Na So Maxillary / Orthodontic Courses by Indian Dental Academy

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GROWTH OF THE
NASOMAXILLARY COMPLEX

INDIAN DENTAL ACADEMY

Leader in continuing dental education
www.indiandentalacademy.com

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Contents
- Anatomy of maxilla
- Prenatal & postnatal development
- Growth of :
Zygomatic region
Palate
Maxillary tuberosity
Lacrimal suture
Nasal airway
Max. sinus
Orbit
- Clinical implication of maxillary growth
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Anatomy:
The maxillary bone is the second largest
bone of face, the first being mandible.

The maxillary bones are two in number
and when two maxillae articulate, they
form:
a. Whole upper jaw.
b. Roof of oral cavity.

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c. Greater part of floor and lateral
wall of nasal cavity
and part of bridge of nose.

d. Greater part of floor of each
orbit.
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Body -
Large and Pyramidal in shape.

Four processes -
Frontal
Alveolar
Zygomatic
Palatine

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Body of maxilla is like a hollow
pyramid.

Base of pyramid is formed by nasal
surface and apex is directed towards
zygomatic process.

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Frontal Process
Maxillary sinus
Maxillary process
[palatine]
Horizontal plate
of palatine
process of maxilla
Alveolar process
Maxillary sinus
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Sites of attachment of maxilla to
surrounding bones:

1. By pterygomaxillary fissure and
pterygopalatine fossa between sphenoid bone
of cranial base and palatine bones or
maxillary bones or posterior face.
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2. The zygomatic bone is attached
to calvaria at temporozygomatic and
frontozygomatic suture.

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3. The maxillary bone and nasal
bones are attached to calvaria at
frontomaxillary and frontonasal
sutures.

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PRENATAL DEVELOPMENT OF
MAXILLA
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Face
Upper
Middle
Lower
Frontonasal
Prominence
Maxillary
prominence
Mandibular
Prominence
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Head development depends upon inductive
activity of prosencephalic and
rhombencephalic organizing centers.

Prosencephalic Upper third of
face.

Rhombencephalic Middle and
lower third of face.

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The branchial arches begin to
develop early in 4
th
week due to
migration of Neural Crest Cells into
future head and neck region.

15
The five facial primordia appear around the
stomodeum or primitive mouth early in 4
th
week.

1. The frontonasal prominence Forms
cranial boundary of stomodeum.

2. Paired maxillary prominences Lateral
boundary of stomodeum.

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3. Paired mandibular prominences Caudal
boundary of stomodeum.

Maxillary
prominence
Mandibular
prominence
Frontonasal
prominence
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By the end of 4
th
week
each side of the inferior part of frontonasal
prominence.
bilateral oval thickenings of surface ectoderm
mesenchyme proliferates producing horseshoe
shaped elevations

Medial Nasal
Prominence
Lateral Nasal
Prominence
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The maxillary prominences enlarge.
grow medially towards each other and
towards the medial nasal prominences.
moves the medial nasal prominences towards
median plane and towards each other.
Each lateral nasal prominence is separated from
maxillary prominence by a cleft or furrow
called as Nasolacrimal groove.
19 www.indiandentalacademy.com
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By the end of 5
th
week.
+ lateral nasal prominence
continuity between side of nose and cheek region.

Maxillary prominence
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The facial bones develop
intramembranously from ossification
centers in embryonic facial
prominences.

1) In the frontonasal prominence single center
appear in 8
th
week for each of
- nasal and
- lacrimal bone
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2) In maxillary prominences numerous
intramembranously ossification centers
develop.
- in 7
th
week IU &
- in 8
th
week IU
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a) In 7
th
week I.U.

1) Primary IM ossification center for each
maxilla appears at termination of infraorbital
nerve just above the canine tooth dental
lamina.

2) Secondary zygomatic, orbitonasal,
nasopalatine and intermaxillary centres
appear and they fuse with primary centre.

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3)Two intermaxillary ossification centres
generate
-alveolar ridge
-primary palate region.

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In 8th week I.U. Ossification centers for

- Medial pterygoid
plates of sphenoid.

- Vomer

- And also single centre for each of
zygomatic bone appears.

