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Anoop J P IVth Yr I BDS SSDC, Varkala

GROWTH & DEVELOPMENT

GROWTH
Growth, according to Todd, its the increase in size

According to Krogmann, its the increase in size, change in proportion, & progressive complexity

DEVELOPMENT
According to Todd, Development is the progress towards maturity.

According to Moyers ,all naturally occurring progressive, unidirectional sequential change occurring in the life of an individual as its existence as single cell to its elaboration as a multifactorial unit , terminating towards death
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 Bones of the base of the skull /cranial base are formed initially in cartilage &are later transformed by endochondral ossification to bone.

Early in embryonic life , centers of ossification appears in chondrocranium , indicating the eventual location of basioccipital, sphenoid , & ethmoid bones that form cranial base
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 ossification proceeds bands of cartillage called Synchondroses remain b/w the centers of ossification. as
Remains of primary cartilaginous skeleton of cranial base

Bands of cartillage present b/w sphenoid, ethmoid & occipital bones

Form important growth sites at the base of the skull
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Cranial base grows by cartilaginous growth in Synchondroses which later get calcified

Types of Synchondroses
Intersphenoidal Intraoccipital Spheno-occipital Spheno-ethmoidal Fuses at birth Fuses at 3-5 yrs Fuses at 20 yrs exactly not known

Fig : Synchondroses
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 Fig. showing growth at the synchondrosis. A band of immature proliferating cartilage cells is located at the center of synchondrosis, while the band of mature cartilage cells proliferate on both sides, away from the center & endochondral ossification takes place on both margins. Growth at synchondrosis lengthens this area of synchondrosis 10

 Spheno occipital Synchondroses are responsible for most of the lengthening of the cranial base b/w foramen magnum & Sella turcica postnatal which in turn helps in the lengthening /growth of the Naso maxillary complex

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HISTOLOGY OF SYNCHONDROSES
Morphologically, a synchondrosis is similar to the long bone growth plate, except that growth at the synchondrosis is not unipolar , but bipolar.

The synchondrosis can be regarded as two growth plates positioned back to back so that they share a common zone of actively proliferating chondroblasts, or the rest zone.

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 The different zones of the synchondrosis mirror each other such that there is cartilage in the centre and bone at each end.

Synchondroses is an area of cellular hyperplasia & hypertrophy in the center with bands of maturing cartilage cells extending in both directions which eventually being replaced by bone.

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Fig. shows histologic appearance of synchondrosis with ossification taking place on both sides of primary cartillage
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CRANIAL BASE ANGLE

Cranial base flexion is a unique cranial feature of modern human beings and also a reflection of brain evolution

Fusion along the Spheno-occipital Synchondroses is believed to be responsible for cranial base flexion,

which develops in concert with the development of the

upper airway and the ability to vocalize.
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 During development, the anterior and posterior cranial base

flexes at the sella turcica in the middle sagittal plane and thus constitutes an angle in the cranial base, termed the cranial base angle or saddle angle

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Clinical implications of growth of cranial base

Abnormal growth of cranial base can result in severe dentofacial deformity eg Craniofacial Dysostosis

An obtuse cranial base angle increases the depth of maxilla & causes Mandibular retrognathism & vice versa
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An Obtuse cranial Base angle causing Maxillary Prognathism

An Acute Cranial Base angle causing Mandibular Prognathism

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Craniofacial
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Enlows Counterpart Principle

Counterpart principle of craniofacial growth states that the growth of any given facial/cranial part relates specifically to other structural counterparts in face & cranium. cranial base growth have effect on maxillary & mandibular growth . Maxillary growth is based on growth of Anterior Cranial Fossa
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 Similarly width of pharyngeal cavity depends on

width of middle cranial fossa

Width of Mid-cranial fossa is same as that ramus width ANS- Posterior Nasal Spine length of maxilla determine the length of Corpus of mandible
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 Maxillary tuberosity determining the width of lingual

tuberosity

Posterior cranial Fossa determine the mandibular position Amount , direction & magnitude of cranial base determine the amount , direction & magnitude of maxilla & mandible
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POSTNATAL DEVELOPMENT OF MAXILLA

Growth at sutures

Translation

Remodeling
Periosteal matrix funtion Deposition/ resorption

1. ZygomaticoActive growth at maxillary tuberosity 2. Zygomaticofrontal Forward & downward 3. Intermaxillary 4. Frontomaxillary
Connective tissue growth

Passive

Capsular matrix

Nasal septum

Bone fill at the space

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Growth Movements
2 Types -

Drift

Displace ment

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DRIFT
Internal displacement of Nasomaxillary complex itself due to growth .

