rapid increase in cell no. Postnatal growth- till 20 yrs- growth starts declining & increasing maturation pickup speed. Maturity-period of stability Old age death
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GROWTH SPURTS
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Sudden increase in growth Is termed "growth spurt". Periods when A sudden acceleration Of growth occurs.

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Physiological alteration in

hormonal secretion cause for Growth Spurts.

TIMINGS OF GROWTH SPURTS.
a. b.

Just before birth One year after birth

c.

Mixed dentition growth spurt

Boys : 8-11 years Girls : 7-9 years

d.

Pre-Pubertal growth spurt

Boys : 14 - 16 years Girls : 11-13 years

Different types of growth

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Size change Positional change Proportional change

Functional change

Maturational change
Compositional

change

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Proportional change

Eg-Head of the infant

Functional change Eg- production of enzymes, hormones

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Size change- height, weight, volume

Positional changeMigration of neural crest cells

Eruption of teeth
Dropping of diaphragm

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Maturational change stability and adulthood

Compositional change Eye pigmentation

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Major themes of development

Changing complexity Shifts from competent to fixation Shifts from dependent to independent Ubiquity of genetic control modulated by environment

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Changing complexity

At all level of organization i.e sub-cellular to whole organism

Complexity is increase in development

Shifts from competent to fixation

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Undifferentiated cells once differentiated become fixed.

Shifts from dependent to independent

Development brings independence at most levels of organization.

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Ubiquity of genetic control modulated by environment

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Genetic control of development is constantly being modified by environmental interactions

Importance of growth and development to orthodontist

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Etiology of malocclusion
Health and nutrition of children comparison of growth

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identification - abnormal occlusal development at an earlier stage use of growth spurts

Surgery initiation

Normal features of Growth & Development

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pattern -Differential Growth -cephalocaudal gradient of growth Variability Predictability Normality Timing, rate & direction

PATTERN
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Pattern in growth represents proportionality .It refers not just to a set of proportional relationships at a point in time but to change in these proportional relationships over time

In orthodontics , use of word pattern has both a morphological and a developmental application

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DIFFERENTIAL GROWTH
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Different organs grow at different rates amount and at different times.

Scammons curve of growth -Richard scammon

SCAMMONS CURVE OF GROWTH

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LYMPHOID NEURAL GENERAL GENITAL

conclusion
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Each tissue grows at different rate

CEPHALOCAUDAL GRADIENT OF GROWTH

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Axis of increased growth

CEPHALOCAUDAL GRADIENT OF GROWTH

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Growth of head and face

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It illustrates the change in overall body proportions during normal growth and development.

Imp aspect of pattern is its predictability.

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Predictability
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Predictability of growth pattern is a specific kind of proportionality that exists at a particular time and progresses towards another, at the next time frame with slight variations. Change in growth pattern indicates some alteration in the expected changes in body proportions.

Variability
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No two individuals with the exception of

siamese twins are like. Hence it is important to have a normal variability before categorizing people as normal or abnormal.

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Normality
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Normality refers to that which is usually expected, is ordinarily seen or typical Moyers

Normality may not necessarily be ideal.

TYPES OF NORMALITY
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STATISTICAL

EVOLUTIONARY

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FUNCTIONAL

ESTHETICAL

CLINICAL

Timing of growth
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One of the factors for variability in growth.

Timing variations arise because biologic clock of different individuals is different.

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It is influenced by: genetics sex related differences physique related environmental influences

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GROWTH STUDIES AND METHODS OF STUDYING GROWTH.

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Longitudinal growth studies

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Methods of studying bone growth Types of growth data Methods of gathering growth data

Types of .growth data

Opinion Observations. Ratings and rankings. Quantitative measurements. direct data. indirect data. derived data.
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Types of growth data.

Opinion clever guess based on experience. crudest form of scientific knowledge. Observations: for studying all or none phenomenon limited use . quantitative data is needed.
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RATING - comparison

RANKING -value

77 Quantitative measurements Includes expressing a fact as a meaningful quantity or numbers.

Direct data: measurements ,living persons or cadaver -measuring device. Indirect data: images or reproductions of actual person.
Derived data comparing at least two measurements.
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Methods of gathering growth data.

Longitudinal studies . Cross sectional studies. Overlapping or semi longitudinal studies.

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Longitudinal studies.
measurements of same person or groupregular intervals through time.

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Advantage: temp. problems are smoothed with time, Variability, serial comparison makes study of specific developmental pattern of individual possible. Disadvantages: time consuming, expensive, sample loss or attrition, averaging.
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Cross sectional studies

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Measurment of different individuals or different samples & studied at different periods ADVANTAGES

repeating Quicker Less costly Statistical treatment made easier

DISADVANTAGES

Variation amongst individuals cannot be studied

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Semi longitudinal studies.