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Growth of maxilla depends upon influence
of several functional matrices
These act upon different areas of bone
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Skeletal Units of Maxilla -- Related skeletal
units

1. Basal body Infraorbital nerve.
2. Orbital unit Eye ball.
3. Nasal unit Septal cartilage.
4. Alveolar unit Teeth.

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POST NATAL GROWTH AND
DEVELOPMENT OF MAXILLA

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As in other regions of the craniofacial
skeleton, growth in maxilla occurs by 2
processes:

1. Appositional and resorptional surface
remodeling.
2. Displacement

Moss referred to these movements as
transposition and translation respectively.
32
Enlow and Bang has described the growth
of maxilla by way of its sutures that attach it
to the cranial base, by applying the principle
of Area Relocation

- (i.e. specific local areas come to occupy
new actual positions in succession, as the
entire bone enlarges, involving both the
processes, translation and transposition).

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For the precise assessment of remodelling
processes 2 methods have been used:

1. Cross sectional study using histological
sections of dried skulls.

2. Longitudinal studies using implant markers
and Cephalometric radiographs.
Bjork was the first to use this technique in
1955. In the first technique it was difficult to
note the individual variability in the growth
amount and rate.

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Postnatal growth of maxilla is mainly
because of:

1. Surface apposition.
2. Sutural growth.
3. Nasal septal growth.
4. Sphenooccipital synchondroses.

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Growth of maxilla can be viewed in 3 aspects:

1. Growth in the Height.
.
2. Growth in the transverse direction.

3. Growth in the anterio-posterior
direction.

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1. Growth in the Height.

a) Enlow & Bang V principle
b) Surface remodelling -alvelar pr.
-orbit
c) Displacement process -primary
-secondary
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1) GROWTH IN HEIGHT
a). In the coronal section, the palate is
V shaped. Applying the Enlow and
Bangs V principle-

Deposition on oral side.

Increases the height of the nasal
cavity.

Resorption on nasal side.
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V principle in sagittal and coronal view

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b) Similarly surface remodeling of bone in
the alveolar process, which increases the
height of palatal vault.
- Increase in height of maxilla also occurs
because of remodelling changes in orbit

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c) In addition to surface remodeling the
height of maxilla is increased by
displacement process i.e. primary and
secondary.

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Primary displacement because of apposition at the
tuberosity and palatine sutures which pushes the
maxilla in a forward direction, thus separating the
sutures and further, causing bone apposition in the
connective tissue.
Primary Displacement
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Primary
displacement

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The increase in height of maxilla because of
primary displacement can be explained on the
basis of

Sutural theory cartilaginous theory

Functional
hypothesis
46
Sutural theory
explaining the
maxillary growth
47
Animal and human studies showing the effect of
removal of nasal septum on the growth of the
midface

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Secondary displacement occurs because of
growth of the anterior and middle cranial
fossa and changes in cranial base flexures.
(Also because of increase in length of
cranial base).

Secondary Displacement
49
Secondary
displacement

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2) Growth in Transverse Direction:
It is finished earlier in postnatal life.
Occurs by two processes:
Alveolar remodeling in the
lateral surface of alveolar
process
Growth of the mid-
palatine suture
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Growth of the mid-palatine suture
Occurs in response to
the functional matrix
Mutual transverse
rotations separate
the posterior
region more than
the anterior
U shaped
arch
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3) Growth in anteroposterior direction:
-- Begins in the 2
nd
year of life and
ceases after the increase in width has taken place.

--Occurs by
a) Surface remodeling
-in the maxillary tuberosity region (i.e. appositional
changes)
-and in the sutures between the palate and the
palatine bones.
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Palato maxillary suture
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b) Cortical drift
The anterior surface of the maxilla is mostly
resorptive, however, the total growth of the
maxilla is seen to be in an antero-inferior
direction. This is because as the maxilla
remodels, it is simultaneously translated in an
antero-inferior direction.
- Thus, it is both the remodeling and
translatory growth process (primary&
secondary displasement), which brings
about the change in anteroposterior
direction.
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The antero-inferior displacement of maxilla

Sutures nasal septum,
sphenooccipital
synchondrosis

the
orofacial
functional
matrix
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Discussion of the study conducted by
Sheldon Baumrind (AJO Jan, 87).