Its the movement of bone surface caused by deposition & resorption towards the depository surface .Its otherwise called Transformation
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DISPLACEMENT
Displacement is the growth of bone as a whole unit so that the bone is taken away from its articulation with other bones.

Also called as Translation

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CONNECTIVE TISSUE PROLIFERATION

Maxilla articulate with the surrounding bone with help of sutures.

Sutures incl. Zygomaticomaxillary, Frontomaxillary, Pterygopalatine , Zygomaticotemporal etc..

According to sicher Growth in sutures maxilla downwards & forwards
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Move

 But its only a secondary & not a primary mechanism

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 Translation/Displacement is process by which specific local areas come to occupy new actual positions in succession as entire bone enlarges.

Active/Primary
2 types

Passive/Secon dary

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Active/Primary Displacement
Active displacement takes place when the growth at the tuberosity of the maxilla pushes the maxilla forward.

Passive/Secondary Displacement
Passive displacement takes place when maxilla grows downward & forward by the growth of the SphenoOccipital Synchondrosis of the cranial base /growth of nasal septum.
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 Passive displacement also takes place when the maxillary bone is translated in space by the growth of corresponding capsular matrices Three main capsules w.r.t Nasomaxillary complex

ORBITA L

NASAL

ORAL

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REMODELLING
In Remodeling simultaneous resorption and deposition of the maxilla while maintaining the integrity & shape of bone.

Maxillary growth matures first in Width followed by Length & Height Width across the 2nd molar & 3rd molar increases until the end of growth in len`gth
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MAXILLARY WIDTH
Midpalatal suture is active up to 15 yrs. There is bone fill in the midpalatal area due to sutural growth resorption in lateral aspect. In case of Maxillary sinus sinus enlarges Resorption on inner aspect & deposition on outer aspect

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NASAL CAVITY

There is removal of bone from periosteum, lining the inner aspect of the nasal cavity & deposition takes place in the endosteal surface , allowing the expansion of nasal cavity

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ANTERO-POSTERIOR DEPTH
In the antero-posterior direction there is growth by apposition in the posterior tuberosity area so that there is increased space for permanent teeth. As the maxilla moves forward , there is resorption of the anterior surface of the periosteum from ANS to alveolar margin incisors, result Concave anterior margin

Deposition occurs in the ANS to make it make prominent

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 Resorption Apposition of zygomatic bone result of zygomatic bone posteriorly

anterior region & posterior region Translation

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MAXILLARY HEIGHT
In vertical direction maxillary bones increase in height by apposition along the alveolar process This increase is seen as long as the teeth erupt This contributes height of maxilla early increase in

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 40% of the maxillary height is achieved by this.

Resorption Deposition End result

Palatal surfaces & Palatal roof Downward shift of palate

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POSTNATAL GROWTH OF PALATE

Follows the concept of expanding V by Enlow

Bone deposition

inner aspect of V Wide end of V

Direction of growth

Periosteal surface lined by Osteoclasts

Endosteal surface lined with Osteoblasts

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TIMING OF GROWTH IN WIDTH, LENGTH & HEIGHT

Growth in width is completed first then length & height

Growth in width of Jaws & Dental arches completed before adolescent growth spurt

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 As the jaws grow in length posteriorly, they also increase in width

for the mandible, both molar & bicondylar widths shows small increase until end of growth in length

Growth in length & height of jaws continues through the puberty .

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In both sexes , growth in vertical height of face continues longer than growth in length, with the late vertical growth in mandible. Increase in facial height & concomitant eruption of teeth continue throughout the life, but decline to adult life

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POSTNATAL GROWTH OF MANDIBLE

Mandible at birth is much smaller in size & there is slight variation in shape from the adult form Infant mandible has a short more or less horizontal ramus with Obtuse Gonial angle Mandibular growth continues at relatively steady rate before puberty.
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The condyles are low & at the position along the occlusal plane . Symphyseal suture has not yet ossified

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GROWTH IN THE FIRST YEAR

o Growth in the first year involves growth at the symphyseal suture & lateral expansion in the anterior region to accommodate the erupting the teeth .
o Mental foramen is directed at right angles to the surface of the corpus.

o There is increased deposition in the posterior

surface of ramus of mandible.

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MANDIBLE IN THE ADULT

Mandible in the adult is different from the mandible of an infant.

Ramus is longer & gonial angle is less obtuse.

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V- PRINCIPLE OF GROWTH
All those changes taking place with the growth of mandible is in the form of expanding V. Its easier to visualize mandible as V-shaped bone than maxilla because of its horseshoe shape.