Merger of either studies

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METHODS
OF STUDYING GROWTH

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CRANIOMETRY.
measurements of skull Neanderthal and Cro-Magnon skull. Found in 18th century in Europe information of extinct population ,growth pattern.

Advantages: Precise measurements. Disadvantages: All data is cross sectional.

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ANTHROPOMETRY:

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soft tissue pts over bony landmarks- living individuals. variation in soft tissue thickness leads to different results Measured at a point at the bridge of nose to a point at the greatest convexity of the rear of skull individual growth directly measured Produce longitudinal data

85 CEPHALOMETRIC RADIOGRAPHY: direct measurement - bony skeletal dimensions follow up same individual over time .

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Disadvantages precise orientation of head ,precise control of magnification. 2D of 3D structure

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Mineralized sections.
Special stains
Thin sections- quench- rapidly

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Micro radiography.
High resolution of images of bone sections

Differential density between primary and

secondary bone.

Bone strength -proportional to degree of

mineralization.

secondary bone has more strength than primary

bone.
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Magnetic Resonance Imaging Depicts- soft tissue growth

contrast with hard tissue.

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Bimetric tests E.g. Skeletal maturation &

ossification

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Fluorescent labels.

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in vivo calcium binding labels anabolic time markers of bone formation. Mechanism of bone growth determined by analysis of label incidence and interlabel distance. Sequential use of different colored labels assess bone growth, healing and functional adaptation. Tetracycline,calcein green,xylenol orange, alizarin complexone,demeclocycline and oxytetracycline

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Radioisotopes.

Radioisotopes of certain elements or compounds are often used as in vivo markers labeled material injected and located within the growing bone by auto radiographic techniques.
1. Technetium 99 2. Calcium 45 3. Potassium 32

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Autoradiography.

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Histological sections are coated with a nuclear track emulsion to detect radiographic precursor for structural and metabolic material.

Specific radioactive labels for protein carbohydrates or nucleic acids are injected.

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Commonly used auto radiographic labels are: A. 3 H thymidine. B. 3 H proline. C. Bromodeoxyuridine.

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Vital staining
John Hunter- alizarin dye Other dyes : tetracycline trypon blue lead acetate procion lead acetate alizarin red 5

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 Vital staining aids in studying:

Manner in which bone is laid down site of bone growth the direction and amount of growth the timing and relative duration of

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growth at different sites.

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Natural markers.
developmental features - serial radiography.

cephalometric landmarks.

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Implant markers.
By arne bjork at royal dental college in

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copenhagen
biologically inert alloys into growing bone

radiographic reference markers for serial

cephalometric study. The method allows precise orientation of serial cephalograms and information on the amount and
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sites of bone growth.

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Mechanisms of bone growth

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Deposition and resorption Growth fields Modelling Remodelling Growth movements drift displacement

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Deposition and resorption

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Bone sides which face the direction of growth are subject to deposition (+) and those opposite to it undergo resorption(-) The surface principal The surface facing towards the direction of progressive growth receives new bone deposition & surface facing away undergoes resorption. The result is the process termed cortical drift, a gradual movement of the growing area of the bone.

Deposition and resorption

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Changes are:a. Change in shape b. Change in size c. Change in proportion d. Change in relationship of the bone with adjacent structures

Growth fields
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Inside and outside of every bone is covered by growth fields which control the bone growth.

They are both resorptive and depository types..

About one half of the bone is periosteal and the other half endosteal. 103 If endosteal surface is resorptive then periosteal surface would be depository. it provides two growth functions: 1. Enlargement of any given bone. 2. Remodelling of any given bone.

Growth sites
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Growth fields having special role in the growth of the particular bone(grows fast) are called growth sites ; e.g. mandibular condyle, maxillary tuberosity, synchondrosis of the basicranium, sutures and the alveolar

Growth sites
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Growth centers
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Special areas which are believed to control the overall growth of the bone e.g.mandibular condyle. Force, energy or motor for a bone resides primarily within its growth centre. But according to recent studies these centers do not control the whole growth process.

MODELING
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Bone modeling involves independent sites of resorption and formation that change the

size and shape of a bone.

Remodelling
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Required differential growth activity required for bone shaping. It involves deposition and resorption occurring on opposite ends Four types

Biochemical remodelling Haversian remodelling Pathologic remodelling Growth remodelling

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1. 2.