In their study, they used implant
markers and computer aided
methods for analyzing the lateral
skull radiographs.

57
They used 3 reference points. ANS, PNS and
Point A.

1)Found out that there was a uniform
displacement of all the 3 points in the vertical
direction.
On an average, the mean downward
displacement was not more than about 0.3mm /
year.
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2) In the horizontal direction, there was a
posterior displacement of all the 3 landmarks.
The displacement of PNS was greater than
point A and ANS.
Thus this finding proves that the increase in
length of hard palate is primarily by growth at
the posterior border.

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3)The backward and downward remodeling
of all the 3 landmarks is reduced after
about 13.5 years. This finding was
consistent with the cross-sectional studies
on dry skull.

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Growth of Zygomatic region
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The malar region
anterior surface Posterior surface
Resorption Apposition
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Posterior remodeling is basically to
keep pace and close contact relation
with the maxillary bone.

The magnitude of relocation is less
as compared to the maxilla.

It ceases after increase in dental
arch length is achieved, during
childhood.

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Bone deposition
inferior edge
of the zygoma
the fronto-zygomatic suture
vertical growth / increase
in the height of the
anterior part of zygomatic
arch and the malar
region.
increase in
vertical length of
lateral orbital
rim.

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The lateral growth of the
zygomatic region.
resorption on the inner
aspect of zygoma.

periosteal deposition on
the lateral surface of
zygoma.
Enlarges the temporal fossa and
keeps the cheek bone in proper
proportion to the enlarging face.

67

The antero-inferior displacement of the
zygoma occurs simultaneously along with
the maxilla and the magnitude is also the
same. This is basically because of primary
displacement of maxilla.

68

Zygoma
displaced
anteriorly
displaced
inferiorly

zygomatico-
temporal suture
frontozygomatic suture
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Growth and Development of Palate

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Oral development in the embryo begins by the
appearance of the prechordal plate in the
bilaminar germ disk on 14
th
day of development.

The face derives from 5 prominences that
surround central depression - the stomodeum
that constitutes the future mouth.

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The 5 prominences are:

1. The single frontonasal
prominence.
2. The paired maxillary prominences
3. The paired mandibular
prominences.

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Oronasopharyngeal
chamber
Oropharyngeal membrane
disintegrates.
Continuity of passage
between mouth and
pharynx.
28
th
day
Primitive stomodeum
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Entrance into gut
Frontonasal
and maxillary
prominences
Horizontal
extensions
Oral
cavity
Nasal
cavity
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Frontonasal
prominence
Maxillary
prominence
Primary
palate
Central part of
upper
lip(tuberculum)
Lateral
shelves
Horizontal
extensions
of
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Palate
Primary palate
Secondary palate
Palatogenesis
5
th
week I.U to 12
th
week I.U.
Critical period
end of the 6
th
week until the beginning
of the 9
th
week.

Structure of Palate
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deep (internal) part of
the intermaxillary
segment.
primary palate or
median palatine
process.
a wedge shaped mass of
mesenchyme between the
internal surfaces of the
maxillary prominences of the
developing maxilla. The Primary
Palate
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Primary palate
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The primary palate becomes the premaxillary
part of the maxilla, which lodges the incisors.

The primary palate gives rise to only a very
small part of the adult hard palate (i.e. the part
anterior to the incisive foramen).

81
internal aspects of the
maxillary prominences
two horizontal
mesenchymal
projections
lateral palatine
processes
Secondary Palate
The Secondary Palate
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Secondary palate
83
the lateral palatine
processes elongate and
move to a horizontal
position.
Lateral palatine
processes
Nasal septum
Primary
palate
ventrally or
anteriorly during the
9
th
week.
dorsally or posteriorly in
the region of the uvula by
the 12
th
week.

fusion
84
Formation and Elevation of palatal shelves:
The development of the tongue fills the oronasal
chamber intervening between the lateral palatal
shelves.

At 6 weeks, tongue is a small mass of un-differentiated
tissue, palatal shelves develop in a wedge shape and,
because of the presence of the tongue, grow downward
into the floor of the mouth along either side of the
tongue.