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Fig. showing Mandibular growth in the form of V

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FUNCTIONAL MATRICES OF MANDIBLE

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GROWTH IN WIDTH
Lateral of ramus Lingual surface Coronoid process its Lateral surface Condyle lateral aspect
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Deposition & Resorption of mylohyoid ridge Apposition Resorption Resorption at

 Thus Inter-ramal distance is efficiently increased by the growth of mandible following the V- Principle

GROWTH IN LENGTH
The growth of mandible in length A-P is by the deposition of bone at the posterior surface of the Ramus & Resorption at the Anterior surface
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 This helps lengthen the mandible anterior part of the ramus is occupied by posterior part of the body in the future to Accommodate permanent molars

Deposition - + Resorption - -

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GROWTH IN HEIGHT
Alveolar process height correlates well with the eruption of teeth Bone deposition taking place in the lower border of mandible also contributes to increase in height of the mandible

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GROWTH ROTATIONS
Arne Bjork et.al , Dept. Of Orthodontics, Royal dental college , Copenhagen, Denmark performed longitudinal Radiographic study by Implant method for studying Jaw rotations Longitudinal study involved about 110 Danish children of 7 yrs. to 18 yrs old.

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Instruments used by Bjork for inserting metallic implants in mandible

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3 types of metallic implants tested

A) Kirschner wire B) Cr-Co Alloy C) Tantalum Wire

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For the radiographic profile analysis of mandibular growth, one implant was inserted in the mid-line of the symphysis, and three on the right side nearest the film: under the first and second premolars, and in the external aspect of the ramus on a level with the occlusal lines. 62

TERMINOLOGY OF ROTATIONAL CHANGES OF JAWS

condition Rotation of mandibular core relative to Cranial Base Rotation of Mandibular plane relative to Cranial base Rotation of Mandibular plane relative to Bjork Total rotation Proffit Internal rotation

Matrix rotation

Total rotation

Intramatrix rotation
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External rotation

 Total Rotation = Internal Rotation - External Rotation

Relationship b/w Total , Internal & External rotation (Proffit)

Relationship b/w Matrix, Total & Intramatrix Rotation (Bjork)

Matrix Rotation = Total Rotation Intramatrix Rotation

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CORE OF THE MANDIBLE

Bone that surrounds the inferior alveolar nerve & the rest of the mandible consists of its functional processes

Functional processes incl. muscular processes , the condylar process, functions incase being the articulation of the jaw with the skull.

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 If implants are placed in areas of stable bone

away from the functional processes, it can be observed that In most individuals , the core of the mandible rotates during growth in a way that tend to decrease the mandibular plane angle (i.e up anteriorly & down posteriorly)

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 Bjork & Skieller distinguished 2 contributions to Internal rotation( Total rotation) of the mandible

Matrix Rotation/rotn around Condyle

Total rotation

Intramatrix Rotation/rotn centered within the body of the mandible

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 Variation of internal rotation of mandible b/w individuals, ranging up to 10 to 15 degrees. For an average individual with normal vertical facial height there is about -15 degrees internal rotation from age 4 adult life

25% - Matrix rotation & 75% - Intramatrix rotation

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 When the core of the mandible rotates forward an average of 15degrees, orientation of jaw from outside

decreases only 2 4 degrees(av..)

Reason

Internal rotation is not expressed in jaw orientation , surface changes tends to compensate i.e. ,posterior part of lower border of mandible may be the area of resorption, while anterior aspect of lower border is unchanged / little apposition
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SHORT FACED INDIVIDUALS/ FORWARD ROTATORS These individuals are characterized by short anterior

lower facial height

Excessive forward rotation of mandible, due to an increase in normal internal rotation & a decrease in external compensation

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 Square type jaw + Low mandibular plane angle+ Square Gonial angle +skeletal Deep bite malocclusion + crowded Incisors

Muscles much stronger they mature early

Space closure is very difficult .

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 Facial height ratio (upper : lower ) 50 : 50 / 50 : 45

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 Characterized by excessive lower anterior face height. Palatal plane rotates down posteriorly.

Creates a negative rather than the normal positive inclination to the true horizontal

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 Mandible shows an opposite ,backward rotation

with an increase in mandibular plane angle

Weak musculature & mature late , so avoid mechanics which increase vertical height of patient facial height ratio (upper: lower) is exaggerated
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In these patients we should avoid :Avoid bite planes Avoid anchor bends Avoid class II elastics
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 This type of rotation is normally associated

with Skeletal Anterior Open Bite malocclusion(because chin rotates back well as down) Backward rotation of mandible also occurs in patients with abnormalities/pathological changes affecting the TMJ In TMJ patients growth of condyle is restricted
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INTERACTION BETWEEN JAW ROTATION & TOOTH ERUPTION

Rotation pattern of jaw growth obviously influences tooth eruption It can also influence the direction of eruption & ultimate antero-posterior position of incisor teeth .