Biomechanical- continuous deposition & removal of ions to maintain mineral homeostasis Growth remodelling- constant replacement of bone during childhood

3.

4.

Haversian remodelling- secondary process of cortical reconstruction as primary vascular bone is replaced. Pathologic remodelling- regeneration & reconstruction of bone during & following trauma.

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E.g. The ramus moves posteriorly by the combination of deposition and resorption. so the anterior part of the ramus gets remodeled into a new addition for the mandibular corpus.

Functions of Remodeling
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1.

Progressively change the size of whole bone Sequentially relocate each component of the whole bone Progressively change the shape of the bone to accommodate its various functions

2.

3.

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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 .

Drift
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It is remodeling process and a combination of deposition and resorption. If an implant is placed on depository side it gets embedded. Eventually marker becomes translocated from one side of cortex to other.

Displacement
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1.

Displacement is a physical movement of the whole bone as it remodels caused due to surrounding physical forces Two types: primary displacement secondary displacement

2.

Primary displacement
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It is a physical movement of a whole bone and occurs while the bone grows and remodels by resorption deposition. As the bone enlarges it is simultaneously carried away from the other bones in direct contact with it. E.g. in maxilla

Secondary displacement
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It is the movement of a whole bone caused by the separate enlargement of other bones.

Example- growth in the middle cranial fossa results in the movement of the maxillary complex anteriorly & inferiorly

Rotation
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According to Enlow, growth rotation is due to diagonally placed areas of deposition and resorption

Two types

Remodelling rotations

Displacement rotations

Principle of Area relocation

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Both remodeling and displacement together cause a shift in existing position of a particular structures with reference to another

Enlows V principal
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Most useful and basic concept in facial growth as many facial and cranial bones have a V- shaped configuration. Bone deposition(+) occurs on the inner side and resorption (-) occurs on the outer surface.

Example with V oriented vertically

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bone deposition on lingual side of coronoid process , growth proceeds and this part of the

ramus increases in
vertical dimension.

V oriented horizontally
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Same deposits of bone also bring about a posterior direction of growth movement. .

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This produces a backward movement of coronoid processes even though deposit is on the lingual side

Same deposits carry base of bone in medial direction . So, the wider part undergoes relocation into a more narrow part as the whole v moves towards the wide part .

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VARIOUS FACTORS AFFECTING GROWTH AND DEVELOPMENTpre-natal factors

Causing INTRAUTERINE GROWTH RETARDATION

(IUGR)1. Chromosomal abnormalities 2. Teratogens a. Infectious agents b. Physical agents c. Chemical agents d. Hormones

3 Congenital infections- a. Rubella

.

b. Toxoplasmosis c. Syphilis

d. HSV, HIV
4. Poor Maternal health- hypertension, renal & cardiac disease 5. Mothers nutritional status/ Socioeconomic status 6. Mothers use of alcohol, cigarettes, drugs etc 7. Placental insufficiency 8. Multiple births

Developmental anomalies

CLEFT LIP & CLEFT PALATE CLEIDOCRANIAL DYSOSTOSIS CRANIOFACIAL DYSOSTOSIS (Crouzons disease) MANDIBULOFACIAL DYSOSTOSIS (Treacher-Collins Syndrome) PIERRE ROBIN SYNDROME FACIAL HEMIHYPERTROPHY ECTODERMAL DYSPLASIA

CLEFT LIP

Natal causes
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Growth can be affected by injuries during birth1. Intrauterine molding Arm pressed against the face -maxillary deficiency

Head flexed against the chestmandibular deficiency.

2. Trauma to mandible during birth process forceps delivery

Post-natal factors

GENETICS/HEREDITY:

GENERAL EPIGENETIC FACTORS: a. Hormonal factors b. Neural control c. General body growth
LOCAL EPIGENETIC FACTORS: a. Function b. Muscles

GENERAL ENVIRONMENTAL FACTORS: a. Nutrition b. Illness c. Race d. Climate and seasonal effects e. Exercise f. Family size & birth order g. Psychological disturbance h. Socioeconomic factors

LOCAL ENVIRONMENTAL FACTORS:

a. Habits

Genetic / hereditary factors

Potential for growth is genetic. Actual outcome of growth - Genetic potential combined with Environmental influences

Advanced rate of maturity in females than males delaying action of Y- chromosome.

Genetic control seen ina. body size, shape, deposition of fat b. patterns & rate of growth c. onset of growth events- menarche, -eruption of teeth, -ossification of bones, -beginning of adolescent growth spurt

Hormonal factors
HORMONES
LOCAL Ex. Acetyl choline Secretin organs) GENERAL(ENDOCRINE) NON-SPECIFIC (all body cells) SPECIFIC (target)

ex. Growth hormone ex. ACTH Thyroid hormones LH, FSH Insulin

Hormones affecting growth

1.