85
At 8 weeks, the steps in the palatal
development result in the movement of the
palatal shelves from a vertical position beside
the tongue to a horizontal position overlying
the tongue.

88
Nasal septum
Palatal shelf
Tongue
89
Nasal septum
Palatal shelf
Tongue
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This change in the position probably involves
movement of both the tongue and palatal
shelves. Several mechanisms have been
proposed for this rapid elevation of the palatal
shelves.
1. Biochemical transformations of the
connective matrix of the shelves.
2. Variations in vasculature and blood
flow to these structures.
3. A sudden increase in their tissue
trigger. www.indiandentalacademy.com
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4. Rapid differential mitotic growth.
5. An intrinsic shelf force.
6. Muscular movement.
7. The withdrawal of the embryos face from
against the heart prominence by uprighting of
the head facilitate jaw opening which in turn
helps in elevation of palatal shelves

92
8. Pressure differences between the nasal and
oral regions due to tongue muscle
contractions may account for palatal shelf
elevation.

9. The nerve supply to the tongue is
sufficiently developed to provide some
neuromuscular guidance to the intricate
activity of palatal elevation followed by
closure.

93
Fusion of the Palatal Shelves:

During palatal closure i.e. following palatal
elevation.

The mandible becomes more prognathic.

The vertical dimension of the stomodeal
chamber increases.

94

Maxillary width remains stable, allowing shelf
contact to occur.

Also forward growth of Meckels cartilage
relocates the tongue more anteriorly, depressing
downward and laterally thus pushing the palatal
shelves slide medially.

95
Epithelial adherence between contacting palatal
shelves is facilitated by degeneration of the epithelial
cells and a surface coat accumulation of
glycoproteins.
Only the medial edge of the epithelium of the
palatal shelves (in contrast to their oral and nasal
epithelia) undergoes cytodifferentiation involving a
decline of epidermal growth factors receptors that
lead to programmed cell death .This is essential for
mesenchymal coalescence of 2 shelves.
Epithelial adherence between contacting palatal
shelves is facilitated by degeneration of the epithelial
cells and a surface coat accumulation of
glycoproteins.
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Fusion of the 3 palatal components initially
produces a flat, unarched roof to the mouth.

The fusing lateral palatal shelves overlap the
anterior primary palate.

The site of junction of the 3 palatal
components is marked by the incisive papilla
overlying the incisive canal.

97
Incisive
foramen
Mid palatine
suture/raphe
98
Mid palatine
suture/raphe
99
The line of fusion of the lateral palatal shelves is
traced in the adult by the midpalatal suture and
on the surface by the midline raphe of the hard
palate..

100
Growth in the Dimensions of the Palate:

The hard palate grows in length, breadth, and
height becoming an arched palate.

The fetal palate increases in length more rapidly
than in width between 7
th
and 18
th
week
intrauterine and widening occurs from 4
th
month
onward.

101

In early prenatal life the palate is relatively long,
but from the 4th month IU it widens as a result
of midpalatal sutural growth and appositional
growth along the lateral alveolar margin.

At birth the length and breadth of the hard palate
are almost equal. The postnatal increase in
palatal length is due to appositional growth in
the maxillary tuberosity region.

102

During infancy and childhood bone apposition
occurs on the entire inferior surface of the
palate and superior (nasal) surface undergoes
resorption.

This remodeling results in descent of palate
and enlargement of the nasal cavity (i.e. to
keep pace with the increasing respiratory
requirements).

103

The appositional growth of the alveolar
processes contributes to deepening and
widening of the vault of the bony palate and
also increases the height and width of palate.

A variable number of transverse palatal rugae
develop in the mucosa covering hard palate.
They appear even before the fusion, which
occurs at 56 days intrauterine.

104
V Principle of Bang and Enlow in the
Remodelling of the Palate:
As mentioned earlier the palate grows in an
inferior direction by subperiosteal bone
deposition on its entire oral surface and
corresponding resorptive removal on the
opposite side.
The entire V shaped structure thereby
moves in a direction towards the wide end of
the V and increases in the overall size at the
same time.