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 Path of eruption of Maxillary teeth is downward & forward Normally maxilla rotates slightly few degrees forward & frequently backward Forward Rotation tends to tip incisors forwards & increasing their prominence. Backward Rotation directs ant. teeth more posteriorly than normal, up righting them & decreasing their prominence
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 Movement of teeth relative to cranial base obviously

could be produced by

Translocation bring about of the total maxillary tooth movement during adolescent growth
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 Eruption path of mandibular teeth is upward &

forward.

Normal Internal rotation of the mandible carries the jaw upward in front

This rotation alters the eruption path of incisors, tending to direct them more posteriorly than would other wise have been the case.
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 When excessive rotation occurs in short face type of development, the incisors tend to carried into an overlapping position even if they erupt very little; hence the tendency for Deep Bite Malocclusion

The rotation also progressively uprights incisors, displacing them lingually & causing a tendency towards Crowding

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 In long face growth pattern anterior open bite will develop as the anterior face height increases unless incisor erupt for an extreme distance
Rotation of jaw also carries the incisor forward , creating a dental protrusion

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AGE CHANGES IN GROWTH PATTERN

Change in Eruption Active & Passive Alignment changes & changes in Occlusion

Change in soft tissues like Nose& Lips

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CHANGES IN FACIAL SOFT TISSUE

Changes in soft tissue not only continues with aging, they are much larger in magnitude than changes in hard tissue . The Lips &other soft tissues of face , sag downward with aging. The result is a decrease in exposure of upper incisors, & an increase in exposure of lower incisors , both at rest & on smile
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 With aging , Lips also become progressively thinner, less vermillion display.

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CHANGES IN ERUPTION Active Eruption

Active eruption has been described as the eruption process of a tooth and their alveoli through the gingival tissues (Moshrefi 2000). This phase ends when the tooth makes contact with the opposing dentition but may continue with occlusal wear or loss of opposing teeth (Dolt 1997).
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PASSIVE ERUPTION
Passive eruption begins once active eruption has completed. This takes place as the dentogingival unit migrates in the apical direction until it is adjacent to the cemento-enamel junction (CEJ) (Evian et al. 1993).

In contrast to active eruption, passive eruption is the apparent lengthening of the crown due to the loss of attachment, or recession of the gingiva, also due to inflammation.
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Passively erupted teeth

After surgical Correctio n

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CHANGES IN ALIGNMENT & OCCLUSION

Its due to

Lack of Attrition

Pressure from 3rd Molars

Late mandibul ar Growth

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LACK OF ATTRITION
Raymond Begg ,a pioneer Australian orthodontist noted his studies of Australian aborigines that malocclusion is uncommon but large amounts of interproximal & occlusal attrition occurred He concluded that in modern populations the teeth became crowded when attrition didnt occur with soft diets, & advocated wide spread extraction of premolar teeth to provide equivalent of the attrition he saw in aborgines

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PRESSURE FROM THIRD MOLARS

a) Late incisor crowding coincides with the time of eruption of 3rd molars b) So one school of thought says that the pressure from the erupting 3rd molars, causes mesial migration of teeth,which is the reason for late incisor crowding c) But the amount of pressure from 3rd molars is not sufficient to cause pressure effect & changes in lower incisors
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LATE MANDIBULAR GROWTH

Mandibular growth continues even after the cessation of the maxillary growth in late teens When mandible grows forward relative to maxilla, in late teens mandibular incisors tends to move lingually, particularly if any excess rotation is present. Due to the mandibular growth, if there where any tight anterior occlusion before the late mandibular growth occurs one of the 3 of the following can occur
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Mandible is displaced distally & can cause TMJ distortion & displacement of Articular disc

Upper incisors may flare forward, opening space b/w the teeth

Lower Incisors may displace distally & become crowded

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CONCLUSION
Malocclusions & Dentofacial deformity arises through variations in normal developmental process A thorough background in craniofacial growth & development is necessary for every dentist A thorough knowledge is also necessary because orthodontic treatment involves the manipulation of skeletal growth & dental growth . So once alteration/modification is been done, its done for ever
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BIBILIOGRAPHY
Contemporary Orthodontics Relationship b/w synchondrosis & craniofacial gth Journal of Dental Research Sutural Growth by Implant method Morphogenic analysis of facial growth Orthodontics (Art & Science) Orthodontics Textbook of orthodontics 99

William R Proffit Open Anatomy Journal 2010/ Vol 2 http//jdr.Sagepub.com http//ejo.oxfordjournals.org

Enlow S I Balaji Sridhar Premkumar Gurkeerat Singh

THANK U
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