2.
3. 4. 5. 6.

Growth Hormone Thyroid Hormones Parathyroid Hormone Calcitonin Insulin Adrenocortical hormones

Growth hormone/ somatotropin

Secreted byACTIONS INDIRECT DIRECT

Protein synthesis synthesis & secretion Lipolysis of IGF Protein breakdown Use of glucose for ATP production Increases size & number of cells Converts chondrocytes into osteogenic cells Deposition of proteins by chondrocytic and osteogenic cells

nutrition

Proteins ( 9 essential amino acids), carbohydrates, fats. Ca, Mg, Mn, , Vit D bone & tooth Fe- Hb formation Vit A- activities of osteoblasts & osteoclasts

Vit B complex- DNA formation & cell maturation

Vit C- collagen formation Oxygen cardiac anomalies stunted growth Teeth- bone- soft tissues

Effects of malnutrition

Delays growth, adolescent spurt

Affects size of body parts, proportions &

chemistry

Quality & texture of tissues bone & teeth

If period of malnutrition short catch-up

growth

Girls better buffered against malnutrition &

illness

Minor childhood illnesses not much effect.

Serious, prolonged, illnesses marked effect

Disease decreased GH.

Cartilage cell growth stopped temporarily.

Catch up growth brings child back on

predetermined genetic curve.

Race

Racial differences-climatic, nutritional or

socioeconomic.

Gene pool differences North American blacks

are ahead of whites in skeletal maturity at birth

& for at least first 2 yrs of life.

Calcification & eruption of teeth 1 yr earlier than whites.

Climate & seasonal effects

Cold climates- increased adipose tissue.

Increased height in spring than autumn.

Increased weight - in autumn than spring. Growth in height & eruption of teeth more at night than day. Fluctuations in hormone release.

Family size & birth order

First-born children weigh less at birth, ultimately less stature. Sizes, maturation, intelligence of individuals- has no correlation with size of family. EXERCISE Effects on growth is not proved. but Development of motor skills, in muscle mass, fitness, general well-being.

Psychological disturbances

Psychological abuse adversely affects growthaccidental discovery in 1948 by German physician. Ht. & wt. gain of children in 2 German orphanages for 1 yr. Orphanage governed by harsh headmistress grew less in ht. & wt. though 20% extra calories. Because of Inhibition of growth hormone. Catch-up growth.

Socioeconomic factors

Favorable socioeconomic status-

-different type of growth -variation in timing of growth

Positive relationship associated with socioeconomic class ; not family income.

Habits
Habits are learned patterns of muscle contraction of a very complex nature. 1. Thumb-sucking 2. Tongue-thrusting 3. Mouth-breathing

Thumb-sucking
Begins

at birth and outgrown by 3-4 years.

Through sucking child obtains- feelings of euphoria, sense of security and feeling of warmth.
Maxillary

constriction- not due to negative

pressure.


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Mandible positioned in a downward manner to accommodate the interposed thumb- causing increased eruption of posterior teeth. Tongue is lowered which decreases the pressure on the upper posterior teeth. Imbalance between tongue & cheek pressures. Cheek pressure increased as buccinator muscle contracts during suckling

Tongue-thrusting

Tongue thrust is forward placement of the tongue between the anterior teeth & against the lower lip during swallowing- Schneider (1982). Tongue thrusting results due to lack of anterior seal. Skeletal open bite Steep mandibular plane. Increased anterior facial height.

Mouth-breathing

Breathing through the mouth alters equilibrium of the jaws & teeth. Lowering of the mandible & tongue & extension of the head is seen.

Adenoid facies-separated lips, small nose, nostrils poorly developed, pout in the lower lip, vacant facial expression.

downward & backward rotation of mandible & increased lower facial height.

REFERENCES:
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Proffit:contemporary orthodontics. T.M.Graber: Orthodontics Principles And Practice 3rd edition Moyers:handbook of orthodontics. Donald H. enlow: facial growth 2nd edition An inventory of United states and Canadian growth record sets.S.Hunter , Baumrind S AJO 1993.

References
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Growth changes in the nasal profile from 7-8 yrs AJO 1988:94 Meng H ,R Nanda Lewis A B, Roche AF pubertal spurts in cranial base & mandible AJO 1985:55 Baumrind S,Korn EL,quantitation of maxillary remodeling. AJO 1987:91 10.Sarnat: Growth pattern of the mandible; AJO-DO 1986: 90;221-233

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