105
V principle in sagittal and coronal view

106
Anomalies of Palatal Development:

1.Epithelial Pearls: Entrapment of epithelial
rest or pearls in the line of fusion of the palatal
shelves, (particularly in the midline) gives rise
to median palatal rest cysts.

107
Epithelial pearls

108
2. Delay in elevation of palatal shelves
from vertical to the horizontal while head is
growing results in widening gap between the
shelves so they cannot meet leading to cleft
of the palate.

Variations in Clefting of Palate: Cleft palate
is part of number of syndromes like
Mandibulofacial dysostosis (Treacher Collin
Syndrome), Micrognathia (Pierre Robbin
Syndrome) and Orodigito facial dysostosis.

111
3. High arched palate seen in Marfans
Syndrome, Cleidocranial dysostosis,
Crouzon syndrome.

4. Torus Palatinus Genetic anomaly
of the palate is a localized mid palatal
overgrowth of bone of varying size. If
prominent, may interfere with the seating
of removable Orthodontic appliance or
upper denture.

113
MAXILLARY TUBEROSITY
114

Maxillary tuberosity helps in horizontal
lengthening of the bony maxillary arch.

Maxillary growth in posterior direction.

Remodeling at the tuberosity region
produces the lengthening.
115
grows posteriorly
Maxilla carried
anteriorly
Tuberosity
lateral surface
Arch
widening
endosteal side of the
cortex(interior surface)
Cortex moves
posteriorly and
laterally
Maxillary Sinus
increases in size
+++ +++
---
117
Clinical Significance:

1. The depository growth potential of the
tuberosity allows the clinician to expand
the arch by moving the teeth posteriorly
into the area of bone deposition.
2. In a Class II molar relation, such distal
molar movement aid in achieving the
treatment goal of a Class I molar
relationship.
ssss
118
Lacrimal Suture
119

Lacrimal bone is a diminutive flake of a bony
island with its entire perimeter bounded by
sutural connective tissue contacts, separating it
from the many other surrounding bones.

120
Lacrimal Suture
Collagenous linkage within sutural cartilage.
Slippage of bones along
perilacrimal sutural interface.
Maxilla displaced
inferiorly.
122
Remodeling Rotation of Lacrimal bone
Medial superior part
Inferior part
Remains with lesser
expanding nasal
bridge.
Moves markedly outward
to keep pace with
expansion of ethmoidal
sinuses.
123
Nasal Airway
124
Nasal Airway
lining surface of the bony
wall and floor
nasal side of the
olfactory fossae
lateral and anterior
expansion of the nasal
chamber
downward
relocation of the
palate
resorption
deposition
125
Ethmoidal Conchae
lateral and inferior
sides
superior and medial
surface
deposition
resorption
downward and lateral movement
126
Inter Nasal Septum
lengthens vertically at its
sutural junctions.
wraps in relation to
variable amounts and
directions of septal
deviation.
Bony portion
127
Individually variable remodeling changes
are seen and the thin plate of bone show
alternate fields of deposition and resorption
on right and left sides producing a buckling
to one side or the other.

129
MAXILLARY SINUS
130
MAXILLARY SINUS
The largest of
paranasal sinuses.
Pyramidal cavity in the
body of the maxilla.
Antero-Posteriorly
posterior to roots of
maxillary canine
area of 3
rd
molar
Borders
131
Supero Inferiorly
Floor of the orbital
cavity.
Root tips of
maxillary
posterior teeth.
Communication:
Posterior part of the
hiatus in the middle
meatus.
maxillary ostium
132
Functions:

Imparts resonance to the voice
during speech.

Lightens the skull or overall bone
weight by being hollowed cavities.

Warms the air as it passes into
respiratory system.
133
Growth of Maxillary Sinus
PRENATAL AT BIRTH
Lateral evagination or
pouch of mucous
membrane of the
middle meatus of the
nose.
Shallow cavity 2cm A-P
in length,1cm in width
and 1cm in height.
3
rd
month I.U
134

Primary pneumatisation early
paranasal sinuses expand into the cartilage
walls and root of the nasal fossae by growth
of mucous membrane sacs into maxillary,
sphenoid, frontal and ethmoid bones.
Starts in 10 weeks I.U from the middle
meatus.
135
Secondary Pneumatization sinus
enlarges into bone from their initial small
outpocketing always retaining
communication with nasal fossa through
ostia..
Starts in the 5th month I.U
136
Postnatal Growth
maxillary internal walls
(except medially)
medial wall
Maxillary Sinus
resorption deposition
Nasal Cavity
nasal surface
resorption
137
The rapid and continuous downward growth of
this sinus after birth brings its walls in close
proximity to the roots of buccal maxillary teeth
and its floor below its osteal opening.

138
As each tooth erupt, the vacated bone
becomes pneumatised by the expanding
maxillary sinus whose floor descends from
its prenatal level above the nasal floor to its
adult level below nasal floor.

Into adult hood the roots of molar teeth
commonly project into sinus lumen.

140
Size: Average sinus is 7mm in length and 4mm
in height & width and
it expands 2mm vertically and
3mm anteroposteriorly each year.
141
ORBITAL GROWTH
142
ORBITAL GROWTH
Orbit
Maxilla
Ethmoid
Lacrimal
Frontal
Zygomatic
Greater and
Lesser wings
of Sphenoid
143
Growth of the
Orbit
Remodeling
growth
Displacement
among bony
elements
144
Orbit
Roof Lining
Floor
deposition
remodels
anteriorly and
inferiorly
Frontal lobe of the
cerebrum expands
forward and downward
resorption on endocranial
side and deposition on
the orbital side.
145
Remodeling
changes in
the orbital
region

146
i. Orbit grows by V principle
The cone shaped orbital cavity moves
(relocation to remodeling) in a direction
towards its wide opening. Deposits on the
inside, thus enlarge the volume rather than
reducing it.
The growth of the orbit can be explained as:
148

ii. Enlarging displacement is directly
involved.
Sutural bone growth at the many sutures
within and outside the orbit. Orbital floor is
displaced and enlarges in progressive
downward and forward direction along with
the rest of maxillary complex.

149

Studies by Enlow, Bang and Bjork have shown
that in addition to the lowering of the nasal floor
by downward growth displacement of the
maxillary body, the nasal floor is further
lowered by resorption and apposition taking
place on the oral surface of hard palate.

150

The floor of the nasal cavity in adults is
positioned much lower than floor of the orbital
cavity, whereas in child they are at the same
level..

152
Clinical Implications

Maxillary Growth
Of
153
Cessation of maxillary growth in 3
planes of space is in the following
order:

1. Tranverse
2. Anterio-posterior

3. Vertical
154
Transverse growth of maxilla

In narrow palatal vault posterior cross
bites are usually seen.

Skeletal
Dental
155
Skeletal

Unilateral
Bilateral
Present in CO and
CR
present at centric
occlusion but not in
centric relation
156
Dental crossbite
Quadhelix W arch
Cross elastics Archwire to
some extent
157
Anteroposterior growth of
maxilla
Class II skeletal malocclusion can be due
to 3 reasons
1. Prognathic maxilla.
2. Deficient mandible.

3. Or combination.
158
Maxillary excess
Head gear Functional appliances
Cervical
HG
Occipital
HG
Removable

Fixed
159
Removable
Activator
Bionator
Twin Block
Fixed
Herbst
Jasper Jumper
160
Maxillary deficiency
Face Mask
Reverse pull
head gear
Petit
Delaire
Reverse
functional
appliance
Class II
frankel
Twin
blocks
161
Vertical growth of maxilla
HP headgear to
functional
appliance
Bite blocks
on functional
appliance
High pull
headgear to
maxillary
splint
.

High pull head gear
to molar.
Long face Class II treatment
162
References
1.Contemporary Orthodontics-William R. Profitt
2.Human Anatomy-Gray
3.Facial Growth-Enlow
4.Human Embryology-Sperber

163
5. Quantitation of maxillary remodeling
(A description of osseous changes relative
to superimposition on metallic implants)
AJO1987:Baumrind, Korn,and Ben-Bassat

6. Oral Orthopaedics And Orthodontics for Cleft
Lip And Palate.-N.R.E Robertson

164
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